CHRISTIAN CARE NURSING CENTER

Based on clinical record review, staff interviews, facility documentation and policy review, the administrator failed to ensure that policies and procedures for physical health services and behavioral health services were established, documented and implemented relative to documentation of implementation of compression stockings for one resident #263. The deficient practice could result in residents not receiving treatment and care based on their needs. Findings Include: Resident #263 was admitted on January 18, 2020 with diagnosis including unspecified dementia, Alzheimer's disease and essential hypertension. The MDS (minimum data set) dated April 20, 2020 revealed a BIMS (brief interview for mental status) score of 4, suggesting severe cognitive impairment. The dashboard in the electronic health record revealed that resident #263 required one-person physical assistance with dressing. A review of the physician's orders dated January 28, 2020 included an order for compression stockings for edema. Review of the care plan initiated February 5, 2020 included that resident #263 was to have compression stockings applied in the morning and taken off at bed time. A review of the physician progress notes dated March 5, 2020 revealed that compression stockings (TED hose/thrombo-embolic deterrent) were in use for resident #263. However, on March 7, 2020 a new order was generated, due to the absence of compression stockings in the facility, to read "compression stockings or CE wraps" to be put on the morning and taken off at night. A review of the progress notes revealed an entry on March 7, 2020, noting a concern expressed by the son that resident #263 was not wearing TED hose. The note further indicated that the floor nurse checked the resident's room and was unable to locate the stockings and that no stockings were located in the supply room. A review of the TAR (Treatment Administration Record) for March 2020 revealed no evidence of a nurse initial or administration check-mark noting compression stocking application on the morning of March 1, 2020. A further review of the TAR revealed the following: -March 10, 2020: no evidence that compression stockings were applied. -March 11, 2020: no evidence that compression stockings were removed. -March 15, 2020: no evidence that compression stockings were applied. Additional review of the care plan further revealed that resident #263 had ADL (activities of daily living) self-care performance deficits due to confusion, dementia and impaired mobility. An interview was conducted on July 21, 2023 with staff #17 (LPN). Staff #17 stated that nurses check to ensure compression stockings are put on and taken off as ordered via visual confirmation. Staff #17 stated that there should always be an entry in the electronic health record indicating application or removal of compression stockings. When staff #17 was asked to review the record for resident #263, she stated that it appeared that no one signed off on March 1, 10, 11, and 15th. She stated that the risk of not wearing compression stockings, as ordered, could include the resident being at risk for an embolism. An interview was conducted on July 21, 2023 at 8:57 a.m. with the Director of Nursing (DON/staff #2) and MDS Nurse, (staff #41). Staff #2 stated that if there were blank signature areas in the MAR (medication administration record) or TAR, it indicated that the task was not completed. Both staff #2 and staff #41 reviewed the electronic health record for resident #263 and stated that based on the observation of the MAR/ TAR, the compression stockings were either not administered or taken off on March 1, 10, 11 and 15 of 2020. Staff #2 stated that the risk to the resident would be that the edema for resident #263 would not be addressed. A review of the Charting Documentation policy, revised date of February 4, 2022, included that treatments or services performed are to be documented in the resident's medical record and that documentation in the medical record will be objective, complete and accurate. The Provision of Physician Ordered Services policy, reviewed/revised February 4, 2022, included the purpose was to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. "Professional Standards of Quality" means that care and services are provided according to accepted standards of clinical practice.

Based on concerns identified during the survey, the narcotic log review, and staff interviews, administrator failed to ensure a plan was established, documented, and implemented for an ongoing quality management program that, at a minimum, included a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice could result in narcotic medications not being accurately accounted for. Findings include: A review of the narcotic logs was conducted on July 20, 2023 at 9:05 a.m. The review revealed that there were multiple missing signatures for the narcotic count log for the months of January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023. The total count of missing signatures was 139. The breakdown by month, revealed the following: January: north medication cart: missing 15 signatures January: south medication cart: missing 14 signatures February: north medication cart: missing 2 signatures February: south medication cart: missing 13 signatures March: north medication cart: missing 21 signatures March: south medication cart: missing 9 signatures April: north medication cart: missing 20 signatures April: south medication cart: missing 12 signatures May: north medication cart: missing 15 signatures May: south medication cart: missing 3 signatures June: north medication cart: missing 7 signatures June: south medication cart: missing 8 signatures An interview was conducted on July 20, 2023 at 1:18 p.m. with the Director of Nursing (DON/staff #2). The DON stated that the expectation for medication storage is that scheduled drugs are kept under lock and key and that storage locations are temperature controlled. She stated that the medication control logs are expected to be counted properly during at the beginning and end of each shift and at the same time every day. She stated that she had scheduled nursing shifts to overlap in an effort to facilitate the medication counts. She stated that missing signatures on the narcotic control logs did not meet her expectations. She stated that she had implemented an additional audit program on the 13th of July, 2023 and noted that 7 of the missing signatures for that month were registry nurses. An interview was conducted on July 20, 2023 at 1:29 p.m. with the Administrator (staff #106). She stated that QAPI meetings are held monthly; however with the relocation process occurring within the facility, meetings are now held every other month. She stated that an area identified by QAPI was the lack of consistent documentation for the narcotic log counts. Staff #106 stated that she knew at the beginning of the year that the narcotic logs were not being signed consistently and had created a PIP (performance improvement plan). She stated that she was focused on performance improvement and had put spot checks in place, but the staff member in charge of the spot checks had left as well as the previous DON. She stated that under the new DON, daily audits have been put in place effective July 13, 2023 and would continue for 4 weeks. She stated that the facility had also identified those registry nurses who are not following the medication count policy and reported them to the agency. The facility was addressing the issues with in-house nurses directly on an individual basis. The administrator stated that some of the tools utilized to correct and monitor identified issues included audits, observations and training. However, staff #106 stated that with changes in staffing and change in facility focus to include the relocation of residents, tracking the effectiveness of the PIP for the narcotic log documentation had not been consistent, which did not meet her expectations. She stated that the lack of review could impact the resolution of the identified concern.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to document treatment and care in accordance with professional standards of practice regarding implementation of compression stockings for one resident #263. The deficient practice could result in residents not receiving treatment and care based on their needs. Findings Include: Resident #263 was admitted on January 18, 2020 with diagnosis including unspecified dementia, Alzheimer's disease and essential hypertension. The MDS (minimum data set) dated April 20, 2020 revealed a BIMS (brief interview for mental status) score of 4, suggesting severe cognitive impairment. The dashboard in the electronic health record revealed that resident #263 required one-person physical assistance with dressing. A review of the physician's orders dated January 28, 2020 included an order for compression stockings for edema. Review of the care plan initiated February 5, 2020 included that resident #263 was to have compression stockings applied in the morning and taken off at bed time. A review of the physician progress notes dated March 5, 2020 revealed that compression stockings (TED hose/thrombo-embolic deterrent) were in use for resident #263. However, on March 7, 2020 a new order was generated, due to the absence of compression stockings in the facility, to read "compression stockings or CE wraps" to be put on the morning and taken off at night. A review of the progress notes revealed an entry on March 7, 2020, noting a concern expressed by the son that resident #263 was not wearing TED hose. The note further indicated that the floor nurse checked the resident's room and was unable to locate the stockings and that no stockings were located in the supply room. A review of the TAR (Treatment Administration Record) for March 2020 revealed no evidence of a nurse initial or administration check-mark noting compression stocking application on the morning of March 1, 2020. A further review of the TAR revealed the following: -March 10, 2020: no evidence that compression stockings were applied. -March 11, 2020: no evidence that compression stockings were removed. -March 15, 2020: no evidence that compression stockings were applied. Additional review of the care plan further revealed that resident #263 had ADL (activities of daily living) self-care performance deficits due to confusion, dementia and impaired mobility. An interview was conducted on July 21, 2023 with staff #17 (LPN). Staff #17 stated that nurses check to ensure compression stockings are put on and taken off as ordered via visual confirmation. Staff #17 stated that there should always be an entry in the electronic health record indicating application or removal of compression stockings. When staff #17 was asked to review the record for resident #263, she stated that it appeared that no one signed off on March 1, 10, 11, and 15th. She stated that the risk of not wearing compression stockings, as ordered, could include the resident being at risk for an embolism. An interview was conducted on July 21, 2023 at 8:57 a.m. with the Director of Nursing (DON/staff #2) and MDS Nurse, (staff #41). Staff #2 stated that if there were blank signature areas in the MAR (medication administration record) or TAR, it indicated that the task was not completed. Both staff #2 and staff #41 reviewed the electronic health record for resident #263 and stated that based on the observation of the MAR/ TAR, the compression stockings were either not administered or taken off on March 1, 10, 11 and 15 of 2020. Staff #2 stated that the risk to the resident would be that the edema for resident #263 would not be addressed. A review of the Charting Documentation policy, revised date of February 4, 2022, included that treatments or services performed are to be documented in the resident's medical record and that documentation in the medical record will be objective, complete and accurate. The Provision of Physician Ordered Services policy, reviewed/revised February 4, 2022, included the purpose was to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. "Professional Standards of Quality" means that care and services are provided according to accepted standards of clinical practice.

Based on observations, clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that the resident environment remained free of accident hazards, by failing to ensure that a shower chair was inspected for safety before use, and that one resident received appropriate transfer assistance (#113). The deficient practice increased the risk for preventable accidents. Findings include: Resident #113 was admitted on October 21, 2022, with diagnoses that included wedge compression fracture of vertebra, fracture of shaft of right arm humerus, difficulty walking and muscle weakness. Review of the admission MDS (minimum data set) dated October 25, 2022 revealed a BIMS (brief interview of mental status) score of 9, indicating moderate cognitive impairment. The assessment revealed that resident required extensive two-plus person physical assistance with transfers. A nurse's notes dated October 27, 2022 at 2:36 p.m. revealed while resident #113 was being transferred from wheelchair to bed the resident began slipping off the side of the bed. Further, the notes revealed the staff noticed the resident was bleeding and discovered a large laceration approximately 12 millimeters long to the right lower extremity. The notes indicated that the resident had edema on both lower extremities and fragile skin. Per the nursing notes, the resident was sent out to an acute care hospital for further evaluation. A physician order written on October 31, 2022 revealed the following order: -Clean right lower extremity laceration with wound cleanser, pat dry, apply Xeroform dressing and wrap with kerlix every other day for laceration. Review of the facility's 5-day investigation report submitted to the State Agency on November 1, 2022 at 9:45 a.m. included the following narrative notes: [The] resident was sitting up in a shower chair following the shower. [A] CNA (certified nursing assistant) performed a transfer from shower to bed. During transfer, the resident was unable to fully sustain her weight. After transfer, the resident was sitting on the mattress but not fully. The CNA called for lifting assistance. When the CNAs looked down, the resident had a skin tear on her right lower leg. Resident was found to have a large leg laceration to the right leg that was not able to be steri-stripped. Further record review revealed the resident was transferred from the shower chair to the bed and that her right lower leg was caught on the shower chair which had protruding capped bolts causing her right leg to rub and the skin to tear. However, record review revealed the resident was transferred only by one CNA from shower chair to bed, and there was no evidence of the shower chair examination prior to use. Review of a care plan problem that was initiated on November 17, 2022 revealed the resident has a skin tear on right lateral lower extremity due to injury during transfer. The interventions included using caution during transfers to prevent striking arms, legs, and hands against any sharp or hard surface. An interview was conducted on July 21, 2023 at 10:29 a.m. with certified nursing assistant (CNA/staff #11). She stated that she gets reports from another CNA she is relieving, and that the report would include how many staff's assistance is needed for transferring the residents under her care. She stated that if a resident required two-person physical assistance for transfers, she could use a mechanical lift or she would ask another CNA or a charge nurse for help. She stated that the same process applies for a resident requiring two-person assistance when transferring from shower chair to bed. An interview was conducted on July 21, 2023 at 10:42 a.m. with a licensed practical nurse (LPN/ staff #17). She said when CNAs arrive to work on the floor, she gives them a report including whether a resident is independent or total care. She stated for residents who required extensive assistance of two-persons, the CNA would call her to help with transfer with the use of gait belts which are located in all resident rooms. Following the interview at 10:57 a.m., staff #17 inspected the shower chair located in the resident's room. She touched the two large knobs located in the front of the shower chair and she immediately pulled back her hand. She stated the knobs were sharp and could cut the skin, especially if the skin was frail. An interview was conducted with the executive director (ED/ staff #6) on July 21, 2023 at 11:13 a.m. She stated that it was her expectation that all DME (durable medical equipment), including shower chairs, must be examined by the maintenance or staff for safety prior to use. Following the interview with staff #6 at 11:22 a.m., she walked into the resident's room and examined the shower chair. She immediately removed the shower chair from the resident's room after touching the knobs located on the front of the shower chair. She stated that the facility owned the shower chair and that the knobs located on the front of the chair, located where the resident's legs would be resting, were sharp. The facility policy, Provision of Quality Care, revised on February 4, 2022 included that each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

§483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

-A review of the narcotic logs was conducted on July 20, 2023 at 9:05 a.m. The review revealed that there were multiple missing signatures for the narcotic count log for the months of January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023. The total count of missing signatures was 139. The breakdown by month, revealed the following: January: north medication cart: missing 15 signatures January: south medication cart: missing 14 signatures February: north medication cart: missing 2 signatures February: south medication cart: missing 13 signatures March: north medication cart: missing 21 signatures March: south medication cart: missing 9 signatures April: north medication cart: missing 20 signatures April: south medication cart: missing 12 signatures May: north medication cart: missing 15 signatures May: south medication cart: missing 3 signatures June: north medication cart: missing 7 signatures June: south medication cart: missing 8 signatures An observation of the medication storage room on July 20, 2023 at 9:21 a.m. was conducted with a Licensed Practical Nurse (LPN/staff #105) revealed no narcotics housed in the medication storage room. Staff #105 stated all narcotics are currently on the medication cart. She stated that as the resident census was so low, that there was only a north medication cart at that time, as there was no longer a need for a south medication cart. An observation of the north medication cart conducted on July 20, 2023 at 9:30 a.m. with an LPN (staff #105) revealed a total of 8 controlled medication cards present, which were reviewed and the counts were confirmed. Staff #105 stated that when medication counts are conducted that one nurse would count the medications, while another nurse would log the count. She stated that medication counts must be conducted every shift, per policy, and must always be signed off on the medication log. An interview was conducted on July 20, 2023 at 1:18 p.m. with the Director of Nursing (DON/staff #2). The DON stated that the expectation for medication storage is that scheduled drugs are kept under lock and key and that storage locations are temperature controlled. She stated that the medication control logs are expected to be counted properly at the beginning and end of each shift, and at the same time every day. She stated that she had scheduled nursing shifts to overlap in an effort to facilitate the medication counts. She stated that missing signatures on the narcotic control logs did not meet her expectations. She stated that she had implemented an additional audit program on the 13th of July, 2023 and noted that 7 of the missing signatures for that month were registry nurses. An interview was conducted on July 20, 2023 at 1:29 p.m. with the administrator (staff #106). She stated that she knew at the beginning of the year that logs were not being signed consistently. She stated that she was focused on performance improvement and had put spot checks in place, but the staff member in charge of the spot checks had left as well as the previous DON. She stated that under the new DON, daily audits have been put into place, since July 13, 2023 and would continue for 4 weeks. She stated that the facility had also identified those registry nurses who are not following the medication count policy and reported them to the agency. The facility was addressing the issues with in-house nurses directly on an individual basis. The administrator stated that if the medication counts and subsequent signatures on the log are not occurring then it was not meeting her expectations. She stated that the risk was that narcotics could be diverted and patient care could be affected. A review of the Medication Storage policy with revise date of February 4, 2023 included that staff must resolve discrepancies and report any discrepancies that cannot be resolved immediately. It further stated staff may not leave the area until discrepancies are resolved. A Controlled Substances policy with a revise date of February 2, 2023 included that nursing staff must count controlled medications at the end of each shift and that the nurse coming on duty in conjunction with the nurse going off duty must make the count together. It further revealed that nursing staff must document and report any discrepancies to the director of nursing services.

§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, interviews, and record review, the facility failed to ensure that food was properly stored, labeled and dated sanitary conditions. The census was 9. The deficient practice could result in residents acquiring a foodborne illness. Findings include: During a brief kitchen inspection conducted on July 17, 2023 at 8:29 a.m. with the Food Service Director (staff #7), the following were identified in the refrigerator and freezer: -Sweet Street Chocolate Peanut Butter Pie with a received date of 4/12/23, was notably exposed to air and had no use by date. -Brand Villa Frizzoni pepperoni slices was open and exposed to air, with no use by date. -1 large box of blueberries with received date of 2/24/23 was open and exposed to air and did not include an open or use by date. The blueberries were withered and wrinkled in appearance. -Oatmeal Raisin English Bay cookies dated 5/12/23 had no open or use by date. -1 large pepperoni pizza opened and exposed to air, with no open or use by date. -Cooked Meatloaf sealed in aluminum foil dated 6/17/23. -Great Value Vanilla and Chocolate Containers of ice cream with no open or use by date. -6 large fresh zucchini were noted with mold, and appeared soft and wrinkled. -Macaroni salad 3-pound container with no open or use by dates, was open and exposed to air. An interview was conducted with the Food Service Director (staff #7) during the inspection. He stated that the food products should be dated with opened and use by dates. He stated that there could be possible contamination or spoilage of the oatmeal cookies. Staff #7 stated that the meatloaf was left over and expired from a previous meal and should have been tossed. He stated that the Activities Department should not be storing food items (ice cream) without permission or his knowledge. Review of the facility policy titled Food Storage included that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.

§483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: §483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. §483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators. §483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation. §483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events. §483.75(d) Program systematic analysis and systemic action. §483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. §483.75(d)(2) The facility will develop and implement policies addressing: (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (ii) How they will develop corrective actions that will be designed to effect chang

Based on concerns identified during the survey, the narcotic log review, and staff interviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to implement and review an appropriate plan of action to correct the deficiency of incomplete narcotic count documentation. The deficient practice could result in narcotic medications not being accurately accounted for. Findings include: A review of the narcotic logs was conducted on July 20, 2023 at 9:05 a.m. The review revealed that there were multiple missing signatures for the narcotic count log for the months of January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023. The total count of missing signatures was 139. The breakdown by month, revealed the following: January: north medication cart: missing 15 signatures January: south medication cart: missing 14 signatures February: north medication cart: missing 2 signatures February: south medication cart: missing 13 signatures March: north medication cart: missing 21 signatures March: south medication cart: missing 9 signatures April: north medication cart: missing 20 signatures April: south medication cart: missing 12 signatures May: north medication cart: missing 15 signatures May: south medication cart: missing 3 signatures June: north medication cart: missing 7 signatures June: south medication cart: missing 8 signatures An interview was conducted on July 20, 2023 at 1:18 p.m. with the Director of Nursing (DON/staff #2). The DON stated that the expectation for medication storage is that scheduled drugs are kept under lock and key and that storage locations are temperature controlled. She stated that the medication control logs are expected to be counted properly during at the beginning and end of each shift and at the same time every day. She stated that she had scheduled nursing shifts to overlap in an effort to facilitate the medication counts. She stated that missing signatures on the narcotic control logs did not meet her expectations. She stated that she had implemented an additional audit program on the 13th of July, 2023 and noted that 7 of the missing signatures for that month were registry nurses. An interview was conducted on July 20, 2023 at 1:29 p.m. with the Administrator (staff #106). She stated that QAPI meetings are held monthly; however with the relocation process occurring within the facility, meetings are now held every other month. She stated that an area identified by QAPI was the lack of consistent documentation for the narcotic log counts. Staff #106 stated that she knew at the beginning of the year that the narcotic logs were not being signed consistently and had created a PIP (performance improvement plan). She stated that she was focused on performance improvement and had put spot checks in place, but the staff member in charge of the spot checks had left as well as the previous DON. She stated that under the new DON, daily audits have been put in place effective July 13, 2023 and would continue for 4 weeks. She stated that the facility had also identified those registry nurses who are not following the medication count policy and reported them to the agency. The facility was addressing the issues with in-house nurses directly on an individual basis. The administrator stated that some of the tools utilized to correct and monitor identified issues included audits, observations and training. However, staff #106 stated that with changes in staffing and change in facility focus to include the relocation of residents, tracking the effectiveness of the PIP for the narcotic log documentation had not been consistent, which did not meet her expectations. She stated that the lack of review could impact the resolution of the identified concern.

-A review of the narcotic logs was conducted on July 20, 2023 at 9:05 a.m. The review revealed that there were multiple missing signatures for the narcotic count log for the months of January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023. The total count of missing signatures was 139. The breakdown by month, revealed the following: January: north medication cart: missing 15 signatures January: south medication cart: missing 14 signatures February: north medication cart: missing 2 signatures February: south medication cart: missing 13 signatures March: north medication cart: missing 21 signatures March: south medication cart: missing 9 signatures April: north medication cart: missing 20 signatures April: south medication cart: missing 12 signatures May: north medication cart: missing 15 signatures May: south medication cart: missing 3 signatures June: north medication cart: missing 7 signatures June: south medication cart: missing 8 signatures An observation of the medication storage room on July 20, 2023 at 9:21 a.m. was conducted with a Licensed Practical Nurse (LPN/staff #105) revealed no narcotics housed in the medication storage room. Staff #105 stated all narcotics are currently on the medication cart. She stated that as the resident census was so low, that there was only a north medication cart at that time, as there was no longer a need for a south medication cart. An observation of the north medication cart conducted on July 20, 2023 at 9:30 a.m. with an LPN (staff #105) revealed a total of 8 controlled medication cards present, which were reviewed and the counts were confirmed. Staff #105 stated that when medication counts are conducted that one nurse would count the medications, while another nurse would log the count. She stated that medication counts must be conducted every shift, per policy, and must always be signed off on the medication log. An interview was conducted on July 20, 2023 at 1:18 p.m. with the Director of Nursing (DON/staff #2). The DON stated that the expectation for medication storage is that scheduled drugs are kept under lock and key and that storage locations are temperature controlled. She stated that the medication control logs are expected to be counted properly at the beginning and end of each shift, and at the same time every day. She stated that she had scheduled nursing shifts to overlap in an effort to facilitate the medication counts. She stated that missing signatures on the narcotic control logs did not meet her expectations. She stated that she had implemented an additional audit program on the 13th of July, 2023 and noted that 7 of the missing signatures for that month were registry nurses. An interview was conducted on July 20, 2023 at 1:29 p.m. with the administrator (staff #106). She stated that she knew at the beginning of the year that logs were not being signed consistently. She stated that she was focused on performance improvement and had put spot checks in place, but the staff member in charge of the spot checks had left as well as the previous DON. She stated that under the new DON, daily audits have been put into place, since July 13, 2023 and would continue for 4 weeks. She stated that the facility had also identified those registry nurses who are not following the medication count policy and reported them to the agency. The facility was addressing the issues with in-house nurses directly on an individual basis. The administrator stated that if the medication counts and subsequent signatures on the log are not occurring then it was not meeting her expectations. She stated that the risk was that narcotics could be diverted and patient care could be affected. A review of the Medication Storage policy with revise date of February 4, 2023 included that staff must resolve discrepancies and report any discrepancies that cannot be resolved immediately. It further stated staff may not leave the area until discrepancies are resolved. A Controlled Substances policy with a revise date of February 2, 2023 included that nursing staff must count controlled medications at the end of each shift and that the nurse coming on duty in conjunction with the nurse going off duty must make the count together. It further revealed that nursing staff must document and report any discrepancies to the director of nursing services.

Based on observations, interviews, and record review, the administrator failed to ensure that the nursing care institution is able to store, refrigerate, and reheat food to meet the dietary needs of the residents. The census was 9. The deficient practice could result in residents acquiring a foodborne illness. Findings include: During a brief kitchen inspection conducted on July 17, 2023 at 8:29 a.m. with the Food Service Director (staff #7) the following were identified in the refrigerator and freezer: -Sweet Street Chocolate Peanut Butter Pie with a received date of 4/12/23, was notably exposed to air and had no use by date. -Brand Villa Frizzoni pepperoni slices was open and exposed to air, with no use by date. -1 large box of blueberries with received date of 2/24/23 was open and exposed to air and did not include an open or use by date. The blueberries were withered and wrinkled in appearance. -Oatmeal Raisin English Bay cookies dated 5/12/23 had no open or use by date. -1 large pepperoni pizza opened and exposed to air, with no open or use by date. -Cooked Meatloaf sealed in aluminum foil dated 6/17/23. -Great Value Vanilla and Chocolate Containers of ice cream with no open or use by date. -6 large fresh zucchini were noted with mold, and appeared soft and wrinkled. -Macaroni salad 3-pound container with no open or use by dates, was open and exposed to air. An interview was conducted with the Food Service Director (staff #7) during the inspection. He stated that the food products should be dated with opened and use by dates. He stated that there could be possible contamination or spoilage of the oatmeal cookies. Staff #7 stated that the meatloaf was left over and expired from a previous meal and should have been tossed. He stated that the Activities Department should not be storing food items (ice cream) without permission or his knowledge. Review of the facility policy titled Food Storage included that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.

Based on observations, clinical record reviews, staff interviews, facility documentation and policy and procedures, the administrator failed to ensure that the nursing care institution's premises and equipmtent were free from a condition or situation that may cause a resident or an individual to suffer physical injury, related to shower chair safety and appropriate transfer assistance for one resident (#113). The deficient practice increased the risk for preventable accidents. Findings include: Resident #113 was admitted on October 21, 2022, with diagnoses that included wedge compression fracture of vertebra, fracture of shaft of right arm humerus, difficulty walking and muscle weakness. Review of the admission MDS (minimum data set) dated October 25, 2022 revealed a BIMS (brief interview of mental status) score of 9, indicating moderate cognitive impairment. The assessment revealed that resident required extensive two-plus person physical assistance with transfers. A nurse's notes dated October 27, 2022 at 2:36 p.m. revealed while resident #113 was being transferred from wheelchair to bed the resident began slipping off the side of the bed. Further, the notes revealed the staff noticed the resident was bleeding and discovered a large laceration approximately 12 millimeters long to the right lower extremity. The notes indicated that the resident had edema on both lower extremities and fragile skin. Per the nursing notes, the resident was sent out to an acute care hospital for further evaluation. A physician order written on October 31, 2022 revealed the following order: -Clean right lower extremity laceration with wound cleanser, pat dry, apply Xeroform dressing and wrap with kerlix every other day for laceration. Review of the facility's 5-day investigation report submitted to the State Agency on November 1, 2022 at 9:45 a.m. included the following narrative notes: [The] resident was sitting up in a shower chair following the shower. [A] CNA (certified nursing assistant) performed a transfer from shower to bed. During transfer, the resident was unable to fully sustain her weight. After transfer, the resident was sitting on the mattress but not fully. The CNA called for lifting assistance. When the CNAs looked down, the resident had a skin tear on her right lower leg. Resident was found to have a large leg laceration to the right leg that was not able to be steri-stripped. Further record review revealed the resident was transferred from the shower chair to the bed and that her right lower leg was caught on the shower chair which had protruding capped bolts causing her right leg to rub and the skin to tear. However, record review revealed the resident was transferred only by one CNA from shower chair to bed, and there was no evidence of the shower chair examination prior to use. Review of a care plan problem that was initiated on November 17, 2022 revealed the resident has a skin tear on right lateral lower extremity due to injury during transfer. The interventions included using caution during transfers to prevent striking arms, legs, and hands against any sharp or hard surface. An interview was conducted on July 21, 2023 at 10:29 a.m. with certified nursing assistant (CNA/staff #11). She stated that she gets reports from another CNA she is relieving, and that the report would include how many staff's assistance is needed for transferring the residents under her care. She stated that if a resident required two-person physical assistance for transfers, she could use a mechanical lift or she would ask another CNA or a charge nurse for help. She stated that the same process applies for a resident requiring two-person assistance when transferring from shower chair to bed. An interview was conducted on July 21, 2023 at 10:42 a.m. with a licensed practical nurse (LPN/ staff #17). She said when CNAs arrive to work on the floor, she gives them a report including whether a resident is independent or total care. She stated for residents who required extensive assistance of two-persons, the CNA would call her to help with transfer with the use of gait belts which are located in all resident rooms. Following the interview at 10:57 a.m., staff #17 inspected the shower chair located in the resident's room. She touched the two large knobs located in the front of the shower chair and she immediately pulled back her hand. She stated the knobs were sharp and could cut the skin, especially if the skin was frail. An interview was conducted with the executive director (ED/ staff #6) on July 21, 2023 at 11:13 a.m. She stated that it was her expectation that all DME (durable medical equipment), including shower chairs, must be examined by the maintenance or staff for safety prior to use. Following the interview with staff #6 at 11:22 a.m., she walked into the resident's room and examined the shower chair. She immediately removed the shower chair from the resident's room after touching the knobs located on the front of the shower chair. She stated that the facility owned the shower chair and that the knobs located on the front of the chair, located where the resident's legs would be resting, were sharp. The facility policy, Provision of Quality Care, revised on February 4, 2022 included that each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.