Christian Care Nursing Center

Based on observations the facility failed to provide adequate fire protection and separation between the skilled nursing center and assisted living facility. Failing to have properly rated systems in the facility could harm patients and staff during a fire emergency.

NFPA 101 2012 Edition. 19.1.3 Multiple Occupancies. 19.1.3.3 Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: 1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation. 2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7

Findings include:

Observations made during the facility tour on September 10, 2024, revealed that the facility failed to provide adequate fire protection and separation between the skilled nursing center and the assisted living facility in the following areas:

1) An examination of doors and the area above the doors at the northwest junction where the skilled nursing and assisted living meet, there is no firewall. The doors did not have the required two-hour fire rating.
2) An examination of doors and the area above the doors at the northeast junction around the administration area there is no firewall. The doors did not have the required two-hour rating.

The management team confirmed during the facility tour and exit conference on September 10, 2024, that there is not adequate fire protection and separation between the skilled nursing center and the assisted living facility.

Based on observations and interviews, the facility failed to provide automatic sprinkler protection for the roof overhang at the entrance to the Skilled Nursing Center on the east side of the facility. This overhang is over four feet in width. Failing to provide automatic sprinklers to all areas of the facility could cause harm to residents and/or staff in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater."
(1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13, Section 8.15.7

Exterior roofs, Canopies, Porte-Cochers, Balconies, Decks or Similar Projections. Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3 , or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies,Porte-cocheres, balconies decks, or similar projections exceeding 4 ft in width.

Findings include:

Observations made while on tour on September 10, 2024, revealed that the roof overhang at the entrance to the Skilled Nursing Center on the east side of the building was not sprinklered. The overhang was greater than four feet in width and appeared to be constructed on combustible materials.

Management staff confirmed during the facility tour and exit conference on September 10, 2024, that the roof overhang at the entrance to the Skilled Nursing Center on the east side of the building was not sprinklered.

Based on observation it was determined the facility failed to properly fill penetrations in multiple areas of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made during a facility tour conducted on September 10, 2024, revealed that the facility failed to maintain the fire/ smoke barrier in the following areas:

1) Several wall patches have been made in the laundry room using drywall to cover the holes. These patches were not sealed.
2) There was a hole in the firewall above the doorway leading into the kitchen.

The management team confirmed the fire/smoke wall penetrations during the facility tour and the exit conference on September 10, 2024.

Based on record review and interviews with staff, it was determined that the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protectives." Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could harm patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

Findings include:

During a review of the facility's records on September 10, 2024, the following deficiencies were noted:

1. The facility did not have written records for the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standards for Fire Doors and Other Opening Protectives.

Facility management confirmed during the exit conference on September 10, 2024, that the facility failed to have documentation of annual door inspections.

Based on interview and document review the facility failed to conduct, maintain, and document electrical receptacle testing in patient care areas specifically in the patient care rooms throughout the facility. Failing to test the receptacles could lead to an ignition hazard in a patient care area resulting in fire and/or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction. NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Findings include:

Observations made as well as interviews and records review conducted on September 10, 2024, revealed the facility failed to provide documentation on the annual receptacle testing in the patient care areas.

Management staff acknowledged during the exit conference on September 10, 2024, that receptacle testing in the patient care areas was not being performed.

Based on personnel record review, staff interviews, and facility policy review, the facility failed to ensure that one of ten sampled staff (#7) was compliant with the fingerprint requirement. The deficient practice could result in inadequate background checks and/or potential danger to residents.

Findings include:

Review of personnel records for Housekeeping staff (#7) revealed hire date of June 6, 2024. The prior fingerprint clearance card application completed by staff #7 on September 22, 2023 for previous employer was rejected.

Continued review of the clinical record revealed that staff #7 submitted another fingerprint application on July 10, 2024 that was also rejected on July 16, 2024. The employee record revealed that staff #7 submitted a completed Good Cause Exemption Form and notarized on August 08, 2024; however, staff #7 had not been notified of hearing date for a decision for her fingerprint card application.

Further review of the personnel file revealed that staff #7 did not have a valid fingerprint clearance card while working at the facility.

Review of employee punch detail revealed that the staff #7 worked as housekeeping at the facility from June 12, 2024 through August 26, 2024.

An interview was conducted with Human Resource Coordinator (HR Coordinator/staff #25) on August 27, 2024 at 3:22 p.m. The HR coordinator stated that newly hired staff had 60 days to get fingerprint clearance card from the date of hire; and, staff #7 had been working approximately 65 days at the facility.

On August 28, 2024 at 4:21 p.m., an interview was conducted with the Director of Nursing (DON/Staff #20) who stated that the risk of staff not having fingerprint clearance could result in a risk to the residents. Further, the DON stated that staff were expected to complete and should have a fingerprint clearance card within 60 days of DPS (Department of Public safety) approval.

The facility policy titled, Fingerprint Clearance Cards revised on April 16, 2024 included a purpose to outline procedures and standards to ensure all employees who are providing direct care to the residents are in compliance with established Fingerprint Clearance Card regulations. It also included that staff will be fingerprinted at the time of hire and again it reprint requested. Within 60 days of the date of employee fingerprinting or reprinting DPS approval required. If not approved within 60 days, employee is suspended unless they provide confirmation that their application is in process or review with DPS. This confirmation must have a current date and be provided every 30 days to avoid suspension. If confirmation of application in process or review is not received and the employee is suspended, they have 30 days to resolve or employment terminated.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that there were no expired food items readily available for resident use in the dining room refrigerator.

Findings include:

On August 26, 2024 at 10:02 a.m. an interview was conducted with the administrator (staff #10)who stated that the kitchen had not been in-use since December 2023; and that, food was brought from the neighboring assisted living facility which was considered their satellite kitchen. The administrator stated that whenever drinks or snacks were requested outside of regular meal times, the items in the dining room refrigerator were available to the residents. An observation of the refrigerator located in the dining room was conducted administrator immediately following the interview. There were five cartons of orange juice with expiration date of August 23, 2024 found inside the refrigerator. In the cabinet beside the refrigerator were twelve peanut butter sandwich crackers without any expiration date on packaging or any dates that would indicate if the crackers were old or newly opened or used by dates. The administrator stated that the dietary aides had not removed the expired juices; and that, the peanut butter sandwich cracker snacks had no used by dates. Further, the administrator said that there was a risk of residents becoming ill if they eat or drink expired items; having expired food items readily available for resident use did not meet the facility's expectations.

Review of the facility's Policy titled, "Food Storage" (revised July 21, 2022) revealed all foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

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.

-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 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.

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.