CATALINA POST ACUTE AND REHABILITATION

Based on observations, staff interviews, review of Centers for Disease Control and Prevention guidelines, the facility failed to ensure multi-dose vials that had been opened and accessed were dated and discarded within the required time frame. Findings include: A medication and storage and labeling inspection was conducted on June 29, 2023 at 8:10 a.m. in West Unit with a registered nurse (staff #6). During the inspection of the medication cart, a box labeled Admelog injection 100 units/ml (milliliter) for resident #295 was open and contained approximately 5 ml of insulin. However, the medication box contained two different insulin vials: the first was marked Admelog (insulin Lispro 100 units/ml); the second was marked Insulin Glargine 100 units/ml. The medication vials revealed no open dates and the second vial has no resident name. The medication cart also had a box labeled Insulin Aspart multi vial use for resident #292 that was open and contained approximately 5 ml of insulin. Another box of Insulin labeled Insulin Lispro with resident #66 had an open vial which contained approximately 3 ml. However, there was no open date written on the vials. Continued medication storage inspection revealed an insulin box for resident #21 labeled Insulin Glargine 100 units. ml. However, the box contained a vial of Insulin Lispro injection 100 units per ml, a different medication than what the box label indicated. An immediate follow up interview was conducted with staff #6. She inspected the medication boxes and vials and stated there were no open dates on the insulin vials and that she will discard them and order new ones. She said the Insulin Glargine for resident #21 was not the same as the Insulin Lispro. An interview was conducted with a licensed practical nurse (LPN/staff #34) on June 29, 2023 at 9:00 a.m. She stated when opening a vial of insulin, it must be dated immediately because the insulin is only good for 30 days after opening. Staff #34 inspected the box with two insulin belonging to resident #295, then stated, "It 's not a good practice to have two different insulin vials in a box." She stated she does not know if the Glargine belongs to the resident because the vial was not labeled with the resident's name. She stated regarding resident #295, the insulin had no open date, and was not the correct insulin for that box because the box was labeled Admelog. She stated there was a high risk of giving the wrong insulin if the insulin was not properly stored. She stated the risk for the resident includes, "It can tank their blood sugar, definitely would put a resident at a health risk." An interview was conducted with the director of nursing (DON/staff #20) on July 6, 2023 at 2:33 p.m. She stated her expectation in terms of insulin multi use vials is that they are dated after opening and labeled. She stated an open insulin vial is only good for 28 days or per manufacturing instruction. She stated the risk of not dating or labeling the insulin vials could include a potential adverse reaction to residents or the insulin could not be as effective. Review of the Centers for Disease Control and Prevention (CDC) guidelines, accessed on May 25, 2023 at 11:31 a.m., indicated that medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. The CDC guidelines further revealed that if a multi-dose vial has been opened or accessed (example, needle-puncture) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

§483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that medication was administered as ordered for one resident ( #140) and that a physician was notified. Findings include: Resident #140 was admitted on June 17, 2023 with diagnoses of sepsis and Clostridium difficile. A physician order dated June 16, 2023 included the following: -Levofloxacin (antibiotic), 500 mg (milligrams) intravenous one time a day for sepsis until June 20, 2023; -Meropenem (antibiotic), use 1 gram intravenous every 8 hours for sepsis until June 26, 2023; and, -Vancomycin HCl Oral Capsule (antibiotic), give 125 mg by mouth one time a day for C-diff prophylaxis until July 11, 2023. A care plan dated June 20, 2023 included that the resident was on antibiotic therapy including intravenous Meropenem and Levaquin and oral Vancomycin related to severe sepsis and Clostridium difficile prophylaxis. Interventions included to administer medication as ordered. A list of medications available in the emergency medication supply included Vancomycin HCl Oral Capsule 125 mg, Levofloxacin Intravenous Solution (antibiotic) 500 mg bag, Meropenem Intravenous Solution (antibiotic) 500mg bag. A discharge assessment Minimum Data Set (MDS) dated June 21,2023 included the resident had received 4 days of antibiotics of the last 7 days. However, the Medication Administration Record (MAR) for June 2023 revealed the following: -Vancomycin was not administered until June 17 which was 1 missed administration, the Meropenem was not administered until 1500 on June 18 which was 6 missed administrations, and the Levofloxin was not administered until June 19 which was 1 missed administration. Review of the clinical record did not find that the physician was informed regarding the missing medication administrations or that an attempt was made to access the emergency medication supply. An interview was conducted June 30, 2023 at 2:28 PM with a Licensed Practical Nurse (LPN/staff #67) who said if a resident's medication was not in the cart, the facility had an emergency medication supply that can be used. She said that if it's an antibiotic, they definitely don't want the resident to miss a dose. She stated that if the medication was not in the emergency medical supply kit then she would contact the provider to see if it was appropriate to use an available alternative medication or to change the order. She stated that she would document that in the progress notes. She further stated that nurses should never hesitate to contact the doctor or to check the emergency supply of medication. She stated in some situations, nurses can contact the pharmacy to put a rush on the order and get an expedited delivery on the medication if needed. An interview was conducted June 30, 2023 at 3:27 PM with the Director of Nursing (DON/staff #20). The DON stated that before a resident comes in the building, admission receives the orders which are then sent to the pharmacy. She stated that usually the pharmacy can get the authorization to allow the staff to pull from the emergency medication supply if needed. She stated that it does not meet her expectation that the physician was not notified regarding unavailable medications. She further that it was a standard practice that staff sign off on the medication administration record(MAR) and in this case,the staff did not sign the MAR. She stated that this also does not meet her expectation. This DON stated that if it's not signed off then it's assumed that it was not done. The facility policy Medication administration(reviewed 9/22) revealed that if medication is withheld, refused or given other than at the scheduled time the documentation be reflected in the clinical record.

Based on personnel file review, staff interview, policy review and regulatory guidelines the facility failed to ensure that 1 employee who had been denied a fingerprint clearance did not continue to provide services. The deficient practice could result in inadequate background checks and/or potential dander to residents. Findings include: A personnel file review was conducted on June 30, 2023 with the Human Resources Director (staff #74). Review of the personnel file for the licensed nurses included the following: -A registered nurse (staff #123), who was hired on April 14, 2023. A review of the personnel file for staff #123 revealed evidence of a fingerprint clearance denial dated April 18, 2023. An interview was conducted on June 30, 2023 at 1:03 p.m. with the Human Resources director (staff #74). He stated that the facility required that employees are at least in the process of obtaining a fingerprint clearance card to begin working. He stated that the employee had previous valid fingerprint clearances and the employee was working on submitting a good cause exemption request. He further stated he had not received training on HB2049, the Arizona revised statute detailing fingerprint requirements. Regulatory review of \'a7ARS36-411 revealed except as provided in subsection F of this regulation, a nursing care institution shall not allow an employee to continue employment or to continue to provide nursing services if the person had been denied a fingerprint clearance card. A review of the employee's time clock details revealed the employee worked a total of 13 days in the facility providing nursing services since the original denial was issued on April 18, 2023. Further review of the personnel record revealed that since the employee had not yet submitted the good cause exception request, the employee was not in compliance to continue providing nursing services as of April 18, 2023. A review of facility policy titled 'Catalina Post-Acute Care and Rehabilitation Center Policy / Procedure - Administration' under the section 'Fingerprinting requirements (AZ State Specific) revealed it is the policy of this facility to follow the current Arizona State Specific guidelines on fingerprinting requirements as outlined in ARS 36-411.

Based on clinical record review, staff interviews and facility policy, t he facility failed to ensure one resident (#140) receive care and services to prevent/heal pressure ulcers. Findings include: Resident #140 was admitted on June 17, 2023 with diagnoses of a stage 4 pressure ulcer of right buttock, abdominal surgical dehiscence. A physician's order dated June 17, 2023 included cleanse sacral wound with normal saline and pat dry, pack with gauze soaked in Dakins Quarter strength 0.125% and cover with dressing every day shift. A wound assessment details report dated June 19, 2023 included that the sacrum wound was a stage 4 pressure ulcer measuring 2.5cm long x 4.00cm wide x 3cm deep. A wound assessment details report dated June 19, 2023 included that the right buttocks/ischium wound was a stage 4 pressure ulcer measuring 19 cm long x 17.00cm wide x 3cm deep. A physician's order dated June 19, 2023 included cleanse wound to right buttock and ischium with normal saline, pat dry, apply medihoney with alginate, secure with ABD and retention tape one time a day every Wednesday, Saturday and Sunday. A discharge assessment Minimum Data Set (MDS) dated June 21,2023 included that this resident was admitted with 1 stage 4 and 1 unstageable pressure ulcer. This assessment included that the resident required extensive to total assistance for most activities of daily living. A care plan dated June 21, 2023 included that the resident has pressure ulcers on the sacralcocyx and right ischium with intervention of administering treatments as ordered. However, a review of the Treatment Administration Record and Wound Team Administration Record for June, 2023 revealed the order for treatment of the sacral wound was not administered on June 17, 18 or 21 and the order for treatment of the right buttock and ischium was not administered on the 21. An interview was conducted June 30, 2023 at 1:36 PM with a wound Registered Nurse (RN/staff #133). She stated that when a resident was admitted she completes a full skin assessment and notes her findings. The RN also would put in orders at that time. She stated that if there are not orders in place, she would send the provider a picture and then put orders in the clinical record. She stated that she would use the orders to treat the resident. She stated that the floor nurses would do treatments on Wednesday and on the weekends and she would do the more extensive treatments including wound vacuums. She reviewed this resident's clinical record and stated that it does not appear that all the resident's treatments were completed as ordered. She further stated that a entry left blank on the treatment record would indicate that the treatment was not done. An interview was conducted June 30, 2023 at 3:27 PM with the Director of Nursing (DON/staff #20) who said that it is standard practice that the staff should sign off on medication administration record (MAR) and treatment administration record (TAR)and the staff did not sign off on several entries for this resident. She stated that it did not meet her expectations that the MAR and TAR are both completed. The DON stated that if it's not signed off, it was assumed that it was not done. A policy titled Wound Management (reviewed 5/2023)revealed that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing.The policy further stated that once a wound has been identified, assessed, and documented, nursing shall administertreatment to each affected area as per the Physician's order.

§483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Based on clinical record review, observation, staff interviews, and policies, the facility failed to ensure one sampled resident (#19) who had an enteral feeding tube received the appropriate treatment and services to prevent complications. The deficient practice could result in potential enteral feeding tube complications. Findings include: Resident #19 was admitted on May 5, 2023 with diagnoses that included malignant neoplasm of the larynx, oropharyngeal phase dysphagia, and chronic respiratory failure with hypoxia. A nutrition/hydration care plan initiated on March 24, 2023 indicated resident was NPO and enteral feeding dependent. The interventions included to administer medications as ordered and to monitor/document for side effects and effectiveness. Review of the physician's orders revealed the following: -3/23/2023: May crush/combine medications for administration if not contraindicated and mix with 4 0z (ounces) of water. May use slow push to facilitate consumption. -3/23/2023: Check tube placement and patency prior to each feeding/flush/medication administration via air bolus auscultation or residual aspiration every shift. -3/24/2023: NPO (nothing by mouth) -3/28/2023: Flush peg tube with 100 cc water every shift every 3 hours. -6/5/2023 Jevity 1.5 per peg via enteral pump at 85 ml (milliliter) per hour for 16 hours to provide 1360 ml. Pump to run from 1600 (4:00 p.m.) to 8:00 a.m. or until volumetric dose is met. . Review of the quarterly MDS (minimum data set) dated June 30, 2023 revealed a BIMS (brief interview of mental status) of 15 which indicated the resident was cognitively intact. The assessment included nutrition approach via feeding tube and a proposed total caloric intake through parenteral nutrition of 51% or more. A medication administration observation was conducted on June 29, 2023 at 7:39 a.m. through 8:10 a.m. with a registered nurse (RN/staff #6). Prior to the medication administration, staff #6 provided a brief report regarding resident #19. Staff #6 stated the pump for the tube feeding and the water flush was already off when she took over the resident's care from the night shift. She stated the tube feeding pump was not supposed to be turned off until 8:00 a.m. and turned back on at 4:00 p.m. Staff #6 stated she doesn't know exactly when the resident's feeding tube pump was turned off by the night shift. Staff #6 stated the resident often request to turn off the tube feeding pump and it varies every day. Continued observation of the medication administration conducted on June 29, 2023 at 8:01 a.m., staff #6 crushed all the medications and mixed it in 4 ounces of water. Upon entrance to the resident's room, the tube feeding pump was off and a bag of formula and a bag of water for flushing were hanging on the pole. Staff #6 placed the medication cup at the bedside and she was observed attempting to aspirate the gastric stomach content of the resident using a 60 cc (cubic centimeter) syringe with no return. Immediately after, staff #6 dipped the syringe in the medication cup and obtained approximately one half of the medication into the 60 cc syringe. Staff #6 was observed slowly pushing the medications into the resident's peg tube in its entirety. Staff #6 repeated the procedure until she has administered all the medications in the cup. Staff #6 did not flush the resident's peg tube before and after medication administration. An immediate follow up interview was conducted with staff #6 in which she stated the water flush and the tube feeding formula will be turned on again at 4:00 p.m. An interview was conducted with a pharmacy consultant (staff #34) on June 29, 2023 at 1:33 p.m. Staff #34 stated it is recommended that the peg tube flush is flushed before and after administration of medication due to potential clogging in the medication coagulating in the tube. Staff #34 stated medication will not be entering the patient's system if the peg-tube is not flushed after medication administration. Staff #34 stated the more serious risk could include the medication not entering the patient's system. An interview was conducted with the director of nursing (DON/staff #20) on July 6, 2023 at 2:36 p.m. Staff #20 stated it is her expectation that when medications are administered via peg tube that the placement is confirmed via injecting air and listening in a stethoscope prior to medication administration. Staff #20 stated that the peg tube has to be flushed with 30 cc of water before and after the medication administration. Staff #20 stated that there is a risk that the tube will clog, or there could be something in the if something is administered later that can be contraindicated if the tube is not flushed appropriately. The facility policy, Professional Standards, revised in November 2022 revealed the facility's expectation is to provide services that meet the professional standards of quality provided by qualified persons in accordance with each resident's care plan. The policy further defined professional standards regarding quality of care practices may be published by a professional organization, licensing boards, accreditation body or other regulatory agency.

Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure one resident (#11) did not receive unnecessary oxygen therapy. The deficient practice could result in high carbon dioxide content in the resident 's blood that can lead to respiratory acidosis and death. Findings include: Resident #11 was readmitted to the facility on February 21, 2022 with diagnoses that included chronic obstructive pulmonary disease, heart failure and chronic respiratory failure with hypoxia. A care plan initiated on April 6, 2020 revealed that the resident was receiving oxygen therapy related to the diagnosis of COPD. The interventions included monitoring for signs and symptoms of respiratory distress and reporting to the MD (medical doctor) pulse oximetry. Review of the physician order dated February 21, 2022 included an order to check pulse ox (oxygen) level on room air and document for oxygen weaning purposes every shift. A physician order dated March 10, 2022 ordered to check pulse ox every shift and oxygen may be applied at 2-4 liters per minute and may titrate to maintain oxygen saturation greater or equal to 88% for diagnosis of COPD (chronic obstructive pulmonary disease). The clinical record revealed that the MAR (medication administration record) dated August 2022 revealed the oxygen saturation ranged from 92-99% on room air. Review of the resident's annual MDS (minimum data set) dated April 11, 2023 revealed a BIMS (brief interview of mental status) of 10 which indicated the resident had moderately impaired cognition. Review of MAR dated June 2023 revealed the oxygen saturation ranged from 92-99% except on June 5, 7, 8, 13 and 25, 2023. Further record review of the MARs revealed a check mark in the box indicating the oxygen was administered on the dates when the resident 's oxygen saturation on room air was within normal limits. Continued record review revealed no evidence that an attempt was made to wean the resident from oxygen use and no evidence that the physician was notified of the oxygen saturation results to determine further treatment. An interview was conducted on July 6, 2023 at 1:35 p.m. with a licensed vocational nurse (LVN/staff #29). She stated oxygen administration required a parameter be included in the physician's order. She stated that when a physician writes an order to check a resident 's oxygen saturation every shift, that is for the purpose of weaning the resident from oxygen use. She stated the oxygen saturation must be checked on room air. She stated the physician should be called to report the oxygen saturation result on room air and the physician notification is charted in the resident's electronic health record (EHR). She stated that in her experience, a resident whom was diagnosed with COPD would have their oxygen use discontinued by the physician if the resident 's oxygen saturation was 88% (percent) and above. She stated that the risks for residents who have been diagnosed with COPD and have too much oxygen included oxygen retention and respiratory arrest. An interview was conducted with the director of nursing (staff #20) on July 6, 2023 at 2:21 p.m. She stated that the process of weaning a resident from using oxygen included removing the oxygen and checking the oxygen saturation to see if it can be discontinued. She stated that usually the doctors like to see at least 88% however, that depends on the doctor's order because everyone is different. She stated, generally the doctor reviewed the oxygen saturation (taken at room air) with the nurse or the nurse notified the doctor of the oxygen saturation results. She stated that if the resident was diagnosed with COPD and they receive too much oxygen it could be a concern because their body may not be able to regulate it. She stated that the resident would have to be sent to the hospital if this occurred. She stated it was her expectation that staff follow the professional standard of practice and notify the physician of the oxygen saturation results for the purpose of weaning the resident from oxygen use. The facility policy, Oxygen Administration, revised in July 2023 revealed that the facility ' s policy is that oxygen therapy is administered by a licensed nurse as ordered by the physician. The policy included the purpose of the oxygen therapy was to provide sufficient oxygen to the bloodstream and tissues. The policy stated the resident's clinical record would include charting and documentation related to oxygen use.

§483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on observations, staff interviews, review of Centers for Disease Control and Prevention guidelines, the facility failed to ensure multi-dose vials that had been opened and accessed were dated and discarded within the required time frame. Findings include: A medication and storage and labeling inspection was conducted on June 29, 2023 at 8:10 a.m. in West Unit with a registered nurse (staff #6). During the inspection of the medication cart, a box labeled Admelog injection 100 units/ml (milliliter) for resident #295 was open and contained approximately 5 ml of insulin. However, the medication box contained two different insulin vials: the first was marked Admelog (insulin Lispro 100 units/ml); the second was marked Insulin Glargine 100 units/ml. The medication vials revealed no open dates and the second vial has no resident name. The medication cart also had a box labeled Insulin Aspart multi vial use for resident #292 that was open and contained approximately 5 ml of insulin. Another box of Insulin labeled Insulin Lispro with resident #66 had an open vial which contained approximately 3 ml. However, there was no open date written on the vials. Continued medication storage inspection revealed an insulin box for resident #21 labeled Insulin Glargine 100 units. ml. However, the box contained a vial of Insulin Lispro injection 100 units per ml, a different medication than what the box label indicated. An immediate follow up interview was conducted with staff #6. She inspected the medication boxes and vials and stated there were no open dates on the insulin vials and that she will discard them and order new ones. She said the Insulin Glargine for resident #21 was not the same as the Insulin Lispro. An interview was conducted with a licensed practical nurse (LPN/staff #34) on June 29, 2023 at 9:00 a.m. She stated when opening a vial of insulin, it must be dated immediately because the insulin is only good for 30 days after opening. Staff #34 inspected the box with two insulin belonging to resident #295, then stated, "It 's not a good practice to have two different insulin vials in a box." She stated she does not know if the Glargine belongs to the resident because the vial was not labeled with the resident's name. She stated regarding resident #295, the insulin had no open date, and was not the correct insulin for that box because the box was labeled Admelog. She stated there was a high risk of giving the wrong insulin if the insulin was not properly stored. She stated the risk for the resident includes, "It can tank their blood sugar, definitely would put a resident at a health risk." An interview was conducted with the director of nursing (DON/staff #20) on July 6, 2023 at 2:33 p.m. She stated her expectation in terms of insulin multi use vials is that they are dated after opening and labeled. She stated an open insulin vial is only good for 28 days or per manufacturing instruction. She stated the risk of not dating or labeling the insulin vials could include a potential adverse reaction to residents or the insulin could not be as effective. Review of the Centers for Disease Control and Prevention (CDC) guidelines, accessed on May 25, 2023 at 11:31 a.m., indicated that medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. The CDC guidelines further revealed that if a multi-dose vial has been opened or accessed (example, needle-puncture) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

§483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated when opened. The deficient practice could result in a potential for food borne illness. Findings include: A freezer observation on June 28, 2023 at 7:15 a.m. revealed vegetable patties and raw chicken not covered, labeled or dated. A refrigerator observation on June 28, 2023 at 7:20 a.m. revealed potatoes, lemons and oranges not labeled or dated. Additionally, 2 oranges were observed to exhibit a fuzzy, grayish substance on the outside of the orange. The discolored oranges were present in a box of oranges. The kitchen manager removed the two oranges and stated that she generally reviews refrigerator contents once a week after deliveries. A box of shredded carrots was observed to be stored in the refrigerator with a use-by date of June 24, 2023. The kitchen manager stated that these should have been removed but had been missed. An interview with the dietary supervisor, staff # 65 was conducted on June 28, 2023 at 12:40 p.m. Staff # 65 stated that she reviewed refrigerator and freezer content once a week and that the food items noted as not labeled, discolored and expired had been missed upon review. She stated that the risk factor to the residents could include a resident becoming ill. An interview with the administrator, staff # 115 was conducted on July 6, 2023 at 12:29 p.m. The administrator stated that the expectation was that all food was labeled and dated. The expectation was that no expired food was kept in the refrigerator and that no foods with negative outcomes, including discolored fruit were stored in the refrigerator. He stated that the risk was potentially adverse effects on residents and staff. A review of the food storage policy, with a review date of April 06, 2023 noted that all products should be inspected for safety and quality and be dated upon receipt, when open and when prepared.

Based on observations, staff interviews, and policy review, the facility failed to ensure the area around the dumpsters was free of refuse/garbage. The deficient practice could result in an unsanitary condition and the harborage of pests and insects. Findings include: An observation on June 29, 2023, revealed trash strewn in front and to the side of both outside dumpsters. Meatballs and what appeared to be mashed noodles were observed directly in front of the first dumpster, as well as to the side of the first dumpster. Small milk cartons and sausages were observed to the immediate left of the second dumpster. Staff # 65 identified the milk cartons as facility milk cartons utilized for residents. An interview with the dietary supervisor, staff # 65 was conducted on June 28, 2023 at 12:40 p.m. Staff # 65 stated she inspects the outside garbage containers at least daily and also relies on kitchen staff to report any adverse refuse conditions. An interview with the administrator, staff # 115 was conducted on June 6, 2023 at 12:29 p.m. He stated that the expectation was that the outside garbage containers remain free of refuse outside of the container and remain sanitary. He stated that the risk is potentially adverse effects on residents and staff. A review of the waste disposal policy with a review date of July, 2023 revealed that each waste container shall be cleaned as needed.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that medication was administered as ordered for one resident ( #140) and that a physician was notified. Findings include: Resident #140 was admitted on June 17, 2023 with diagnoses of sepsis and Clostridium difficile. A physician order dated June 16, 2023 included the following: -Levofloxacin (antibiotic), 500 mg (milligrams) intravenous one time a day for sepsis until June 20, 2023; -Meropenem (antibiotic), use 1 gram intravenous every 8 hours for sepsis until June 26, 2023; and, -Vancomycin HCl Oral Capsule (antibiotic), give 125 mg by mouth one time a day for C-diff prophylaxis until July 11, 2023. A care plan dated June 20, 2023 included that the resident was on antibiotic therapy including intravenous Meropenem and Levaquin and oral Vancomycin related to severe sepsis and Clostridium difficile prophylaxis. Interventions included to administer medication as ordered. A list of medications available in the emergency medication supply included Vancomycin HCl Oral Capsule 125 mg, Levofloxacin Intravenous Solution (antibiotic) 500 mg bag, Meropenem Intravenous Solution (antibiotic) 500mg bag. A discharge assessment Minimum Data Set (MDS) dated June 21,2023 included the resident had received 4 days of antibiotics of the last 7 days. However, the Medication Administration Record (MAR) for June 2023 revealed the following: -Vancomycin was not administered until June 17 which was 1 missed administration, the Meropenem was not administered until 1500 on June 18 which was 6 missed administrations, and the Levofloxin was not administered until June 19 which was 1 missed administration. Review of the clinical record did not find that the physician was informed regarding the missing medication administrations or that an attempt was made to access the emergency medication supply. An interview was conducted June 30, 2023 at 2:28 PM with a Licensed Practical Nurse (LPN/staff #67) who said if a resident's medication was not in the cart, the facility had an emergency medication supply that can be used. She said that if it's an antibiotic, they definitely don't want the resident to miss a dose. She stated that if the medication was not in the emergency medical supply kit then she would contact the provider to see if it was appropriate to use an available alternative medication or to change the order. She stated that she would document that in the progress notes. She further stated that nurses should never hesitate to contact the doctor or to check the emergency supply of medication. She stated in some situations, nurses can contact the pharmacy to put a rush on the order and get an expedited delivery on the medication if needed. An interview was conducted June 30, 2023 at 3:27 PM with the Director of Nursing (DON/staff #20). The DON stated that before a resident comes in the building, admission receives the orders which are then sent to the pharmacy. She stated that usually the pharmacy can get the authorization to allow the staff to pull from the emergency medication supply if needed. She stated that it does not meet her expectation that the physician was not notified regarding unavailable medications. She further that it was a standard practice that staff sign off on the medication administration record(MAR) and in this case,the staff did not sign the MAR. She stated that this also does not meet her expectation. This DON stated that if it's not signed off then it's assumed that it was not done. The facility policy Medication administration(reviewed 9/22) revealed that if medication is withheld, refused or given other than at the scheduled time the documentation be reflected in the clinical record.

Based on observations, clinical record review, staff interviews and facility policy, the facility failed to assist the resident in maintaining the highest practicable well being according to the comprehensive assessment by failing to ensure care, and services related to pressure ulcer was provided to one resident (#140) and failing to ensure appropriate treatment and services related to enteral feeding tube was provided to one resident (#19). Findings include: -Resident #140 was admitted on June 17, 2023 with diagnoses of a stage 4 pressure ulcer of right buttock, abdominal surgical dehiscence. A physician's order dated June 17, 2023 included cleanse sacral wound with normal saline and pat dry, pack with gauze soaked in Dakins Quarter strength 0.125% and cover with dressing every day shift. A wound assessment details report dated June 19, 2023 included that the sacrum wound was a stage 4 pressure ulcer measuring 2.5cm long x 4.00cm wide x 3cm deep. A wound assessment details report dated June 19, 2023 included that the right buttocks/ischium wound was a stage 4 pressure ulcer measuring 19 cm long x 17.00cm wide x 3cm deep. A physician's order dated June 19, 2023 included cleanse wound to right buttock and ischium with normal saline, pat dry, apply medihoney with alginate, secure with ABD and retention tape one time a day every Wednesday, Saturday and Sunday. A discharge assessment Minimum Data Set (MDS) dated June 21,2023 included that this resident was admitted with 1 stage 4 and 1 unstageable pressure ulcer. This assessment included that the resident required extensive to total assistance for most activities of daily living. A care plan dated June 21, 2023 included that the resident has pressure ulcers on the sacralcocyx and right ischium with intervention of administering treatments as ordered. However, a review of the Treatment Administration Record and Wound Team Administration Record for June, 2023 revealed the order for treatment of the sacral wound was not administered on June 17, 18 or 21 and the order for treatment of the right buttock and ischium was not administered on the 21. An interview was conducted June 30, 2023 at 1:36 PM with a wound Registered Nurse (RN/staff #133). She stated that when a resident was admitted she completes a full skin assessment and notes her findings. The RN also would put in orders at that time. She stated that if there are not orders in place, she would send the provider a picture and then put orders in the clinical record. She stated that she would use the orders to treat the resident. She stated that the floor nurses would do treatments on Wednesday and on the weekends and she would do the more extensive treatments including wound vacuums. She reviewed this resident's clinical record and stated that it does not appear that all the resident's treatments were completed as ordered. She further stated that a entry left blank on the treatment record would indicate that the treatment was not done. An interview was conducted June 30, 2023 at 3:27 PM with the Director of Nursing (DON/staff #20) who said that it is standard practice that the staff should sign off on medication administration record (MAR) and treatment administration record (TAR)and the staff did not sign off on several entries for this resident. She stated that it did not meet her expectations that the MAR and TAR are both completed. The DON stated that if it's not signed off, it was assumed that it was not done. A policy titled Wound Management (reviewed 5/2023)revealed that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing.The policy further stated that once a wound has been identified, assessed, and documented, nursing shall administertreatment to each affected area as per the Physician's order.

Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated when opened. Findings include: A freezer observation on June 28, 2023 at 7:15 a.m. revealed vegetable patties and raw chicken not covered, labeled or dated. A refrigerator observation on June 28, 2023 at 7:20 a.m. revealed potatoes, lemons and oranges not labeled or dated. Additionally, 2 oranges were observed to exhibit a fuzzy, grayish substance on the outside of the orange. The discolored oranges were present in a box of oranges. The kitchen manager removed the two oranges and stated that she generally reviews refrigerator contents once a week after deliveries. A box of shredded carrots was observed to be stored in the refrigerator with a use-by date of June 24, 2023. The kitchen manager stated that these should have been removed but had been missed. An interview with the dietary supervisor, staff # 65 was conducted on June 28, 2023 at 12:40 p.m. Staff # 65 stated that she reviewed refrigerator and freezer content once a week and that the food items noted as not labeled, discolored and expired had been missed upon review. She stated that the risk factor to the residents could include a resident becoming ill. An interview with the administrator, staff # 115 was conducted on July 6, 2023 at 12:29 p.m. The administrator stated that the expectation was that all food was labeled and dated. The expectation was that no expired food was kept in the refrigerator and that no foods with negative outcomes, including discolored fruit were stored in the refrigerator. He stated that the risk was potentially adverse effects on residents and staff. A review of the food storage policy, with a review date of April 06, 2023 noted that all products should be inspected for safety and quality and be dated upon receipt, when open and when prepared.

Based on observations, staff interviews, and policy review, the facility failed to ensure the area around the dumpsters was free of refuse/garbage. Findings include: An observation on June 29, 2023, revealed trash strewn in front and to the side of both outside dumpsters. Meatballs and what appeared to be mashed noodles were observed directly in front of the first dumpster, as well as to the side of the first dumpster. Small milk cartons and sausages were observed to the immediate left of the second dumpster. Staff # 65 identified the milk cartons as facility milk cartons utilized for residents. An interview with the dietary supervisor, staff # 65 was conducted on June 28, 2023 at 12:40 p.m. Staff # 65 stated she inspects the outside garbage containers at least daily and also relies on kitchen staff to report any adverse refuse conditions. An interview with the administrator, staff # 115 was conducted on June 6, 2023 at 12:29 p.m. He stated that the expectation was that the outside garbage containers remain free of refuse outside of the container and remain sanitary. He stated that the risk is potentially adverse effects on residents and staff. A review of the waste disposal policy with a review date of July, 2023 revealed that each waste container shall be cleaned as needed.