Ohio Valley Health Care

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Based on observation and staff interview, the facility failed to maintain a safe and accident free environment as possible regarding the disposal of razors. This was a random opportunity for discovery and had the potential to affect no more than an isolated number of residents. Resident Identifier: #43. Facility Census: 42.
Findings included:
a) Resident #43
On 08/25/24 at 10:55 AM, an observation was made of two (2) used disposable razors laying in the soap dish in the shower in Resident #43's bathroom.
On 08/25/24 at 10:58 AM, Nurse Aide (NA) # 35 was notified. NA #35 stated, let me get rid of those.
On 08/25/24 at 11:16 AM, the Administrator was notified and confirmed the two (2) used disposable razors should not be left in the shower.

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Based on record review and staff interview, the facility failed to ensure annual performance reviews were completed for nursing staff. This was true for four (4) of five (5) staff members reviewed under the care area of sufficient and competent nurse staffing. Facility Census: 42.
Findings Include:
a) Annual Performance Reviews
On 08/27/24 at 3:00 PM, a review of the staff employment files was completed. The review found the annual performance evaluations were not completed for the following nurse aides (NAs):
-NA #71
-NA #50
-NA #72
-NA #14
On 08/28/24 at approximately 9:45 AM, the Administrator was notified of the missing evaluations. The Administrator stated, we will be working on this.

Based on record review and staff interview, the facility failed to monitor behaviors and/or side effects for residents prescribed psychotropic medications. This was true for three (3) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifiers: #43, #21 and #5. Facility Census: 42.
Findings Include:
a) Resident #43
On 08/27/24 at 12:35 PM, a record review was completed for Resident #43. The review found the resident had three psychiatric diagnoses; Unspecified Dementia, Bipolar Disorder and Depression. The resident was prescribed Risperdal (antipsychotic medication) 2mg (milligram) daily for bipolar disorder. The review also, found no documentation regarding the monitoring of behaviors for the resident who was receiving an antipsychotic medication.
On 08/27/24 at 2:00 PM, the Director of Nursing (DON) was interviewed regarding the monitoring of behaviors. The DON stated, I don't have any documentation for behavior monitoring .I added it.
b) Resident #21
A review of Resident #21's medical record found they were prescribed Celexa, an antidepressant medication , Wellbutrin an antidepressant medication and Zyprexa an antipsychotic medication.
The medical record was void of any behavior monitoring related to the use psychotropic medications for Resident #21.
In an interview with the Director of Nursing (DON) on 08/27/24 at 2:30 PM, she confirmed they have not been monitoring for behaviors for Resident #21.
c) Resident #5
A review of Resident #5's medical record on 08/27/24 at 2:15 PM revealed, Trazodone was prescribed for an improper diagnosis of G47.00 : Insomnia, unspecified. There was no documentation of monitoring for side effects associated with this psychotropic medication. The medical record was also void of any behavioral monitoring related to the use of trazadone.
On 08/27/24 at 2:15 PM, the Director of Nursing (DON) was notified of the issue. Upon their return at approximately 2:30 PM, the DON acknowledged the facility did not monitor for side-effects or behaviors related to the use of trazadone.

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Based on record review, resident interview and staff interview, the facility failed to ensure resident safety for medication administration. Resident Identifiers: #3 and #13. Facility Census: 42.
The state agency notified the Nursing Home Administrator of the immediate jeopardy at 4:30 PM on 08/26/24. The facility submitted a plan of correction (POC) at 6:09 PM. At 6:25 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 10:15 AM on 08/27/24.
Findings Include:
a) On 08/25/24 at approximately 11:25 AM, the resident was interviewed regarding receiving the wrong medication on 07/01/24. Resident #3 responded, I don't even know what medication I take, there is probably eight (8) or nine (9) of them.
On 08/26/24 at 11:30 AM, a review of the facility's reportables regarding medication errors was completed. The review found two (2) events occurred for two (2) different residents on 07/01/24 and 08/20/24. Resident #3 was administered the following medications in error: Norco 7.5/325mg (opiate for pain), Xanax 0.25mg (anti-anxiety) and Metoprolol 37.5mg (hypertension). Resident #13 was administered Lyrica 150mg (anticonvulsant used for pain control). Neither Resident #3 nor Resident #13 were ordered the medications that were administered.
On 08/26/24 at 11:50 AM, the Director of Nursing (DON) was interviewed regarding these events. The DON stated, The first event was a seasoned nurse, Registered Nurse (RN) #85 .the second event was LPN #94, who was on orientation with LPN #105.
The DON stated, There really isn't an excuse for the mistake RN #85 made, and the reason the event happened with LPN #94 is the seasoned nurse (LPN #105) was not with LPN #94 when the medication was administered.
On 08/26/24 at 12:20 PM, the DON stated, a disciplinary write-up and re-education regarding the rights of medication administration was provided to RN #85, at which time, the same education was provided to all nurses. LPN #94 was re-educated regarding the rights of medication administration as well.
On 08/26/24 at 2:00 PM, the sign-in sheets dated for 07/05/24 and 07/23/24 were reviewed. Of the 25 nurses employed by the facility, only 18 signed the acknowledgement sheets of attendance.
On 08/26/24 at 3:30 PM, Resident #13 was interviewed regarding the medication error. The resident stated, I knew something was wrong when they told me about taking my vitals all night. The nurse was scared, and she told me she was sorry for giving the wrong medication .I was afraid of what might happen to me .this has never happened
before.
The state agency notified the Nursing Home Administrator of the immediate jeopardy at 4:30 PM on 08/26/24. The facility submitted a plan of correction (POC) at 6:09 PM. At 6:25 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 10:15 AM on 08/27/24.
b) Facility's Plan of Correction
IJ Abatement Plan
1. Resident #3 and Resident #13 were assessed by the Assistant Director of Nursing (ADON) on 8/26/2024 for any further possible adverse outcomes from the medication administration errors that occurred 07/01/24 and 08/20/24.
Med Pass observation to be completed by the ADON/ Designee on all current license nurses working this shift beginning on 8/26/24 at 5:30pm. Licensed nurses not available during this timeframe will be completed on their next scheduled shift.
2. All current residents of the facility have the potential to be affected.
3. The Director of Nursing (DON) will immediately initiate re-education beginning on 8/26/24 at 5:15pm to all licensed nurses that are working and prior to his/her next scheduled shift regarding medication administration process to include the 6 rights of administration to be completed by 9/5/2024. Licensed nurses not available during this timeframe will be provided reeducation including posttest prior to the next scheduled shift by the DON/ designee. New Licensed nurses during orientation will receive education prior to completion of orientation.
4. Nurse Med Pass observation will be monitored for 5 residents by the DON/ Designee daily during all shifts x 14 days then monthly during all shifts x 3 months with on-going as indicated by audits and monitoring.
The DON/ Designee will present results of medication admission audits or monitoring monthly to the Quality Improvement Committee for any additional follow up and/or in-serving .

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Based on record review and staff interview, the facility failed to monitor refrigerator temperatures in the medication room on the 300 hall. This was a random opportunity for discovery and has the potential to affect more than a limited numberof residents. Facility Census: 42.
Findings Include:
a) Medication Refrigerator
On 08/26/24 at 8:10 AM, a tour of the medication room on the 300 hall was completed. The tour found the medication refrigerator temperatures were not monitored and documented on the following dates:
--08/02/24 AM
--08/02/24 PM
--08/03/24 AM
--08/04/24 AM
--08/04/24 PM
--08/05/24 PM
--08/07/24 AM
--08/08/24 AM
--08/10/24 AM
--08/11/24 AM
--08/12/24 AM
--08/13/24 AM
--08/13/24 PM
--08/15/24 AM
--08/16/24 AM
--08/17/24 AM
--08/17/24 PM
--08/18/24 AM
--08/18/24 PM
--08/19/24 PM
--08/21/24 AM
--08/22/24 AM
On 08/26/24 at 8:18 AM, the Director of Nursing (DON) was notified. The DON stated, the nurse on the 300 hall let me know.
b) Facility Policy
On 08/26/24 at 8:30 AM, the facility policy entitled, Medication Storage was reviewed. The review found under Procedures #11 the following:
Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on observation and staff interview the facility failed to ensure Resident #18's call light was with in reach. This was true for one (1) of 42 residents currently residing in the facility. Resident identifier: #18. Facility Census: 42.
Findings included:
a) Resident #18.
An observation of Resident #18 on 08/25/2024 at 11:35 AM, found the resident was unable to reach her call bell and therefore could not call for help if and when she needed help.
An interview on 8/25/2024 at 11:40 AM, Registered Nurse (RN) #13 confirmed Resident #18's call light was not within the resident's reach.

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Based on record review and staff interview, the facility failed to ensure completion of the required staff education for one (1) of five (5) staff members reviewed under the care area of sufficient and competent nurse staffing. Employee identifier: Nurse Aide (NA) #35. Facility Census: 42.
Findings included:
a) NA #35
On 08/27/24 at 3:00 PM, a review of the staff education was completed. The review found the required staff education was not completed for the following nurse aide (NA):
-NA #35
On 08/28/24 at approximately 9:45 AM, the Administrator was notified of the missing staff education. The Administrator stated, We will be working on this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #5 maintained acceptable perimeters of nutrition by not implementing recommendations made by the registered dietician. This was true of one (1) of two (2) residents reviewed for the care area of nutrition during the long term care survey process. Resident identifier: #5. Facility Census: 42.
Findings included:
a) Resident #5
A review of Resident #5's medical record on 08/27/24 at 1:30 PM revealed a nutritional assessment dated [DATE] which included the following recommendation: .protein added to meals to encourage healing. Further review of the resident's record found the following care plan intervention: Encourage foods high in protein & offer protein supplements as ordered. This intervention was added to the care plan on 01/31/24.
Further review of Resident #5's medical record found protein was not added to the resident's meals and no nutritional supplements to increase protein intake were added to the resident's physician orders.
At 2:30 PM on 08/27/24 the Director of Nursing (DON) acknowledged orders for nutritional recommendations had not been implemented appropriately.

Based on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for Resident #21. This was a random opportunity for discovery. Resident Identifier: #21. Facility Census: 42.
Findings included:
a) Resident #21
An observation on 08/25/24 at 11:45 AM, of Resident # 21's room found the wallpaper had horizontal strips torn from it along the wall from the bathroom door to the window.
During an interview on 08/27/24 at 9:20 AM, with Corporate [NAME] President (CVP) #107, CVP #107 confirmed the wallpaper was torn in Resident #21's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure all admitting diagnosis were reflected on the Preadmission Screening and Resident Review (PASRR). This was true on two (2) of four (4) PASRRs reviewed during the Long-Term Care Survey Process. Resident identifiers: #36 and #21. Facility Census: 42
Findings included:
a) Resident #36
On 08/26/24 at 3:27 PM a record review found Resident #36 was admitted on [DATE] with an admitting diagnosis of: Unspecified Dementia with Psychotic disturbance, Psychosis and Major Depressive Disorder.
Review of the PASRR which was submitted on 03/15/22 reflected Resident #36 had a diagnosis of Alzheimer's, multi-infarct, senile dementia but did not have a diagnosis of psychosis or major depressive disorder.
This was confirmed during an interview on 08/26/24 at 3:30 PM with Social Worker #58 when she agreed the admitting diagnosis of psychosis and major depressive disorder should have been on the PASRR .
b) Resident #21
On 08/27/24 a record review found Resident #21 had the following diagnoses:
Unspecified Psychosis, Onset date 06/02/22
Unspecified Mood disorder, Onset date 06/02/22
Major Depressive Disorder, Onset date 05/31/22
Review of the PASSR dated 08/27/24 found the following medical diagnoses were not identified on the PASSR:
Major Depressive Disorder
The above information was confirmed with the Admissions Director (AD) on 08/28/24 at 11:41 AM. The AD agreed the additional medical diagnosis should have been on the PASRR.

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Based on record review and staff interview the facility failed to comply with the Medical Power of Attorneys' (MPOA) wishes regarding administration of immunizations. This was true for two (2) of six (6) immunizations reviewed during the long term care survey process. Resident identifiers: #35 and #36. Facility Census: 42
Findings included:
a) Resident #35
On 08/26/24 at 1:27 PM, a record review found Resident #35 received a COVID vaccine without consent.
Review of the Medication Administration Record shows Resident #35 received Comirnaty 2023-24 (12y up) (COVID vac 2023-24) Suspension; 30 mcg/0.3 ml, administered 0.3 ml intramuscular COVID vaccine on 02/02/24 by Registered Nurse (RN) #24.
A progress note dated 01/05/24 at 5:52 PM states Spoke with the POA son (name) regarding upcoming vaccines. Consented to RSV, Prevnar 20 (pneumonia) and Shingrix (Shingles) but no COVID vaccines were to be given This progress note was initiated and signed by RN #24.
The MPOA was notified of the administration of the COVID vaccine, as well as the Physician. According to the Incident Report and the reporting documentation to Office of Health Facility Licensure & Certification (OHFLAC) there were no adverse reactions. A new order was received from the Physician to monitor the resident for any changes in condition.
The facility provided education to the nursing staff of ensuring consents were on record for any immunizations administered. The Vaccination Consent form was redesigned in April 2024 to reflect consent or declination of all vaccines offered on one page to simplify the review of the Resident or responsible parties wishes. This was addressed in the Quality Assurance Performance Improvement QAPI meeting as well.
The above findings were confirmed with the Administrator and the Manager Quality RN #69 on 08/27/24 at 2:15 PM.
b) Resident #36
On 08/26/24 at 1:26 PM, a record review found Resident #36 received a Shingrix (Shingles) vaccine on 07/22/24 by Manager Quality RN #69.
Additional record review shows Resident #36's Medical Power of Attorney signed a declination of the Shingrix (Shingles) vaccine on 06/24/24.
The MPOA was notified as well as the Physician. According to the review of the Incident Report and the reporting documentation to Office of Health Facility Licensure & Certification (OHFLAC) there were no adverse reactions. A new order was received from the Physician to monitor the resident for any changes in condition.
The facility provided education to the nursing staff of ensuring the right resident prior to administering any medication.
On 08/27/24 at 9:10 AM during an interview with the Director of Nursing she stated the nurse confused Resident #36 with another resident with a similar last name but residing on a different hall. It was confirmed at this time that the vaccine should not have been administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to report a serious bodily injury after a fall to the proper State authorities for one (1) of two (2) residents reviewed for the care area of abuse. This was a random opportunity for discovery. Resident Identifier: #12. Facility Census: 54.
Findings Included:
a) Resident #177
Policy
A review of the facility policy entitled Reporting Abuse/The Complaint Procedure was completed on 01/04/23 at 12:15 PM was completed. Section 3 (three) states If the alleged incident is abuse or serious bodily injury (injury involving extreme physical pain, involving substantial risk of death, impairment of a bodily member, organ or mental facility, or requiring medication intervention such as surgery or hospitalization) these allegations must be reported within two hours to the appropriate agencies .
During a review of the incident reports on 01/04/23 at 10:17 AM, for Resident #12, it was discovered on 12/11/22 at 6:00 PM, the resident was found to have a fall which resulted in serious bodily injury.
A progress note dated 12/11/22 at 6:00 PM, states RESIDENT FELL IN FLOOR IN ROOM AND ASKED WHAT SHE WAS DOING SHE REPLYED CLOSING THE BLIND AND FELL. ATTEMPTED TO MOVE RESIDENT AND SHE SCREAMED IN PAIN IN HER LEFT HIP AREA AND 911 CALLEED AND RESIDENT SENT TO (Name of acute care facility) FOR EVAL (evaluation) AND TREATMENT. RESIDENT DID SAY SHE HAS HAD BOTH HIP JOINTS REPLACED. (Typed as written.)
An additional progress note dated 12/14/22 at 11:35 AM states SW (social worker) received a call from (Name of nurse at the acute care facility) regarding resident #177. Advised that they are still managing her pain for her right ilium fracture, stated that they are not having a surgical intervention. Advised that she is not ready for discharge quite yet, but anticipate discharge in the next day or two. Inquired if facility would need a COVID test prior to discharge back, SW advised yes. (Name of acute care facility) advised would keep facility updated on status of residents discharge back to facility. (Typed as written.)
A review of the acute care facility discharge paper work stated the following:
Abnormal exam. Minimally displaced fracture of the right supra-acetabular ilium, not evident on earlier pelvic radiograph. No fractures are seen about the right femur. Good appearance following remote right hip and right knee arthroplasty.
A progress note dated 12/16/22 12:18 PM states Resident re-admitted to the facility on [DATE] under skilled nursing, she will resume her previous stay. Resident is alert, able to communicate her needs and make daily decisions. Resident did have a fracture from her fall, monitoring her pain. No surgical intervention was provided. Resident continues to need assistance with ADL's (activities of daily living). Residents discharge plan remains the same, resident will be long term care at the facility. (Typed as written.)
On 01/04/23 at 11:25 AM, the Administrator #26 stated, the fall with injury was not reported. It's my fault it wasn't reported .I was in training.
No further information was obtained during the long-term survey.
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Based on medical record review, observation, and staff interview, the facility failed to ensure a Resident received treatment and care in accordance with professional standards of practice. Specifically, a physician's order was not obtained for an ace wrap applied to a resident's left wrist and arm . This was true for one (1) of 16 residents reviewed during the long term care survey process. Resident identifier: #56. Facility census: 54.
Findings Included:
a) Resident #56
During an Interview and observation on 01/03/23 at 12:15 PM, Resident #56 stated that he has a lot of pain in his left wrist from a contracture. Observations found an ace wrap was in place on his left wrist and arm.
A medical record review for Resident #56 revealed, there was no physician order for an ace wrap to be in place on his left wrist or arm.
During an interview on 01/04/23 at 2:35 PM, Licensed Practical Nurse (LPN) #55 verified there was no order for the ace wrap on Resident #56's left wrist. She stated she thought he was admitted with it on, but she was unsure where it came from.
On 01/04/23 at 12:48 PM, during an interview with the therapy department, the Occupational Therapy Assistant (OTA) #43 verified she had put the ace wrap in place but stated they did not order the ace wrap. OTA #43 stated the resident liked the ace wrap in place for comfort, to help with pain control.
A continued medical record review for Resident #56 revealed, Occupational Therapy Treatment Encounter Note's:
--12/13/22, Resident complained of left wrist pain and requested that it be wrapped with an ACE bandage. Resident states that they straightened it out first before they wrap it.
--12/19/22, Resident reported wrist feels relieved after wrap applied.
--12/22/22, Resident's left contracted wrist is ACE wrapped and Resident is happy with it.
--12/24/22, Resident has left wrist with ACE wrap and states that it feels pretty good, he likes the wrap.
--12/27/22, Left wrist wrapped with ACE wrap per resident request.
On 01/04/23 at 1:44 PM, the Director of Nursing (DON) confirmed, there should be a Physician order if Resident #56 is wearing an ACE wrap.
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ased on record review and staff interview, the facility failed to ensure one (1) of 16 residents reviewed received services to prevent a decrease in range of motion. Resident identifier: #28. Facility census: 54.
Findings included:
a) Resident #28
On 01/04/23 medical records show that Resident #28 has an active order dated 12/03/22 for Restorative Nursing Services (RNS) for Passive Range of Motion (PROM) to bilateral upper and lower extremities, all planes and digits. Two (2) sets of five (5) with twenty (20) second holds three (3) times a week for six (6) weeks as tolerated. Once a day on Tuesday, Thursday and Saturday.
The six (6) week time frame for the treatments would include 12/06/22 through 1/17/23.
Further documentation shows that during the time period of 12/06/22 through 1/04/23 Resident #28 received ten (10) of the thirteen (13) scheduled treatments with no explanations of the missing treatments.
The care plan indicates Functional Limitations in range of motion to bilateral lower extremities, contractures noted to left hand, left shoulder, left neck and left knee. The goal is to slow down progression of contractures, maintain comfort and improve range of motion (ROM) as much as possible this quarter. The approach is mild PROM and ROM as tolerated by RNS/Therapy as ordered.
On 1/05/23 at 11:10 AM, the Director of Nursing confirmed the physician's orders were not followed.
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Based on resident interview, staff interview, and record review, the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice in regards to monitoring pain levels. This was true for one (1) of 16 residents reviewed during the recertification process. Resident Identifier: #56. Facility census: 54.
Findings included:
a) Resident #56
During an Interview and observation on 01/03/23 at 12:15 PM Resident #56 stated that he has a lot of pain in his left wrist from a contracture. Observation found an ace wrap in place on his left wrist and arm.
Medical record review revealed Resident #56's Physician orders for pain management:
--Tylenol (Acetaminophen) tablet, give 500 mg 1 tablet; oral as needed, with start date
12/12/22.
A continued review of Medication Administration Record (MAR) revealed:
--Assess Pain Every Shift, Special Instructions: Document The intensity of Pain:
(Pain scale on a scale of zero 0 to 10) Every Shift -Day, Evening, Night.
Subsequent record review found the pain scale was not documented as ordered.
On 01/04/23 at 12:20 PM, an interview with the Minimal Data Set (MDS) Coordinator, confirmed there was no pain scale documented on Medication Administration Record (MAR). He stated that the nurses should have documented the pain levels in the progress note.
An interview on 01/04/23 at 12:42 PM with the Director of Nursing (DON), confirmed Resident #56's pain scale was not being documented as ordered. She stated she would fix the pain level order to reflect the Resident's pain scale.
No further information was provided prior to the end of the survey on 01/05/23 at 1:00 PM.
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Based on staff interview and record review, the facility failed to ensure timely notification to the physician of a Resident's significant weight loss. This is true for one (1) of two (2) Residents reviewed for nutrition. Resident identifiers: R #54. Facility census: 54.
Findings included:
a) Policy
Record review of the facility's policy titled, Weight Assessment and Intervention, revision dated September 2008, showed:
--The Doctor of Medicine (MD), dietary personnel and the resident's responsible party will be notified of any significant weight change.
--The threshold for significant unplanned and undesired weight change will be based on the following criteria:
a) 1 month -5% weight loss is significant; greater than 5% is severe.
b) 3 month-7.5% weight loss is significant; greater than 7.5% is severe.
c) 6 month-10% weight loss is significant; greater than 10% is severe.
b) Resident #54
A medical record review on 01/04/23 revealed a significant weight loss. Resident #54 weighed 117.8 pounds (LBS.) on 11/10/22 and weighed 102.0 LBS. on 01/04/23 equaling a 13.41% weight loss.
Resident #54s Weight log showed:
--11/10/2022
117.8 LBS.
--11/17/2022
113.0 LBS.
--11/24/2022
110.0 LBS.
--12/01/2022
110.5 LBS.
--12/22/2022
103.5 LBS.
--01/04/2023
102.0 LBS.
A further review on 01/04/23 of Resident #54's medical record found the Physician was notified on 11/29/22 of a significant weight loss.
Subsequent review of the resident's medical record found the Resident's physician was not notified of the continued weight loss occurring on 12/22/22 and 01/04/23 until surveyor surveyor intervention.
During an interview on 01/05/23 at 9:43 AM, the Director of Compliance confirmed that there was no documentation the physician was not notified of the significant weight loss from 12/01/22 through 01/04/23 for Resident #54.
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Based on staff interview and record review, the facility failed to employ a qualified Dietary Manager. This has the potential to affect more than a limited number of Residents that receive their nutrition from the kitchen. Facility census: 54
Findings included:
a) Dietary Manager
On 01/05/23 at 9:10 AM, a review of kitchen training certifications found: No proof of dietary training or Certification Dietary Manager (CDM).
On 01/05/23 at 10:21 AM, an interview with the Director of Compliance confirmed the facility did not have the CDMs certificate for the Dietary Manager.
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Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Items in the kitchen, service area and coffee bar were opened, without being dated to indicate when to discard. This practice has the ability to affect more than a limited number of Residents that get their nutrition from the kitchen. Facility census: 54
Findings Included:
Record review of the facility's policy titled, Food Receiving and Storage, showed that All food stored in the refrigerator or freezer will be covered, labeled, and dated.
a) Kitchen tour
During the initial kitchen tour on 01/03/22 at 10:30 AM, the following was found:
1) Kitchen
--Walk-in refrigerator - One container of pimento spread, one bag of Organic Blend Vegetables, One bag of Naan Bread opened, not labeled, or dated.
-- Reach in refrigerator - one container black berries, one container blueberries and one container of tomato salsa - opened, not dated, or labeled.
2) Service Area
-- Reach in Refrigerator - 26 fruit cups, 16 apple sauce, seven (7) Jell-O, six (6) cottage cheese, nine (9) pudding desserts - not dated or labeled.
--Ice cream freezer -Three (3) trays of dipped ice-cream cups not labeled or dated.
--Kitchen Cabinet -Hershey syrup, Carmel syrup, Sprinkles, opened and not dated or labeled
3) Coffee Bar
-- Reach in Refrigerator - One (1) gallon of milk, One (1) Hershey's syrup, One (1) Carmel syrup not dated or labeled.
--Counter - 12 Coffee flavorings opened, and not dated or labeled.
During an interview on 00/13/23 at 10:48 AM the Personal Director, confirmed the items were opened and not labeled or dated. She confirmed that all food items should be labeled and dated.
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Based on observation, staff interview, and record review, the facility failed to provide
privacy and confidentiality of all residents residing on the 100 hall of the facility. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Facility Census: 59
Findings included:
a) Observations on 09/14/21 at 8:05 AM, on the 100 hall, found the medication
cart parked in the hall unattended. The computer was sitting of the cart. The computer screen was on and visible to anyone passing by. On the screen you could see the names and pictures of the residents who reside on the 100 hall of the facility.
An Interview with Registered Nurse (RN) #18 immediately following this observation, confirmed the screen on the computer should be locked when not attended so you can see personal information regarding the residents.
At approximately 12:00 PM on 09/14/21 an Interview with the Director of Nursing (DON), confirmed the computers should be locked when stepping away from the medication cart.
On 09/14/21 at 3:00 PM, a review of the facility's privacy policy, with an effective date, 02/26/18 found the following in regards to Privacy Safeguarding and storing protected health information, .Documents should not be easily accessible to any unauthorized staff or visitors.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview the facility failed to provide a Notice of Transfer to the State Ombudsman. This was discovered for one (1) of two (2) residents reviewed for the care area of hospitalization during the Long Term Care Survey Process (LTCSP). Resident #58 was transferred to the hospital and no notification was sent to the State Ombudsman. Resident identifier: #58 Facility census: 59.
Findings included:
a) Resident #58
A medical record review on 09/14/21 revealed Resident #58 was discharged to the hospital on [DATE]. There was no evidence the State Ombudsman had been notified of the hospital discharge for Resident #58.
An interview with the Social Service Director on 09/14/21 at 2:21 PM, verified she had not sent notification of the hospitalization for Resident #58 to the State Ombudsman.
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Based on medical record review, and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for one (1) of fifteen (15) residents reviewed during the Long-Term Care Survey (LTCSP). The MDSs for Resident #57 did not accurately reflect the number of days an opioid was received. Resident identifier: #57 Facility Census: 59
Findings Included:
a) Resident #57
Review of the quarterly MDSs on 09/14/21 with Assessment Reference Dates (ARD) of 06/01/21 and 08/31/21 discovered the following: Section N, titled Medication, Section N0410H, Opioid was coded as: zero (0).
MDS RAI version 3.0 manual coding instructions for N 0410H (typed as written):
--Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period.
A review of Resident #57's medical record on 09/14/21, found a physician order dated 09/23/19, for Tramadol 50 mg for pain at 8:00 AM and 8:00 PM and had been give as scheduled daily during each of the seven -day look back periods.
On 09/14/21 at 8:30 AM, Licensed Practical Nurse (LPN) #84 stated she takes Tramadol two times a day and is given Tylenol whenever she needs it. We also do Sombra cream with massage in that area, and that seems to get some relieve.
On 09/14/21 at 1:56 PM, The MDS Coordinator #64, acknowledged Tramadol is an opioid and Resident #57 received it daily during the 7 day look back period for each of the MDSs. She confirmed this was not coded correctly on the MDS with the ARD dates of 06/01/21 and 08/31/21.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on a random opportunity for discovery, though observation and interview, the facility failed to maintain an environment free of accident hazards for which they had control. The facility failed to secure medications found in a resident's room and failed to have an emergency call light in an unlocked restroom accessible to residents. This practice had the potential to affect a limited number of residents residing in the facility. Resident Identifier: Resident #52. Census: 59
Findings included:
a) Front hallway restroom
A random observation of the front hallway of the facility, on 09/13/21 at 03:49 PM, noted a room, adjacent to the nursing station, that was labeled as a restroom. Upon further observation, it was revealed the restroom was not locked and did not contain a way to summons help in case of an emergency.
An additional observation of the front hallway restroom, on 09/14/21 at 09:30 AM, revealed the restroom door was unlocked.
An interview with the Assistant Administrator, on 09/14/21 at 09:30 AM, verified the restroom door in the front hallway was unlocked and confirmed the area could be accessed by residents. It was also verified there was no call system in the restroom in case of emergency or if help was needed while in the restroom.
b) Resident #52.
During facility tour on 09/13/21 at 12:26 PM, a bottle of Normal saline dated 6/15/21 and a bottle of normal saline with no date was observed in room [ROOM NUMBER]'s bathroom on the sink counter. room [ROOM NUMBER] is occupied by Resident #52.
On 09/14/21 at 10:16 AM, License Practical Nurse (LPN) #84 confirmed the following items were on the bathroom sink counter: three (3) packages of sombra cream, two (2) bottles of normal saline, four (4) skin prep pads, three (3) adhesive remover pads and one (1) 4x4 pad. LPN #84 stated I don't know what this is even for or why its even in here. LPN #84, took the items, stating I will dispose of these properly.
Then LPN #84 reviewed the electronic medical records for Resident #52 and confirmed there was no physician's order for normal saline.
This issue was discussed with the Director of Nursing (DON) # 70 on 09/14/21 at 12:16 PM, with no further information provided.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, staff interview and policy and procedures review the facility failed to ensure proper storage of the oxygen nasal cannula and tubing in proper respiratory equipment bag, This failed practice was true for one (1) out of three (3) residents reviewed for oxygen. Resident identifier: # 57 Facility census: 59
Findings Included:
a) Resident #57
Respiratory Care
During the facility tour, on 09/13/21 at 11:31 AM, a wheelchair was observed in the hallway next to room [ROOM NUMBER]. In the wheelchair seat was a nasal cannula and oxygen tubing which was not in a bag, but was laying directly on the wheelchair seat. The wheelchair was labeled with Resident #57's name.
Another observation on 09/14/21 at 8:31 AM, found the nasal cannula and tubing was again not stored in the proper respiratory equipment bag.
On 09/14/21 at 8:32 AM, Licensed Practical Nurse (LPN) #84, verified the wheelchair belonged to Resident #57's, and the nasal cannula and oxygen tubing was not in the proper respiratory equipment bag.
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Based on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored in accordance with current accepted professional practices. Refrigerated medications and biologicals were kept at a temperature below the temperature of manufacturer's recommendation for storage and the facility failed to maintain a complete daily documentation of temperatures for the medication room refrigerator. This practice had the potential to affect more than a limited number of residents. Facility census: 59.
Findings included:
a) Temperature log
Observation of the Front Hall Medication room on 09/14/21 at 08:44 AM, revealed a temperature log for the medication room refrigerator to be incomplete for recorded temperatures.
An interview with Licensed Practical Nurse (LPN #84), on 09/14/21 at 08:44 AM, verified three (3) dates were missing from the temperature log. These dates were 09/05/21, 09/06/21 and 09/11/21. LPN #84 stated the temperature logs were to be completed on night shift and there were three (3) days the logs were missing temperature checks.
b) Storage
Further observation of the Front Hall Medication room on 09/14/21 at 08:44 AM, revealed four (4) boxes of flu vaccine in the refrigerator. According to the manufacturer's recommendation for storage, the flu vaccine was required to be stored at a temperature between 36 and 46 degrees Fahrenheit.
Review of the refrigerator temperature log for September 2021, noted seven (7) days the temperature recorded was not within the temperature range of the manufacturer for the flu vaccine.
Temperatures recorded included the following dates the temperature was below the recommended storage temperature of 36 degrees Fahrenheit for the Flu vaccine :
On 09/01/21 and 09/02/21, the refrigerator temperature was recorded as 35 degrees Fahrenheit
On 09/03/21, the refrigerator temperature was recorded as 34 degrees Fahrenheit.
On 09/04/21, the refrigerator temperature was recorded as 35 degrees Fahrenheit.
On 09/05/21 and 09/06/21, there was no recorded temperature to ensure the temperature was within an acceptable range for the storage of the drugs and biologicals.
On 09/07/21, 09/08/21 and 09/09/21, the refrigerator temperature was recorded as 35 degrees Fahrenheit.
On 09/11/21, there was no recorded temperature to ensure the temperature in the medication room refrigerator was within an acceptable range for the storage of the drugs and biologicals.
An interview with the Director of Nursing (DON) on 09/14/21 at 11:39 AM, confirmed the medication room refrigerator was supposed to be checked and a temperature recorded every day on night shift and and was not done. During the interview, the DON verified the shipment of the Flu vaccine had been delivered and was in the facility during the month of September 2021.
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Based on observations and staff interview the facility failed to store food in accordance with professional standards for food service safety. It was discovered during the kitchen tour several food items were not dated after opening. This failed practice had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 59
Findings included:
a) Kitchen tour
During the kitchen tour on 09/13/21 at 11:10 AM, it was discovered in the walk-in freezer open packaging for breaded shrimp, cauliflower and mixed vegetables, which were not dated after opening. In the pantry, open packaging for self rising flour, strawberry gelatin mix, and egg noodles were also not dated after opening.
An interview with the Dietary Manager (DM) on 09/13/21 at 11:15 AM, verified the breaded shrimp, cauliflower, mixed vegetables, self-rising flour, strawberry gelatin mix, and egg noodles were not dated after opening, which allowed for improper food storage.
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Based on observation, policy and procedure review and staff interview, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment. To help minimize the risk of contamination and ensure all persons in the facility had the proper personal protective equipment (PPE). The facility failed to ensure proper distribution of water pitchers in a sanitary manner and and failed to properly screen vendors for appropriate PPE. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility census 59.
Findings included:
a) Distributing water pitchers
On 09/13/21 at 2:47 PM, the ice pass was observed on the 100 hall, Nurse Aide (NA) #50, was placing used resident's water pitchers in the clean water pitcher area of a storage rack . The clean water pitchers had unwrapped straws, which were touching the storage rack holding the used water pitchers. NA #50 was observed not sanitizing her hands between touching the used water pitchers, and before distributing a clean water pitchers into other resident rooms.
On 09/13/21 at 2:50 PM the Assistant Administrator (AA) #69 stated I do not see a problem with the method. The AA #69 said to NA #50 don't put the straws in the cups till its delivered into the Resident's room. I will get you some Purell to sanitize after touching the dirty pitchers.
b) Personal Protective Equipment (PPE)
An observation on the 300 Hall, on 09/14/21 at 08:23 AM, revealed an outside vendor (Vendor #100) standing at the nursing station desk stating they were there to transport Resident #2 to an outside appointment.
An observation of PPE usage, on 09/14/21 at 08:23 AM, revealed Vendor #100 was wearing a surgical mask only. An interview with Vendor #100, on 09/14/21 at 08:23 AM, verified the outside vendor was only wearing a surgical mask . Vendor #100 stated she had been screened by the facility but was permitted in with a surgical mask. It was further stated Vendor #100 usually wore a N95 mask but had forgotten the N95 mask that morning.
An interview with the Administrator and Assistant Administrator, on 09/14/21 at 09:45 AM. revealed the facility was in an outbreak and all persons who enter the building were required to wear a N95 mask.
An interview with the Director of Nursing (DON), on 09/14/21 12:08 PM, revealed transporters usually came to the door only, however, if vendors came into the building during this time all should have had appropriate PPE, which included a N95 mask in place.
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