rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,550,D,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to protect and promote the rights of 2 of 43 sampled residents (Resident identifiers are #18 and #49). Findings include: Resident #18 was admitted to the facility on [DATE] without having a [DIAGNOSES REDACTED]. However on 7/18/16 Resident #18 was diagnosed with [REDACTED]. The facility from 7/18/16 when the [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type [DIAGNOSES REDACTED].#18. Staff L (Social Services Director) aknowledged during a 3/2/18 interview that the facility has not made a PASARR II referral for Resident #18. Resident #18's new [DIAGNOSES REDACTED]. Resident #49, according to Staff L was an emergency admission who was admitted into the facility on [DATE]. The Consent to Admission and Treatment form was signed by a Family Friend without any documentation being provided to the facility which showed that this individual had been given the legal authroization to sign for Resident #49 on their behalf. Also, this family friend of Resident #49 signed consent forms without having any documentation showing that they had the authority to do so for administering antipsychotic, antidepressant, antianxiety and hypnotic medications to Resident #49. Resident #49's comprehensive care plan states that Resident #49 is able to make her own health care decisions at this time. A Social Service note of 9/26/17 stated that Resident #49 is able to make (his/her) own decisions. Interviews on 3/2/18 and 3/5/18 with respectively Staff L (Social Service Director) and Staff D (Unit Manager) revealed that Resident #49 was not competent to make his/her own health care decisions. This was confirmed by Resident #49's admission MDS assessment of 9/25/17 and 12/18/17 quarterly MDS that indicated Resident #49 is severely cognitively impaired. Also, Resident #49's care plan indicated that their Advance directives are not on file. A Social Service note of 9/26/17 stated that Social Services is attempting to locate DPOA paperwork. A Social Service note of 12/19/17 revealed that Social Services will follow up with Resident #49's son regarding pursuing guardianship. Social Service notes of 1/18/18 and 1/30/18 indicated that Resident #49's son was continuing to look for DPOA documentation. A Social Service note of 3/2/18 stated when communicating with Resident #49's son that the facility needs this paperwork the DPOA documentation and that if we can not locate it we will need to file for guardianship almost six months following Resident #49's admission to the facility.",2020-09-01
2,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,609,D,0,1,6C1411,"Based on interview and record review, it was determined that the facility failed to ensure that the all alleged violations involving abuse, neglect, exploitation and/or mistreatment are reported to the State Survey Agency within the prescribed time frames (see regulation above for timeframes) for one resident out of a subgoup of one resident, with an allegation of resident to resident abuse, in a survey sample of 43 residents. (Resident identifier is #130). Findings include: Resident #130: 2/27/18 1:37 PM: Interview with Resident #130 revealed a verbal report as follows: (Resident #121) came at me and knocked me down. I thought (he/she) would kill me but two staff saved me. This was a couple of months ago. I will never forget the experience! Social services comes to talk to me and make sure I'm okay. I still watch (him/her) like a hawk whenever (he/she) is nearby. (He/She) hasn't tried anything lately. 2/28/18 1:00 pm: Interview with Staff D, Unit Manager revealed that Staff D felt that the incident was overplayed by Resident #130, and it was most likely that both residents were frightened by each other and that caused Resident #130 to fall. Staff D stated, when asked, that the facility did not report this incident as the residents both have dementia, and would not remember what happened. Staff D went on to say that she was unaware that resident to resident altercations needed to be reported to the State Survey Agency if the residents both had dementia. 03/02/18 07:52 AM: Review of nurses notes from the alleged incident on 2/14/18 confirm that there was a resident to resident altercation in Resident #130's room with Resident #121, who held Resident #130 by the upper arms and knocked him/her down. This was witnessed by a nurse, Staff F, and an LNA (un-named) assisted with separating Resident #121 and redirecting him/her from the room so that Resident #130 could be assessed for injury. On nursing assessment by Staff F, an abrasion to the left elbow was noted to be sustained by Resident #130, and neurological checks were initiated as Resident #130 bumped his/her head on a chair when he/she was knocked down. 3/2/18, 10:30 am: The facility's investigation on this incident was reviewed. Facility Policy & Procedures state that resident to resident altercations are not reported to the State unless there is: .serious injury sustained requiring transfer to a hospital, or transfer for a psychiatric evaluation, and/or prolonged emotional upset.A system for follow up on altercations, with an emphasis to prevent future altercations will be in place, including: .Care plans will be updated to incorporate recommendations from the formal incident review process . This incident was not reported to the State Survey Agency as per interview with Staff D, related to the Facility Policies and Procedures for Resident to Resident Altercation Reporting, and that Staff D did not think it needed to be reported because both residents had dementia.",2020-09-01
3,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,655,B,0,1,6C1411,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission for one resident in standard survey sample of 43 (Resident identifier is #194). Findings include: During recertification survey on 3/4/18 and 3/5/18 Resident #194's medical record was reviewed. In this review it was identified that the resident was admitted to the facility on [DATE]. Review of the care plan section of the medical record given to this surveyor for review by Staff M (Assistant Administrator) identified that the first care plan that had been developed for Resident #194 had been developed and initiated on 2/13/18 In addition to being late this initial baseline care plan did not include any reference to dietary orders or social services involvment. Interview with Staff M on 3/5/18 confirmed that the document given to this surveyor was a copy of the initial care plan.,2020-09-01
4,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,656,D,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility Comprehensive Person-Centered Care Plan policy and procedure the facility failed to develop and implement a person-centered comprehensive care plan for 5 residents in a survey sample of 43 residents. (Resident identifiers are #15, #49, #80, #93 and #152.) Findings include: Resident #152. Record review on 3/5/18 of the Physical Therapy Plan of Care for Resident #152 dated 1/28/2018 revealed in the section titled Medical History Related to Diagnosis/Condition: . R (right) BKA (below knee amputation) due to osteo[DIAGNOSES REDACTED] 6/2105 . Record review on 3/5/18 of the PT (physical therapy) - Therapist Progress note for Resident #152 dated 2/26/18 revealed The pt (Resident #152) continues to have deficits in ROM (range of motion) in B LE (bilateral lower extremities), which limit pt's ability to stand upright on LLE (left lower extremity) and prepare for ambulation via prosthesis due to limited ROM in R knee .barrier is that the pt. (Resident #152) does not currently have a functional prosthesis, as .socket does not fit despite use of shrinker nearly 24/7. PT has been working with prosthesis to obtain a new socket . Interview and review, on 3/5/18 at approximately 12:30 pm. with Staff [NAME] (Registered Nurse), of the comprehensive care plan for Resident #152 revealed no documented evidence of care plan indicating a below knee amputation with interventions for Resident #152. Staff [NAME] reported that if you read this care plan and had not seen .(Resident #152) you wouldn't know that .had a [MEDICAL CONDITION]. Resident #49 who was admitted to the facility on [DATE] has a comprehensive plan of care initiated on 9/26/17 which states that this resident is able to make (his/her) own health care decisions at this time. Interviews on 3/2/18 and 3/5/18 with respectively Staff L ( Social Services Director) and Staff D (Unit Manager, RN) revealed that Resident #49 was not competent upon their admission to make his/her own health care decisions. In addition both Resident #49's admission MDS assessment of 9/25/17 and quarterly MDS assessment of 12/18/18 coded Resident #49 as being severely cognitively impaired. Record review revealed that Resident #49's care plan states Resident #49's Advance directives are not on file. Staff L stated in a 3/2/18 interview that there wasn't either any guardianship or durable power of attorney documents on file at the facility for Resident #49 since Resident #49's admission on 9/18/17. A 3/5/18 interview with Staff L revealed that a New Hampshire Durable Power of Attorney Form for Resident #49 appointing his/her son as Resident #49's durable power of attorney had been found on 3/5/18 among Resident #49's admission paperwork. A review of this Durable Power of Attorney revealed that it is only for financial matters and states that this document does not authorize the Attorney-in-Fact to make medical decisions for the Principal Resident #49. Resident #93 Review on 03/02/18 of Resident #93's medical record revealed that Resident #93 has dementia. Review of Resident #93's the care plan on 03/05/18 reveals Resident #93 is an extensive assist with a shower. Review of Resident #93's activities of daily living task for showers revealed that during the time frame of 2/3/18-3/5/18 he/she only received one shower since 2/3/18. He/she refused a shower on 2/17/18. Interview on 3/2/18 with Staff N, (Licensed Practical Nurse) revealed that he/she is to be re-approached on another day to receive a shower for the week that he/she missed. There is no documentation that showes that Resident #93 was reapproached and Resident #93 only received a bedbath. Resident #80 Observation of Resident #80 on 3/2/18 at 10:15 a.m. during interview revealed the resident's right foot was not resting on the foot platform of their wheelchair and the resident's slipper was dangling from their foot. There was towel wrapped on the foot platform. Interview with Resident #80 on 3/2/18 at 10:15 am. revealed that when Resident #80 was admitted , the resident had brought an electric wheelchair from home that was no longer taking a charge so was now using a facility manual wheelchair. Resident #80 also revealed that the resident had limited range on motion of the right hip and knee. Review of Resident #80's current care plan on 3/5/18 at 9:09 a.m. revealed there were no interventions for positioning or limited range of motion for the resident's lower right extremity. Interview with Staff M (Assistant Administrator) on 3/5/18 at approximately 10:30 a.m. confirmed there were no care plan interventions for positioning or range of motion. Resident #15 Review of medical record on 3/2/18 at approximatley 10:15 am revealed that Resident #15 had a [DIAGNOSES REDACTED]. Review of Resident #15's care plan revealed that there was no care plan for communication or [MEDICAL CONDITION]. Interview on 3/2/18 at approximatley 11:45 am with Staff G (Unit Manager building 5-3) confirmed that resident has a communication deficit and uses gestures and yes and no answers to communicate with staff and that there is no care plan in place for communication or [MEDICAL CONDITION].",2020-09-01
5,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,658,D,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to note/validate a medication order for 1 Resident in a sample size of 43 (Resident identifier is #180.) and failed to ensure proper assessments were performed before moving residents after they sustained falls. (Resident identifiers are: #152 and #186.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 16 Nursing Assessment, page 243. Data Documentation Data documentation is the last part of a complete assessment. The timely, thorough and accurate documentation of facts is necessary when recording client data . If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client. If there is not specific information, the reader is left with only general impressions. Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. Resident #186 This Surveyor requested an Accident /Incident Report and an Investigation Report. Review of an Event Report, written by Staff O, LPN (Licensed Practical Nurse), and provided by Facility Staff for an Event that occurred on 2/25/18 at 0100 hours revealed the following: While standing in the hallway heard a bump heard a resident yelling for help, found resident laying between the beds, on her R (right) side (Resident) stated unsure all (he/she) know (sic) that (he/she) was asleep. ask (sic) resident if (he/she) hit (his/her) head, (stated no) resident assist to bed X3 (times three person assist), while in bed began a head to toe assessment no apparent bruising or open areas noticed at this time, Neuro checks performed as protocol per facility (sic). There was no Investigation Report provided. Review of this residents Progress Notes for 2/25/18 written at 3:49 a.m. reveals at approximately 1:00 a.m.this date, this resident was status [REDACTED]. Assessment: nose bleeding, no sign of open injuries, residents BP (blood pressure) as follows 69/41 (BP) 98 (TEMPERATURE) 70 (HEART RATE) 18 (RESPIRATION RATE) 96% RA (room air)(PULSE OXIMETRY LEVEL) 72/45 97.6 18 100% RA, c/o (complaint of) pain both knees. Background: Resident is paralyzed from the hips down, c/o severe pain frequently (sic). On interview, 3/2/18 at approximately 2:10 p.m. Staff C, RN DON (Director of Nurses) stated that Resident #186 raised the bed to a higher position on his/her own. While this resident is paralyzed from the waist down he/she is quite capable of moving himself/herself around in bed and in using the bed control. Because this resident spends a fair amount of time in her bed he/she is on an air mattress to decrease the chance of developing pressure areas. During this interview Staff C stated that there was no Investigation Report and no report to the State Agency because the Facility did not feel there was any mystery as to how Resident #186 had been able to fall out of bed. Resident #152. Record review on 3/05/18 10:16 of the Nurse Note dated 2/22/18 for Resident #152 revealed This nurse informed by supervisor that resident had an un-witnessed fall w/o injury. Resident found in PT (physical therapy) performing exercises w/ staff, stated he had 0 pain, was assessed for injury by PT and supervisor. Denied hitting his head will continue to monitor. No documented evidence of an assessment could be found for Resident #152 un-witnessed fall on 2/22/18. Review on 3/5/18 of incident report dated 2/21/18 for Resident #152 revealed the following, Slipped from chair to floor, in siting position, while attempting to transfer to bed denied hitting head . Assessed by PT and supervisor, no injury noted, vitals taken neuros initiated . Transferring w/out calling for assistance. Interview on 3/5/18 at approximately 12:30 p.m. with Staff [NAME] (Registered .Nurse) revealed that after review of the medical record and nurse notes, Staff [NAME] confirmed that there was no documented evidence of an assessment done by a nurse or a PT following the fall for Resident #152 on 2/22/18. Resident #180 During review of the use of medications in the insulin and anti-coagulant investigative category, an incidental finding of a non-transcribed [MEDICATION NAME] order was identified. Written on 2/20/18 the order reads [MEDICATION NAME] 50 mg Per Oral at bedtime as needed for [MEDICAL CONDITION] signed by Physician Assistant Certified. Order had no indication that it had been transcribed. Review of MAR (Medication Administration Record) for the month of (MONTH) was conducted. There is no entry on the MAR for [MEDICATION NAME] nor any indication that the resident received any doses. Interview with Staff F Registered Nurse (RN) validated the above findings.",2020-09-01
6,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,677,D,0,1,6C1411,"Based on medical record and interview it was determined that the facility failed to provide assistance with activities for daily living for 1 resident in a standard survey sample of 43 residents. (Resident identifier is #93.) Findings include: Resident #93 Review on 03/02/18 of Resident #93's medical record revealed that Resident #93 has dementia. Review of Resident #93's the care plan on 03/05/18 reveals Resident #93 is an extensive assist with a shower. Review of Resident #93's activities of daily living task for showers revealed that during the time frame of 2/3/18-3/5/18 he/she only received one shower since 2/3/18. He/She refused a shower on 2/17/18. Interview on 3/2/18 with Staff N, (Licensed Practical Nurse) revealed that he/she is to be re-approached on another day to receive a shower for the week that he missed. There is no documentation that showes that Resident #93 was reapproached and Resident #93 only received a bedbath. Resident Council notes. On 2/28/18 at approximately 11:00 a.m. during a Resident Council meeting with seven (7) residents in attendance it was stated that 2 nurses were known to residents to give showers; most (nurses) do not seem to have the time to do that. Additionally, one of the residents stated that some days they are told that no one is available to give showers on some shifts. As residents are only scheduled for 1 or 2 showers per week, if residents miss a scheduled shower, it could be several days before they receive another shower. It was further stated by Resident Council members that some call lights are being shut off by staff reaching behind curtains and canceling the call lights without acknowledging the residents affected. Interview on 3/1/18 at approximately 7:15 a.m. with Staff U, Licensed Nursing Assistant revealed, Staffing here really impacts the residents a lot here. 2nd shift showers are missed a lot because there is not enough staff. Interview on 3/1/18 at approximately 7:20 a.m. with Staff V, Licensed Nursing Assistant revealed, We are always short staffed, but the weekends are extremely short. I have had a lot of residents soil themselves because we are with others and can't get to them.",2020-09-01
7,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,684,D,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff, and interview with resident, it was found that the facility failed to provide care and services to meet 1 of 1 resident's bowel regime by failing to notified the physician to establish a bowel regime in a survey sample of 43 residents. (Resident identifier is #192) Findings include: During the initial tour of the facility on 2/27/18 it was stated by Resident #192 to surveyor during interview that they had not had a bowel movement for over 5 days and had told staff several times but no medications where given to help. Resident #192 did state that they did finally move their bowels but it was very uncomfortable during that period of time. On review of the bowel record for the month of (MONTH) it was found that from 2/20/18 until 2/25/18 Resident #192 did not have a bowel moment as documented on the bowel record, not until 2/26/18 did it show that a bowel movement occurred. On 3/2/18 at 11:35 a.m. Resident #192 record was further reviewed and on 3/1/18 a Bowel and Bladder Evaluation was in progress and under section 13 Bowel Evaluation Summary part (B) it states Does the resident have bowel movements with regularity (every 3 days or more often)? If no please establish bowel regime with Physician. This information was shown to Staff C (DON) at 8:45 a.m. on 3/2/18 who confirmed the finding and notified the physician, getting orders that state Senna Tablet 8.6 mg Give 1 tablet by mouth at bedtime for constipation and [MEDICATION NAME] Suppository 10 mg insert 1 suppository rectally as needed for Constipation if no BM x 2 days.",2020-09-01
8,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,688,D,0,1,6C1411,"Based on observation and interview, the facility failed to ensure that residents with limited range of motion receive appropriate equipment for 1 of 2 residents with limited range of motion in a sample size of 43 residents. (Resident identifier is #80.) Findings include: Resident #80 Observation of Resident #80 on 3/2/18 at 10:15 a.m. revealed the resident's right foot was not resting on the foot plate of their wheelchair and the resident's slipper was dangling from their foot. There was towel wrapped on the foot plate. Interview with Resident #80 on 3/2/18 at 10:15 am. revealed that when Resident #80 was admitted the resident had brought an electric wheelchair from home that was no longer taking a charge so was now using a facility manual wheelchair. Resident #80 also revealed that the resident had limited range on motion of the right hip and knee. Interview on 3/2/18 at 10:30 a.m. with Staff G (5-2 Unit Manager) revealed the Staff G had not seen Resident #80 using the electric wheelchair in a while because the battery would no longer charge. Interview also revealed that the unit manager believed that Occupational Therapy (OT) was working with Resident #80 on the manual wheelchair currently being used by the resident. Interview with Staff P (Rehabilitation Program Director) revealed the director did not know that Resident #80 was not using the electric wheelchair anymore. Interview further revealed that the rehabilitation department was not aware was that Resident #80 was not positioned properly in the manual wheelchair and did have not referral to work with Resident #80 on the manual wheelchair.",2020-09-01
9,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,689,E,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for all residents with 2 residents identified as smoking in an initial survey pool of 59 residents in a non-smoking facility. (Resident identifiers are #80 and #138.) Findings include: Observation on 2/28/10 at 8:25 a.m. revealed Resident #80 was outside in front of the main entrance smoking. Observation on 2/28/18 at 9:00 a.m. revealed Resident #80 was outside in front of the main entrance bundled up for weather with a bath blanket over legs in a manual wheelchair. Resident #80 had a cigarette that was put out wrapped in tissue paper. Interview with Staff G (5-2 unit manager) on 2/28/18 9:45 a.m. revealed that staff are aware that Resident #80 goes outside to smoke. Interview further revealed that Staff G did not know where Resident #80 gets or stores their cigarettes and if staff see lighters or cigarettes, they are supposed to take and hold them. Observation on 3/1/18 at 8:05 a.m. revealed Resident #80 outside the main entrance smoking. Observation also revealed three old cigarettes butts on the ground near the main entrance. Review of the facility's smoking policy (not titled or dated) revealed that the facility prohibits the use of tobacco and tobacco products on the facility's premises and there are no designated smoking times or locations. Interview on 3/2/18 at 9:07 a.m. with Staff C (Director of Nursing) revealed that they are a non-smoking facility and have always been a non-smoking facility. Interview also revealed that Staff C did not know where Resident #80 gets cigarettes. Interview confirmed the above smoking policy. Interview with Staff C on 3/2/18 at 9:45 a.m. there was a smoking assessment done on 12/29/17 for Resident #80 that looked at the resident's cognitive ability/vision/and functioning. The assessment did not include any observations of smoking. Interview further revealed that they do not do a complete assessment because they are a non-smoking facility. Review on 3/2/18 at 9:35 a.m. of Resident #80's current care plan showed the following smoking goal: (Resident name omitted) wishes to smoke and is assessed for supervision level: Independent. Interview with Resident #80 on 3/2/18 at 10:15 a.m. revealed the resident goes outside to smoke and the resident hides a lighter and the resident's cigarettes in the resident's room. Interview also revealed that Resident #80 was outside smoking and the wheelchair rolled off the curb and the resident fell out of their wheelchair on 2/26/18. Interview with Staff G on 3/2/18 10:30 a.m. revealed there is a sign-out book that residents are to use when they leave the building but residents do not usually use it. Review of the sign-out book with Staff G revealed that Resident #80 had signed out 4 times, once time a month in September, October, November, and (MONTH) of (YEAR). Review on 3/2/18 at 1:33 p.m. of Resident #80's progress notes revealed the following entries: On 7/7/17 at 2:57 p.m.Pt (patient) wears oxygen during the day. Will frequently take it off and wheel herself outside to smoke . On 8/1/17 at 2:25 p.m. Pt (patient) wears oxygen during the day. Will frequently take it off and wheel .outside to smoke . On 10/19/17 at 8:51 a.m. Last night around midnight, I received a phone call from a concerned individual that there's somebody in (sic) the sidewalk in front of the bld. in a wheelchair with blanket and pillow. I went outside immediately to check and found (Resident #80) smoking in (sic) the sidewalk. I asked (pronoun omitted) to come back inside the building with me because it is not safe for (pronoun omitted) to be out there in the middle of the night. (Pronoun omitted) continued to smoke until (pronoun omitted) was done . I explained to (pronoun omitted) that (pronoun omitted)might get hit or . might fall navigating the wheelchair in the incline . Interview on 2/28/18 1:41 p.m. with Resident #138 revealed that he/she is a smoker and has been for [AGE] years and has no intention on giving it up. He/She acknowledged that the facility is a non-smoking facility. Resident #138 stated he/she has been directed by staff to go out back and smoke near the fence if he/she wants to smoke. Resident #138 stated that because he/she can't get up the ramp to get back in the building that he/she goes out on the platform which is under the awning of the building and smokes out there. Resident #138 explained that since staff are not able to push him/her back up the ramp because they are short staffed most of the time, that he/she has no other option for where he/she smokes. Resident #138 stated that he/she does keep his/her cigarettes and lighter on his/her person. Review of Resident #138's medical record revealed a signed Tobacco Free Policy Acknowledgement form signed by Resident #138 on 3/3/17. Review of the facility's smoking policy revealed that the facility prohibits the use of tobacco and tobacco products on the facility's property and the facility is posted with no smoking signs at the entrances of the facility. Interview with Staff B (LNA) on 2/28/18 at approximately 1:45 p.m. revealed that this is a non-smoking facility and the facility is posted as such.Staff B confirmed that Resident #138 does smoke on the property and there are several other residents in the facility that smoke on the property. Interview with Staff C (RN/DON) on 2/28/18 at approximately 2:15 p.m. revealed there was a smoking assessment done for Resident #138 that only assessed Resident #138's cognitive ability/vision/and physical functioning.",2020-09-01
10,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,725,F,0,1,6C1411,"Based on observation, interview (Residents, Family, Staff) and review of staffing records, the facility failed to provide adequate staffing to provide care, safety, and a healthy milieu to all residents at the facility. Findings include: During the recertification survey from 2/27 to 3/5, four members of the facility staff were asked if they had enough staffing to properly care for residents. Based on answers received from direct interviews, two of the four interviewed, Staff D Registered Nurse (RN) and Staff F (RN) replied there was not enough staff to properly care for residents. Staff [NAME] (RN) replied that adequate staffing depended on the shift, the occasion, residents, and acuity. Staff G replied that staffing was tough on the evening, nights, and weekend shifts. Resident #160. Interview on 2/17/18 at approximately 10:20 a.m. with Resident #160 revealed the following information: . not enough staff , especially evening, nights and weekends. . if you ring and they don't answer I expect they are doing something urgent so you fend for yourself. . sometimes you know at the beginning of shift whether your bell will get answered or not depending on whose working or who is not working. . sometimes medications are late and you have to ask for them . as long as two hours. Resident #404. Interview on 2/17/18 at approximately 10:45 a.m. with Resident #404 revealed the following information: . not enough staff, the staff here work hard but just not enough with all the people who need a lot more help then me. . call bells not always answered, we help each other out when they don't come . you can tell when the bells will be answered depending on the staff working that shift. . can be any shift but mostly evening, nights and weekends . you have to wait for medication you are suppose to get at certain times, you end up asking for them. In a 3/5/18 confidential family interview it was revealed that there has been a shortage of nursing staff for building one during the last five months. This family member stated that because of staff being unavailable to provide direct care to residents in building one the resident's families have had to assist residents with their meals and as a safety measure accompany residents ambulating to their rooms. On 3/2/18 Staff D (Unit Manager, RN) who stated during the survey that she manages both building one and building two was observed on one of building one's two units, the Highway Side apparently filling in as a floor nurse throughout the day dispensing medications and assisting resident's with their meals. The following resident and staff interviews were conducted on the east wing: Resident #194 Interview on 2/27/18 at approximately 10:00 a.m. with Resident #194 revealed that the resident had concerns with staffing. Resident #194 stated, I wait over an hour daily for toileting, this place is so short staffed. Resident and family member were present during interview and confirmed Resident #194's staffing concerns. Resident #192 Interview on 2/27/18 at approximately 10:45 a.m. with Resident #192 revealed that Resident #192 stated, I feel that it takes along time for staff to answer my light. Time of day does not matter, there is always a long wait. Resident #55 Interview on 2/27/18 at approximately 11:35 a.m. with Resident #55 revealed, This place is so short staffed, appear to be exhausted. 3-11 is the worst for staff and on 11-7 good luck if anybody comes at all. Resident #55 states, I hear others in the halls yelling out for help, no one comes so I call 0 on the telephone. Resident #196 Interview on 2/27/18 at approximately 12:00 p.m. with Resident #196 revealed, There is not enough staff here, 1 aide and 1 nurse most of the time. Sometimes it takes them so long to come, I have accidents. Resident #161 Interview on 2/27/18 at approximately 12:30 p.m. with Resident #161 revealed, These girls need help here, they are constantly running especially around meal times. It takes forever to get help in this place. Resident #855 Interview on 2/27/18 at approximately 1:30 p.m. with Resident #855 revealed, Sometimes I wait over 2 hours for help here an example, on Sunday I called 911 because I was crying in pain and did not know what else to do. Resident #186 Interview on 2/28/18 at approximately 7:30 a.m. with Resident #186 revealed the following information regarding staffing, I have to wait a long time to get in bed and get out of bed. There are not enough people to help us here. Interview on 2/28/18 at approximately 7:45 a.m. with Staff S, Licensed Practical Nurse revealed, There is not enough staff here, most days there are 1 nurse and 1 Licensed Nursing Assistant. Interview on 2/28/18 at approximately 9:45 a.m. with Staff T, Unit Coordinator revealed there are currently 17 residents on the unit. Four of these residents require a hoyer lift for transfers which requires 2 staff members. Interview on 3/1/18 at approximately 7:15 a.m. with Staff U, Licensed Nursing Assistant revealed, Staffing here really impacts the residents a lot here. 2nd shift showers are missed a lot because there is not enough staff. Interview on 3/1/18 at approximately 7:20 a.m. with Staff V, Licensed Nursing Assistant revealed, We are always short staffed, but the weekends are extremely short. I have had a lot of residents soil themselves because we are with others and can't get to them. Resident #22 Record review of this resident's Quarterly MDS with an Assessment Reference Date of 12/4/17 revealed that the resident's Summary Score for Brief Interview for Mental Status was 15/15. During resident interview on 2/27/18, this resident related that sometimes when staff do not arrive in time when s/he uses the call bell for toileting, s/he is incontinent Resident #80 During interview on 3/2/18, this resident related there are not enough staff, the facility is trying to get more people but haven't, so bedside commodes are not emptied every shift, trays aren't picked up, and beds aren't straightened out. Resident Council notes. 2/28/18 10:58 a.m. Resident Council was held on 2/28/18 at approximately 10:40 a.m. Seven (7) Residents were in attendance, representing 3 of the Facilities Residential Units, all of whom are regular Resident Council members. Staffing was a major concern to these Council members, length of wait times after call bells were activated by residents vary widely. Council members agreed the length of the wait varies directly with the number of LNA's on the floor. They stated they have waited more than a half an hour to an hour to have their needs met. They further stated that coverage is worse on 3 to 11 and 11 to 7 shifts and that on weekends the wait times are atrocious. They mentioned that staff sometimes work through their (personal) lunch time. They also stated that there is a near constant outflow of staff members leaving because of difficult staffing ratios. Some facility staff have actually sought out some residents, including some Resident Council members and tearfully said they do not want to leave but feel they must because they cannot continue to work non-stop. It was stated that 2 nurses were known to residents to give showers; most (nurses) do not seem to have the time to do that. One of the residents stated that some days they are told that no one is available to give showers on some shifts. As residents are only scheduled for 1 or 2 showers per week, if residents miss a scheduled shower, it could be several days before they receive another shower. It was further stated by Resident Council members that some call lights are being shut off by staff reaching behind curtains and canceling the call lights without acknowledging the residents affected. Resident #162 Interview with Resident #162 on 2/27/18 at approximately 10:30 a.m. revealed that she/he often has to stay in bed for the day because the facility does not have enough staff to get her/him out of bed. This resident stated that she/he knows when they are short staffed because the staff will come in and tell her/him that she/he won't be able to get out of bed today because we are short staffed. She/he has not had a negative outcome as a result of having to wait to have her/his call bell answered. Resident #64 Interview with Resident #64 on 2/28/18 at approximately 9:15 a.m. revealed that the resident feels she/he must wait a significantly long time to have her/his call bell answered. She/he stated she/he usually waits a half hour or more and on occasion, an hour or more for her/his call bell to be answered. She/he has not had a negative outcome as a result of having to wait to have her/his call bell answered. Resident #63 Interview with Resident # 93's family member revealed that often times during his/her visit the resident is still in a johnny or in bed when other residents are up and about after 10 a.m. and there are times when this happens after 1 p.m. Resident #124 Interview with Resident #124 on 2/28/18 at 9:48 a.m. revealed that there is not enough staff. She/he has to wait quite a while when she/he rings her/his call bell for assistance, usually a half an hour or more. She/he has not had a negative outcome as a result of having to wait to have her/his call bell answered. A confidential interview on 2/28/18 at approximately 11:30 a.m. with a direct care staff person revealed that staff typically work short staffed and often times cannot meet all the needs of their residents. This staff person stated that staff have convinced their family members to come to work at the facility to try and get enough staff but this option has been exhausted. This person stated that keeping staff is an issue because many staff have left to go to work in Massachusetts where they pay more. This staff person stated that the facility does use agency staff but only for nurses, never LNA's and this is where they are hurting the most.",2020-09-01
11,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,745,D,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to protect and promote the rights of 2 of 43 sampled residents (Resident identifiers are #18 and #49). Findings include: Resident #18, according to record review was admitted to the facility on [DATE] without having a [DIAGNOSES REDACTED]. Further record review revealed that on 7/18/16 this facility resident was newly diagnosed with [REDACTED]. The facility from 7/18/16 when the [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type [DIAGNOSES REDACTED].#18. Staff L(Social Services Director) aknowledged during a 3/2/18 interview that the facility has not made a PASARR II referral for Resident #18 even though the [DIAGNOSES REDACTED]. Resident #49, according to a 3/5/18 interview with Staff L was an emergency admission who was admitted into the facility on [DATE]. Record review revealed that the Consent to Admission and Treatment form was signed by a Family Friend without any documentation being provided to the facility, according to a 3/5/18 interview with Staff L which showed that this individual had been given the legal authroization to sign for Resident #49 on their behalf. Also record review further revealed this family friend of Resident #49 signed consent forms without having any documentation showing that they had the authority to do so for administering antipsychotic, antidepressant, antianxiety and hypnotic medications to Resident #49. Resident #49's comprehensive care plan states that Resident #49 is able to make her own health care decisions at this time. A Social Service note of 9/26/17 stated that Resident #49 is able to make her own decisions. Interviews on 3/2/18 and 3/5/18 with respectively Staff L(Social Service Director) and Staff D (Unit Manager) revealed that Resident #49 was not competent to make her own health care decisions. This was confirmed by Resident #49's admission MDS assessment of 9/25/17 and her 12/18/17 quarterly MDS that coded Resident #49 as severely cognitively impaired. Also Resident #49's care plan indicated that Resident #49's Advance directives are not on file. A Social Service note of 9/26/17 stated that Social Services is attempting to locate DPOA paperwork. A Social Service note of 12/19/17 revealed that Social Services will follow up with Resident #49's son regarding pursuing guardianship. Social Service notes of 1/18/18 and 1/30/18 indicated that Resident #49's son was continuing to look for DPOA documentation. A Social Service note of 3/2/18 stated when communicating with Resident #49's son that the facility needs this paperwork the DPOA documentation and that if we can not locate it we will need to file for guardianship almost six months following Resident #49's admission to the facility.",2020-09-01
12,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,761,E,0,1,6C1411,"Based on interview, observation and record review it was determined that the facility failed to follow currently accepted professional principles for labeling and/or storing drugs and biologicals, storing drugs in locked compartments, and/or locking controlled drugs separately, for 3 out of a sample selection of 6 medication carts reviewed. Findings include: Medication Storage and Labeling 02/28/18: 7:18 AM: Observation of Facility Medication carts, medication rooms, and control logs for blood glucose machine quality control was initiated. 6 out of a possible 11 medication carts were reviewed with identified issues found in 3 out of 6 Medication Carts reviewed. Issues are as follows: Bld #2: 3/1/18 Medication cart review with (Staff I, RN) revealed that the narcotic medications were not double locked as required. Observation revealed that the medication cart itself was locked, but the narcotic boxes inside the cart were left ajar. Bldg #5: 3/1/18: 8:15 am Med cart: 3rd floor: Observation of box of blood glucose machine control fluids revealed that the boxes (which don't need to be dated) were dated with an opening date, but the control fluid bottles (which need to be dated) were not dated as to when they were opened. 3/1/18, 8:35: 2nd floor Med cart: Staff J, LPN: Observation of the cart revealed that the cart was not locked. Medications with several resident names and prescriptions were left out on top of medication cart, and the cart was left unattended. In the bottom drawer of the cart, there were empty bags with resident names and prescriptions, and creams and ointments that were not in resident identifiable bag(s). Open insulin vials/pens were not dated as to when they were opened. The nurse, Staff J, was observed to begin pulling out many empty bags and putting creams/ointments back into the labeled bags. The narcotics box inside of the cart was not locked, and cart was also not locked. Observation on 2/28/18 at approximately 6:40 a.m. in Building #3 revealed an unlocked, unattended medication cart in the resident hallway in building 3 with multiple open drawers containing medications in pill packs, bottles, sprays, eye drops and boxes. The top of this medication cart also had multiple containers of individual patient labeled medications. Interview on 2/28/18 at the time of this observation with Staff R (Registered Nurse) revealed that the above listed medication cart was unlocked and unattended with multiple drawers opened and multiple patient labeled medication containers, boxes and pill packs on top of this unlocked medication cart.",2020-09-01
13,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,812,E,0,1,6C1411,"Based on observation during tour and interview with the director of food services it was found that the facility failed to maintain a sanitary environment along with maintaining kitchen equipment in safe operating conditions. Findings include: During the initial tour of the facility's kitchen on 2/27/18 at 12:17 p.m. it was observed and shown to Staff A (Director of Food Services) during interview that the floors throughout the kitchen areas had broken, chipped and missing tiles creating uneven surfaces throughout the whole kitchen. Also none of the floor surfaces can be cleaned due to deep porous grout lines that are broken and missing grout along with uneven surfaces creating areas that hold water and grease. Also it was observed that the wall behind the cooking equipment (one bay sink, dirty dish rack, double convection oven, main cooking stoves, kettle, and double steamer) had grease and staining along with mold damage as observed from the opposite side of the wall in the dinning room hallway which is under construction due to water damage. There was large amount of dust build up over the cooking area which could inadvertently enter the food, due to the hood suppression system not being cleaned. On review of the inspection tag it was found that the last inspected date was 7/2017 making it one month over due. While touring the units it was found that the delivery food cart doors, while passing trays were mostly left open and staff had trouble latch or close tightly due to gaps. On 3/5/18 all 14 carts were inspected with Staff A and found that all the doors on the carts were either bent, or broken with large splits in the metal doors preventing them from fully closing as designed.",2020-09-01
14,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,880,E,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to maintain a safe, sanitary enviroment to prevent the development and transmission of infections. Findings include: Observation on 3/1/18 at approximately 8:45 a.m. of the facility rehabilitation area showed multiple individual cloth gait belts and multiple individual synthetic gait belts. Review of the manufacturer's instructions, at the time of survey, with Staff P (Rehabilitation Director) revealed the following: Gait belts made from woven fibers, either natural or man-made can be laundered recommends washing in lukewarm water (100 degrees F / 38 degrees C) without bleach and low dry in order to maintain color brightness and product longevity. If, however, the woven Gait Belts are contaminated, they may be cleaned per the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health-care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) . by washing in hot water (.160 degrees F / 71 degrees C) for a period of 25 minutes or more with, if desirable, the appropriate bleach concentration . Interview on 3/1/18 at approximately 9:00 a.m. with Staff P (Rehabilitation Director) revealed that the facility gait belts, (both the cloth and the synthetic) are wiped down with disinfectant after patient use and are not sent to the laundry to be cleaned. The rehabilitation department failed to ensure that the facility gait belts are cleaned and maintained to prevent the development and transmission of communicable diseases and infections. On 2/27/18 at approximately 1:23 PM Staff K (License Nursing Assistant ) was observed to come out out of room [ROOM NUMBER] without any garb on except for gloves. Staff K then discarded the gloves into room [ROOM NUMBER] and then proceed down the hallway without washing his/her hands. room [ROOM NUMBER] is a precaution room where as Resident #193 is on contact precautions for VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) in urine and and Resident #79 is on contact precaution for shingles. Staff K had assisted another staff member to get Resident #193 into bed for the afternoon. Medication Cart Observation: 3/1/18 8:00 am: Building #1, Locked Dementia Unit: Observation of medication cart with Staff H, RN revealed one blood glucose meter (BGM) with a dried, brownish red substance smeared on the sides and back. Staff H was able to clean the substance off of the BGM with a bleach wipe during the observation.",2020-09-01
15,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,881,D,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents who required an antibiotic were prescribed the appropriate antibiotic by obtaining a culture for organism identification. Findings include: Review on 3/5/18 of the infection control line listings, revealed many residents who had infections within the past 5 months and who were placed on antibiotics without obtaining a culture for organism identification. Review on 3/5/18 of the facility's policy and procedure titled, Antibiotic Stewardship - Order for Antibiotics, date established was 11/2017, last revised is documented as 11/2017 and is listed as version 1.0. Section A, third paragraph reveals the following verbiage: Appropriate indications for use of antibiotics include: b. Criteria met for clinical definition of active infection or [MEDICAL CONDITION]; and c. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). During review of the facility's Infection Control Logs, the following infections were revealed with no culture obtained but antibiotics were prescribed: Date identified Organism Antibiotic ordered Meets McGeer's Criteria 11/4/17 [MEDICAL CONDITION] - Wound [MEDICATION NAME] No 11/6/17 (blank) - UTI [MEDICATION NAME] No 11/7/17 (blank) - Infection [MEDICATION NAME] No 11/7/17 (blank) - Cyst [MEDICATION NAME] No 11/7/17 (blank) - Cyst [MEDICATION NAME] No 11/14/17 (blank) - Infection [MEDICATION NAME] No 11/14/17 (blank) - PNA (Pneumonia) [MEDICATION NAME] No 11/14/17 (blank) - Infection [MEDICATION NAME] No 11/20/17 (blank) - Wound Infection Keflex No 11/27/17 (blank) - PNA [MEDICATION NAME] No 11/27/17 (blank) - PNA [MEDICATION NAME] No 11/30/17 (blank) - Vaginal Itch [MEDICATION NAME] No 12/4/17 (blank) - PNA (normal flora) [MEDICATION NAME] No 12/11/17 (blank) - [MEDICAL CONDITION] [MEDICATION NAME] No 12/20/17 (blank) - PNA [MEDICATION NAME] No 12/21/17 [MEDICATION NAME] Keflex (Indefinitely) (line drawn through area) 12/25/17 (blank) - PNA Keflex No 12/28/17 (blank) - UTI [MEDICATION NAME][MEDICATION NAME] (line drawn through area) 12/29/17 (blank) - UTI Bactrim - DS No 12/29/18 (blank) - UTI [MEDICATION NAME] No 12/29/17 (blank) - Sinus Infection [MEDICATION NAME] No 1/2/18 (blank) - UTI [MEDICATION NAME] No 1/2/18 (blank) - UTI [MEDICATION NAME] No 1/3/18 (blank) - Increased WBC [MEDICATION NAME] No 1/3/18 (blank) - PNA [MEDICATION NAME] No 1/3/18 (blank) - Increased [MEDICATION NAME] No 1/4/18 (blank) - UTI [MEDICATION NAME] No 1/5/18 (blank) - URI [MEDICATION NAME] No 1/5/18 (blank) UTI [MEDICATION NAME] No 1/7/18 (blank) - PNA [MEDICATION NAME] No 1/7/18 (blank) - PNA [MEDICATION NAME] No 1/8/18 (blank) - [MEDICAL CONDITION] [MEDICATION NAME] No 1/9/18 (blank) - UTI [MEDICATION NAME] No 1/10/18 (blank) - PNA Levoquin No 1/10/18 (blank) - [MEDICAL CONDITION] [MEDICATION NAME] No 1/15/18 (blank) - UTI [MEDICATION NAME] No 1/17/18 (blank) - [MEDICAL CONDITION] Infection [MEDICATION NAME] Yes 1/19/18 (blank) - PNA [MEDICATION NAME] No 1/26/18 (blank) - [MEDICAL CONDITION] Keflex No 1/29/18 (blank) - SOB (shortness of breath) [MEDICATION NAME] No 1/29/18 (blank) - UTI [MEDICATION NAME] No 1/13/18 (blank) -[MEDICAL CONDITION] [MEDICATION NAME] No 1/31/18 (blank) - [MEDICAL CONDITION] Bactrim, [MEDICATION NAME], Vanco No 1/31/18 (blank) - UTI [MEDICATION NAME] No 1/31/18 (blank) - [MEDICAL CONDITION] Cephaloxin No 2/2/18 (blank) - PNA Levoquin No 2/5/18 (blank) - Cough/URI Azithomax No 2/5/18 (blank) - [MEDICAL CONDITION] Keflex No 2/9/18 (blank) - PNA Levoquin No 2/11/18 (blank) - Fever Keflex No 2/11/18 (blank) - Fever [MEDICATION NAME] No 2/17/18 (blank) - Wound Infection Bactrim - DS No 2/20/18 (blank) - [MEDICAL CONDITION] Keflex No 2/20/18 (blank) - UTI [MEDICATION NAME] No ( 2/28/18 (blank) - Wound Infection Bactrim No 2/28/18 (blank) - [MEDICAL CONDITION] Cephalox No Interview on 3/5/18 at approximately 2:15 p.m. with Staff Q (RN Infection Control Program) revealed that cultures were not done to determine the most appropriate antibiotic based on the organism. Interview on 3/5/18 at approximately 2:15 with Staff B (RN Director of Nursing) revealed that cultures were not done to determine the most appropriate antibiotic based on the organism.",2020-09-01
16,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,883,D,0,1,6C1411,"Based on record review and interview, it was determined that the facility failed to provide influenza vaccination in a timely manner for one resident in a standard survey sample of 43 residents. (Resident identifier is #157.) Findings include: Interview with Staff D, unit manager, on 3/2/18 revealed Resident #157 was transferred to their unit from another unit in the facility in (MONTH) or (MONTH) of (YEAR), and that resident had not received a flu shot in the Fall of (YEAR). Another interview With Staff D on 3/5/18 revealed that there was a standing order for flu vaccine if not allergic to eggs, and Staff D related the resident is not allergic to eggs, and that there is no documentation in the record why the influenza vaccine was not given during the last four months of (YEAR) or documentation that the doctor was notified that the order for influenza vaccine was not administered. Review of the temperature log in the electronic medical record for Resident @157 revealed that for the period from 8/12/17 through 1/9/18 all recorded temperatures were less than 100.0, with the exception of 1/3/18 when the temperature was 103.6 degrees. Review of a nurses not for 1/3/18 reveals that the resident was sent out to the hospital, fever was 103.6, an update from the hospital confirmed flu.",2020-09-01
17,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,908,E,0,1,6C1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview it was found that the facility failed to maintain patient care equipment in safe operating condition to meet residents needs due to 5 of 6's batteries that failed to hold a charge and left 14 residents who are Hoyer lifts from getting care if needed. Also the facility failed to document temperatures of the hydrocllator on a daily bases to prevent burning during resident treatment. (Resident identifier is #90). Findings include: On 2/27/18 at 10:58 a.m. interview with Resident #90 stated they did not get a shower on 2/23/18 due to the Hoyer lift's not working and being able to get them out of bed. On review of the shower schedule for Resident #90 it was found that the information provided was correct and Resident #90 did not get a shower as documented on 2/23/18. Interview with Staff B (LNA) confirmed that none of the Hoyer lifts work due to the batteries not able to hold a charge. Staff B also confirmed that Resident #90 did not get a shower that day due to the lifts not working and also said other residents also did not always get up for the day due to the battery issues. Staff B when on to say that the Hoyer's would work for about 2 seconds and then they would have to find another battery to continue the task. Staff B also stated that lots of times the resident's would get stuck in the middle of transferring them and they would have to physically remove the resident from the Hoyer lift. On review of the facility's Battery Charging Tracking Tool sheet for 2/26/18 it documents that battery #'s (1, 3, 4, 6, and 7) under Comments no good. Observation on 3/1/18 at approximately 9:00 a.m. of the facility rehabilitation area with Staff P (Rehabilitation Director) revealed that the facility hydrocllator log did not have temperatures taken on the following dates: 1/1/18, 2/18/18, 12/25/17, 11/23/17, 10/6 & 10/7/17, 9/2/17, 9/4/17, 9/9/17, 9/16/17, 9/23/17, 9/30/17, 8/5/17, 8/12/17, 8/19/17, 8/26/17. Temperatures were not done on Sundays for the following dates 1/7/18,1/14/18, 1/21/18 and 2/28/18, 2/4/18, 2/11/18, 2/25/18, 12/3/17, 12/10/17, 12/17/17 and 12/24/17,11/5/17, 11/12/17, 11/19/17, 11/26/17 and 10/1/17, 10/8/17, 10/15/17, 10/22/17 and 10/29/17. Review of the facility policy and procedure titled Clinical Practice Guidelines for the [MEDICATION NAME] dated 9.23.14 revealed the following [MEDICATION NAME] Unit Maintenance . The unit water temperature should be checked and recorded on a daily basis. Review of the INSTRUCTIONS FOR THE USE AND OPERATION OF THE [MEDICATION NAME] M-2 MASTER HEATING UNIT revealed the following: PRECAUTIONARY INSTRUCTIONS 3. REMEMBER. the water temperature in the [MEDICATION NAME] is approximately 160 degrees F (71 degrees C) and the water scalding temperature is approximately 120 degrees F (49 degrees C) . The following steps should be taken when applying the Steam Packs. 1. Know and apply the Precautionary rules. They are for the protection of both the patient and the therapist. Interview on 3/1/18 at approximately 9:00 a.m. with Staff P during this observation confirmed that the [MEDICATION NAME] temperatures were not consistently taken as listed in the above findings. Observation on 03/05/18 at 09:55 AM the tiles, on Unit 2 in rooms 16,19,21.18. 22, 23, 24, 25, and 27 are all cracked and are hard to maintain the integrity to the floor. The wallpaper outside rooms 17, 19, 21 and 22 are peeling and or missing. Interview on 2/28/18 at 1:00 p.m. with Staff C (Director of Nursing) we review the Capital budget which has some improvements for the roof, floor and medication room but not the individual floors or replacing the wallpaper.",2020-09-01
18,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-03-05,926,E,0,1,6C1411,"Based on observation, interview, and record review, the facility failed to have smoking policies and procedures that reflect practices at the facility. Findings include: Observation on 2/28/10 at 8:25 a.m. revealed Resident #80 was outside in front of the main entrance smoking. Observation on 2/28/18 at 9:00 a.m. revealed Resident #80 was outside in front of the main entrance bundled up for weather with a bath blanket over legs in a manual wheelchair. Resident #80 had a cigarette that was put out wrapped in tissue paper. Interview with Staff G (5-2 unit manager) on 2/28/18 9:45 a.m. revealed that staff are aware that Resident #80 goes outside to smoke. Interview further revealed that Staff G did not know where Resident #80 gets cigarettes and if staff see lighters or cigarettes, they are supposed to take and hold them. Observation on 3/01/18 at 8:05 a.m. revealed Resident #80 outside the main entrance smoking. Observation also revealed three old cigarettes butts on the ground near the main entrance. Review of the facility's smoking policy (not titled or dated) revealed that the facility prohibits the use of tobacco and tobacco products on the facility's premises and there are no designated smoking times or locations. Interview on 3/02/18 at 9:07 a.m. with Staff C (Director of Nursing) revealed that they are a non-smoking facility and have always been a non-smoking facility. Interview also revealed that the Staff C did not know where Resident # 80 gets cigarettes. Interview confirmed the the above smoking policy. Interview with Staff C on 3/02/18 at 9:45 a.m. there was a smoking assessment done for Resident #80 that looked at the resident's cognitive ability/vision/and physical functioning. The assessment did not include any observations of smoking. Interview further revealed that they do not do a complete assessment to include observation or Interdisciplinary team determination, because they are a non-smoking facility. Review on 3/2/18 at 9:35 a.m. of Resident #80's current care plan showed the following smoking goal: (Resident name omitted) wishes to smoke and is assessed for supervision level: Independent. Interview with Resident #80 on 3/2/18 at 10:15 a.m. revealed the resident goes outside to smoke and the resident hides a lighter and the resident's cigarettes in the resident's room. Interview also revealed that Resident #80 was outside smoking and the wheelchair rolled off the curb and the resident fell out of their wheelchair on 2/26/18. Review on 3/2/18 at 1:33 p.m. of Resident #80's progress notes revealed the following entries: On 7/7/17 at 2:57 p.m.Pt (patient) wears oxygen during the day. Will frequently take it off and wheel herself outside to smoke . On 8/1/17 at 2:25 p.m. Pt (patient) wears oxygen during the day. Will frequently take it off and wheel herself outside to smoke . On 10/19/17 at 8:51 a.m. Last night around midnight, I received a phone call from a concerned individual that there's somebody in (sic) the sidewalk in front of the bld. in a wheelchair with blanket and pillow. I went outside immediately to check and found (Resident #80's name omitted) smoking in (sic) the sidewalk. I asked (pronoun) omitted to come back inside the building with me because it is not safe for (pronoun omitted) to be out there in the middle of the night. (Pronoun omitted) continued to smoke until (pronoun omitted) was done . I explained to (pronoun omitted) that (pronoun omitted) might get hit or (pronoun omitted) might fall navigating the wheelchair in the incline .",2020-09-01
19,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2017-09-07,157,D,1,0,9SPV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician with a change of condition of a resident resulting in a hospitalization , for 1 resident in a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on [DATE] of Resident #1's (MONTH) (YEAR) Care Plan revealed DPOA (Durable Power of Attorney) was activated [DATE]. The ADL Self Care Performance . section of this Care Plan revealed that Resident #1 was independent with transfers, toilet use, personal hygiene, oral hygiene and eating. This Care Plan also revealed that Resident #1 was an elopement risk/wanderer . Review on [DATE] of Resident #1's Care Plan revealed further that Resident #1 uses antidepressant medication with the Interventions/Tasks listed as Monitor/document/report to MD (medical doctor) prn (as needed) s/sx (signs/symptoms) of depression .slowed movement .disrupted sleep, fatigue, lethargy .changes in cognition . and in the section for . anti-anxiety medications r/t (related to) anxiety . with the Interventions/Tasks listed as . ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy .confusion and disorientation .Implement interventions based on results of behavior assessment. Review on [DATE] of the nursing Progress Notes dated [DATE] at 23:36 revealed the following; Resident (Resident #1) had gone out with daughter today. (Resident #1) came back around ,[DATE]. Shortly after (Resident #1) came back, (Resident#1) started to obsess about .daughter . (Resident#1) couldn't sit still for more than 5 to 10 minutes before (Resident#1) got up and continued with .anxiety . After the LNA (Licensed Nursing Aide) got (Resident #1) in bed, (Resident #1) was quiet for a while, but then came back out into the hallway after 2100 still obsessed . Review on [DATE] of the nursing Progress Notes dated [DATE] for Resident #1 revealed the following three individual entries: when the writer was given off report to the on coming nurse, the friend came to visit and was concern (sic). Both the on coming nurse and the writer checked up on the resident and resident was lethargic and non responsive. Immediate response was taken . At approximately 1630 this writer was paged to unit by Charge nurse. Nurse stated that the resident was unresponsive and had vomited. This writer entered the room and observed the resident lying on L (left) side w/scant amount of emesis and drool next to mouth. Resident had a visitor in the room. Upon initial assessment of pupil dilatation this writer noted that pupils were unreactive and requested that 911 be called. LNA (Licensed Nursing Assistant) was instructed to get O2 (oxygen) tank and place resident on 4 liters r/t (related to) O2 saturation in low 80's. This writer also began sternal rub w/o (without) positive effect. This writer left the resident with another RN (Registered Nurse) on the unit to inquire on the status of emergency transport and paperwork. Upon return to the room, the daughter had arrived .Another attempt to arouse resident was made and O2 saturation once again checked. O2 saturation had increased to 93%. EMTs (Emergency Medical Technician) then arrived on unit and took over. At 16:35, this nurse was called down to the resident's room. Resident was in bed on . left side, snoring, emesis and drool on the sheets around . face, unresponsive. Notified supervisor who came right up. Pupils unreactive, ,[DATE], Pulse 118, 86% O2 (oxygen) RA (room air), resp (respirations) 18, temp (temperature) 99.5. Resident is a Full Code. Called 911 . Review on [DATE] of Staff C's (Licensed Nursing Assistant) written statement dated [DATE] revealed the following: After breakfast I was told by my nurse (Staff D) that the resident was very tired and she put (Resident #1) in .chair because she could not convince the resident to lay down on (Resident #1) bed. I (Staff C) checked on resident twice and reported to nurse (Staff D) that (Resident #1) was still sleeping A few hours after my nurse (Staff D) asked me (Staff C) to help her transfer the resident to . bed because (Resident #1) was hanging over .chairarm and she did not want (Resident#1) falling. The resident did not wake up during the transfer, after we got (Resident#1) on .bed, the visitor that was also in the room tried speaking to the resident at which the resident mumbled an unrecognized word. I (Staff C) checked on the resident two more times before my (Staff C) shift ended and reported to nurse (Staff D) that the resident was snoring. My nurse (Staff D) said let (Resident#1) sleep because (Resident#1) was very tired. Interview on [DATE] at approximately 4:25 p.m. with Staff C (LNA) regarding this incident, revealed that Staff C went to get Resident #1 in the morning after breakfast, went to (Resident #1's) room .(Resident #1) not there. Thought Resident #1 went to get coffee. Later observed Resident #1 sitting in chair beside bed and that the Resident #1 looked like a drunk and acted like a drunk person, limp and leaning on staff . Staff C reported to Staff D what she observed and was told let (Resident #1) sleep because (Resident #1) didn't sleep last night. Staff C reported at this time that this was not like Resident #1 and that Resident #1 usually doesn't sleep that late and is usually up & about. Staff C was told by Staff D to leave Resident #1 alone and let Resident #1 sleep. Staff C further revealed during this interview that Staff D asked Staff C to help transfer Resident #1 back to bed and reported that Resident #1 was leaning on staff for support and that Resident #1 was very limp with Resident #1's upper extremities, like (Resident #1) was zonked and staff had to lift Resident #1 into bed. Staff C revealed that during this transfer Resident #1 didn't say words .mumbled and staff were unable to understand Resident #1. Staff C revealed that Staff C checked Resident #1 and could hear (Resident #1) snoring. Staff C revealed that Resident #1 was not awake for lunch on [DATE]. Staff C was told to let (Resident #1) sleep .(Resident #1) is very tired by Staff D. Staff C revealed during this interview that when Staff C rendered care after lunch at the time of change of shift to check and change (check for urination and change under garment) Resident #1 was rolled on the bed to change undergarment. Staff C revealed that a clean undergarment was applied to Resident #1 and that Resident #1 was not awake, did not stir or verbalize anything during this task. Interview on [DATE] at approximately 2:15 p.m. with Staff A (Administrator) and Staff B (Assistant Director of Nurses) confirmed that Resident #1 had a change in condition on [DATE] when Resident #1 was leaning on staff for support and was limp with upper extremities and mumbling words staff could not understand during transfer from the chair to bed. The facility failed to notify the physician at the time Resident #1 had a change in condition which was confirmed by Staff A and B during interview on [DATE]. Staff A reported that facility staff were educated on the procedure for What is a change in condition and When to Notify on [DATE]. Surveyor:[NAME]B. Review on [DATE] of Resident #1's incident revealed a signed statement dated [DATE] by Staff D (Licensed Practical Nurse/Licensed Vocational Nurse) who documented the following: Morning routine (Resident #1) always up and about. As I went in my morning shift (Resident #1) kept talking to me as usual. (Resident #1) is always up in the morning and comes to talk to me and the LNA's. (Resident #1) looked exhausted but I had been told (Resident #1) usually doesn't get much sleep in the night. Around 9:30 - 10:00 I told (Resident #1) . try (sic) to take a nap (Resident #1) was sitting in (sic) the couch in front of elevators and was ambulating and walked to . room. Sat down in the recliner because (Resident #1) refused to be in bed. (Resident #1) was fine @ (sic) that time and then .friend (name omitted) came to visit .friend said we should come in went to see (Resident #1) and (Resident #1) was sleeping, no hard breathing noted, no high respirations no sweating or excessive sweating noted. The snoring was normal. Not deepen at this time @ (sic) 11:00. Resident was transferred 1200 (sic) from the recliner to bed. Resident usually doesn't eat much through the day. (Resident #1) didn't eat breakfast or lunch. Resident usually can take a nap during the day. The LNA and I checked up on resident throughout the day. The resident did not throw up the times that I rounded . pupils were reactive when I checked upon (Resident #1). After giving report to the on coming nurse (Resident #1's) friend came to us and said something is wrong we went to see (Resident #1) was on (Resident #1's) left side emesis (sic), . was breathing heavily, .was sweating profusely so immediate action was place called 911 supervisor was called and (unreadable writing) and doctor. Interview on [DATE] at approximately 11:20 a.m. with Staff D, Staff D stated the events occurring on [DATE] that lead up to Resident #1 being transported out to the hospital: Staff D stated that she had come in to her shift and was told the Resident #1 had not slept well the previous night. When Staff D left report Resident #1 approached her to talk and then Resident #1 went downstairs as Resident #1 usually does to get breakfast. When Resident #1 came back upstairs Resident #1 sat on the couch in front of the elevators and dozed off. Staff D approached Resident #1 and encouraged Resident #1 to go back to his/her room and take a nap. Resident #1 ambulated back to his/her room and sat in Resident #1's recliner - this was around 10:30 a.m. Around 11:00 a.m. Staff D was approached by Resident #1's family friend who stated she was concerned about Resident #1 as she was sleeping in the recliner chair in the room and was slumped over the side of the chair and was not responsive. Staff D asked Staff C (LNA) to assist Staff D in getting Resident #1 into the bed for a nap. Staff D and Staff C arrived in Resident #1's room and stood and pivoted Resident #1 into bed. Resident #1 did not wake up or respond to this transfer. Once Resident #1 was in bed Resident #1 opened one eye, looked at the family visitor and mumbled something to her that was unintelligible the Resident #1 appeared to be sleeping. Staff D was asked if Staff D had performed an assessment of Resident #1 and Staff D stated that she had performed an assessment that appeared to be normal but that she had another resident that was in crisis and needed to be sent out to the emergency room . Staff D stated that she did not document the assessment because she was too busy with the other resident and had forgotten. Staff D was asked if Staff D notified Resident #1's physician and Staff D stated she had not as she believed Resident #1 was just tired based on the report she had received during morning report. This writer asked if the way Resident #1 had presented during Staff D's shift was the way Resident #1 usually presented and Staff D stated, No, generally (Resident #1) was up and about walking around and socializing. Staff D went on to explain that later in the day the family friend had returned, probably around 4:00 p.m. and asked Staff D to come see Resident #1 because Resident #1 was not responding and had vomited in Resident #1's bed. Staff D performed an assessment at this time of Resident #1 who was found on left side in vomit and drool around face, unresponsive, pupils were not reactive, blood pressure was ,[DATE], pulse was 118 and oxygen saturation on room air was 86% and Resident #1 had a temp of 99.5. On call MD was notified and 911 called for transport. The shift supervisor for the facility was notified of the situation. Staff D stated that the resident was transported to the hospital and died approximately 23 hours later. Interview on [DATE] at approximately 4:25 p.m. with Staff C (Licensed Nursing Assistant) regarding the events of [DATE] with Resident #1, Staff C stated that she was concerned throughout her shift and notified the Staff D a couple of times that the resident was still sleeping. Staff C stated that she was told by Staff D to just let Resident #1 sleep as she did not sleep well the night before and was just tired. When asked Staff C if Resident #1 had lunch and Staff C stated that Resident #1 did not as Staff C had been instructed not to wake Resident #1 because Resident #1 was so tired. Staff C stated that she did assist Staff D with transferring the resident around 11 a.m. from the recliner chair to the bed because Resident #1 was hanging over the side of the recliner. Staff C stated that during this transfer the resident acted like a drunk person, she was limp and leaning on staff as Staff C and Staff D pivoted Resident #1 into bed. Staff C stated that Resident #1 did not wake up during this transfer but did mumble something once Resident #1 had been transferred to bed but Staff C could not understand what Resident #1 had said and then Resident #1 slept.",2020-09-01
20,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2017-09-07,281,D,1,0,9SPV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to follow the professional standard of practice for the assessment of a resident, for 1 resident in a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Reference for the professional standard of practice for assessment documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009, which revealed the following: Chapter 16 Nursing Assessment page 243. Data Documentation Data documentation is the last part of a complete assessment. The timely, thorough, and accurate documentation of facts is necessary when recording client data. If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone caring for the client. If there is not specific information, the reader is left with only general impressions. Observation and recording of a client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. Review on [DATE] of Staff C's (Licensed Nursing Assistant) written statement dated [DATE] revealed the following: After breakfast I was told by my nurse (Staff D) that the resident was very tired and she put (Resident #1) in .chair because she could not convince the resident to lay down on (Resident #1's) bed. I (Staff C) checked on resident twice and reported to nurse (Staff D) that (Resident #1) was still sleeping A few hours after my nurse (Staff D) asked me (Staff C) to help her transfer the resident to . bed because (Resident #1) was hanging over .chairarm and she did not want (Resident #1) falling. The resident did not wake up during the transfer, after we got (Resident #1) on .bed, the visitor that was also in the room tried speaking to the resident at which the resident mumbled an unrecognized word. I (Staff C) checked on the resident two more times before my (Staff C) shift ended and reported to nurse (Staff D) that the resident was snoring. My nurse (Staff D) said let (Resident #1) sleep because (Resident #1) was very tired. Interview on [DATE] at approximately 4:25 p.m. with Staff C (LNA) regarding this incident, revealed that Staff C went to get Resident #1 in the morning after breakfast, went to (Resident #1's) room . resident not there. Thought resident went to get coffee. Later this LNA (Staff C) observed Resident #1 sitting in chair beside the bed and that the resident looked like a drunk. This LNA (Staff C) reported to the nurse what she observed and was told by Staff D to let (Resident #1) sleep . (because Resident#1) didn't sleep last night. Staff C revealed that this was not like Resident #1 and that Resident #1 usually doesn't sleep that late and is usually up & about. Staff C was told by the Staff D to leave Resident #1 alone and let Residen t#1 sleep. Staff C further revealed at this time that Staff D asked her to help transfer Resident #1 back to bed and reported that Resident #1 was leaning on staff for support and that Resident #1 was very limp with Resident #1's upper extremities, like (Resident #1) was zonked and staff had to lift Resident#1 into bed. During this transfer Staff C reported that the Resident #1 didn't say words . mumbled and staff were unable to understand Resident #1. Staff C checked Resident #1 and could hear (Resident #1) snoring. Resident #1 was not awake for lunch on [DATE]. Staff C was told by Staff D to let (Resident #1) sleep .(Resident #1) is very tired. The facility failed to assess Resident #1 at the time Resident #1 was transferred from the chair to the bed by two staff. Resident #1 was reported as limp, leaning on staff for support and mumblingduring this transfer when Resident #1 was usually independent in walking. Staff C revealed that Resident #1 was not himself/herself and not coherently talking with staff. Interview on [DATE] at approximately 2:15 p.m. with Staff A (Administrator) and Staff B (Assistant Director of Nurses) confirmed that Resident #1 had a change in condition on [DATE]. when Resident #1 was leaning on staff for support and was limp with his/her upper extremities and mumbling words staff could not understand during transfer from the chair to bed. Staff A and Staff B revealed that the facility failed to assess Resident #1 for a change in condition. Review on [DATE] of the incident report revealed a signed statement dated [DATE] by Staff D (Licensed Practical Nurse/Licensed Vocational Nurse) who documented the following: Morning routine (Resident #1) always up and about. As I went in my morning shift (Resident #1) kept talking to me as usual. (Resident #1) is always up in the morning and comes to talk to me and the LNA's. (Resident #1) looked exhausted but I had been told (Resident #1) usually doesn't get much sleep in the night. Around 9:30 - 10:00 I told (Resident #1) . try (sic) to take a nap (Resident #1) was sitting in (sic) the couch in front of elevators and was ambulating and walked to . room. Sat down in the recliner because (Resident #1) refused to be in bed. (Resident #1) was fine @ (sic) that time and then .friend (name omitted) came to visit .friend said we should come in went to see (Resident #1) and (Resident #1) was sleeping, no hard breathing noted, no high respirations no sweating or excessive sweating noted. The snoring was normal. Not deepen at this time @ (sic) 11:00. Resident was transferred 1200 (sic) from the recliner to bed. Resident usually doesn't eat much through the day. (Resident #1) didn't eat breakfast or lunch. Resident usually can take a nap during the day. The LNA and I checked up on resident throughout the day. The resident did not throw up the times that I rounded . pupils were reactive when I checked upon (Resident #1). After giving report to the on coming nurse (Resident #1's) friend came to us and said something is wrong we went to see (Resident #1) was on . left side emesis (sic), . was breathing heavily, .was sweating profusely so immediate action was place called 911 supervisor was called and (unreadable writing) and doctor. Interview on [DATE] at approximately 11:20 a.m. with Staff D, Staff D stated the events occurring on [DATE] that lead up to Resident #1 being transported out to the hospital: Staff D stated that she had come in to her shift and was told that Resident #1 had not slept well the previous night. When Staff D left report Resident #1 approached her to talk and then Resident #1 went downstairs as Resident #1 usually does to get breakfast. When Resident #1 came back upstairs Resident #1 sat on the couch in front of the elevators and dozed off. Staff D approached Resident #1 and encouraged Resident #1 to go back to Resident #1's room and take a nap. Resident #1 ambulated back to room and sat in the recliner - this was around 10:30 a.m. Around 11:00 a.m. Staff D was approached by Resident #1's family friend who stated she was concerned about Resident #1 as he/she was sleeping in the recliner chair in the room and was slumped over the side of the chair and was not responsive. Staff D asked Staff C (LNA) to assist Staff D in getting Resident #1 into bed for a nap. Staff D and Staff C arrived in Resident #1's room and stood and pivoted Resident #1 into bed. Resident #1 did not wake up or respond to this transfer. Once Resident #1 was in bed Resident #1 opened one eye, looked at the family visitor and mumbled something to her that was unintelligible then Resident #1 appeared to be sleeping. Staff D was asked if Staff D had performed an assessment of Resident #1 and Staff D stated that she had performed an assessment that appeared to be normal but that she had another resident that was in crisis and needed to be sent out to the emergency room . Staff D stated that she did not document the assessment because she was too busy with the other resident and had forgotten. Staff D was asked if the way Resident #1 had presented during Staff D's shift was the way Resident #1 usually presented and Staff D stated, No, generally (Resident #1) was up and about walking around and socializing. Staff D went on to explain that later in the day the family friend had returned, probably around 4:00 p.m. and asked Staff D to come see Resident #1 because Resident #1 was not responding and had vomited in the bed. Staff D performed an assessment at this time of Resident #1 who was found on Resident #1's left side in vomit and drool around face, unresponsive, pupils were not reactive, blood pressure was ,[DATE], pulse was 118 and oxygen saturation on room air was 86% and Resident #1 had a temp of 99.5. On call MD was notified and 911 called for transport. The shift supervisor for the facility was notified of the situation. Staff D stated that the resident was transported to the hospital and died approximately 23 hours later. Interview on [DATE] at approximately 4:25 p.m. with Staff C (Licensed Nursing Assistant) regarding the events of [DATE] with Resident #1, Staff C stated that she was concerned throughout her shift and notified Staff D a couple of times that the resident was still sleeping. Staff C stated that she did assist Staff D with transferring the resident around 11:00 a.m. from the recliner chair to the bed because Resident #1 was hanging over the side of the recliner. Staff C stated that during this transfer the resident acted like a drunk person, was limp and leaning on staff as Staff C and Staff D pivoted him/her into bed. Staff C stated that Resident #1 did not wake up during this transfer but did mumble something once he/she had been transferred to bed but Staff C could not understand what Resident #1 had said and then Resident #1 slept.",2020-09-01
21,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-10-16,658,D,1,0,QTPI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and facility policy review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #2.) Findings include: Review on 10/16/18 of Resident #2's Order Summary Report revealed that Resident #2 had a physician order [REDACTED]. Review on 10/16/18 of Resident #2's nurses notes, dated 9/20/18, revealed that Resident #2 was .admitted to (Proper Noun) hospital for [MEDICAL CONDITION], without any further notes indicating the signs or symptoms that Resident #2 was experiencing. The last documented nurses note prior to that note was a nurse's note, dated 9/18/18. Review on 10/16/18 of the Facility Policy, titled Charting and Documentation, last revised 4/2018, revealed that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . Interview on 10/16/18 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed that there was no documentation of daily skilled notes.",2020-09-01
22,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-10-16,660,D,1,0,QTPI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and facility policy and procedure it was determined that the facility failed to implement the discharge planning process to ensure that the needs of 1 resident were met at the time of discharge back to the home setting in a survey sample of 12 discharged residents. (Resident identifier is #1.) Findings include: Review on 10/16/18 of the facility policy and procedure titled Discharge Summary and Plan dated 11/2017 revealed the following: POLICY When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Guidelines a) When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ,,,, etc.), a discharge summary and post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. b) The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. Current diagnosis; b. Medical history .; c. Course of illness, treatment and/or therapy since entering the facility; d. Current laboratory, radiology, consultation, and [DIAGNOSES REDACTED].>e. Physical and mental functional status; f. Ability to perform activities of daily living .; g. Sensory and physical impairments (neurological, or muscular deficits, for example, a decrease in vision and hearing, paralysis, and bladder incontinence); h. Nutritional status and requirements; . i. Special treatments or procedures . j. Mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indications of resident behavior and mood); k. Discharge potential (the expectation of discharging the resident from the facility within the next three months); l. Dental condition . m. Activities potential . n. Rehabilitation potential . o. Cognitive status . p. Medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration and recognition of significant side effects that would be most likely to occur in the resident). c.) As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. d.) Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. e.) The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include; . f.) The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. g.) The resiident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan; h.) Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. i.) If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. j.) Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals and treatment preferences. Data used in helping the resident select an appropriate facility includes the receiving facility's . k.) The resident or representative . should provide the facility with notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed. l.) A member of the IDT (interdisciplinary team) will review the final post-discharge plan with the resident and family before the discharge is to take place. m.) A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records . k. An evaluation of the resident's discharge needs. l. The post-discharge plan; and m. The discharge summary. Resident #1. Review on 10/16/18 of Resident #1's electronic medical record and the soft paper record revealed that Resident #1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review on 10/16/18 of the Nurse Notes for Resident #1 revealed the following; - 2/19/18 TC (telephone call) to (name and telephone number) re (regarding) Status of getting (Resident#1) home. ML (message left) waiting for (Sentence not completed.) - 4/26/18 S.S. (social service) spoke with (Resident #1) about .over all plan as far as discharging home. S.W. (social worker) has been following up with .in the county where (Resident #1) lives to find assistance for . (Resident #1) when (Resident #1) has an actual discharge date . - 5/10/18 .S.S. working on d/c (discharge) plan for (Resident #1) to get home with equipment and services - 8/28/18 @ 13:58 S.W. spoke with (Resident #1) prior to .discharge tomorrow in the S.S. office. (Resident #1) had this writer buy (Resident #1) a sit to stand lift and have it delivered to (Resident #1's) home. During this time this writer stated that (Resident #1) will need to stay a few more days longer do (sic) to it taking 5-10 days for this lift to even be delivered. There was (sic) witnesses in the office when (Resident #1) stated that is was able (sic) to scoot slide out of . power chair and would like to go home knowing that (Resident #1) will not receive the sit to stand lift on discharge. (Supplier) will be providing the rest of his DME (durable medical equipment) tomorrow. Services were set up through (visiting nursing) and (ambulance) was booked for 2pm pickup to home. S.S. will follow up as needed. - 8/28/18 Resident (#1) had a pulmonologist appointment and new medications were prescribed. (Physician) notified and ordered for the resident (#1) to be given prescripts tomorrow on discharge to home. - 8/29/18 Resident left (discharged ) for home at 1500. Review on 10/16/18 of the physician note for Resident #1 dated 8/17/2018 revealed the following: Pt (patient) is wheelchair dependent, (Resident #1) can use a manual w/c for short distances, due to carpal tunnel syndrome bilateral wrists, (Resident #1) is currently able to use an electric w/c. Needs a stand assist to transfer. Pt is cont (continent) of B&B (bladder & bowel), needs assist to transfer to commode. 1. The patient requires a wide/heavy duty commode chair due to (Resident #1's) weight is over 300lbs (pounds) and pt is confined to a single room. 2. (Resident#1) will require a manual wheelchair for inside .home use as (Resident #1) is a paraplegic and nonambulatory . 3. Pt. requires a hospital, semi electric hospital bed, due to pt. [MEDICAL CONDITION], hx (history) GERD, and persumptive dx (diagnosis) of [MEDICAL CONDITION] with chronic cough. Pt needs .head elevated when .in bed to be more than 30 degrees .requires frequent positioning. 4. Pt needs a Patient Lift, (stand assist) to transfer between .bed, wheel chair and commode. Pt cannot transfer independently due to [MEDICAL CONDITION] without a lift pt would be bed bound. 5. Pt requires a support surface, a mattress overlay due to [MEDICAL CONDITION] and inability to independently reposition Record review on 10/16/18 revealed the Physician Attestation of Face to Face Encounter for Home Health Referral dated 8/23/18 for PT (physical therapy), OT (occupational therapy) therapeutic exercise ROM (range of motion), safety endurance. RN (Registered Nurse) assess & med (medication) management, HHA (home health aide) ass (assist) + ADLs (activities of daily living), SW (social worker) liaison to community resources. Review on 10/16/18 revealed a fax to a home health agency dated 8/29/18 the day of discharge from the facility for PT, OT, HHA, SW services for Resident #1. Review on 10/16/18 of Resident's #1 electronic medical record revealed the following; - 8/30/18 . This writer (social worker) had a home care agency in place as well for them to go out and see (Resident #1) 48 hours after d/c (discharge). This writer received a voicemail from the agency that stated they could not take (Resident #1) on case load due to not having the staff to go to (Resident #1's town). The agency left this writer another agency to call that could better service. This writer called (home health agency) and faxed all .paper work to them for RN and HHA in the home Interview on 10/16/18 at approximately 11:30 a.m. with Staff C (Social Worker) revealed after review of the electronic and paper record for Resident #1that there is no documented evidence that the social worker followed up with discharge plans on 2/19, 4/26, 5/10 and 8/28/18, that there was no documented evidence of a discharge plan with goals and needs to ensure a safe transition from the facility, no documentation prior to discharge that the referral home health agency accepted Resident #1 for the services ordered in the home, no documentation that Resident #1 was given the prescriptions for new medications ordered at the time of discharge and no documentation of a copy of the evaluation of Resident #1's discharge needs, post-discharge plan and discharge summary. Interview on 10/16/18 at approximately 3:00 p.m.with Staff A (Registered Nurse) and Staff B (Registered Nurse) confirmed the findings listed above for Resident #1. The facility failed to fully implement the discharge planning process prior to discharge and Resident #1 was discharged to Resident #1's home with no ordered home health services and adaptive equipment in place to meet Resident #1's needs in the home setting.",2020-09-01
23,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,580,D,0,1,TYS711,"Based on interview and record review, it was determined that the facility failed to notify a physician for a resident who had a change in an AIMS (Abnormal Involuntary Movement Scale) assessment for 1 resident in a final survey sample of 35 residents. (Resident identifier is #17.) Findings include: Review on 10/28/19 of Resident #17's AIMS revealed the following: 11/9/18 - score 0 (no abnormal movements) 2/9/19 - score 0 (no abnormal movements) 5/9/19 - score 0 (no abnormal movements) 7/31/19 - score 6 (Resident scored a 1 in upper (arms, wrists, hands, fingers) include chronic movements, scored a 1 in lower (legs, knees, ankles, toes), scored a 2 in severity of abnormal movements, scored a 2 in incapacitation due to abnormal movements. Interview on 10/28/19 at approximately 1:00 p.m. with Staff K (Licensed Practical Nurse) revealed that there was no documentation that the physician was notified of the changes in Resident #17's AIMs.",2020-09-01
24,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,584,B,0,1,TYS711,"Based on observation and interview, it was determined that the facility failed to provided a safe, clean, comfortable and homelike environment for 2 of 5 units. Findings include: Observation on 10/23/19 at 1:12 p.m. during tour of the third floor revealed that the shower room located behind the nurses station had black like tar in 3 inch strips around the outside edges of the shower unit where the walls meet the floor. Also several tiles were broken failing to meet a home like environment. Interview on 10/23/19 at approximately 1:15 p.m. with Staff A (Unit Manager) reviewed the above findings and Staff A stated they are to be remodeling the shower units at some time but was not sure when. Observation on 10/26/19 at approximately 9:30 a.m. of unit one of building one had a strong and pervasive urine like odor which lasted until almost noontime. Observation on 10/23/19 at approximately 11:45 a.m. on the dementia unit revealed a strong urine like odor in the left hallway.",2020-09-01
25,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,656,B,0,1,TYS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that would include measurable objectives and time frames to meet the residents' needs for 3 residents who were smokers and 2 residents with other care needs out of a final survey sample of 35 Residents. (Resident identifiers are #49, #88, #340, #341 and #540). Findings include: Resident # 49 Interview on 10/23/19 at 01:03 p.m. with Resident #49 resulted in Resident #49 stating I get my cigarettes from the nurse. There's a sign out book at the nurse's station. I sign out the book and the nurse gets me my smoking materials. Then I go outside and smoke off the property. We have to smoke off the facility property, out on the sidewalk. When I'm done, I go back to the nurse's station to turn in my smoking materials to the nurse and then I sign back in. If no one is there to take my smoking materials, I keep them on me until I can find a staff member to give them to. This is what they tell me I have to do. Review of the Facility's Tobacco Free Environment Policy on 10/23/19 at 1:35 p.m. revealed that: (Summarized): *The facility will educate prospective admissions on the Tobacco Free Environment Policy. *The prospective resident will agree not to smoke at the facility or on the premises and will be offered smoking cessation information. *On admission, resident or resident representative will sign indicating that there is understanding that the resident will not smoke in the facility or on the premises. *Any residents who were smokers prior to the implementation of this policy will be allowed to smoke in a designated area and will receive a smoking safety assessment to determine the level of supervision to be provided and interventions to mitigate risk of injury. *Residents new to the facility will not receive a smoking assessment. *Policy will be placed in areas that are highly visible. Enforcement of the Tobacco Free Policy will consist of: *Requesting that visitors leave if they fail to comply; *Asking residents to immediately comply, and, * assessing residents for related distress; and, *confiscating tobacco products and lighting materials found in the facility and returning such materials to the resident/owner upon the resident's discharge from the facility. Review on 10/28/19 at approximately 9:00 a.m. of record and Smoking Care Plan for Resident #49 revealed that the Care Plan includes the following (summarized) verbage: *Resident has a history of noncompliance with following the facility's non-smoking policy and chooses to make independent choices to smoke. *Declines smoking cessation programs. There are no individualized interventions in the smoking care plan for Resident #49 that are measurable, include safety goals and ongoing assessments, smoking cessation opportunities, or that meet Resident # 49's needs for smoking safety. Interview on 10/28/19 at approximately 10:48 a.m. with Staff A (Registered Nurse, Unit Manager) confirmed that residents who smoke are to come to the Nurse's Station to sign out, pick up their cigarettes and lighter and leave the facility grounds to smoke. The residents then return to the nurses station, sign back in, and turn in the cigarettes and lighter. If there is no staff covering the nurses station upon return of the resident, then the resident keeps the smoking paraphenalia with them until they can find a staff member they can give them to. Observation on 10/28/19 at 10:56 a.m. revealed that Resident #49 was seen to approach the nurse's station, sign out, obtain smoking materials and then proceed to go outside to smoke. This observation of Resident #49, and interview with Staff A, (as written in above paragraphs), demonstrate that the facility is keeping cigarettes and lighters at the nurse's station for resident use. This process is not reflected in the resident's care plan. Resident #88 Interview on 10/23/19 at 9:30 a.m. with Resident #88 revealed that Resident #88 is a smoker and goes out to the bus stop to smoke. Resident #88 stated that he/she does not smoke in the building, and that smoking materials are kept in Resident #88's drawer. It was observed that resident keeps the cigarettes on his/her person. Resident #88 is alert and oriented and states that the facility is aware of this process for smoking used by Resident #88. Review on 10/28/19 at approximately 1:00 p.m. of care plan for Resident #88 revealed that the care plan has the following items listed for Resident #88: * Discourage resident from providing smoking items to other residents. * Educate and remind resident to check self out on Leave of Absence (LOA) when leaving facility property and inform staff/nurse as needed (PRN). *Offer 1:1 education with Respiratory Therapist (RT) on adverse effects of smoking and support for smoking cessation PRN. * Offer resident a smoking cessation program. *Smoking Policy is reviewed with resident and/or responsible party. Interview on 10/28/19 at approximately 2:00 p.m. with Staff B (Director of Nurses) confirmed the above findings. Resident #340 Review on 10/25/19 at 12:00 p.m. of Resident #340's medical record revealed Resident #340's care plan states under Focus (Resident #340) has a history of non-compliance with the facility's non-Smoking policy, (Resident #340) declines smoking cessation programs offered. Under Intervention Educate (Resident #340) and family/friends regarding center's NON-smoking policy. Designated smoking areas OFF property, and storage of smoking materials. Review on 10/25/19 of Resident #340's nurses notes reveal multiple entries of none compliance with the facility's policy as written. Nurses notes 10/8/19 reveal (Resident #340) continues to be non-compliant with the facility smoking policy. At time of medication administration this nurse could not find patient, (Resident #340) did not sign the LOA book. This nurse observed patient sitting on (his/her) rollator directly outside the sliding glass door on building 4, (Resident #340) was actively smoking. this nurse had (Resident #340) extinguish (his/her) cigarette and explained again the policy. (Resident #340) states (she/he) knows the policy and before this nurse could finish (Resident #340) told this nurse 100% correctly and policy . Nurses notes dated 10/10/19 (Resident #340) was again noted to be non-compliant with facility smoking policy .nurse asked if (he/she) had recently smoked, (he/she) said (he/she) did, and voluntarily gave this nurse (his/her) cigarettes, lighter and clothes pin (which (he/she) uses to hold the cigarette. Nurses notes dated 10/11/19 (Resident#340) continues to smoke outside with out following the facility policy .sitting on ramp outside building 4; .reminding (Resident #340) needed be off property. Nurses notes dated 10/12/19 (Resident #340) again is noted to not be following the smoking policy . Nurses notes dated 10/14/19 (Resident #340) caught outside several times this evening, (Resident #340) was not willing to give up (his/her) cigarettes or lighter, (Resident #340) states its all done now I already smoked it. Nurses notes dated 10/15/19 (Resident #340) is continuing to smoke on premises, despite staff taking (his/her) smoking items and locking them in the med room (he/she) continues to produce cigarettes and a lighter, not sure where (he/she) is getting this from, (he/she) will not answer when asked. Review on 10/25/19 of Resident #340's Nurses notes 10/16/19 .(Resident #340) went out to smoke a couple of times and continues to smoke on the property and not sign the LOA book at the nurse station . Nurses notes dated 10/19/19 .(Resident #340) was not in (his/her) room or on the unit, (he/she) had not signed LOA book. this nurse went to building 4 and there (Resident #340) was noted to be sitting on (Resident #340) rollator smoking at the slider door . Nurses notes dated 10/22/19 .continues to be non-compliant with smoking policy . Interview on 10/28/19 with Staff D (Administrator) the question was asked in regards to a smoking assessment being completed for the safety and change of condition of residents ability to maintain smoking privileges off campus. Staff D stated the facility dose not do smoking assessments due to the fact the facility is a non smoking facility. Resident #341 Review on 10/25/19 of Resident #341's nutrition note, dated 10/2/19, revealed that Staff L (Registered Dietitian) wrote .resident now with sig. (significant) weight loss . Review on 10/25/19 of Resident #341's nutrition note, dated 10/22/19, revealed that Staff L wrote that Weight of 165.5 is down 9.5 pounds in one month . Review on 10/25/19 of Resident #341's Weight and Vitals summary revealed that on 9/20/19, Resident #341 weighed 175 pounds, and on 10/18/19 Resident #341 weighed 165.5 pounds, which was a 5.4% weight loss. Review on 10/25/19 of Resident #341's current care plan revealed that (Resident #341) has nutritional problem or potential nutritional problem r/t (related to) .need for tube feed .overweight . There was nothing documented in the care plan regarding the actual weight loss that Resident #341 had. Interview on 10/28/19 at approximately 11:40 a.m. with Staff M (Licensed Practical Nurse) confirmed that Resident #341 had a significant weight loss and that it was not documented on Resident #341's care plan. Staff M also confirmed that Resident #341's weight loss should have been documented in their care plan Resident #540 Review on 10/24/19 of Resident #540's active physician orders [REDACTED]. Interview on 10/28/19 at approximately 10:45 a.m. with Staff N (Licensed Practical Nurse) revealed that Resident #540 had a pressure ulcer on their coccyx, which resolved on 10/16/19. Review on 10/28/19 of Resident #540's current and resolved care plans revealed that there was no care plan in place for Resident #540's pressure ulcer on their coccyx and no care plan for dressings changes to the coccyx area. Interview on 10/28/19 at approximately 10:45 a.m. with Staff N confirmed that there was no care plan in place for Resident #540's coccyx pressure ulcer. Staff N also confirmed that a care plan should have been in place for the pressure ulcer and for the dressing changes.",2020-09-01
26,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,658,E,0,1,TYS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, it was determined that the facility failed to meet professional standards for medication administrations via a Gastrostomy tube ([DEVICE]), and checking patency for a Peripherally Inserted Central Catheter (PICC) line prior to medication administrations for 2 out of 37 medication administrations observed; and 2 medication omissions noted on record review for 3 resident out of final sample size of 35 residents. (Resident identifiers are #22, #39, and #46.) Findings include: Resident #46 Wolters Kluwer Health (edited by [NAME] M. Nettina), Manual of Nursing Practice. 9th ed. Ambler, Pennsylvania: Lippincott[NAME] and Wilkins, 2010. Page 86 .Types of I.V. (Intravenous) Administration . .Precaution and Recommendations . .1. Before medication administration . .f. Assess patency of the I.V. line by the presence of blood return . Observation on 10/23/19 at 2:05 p.m. with Staff A (Unit Manager) during medication administration for Resident #46's Meropenem (antibiotic) revealed that Staff A cleaned Resident #46's needleless connector of the PICC line with an alcohol wipe then waited for needless connector to air dry. Staff A used a 10 ml (milliliter) Normal Saline Flush to flush the needless connector. Staff A was not observed to have aspirated the PICC line catheter and no red blood-like substance was observed when Staff A flushed Resident #46's PICC line catheter. Staff A then proceeded to administer Meropenem 1 Gm (gram) I.V. Review on 10/24/19 of facility's procedure titled, Central Vascular Access Device ([MEDICAL CONDITION]) Flushing and Locking, revision dated 5/1/2016, revealed that .[MEDICAL CONDITION] .considerations .1.1 Peripherally Inserted Central Catheter (PICC) .flushing/locking (sic) is performed to ensure and maintain catheter patency .5. Catheter patency must be verified prior to each access. To assess patency, aspirate catheter to obtain a positive blood return. The aspirated blood should be the color and consistency of whole blood .Procedure: .9. Attach syringe with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain blood return to verify vascular access patency . Interview on 10/24/19 at 9:10 a.m. with Staff A confirmed above observation. Staff A stated that when they flush Resident #46's PICC line catheter with 10 ml Normal Saline there was no resistance which indicated that the PICC line was patent. Staff A was unable to state facility's procedure in checking patency of a PICC line. Resident #22 Interview on 10/23/19 at 9:58 a.m. with Resident #22 revealed that the resident had a concern with medication administration. Resident #22 stated; I am very independent. The staff here help me with showers and they give me my medications. There is always a problem with my medications. Often times I get the wrong ones or some meds are missing and I make them take back the meds and get me the right ones. My inhalers have been unavailable for weeks at a time. Review on 10/25/19 at 12:30 p.m. of Resident #22's nursing notes and MAR (Medication Administration Record) revealed that on the following dates, medication that was ordered was not administered: 10/4/19: [MEDICATION NAME] Diskus Aerosol Powder 1 Puff BID (twice per day). Reason Missed: Waiting for Pharmacy to deliver. Signed by Staff H, (licensed Practical Nurse), LPN. 10/5/19: [MEDICATION NAME] Diskus Aerosol Powder 1 Puff BID. Reason Missed: Medication is unavailable. Signed by Staff H. 10/6/19: [MEDICATION NAME] Tablet 40 mg, 4 tabs PO (by mouth) QD (once per day). Reason not given: Unavailable. Signed by Staff [NAME] 10/6/19: [MEDICATION NAME] Diskus Aerosol Powder 1 Puff BID. Reason not given: Medication unavailable. Signed by Staff [NAME] 10/7/19: Note text: [MEDICATION NAME] Tablet 50 mg, give 4 tablets PO QD for tremors. (Not given): Med ordered but has not been delivered by pharmacy, nurse called pharmacy and according to pharmacy, resident is still hospitalized in their computing system but informed patient has been discharged and is in the facility. Signed by Staff G, LPN 10/7/19: [MEDICATION NAME] Diskus Aerosol Powder 1 Puff PO BID. (Not given): Med ordered but has not been delivered by pharmacy, nurse called pharmacy and according to pharmacy, resident is still hospitalized in their computing system but informed patient has been discharged and is in the facility. Signed by Staff [NAME] 10/16/19: [MEDICATION NAME] Diskus Aerosol Powder 1 Puff BID. Reason not given: Awaiting Delivery. Signed by Staff [NAME] 10/20/19: [MEDICATION NAME] Diskus Aerosol Powder 1 Puff BID. Reason not given: Pending delivery from the pharmacy. Signed by Staff F, RN. Review of Resident #22's medical record on 10/28/19 at approximately 12:55 pm revealed that there were no notes to the physician to communicate that these medications were missed, and how to proceed. Interview on 10/28/19 at approximately 1:15 p.m. with Staff B Director of Nursing (DON) confirmed that Resident #22's record did not have documentation to support that the physician had been informed of the missed medications, or how to proceed. Staff B could not provide rationale for the missed medications, for not notifying the physician of the missed medications, or administering staff not inquiring of the physician as to how to proceed. Record review on 10/28/19 at approximately 1:45 p.m. after Staff B provided a printed Order-Search of Omnicare Pharmacy Delivery records dated from 10/1/19 to 10/28/19 revealed the following information for Resident #22's [MEDICATION NAME] and [MEDICATION NAME] medication deliveries: 10/8/19: [MEDICATION NAME] Diskus Delivered on 10/8/19 at 3:09 a.m. 10/8/19: [MEDICATION NAME] 50 mg Delivered on 10/8/19 at 3:09 a.m. 10/18/19: [MEDICATION NAME] Diskus Delivered on 10/18/19 at 7:44 p.m. Resident #39 [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 708 The prescriber often gives specific instructions about when to administer a medication Observation on 10/24/19 at approximately 9:30 a.m. of Resident #39's Gastrostomy tube medication administration with Staff J (Licensed Practical Nurse) revealed that during the administration of 8 medications the tube was not flushed in between medications. Medications administered: Atorvastatin 10 milligrams Calcium with Vitamin D 600-400 milligrams [MEDICATION NAME] 25/100 milligrams Vitamin B12 1000 milligrams [MEDICATION NAME] HCL ([MEDICATION NAME]) 500 milligrams Buproprian HCL 100 milligrams Sodium Chloride 1 gram [MEDICATION NAME] Acid 250 milligrams- 5 milliliters (15 milliliters) Review on 10/24/19 of Resident #39's Medication Administration Record [REDACTED] Flush tube with 5 ml's (milliliters) of water between each medication. Interview on 10/24/19 at at approximately 9:40 a.m. with Staff J confirmed that there were no water flushes administered in between the 8 medications. Review on 10/25/19 of the facility's policy and procedure titled, 6.0 General Dose Preparation and Medication Administration, Revision date; 12/1/07 revealed: .Procedure . 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate .",2020-09-01
27,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,676,D,0,1,TYS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that a resident received the appropriate monitoring to maintain or improve his or her ability to carry out the activities of daily living for 1 out of 2 residents reviewed for activities of daily living out of a final survey sample of 35 residents . (Resident identifier is #144.) Findings include: Review on 10/28/19 of Resident #144's medical record revealed that Resident #144 had an MBS (Modified [MEDICATION NAME] Swallow) done on 7/31/19 revealed the the following actions are recommended regarding the patient's feeding: .Treatment plan and further recommendations: . The following actions are recommended regarding the patient's feeding: Alternate Solids/Liquids, Positioned Upright, Small Bites/Sips, Upright at 90 degrees during PO (by mouth) and 30 minutes after meal. . Review on 10/28/19 of ST (Speech Therapist) notes revealed the following: Resident was seen by ST from 7/17/19-8/7/19. The following recommendations were noted on the ST progress and discharge summary: . Recommended strategies include alternating bites/sips, upright for all P.O., small bites/sips. . Discharge plans and instructions: . Monitor and report changes of vocal quality or swallow function. Review on 10/28/19 of Resident #144's care plans revealed that these interventions were not in Resident #144's care plan to be monitored. Interview on 10/28/19 at approximately 1:00 p.m. with Staff K (Licensed Practical Nurse) confirmed that the recommendations were not implemented in Resident #144's care plans.",2020-09-01
28,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,690,D,0,1,TYS711,"Based on record review, and interview, it was determined that the facility failed to provide care and services for 1 resident who is totally incontinent of urine in a final survey sample of 35 residents. (Resident identifier is #590.) Findings included: Interview on 10/24/19 at 8:11 a.m. Resident #590 stated the unit is short staffed. Resident #590 also states that prior to coming to this unit when they were on the skilled unit they were getting checked and changed every 3 hours. Resident #590 states now that they are on this unit they get changed 1-2 times per day. Review on 10/25/19 at 12:54 p.m. of Resident #590's medical record revealed LNA (Licensed Nursing Assistant) documentation showed that from 10/15/19-10/28/19 they are getting toileted only two times a day. Review on 10/25/19 of Resident #590's care plan states skin Actual Alteration in Skin Integrity Related to Rash/fungal infection in groin and abdominal fold . Care Plan states (Resident #590) has frequent bowel and bladder incontinence r/t Impaired Mobility/reconditioning. Review on 10/28/19 of the P[NAME] (Point of Care) Response History under Urinary continence for a 14 day look back period shows Resident #590 being incontinent daily. The times provided by the facility are as follows: 10/15/19 shows Resident #590 being changed only two times in a 24 hour period 10/16/19 shows Resident #590 being changed only two times in a 24 hour period 10/17/19 there is no documentation at all 10/18/19 shows Resident #590 being changed only three times in a 24 hour period 10/19/19 shows Resident #590 being changed only two times in a 24 hour period 10/20/19 shows Resident #590 being changed only two times in a 24 hour period 10/21/19 shows Resident #590 being changed only three times in a 24 hour period 10/22/19 shows Resident #590 being changed only one time in a 24 hour period 10/23/19 shows Resident #590 being changed only one time in a 24 hour period 10/24/19 shows Resident #590 being changed only two times in a 24 hour period 10/25/19 shows Resident #590 being changed four times in a 24 hour period 10/26/19 shows Resident #590 being changed only one time in a 24 hour period 10/27/19 shows Resident #590 being changed only one time in a 24 hour period 10/28/19 shows Resident #590 being changed only one time in a 24 hour period Interview on 10/28/19 with Staff D (Administrator), the findings were reviewed and Staff D confirmed them.",2020-09-01
29,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,692,D,0,1,TYS711,"Based on interview, record review and facility policy review, it was determined that the facility failed to ensure that weight loss is monitored and weights are obtained for 2 residents in a final survey sample of 35 residents. (Resident identifiers are #135 and #172.) Findings include: Review of the facility policy, titled Weight Measurement, dated 5/23/18, revealed that .Weights will be obtained weekly X 4 (weekly for 4 weeks) after admission. Subsequent weights will be monthly, unless physician's orders or the resident's condition warrants more frequent as determined by Interdisciplinary Team .All residents with significant weight changes will be reweighed to assure accuracy of the weight. Verify re-weigh for accuracy and documentation purposes .Residents with significant unintended weight changes will be added to weekly weights X 4 weeks or until weight stabilizes . Resident #135 Review on 10/24/19 of Resident #135's weights and vitals summary revealed that Resident #135 had a weight of 116.8 pounds on 9/6/19, the date that they were admitted to the facility. The next weight documented was on 9/12/19 which was 113 pounds, which represented a 3.2% weight loss. There were no other weights documented after 9/12/19. Review on 10/25/19 of Resident #135's active physician orders revealed that there was no order to discontinue weights. Review on 10/25/19 of Resident #135's nutrition assessment, dated 9/22/19, revealed that there was no documented evidence that Resident #135 was not being weighed. Interview on 10/28/19 at approximately 11:20 a.m. with Staff J (Licensed Practical Nurse) confirmed that the last weight obtained for Resident #135 was the weight obtained on 9/12/19. Staff J also confirmed that they should have been obtained because there was no physician's order to discontinue them. Resident #172 Review on 10/25/19 of Resident #172's weights and vitals summary revealed that Resident #172 had a weight loss from 222 pounds on 8/9/19 to 178.5 pounds on 9/6/19, which represented a 19.5% weight loss. There was a reweigh obtained on 9/6/19 which was 178 pounds. The next weight obtained for Resident #172 was on 10/10/19. Review of Resident #172's nutrition assessment, dated 10/10/19 revealed that Resident #172 had a significant loss of 17.6% in the last 6 months. Interview on 10/28/19 at approximately 11:15 a.m. with Staff J confirmed that Resident #172 had a significant weight loss and that Resident #172 should have had other weights obtained between 9/6/19 and 10/10/19.",2020-09-01
30,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,697,D,0,1,TYS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility has failed to ensure that proper pain management is provided to meet professional standards of care for 1 resident in a final survey sample of 35 residents. (Resident identifier is #47) Findings include: Interview on 10/24/19 at 9:47 a.m. with Resident #47 stated that they were not getting enough pain control. Review on 10/24/19 of the medial record shows Resident #47 is receiving scheduled pain medication along with PRN (as needed), these orders are written as follow: [MEDICATION NAME] Tablet 325 mg Give 2 tablet by mouth every 6 hours as needed for mild to moderate Pain NTE (Not to Exceed) 3 GM(grams)/24 hours . [MEDICATION NAME] HCI Tablet 5 MG (milligrams) Give 1 tablet by mouth as needed for for muscle pain Take one tablet once daily as needed. [MEDICATION NAME] HCI Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain. Pain Monitoring using Verbal/Non-Verbal 0-10 Scale every shift for Monitoring Level of Comfort Interview on 10/28/19 at 12:30 p.m. with Staff B (Director of Nurses) was asked if a resident is cognitively intact and what type of pain scale would be used. Staff B stated the numerical scale because Resident #47 is cognitively intact. Staff B was then shown the orders which are written above and asked if you are using the verbal pain scale and documenting using 1-10 but are administering PRN medication using mild-moderate or moderate to severe. Staff B was then asked what would the numerical pain scale in translation to mild-moderate or moderate to severe be. Staff B was not able to answer the question. Staff B then was asked if these levels are from the Wong backer assessment tool for pain, Staff B said yes. On review of this tool it is rated as 1-3 mild, 4-6 moderate, 7-10 severe. Review on 10/28/19 of the PRN orders for [MEDICATION NAME] 325 mg 2 tablets being given using numerical numbers from 7-10 which when using the mild-severe scale would be coded as sever meaning the wrong pain medication was given for the pain level told 6 times in a row. Review on 10/28/19 of the PRN orders for [MEDICATION NAME] tablet 50 mg given by mouth every 6 hours shows it being given 3 times a day almost every day for the month of (MONTH) with pain levels fluctuating from pain levels of 3-8. On review of the times and doses this medication was being given always at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Review on 10/28/19 of the PRN order for [MEDICATION NAME] 5 mg for muscle pain revealed this medication is again being given every day around 11-12 p.m. Interview on 10/28/19 with Staff B was shown the clinical information regarding substance abuse and Staff B stated it was a long time ago and it was not pills but alcohol. Staff B also stated the resident and physician have agreed to administer medication on a PRN schedule making Resident #47 feel like they have control of their pain.",2020-09-01
31,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,756,D,0,1,TYS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the pharmacist reports for irregularities in medications, it was determined that the facility has failed to act upon the reports in a timely manner for 2 residents in a final survey sample of 35 residents. (Resident identifiers are: #17 and #31.) Findings include: Resident #31 Review on 10/25/19 of Resident #31's medical record revealed a pharmacy review report showing a irregularity on 9/6/19. Review on 10/26/19 of Resident #31's pharmacy Consultation Report dated 9/6/19 with a Recommendation Please discontinue Montelukast. Rationale for Recommendation Due to a lack of adequate testing, guidelines do not recommend the use of leukotriene receptor antagonists for [MEDICAL CONDITIONS]. Use may be appropriate in the presence of allergic rhinitis or asthma-[MEDICAL CONDITION] overlap syndrome Physician's Response: I accept the recommendation(s) above, please implement as written: This was dated 10/2019 and signed by the physician. Interview with Staff B (Director of Nurses) on 10/26/19 was asked what day was it signed and Staff B stated just now the 26th. Review on 10/26/19 of the MAR (Medication Administration Record) revealed both (MONTH) and (MONTH) have orders that state Montelukast Sodium Tablet 10 MG Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] which have been given daily since the pharmacy report stating Please discontinue Montelukast. Resident #17 Review on 10/25/19 of Resident #17's medical record revealed that the pharmacist did an MRR (medication record review) on 9/3/19 with the following recommendation: Please attempt a gradual dose reduction (GDR) to quetiapine 50 mg (milligrams) HS (hour of sleep) while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms. Physician's Response: I accept the recommendation(s) above, please implement as written. (signed 9/30/19) Review on 10/25/19 of Resident #17's Medication Administration Record [REDACTED] Quetiapine 12.5 mg by mouth one time a day, dated 11/13/18 and Quetiapine 50 mg by mouth at bedtime, dated 10/21/2018. Interview on 10/25/19 at approximately 1:00 p.m. with Staff K (Licensed Practical Nurse) confirmed that the MRR that was done on 9/3/19, signed by the physician on 9/30/19 but Resident #17 was still receiving the 12.5 mg of Quetiapine that was ordered to be stopped on 9/30/19. Review on 10/28/19 of the MRR dated, 10/11/19 revealed the following: (pronoun omitted)'s prescriber accepted a pharmacy recommendation to decrease dose of quetiapine on 9/30/19, but the order has not yet been processed. Review on 10/28/19 of the facility's policy and procedure titled Medication Regimen Review, effective date 12/1/07 revealed: .Procedure . 6. Facility should ensure that Facility Physicians/Prescribers are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either (a) accept and act upon in the recommendations contained within the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 8. Facility should provide the Medical Director with a copy of MRRs and should alert the Medical Director where MRRs require follow-up. .",2020-09-01
32,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,757,D,0,1,TYS711,"Based on interview and record review, it was determined that the facility failed to monitor behaviors for 1 resident taking antipsychotic medications, in a final survey sample of 35 residents. (Resident identifier is #25.) Findings include: Review on 10/25/19 of Resident #25's (MONTH) 2019 Medication Administration Record, [REDACTED]. Review on 10/25/19 of Resident #25's (MONTH) 2019 and (MONTH) 2019 nurses notes revealed that there was no documented behavior monitoring for Resident #25. There was also no behavior log found in Resident #25's medical record. Interview on 10/28/19 at approximately 11:00 a.m. with Staff N (Licensed Practical Nurse) confirmed that there was no behavior log for Resident #25 and that there should have been one.",2020-09-01
33,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,758,D,0,1,TYS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that residents who use [MEDICAL CONDITION] medication received a gradual dose reduction for 1 resident, and ensure that PRN (as needed) orders for [MEDICAL CONDITION] medication was limited to 14 days, except, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should indicate the duration for the PRN order for 1 resident out of a final sample size of 35 residents. (Resident identifiers are #17 and #42.) Findings include: Resident #42 Review on 10/28/19 of Resident #42's current physician order [REDACTED].#42 had an order for [REDACTED].#42's [MEDICATION NAME] order revealed no indicated duration of use. Review on 10/28/19 of Resident #42's (MONTH) to (MONTH) 2019 EMAR (Electronic Medication Administration Record) revealed that Resident #42's [MEDICATION NAME] 0.5 mg PRN with an order date of 6/5/19 was given on 6/10/19, 6/11/19, 6/16/19, 6/22/19, 6/30/19, 8/15/19, 8/19/19, 8/27/19, 8/28/19, 9/1/19, 9/11/19, 9/12/19, 9/20/19, 9/25/19, 9/29/19, 10/2/19, 10/4/19, 10/6/19, 10/14/19, 10/18/19, and 10/19/19. Review on 10/28/19 of Resident #42's Medication Regimen Review (MRR) dated 7/19/19 revealed .Comments: (Resident #42) has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date: [MEDICATION NAME] 0.5 mg BID PRN since 6/5/19 .Recommendation: Please discontinue PRN [MEDICATION NAME]. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication of use, the intended duration therapy and the rationale for the extended time period . Further review of Resident #42's MRR dated 7/19/19 revealed that recommendations were declined by the physician on 7/23/19 and rationale to extend therapy was documented but no documented duration of use. Review on 10/28/19 of Resident #42's MRR dated 10/18/19 revealed .Comment: REPEATED RECOMMENDATION (sic) from 7/19/19: Please respond promptly to assure facility compliance with Federal regulations. (Resident #42) has an order for [REDACTED]. Interview on 10/28/19 at 4:36 p.m. with Staff B (Director of Nursing) confirmed above findings. Staff B stated as Resident #42 had an order for [REDACTED].#42's physician or psychiatrist regarding Resident #42's [MEDICATION NAME] PRN duration of use. Resident #17 Review on 10/25/19 of Resident #17's medical record revealed that Resident #17 was on the Anti-psychotic medication Quetiapine since admission on 10/28/18. There was no documentation of Resident #17 having a GDR (Gradual Dose Reduction). Review on 10/25/19 of Resident #17's MAR (Medication Administration Record) revealed that Quetiapine was being administered for the [DIAGNOSES REDACTED]. Interview on 10/28/19 at approximately 1:00 p.m. with Staff K (Licensed Practical Nurse) confirmed that Resident #17 had not had a GDR of the Anti-psychotic medication Quetiapine since admission. Staff K also confirmed that Resident #17 did not have a supporting [DIAGNOSES REDACTED].",2020-09-01
34,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,812,E,0,1,TYS711,"Based on observation, record review, and interview, it was determined that the facility failed to properly maintain the dish machine in working order. Findings include: Observation on 10/23/19 while doing the initial inspection of the kitchen with Staff [NAME] (Director of Food Services) revealed that the high temperature dish machine failed to reach its max temperature of 180 degrees. Staff [NAME] ran the dish machine 5 times and the gauge never reached over 165 degrees. On review of the months temperature logs it revealed several days where the dish machine failed to reach its minimum temperature of 180 degrees. Interview on 10/23/19 at approximately 9:30 a.m. with Staff [NAME] confirmed the findings and provided the temperature logs to surveyor. Staff [NAME] contacted the vendor who came to the facility validating that the gauge was broken but the dish machine was running to temperature. The vendor provided a 160 degrees T test strip that tests the dish surface not the water temperature. The test result reflected that the dish machine is running at 180 degrees.",2020-09-01
35,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,865,B,0,1,TYS711,"Based on record review and interview, it was determined that the facility failed to develop a written Quality Assurance Performance Improvement (QAPI) plan for the facility. Findings: Review on 10/25/19 of the document provided by the facility for the Quality Assurance Performance Improvement (QAPI) plan requested at the time of survey entrance revealed a packet of information titled Quality Assurance and Performance Improvement Program Resource Guide with a revised date of 6/2019. Interview on 10/28/19 at approximately 2:45 P.M. with Staff D (Administrator) and Staff B (Director of Nursing) confirmed that the facility QAPI plan was the packet of information titled Quality Assurance and Performance Improvement Program Resource Guide listed above and that there was no written QAPI plan for the facility.",2020-09-01
36,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2019-10-28,880,D,0,1,TYS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, it was determined that the facility failed to maintain infection control in regards to hand hygiene during medication administration for 2 out of 37 medication administration observed. (Resident identifiers are #46 and #136.) Findings include: Review on 10/24/19 of facility's policy titled, Handwashing/Hand Hygiene, revision dated 4/2018, revealed that .Use an alcohol-based hand rub .alternatively soap . and water for the following situations: .before and after direct contact with residents .before preparing or handling medications .before and after handling an invasive device (intravenous access sites) .before donning gloves . .Washing hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds or longer, under a moderate stream of running water, at a comfortable temperature . 2. Rinse hands thoroughly under running water. Hold hands lower than wrist. Do not touch fingertips to inside of sink . 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . .Using Alcohol-Based Hand Rub (ABHR) 1. Apply generous amount of product to palm of hand and rub hands together . 2. Cover all surfaces of hands and fingers until hands are dry . Resident #136 Observation on 10/23/19 at 1:30 p.m. with Staff C (Unit Manager) during Resident #136's medication administration of Klonopin (benzodiazapine) revealed that Staff C went into Resident #136 room then left the room with medication cup in hand and headed to the supply closet and obtained a unopened 60 ml (milliliter) syringe and 500 ml basin. Staff C went to Resident #136's bathroom, opened the 60 ml syringe package and washed the 500 ml basin and the 60 ml syringe. Staff C went to Resident #136 without performing hand hygiene and used Resident #136's side table, placed the 500 ml basin and 60 ml syringe on the table and the crushed Klonopin in a medication cup then Staff C donned gloves. Staff C removed gloves and left Resident #136's room with medication cup in hand and went to the nurse's station and answered a doctor's phone call. After the phone call Staff C went back to Resident #136's room with the medication cup, Staff C donned new gloves without performing hand hygiene, and used the 60 ml syringe to push air to the [DEVICE] to check placement then administered the medication the flushed the [DEVICE]. Interview on 10/24/19 at 9:20 a.m. with Staff C confirmed above observation. Staff C was unable to provide explanation for not performing hand hygiene prior to medication administration. Resident #46 Observation on 10/23/19 at 2:00 p.m. with Staff A (Unit Manager) during medication administration of Meropenem for Resident #46 revealed that Staff A went to Resident #46's room, washed their hands with soap and water, dried their hands with paper towel then donned gloves. Staff A then removed gloves went out of Resident #46's room and went to the 5-2 treatment cart and obtain alcohol wipes. Staff A went back to Resident #46's room, donned gloves without performing hand hygiene and continued to flush Resident #46's PICC line catheter, prime the administration set with the Meropenem medication and administered Resident #46's Meropenem. Interview on 10/24/19 at 9:10 a.m. with Staff A confirmed above findings. Staff A stated that they thought that they did hand hygiene prior to medication administration.",2020-09-01
37,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,550,C,0,1,P2R411,"Based on dining observations made on the West wing of building one during lunch on 12/13/18 and during lunch on 12/18/18 a confidential family interview and a staff interview, the facility failed to serve residents requiring assistance in a dignified manner. Findings include: On 12/13/18 in the West wing dining room of building one during lunch twenty-three residents had been brought into the room for this meal. Staff AA (RN) and Staff BB (LNA) each stood over residents instead of sitting while feeding them. Staff BB stood while helping to feed three residents (#81, #141 and an unidentified resident) at the same time going from resident to resident helping each with a few bites of food or a sip of a beverage before moving on to aid another of these three residents with their meal. Staff AA asssisted one resident with their meal standing the entire time while assisting them. Observation made on 12/18/18 during lunch two unidentified LNA's stood while they assisted one unidentified resident each with eating their meal. Interview with a family member on 12/14/18 confirmed that staff routinely stand in the West Wing dining room of building one while assisting residents with their meals. This family member stated that there's frequently not enough staff available to supervise, encourage or assist residents in theWest Wing dining room of building one which is why staff are standing while assisting residents to eat their meals. Observation on 12/13/18 in the West wing dining room of building one revealed that for the entire lunch Resident #40 remained asleep and at the waist slumped over the right arm of the chair they were sitting in without receiving the supervisory assistance and encouragement that Resident #40's care plan says they require during mealtimes. There was an over the bed table in front of Resident #40's chair with their uncovered lunch tray on the over the bed table. No staff member was observed during lunch attempting to assist Resident #40 with their meal. While Resident #40 slept in the chair their meal tray which had been delivered at approximately 12 noon was removed at 12:50 pm without any food on the tray having been consumned but Staff BB documented in Resident #40's medical record that Resident #40 had eaten more than 75% of this meal. Staff BB confirmed this during a 12/18/18 interview but said she'd made a documentation error. Observations of the twenty-three residents in the West Wing dining room of building one during lunch on 12/13/18 confirmed that several residents needed cueing, supervision and encouragement from staff to assist them in eating their meals but this wasn't observed to be happening. As a result multiple resident's uncovered meal trays remained untouched in front of them for long periods of time during lunch. Some residents barely picked at their food with one unidentified resident asking what should I eat without receiving a response or assistance from staff.",2020-09-01
38,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,561,B,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to put procedures in place for self administration of medications for 1 resident in a final survey sample of 40 residents. (Resident identifier is #196.) Findings include: Observation on 12/13/18 at approximately 1:00 p.m. of Resident #196's bedside table revealed an opened bottle of nasal spray and an opened bottle of [MEDICATION NAME] oral rinse on top of the bedside table that was right next to Resident #196's bed. Observation on 12/14/18 at approximately 8:50 a.m. of Resident #196's bedside table again revealed an opened bottle of nasal spray and an opened bottle of [MEDICATION NAME] oral rinse on top of the bedside table. Interview on 12/14/18 at approximately 8:50 a.m. with Resident #196 revealed that Resident #196 stated that they self administer the spray and the rinse whenever they need them. Resident #196 also revealed that they did not notify any staff members of when they had used them. Review on 12/17/18 of Resident #196's current Physician Orders revealed that there were no physician orders for the nasal spray or the [MEDICATION NAME] oral rinse. Review on 12/17/18 of Resident #196's current care plan revealed that there was no care plan for Resident #196's self administration of medications. Review on 12/17/18 of Resident #196's list of assessments revealed that there was no assessment done for Resident #196's ability to self administer medications. Interview on 12/18/18 at approximately 8:30 a.m. with Staff J (Unit Manager) revealed that they were unaware that Resident #196 was self administering any medications. Staff J also confirmed that there should have been physician orders and a self medication assessment done.",2020-09-01
39,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,580,D,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to notify the physician of significant change for 1 resident out of a final sample size of 40 residents. (Resident identifier is #207.) Findings include: Review on 12/18/18 of Resident #207's EMAR (Electronic Medication Administration Record) for the month of (MONTH) revealed that on 11/9, 16, 19, 21, 26, 28, and 30/2018 there were medications scheduled for 9:00 a.m. that were coded as 1 Out of the Facility which were [MEDICATION NAME] Acid 500 mg (milligram), Aspirin 325 mg, [MEDICATION NAME] 1000 units,[MEDICATION NAME] mg, [MEDICATION NAME] 6 units, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 250 mg, Acidophilus 2 capsules, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 800 mg, and Sodium [MEDICATION NAME] 650 mg. Review on 12/18/18 of Resident #207's EMAR for the month of (MONTH) (YEAR) revealed that on 12/3, 5, 7, 10, 12, 14, and 17/ (YEAR) there were medications scheduled for 9:00 a.m. that were coded as 1 Out of the Facility which were [MEDICATION NAME] Acid 500 mg, Aspirin 325 mg, [MEDICATION NAME] 1000 unit,[MEDICATION NAME] mg, [MEDICATION NAME] 6 units, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 250 mg, Acidophilus 2 capsules, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 800 mg, and Sodium [MEDICATION NAME] 650 mg. Interview on 12/18/18 at 2:08 p.m. with Staff J (Unit Manager) confirmed the above findings and that Resident #207 was out of the facility on the said dates listed above. Staff J also confirmed that on the EMAR for 12/14/18 it was their initials on the 9:00 a.m. medications, which were listed above, and that they did not administer as Resident #207 was at [MEDICAL TREATMENT]. Staff J revealed that Resident #207 goes to the [MEDICAL TREATMENT] center on Monday, Wednesday and Friday and that Resident #207 leaves that facility around 7:30 a.m. and comes back from [MEDICAL TREATMENT] around 11:30 a.m. Staff J also revealed that 11/9, 16, 19, 21, 26, 28, and 30/2018 and 12/3, 5, 7, 10, 12, 14, and 17/ (YEAR) were [MEDICAL TREATMENT] days. Staff J was unable to provide more information and explanation if the physician was notified for the 9:00 a.m. medications that was not given on dates listed above. Review on 12/18/18 of Resident #207's nurses notes for the month of (MONTH) and (MONTH) (YEAR) revealed that there were no nurses notes regarding physician notification of 9:00 a.m. medications, as listed above, not being administered on dates listed above. Review on 12/18/18 of Resident #207's physician, nephrologist, and nurse practitioner notes for the month of (MONTH) and (MONTH) (YEAR) revealed that there were no physician or nurse practitioner notes regarding being notified of medications, as listed above, not being administered on dates listed above. Interview on 12/19/18 at 8:59 a.m. with Staff W (License Practical Nurse) confirmed that it was their initials on 11/16, 26, 28, and 30/2018 and 12/ 3, 5, 7, 10, 12, and 17/2018 on the 9:00 a.m. medications, as listed above. Staff W revealed that Resident #207 was at the [MEDICAL TREATMENT] center and that they did not administer the 9:00 a.m. medications or send medications with Resident #207. Staff W was unable to provide more information or explanation if physician was notified.",2020-09-01
40,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,584,B,0,1,P2R411,"Based on observation, and interview, it was determined that the facility failed to provide a homelike dining environment for 3 out of 5 buildings. (Resident identifiers #87,#187 and #191.) Findings include: Observation on 12/13/18 of Building 2 dining area at 12:56 p.m. revealed a white erasable board that stated that lunch would be at 12:00. Several residents were at various tables waiting for lunch to be delivered complaining to each other that lunch is always late and wondering how long today. Interview at 12:15 p.m. with Resident #87, #187 and #191, revealed that lunch is always late. Observation at 12:56 p.m. revealed that the lunch cart arrived and that lunch trays were being distributed to different tables by two staff members. At 1:03 p.m. Resident #87 did not like the meal serve and pushed the tray away. The staff members did not stop and ask Resident #87 if Resident #87 wanted an alternate. At 1:14 p.m. this resident got up to leave the room and the staff asked if Resident #87 was done and which time an affirmative answer was stated. Further observations revealed that all meals stay on the trays whether in the dining area or in the rooms in Building 2. Interview with Resident #87 at 1:45 p.m. revealed that the lunch trays are always late and if you do not like the main meal you can ask for an alternate but it will take up to an hour to get it so why bother. It would be nice to have some music while we eat; it is so quiet it and so institutional on the lunch trays. Interview on 12/19/18 at 1:45 p.m. with Staff C, (Administrator) revealed that they have tried everything with dining. With trays and without trays but can not seem to keep boundaries from other residents; so it is easier with the trays. Observation on 12/13/18 in the West Wing dining room of building one, a dementia unit, revealed the absence of a homelike environment as all twenty-three residents there for lunch received their meals on trays which remained left in front of them for the entire meal.",2020-09-01
41,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,641,C,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that assessments accurately reflect the resident's status for 25 residents out of the sample size of 40 residents. (Resident identifiers are #7, #13, #18, #19, #22, #25, #27, #74, #80, #84, #88, #89, #91, #94, #109, #112, #118, #135, #140, #177, #190, #204, #210, #212, and #226.) Findings include: Review on 12/19/18 of Resident #7, #18, #22 #25, #74, #80, #84, #88, #89, #91, #94, #109, #112, #118, #135, #140, #177, #190, #204, #210, #212, and #226 MDS (Minimum Data Set) for the month of (MONTH) to (MONTH) (YEAR) revealed that section C0100-C0500 (BIMS (Brief Interview of Mental Status)) was coded not assessed and with no BIMS score. Review on 12/19/18 of Resident #7, #18, #22, #25, #74, #80, #84, #88, #89, #91, #94, #109, #112, #118, #135, #140, #177, #190, #204, #210, #212, and #226 previous MDS dated between (MONTH) to (MONTH) (YEAR) revealed that Section C0100-0500 was coded with BIMS scores. Interview on 12/19/18 at 9:00 a.m. with Staff X (Social Worker) confirmed that above findings. Staff X revealed that they evaluate and document residents BIMS.Staff X states that they started working at the facility the last week of (MONTH) (YEAR) and that many of the BIMS for the month of (MONTH) to (MONTH) (YEAR) were not done and that they are trying to catch up with the BIMS assessments. Review on 12/19/18 of Resident #18, #22, and #88 BIMS assessment revealed that their last documented assessment were 727/18, 9/13/18, and 7/13/18, respectively. Interview on 12/19/18 at 10:47 a.m. with Staff U (MDS Head Coordinator) confirmed that Resident #18, #22, and #88's BIMS were not completed. Staff U states that the BIMS should have been completed. Staff U stated that the social worker evaluates residents BIMS and completed Section C of the MDS and the MDS coordinators electronically signs for the completion of the MDS. Resident #13 Review on 12/18/18 of Resident #13's Minimum Data Set ((MDS) dated [DATE] revealed Section C0100 Should Brief Interview for Mental Status (C0200-C0500) be Conducted? dashes though sections C0100-C0500 with no BIMS score. Review on 12/18/18 of Resident #13's medical record revealed that Resident #13 had a previous Brief Interview for Mental Status (BIMS) score of 15 in previous MDS dated [DATE]. Interview on 12/18/18 at approximately 10:40 a.m. with Staff H (MDS Coordinator) confirmed the above findings and revealed the 9/28/18 MDS sections were completed in error due to no social service worker available to do the work and that Resident #13 should still have a BIMS score. Resident #27 Review on 12/18/18 of Resident #27's MDS dated [DATE] revealed Section J0100 Pain Management revealed that Resident #27 had received no scheduled pain medication in the past 5 days. Review on 12/18/18 of Resident #27's physician orders [REDACTED]. Interview on 12/18/18 at approximately 10:40 a.m. with Staff H confirmed the above findings and revealed the above MDS sections were completed in error. Resident #19 Review on 12/18/18 at 9:34 a.m. Resident #19's medical record shows a 14 day MDS Medicare review completed on 8/9/18 coding section C Cognitive Pattern Section C0500. BIMS with a summary score of 12. Then on 10/31/18 a Quarterly MDS was competed and section C0500 was not completed with prior sections coded as Not assessed . Interview on 12/18/18 at 10:00 a.m. with Staff N (MDS coordinator) confirmed that there was no Social Services personal employed during this time and this area was not completed.",2020-09-01
42,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,656,D,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to develop and implement a person-centered comprehensive care plan for 2 resident out of a final survey sample of 40 residents. (Resident identifiers are #149, and #226.) Findings include: Resident #226 Review on 12/19/18 of Resident #226's medical record revealed that Resident #226 has Dow[DIAGNOSES REDACTED], Alzheimer and Dementia and was remitted on 10/5/18. Review of Resident #226's the care plan on 10/5/18 reveals Resident #226 is an extensive assist with Activities of daily living. Review on 12/19/18 of Resident 226's nurses notes revealed that Resident #226 had a fall on 10/9/18, 10/14/18, and 10/20/18 and a behavior where Resident #226 sat oneself onto the floor on 10/10/18. All falls had no injuries. Interview on 12/19/18 at 11:27 a.m. with Staff F, (Building 2 Unit Manager) confirmed that Resident #226 did not have a fall care plan since Resident #226 readmission. It had been created in the previous admission and resolved and Staff F did not know why the fall care plan would have been resolved. Resident #149 Review on 12/17/18 of Resident #149's medical record has a note dated 7/23/18 at 16:54 from social service stating When speaking with (Resident #149) this afternoon (Resident #149) said that (Resident #149) wanted to commit suicide earlier in the day. (Resident #149) stated that (Resident #149) had a plan of hanging himself with a cord. After speaking with (Resident #149) about this (Resident #149) stated (Resident #149) no longer wanted to hurt (self) . On 7/24/18 at 14:13 nurses note states (Resident #149) sent out via ambulance to (hospital) for Evaluation for SI (Suicidal Ideation). (Resident #149) states (Resident #149) wants to hurt (self) and verbalizes a plan. (Resident #149) was seen by our psych services and have stated that (Resident #149) should be evaluated at the hospital . On 7/27/18 at 16:00 an Evaluation Summary was complete and within the note is states . (Resident #149) has a history of suicidal ideation . On 12/17/18 Resident #149 care plan was updated with a description area of (Resident #149) has mood problem r/t [MEDICAL CONDITION] disorder, [MEDICAL CONDITION]. (Resident #149) has a history of Suicidal ideation, but no recent verbalization. Observation on 12/13/18 at 11:00 a.m. revealed Resident #149's call bell was ringing. When entering the room Resident #149 gestured to say they were choking lightly spoke with a gurgled voice, and pointed to the suction machine at Resident #149's bed side. Review on 12/13/18 Resident #149's medical record revealed there was not a physicians order for the use of [REDACTED]. Once the above findings were shown to Staff [NAME] (Director of Nurses) a care plan was crated dated 12/17/18 with a Focus stating potential for alteration in respiratory status r/t Tube Feeding, increased secretions, need for oral suctioning PRN.",2020-09-01
43,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,689,E,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that the facility failed to ensure that the non-smoking facility is free from accident hazards of smoking by allowing residents to have cigarettes and lighters on their person and not supervising residents when necessary who smoke on the facility's property for 5 of 5 residents in a final sample of 40 residents. (Resident identifiers are #227, #15, #105, #214 and #27.) Findings include: Review on 12/14/18 of the facility's policy titled Tobacco-Free Environment Policy, dated 11/2017, revealed the following: 3. Upon admission the patient/family sign the acknowledgment herein to demonstrate their understanding the patient will not smoke anywhere in the facility or on the premises . 11. The CEO/CCO (Chief Executive Officer/Chief Compliance Officer), ED/DNS (Director of Nursing Services), management and security personnel designate by the CEO/CCO and ED/DNS will enforce the Tobacco -Free policy by: .2) Confiscating tobacco products and light materials found in the facility (and returning such materials to the resident -owner upon the resident's discharge) . Resident #227 Interview on 12/14/18 at 9:31 a.m. with Resident #227 revealed the resident keeps cigarettes and lighter on their person or in their room. Resident #227 also revealed that they were told yesterday by staff (12/13/18) that they needed to smoke up by the street to smoke instead of on the facility property. Resident #227 stated It is dangerous up there and some of the smokers here should not be up there by the traffic. Review on 12/19/18 at 8:14 a.m. of Resident #227's admission packet revealed that on 11/20/2018 Resident #227 signed the following acknowledgment The Resident acknowledges that he/she received, reviewed, and understands the facility's Tobacco-Free Environment Policy and agrees not to use tobacco produces (sic) on the premises of the Center. Resident #15 Interview on 12/13/18 at approximately 10:45 a.m. with Resident #15 revealed that Resident #15 stated that they smoke outside the building, on the buliding premises, and that they keep their own cigarettes and lighter with them at all times. Observation on 12/13/18 at approximately 12:30 p.m. with Resident #15 revealed that the gloves that they wore outside when smoking had multiple burn marks on them. Review on 12/18/18 of Resident #15's Smoking Evaluation, dated 8/9/18, revealed that the question of .Does the resident have any evidence of burn holes on clothing or wheelchair, etc? . was answered Yes. The evaluation also revealed that the sentence .Resident is safe to light own cigarettes with staff supervision . was checked off. Review on 12/18/18 of Resident #15's current care plan revealed that there was no intervention for supervision with lighting cigarettes, no mention of the burn marks in Resident #15's gloves and no intervention regarding Resident #15 keeping their own cigarette and lighter with them. Interview on 12/18/18 at approximately 8:30 a.m. with Staff J (Unit Manager) revealed that Resident #15 was non compliant with returning their cigarettes and lighter to staff. Staff J revealed that staff were supposed to be encouraging Resident #15 to return these items and that they should have been documenting Resident #15's refusal to give them to staff. Staff J confirmed that Resident #15 did not receive supervision with lighting cigarettes and that Staff J was not aware that there were burn marks on Resident #15's gloves. Resident #105 Interview on 12/14/18 at approximately 8:30 a.m. with Resident #105 revealed that Resident #105 stated that they smoke outside the building and that they keep their own cigarettes and lighter with them at all times. Review on 12/18/18 of Resident #105's current care plan revealed that there was no intervention regarding Resident #105 keeping their own cigarette and lighter with them or for staff reminding or encouraging Resident #105 to return cigarettes and lighter to staff after smoking. Interview on 12/18/18 at approximately 8:30 a.m. with Staff J revealed that Resident #105 was non compliant with returning their cigarettes and lighter to staff. Staff J revealed that staff were supposed to be encouraging Resident #105 to return these items and that they should have been documenting Resident #105's refusal to give them to staff. Resident #27 Interview on 12/14/18 at 9:05 a.m. with Resident #27 revealed that Resident #27 was a smoker and the they kept their own cigarettes and lighter on their person and in their room. Resident #27 also revealed that they independently smoke and go outside the facility premises. Observation on 12/14/18 at 9:05 a.m. at Resident #27's room revealed that Resident #27 had an oxygen concentrator turned on and the nasal cannula tubing was at their bedside. Interview on 12/14/18 at 9:06 a.m. with Resident #27 revealed that Resident #27 was using oxygen every night. Resident #27 also revealed that their roommate rummages on their side of the room to look for food and that they constantly have to hide their important belongings including their smoking materials (e.g. cigarettes and lighter). Interview on 12/14/18 at 9:10 a.m. with Staff A (Unit Manager) confirmed that Resident #27 was a smoker. Staff A revealed that the facility was a smoke-free facility and Resident #27 was required to sign out on the LOA (Leave of Absence) book and go out of the facility premises to smoke and that residents that smoke were not allowed to keep their smoking materials (e.g. cigarettes and lighters) with them in the facility. Review on 12/18/18 of Resident #27's current physician orders [REDACTED].#27 has an order for [REDACTED]. Review on 12/18/18 of Resident #27's smoking evaluation revealed that the last documented smoking evaluation was on 7/18/18 which revealed that Resident #27 was a independent smoker and a safe smoker under current facility policy. Interview on 12/18/18 at 9:15 a.m. with Staff A revealed that smoking evaluation was to be done quarterly and then stated that it was not required to be done anymore as the facility has a smoke-free policy. Staff A also revealed that smoking materials were to be kept in the medication room. Observation on 12/18/18 at 9:30 a.m. with Staff S (Licensed Practical Nurse) at the 5-2 unit medication room revealed that smoking materials were kept in the medication room but no smoking materials were found for Resident #27. Interview on 12/18/18 at 9:30 a.m. with Staff S revealed that they do not always get the smoking materials back from the residents who smokes and that Staff S does not document the refusal in the resident records. Staff S also revealed that they should be following up with the residents, who smoke, on their smoking materials to be locked in the medication room and document any refusals. Interview on 12/18/18 at 10:39 a.m. with Staff R (Licensed Nursing Assistant) confirmed that Resident #27 kept their smoking materials on their person and in their rooms and that Resident #27's roommate does rummage on Resident #27 side of the room and other resident rooms as well. Staff R revealed that the residents, who smoke, kept their smoking materials on their person and in their rooms. Interview on 12/18/18 at 11:00 a.m. with Resident #27 revealed that the nurses was asking for their smoking materials to be locked in the medication room and it was their first time hearing about it on 12/18/18. Resident #214 Interview on 12/14/18 at 8:30 a.m. with Resident #214 revealed that Resident #214 was a independent smoker. Review on 12/18/18 of Resident #214's smoking evaluation revealed that the last documented smoking evaluation was on 8/30/18 which revealed that Resident #214 was an independent smoker. Review on 12/18/18 of Resident #214's smoking care plan revealed that smoking policy was reviewed with resident. Interview on 12/18/18 at 10:00 a.m. with Staff R revealed that Resident #214 kept their own cigarettes and lighter on their person and in their room. Interview on 12/18/18 at 10:05 a.m. with Staff A and Resident #214 revealed that Resident #214 kept their own cigarette materials on their person. Staff A had asked Resident #214 about their smoking materials to be handed over but Resident #214 declined and states that it was their first time hearing about handing over their smoking materials. Resident #214 states they have always kept their cigarette materials with them. Staff A was unable to explain what to do when the resident does not follow smoking policy.",2020-09-01
44,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,692,E,0,1,P2R411,"Based on interview, record review, and facility policy review, it was determined that the facility failed to monitor significant weight loss for 4 residents in a final survey sample of 40 residents. (Resident identifiers are #15, #105, #118, and #196.) Findings include: Review on 12/18/18 of the Facility Policy titled, Weight Measurement, dated 5/23/18 revealed that .All residents with significant weight changes will be rewighed to assure accuracy of the weight. Verify re-weigh for accuracy and documentation purposes .Residents with significant unintended weight changes will be added to weekly weight X (times) 4 weeks or until weight stabilizes . Resident #15 Interview on 12/13/18 at approximately 12:00 p.m. with Resident #15 revealed that Resident #15 stated that they had a weight loss. Review on 12/14/18 of Resident #15's weight documentation log revealed that Resident #15 had a weight loss from 105 pounds on 6/4/18 to 92 pounds on 11/5/18. This was a 12.3% loss in approximately 5 months. Resident #15's weight on 10/8/18 had been 98 pounds, which indicated a 6 pound or 6.1% weight loss in 1 month The review also revealed that after the weight that was documented on 11/5/18 indicating the 6 pound weight loss, there was not another documented weight until 12/9/18. The review also revealed that the Resident #15's weight was documented approximately once a month and that the last documented weight was the one taken on 12/9/18. Resident #118 Review on 12/14/18 of Resident #118's weight documentation log revealed that Resident #118 had an unintended weight loss from 200 pounds on 7/20/18 to 186 pounds on 8/6/18. This represented a 7% weight loss in 17 days. There was no documentation of a reweight to confirm this weight loss in one month and the next documented weight for Resident #118 was on 9/4/18, which was 187 pounds. Resident #118's weight on 12/5/18 was 171.5 pounds which represents a 14.2% loss in less than 5 months. There were no documented weights since the one obtained on 12/5/18. The review of weights documented for Resident #118, since their admission on 7/20/18, revealed that Resident #118's weight is documented approximately once a month and that the last documented weight was the one taken on 12/5/18. Resident #196 Interview on 12/14/18 at approximately 8:40 a.m. with Resident #196 revealed that Resident #196 stated that they had a weight loss. Review on 12/14/18 of Resident #196's weight documentation log revealed that Resident #196 had a weight loss from 141.5 pounds on 6/5/18 to 126 pounds on 9/1/18. This was a 10.9% weight loss in less than 3 months. After the documented weight on 9/1/18, another weight was not documented on Resident #196 until 10/1/18, which was 126.2 pounds. The next weight documented after the 10/1/18 weight on Resident #196 was not until 11/16/18, which was 128 pounds. Review on 12/18/18 of Resident #196's .Medical Nutrition Therapy Assessment . dated 11/15/18, revealed that the Dietitian documented that Resident #196 had a weight loss and when documenting the Most Recent Weight the dietitian indicated that the most recent weight was taken on 10/1/18. Resident #105 Interview on 12/14/18 at approximately 8:34 a.m. with Resident #105 revealed that Resident #105 stated that they had a weight loss. Review on 12/14/18 of Resident #105's weight documentation log revealed that Resident #105 had a documented weight on 8/6/18 of 138 pounds. The next weight documented for Resident #105 was on 9/4/18, which was 127 pounds. This was a 7.9% weight loss in approximately a month. There were no documented reweights to confirm this loss and the next documented weight for Resident #105 was on 10/26/18. Interview on 12/18/18 at approximately 9:05 a.m. with Staff J (Unit Manager) regarding the weights for each of the above referenced residents confirmed that when there was a significant weight change a reweight should have been obtained either that day or the next day.",2020-09-01
45,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,695,D,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview it was determined that the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, with a comprehensive person-centered care plan, to meet resident's goals for 1 resident out of a final survey sample of 40 residents. (Resident identifier is #149.) Findings include: Observation on 12/13/18 at 11:00 a.m. revealed Resident #149's call bell was ringing. When entering the room Resident #149 gestured to say she/he was choking, lightly spoke with a gurgled voice, and pointed to the suction machine at Resident #149's bed side. Review on 12/13/18 of the medical record there failed to be a physicians order for the use of [REDACTED]. Interview on 12/14/18 at approximately 2:30 p.m. with Staff [NAME] (Director of Nurses) revealed there were only two residents are needing suction and that Resident #149 was not one of those residents. Interview on 12/18/18 at 09:19 a.m. with Staff I (Nurse) on the phone revealed that Staff I provides suction to Resident #149 every morning and sometime in the afternoon pending on how much secretions form in Resident #149 throat. Staff I also stated when suctioning Resident #149's Staff I always removes clear/yellow discharge. Staff I stated Resident #149 needs the services but also feels it's a comfort measure that provides Resident #149 relief. Review on 12/18/18 at 11:52 a.m. of Resident #149 medical record revealed that new order were written for Resident #149, the orders written are: 1) Oral suctioning of increased secretion using [MEDICATION NAME]--every shift for maintain airway 2) (speech) Eval &(treat)/swallowing Also on 12/17/18 a care plan was written with a Focus stating potential for alteration in respiratory status (related to) Tube Feeding, increased secretions, need for oral suctioning PRN.",2020-09-01
46,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,725,E,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, it was determined that the facility failed to ensure sufficient staffing to provide nursing care for 16 residents out of a facility census of 234 residents. (Resident identifiers are #15, #18, #27, #30, #78, #79, #89, #91, #140, #164, #165, #177, #190, #196, #203, and #535.) Findings include: Resident #165 Interview on 12/13/18 at 9:53 a.m. with Resident #165 revealed that there were not enough staff and that at times it took hours for nursing staff to answer call lights. Resident #91 Interview on 12/13/18 at 10:06 a.m. with Resident #91 revealed that on early mornings between 5:00 a.m. to 6:00 a.m. the call lights took up to 2 hours to be answered. Resident #140 Interview on 12/13/18 at 10:27 a.m. with Resident #140 revealed that weekend nursing staff are short, 3-11 shift would have 3 nursing staff on the floor (5-2 unit) and most times they do not get showers. Resident #30 Interview on 12/13/18 at 10:40 a.m. with Resident #30 revealed that most nights, it took 3 hours to get Resident #30 to be assisted back to bed because of short nursing staff. Resident #30 stated that they need the assistance to go back to bed. Resident #30 stated that there were 2 LNA's (Licensed Nursing Assistant) most nights. Resident #89 Interview on 12/13/18 at 11:53 a.m. with Resident #89 revealed that Resident #89 states that there were not enough nursing staff. Resident #18 Interview on 12/13/18 at 1:13 p.m. with Resident #18 revealed that the facility needs more nursing staff and that nursing staff were worst at night as they had one LN[NAME] Interview on 12/14/18 at 6:30 a.m. with Staff L (LNA) confirmed that there was one LNA scheduled most 11-7 (Night) shifts. Staff L states that the 5-3 unit residents need more assistance, staffing was unsafe and call lights were going to be answered when they were available to do so and residents had to wait. Resident #27 Interview on 12/14/18 at 8:11 a.m. with Resident #27 revealed that the facility was short of nursing staff. Resident #27 stated that they had to wait for 1-2 hours on 3-11(Evening) and 11-7 (Night) shifts. Resident #27 stated that there were 2 LNA's on 3-11 and 11-7 shifts on 5-2 unit. Resident #78 Interview on 12/14/18 at 8:44 a.m. with Resident #78 revealed that the facility were short staff and it took an hour to answer the call light on all shifts. Resident #535 Interview on 12/14/18 at 9:06 a.m. with Resident #535 revealed that Resident #535 had to spend nights in their day clothes as no one got them ready for bed between 8:00 p.m. to 10:00 p.m. Resident #164 Interview on 12/14/18 at 10:09 a.m. with Resident #164 revealed that it took a long time for nursing staff to answer call lights and that Resident #164 felt that there were not enough staff on the unit (5-2 unit). Resident #190 Interview on 12/14/18 at 1:16 p.m. with Resident #190's family member revealed that there main concern was staff shortage. Family member stated that they had to do care for Resident #190 because the unit (Building #1 unit) was short staffed. Interview on 12/19/18 at 12:54 p.m. with Staff K (Staff Development Coordinator) revealed that the 5-3 unit residents were more acute and needed more assistance. Staff K was unable to provide more information on how the facility assess's the level of assistance that the residents need and how to appropriately staff in regards to the resident needs. Interview on 12/14/18 at 10:35 a.m.with Resident Council had 11 Residents present representing 3 different units in the building. When asked if Facility staff listened about grievances, Resident #140 responded with: The staff will listen and respond back, but not always timely. Resident #72 added: but the next step is actions, and those seem to be rarely taken. Resident #138 stated: when waiting for a call bell to be answered you can wait a half hour or more without anyone to even check to see if you are safe; Activities staff has been doing more and more to help other staff members in the building; i.e. (A greater) percent of the transporting of people to meetings. Resident #72 stated: There seems to be a shortage of people working in the Kitchen. They always seem to be 2 or 3 people short in the kitchen. Resident #72 also said there seems to be a lack of supervision in the kitchen, why else would we get such poor (food) service. There is a lot of turnover in the Kitchen. The turnover is incredible, in my lifetime of working, I've never seen turnover this bad. Resident #140 stated: that Monday through Friday (staffing) is bad, the weekends are brutal. The question was raised by a Resident as to who is managing the kitchen. Resident #72 said: They should have a person in the kitchen that knows the business inside and out so that they can tell staff what they should be doing. Resident #72 has also observed desserts to be uncovered during transport and was worried that dust or crumbs from carts or trays could get into those uncovered desserts. Resident #72 also stated: There are people in management throughout the entire organization who seem to lack experience. Resident #72 stated that on Thanksgiving Day there were 6 LNA's on the one floor because there were so many families on the unit. This resident further stated that ordinarily there were one or two aides on the unit. Interview on 12/18/19 at 1:09 p.m. with the Family Council revealed the family members present all said they need to provide activities of daily living such as feeding, grooming, and toileting to their family member residents when they visit. Interview on 12/14/18 with a family member revealed that there's a staffing shortage on the West Wing in building one. This family member stated that residents go for long periods of time without being changed after they've deficated or urinated in their disposable diapers. This family member said that the lack of sufficient staff is particularly apparent on weekends. In addition this family member reported having had to change their own spouse because of a shortage of available staff. In addition this family member reported that there's a lack of available staff to provide assistance to residents who need help during meals. Some residents, according to this family member, have missed eating altogether during a meal because of a lack of staff asssistance. Review of the minutes of a 11/27/18 meeting of the Resident's Food Committee noted cold food being served on unit 5-3. The Resident's Food Committee notes of the 11/27/18 meeting further stated that on unit 5-3 there's not enough nursing staff available to serve trays no one is there to pass out trays resulting in residents receiving cold food. Resident #203 Observation on 12/13/18 from approximately 12:30 p.m. to 12:45 p.m. of room [ROOM NUMBER]'s call light was on for assitance. During this observation, the light was visibly flashing and the sound was heard. It was observed that 5 different staff members walked past this room without entering. Interview on 12/13/18 at approximately 12:45 p.m. with Staff A (Unit Manager) stated that, Everybody answers lights. Resident #64 Interview on 12/14/18 at approximately 9:50 a.m with Resident #64 revealed the following statement, It takes too long for people to answer my call light, sometimes up to an hour. The food is always cold and it takes too long for anybody to warm it up. Resident #165 Interview on 12/14/18 at approximately 10:00 a.m. with Resident #165's family member revealed that sometimes when visiting the call light goes off for an hour without staff entering the room. Resident #165 also stated that at 6:00 a.m. on a regular basis staff can take up to an hour to answer call light. Resident #15 Interview on 12/13/18 at approximately 10:50 a.m. with Resident #15 revealed that Resident #15 stated that the facility was very short staffed. Resident #15 stated that food was frequently served cold and that if asked the nursing staff would heat it up but that Resident #15 did not ask the staff to heat up food because they were already so busy and that would take them away from their work. Resident #61 Interview on 12/13/18 at approximately 10:10 a.m. with Resident #61 stated that the facility was very short staffed. Resident #61 stated that their roommate, who was non interviewable, had to wait long periods of time for help. Resident #61 stated that they felt bad for their roommate and tried to help them but that the staff got upset when they tried to help their roommate. Resident #61 stated that it was for that reason that they were looking to transfer to another facility. Resident #79 Interview on 12/13/18 at approximately 11:45 a.m. with Resident #79 revealed that Resident #79 stated that the facility was very short staffed and that the residents had to wait for long periods of time for assistance. Resident #177 Interview on 12/13/18 at approximately 11:40 a.m. with Resident #177 revealed that Resident #177 stated that the facility was very short staffed and that residents had to wait long periods of time for assistance. Resident #196 Interview on 12/14/18 at approximately 8:45 am with Resident #196 revealed that Resident #196 stated that the facility was very short staffed. Resident #196 stated that the 11-7 shift was extremely short staffed and that they have had to wait over an hour for assistance.",2020-09-01
47,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,726,D,0,1,P2R411,"Based on observation record review and interview, it was determined that the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 1 resident in a final survey sample of 40 residents. (Resident identifier is #149.) Findings include: Observation on 12/13/18 at approximately 10:00 a.m. revealed Resident #149's call bell was ringing. When entering the room, Resident #149 gestured to say they were choking, lightly spoke with a gurgled voice, and pointed to the suction machine at Resident #149's bed side. Staff member was looked for to care for Resident #149 and no aide's could be found on the floor. Walking the length of the floor did not locate a staff member. Finally Staff G (Nurse) who was distrubuting medications, was told of the event , asking that they come to Resident #149 needs. Staff G walked down the hall and entered Resident #149's room. At this time Staff G told Resident #149 to clear their mouth themselves and use tissues, but Resident #149 was not able to clear their throat. The nurse then went to use the suction machine that was at Resident #149's bedside, but the canister was full and had to emptied. When doing this, the nurse removed the suction lines to the equipment, emptied the canister and cleaned it in the bathroom and returned to the suction machine at Resident #149 bedside. Then the nurse tried to hook up the suction machine but appered to not know where the suction lines hooked to. At this time surveyor showed Staff G where the suction lines go so the equipment could be used to help provide care to Resident #149. Once the tubing was properly connected to the suction machine Staff G said they did not have a piece of equipment for suction even though they had the yanko suction tube hooked to the machine. Staff G left the room again at 10:25 a.m. and returned with suction tubing trying to attach it to the end of the yanko then stopped. Staff G then said they will just use this (yanko tube) turning the suction machine on and off to extended the yanko further to clear Resident #149 throat. Staff G did this several times hitting Resident #149 gag reflex causing them to gag and cough. At the end of this process Resident # 149 had relief and was able to speak by 10:30. Resident #149 was asked if this nurse does this for them all the time and Resident #149 said not always. Resident #149 said, Staff I (Nurse) usually does it for me, they really know how to do it. Staff G after suctioning Resident #149 left the yanko uncovered and the suction tubing filled with mucus. Resident #149 told surveyor that Resident #149 was scared during the event but feels much better now that there throat was cleared. Resview on 12/17/18 Staff G personal file with education and training revealed that they had not completed their competencies for how to use a suction machine. Following this incident, the facility had Staff G complete the competencies needed on how to use and care for residents needing suction. Interview on 12/18/18 09:19 AM with Staff I confirmed that they provides suction to Resident #149 every morning and sometime in the afternoon depending on how much secretions form in Resident #149 throat. Staff I also stated when they suction Resident #149 they always removes clear/yellow discharge. Staff I stated Resident #149 needs the services but also feels it's a comfort measure that provides Resident #149 relief.",2020-09-01
48,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,755,D,1,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and facility policy and procedure the facility failed to ensure accurate reconciliation of controlled narcotic medications for two residents resulting in the actual loss of the prescribed narcotic medications. (Resident identifiers are #30 and #48.) Findings include: Review on 12/14/18 of the facility policy and procedure titled Inventory Control of Controlled Substances with revision date of 1/1/13 revealed the following: Applicability: This Policy 5.4 sets forth the procedures for inventory control of controlled substances. Procedure: 1. With respect to Schedule II controlled substances . 1.2 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results in the 'Controlled Substance Count Verification/Shift Count Sheet' set forth . 1.2.1 Reconcile the total number of controlled medications on hand , add newly received medications to the inventory and remove medications that are completed or discontinued from the inventory, pursuant to the Controlled Substance Verification Count Sheet and 1.2.2 Reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification Count Sheet. 1.2.3 The Facility should routinely reconcile the number of doses remaining in the package to the number of remaining doses recorded in the Controlled Substance Verification/Shift Count Sheet, to the medication administration record. Observation on 12/14/18 at approximately 7:30 a.m. showed Staff Y (Licensed Practical Nurse) and Staff Z (Registered Nurse) doing a shift change narcotic count. Observation showed Staff Y. oncoming nurse, holding individual resident narcotic packaged medications and verbally confirming the number of doses left in the medication package. Staff Z, outgoing nurse, verbally confirmed the number of doses left from the narcotic count sheet. Staff Y and Staff Z failed to visualize each of the individual residents' medication packages with the number listed in the narcotic count log to confirm the correct count. Interview on 12/14/18 at approximately 7:50 a.m. with Staff Z revealed that Staff Z verbally reports the number of narcotic doses left from the narcotic record for each individual resident to Staff Y. Staff Y verbally confirms the number of doses left in each individual resident narcotic package. Staff Z reported that visualization of the each individual resident narcotic packaged medication was not done. Staff Z reported confirmation of number of medication doses left were verbally confirmed by Staff Y and Staff Z. Review on 12/14/18 of a Narcotic Book at approximately 2:00 p.m. for Resident #48 on page #3 dated 10/28/18 revealed [MEDICATION NAME] 5 mg. (1/2 tab) 19 tablets as amount left. This medication was documented as MEDICATION TRANSFERRED to Page 26 Review on 12/14/18 of the Narcotic Book at approximately 3:00 p.m. for Resident #48 on page #26 dated 10/28/18 transferred from page #3 revealed 18 tablets of [MEDICATION NAME] not 19 tablets as indicated on page #3. Further review of page #26 for Resident #48 showed three entries on 10/29/18, three entries on 10/30/18 and two entries on 10/31/18 indicating [MEDICATION NAME] being dispensed to Resident #48 with the incorrect [MEDICATION NAME] count from 10/29/18 through 10/31/18. Interview on 12/14/18 at approximately 2:00 p.m. with Staff [NAME] (Director of Nursing) confirmed after review of the Narcotic Book listed above that the [MEDICATION NAME] narcotic count for Resident #48 was incorrect. Staff [NAME] reported that this discrepancy of the incorrect count was missed when audit was done. Review on 12/14/18 at approximately 1:30 p.m. of the facility reported missing narcotic medication on 10/31/18 for Resident #30 and Resident #48 revealed 11 missing [MEDICATION NAME] pills for Resident #48 and 24 missing [MEDICATION NAME] pills for Resident #30. Interview on 12/14/18 at approximately 2:30 p.m. with Staff C (Administrator) and Staff [NAME] (Director of Nursing) confirmed that the reported 11 missing [MEDICATION NAME] medications for Resident #48 and the 24 missing [MEDICATION NAME] medications for Resident #30 were investigated and never found. Staff [NAME] reported that the above listed incorrect [MEDICATION NAME] count for Resident #48 was missed when audit was done during the investigation for the missing [MEDICATION NAME] medications for Resident #48 and Resident #30.",2020-09-01
49,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,756,D,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to receive and follow pharmacist report of irregularities to the attending physician for 1 resident in a final survey sample of 40 residents. (Resident identifier is #19.) Findings include: Resident #19 Review on 12/18/18 of Resident # 19's record had three pharmacist reviews checked off stating see recommendations. Review of the medication tab section of the record revealed that these recommendations were not within the chart with dates of service, 10/18/18, 11/14/18 and 12/10/18 Review on 12/18/18 of Resident #19 Consultation Report for 10/18/18, 11/14/18 and 12/10/18, reveled they were forwarded to the facility by the pharmacist. Review on 12/18/18 of an evaluation that was within the record dated 8/27/18 states Rationale for Recommendation: Evidence for the efficacy and safety of combined use of 2 or more antidepressant medications is limited. The risk for drug interactions, adverse events, noncompliance, and mediation errors are increased. The medication are: [MEDICATION NAME] and [MEDICATION NAME]. Review on 9/13/18 of the medical recorded revealed that the APRN wrote D/C [MEDICATION NAME] (sic-[MEDICATION NAME]), D/C [MEDICATION NAME], and [MEDICATION NAME] decreased to QHS. Both [MEDICATION NAME] and [MEDICATION NAME] are PRN medication and [MEDICATION NAME] was decreased from TID (three times a day) to QD (One time a day). Review on 12/18/18 of the The first Consulation Report dated 10/18/18 which was not in the cart was sent to the facility on [DATE] which states under comment REPEATED RECOMMENDATION from 8/27/18: Please respond promptly to assure facility compliance with Federal regulations Once the facility recived the report called the physican on 12/18/18 and wrote TORB (Telephone order read back) already addressed 9/13/18. Review on 12/18/18 of the second Consultation Report dated 11/14/18 that was sent to the facility on [DATE] with a Recommendation: Please attempt a gradual dose reduction of [MEDICATION NAME], with the end goal of discontinuation, while monitoring for re-emergence of target behaviors and /or withdrawal symptoms. This recommendation was not addressed since facility did not have the report. Review on 12/18/18 of the third Consultation Report dated 12/10/18 that was not within the chart and was sent to the facility on [DATE] with a Comment (Resident #19) has received an antidepressant [MEDICATION NAME] 60 mg po BID . with Recommendation stating Please consider a gradual dose reduction (GDR) attempt . This was addressed on 12/18/18 through interview with Staff F (Unit Manger) once facility was told of the missing documentation and had it forward to the facility from pharmacy.",2020-09-01
50,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,758,D,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure PRN (As Needed) orders for [MEDICAL CONDITION] drugs are limited to 14 days except, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 resident out of a final sample size of 40 residents. (Resident identifier is #212.) Findings include: Review on 12/18/18 of Resident #212 current physician orders [REDACTED].#212 had an order for [REDACTED]. Review on 12/18/18 of Resident #212 physician orders [REDACTED]. Review on 12/18/18 of Resident #212 EMAR (Electronic Medication Administration Record) for the month of (MONTH) (YEAR) revealed that [MEDICATION NAME] 1 mg by mouth every 6 hours PRN for anxiety with start date of 9/20/18 and with no end date was given on 9/21, 23, 24, 25, 26, 27, 28, and 30/2018. Review on 12/18/18 of Resident #212 EMAR for the month of (MONTH) (YEAR) revealed that [MEDICATION NAME] 1 mg by mouth every 6 hours PRN for anxiety with start date of 9/20/18 and with no end date was given on 10/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, 14, 15, 17, 18,19, 20, 21, 22, 23, 24, 25, 26, 27, 29 and 30/2018. Review on 12/18/18 of Resident #212 EMAR for the month of (MONTH) (YEAR) revealed that [MEDICATION NAME] 1 mg by mouth every 6 hours PRN for anxiety with start date of 9/20/18 and with no end date was given on 11/1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 22, 23, 25, 26, 27 and 29/2018. Review on 12/18/18 of Resident #212 EMAR for the month of (MONTH) (YEAR) revealed that [MEDICATION NAME] 1 mg by mouth every 6 hours PRN for anxiety with start date of 9/20/18 and with no end date was given on 12/ 5-6, 9-12, and 14-17/2018. Review on 12/18/18 of Resident #212 physician and nurse practitioner notes dated 9/24/18, 10/1/18, 10/3/18, 10/12/18, 10/26/18, 11/19/18, and 11/27/18 revealed that there were no notes regarding rationale for the PRN [MEDICATION NAME] use and indication of the duration for the PRN [MEDICATION NAME] order. Review on 12/18/18 of Resident #212 consult notes revealed that there were no psychiatry consult notes from (MONTH) to (MONTH) (YEAR) regarding rationale for the PRN [MEDICATION NAME] use and indication of the duration for the PRN [MEDICATION NAME] order. The last psychiatry notes documented was dated 8/28/18. Interview on 12/18/18 at 9:30 a.m. with Staff A (Unit Manager) confirmed the above findings. Staff A revealed that Resident #212 was transferred to their unit (5-2) since (MONTH) (YEAR) and had been using the [MEDICATION NAME] PRN order. Staff A was unable to give explanation of Resident #212's [MEDICATION NAME] PRN order not having a documented rationale for use and duration.",2020-09-01
51,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,761,D,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to ensure that all medications are labeled, stored in locked compartments and discarded when expired for 3 residents in a final survey sample of 40 residents. (Resident identifiers are #109, #165 and #29) Resident #109 Observation on [DATE] at approximately 9:45 a.m. in Resident #109's room revealed the following treatment items: Wound packing strip container without a cover and open to air, and sterile water (single use container) opened and on Resident #109's dresser. Interview on [DATE] at approximately 9:46 a.m. with Staff A (Unit Manager) confirmed that the items did not have a date of opening, Staff A put the items in the garbage. Resident #165 Observation on [DATE] at approximately 10:00 a.m. in Resident #109's room revealed the following treatment item: lac-hydrin five lotion expiration date of ,[DATE]. Interview on [DATE] at approximately 10:30 a.m. with Staff B (Licensed Practical Nurse) confirmed that the items on the dresser were expired and the items were thrown in the garbage. Resident #29 Observation on [DATE] at approximately 12:30 p.m. in Resident #29's room revealed on the dresser was an opened, undated (single container) of sterile water. The sterile water container had several floating black substances in it. Interview on [DATE] at approximately 12:35 p.m. with Staff A (Unit Manager) was not able to identify the floating substances in the container of sterile water. Staff A confirmed that the container was opened and not dated. Review on [DATE] of the facility policy and procedure titled, Storage of Medications, Revision date ,[DATE] revealed: Policy: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Guidelines: . 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.",2020-09-01
52,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,802,C,0,1,P2R411,"Based on observation, interview, and record review, it was determined that the facility failed to employ sufficient staff to effectively carry out food functions for 5 of 5 nursing units (Building 2, 5-2, 5-3). Findings include: Observation on 12/13/18 1:15 p.m. on unit 3 East revealed lunch meal trays being delivered to residents in their rooms. Review on 12/18/18 of meal delivery times revealed that 3 East is scheduled to have food delivered for lunch at 11:14 a.m. Observation on 12/13/18 approximately at 10:00 a.m. on Building 2 revealed Resident #191 eating breakfast in the bedroom. Resident #191 complained that the breakfast always has toast but today was different because it had peanut butter on the tray; usually the toast does not even have butter on it it is always burnt. Observation on 12/13/18 of Building 2 dining area at 12:56 p.m. revealed a white erasable board that stated that lunch would be at 12:00. Several residents were at various tables waiting for lunch to be delivered complaining to each other that lunch is always late and wondering how long today. Interview at 12:15 p.m. with Residents #87, #187 and #191 revealed that lunch is always late. Observation at 12:56 p.m. revealed that the lunch cart arrived and that lunch trays were being distributed to different tables by two staff members. At 1:03 p.m. Resident #87 did not like the meal served and pushed the tray away. The staff members did not stop and ask Resident #87 if Resident #87 wanted an alternate. At 1:14 p.m. this resident got up to leave the room and the staff asked if Resident #87 was done and which time an affirmative answer was stated. Further observations revealed that all meals stay on the trays whether in the dining area or in the rooms in Building 2. Interview with Resident #87 at 1:45 p.m. revealed that the lunch trays are always late and if you do not like the main meal you can ask for an alternate but it will take up to an hour to get it so why bother. It would be nice to have some music while we eat; it is so quiet it and so institutional on the lunch trays. Interview on 12/19/18 at 1:45 p.m. with Staff C, (Administrator) revealed that they have tried everything with dining. With trays and without trays but can not seem to keep boundaries from other residents; so it is easier with the trays. Interview on 12/13/18 with Staff T (Food service manager) revealed that Staff T's department is operating short staffed and in need of filling six dietary positions including a cook, two full-time dietary aides and three part-time dietary aides. This staffing shortage is causing tray carts containing the resident's meals to be delivered late to the facility units. Interview on 12/19/18 with Staff T revealed that on 12/19/18 the dietary department only had four of seven needed staff available to help prepare the food carts in the kitchen. As a result on 12/19/18 the food carts for every unit left the kitchen late and Staff T's documentation revealed that the food carts were late leaving the kitchen on all days of the survey. A test tray on 12/19/18 done by Staff P (Dietician) on unit 5-3 documented the meal temperatures at a unaccpetable low level temperatures according to the dieticians form with the entree temperature recorded at 107 degrees and the vegetables at 115 degrees. Interview on 12/14/18 at 9:44 AM with Staff C (Administrator) confirmed that they are short staffed in the kitchen by 5 dietary aide's and one cook. The Staff C states they are doing the best they can trying to hire staff for the department but it has been very difficult. Observation on 12/13/18 at approximately 9:20 a.m. of the dining room on Unit 5-2 revealed the food truck arrived to the unit at 9:20 a.m. Observation on 12/14/18 at approximately 9:15 a.m. of the dining room on Unit 5-2 revealed the food truck arrived to the unit at 9:15 a.m. Interview on 12/14/18 at approximately 9:15 a.m. with Resident #226 and Resident #5 revealed that Resident #226 had been waiting about an hour to an hour and a half for breakfast. It's ridiculous, we wait like this everyday for all of our meals. Resident #5 confirmed Resident #226's statement that meals are always about an hour to an hour and a half late. Review on 12/13/18 of the facilitys Cart delivery sheet revealed that breakfast leaves the kitchen at 8:23 a.m. Interview on 12/14/18 at approximately 10:00 a.m. with Resident #164 revealed that meals are always cold. I don't ask for it to be warmed up anymore because it takes so long. Observation on 12/19/18 at approximately 9:00 a.m. of the dining room on Unit 5-2 revealed the food truck arrived to the unit at 9:05 a.m. Interview on 12/13/18 at approximately 10:45 a.m. with Resident #15 revealed that the meals arriving from the kitchen were frequently late and were frequently cold. When asked if the facility staff would heat the food up, Resident #15 stated that they would heat it up, but that Resident #15 didn't ask because they felt that it would have taken staff away from their work and they were already short staffed. Observation on 12/13/18 of the dining room on Floor 5-3 revealed that the lunch food carts arrived on the unit from the kitchen at 1:35 p.m. Interview on 12/13/18 at approximately 1:15 p.m. with Staff J (Unit Manager) revealed that the lunch carts were late and that they should have arrived earlier. Observation on 12/14/18 of the dining room on Floor 5-3 revealed that the lunch food carts arrived on the unit from the kitchen at 1:15 p.m. Review on 12/19/18 of the facility form, titled Cart delivery . time . revised 12/11, revealed that the lunch carts that went to Floor 5-3 were supposed to leave the kitchen at 12:18 p.m. Interview on 12/13/18 at 11:00 a.m. with Staff J (Unit Manager) revealed that lunch is served at 12:30 p.m. Observation on 12/13/18 at 12:38 p.m. of the 5-3 unit revealed that there were no meal trays for lunch delivered on the unit. Interview on 12/13/18 at 12:38 p.m. with Staff J revealed that the meal trays for lunch will be delivered in 5-10 minutes. Interview on 12/13/18 at 1:00 p.m. with Resident #62 and Resident #18 revealed that their lunch was often served late around 1:30 p.m. Observation on 12/14/18 at 12:30 p.m. of the 5-3 unit revealed that the meal trays for lunch were not on the unit. Interview on 12/14/18 at 12:30 p.m. with Staff M (Licensed Nursing Assistant) confirmed that meal trays have not been delivered to the 5-3 unit. Observation on 12/14/18 at 1:00 p.m. of the 5-3 unit revealed that the meal trays for lunch were not on the unit. Interview on 12/14/18 at 1:00 p.m. with Staff M (Licensed Nursing Assistant) confirmed that meal trays have not been up in the 5-3 unit. Observation on 12/14/18 at 1:20 p.m. of the 5-3 unit revealed that meal trays for lunch were just delivered on the unit.",2020-09-01
53,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,804,E,0,1,P2R411,"Based on a resident complaint, resident record review, interview and observation it was determined the facilty failed to ensure that food is served at appetizing temperatures and not served cold. (Resident identifiers are #72 and #138) Findings include: Review on 12/19/18 Staff P's (Dietician) of documentation of the results of a test tray conducted on unit 5-3 recorded the food temperatures at unacceptably low levels according to the facility form the entree was recorded at 107 degrees and the vegetables recorded at 115 degrees. Staff T (Dietary manager) documented on 12/19/18 and on the other days of survey when the food carts were actually going out to the units next to the times they were supposed to be dispensed to each unit. This documentation showed that on all days of survey the food carts were being dispensed late to all units during all three meals daily because of a shortage of dietary staff. Interview on 12/19/18 with Staff T revealed that on 12/19/18 dietary had only four of the seven needed staff available to help prepare the food carts for dispensing lunch to the facility units. Staff T also revealed that the dietary department needed another cook, two full-time dietary aides and three part-time dietary aides. Review of a resident complaint regarding cold food noted in the minutes of the 11/27/18 meeting of the Resident's food committee revealed that this came from a resident on unit 5-3. The complaint stated that there's not enough staff to serve trays no one is there to pass out trays. Staff T confirmed that this information was verbally passed on to Staff P (Dietician). Interview with Staff P acknowledged receiving this complaint of cold food from Staff T but stated that there was no test tray or other follow up done in response to this resident's complaint of cold food on unit 5-3. Interview on 12/14/18 at 10:35 a.m.with Resident Council had 11 Residents present representing 3 different units in the building. All of the 11 residents in attendance felt like meals were always late getting to the floor and Resident 72 said: the meals are getting colder & colder. Resident #72 also said: In some cases residents are not getting specialized diets or are not always getting what they ordered. Resident #72 also stated that it (meal service) is getting really bad. One resident (Resident number was not identified) has pictures of the meals as presented. One picture showed a hamburger patty, dried out, overcooked (resident said blackened) and curled up. Resident #72 stated: There seems to be a shortage of people working in the Kitchen. They always seem to be 2 or 3 people short in the kitchen. Resident #72 also said there seems to be a lack of supervision in the kitchen, why else would we get such poor (food) service. There is a lot of turnover in the Kitchen. The turnover is incredible, in my lifetime of working, I've never seen turnover this bad. Resident #138 stated: I am about ready to deduct money from my monthly payments for every meal I can't eat. The question was raised by a Resident as to who is managing the kitchen. Resident #72 said: They should have a person in the kitchen that knows the business inside and out so that they can tell staff what they should be doing. Resident #72 has also observed desserts to be uncovered during transport and was worried that dust or crumbs from carts or trays could get into those uncovered desserts. Resident #72 also stated: There are people in management throughout the entire organization who seem to lack experience.",2020-09-01
54,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,806,E,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to provide food that was appealing, and to ensure that the food offered took into consideration resident allergies and preferences for 4 out of 6 nursing units. Findings include: Resident #196 Interview on 12/14/18 at approximately 8:40 a.m. with Resident #196 revealed that Resident #196 stated that the food was not good. They stated that they have a [MEDICAL CONDITION] and are bothered by gassy foods. They stated that they met with the dietitian and that the dietitian listened and wrote down what their preferences were, but that it did not seem as though that information had been communicated with the kitchen, as they frequently got served the foods that they could not tolerate. Review on 12/19/18 of Resident #196's Diet History/Food Preferences form, that was not dated, revealed that Resident #196 indicated that they did not want to be served spicy foods, fish, broccoli, cabbage, cauliflower, spinach, yellow squash or zucchini. Review on 12/19/18 of Resident #196's Diet Order and Communication form, dated 9/17/18, revealed that Resident #196 was allergic to mushrooms. Review on 12/19/18 of Resident #196's diet slips from the kitchen revealed that it read that Resident #196 was allergic to mushrooms. There was nothing documented on the diet slip about Resident #196's preference not to be served spicy foods, cabbage, spinach, yellow squash or zucchini. Interview on 12/19/18 at approximately 11:10 a.m. with Resident #196 and Staff P (Registered Dietitian) confirmed that Resident #196 had an allergy to mushrooms and that they did not want to be served spicy foods. Resident #196 stated that they were served clam chowder for supper on 12/18/18, that they were served mushrooms very frequently and that they are served brussel sprouts, broccoli and cauliflower. Resident #536 Interview on 12/14/18 at 1:45 p.m. revealed that Resident #536 was not eating lunch because Resident #536 got fish for a meal even though Resident #536 has a fish allergy. Observation on 12/14/19 at 1:50 p.m. of Resident #536's meal tray and meal ticket revealed a plate with a fish meal and a meal ticket for Resident #526 that had Allergies: FISH bolded in red printed across the top. Interview on 12/14/18 at 1:55 p.m. with Staff V (Licensed Nursing Assistant) confirmed there was fish on Resident #536's meal tray. Review on 12/18/18 of Resident #526's medical record revealed a list of Resident #536's allergies that listed fish as an allergy. Interview on 12/14/18 at 9:44 AM with Staff C (Administrator) stated that they are short staffed in the kitchen by 5 dietary aides and one cook. The Staff C states they are doing the best they can trying to hire staff for the department but it has been very difficult. Resident #92 Interview on 12/13/18 at 10:55 a.m. with Resident # 92 revealed their meal ticket, is the same meal ticket I get every meal since I've been here. But every time my meal tray comes up it is always something different then what the meal ticket says. Resident #152 Interview on 12/13/18 at 9:49 a.m. Resident #152's husband stated his wife has been waiting for her cereal for over a hour which was not on her food tray. Resident #152's meal ticket was observed on their tray, review of the meal ticket reveals 3/4 cup Cereal-cold. The husband stated this happens all the time, I'm just glad I'm here to make sure my wife gets what she needs. Resident #41 Interview on 12/14/18 at approximately 10:00 a.m. with Resident #164 revealed that items are missing from the food menu on a daily basis. At least 1 thing is missing off of the menu every day. The other day it was brussel sprouts, another day was potato chips.",2020-09-01
55,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2018-12-19,880,D,0,1,P2R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, it was determined that the facility failed to provide a safe and sanitary environment for infection control in regards to following transmission-based precautions and a unsanitary suction machine for 2 residents out of the facility census of 234 residents. (Resident identifiers are #84, and #118.) Findings include: Policy review Review on 12/14/18 of the facility's policy titled, Isolation- Categories of Transmission-Based Precaution, last revised date of 4/2018, revealed that .Droplet Precautions .when a private room is not available and cohorting is not achievable, use a curtain and maintain at least 3 feet of space between the infected resident and other residents and visitors .put on a mask when entering the room .the facility will implement a system to alert staff and visitors to the type of precaution the resident requires . Resident #84 Observation on 12/14/18 at approximately 8:10 a.m. in Resident #84's room revealed a mouth suction machine on the night stand next to Resident #84's bed. The suction machine canister was 1/2 filled with what appeared to be yellow/white remnants of mouth suctioning. The tubing connected to the canister had a film noted on the inside that was consistent with what was in the canister. Interview on 8/14/18 at approximately 8:15 a.m. with Staff B (Licensed Practical Nurse) confirmed that the canister was 1/2 filled with remnants of mouth suctioning and the tubing also. Staff B revealed that mouth suctioning had not been done on Staff B's shift, the night nurse may have done mouth suctioning on (pronoun omitted). Interview on 8/14/18 at approximately 8:20 a.m. with Staff D (Registered Nurse) who worked the night shift revealed that Staff D did not do any mouth suctioning with Resident #84. Review on 12/14/18 of Resident #84's physician orders [REDACTED]. Oral suctioning PRN (as needed) for increased secretions, start date 2/9/16. Review on 12/14/18 of Resident #84's Medication Administration Record [REDACTED]. Interview on 12/14/18 at approximately 2:30 p.m. with Staff [NAME] (Director of Nurses) revealed that Resident #84 had not been suctioned recently, and stated that It could be up to 3 months without cleaning the suctioning system. It is a closed system. Review on 12/17/18 of the facility policy and procedure titled, Suctioning the Upper Airway (Oral Pharyngeal Suctioning), Revision date 4/2018 revealed the following: . Steps in the Procedure . 22. Discard water or saline in commode. Dispose cup in designated receptacle. 23. Empty and rinse collection container if necessary or as indicated by facility policy. . Resident #118 Interview on 12/13/18 at approximately 9:30 a.m. with Staff J (Unit Manager) revealed that Resident #118 was on contact precautions for [MEDICAL CONDITION]. When asked what personal protective equipment needed to be worn when entering Resident #118's room, Staff J stated that gowns, gloves and masks needed to be worn. Observation on 12/14/18 at approximately 8:15 a.m. of Resident #118 being fed by Staff Q (Licensed Nursing Assistant) who was standing right next to Resident #118's bed while feeding them, revealed that Staff Q was wearing gloves, but was not wearing a gown. Interview on 12/14/18 at approximately 9:00 a.m. with Staff Q revealed that Staff Q stated that they only needed to wear a gown when washing Resident #118, not when they are feeding them. Interview on 12/19/18 at approximately 1:15 p.m. with Staff K (Infection Control Nurse) confirmed that, for residents on contact precautions, gowns and gloves are to be worn when in the room. Staff K also confirmed that masks did not have to be worn, that when feeding a resident in their room who is on contact precautions a gown was to be worn, and that the signs alerting visitors needed to be visible where they could be easily seen.",2020-09-01
56,HANOVER HILL HEALTH CARE CENTER,305009,700 HANOVER STREET,MANCHESTER,NH,3104,2020-01-31,585,B,0,1,0IIF11,"Based on interview and record review the facility failed to maintain a complaint/grievance log. Findings include: Review on 1/31/20 of the facility policy and procedure titled Grievances revealed the following: Policy Interpretation and Implementation: 7. The patient/resident, or person filing the grievance on behalf of the patient/resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or her designee, within ten working days of the completion of initial investigation of the grievance. A written summary of the report will also be provided to the patient/resident upon request, and a copy will be filed in the Social Services Office. Review on 1/31/20 of the facility policy and procedure titled Investigating Grievances revealed the following: 3. The Grievance Investigation Report must be filed with the administrator within five (5) working days of the receipt of the grievance. 4. The patient/resident, or person acting on behalf of the patient/resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten (10) working days of the filing of the grievance. 5. A copy of the Grievance Investigation Report must be filed in the social services office. 6. Copies of all reports must be signed and a written summary of the report will be provided upon request to patient/resident or person acting on behalf of the patient/resident. Interview on 1/30/20 at approximately 11:30 a.m. with Staff [NAME] (Director of Social Services) revealed that grievances/complaints are addressed at the time of the grievance/complaint is reported to the facility. Staff [NAME] confirmed that there was no documented complaint/grievance log to track and/or trend complaints/grievances investigated by the facility within 3 years from the date of a complaint/grievance resolution.",2020-09-01
57,HANOVER HILL HEALTH CARE CENTER,305009,700 HANOVER STREET,MANCHESTER,NH,3104,2020-01-31,658,D,0,1,0IIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to follow physician orders [REDACTED]. (Resident identifier is #47.) Findings include: Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders revealed the following: The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 1/31/2020 of Resident #47's medical record revealed a physician's orders [REDACTED].#47 would have weekly skin assessment. Review on 1/31/2020 of Resident #47's weekly skin condition record revealed that Resident #47 did not receive timely weekly skin assessment. Resident #47 received one on 1/4/2020, which stated wounds to buttocks treated as ordered in MAR (Medication Administration Record) No s/s (signs/symptoms) of infections; the following week 1/11/2020 it revealed that it Continues with multiple open areas to coccyx/buttocks. Dressing and ointments applied as ordered. No changes noted. No s/s infection. This was the last note/input to the skin condition record. Review on 1/31/2020 of Resident #47's care plan revealed that Resident #47 has an alteration in skin integrity r/t (related /to) the pressure of Deep Tissue Injury (DTI). The care plan inventions include dressings as ordered. assesses placement and integrity of the dressing every shift and change if compromised. Interview on 1/31/2020 at approximately 2:00 p.m. with Staff D (Unit Manager) confirmed that Resident #47 developed a DTI on the heel. Staff D confirmed the heels started to be offloaded at this time. Review on 1/31/2020 of physician orders [REDACTED]. Heel foam cups BL (bilateral) heels- change weekly off-loading boot while in bed at all times. Staff D confirmed this was started after the DTI was discovered. Review on 1/31/2020 of Resident #47's medical record revealed no documentation that the heels had been looked at prior to the DTI developing.",2020-09-01
58,HAVENWOOD-HERITAGE HEIGHTS,305016,33 CHRISTIAN AVENUE,CONCORD,NH,3301,2019-05-23,926,D,0,1,XFUZ11,"Based on observation, interview, record review and policy review, it was determined that the facility failed to follow facility smoking policy for 1 out of 1 resident who smoked. (Resident identifier is #11.) Findings include: Review on 5/22/19 of facility's policy titled, Resident Smoking while in the Health Service Center, dated 10/07/16, revealed .complete a smoking evaluation .review status of resident's smoking privileges at least quarterly and more often as needed .update the resident's care plan to indicate the current status of smoking privileges/restrictions Review on 5/22/19 of facility's smoking evaluation, revision date 10/7/16, revealed .for resident who wishes to smoke, perform evaluation on admission, quarterly, at a significant change, or if there has been an incident of unsafe smoking observed or reported Interview on 5/21/19 at 11:42 a.m. with Resident #11 revealed that Resident #11 smoked once a day at the parking lot with staff supervision. Resident #11 stated that they kept their cigarettes in their bedside drawer and that the nurses kept their lighter. Observation on 5/21/19 at 11:42 am in Resident #11's room revealed that Resident #11 had a box of cigarette in their bedside table. Review on 5/23/19 of Resident #11's current smoking care plan revealed that Resident #11 wanted to continue to smoke and that Resident #11 will not smoke without someone present, Resident #11 will smoke 1 cigarette per outing, and Resident #11's friend will accompany resident outside of sliding glass doors, down the ramp, and outside the fence to smoke. Review on 5/23/19 of Resident #11's chart and EHR (Electronic Health Record) revealed that Resident #11's smoking evaluation was completed on 10/7/16. Further review of Resident #11's chart and EHR revealed no other smoking evaluation after 10/7/16. Interview on 5/23/19 at 8:45 a.m. with Staff B (Registered Nurse) confirmed that Resident #11 was the only resident who smoked. Staff B revealed that there was no smoking evaluation done. Staff B stated that they do not do smoking evaluation. Staff B was unable to provide more information regarding smoking evaluation. Interview on 5/23/19 at 8:45 a.m. with Staff D (Unit Coordinator) revealed that Resident #11 was supervised when smoking and that Resident #11 utilized a smoking apron. Interview on 5/23/19 at 9:00 a.m. with Staff A (Unit Manager) revealed that there was no smoking evaluation done after 10/7/16. Staff A stated that they did not know about the smoking policy and smoking evaluations. Staff B also stated that the care plan was not updated as Resident #11 needed a smoking apron and that Resident #11's lighter would be kept at the nurse's medication cart when not used by Resident #11.",2020-09-01
59,HAVENWOOD-HERITAGE HEIGHTS,305016,33 CHRISTIAN AVENUE,CONCORD,NH,3301,2017-09-22,226,D,0,1,NEVL11,"Based on interview and review of the facility policy, it was determined that the facility failed to include two of the seven required components that assure the facility is doing all that is within its control to prevent occurrences of abuse and neglect. Findings include: Review on 9/21/17 of the facility policy for abuse and neglect titled Resident Abuse, Neglect, & Exploitation dated 5/31/2017 revealed that of the seven required components that must be included in the facilities abuse policy two were not included. The components are: Screening, training, protection, prevention, identification, investigation, and reporting/response. The two components that were not included in the facility's policy are screening and identification. Interview on 9/21/17 at approximately 2:10 p.m. with Staff B (Director of Nursing) confirmed that the two components had been left out of the current policy when it was put into effect on 5/31/17.",2020-09-01
60,HAVENWOOD-HERITAGE HEIGHTS,305016,33 CHRISTIAN AVENUE,CONCORD,NH,3301,2017-09-22,279,D,0,1,NEVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop comprehensive care plans for 2 residents out of a sample size of 18 residents. (Resident Identifiers are #3 and #9.) Findings include: Resident #9 Review on 9/21/17 of Resident #9's medical record in the nursing note dated 6/15/17 02:28 p.m. revealed that Resident #9 had a pacemaker. Review on 9/21/17 of Resident #9's care plans revealed that there was not a care plan for the pacemaker. Interview on 9/21/17 at approximately 2:00 p.m. with Staff A (Registered Nurse) confirmed that there was not a care plan for Resident #9's pacemaker. Resident #7 Review on 9/18/17 of Resident #7's comprehensive care plan indicates Resident #7 is receiving a regular diet. Interview on 9/22/17 with Staff H (Registered Dietician) revealed that Resident #7 since 8/28/17 Resident #7 has been receiving a mechanical soft diet with ground meat. The Facility failed to ensure that Resident #7's comprehensive care plan reflected the actual diet Resident #7 was receiving. Resident #3 Review on 9/21/17 of Resident #3's [DIAGNOSES REDACTED].#3 had a pacemaker in place. Review on 9/21/17 of Resident #3's current Care Plan, dated 7/13/17, revealed that there was no care plan for Resident #3's use of a pacemaker. Interview on 9/22/17 at approximately 11:00 a.m. with Staff [NAME] (Registered Nurse) confirmed that Resident #3 had a pacemaker and that there was no care plan in place for the pacemaker.",2020-09-01
61,HAVENWOOD-HERITAGE HEIGHTS,305016,33 CHRISTIAN AVENUE,CONCORD,NH,3301,2017-09-22,431,D,0,1,NEVL11,"Based on observation and interview, it was determined that the facility failed to discard expired medications found in the medication room on Lighthouse Lane and medication cart on[NAME]Lane medication cart. Findings include: Observation on 9/22/17 at approximately 7:15 a.m. of the[NAME]Lane medication storage room refrigerator revealed the following expired medications: [REDACTED] Prochloroperazine 25 mg (milligram) suppositories expiration date 6/17. (House Stock) Glycerin suppositories expiration date 1/17. (House Stock) Interview on 9/22/17 at approximately 7:15 a.m. with Staff D (Licensed Practical Nurse) confirmed that the above medications were expired. Observation on 9/22/17 at approximately 8:10 a.m. of the medication cart on[NAME]Lane revealed the following expired medications: [REDACTED] Melatonin 3 mg (milligram) expiration date 3/16. (Resident # 10) Nitrostat 0.4 mg expiration date 5/25/17. (Resident #19) Nitrostat 0.4 mg expiration date 6/29/17. (Resident #20) Nitrostat 0.4 mg expiration date 6/28/17. (Resident #21) Risperdal 0.25 mg expiration date 7/19/17. (Resident #22) Tylenol 325 mg expiration date 9/6/17. (Resident #23) Sennokot S 8.6/50 mg expiration date 9/6/17. (Resident #23) Tylenol 325 mg expiration date 6/28/17. (Resident #24) Acidophilus with Pectin expiration 6/14/17. (Resident #24) Preservision Areds expiration date 5/30/17. (Resident #25) Sennokot S 8.6/50 mg expiration date 9/16/17. (Resident #26) Siltussin 100 mg/5 ml (milliliter) expiration date 9/3/17. (Resident #27) Siltussin 100 mg/5 ml expiration date 3/26/17. (Resident #27) Siltussin 100 mg/5 ml expiration date 5/14/17. (Resident #28) Clindamyocin 300 mg expiration date 6/23/17. (Resident #29) Interview on 9/22/17 at approximately 8:20 a.m. with Staff D and Staff C (Medication Nurse Assistant) confirmed that the above medications were expired. Interview on 9/22/17 at approximately 2:30 p.m. with Staff B (Director of Nurses) revealed that there was not a facility policy and procedure for discarding expired medications. Observation on 9/21/17 at approximately 3:00 p.m., of the Medication Room refrigerator on Lighthouse Lane, revealed an opened vial of Tuberculin Purified Protein Derivative, which was not dated. Review on 9/21/17 of the Manufacturer's instructions for the Tuberculin Purified Protein Derivative revealed that A vial of Tubersol which has been entered and in use for 30 days should be discarded. Interview on 9/21/17 at approximately 3:00 p.m. with Staff G (Licensed Practical Nurse) confirmed that all multidose vials were to be dated when opened and that this multidose vial was not dated.",2020-09-01
62,HAVENWOOD-HERITAGE HEIGHTS,305016,33 CHRISTIAN AVENUE,CONCORD,NH,3301,2017-09-22,441,D,0,1,NEVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, it was determined that the facility failed to prevent the potential for cross contamination during blood glucose monitoring on 1 of 2 units and that the professional standard of practice for hand hygiene was implemented to reduce the spread of infection and prevent cross contamination for 3 of 3 residents observed during medication pass observation. (Resident identifiers are #16, #17 and #18) Findings include Resident #16 Observation on 9/22/17 at approximately 7:30 a.m. of the medication pass on Lighthouse Lane B revealed Staff F, MNA (Medication Nursing Assistant) administering medications to Resident #16. The medications administered to Resident #16 were Tylenol tablets and Artificial Tears eye drops. Staff F administered the Tylenol and then donned gloves to administer the eye drops. Staff F removed the gloves after administering the eye drops and did not wash hands or apply hand sanitizer when done. Staff F walked over to the medication cart to start pouring medications for the next resident, Resident #17. Resident #17 Observation on 9/22/17 at approximately 7:40 a.m. of the medication pass on Lighthouse Lane B revealed Staff F, who had just finished administering medications to Resident #16, go over to the medication cart and started pouring medications for Resident #17. Staff F did not wash hands or apply hand sanitizer before pouring the medications for Resident #17. Staff F brought the medications, which included several tablets as well as Refresh eye drops, to Resident #17. Staff F administered the tablets and then donned gloves to administer the eye drops. Staff F removed the gloves after administering the eye drops and did not wash hands or apply hand sanitizer when done. Staff F walked over to the medication cart to start pouring medications for the next resident, Resident #18. Resident #18 Observation on 9/22/17 at approximately 7:50 a.m. of the medication pass on Lighthouse Lane B revealed Staff F, who had just finished administering medications to Resident #17, go over to the medication cart and started pouring medications for Resident #18. Staff F did not wash hands or apply hand sanitizer before pouring the medications for Resident #18. Staff F brought the medications, which included several tablets as well as Nasal Spray and [MEDICATION NAME] inhaler, to Resident #18. Staff F administered the tablets and then donned gloves to administer the Nasal Spray and the inhaler. Staff F removed the gloves after administering the eye drops and did not wash hands or apply hand sanitizer when done. Review on 9/22/17 of the Facility Policy, Titled Administration of Medications. Date 9/5/02 revealed Procedure: Action .Wash hands using proper hand washing technique. Don gloves when appropriate. Rationale .Decreases transfer of microorganisms when there is any chance of exposure to resident body secretions. Lessens transfer of microorganisms . Interview on 9/22/17 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that hand hygiene was supposed to be done between residents during medication administration. Observation on 9/22/17 at approximately 8:00 a.m. of the glucometer on[NAME]Lane medication cart revealed a brown/red dried substance on the back of the Glucometer. Interview on 9/22/17 at approximately 8:00 a.m. with Staff C (Medication Nurse Assistant) and Staff D (Licensed Practical Nurse) revealed that the glucometer was ready for use. Staff D confirmed that there was a brown/red dried substance adhered on the back of the meter.",2020-09-01
63,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,552,D,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to inform 1 resident in a standard survey sample of 22 residents of the increased risk of mortality in patients with a [DIAGNOSES REDACTED].e. Black Box Warning) in advance of treatment involving an antipsychotic medication (Resident identifier is #50.) Findings include: Resident #50 Review on 4/13/18 at approximately 11:00 am of Resident #50's medical record revealed a physicians order for [MEDICATION NAME] 5 mg tablet (ARIPiprazole) give 5 mg by mouth one time a day for Major [MEDICAL CONDITION], dated 2/23/18. Further review of resident #50's medical record revealed that there was no documentation that Resident #50 was informed of the increased risk of mortality in patients with a [DIAGNOSES REDACTED].e. Black Box Warning) prior to the administration of [MEDICATION NAME]. Interview on 4/13/18 at approximately 11:15 am with Staff H (Unit Manager) confirmed the above findings for the administration of Abilfy.",2020-09-01
64,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,625,B,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed notify the resident of the facility's bed hold policy for 1 of 1 transferred residents in a sample of 22 residents. (Resident identifier #55) Findings include: Review of Resident #55's progress notes on 4/13/18 at 08:56 am revealed Resident #55 was transferred to the hospital on [DATE]. Further review of the resident's medical record revealed [REDACTED]. Interview with Staff I (Regional Director of Operations) on 4/13/18 03:02 pm confirmed that there was no written evidence of notification of the bed hold policy for Resident #55 on 4/9/18. Interview further revealed that it is the facility notifies residents of the facility's bed hold policy on admission and not at transfer.",2020-09-01
65,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,656,C,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to develop comprehensive care plans that included medical, nursing and psychosocial needs for 6 residents in a standard survey sample of 22 residents. (Resident identifiers are #5, #25, #52, #66, #80 and #185.) Findings include: Resident #66 Observation on 4/11/18 at approximately 10:35 a.m. revealed that Resident #66 was using oxygen that was being administered through a nasal cannula. Review on 4/13/18 of Resident #66's current care plan revealed that there was no care plan for Resident #66's use of oxygen. Interview on 4/13/18 at approximately 11:30 a.m. with Staff [NAME] confirmed that a care plan should be in place for Resident #66's use of oxygen. Resident #80 Interview on 4/12/18 at approximately 9:00 a.m. with Resident #80 revealed that Resident #80 does not feel that they are getting good pain relief with the pain medications being administered. Resident #80 revealed that an acceptable pain level for them after medication would be about a 5 or 6 out of 10. Review on 4/13/18 of Resident #80's current care plan revealed that the goal for Resident #80's acute pain was written as The resident will voice a level of comfort of (SPECIFY residents states range of comfort) out of (SPECIFY) through the review date. Date initiated: 03/30/2018 . Interview on 4/13/18 at approximately 1:20 p.m. with Staff F (Registered Nurse) confirmed that Resident #80's care plan did not specify what the acceptable goal level of pain was for Resident #80. Resident #185 Observation of Resident #185 in their room on 4/11/18 at 8:35 am revealed the resident has extreme swelling in their hands and feet. Review of Resident #185's progress notes on 4/13/18 at approximately 7:45 am revealed a progress note from 3/25/18 stating that Resident #185 was sent to the hospital for [MEDICAL CONDITION]. Review of Resident #185's current care plan on 4/13/18 at approximately 7:45 am revealed no goals or interventions for [MEDICAL CONDITION]. Interview with Staff A (Director of Nursing) on 4/13/15 at approximately 12:45 pm confirmed Resident #185 had [MEDICAL CONDITION] and there were no goals or interventions for [MEDICAL CONDITION] on Resident #185's care plan. Resident #52 On 4/12/18 at10:15 a.m. an interview with resident #52 revealed that Resident #52 is a smoker and keeps smoking supplies on his person. Resident #52 verbalizes understanding that supplies are to be kept at the nurses station as per facility policy, and that smoking privelages can be lost for non-compliance with the policy. Resident #52 also stated that he/she goes outside to a designated area to smoke, and verbalized keeping smoking materials on his/her person, or in the side of the wheelchair, but not at the nurses station. Review of the care plan for Resident #52, and Policy & Procedure for Resident Smoking on 4/12/18 at 1:30 p.m. revealed that all smoking materials must be returned to the Nurses Station immediately after use. Review of Resident #52's Care Plan on 4/13/18 at approximately 10:30 a.m. revealed that the smoking care plan for Resident #52 is addressed with interventions in place, however, the care plan is not individualized and updated for this specific resident as indicated by the following 2 entries on the care plan: 1.) Resident requires flame retardant apron while smoking: An interview with Staff A, Director of Nursing at 9:55 a.m. revealed that the resident does not require a flame retardant apron while smoking. This is reinforced by a smoking evaluation mentioned below. Staff A, DON, stated that this statement should not be on the care plan as it is not true for this Resident. Resident #52 was observed on 4/11/18 at 2:30 p.m., 4/12/18 at 2:30 p.m. and 4/13/18 at 7:30 a.m. and 9:00 a.m. to be outside in the smoking area. He was not donning a flame retardant apron. 2.) Smoking materials to be held by nursing staff: Interview with Staff A, DON, and Staff D, Licensed Nursing Assistant (LNA) on 4/13/18 at 10:00 a.m. revealed that the smoking materials are to be kept in a locked cabinet at the nurses station when not in use. When Staff D LNA was asked to reveal the contents of the smoking cabinet, there were no smoking materials belonging to Resident #52 observed in the cabinet. Interview on 4/13/18 at 10:40 a.m. with Resident #52 resulted in the resident producing the smoking materials when reqested. The materials were being held by Resident #52 on his/her person. Staff D, LNA also stated when asked, that staff on this unit do not have or use a method for tracking when smoking materials are taken from the nurses station by a resident, or when/if they are returned to the nurses station after use. This statement was confirmed with Staff A, DON. A smoking evaluation was performed on 3/26/18. Review of this document on 4/13/18 at 1:35 p.m. revealed that Resident #52 is safe to handle his/her own smoking materials while in use, but the smoking evaluation stated that the facility Smoking Policy must be followed. Review of Smoking Policy and Procedure on 4/13/18 at 1:40 p.m. revealed that the policy states that the materials are to be kept at the nurses station when not in use by the resident. An interview with Staff A, DON on 04/13/18 at 1:50 p.m. was conducted regarding the discrepancies between assessments offered, policy and procedure, care plan, and what is actually happening with this resident regarding smoking practices. Staff A stated that the facility smoking process for residents was part of a recent Performance Improvement Plan (PIP) of the facility conducted on 3/20/18, and that they had addressed these issues at the time, and the PIP was considered to be completed. Staff A stated that they will need to put a monitoring system in place, as this was part of the PIP, which stated: The Unit Managers will review patient compliance with returning smoking materials., and there was no monitoring system in place as verified by Staff D, LNA and Staff A, DON. Resident #5 Review on 4/12/18 at approximately 11:56 am of Resident #5's medical record revealed a physicians order written on 1/3/18 for an indwelling Foley catheter. Review of Resident #5's care plan on 4/12/18 revealed that there was no documented evidence addressing the indwelling Foley catheter. Interview on 4/12/18 at approximately 12:15 pm with Staff H (Unit Manager) confirmed that there was no documented evidence addressing Resident #5's indwelling Foley catheter. Resident #25 Review on 4/13/18 at approximately 9:42 am of Resident #25's medical record revealed a physicians order dated 12/29/17 for a [MEDICAL CONDITION] pump to be placed on Resident #25's legs for 1 hour in the morning while reclining. Review of Resident #25's care plan on 4/13/18 revealed that there was no documented evidence in the care plan addressing the [MEDICAL CONDITION] pump. Interview on 4/13/18 at approximatley 10:00 am with Staff H (Unit Manager) confirmed that there was no documented evidence in Resident #25's care plan addressing the [MEDICAL CONDITION] pump.",2020-09-01
66,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,658,B,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to obtain and follow physician orders for 2 residents in a standard survey sample of 22 residents. (Resident identifiers are #66 and #185.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #66 Observation on 4/11/18 at approximately 10:35 a.m. revealed that Resident #66 was using oxygen that was being administered through a nasal cannula. Review on 4/13/18 of Resident #66's Active Physician Orders revealed no physician order for [REDACTED].>Review on 4/13/18 of Resident #66's Health Status Progress note, dated 3/17/18, revealed a note which read .O2 (oxygen saturation) 92% 2L (on 2 liters) NC (nasal cannula.) Review on 4/13/18 of Resident #66's Respiratory therapy progress note, dated 3/15/18, revealed a note which read .Patient has required supplemental O2 to normalize O2 saturations . Interview on 4/13/18 at approximately 11:30 a.m. with Staff [NAME] (Respiratory Therapist) confirmed that there should have been a physician order in place for Resident #66's use of oxygen. Resident #55 Review on 4/13/18 at 8:56 am of the physician orders dated 3/28/18 revealed an order for [REDACTED]. Review on 4/13/18 at approximately 9:00 am of Resident #55's progress notes revealed the following: on 4/9/18 the resident was receiving O2 at 3 LPM, on 4/8 the resident was receiving O2 at 4 LPM, on 4/6/18 the resident was receiving O2 at 3 LPM, on 4/5/18 the resident was receiving O2 at 3 LPM, on 4/3/18 the resident was receiving O2 at 3 LPM, and on 4/2/18 the resident was receiving O2 at 3 LPM. Interview with Staff A (Director of Nursing) on 4/13/18 at approximately 2:15 pm confirmed the above findings.",2020-09-01
67,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,690,D,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that a resident with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary, for 1 of 2 residents reviewed for catheters in a sample of 22 residents (Resident identifier is #185). Findings include: Observation of Resident #185 on 4/11/18 at 8:36 am revealed the resident had a urinary catheter. Review of physician orders [REDACTED].#185 revealed an order dated 4/8/18 for catheter 16 French with 10 cc balloon to straight drainage. Review of Resident #185's list of [DIAGNOSES REDACTED]. Interview with Staff J (Licensed Practical Nurse) on 4/13/18 at 9:37 am revealed that Resident #185 had a catheter when admitted from the hospital on [DATE] and the reason for the catheter was patient request. Interview with Staff A (Director of Nursing) on 4/13/17 at approximately 1:30 am confirmed there was no clinical [DIAGNOSES REDACTED].",2020-09-01
68,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,695,B,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to provide and document that they maintained their schedule for changes in oxygen tubing for 4 residents in a standard survey sample of 22 residents. (Resident identifiers are #18, #23, #66 and #68.) Findings include: Resident #18 Observation on 4/11/18 at approximately 9:55 a.m. of Resident #18 revealed that Resident #18, who was on precautions for [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus,) had oxygen tubing attached to an oxygen tank that Resident #18 was using and another oxygen tubing attached to an oxygen concentrator that they were not presently using. Neither of the two oxygen tubings had dates on them. Review on 4/13/18 of Resident #18's (MONTH) (YEAR) Treatment Administration Record revealed that there was no documentation that Resident #18's oxygen tubing was changed on 4/6/18, when it was due to be changed. The box for the nurses initials, documenting the change, was blank for 4/6/18. Review on 4/13/18 of Resident #18's (MONTH) (YEAR) Treatment Administration Record revealed that the last documented date that Resident #18's oxygen tubing was changed was on 3/27/18. Resident #23 Observation on 4/11/18 at approximately 9:40 a.m. of Resident #23 revealed an oxygen concentrator that was running next to Resident #23's bed as Resident #23 was laying in bed sleeping. The oxygen tubing had a piece of tape on the tubing that read 3/31/18. Review on 4/13/18 of Resident #23's Active Physician Orders revealed that Resident #23 had an order for [REDACTED]. Review on 4/13/18 of Resident #23's (MONTH) (YEAR) Medication Administration Record and Treatment Administration Record revealed that there was no documentation of changes to Resident #23's oxygen tubing. Resident #66 Observation on 4/11/18 at approximately 10:35 a.m. revealed that Resident #66 was using oxygen that was being administered through a nasal cannula. The oxygen tubing had tape attached to it that had the resident initials and room number on it, but no date. Review on 4/13/18 of Resident #66's Active Physician Orders revealed no physician order for [REDACTED].#66. Review on 4/13/18 of Resident #66's (MONTH) (YEAR) Medication Administration Record and Treatment Administration Record revealed that there was no documentation of changes to Resident #66's oxygen tubing. Resident #68 Observation on 4/11/18 at approximately 10:30 a.m. revealed that Resident #68 was using oxygen that was being administered through a nasal cannula. The oxygen tubing had tape attached to it that had the date of 3/29/18 on it. Review on 4/13/18 of Resident #68's (MONTH) (YEAR) Medication Administration Record and Treatment Administration Record revealed that there was no documentation of changes to Resident #68's oxygen tubing. Interview on 4/13/18 at approximately 12:00 p.m. with Staff A (Director of Nursing) revealed that there was no facility policy for care of oxygen and tubing, but stated that oxygen tubing was to be changed every week and the change was to be documented on the Medication Administration Record. Review on 4/13/18 of the facility's Performance Improvement Action Plan, dated 3/13/18, revealed the .Topic/Opportunity/Problem . was .Respiratory Equipment Oxygen tubing/infection control . The Plan identified that .oxygen tubing is not always signed off when changed on TAR (Treatment Administration Record) . The Systematic Changes that were put in place were .The staff nurse will sign off weekly on 11-7 shift and document on TAR .The unit managers will monitor weekly that tubing changes has (sic) been signed off per facility infection control practice . The Plan's follow up revealed .Mock survey completed by (Proper Noun) 4/3/18-4/4/18 and identified compliance with facility oxygen tubing change policy .",2020-09-01
69,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,697,D,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to provide sufficient pain management to 2 residents in a standard survey sample of 22 residents. (Resident identifiers are #80 and #329.) Findings include: Resident #80 Observation on 4/12/18 at approximately 9:00 a.m. of Resident #80 revealed that Resident #80's facial expressions looked as though they were uncomfortable while laying in bed. Interview on 4/12/18 at approximately 9:00 a.m. with Resident #80 revealed that Resident #80 stated that they are not getting good pain relief from the medications that are being administered to them by the facility. Resident #80 reported that an acceptable pain level for them would be 5-6 out of 10. Review on 4/12/18 of Resident #80's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review also revealed that Resident #80 had an order for [REDACTED]. Review on 4/12/18 of Resident #80's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review on 4/12/18 of Resident #80's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview on 4/13/18 at approximately 10:10 a.m. with Resident #80 revealed that when they complained of pain, the nurses would bring in [MEDICATION NAME], but Resident #80 stated that Resident #80 preferred [MEDICATION NAME]. Interview on 4/13/18 at approximately 1:20 p.m. with Staff F (Registered Nurse) confirmed that documentation revealed that the parameters, put in place for Resident #80's pain medications were not being followed, and that the parameters should be followed. Resident #329 Interview on 4/11/18 at approximately 1:30 p.m. with Resident #329's granddaughter revealed that Resident #329 complains of not getting relief from pain medications administered for Resident #329's back pain. Review on 4/12/18 of Resident #329's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review revealed that Resident #329 also had an order for [REDACTED].#329 had orders for [MEDICATION NAME] HCL Tablet 50 mg Give 50 mg by mouth every 6 hours as needed for moderate pain 4-7. Review on 4/12/18 of Resident #329's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review revealed that Resident #329 received [MEDICATION NAME] on 4/8/18 for a pain level of 3 and on 4/11/18 for a pain level of 4. Review also revealed that Resident #329 received [MEDICATION NAME] on 4/7/18 and 4/11/18 with no documented pain level prior to administration and that the results of the 4/11/18 administration of [MEDICATION NAME] was documented as unknown. Interview on 4/13/18 at approximately 1:20 p.m. with Staff F confirmed that there was no clear indication of when to administer [MEDICATION NAME] or [MEDICATION NAME] to Resident #329 and that documentation revealed that the parameters that were ordered were not being followed, which they should have been.",2020-09-01
70,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,812,E,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the facility's policy and procedure, and interview, it was determined that the facility failed to ensure that perishable food was not stored later than use by date and when food appeared to be spoiling. Findings include: Observation on [DATE] at approximately 8:15 a.m. during kitchen tour in the walk in refrigerator revealed the following: 1 box of romaine lettuce that was discolored brown. 1 pan of meatballs with a use by date of [DATE]. 1 container of brown oranges. 1 box of withered apples. Interview on [DATE] at approximately 8:15 a.m. with Staff B (Cook) revealed that the food in the walk-in refrigerator was stored later than use by date and when food appeared to be spoiling. Interview on [DATE] at approximately 9:05 a.m. with Staff C (Dietary Manager) revealed that the expired items were supposed to be removed from the refrigerator the night before. Review on [DATE] of the facility's policy and procedure titled, Food Storage, Revised date ,[DATE] revealed: Policy: It is the policy of this facility that sanitary conditions should be maintained in all storage areas of food. . Proper Food Preparation: 7. Food that is outdated or of questionable quality will be discarded.",2020-09-01
71,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-04-13,842,B,0,1,WGWA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Resident #76's medical record , and interview it was determined that the facility failed have a baseline assessment for a seat belt for 1 resident in a standard survey sample of 22 residents (Resident identifier is #76.) and it was determined that the facility failed to document the notification of the physician of drug warnings triggered for 2 residents in a standard survey sample of 22 residents. (Resident identifiers are #35 and #329.) Findings include: Resident #76 Interview on 4/11/18 at approximately 9:15 a.m. with Resident #76 revealed that Resident #76 used a seatbelt whenever they are in their wheelchair. Review on 4/13/18 of Resident #76's medical record revealed that on the 24 hour positioning plan there was a seat belt iniated on 3/2/18 for positioning. There was no baseline assessment done for the residents ability to self release the seat belt. Interview on 4/13/18 at approximately 11:45 a.m. with Staff A (Director of Nursing) revealed that there was no assessment for Resident #76's use of a seat belt while in wheelchair. Resident #329 Review on 4/13/18 of Resident #329's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review revealed that Resident #329 also had an order for [REDACTED]. Review revealed that Resident #329 also hadan order for [REDACTED].>Review on 4/13/18 of Resident #329's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review on 4/13/18 of Resident #329's Progress notes revealed an order note, dated 4/4/18, which was time stamped at 17:34 (5:34 p.m.) and read .The order you have entered [MEDICATION NAME] Tablet 200 mg Give 200 mg by mouth every 6 hours as needed for pain/fever Has (sic) triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: [MEDICATION NAME] Sodium Solution 30 mg/0.3 ml Inject 30 mg subcutaneously one time a day for blood thinner Severity: Severe Interaction: The risk of bleeding induced by [MEDICATION NAME] Sodium Solution 30 mg/0.3 ml may be increased by coadministration of [MEDICATION NAME] Tablet 200 mg, including the development of procedure-related [MEDICATION NAME] or spinal hematomas . Aspirin Tablet 325 mg give 325 mg by mouth one time a day for heart Severity: Severe Interaction: Regular use of [MEDICATION NAME] Tablet 200 mg may decrease the antiplatelet effects of Aspirin Tablet 325 mg. Reduced antiplatelet efficacy in patients with underlying cardiovascular risk may occur. Additionally, the potential for gastrointestinal side effects, including bleeding, may be increased with regular use of full-dose or low-dose aspirin. Review on 4/13/18 of Resident #329's Progress notes revealed an order note, dated 4/4/18, which was time stamped at 18:58 (6:58 p.m.) and read .The order you have entered [MEDICATION NAME] Sodium Solution 30 mg/0.3 ml (milliliters) Inject 30 mg subcutaneously one time a day for blood thinner until 04/09/2018 23:59 (11:59 p.m.) Has (sic) triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: Aspirin Tablet 325 mg give 325 mg by mouth one time a day for heart Severity: Severe Interaction: The risk of bleeding in [MEDICATION NAME] Sodium Solution 30 mg/0.3 ml treated patients may be increased by Aspirin Tablet 325 mg, including the development of procedure-related [MEDICATION NAME] or spinal hematomas. [MEDICATION NAME] Tablet 200 mg Give 20 mg by mouth every 6 hours as needed for pain/fever Severity: Severe Interaction: The risk of bleeding induced by [MEDICATION NAME] Sodium Solution 30 mg/0/3 ml may be increased by coadministration of [MEDICATION NAME] Tablet 200 mg , including the development of procedure-related [MEDICATION NAME] or spinal hematomas . Review on 4/13/18 of Resident #329's Progress notes revealed that there was no documented evidence that the facility notified Resident #329's physician of these warnings. Interview in 4/13/18 at approximately 1:20 p.m. with Staff F (Registered Nurse) confirmed that there was no documented evidence that Resident #329's physician was notified of the warnings, and that the physician should have been notified. Resident #35 Review of Resident #35's physician orders [REDACTED]. Review on 04/13/18 at 8:05 am of Resident #35's Medication Administration Record [REDACTED]. Review on 4/13/18 at 12:49 pm of Resident #35's progress notes revealed on 3/22/18 an order for [REDACTED]. Interview with Staff H (Registered Nurse, Unit Manager) on 4/13/18 at 11:03 am revealed when orders are entered into the computer, nurses immediately receive an alert if there are pharmacy irregularities. Staff H revealed that Staff H notifies the provider knows when Staff H recieves alerts of pharmacy irregularites but does not have the provider sign anything. Interview with Staff I (Licensed Practical Nurse) on 4/13/18 at 11:17 am revealed that when Staff I receives an alert of a pharmacy irregularity Staff I would call the provider and notify them of the interactions and document the notification in the electronic medical record but they do not have the provider sign anything.",2020-09-01
72,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2019-05-13,804,E,0,1,5N2V11,"Based on observation, resident interviews and resident council it was determined that the facility failed to provide foods that are palatable, attractive and at an appropriate temperature. (Resident identifiers are: #5, #56, #66, #79, and #244) Findings include: Observation on 5/8/19 at 1:00 p.m. during mealtime observations meal carts on the Glennwood unit arrived over an hour late. The carts were to arrive at 12:00 p.m. but instead arrived at 1:00 p.m. Staff on the unit stated to surveyor that this happens a lot and it's difficult to care for residents and for staff to schedule their lunch breaks when the food cart come to the floor so late. Several residents on the unit during interviews stated that the food is cold lots of time, staff will heat it up but then it gets tough and chewy because it has to be microwaved. Interview on 5/9/19 at 2:04 p.m. with Staff A (Administrator), Staff B (Regional manager), and Staff C (Director of food services from Massachusetts) confirmed that all food products are canned foods and are not cooked to order just poured out of a can and heated. Observation on 5/9/19 at 11:30 a.m. of the Foods prepared were Turkey stew, Diced Pork with Gravy, Mashed potatoes, etc A test tray was performed at this time, the foods that was served were Diced Turkey with Gravy, Mashed potatoes along with a salad and Pear Crisp with Topping. The diced Turkey with gravy was none palatable and looked and tasted like ham. Also the potatoes were bland, and non palatable. These findings were told to Staff C and Staff A at the time of the test tray being performed. Staff C also questioned the looks of the Turkey and the taste along with the potatoes, stating they need to work outside the food menu that is provided by corporate to have these foods taste better. Interview on 05/09/19 8:38 a.m. with three kitchen staff, regarding times the cart gets to the units, and food temperatures, and what may be the cause. One staff member spoke up Staff D (Cook), who revealed that the right side of the main steam tray line is not as hot as it used to be. At this time food was removed from the steam cart and water temp was tested the right bay temperature closest to the oven tested at 120 degrees and the other two bays were over 140 degrees but could not continue hold the thermometer due to temperature of steam. Interview on 5/10/19 10:41 a.m. with Staff C and Staff D (Cook) regarding meal times and times of cart services were asked if the main dining room is served their meals at 12 p.m. how do you service Glennwood's meals since on the Meal Delivery Times shows that Glennwood is being served trays at 12 p.m. and 12:15 p.m. Staff D said they do their best to get the trays out but sometimes they have to stop tray services to the units at 12 p.m. and serve the main dining room then they will start tray line again to the units which does cause trays to be late. A Resident's Council meeting of 5/9/19 revealed that all twelve residents present felt that the food at the facility was not palatable. Residents who attended this meeting mentioned mystery meat being served at the facility meaning they didn't know from tasting it what kind of meat had been served. They felt that this was because of the poor quality of the food. Resident #244. Interview on 5/8/19 at approximately 10:30 a.m. with Resident #244 revealed that the facility's food is cold and that staff do offer to heat the food but when they do it is over cooked or dried out so that you don't want to eat it. Resident #244 reported that the food was bland no taste and that family brings in food. Resident #244 also reported at this time that the coffee is warm not hot and that when asked the staff will heat it up. Resident #79 Interview on 5/8/19 at approximately 10:00 a.m. with Resident #79 revealed, The food is not good and when you call the kitchen staff to ask for something they are rude and then hang up on you. Resident #56 Interview on 5/8/19 at approximately 11:30 am. with Resident #56 revealed, The food is often times cold and food is not very good. I ordered pancakes today and as soon as I took the cover off of them, I put butter on them and it just sat there - it didn't melt. Resident #66 Interview on 5/8/19 at approximately 9:45 a.m. with Resident #66 revealed Supper meals have changed and are not appetizing, this has come up at council and no changes have been made. We have been asking for oranges for months and there still aren't any available and they run out of what is on the menu all the time. Interview on 5/8/19 at approximately 12:15 p.m. with Staff [NAME] (Medication Nurse Assistant) revealed, The food trucks are late most of the time. Interview on 5/8/19 at approximately 12:20 p.m. with Staff F (Licensed Practical Nurse) revealed, The food trucks are more late than not. It makes it difficult for nursing to assist with toileting with residents from the dining room. They are coming back to the unit when the food trucks are just getting here. Staff are having a hard time taking their own lunches because of this too. Resident #5 Interview on 5/9/19 at approximately 7:35 a.m. with Resident #5 revealed, The food is often cold and doesn't taste well at all.",2020-09-01
73,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2019-05-13,812,E,0,1,5N2V11,"Based on observation and interview it was determined that the facility failed to prepare, distribute and serve food in accordance with professional standards for food serviced safely. Findings include: Observation on 5/8/19 during the initial tour of the kitchens walk in refrigerator at 9:00 a.m. revealed two different jars of pickles one B---- slices 1/8 smooth pickles with multiple use by dates of 11/15, 3/19, 3/17/19, and 4/25/19. The jar itself internally had buildup on the inside of the glass and cover. This finding was shown to Staff A (Administrator) who discarded the product right away. The second jar of (K----- Dill Pickles) with a use by date of 3/22/19 and 4/19/19. This product was also discarded by Staff A at time of finding. Observation on 5/8/19 at 10:25 a.m. revealed a counter mounted can opener that was ready for use covered with food product that was not properly cleaned. Staff A was also shown this who removed it from services. Observation on 5/9/19 11:30 a.m. while observing the tray line for the test tray it seemed very non-functional. The kitchen aide starts the tray set up with pellet warmer, utensils, and meal ticket. Then the tray is slid down on a steel table to the cook who reads the meal ticket off the tray touching the ticket with their gloved hand, then distributes the foods they read off the ticket and then places the plate onto the tray. During this time several items had been missed which were picked up by other staff and corrected. During these observations multiple times kitchen staff are reaching and placing items from different areas to meet the needs of the resident's meal tickets but failing to maintain safe food handling by touching multiple different surface areas and not changing gloves.",2020-09-01
74,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-12-07,580,D,1,1,9HC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to notify resident representatives when a resident made an allegation of abuse and when a resident pulled out a urinary catheter, prior to insertion of another catheter, for 2 residents in a standard survey sample of 22 residents. (Resident identifiers are #41 and #55.) Findings include: Resident #41 Review on 12/4/18 of the Facility Report to the Long Term Care Ombudsman, dated 11/13/18, revealed that Resident #41 reported to therapy staff on 11/13/18 that they were assaulted by the male night staff. Resident #41 reported that .a man came in my room and was touching me inappropriately .Resident reported that he was not alone . The report revealed that staff member, Staff B (Licensed Practical Nurse) .was assisting with rounds on this resident Staff B reported that they had Staff D (Licensed Nursing Assistant) .assisting (pronoun for Staff B) with rounds on this resident. They changed resident (sic) brief at this time . Further review of the Facility Report revealed that there was no documentation indicating that Resident #41's guardian was notified of the allegation. Review on 12/6/18 of Resident #41's current care plan revealed that Resident #41 has a guardian from the Office of Public Guardian. Review on 12/6/18 of the Facility's investigation, and the nurses notes for Resident #41 revealed that there was no documented evidence that Resident #41's guardian was notified of the allegation of abuse made by Resident #41 or of the investigation that followed. Review on 12/7/18 of the Facility's policy, titled Abuse, revised on 3/18, revealed that the Facility's Reporting/Documentation Requirements were that .family or responsible party are to be notified immediately after the incident has occurred . Interview on 12/7/18 at approximately 8:30 a.m. with Staff [NAME] (Director of Nursing) confirmed that there was no documented evidence that Resident #41's guardian was notified of the allegation or the investigation, and that there should have been documented evidence. Resident #55 Review on 12/6/18 of Resident #55's nursing progress notes revealed a note, dated 9/11/18 at 2:11 a.m., that read Resident pulled out .foley catheter and stated, 'I don't want it.' Refused to allow insertion of new catheter. Dr notified. Review on 12/6/18 of Resident #55's Physician orders [REDACTED]. Review on 12/6/18 of Resident #55's Physician Order, dated 1/5/18, revealed an order that read Activate DPOA . Review on 12/6/18 of Resident #55's nursing progress notes revealed a note, dated 9/11/18 at 2:19 p.m., that read Foley catheter 16 French with 10 cc (cubic centimeter) balloon was placed via (by way of) sterile technique. Catheter is patent and draining yellow urine without issue . There was no documented evidence that Resident #55's DPOA was notified of Resident #55 pulling out their catheter or that there was a discussion about the plan of care for Resident #55. Interview on 12/7/18 at approximately 8:30 a.m. with Staff [NAME] confirmed that there was no documented evidence of notification of Resident #55's DPOA or discussion regarding plan of care, and that there should have been.",2020-09-01
75,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-12-07,610,D,1,1,9HC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and facility policy review, it was determined that the facility failed to thoroughly investigate an alleged violation of abuse and to implement appropriate corrective actions to prevent further allegations of abuse for 1 resident in a standard survey sample of 22 residents. (Resident identifier is #41.) Findings include: Interview on 12/4/18 at approximately 11:30 a.m. with Resident #41 revealed that Resident #41 stated that a couple of weeks ago, they were inappropriately touched in their perineal area by a male staff member. Resident #41 stated that this male had also groped them several times since this original incident. While explaining the groping, Resident #41 was rubbing their chest area, indicating that it was their chest area that was groped. Resident #41 stated that this staff member was in their room last night and had groped their chest area again. Review on 12/4/18 of the Facility Report to the Long Term Care Ombudsman, dated 11/13/18, revealed that Resident #41 reported to therapy staff on 11/13/18 that they were assaulted by the male night staff. Resident #41 reported that .a man came in my room and was touching me inappropriately .Resident reported that he was not alone . The report revealed that staff member, Staff B (Licensed Practical Nurse) .was assisting with rounds. Staff B reported that (pronoun) had Staff D (Licensed Nursing Assistant) .assisting (pronoun) with rounds on this resident. They changed resident (sic) brief at this time . The Facility Report also revealed that Resident #41's care plan was reviewed and updated to have only female caregivers and two for ADL's (Activities of Daily Living.) Review on 12/6/18 of the Facility's investigation regarding the allegation made by Resident #41 revealed a statement, dated 11/13/18, which was written by Staff [NAME] (Director of Nursing) and had a verbal explanation given to Staff [NAME] by Staff B, the alleged perpetrator. In the statement, Staff B reported that on the 11-7 shift on 11/12/18 (the shift started at 11:00 p.m. on 11/12/18 and ended at 7:00 a.m. on 11/13/18) they were walking by Resident #41's room and saw Resident #41 ambulating by themselves. Staff B stated that they assisted Resident #41 back to bed. They stated that Staff C (Licensed Practical Nurse) heard them ask for assistance and Staff C immediately responded. Staff B reported that Resident #41 told Staff B to get out now. Staff B reported that they left at that time and did not provide personal care to Resident #41. There was nothing in the statement about the incontinent care that Staff B and Staff D had provided to Resident #41 earlier in the shift. Review on 12/6/18 of the Facility's investigation regarding the allegation made by Resident #41 revealed another statement. This statement was also written by Staff E, but signed and dated on 11/12/18, (Resident #41 did not report the incident to staff until 11/13/18) by Staff C. In that report, Staff C stated that Staff B was returning from break and saw Resident #41 walking by themselves. Staff B immediately got Staff C to assist Resident #41 back to bed. Staff B placed their hand on Resident #41's shoulder for assistance. The statement also revealed that Staff B was the only male staff member on 11/12/18 and was not alone in the room. Review on 12/6/18 of the Facility's investigation regarding the allegation made by Resident #41 revealed that there was no statement from Staff D. There was no evidence in the investigation file that Staff D was ever interviewed regarding the interaction that occurred when Staff B and Staff D changed Resident #41's brief. Interview on 12/7/18 at approximately 7:10 a.m. with Staff C revealed that Staff C stated that on 11/12/18, Staff B saw Resident #41 going to the bathroom by themselves and asked Resident #41 to wait for help. Staff B called out in the hallway but did not go in to Resident #41's room. Staff C took over and assisted Resident #41. Interview on 12/7/18 at approximately 7:15 a.m. with Staff B revealed that Staff B stated that they did not know anything about the incident on 11/12/18. Staff B reported that they were not even working on that night. Staff B denied having provided incontinent care to Resident #41 with Staff D. Staff B stated that the incident was not discussed with them by Staff [NAME] and that they knew that there were to be no male caregivers, but had only heard that through the grapevine a while later. Review of the Facility's Daily Attendance report revealed that Staff B did work from 10:45 p.m. until 7:15 a.m. on 11/12/18. Interview on 12/7/18 at approximately 10:10 a.m. with Staff D revealed that Staff D stated that on 11/12/18, they assisted Staff B, who was working as an LNA that night, to change Resident #41's incontinent brief. Staff D stated that later on in the shift, Staff D was told by Staff C that Staff B saw Resident #41 ambulating in their room by themselves. When Staff B called for assistance, Staff C responded and Staff C and Staff B assisted Resident #41 to the bathroom and provided care. Staff D reported that they had not been interviewed about anything that had occurred on 11/12/18 by any Administrative staff. They also stated they they were aware that there were to be no male caregivers, but only heard that through the grapevine about a week later, when they also heard that there was an allegation made by Resident #41. Staff D stated that they were not aware of how many staff were to care for Resident #41. Review on 12/6/18 of Resident #41's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration and Treatment Administration Records revealed that there was documentation that Staff B checked placement of Resident 41's [MEDICATION NAME] on 11/26/18, on 12/3/18 with the documented placement on Resident #41's chest, and on 12/4/18 with the documented placement on Resident #41's chest. Review on 12/6/18 of Resident #41's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration and Treatment Administration Records revealed that there was also documentation that another male staff member, Staff F (Licensed Practical Nurse,) performed procedures on Resident #41. The documentation revealed that Staff F applied barrier cream to Resident #41's buttocks on 11/16/18, 11/19/18, 11/23/18, 11/24/18, and 11/25/18, Staff F did a skin check on Resident #41 on 11/19/18. Staff F also checked [MEDICATION NAME] placement on Resident #41 on 11/25/18, cleansed a wound on Resident #41's right knee on 11/23/18, removed compression stockings on Resident #41 on 11/16/18, 11/19/18, 11/23/18, 11/24/18, 11/25/18, and 12/4/18, and applied warm compresses to Resident #41's right knee on 11/16/18, 11/19/18, 11/23/18, 11/24/18 and 11/25/18. Review on 12/6/18 of the Facility's Policy titled Abuse, revised on 3/18, revealed that The administrative staff .assumes responsibility for .Immediate investigation into the alleged incident .Interview staff member implicated. Have employee document their knowledge/version of incident in written narrative that is dated and signed Interview witnesses or other available witnesses. Witnesses are to document incident in a written narrative that is dated and signed. Supervisory staff to discuss written statements with employee . Facility investigation will be completed within 72 hours of the incident .Immediately after the incident occurs an interim conference is to be held to develop interventions to ensure the resident does not experience any physical harm, pain or mental anguish . Interview on 12/7/18 with Staff [NAME] confirmed that the facility policy for an investigation was to get statements from all staff involved. If they were unable to get a written statement, they would get a verbal one, which was followed up by a written statement, dated and signed, as soon as possible. Staff [NAME] confirmed that there were no statements written by Staff B or Staff C and that there was no statement at all for Staff D. Staff [NAME] also confirmed that Staff B did work on the night of 11/12/18 and did provide incontinent care to Resident #41 with Staff D, earlier in the shift before Resident #41 was found ambulating independently in their room. Staff [NAME] also confirmed that as part of the follow up plan, no physical care to Resident #41 should have been provided by male staff. Staff [NAME] stated that there were always female nurses in the building and that male staff could always get a female to perform the tasks and to document them.",2020-09-01
76,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-12-07,641,B,0,1,9HC411,"Based on record review and and interview, it was determined that the facility incorrectly coded the Minimum Data Set assessment for one resident, in a survey sample of 22 residents. (Resident identifier is #7.) Findings include: Resident #7 Interview with this resident on 12/5/18 p.m. revealed that they had a below knee amputation and a Charcot foot 5 years ago, and since then they have a prosthesis for the right lower extremity and they use a boot for the left lower extremity. Review on 12/6/18 p.m. of Resident #7's medical record revealed that both the 6/13/18 and the 9/8/18 quarterly Minimum Data Set assessments code the resident in Section G as having no Limp prosthesis. However, record review of the 5/9/18 Admission/Readmission Evaluation document reveals at Section F.m. that the resident does have a prosthesis.",2020-09-01
77,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-12-07,726,D,1,1,9HC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure an aide in training was properly supervised during the administration of care for one resident in a survey sample of 22 residents. (Resident identifier is #7.) Findings include: Resident #7 Interview on 12/5/18 a.m. with this resident revealed that on 10/2/18 a new male aide put Resident #7 to bed against Resident #7's will and hurt Resident #7 by doing it roughly, and when the resident asked him to stop he didn't until Resident #7 yelled. Then he sponge bathed her peri area but didn't use dry sponge as resident requested; he put on a brief but he made a wound in the area. At next shift the (another) aide said the brief was put on incorrectly and changed it and the resident had pain and is still being treated for [REDACTED].#7 identified the aide, Staff J (LNA), by name and that the resident .was aware that . (Staff J) was a newly licensed nursing assistant and that he had only been working for about a week Review on 12/6/18 a.m. of the wound weekly observation tools for 10/9/18, for Resident #7, revealed right posterior upper thigh superficial abrasion acquired 10/9/18 and left posterior upper thigh superficial abrasion acquired 10/9/18. Record review of the 10/9/18 Skin/Wound Note reveals . skin check was done on resident's buttocs (sic) and upper legs Two superficial skin abrasions observed . right posterior thigh left posterior thigh Wound consult order was also obtained Interview on 12/7/18 a.m. with Staff [NAME] (director of nursing), revealed that Staff J started in the kitchen as a dietary aide, until he was certified as nurse aide. Review on 12/07/18 a.m. of Staff J's employee record revealed a Personnel Action Form for Dietary Aide effective date 5-11-18 lists date employed as 5-11-18. The NH (New Hampshire) State Police Criminal Records Unit check completed 5/8/18 found no record. The BEAS (bureau of elderly and adult services) State Registry check completed 5/11/18 was no finding. The OIG (office of inspector general) search conducted 11/23/18 was negative. And the NH Online Licensing printout reveals the issue date for LNA as 10/12/18. Review on 12/07/18 p.m. of the Mandatory Competency Check off List for Staff J revealed most Skills were rated Acceptable on 11/1/18; but Peri / Incontinence Care, Indwelling Catheter Care, Mouth Care and Nail care were all rated Unacceptable on 11/1/18, with a Re-demonstration Date of 11/15/18. Interview on 12/07/18 01:08 PM with Staff [NAME] revealed Staff J was in training (still enrolled in LNA class at that time and was competent to do that care from that class) when he did the peri-care to the resident on 10/2/18, he was doing that care alone but should not have been as he wasn't cleared to be on the floor but Resident #7 wanted him to come in and do the care and the resident knew he was in training. The buttock abrasions are not related to that 10/2/18 care as they did not appear until some days later. The 10/2/18 incident was reported to Staff [NAME] that day or shortly after. Staff J was off the floor and not working alone while the incident was investigated. His abuse training was on 5/11/18.",2020-09-01
78,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2018-12-07,880,B,0,1,9HC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Transmission Based Contact Precautions were maintained with Personal Protective Equipment for two of two residents in a survey sample of 22 residents, failed to ensure a facility wide Infection Control surveillance and documentation was completed. (Resident identifiers are #41 and #292.) Findings include: Resident #292. Review on 12/6/18 of Resident #292's medical record showed that Resident #292 was admitted to the facility on [DATE] with the multiple [DIAGNOSES REDACTED]. Resident #292 was placed on Transmission Based Contact Precautions at the time of admission due to [MEDICAL CONDITION]. Observation 12/4/18 13:28 p.m. showed an individual (non staff member) in Resident #292's room without any gown or gloves (Personnel Protective Equipment) on for Transmission Based Contact Precautions going several times in & out of Resident #292's bathroom. Observation on 12/5/18 at approximately 12:30 P.M. showed two visitors in Resident #292's room with gowns & gloves on. Interview with these two individuals, identified by Resident #292 as son & daughter of Resident #292, revealed that these two individuals reported they know what to wear when visiting due to white index card attached to yellow over the door precaution supply of PPE. The son reported that at the hospital there was a sign posted on . (Resident #292) door indicating See nurse before entering and hospital staff would tell visitors what PPE was needed when visiting in (Resident #292's) room. Interview & observation on 12/6/18 at 1:30 p.m. with Staff A (Licensed Practical Nurse) confirmed that the PPE supplies contained in the yellow multi-pouched over the door hanger with a piece of white paper attached on the front of this yellow PPE supply container indicating STOP was checked off in boxes on this white paper indicating Gown, Gloves and wash hands. Staff A (LPN) confirmed that a gown & gloves would be worn by individuals when entering room to visit Resident #292 Observation on 12/5/18 at 1:30 p.m. with Staff A ( LPN) revealed that when Resident #292's room door is open the white sheet of paper indicating PPE is not visible and that visitors can enter Resident #292's room and visit without wearing PPE. Staff A ( LPN) agreed and reported no other signs or information is visible or posted to ensure individuals entering Resident #292's room wear gown and gloves to comply with Contact Precaution protocol. Observation and interview on 12/6/18 at approximately 3:25 p.m showed a female and male visitor in Resident #292's room with no gowns or gloves ( PPE) . Resident #292 introduced the female as his wife and the male visitor as a good friend. Wife reported that they don't have to use . (PPE) available on Resident #292's door because they told me at the hospital we only had to do that (pointing to the PPE) for 10 days and the 10 days are up. Resident #292 confirmed that the son & daughter visiting yesterday, 12/5/18, had the gowns and gloves on during the visit. Interview on 12/4/18 at approximately 11:30 a.m. with Staff I (Registered Nurse, Infection Control), revealed that walking rounds do not include the kitchen or the laundry. Staff I explained that she/he does walking rounds every Monday which consists of all the nursing areas. She/he does not go into the kitchen or the laundry as this is done by the maintenance staff for review of life safety and fire hazards, not infection control. Staff I presented a form, titled Facility Unit Rounds, this includes the areas that Staff I inspects every Monday for her/his walking rounds and do not include the kitchen, laundry or rehabilitation areas. Interview on 12/7/18 at approximately 2:30 p.m. with Staff [NAME] (Director of Nursing), revealed that walking rounds do not include the kitchen or the laundry. Staff [NAME] provided a form, titled Facility Unit Rounds, this includes the areas that are considered walking rounds that are currently reviewed by Staff I. This form consists of nursing unit specific areas only. At this time, the kitchen, laundry and rehabilitation areas are not being reviewed for potential infection control issues. Resident #41 Interview on 12/4/18 at approximately 9:30 a.m. with Staff G (Unit Manager) revealed that Resident #41 was on droplet precautions [MEDICAL CONDITIONS] in the nares, and that when entering the room a gown, gloves and a mask must be worn. Observation on 12/4/18 at approximately 11:15 a.m. revealed that Resident #41 was laying in their bed. Staff H (Housekeeper) was cleaning Resident #41's room, and was standing right next to Resident #41's bed using a mop to clean under the bed. Staff H was wearing a gown and gloves and was also wearing a mask, but the mask was only covering Staff H's mouth, it was not covering Staff H's nose. Interview on 12/4/18 at approximately 11:20 a.m. with Staff G (Unit Manager) confirmed that Staff H's mask should have been covering both their mouth and their nose.",2020-09-01
79,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2019-02-01,609,D,0,1,XVXH11,"Based on medical record review, and interview, it was determined that the facility failed to report a case of neglect, to the state survey agency for 1 of 1 resident in a final survey sample of 21 residents. (Resident identifier is #33.) Findings include: Review on 1/31/19 at 9:06 a.m. of Resident #33's nurses note dated 6/26/18 revealed Resident heard calling for help from South wing whirlpool room. Staff entered to find resident sliding down in tub filed with water. Tub drain opened and several staff members assisted holding resident while Hoyer pad was placed under (resident). At no time was (resident's) face or head under water. Resident then Hoyer transferred to w/c (wheelchair) and back to bed to get dressed. No pain or apparent injures noted to resident. Facility DON (Director of Nurses) and POA (Power of Attorney) notified of incident. Review on 1/31/19 at 9:59 a.m. of Resident # 33's care plan revealed under (focus) care area for ADLs (Activities of Daily Living): I have an ADL self-care performance deficit r/t (related to) left parietal intraparenchymal hemorrhage, right hemipligia, and decreased strength Date initiated: 7/12/17 Under (interventions) states Bathing/showering: I require extensive assistance by one staff with bathing/showering. Interview on 1/31/19 at 10:04 a.m. with Resident #33, Resident #33 stated I was so scared I almost drowned Resident #33 was asked if anyone was with (Resident #33) at the time of the event Resident #33 stated no. Resident #33 also said since that event I have not had a tub since, and I love having tubs. Maybe if someone stayed with me I could try again. Interview on 1/31/19 at 11:51 a.m. with Staff A (Administrator), Staff B (Director of Nurses). and Staff C (Unit manger) confirmed that the event as written occurred and that the staff member who was caring for Resident #33 was not in the tub room at time of the event. Since this incident, the staff member has quit due to the what had occurred. The Administrator also was asked if the event was sent to the state survey agency? The administrator stated, no, because the resident was not hurt and it was not felt to be reportable.",2020-09-01
80,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2019-02-01,689,D,0,1,XVXH11,"Based on medical record review and interview, it was determined that the facility failed to ensure that 1 of 1 resident receives adequate supervision to prevent accidents in a final survey sample of 21 residents. (Resident identifier is #33.) Findings include: Review on 1/31/19 at 9:06 a.m. of Resident #33's nurses note dated 6/26/18 at 11:37 states Resident heard calling for help from South wing whirlpool room. Staff entered to find resident sliding down in tub filed with water. Tub drain opened and several staff members assisted holding resident while Hoyer pad was laced under him. At no time was (residents) face or head under water. Resident they Hoyer transferred to w/c and back to bed to get dressed. No pain or apparent injures noted to resident. Facility DON (Director of Nurses) and POA (Power of Attorney) notified of incident. Review on 1/31/19 at 09:59 a.m. Resident #33's care plan states under (focus) care area for ADLs (Activities of Daily Living): I have an ADL self-care performance deficit r/t (related to) left parietal intraparenchymal hemorrhage, right hemipligia, and decreased strength Date initiated: 7/12/17 Under (interventions) states Bathing/showering: I require extensive assistance by one staff with bathing/showering. Interview on 1/31/19 at 10:04 a.m. Resident #33 stated I was so scared I almost drowned Resident #33 was asked if anyone was with him at the time of the event Resident #33 stated no. Resident #33 also said since that event I have not had a tub since, and I love having tubs. Maybe if someone stayed with me I could try again. Interview on 1/31/19 at 11:51 a.m. with Staff A (Administrator), Staff B (Director of Nurses). and Staff C (Unit manger) confirmed that the event as written occurred and that the staff member who was caring for Resident #33 was not in the tub room at time of the event. Since this incident, the staff member has quit due to the what had occurred.",2020-09-01
81,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2017-02-10,329,D,0,1,FQ0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to adequately monitor residents with identified target behaviors for the effects and potential adverse consequences of antipsychotic medications for 2 of 2 residents receiving antipsychotic medications in a survey sample of 22 residents. (Resident identifiers are #3 and #5.) Findings include: Resident #5. Record review on 2/7/17 and 2/8/17 of the MEDICATION ADMINISTRATION RECORD (MAR) for Resident #5 dated 1/1/17 and 2/1/17 revealed the following physician orders [REDACTED]. [MEDICATION NAME] 12.5 mg by mouth every morning and at bedtime related to Hallucinations [MEDICATION NAME] 0.5 mg by mouth every 4 hours as needed for [MEDICAL CONDITION]/restlessness PRN (as needed) [MEDICATION NAME] 12.5 mg by mouth every 24 hours as needed for distressing hallucinations PRN. Review of the (MONTH) MAR revealed the following physician orders: [MEDICATION NAME] 0.5 mg by mouth every 4 hours as needed for [MEDICAL CONDITION]/restlessness PRN [MEDICATION NAME] 12.5 mg by mouth every 24 hours as needed for distressing hallucinations PRN. Further record review showed no documented evidence of ongoing monitoring with an identified target behavior for the prescribed antipyschotic medications listed above for Resident #5. During interview on 2/8/17 at approximately 4:45 p.m. with Staff A (Registered Nurse) after Staff A reviewed the above listed physician orders, the (MONTH) and (MONTH) MAR and computer E-MAR (Electronic Medication Administration Record), Staff A stated that there was no documented evidence of ongoing monitoring with an identified target behavior for the prescribed antipsychotic medications for Resident #5 during the months of (MONTH) and (MONTH) (YEAR). Resident #3 Record review on 2/7/17of the MAR dated 2/1/17-2/28/17 revealed the following physician orders [REDACTED]. There was no documented evidence of behavior monitoring in the medical record or the MAR with an identified target behavior for the prescribed antipsychotic medications.",2020-09-01
82,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2017-02-10,371,E,0,1,FQ0H11,"Based on observation and interview the facility failed to ensure safe sanitation practices, including kitchen personnel wearing hairnet covering all hair and food handling processes. Findings include: During the kitchen tour on 2/7/17 at approximately 9:40 a.m. with Staff [NAME] (Food Service Director) it was observed that the high temp dishwasher rinse cycle only reached 176 degrees Fahrenheit after 4 empty trays were processed through. Review of the facility's temperature logs revealed the following below range entries: 1/27/17 the rinse cycle reached 160 degrees Fahrenheit, 1/29/17 the rinse cycle reached 140 degrees Fahrenheit, 2/1/17 the rinse cycle reached 160 degrees Fahrenheit, 2/2/17 the rinse cycle reached 160 degrees Fahrenheit. During interview with Staff [NAME] on 2/7/17 at approximately 9:50 a.m., Staff [NAME] confirmed the above findings and stated that the rinse cycle did not reach the required temperature of at least 180 degrees Fahrenheit. During tour of the kitchen on 2/7/17 at approximately 9:55 a.m. with Staff E, the meat slicer was observed to be covered with a plastic cover. This surveyor asked Staff [NAME] if the meat slicer was ready for use and Staff [NAME] stated that it was ready for use. The plastic cover was lifted to view the entire surface area of the meat slicer and it was discovered that the back side of the meat slicer blade in the center of the blade had a ring around the blade of a thick, light brown thick, greasy substance that was easily scraped off when touch by this surveyor. Interview at approximately 10:00 a.m. with Staff [NAME] confirmed the above findings. During tour of the kitchen on 2/7/17 at approximately 10:15 a.m. with Staff E, the walk-in cooler/large walk-in refrigerator, observation revealed a small box of take-out Chinese food and a container of what was labeled as Japanese Soy Product that were sitting among other food items in this cooler. These items did not contain a date. Interview on 2/7/17 at approximately 10:20 a.m. with Staff E, Staff [NAME] stated that these items were left over from the Japanese New Year. Staff [NAME] removed these items from the walk-in cooler and threw them in the trash.",2020-09-01
83,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2017-02-10,441,E,0,1,FQ0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview it was determined that the facility failed to ensure an environment that is safe and sanitary by not implementing a facility wide surveillance of infection control practices and investigations throughout the facility that provides a safe, sanitary and comfortable environment. (Resident identifier is #11.) Findings include: Observation on 2/8/17 during a medication pass with Staff B (Licensed Practical Nurse) at approximately 9:20 a.m. showed Staff B entered Resident #11's room with prepared medications. Staff B donned a pair of gloves and proceeded to perform trach suctioning on this ventilated resident. When this procedure was completed Staff B proceeded to assemble items to administer medications through Resident #11's [DEVICE] (gastrostomy). Staff B with the unchanged gloves proceeded to open the top drawer in the resident's storage bureau and retrieved a plastic 30 cc syringe. Staff B was observed numerous times touching her (Staff B) face and her (Staff B) clothing with the gloved hands related to the heat in the room. Staff B was observed flushing and administering the prescribed medications through Resident #11's [DEVICE] and when finished proceeded to assemble and prepare the pump and tubing for the continuous [DEVICE] enteral feed solution. Following this procedure Staff B with the same unchanged gloves proceeded to administer prescribed eye drops to Resident #11's left eye. Staff B then discarded the appropriate used items in the trash along with the pair of gloves worn throughout this observation. Staff B failed to change gloves and perform hand hygiene following each direct resident contact to prevent cross contamination between the trach suctioning, administration of medications through the [DEVICE], the preparation and assembling of the [DEVICE] enteral feed solution, after touching her (Staff B) own face and clothing and after the administration of eye drops to Resident #11. During interview on 2/10/17 with Staff C (Infection Control Registered Nurse) at approximately 1:00 p.m. Staff C stated that no infection control surveillance, like walking rounds are done in the facility kitchen, laundry, rehabilitation area. Staff C also stated that there is no documentation of infection control surveillance related to medication pass observation techniques. Cross reference F371. During tour of the rehabilitation department on 2/7/17 at approximately 10:15 a.m. this surveyor observed a wedge cushion that had numerous cracks in the outside plastic covering exposing the foam of the cushion. The entire end of the wedge presented with orange duct tape. The seat cushion on a rolling stool had numerous cracks in the outside plastic covering exposing the foam of the cushion. These cushions cannot be cleaned due to the poor surface integrity. During interview with Staff D (Rehabilitation Director) on 2/7/17 at approximately 10:35 a.m. Staff D confirmed the above findings.",2020-09-01
84,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2017-11-15,278,B,0,1,L8GV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that the MDS (Minimum Data Set) assessments were accurate with the election of the hospice benefit for 2 residents in a survey sample of 23 residents. (Resident identifiers are #4 and #7.) Findings include: Resident #4 Review on 11/14/17 of Resident #4's Significant Change MDS assessment dated [DATE] it was noted that the MDS section entitled J1400 Prognosis-Life expectancy less than 6 months is answered no. The MDS section O100 special treatments and programs in column 2. is answered with k. Hospice. A prognosis of less than 6 months life expectancy is a general prerequisite of acceptance into a hospice program and these two assessment areas should be in agreement. Interview on 11/ 15/17 at approximately 4:30 p.m. Staff B (Registered Nurse) concurred that the prognosis did not support the election of the Hospice benefit, as written. Resident #7 Review on 11/14/17 of Resident #7's Quarterly MDS assessment dated [DATE] revealed that section entitled J1400 Prognosis-Life expectancy less than 6 months was answered no. The MDS section O100 Special Treatments and Programs column 2, line K was checked the resident receiving Hospice services. A prognosis of less than 6 months life expectancy is a requirement of acceptance into a hospice program and these two assessment areas need to be in agreement. Review of Resident #7's medical record revealed that Resident #7 is receiving the hospice benefit. Interview on 11/15/17 at approximately 1:30 p.m. with Staff C (Director Of Nurses/Registered Nurse) confirmed that the prognosis did not support the election of the hospice benefit.",2020-09-01
85,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2017-11-15,281,B,0,1,L8GV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to provide parameters for PRN (as needed) pain medications for 8 resident in a standard survey sample of 24 residents. (Resident identifiers are #2, #6, #8, #9, #11, #12, #17, and #19.) Findings Include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Pages 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Resident #2 Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet 400 mg (milligrams). Give 400 mg by mouth every 6 hours as needed for pain/fever. Tylenol tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed for pain or elevated temperature. Resident #12 Review of the MAR indicated [REDACTED] [MEDICATION NAME] Tablet 325 mg. Give 2 tablets by mouth (PO) every 4 hours as needed for pain/elevated temp. [MEDICATION NAME] Solution 20 mg/ml (milliliters). Give 5 mg PO every 4 hours as needed for pain/dyspnea. Interview on 11/14/17 at approximately 3:00 p.m. with Staff C (Director of Nursing), confirmed that the PRN pain orders were missing indications/parameters for administration. Resident #17 Review 11/15/17 of Resident #17's MAR for (MONTH) (YEAR), revealed that this resident had an order for [REDACTED]. Administer 650 mg. PO q4h (every 4 hours) PRN for pain or elevated temperature, per standing order. Review 11/15/17 of Resident #17's MAR for (MONTH) (YEAR), also reveals that this resident has an order for [REDACTED]. should be administered. Interview on 11/15/17 at approximately 4:40 p.m. with Staff A (Registered Nurse/Resource Nurse) acknowledged that this issue has come to their attention and they are working to make sure all residents have parameters for the administration of pain medications. Resident #8 Review on 11/13/17 of resident # 8's MAR for (MONTH) (YEAR) revealed an order for [REDACTED]. Review on 11/13/17 of resident #8's MAR indicated [REDACTED]. There were no parameters for when to give the medication. Interview on 11/15/17 at approximately 1:00 p.m. with Staff C (Director of Nursing) confirmed the above findings. Resident #19 Review on 11/14/17 of Resident #19's MAR for (MONTH) (YEAR) revealed an order for [REDACTED]. Interview on 11/15/17 at approximately 1:00 p.m. with Staff C (Director of Nursing) confirmed the above findings. Resident #9 Review of Resident #9's MAR indicated [REDACTED] Tylenol tablet 325 MG ([MEDICATION NAME]) Give 2 tablets by mouth every 6 hours as needed for pain scale 1-3. Start Date 10/10/17 1200 and a second PRN pain medication as listed below was noted to be missing a parameter/pain severity for use: [MEDICATION NAME] Tablet 50 MG ([MEDICATION NAME] HCI) (sic) Give 1 tablet by mouth as needed for pain (MONTH) use BID (twice a day) Interview on 11/15/17 at approximately 1:40 p.m. with Staff C (Director of Nursing) confirmed the above findings. Resident #11 Review on 11/14/17 of Resident #11's MAR indicated [REDACTED]. Resident #11 also had an order for [REDACTED]. Interview on 11/14/17 at approximately 11:30 a.m. with Staff F (Unit Manager) confirmed that there was no clear indication of whether to give Tylenol or [MEDICATION NAME] for pain.",2020-09-01
86,EDGEWOOD CENTRE (THE),305022,928 SOUTH STREET,PORTSMOUTH,NH,3801,2017-11-15,514,B,0,1,L8GV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that residents received the black box warning information for antipsychotic medication prescribed for them for 2 residents in a standard survey sample of 25 residents. (Resident identifiers are #6, and #10.) Findings include: Professional reference: Per FDA US Food and Drug Administration (8/15/13) .FDA is requiring the manufacturers of conventional antipsychotic drugs to add a Boxed Warning and Warning to the drugs ' prescribing information about the risk of mortality in elderly patients treated for [REDACTED]. (See https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm 0.htm accessed 11/27/2017.) Resident #6 Review on 11/13/17 of Resident #6's Medication Administration Record [REDACTED]. If ineffective use [MEDICATION NAME] 25 mg by mouth every 6 hours PRN delusions. The start date on this order was 10/19/17 and the discontinue date was 10/25/17. There was no documented evidence that Resident #6 or Resident #6's POA (Power of Attorney) had received the black box warning information for this medication. Interview on 11/14/17 at approximately 11:00 a.m. with Staff G (Registered Nurse) confirmed that there was no documented evidence that Resident #6 or Resident #6's POA had been given the black box warning information for antipsychotic medications. Resident #10 Review on 11/14/17 of Resident #10's Medication Administration Record [REDACTED]. Start date 5/24/17. There was documented evidence that Resident #10 signed the Psychoactive Drug Administration Consent Form on 5/24/14, but there was no documented evidence that Resident #10 had received the black box warning information for this medication. Interview on 11/14/17 at approximately 11:30 a.m. with Staff F (Unit Manager) confirmed that there was no documented evidence that Resident #10 had been given the black box warning information for antipsychotic medications.",2020-09-01
87,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2017-04-13,160,B,0,1,K2IK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident trust fund and interview, it was determined that the facility failed to convey resident funds within 30 days to the individual(s) or probate jurisdiction administering the resident's estates for 5 out of sample residents. (Resident identifiers are #23, #24, #25, #26, and #27.) Findings include: Review of the following accounts revealed the following: Resident #23 had expired on [DATE] with a balance of $18.74 remaining in this resident's account. Probate paperwork for Resident #23 was filed on [DATE]. Resident #24 had expired on [DATE] with a balance of $35.00 remaining in this resident's account. Probate paperwork for Resident #24 has not been filed as of [DATE]. Resident #25 had expired on [DATE] with a balance of $1697.10 remaining in this resident's account. Probate paperwork for Resident #25 has not been filed as of [DATE]. Resident #26 had expired on [DATE] with a balance of $2,129.24 remaining in this resident's account. Probate paperwork for Resident #26 was filed on [DATE]. Resident #27 had expired on [DATE] with a balance of $368.76 remaining in this resident's account. Probate paperwork for Resident #27 was filed on [DATE]. Interview on [DATE] at approximately 11:30 a.m. with Staff A (Business Office Manager) confirmed that probate paperwork wasn't filed in thirty days.",2020-09-01
88,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2017-04-13,279,D,0,1,K2IK11,"Based on record review and interview, it was determined that the facility failed to develop a coordinated/integrated Plan of Care for 2 of 2 residents receiving Hospice services in a survey sample of 17 residents. (Resident identifier's are #12 and #16.) Findings include: Review on 4/13/17 of Resident #12 and Resident #16 medical record revealed that Resident's #12 and #16 were receiving Hospice services. Record review revealed that the facility failed to show a coordinated Plan of Care as evidenced by not including or documenting the Hospice goals and interventions in order to ensure that facility staff is providing consistent care when Hospice staff are not scheduled in the facility. Resident #16 Review on 4/13/17 of Resident #16's hospice care plan with a start date of 8/25/16 revealed the following disciplines visiting Resident #16: skilled nurses, Medical social worker, Nurses aide, and a chaplain. Review on 4/13/17 of Resident #16's facility's care plan revealed a hospice care plan with a start date of 8/25/16. Under the interventions section it revealed the hospice nursing assistant to compliment ADL (activities of daily living) care, provide comfort and companionship .Provide resident with food & fluids as desired for physical & emotional comfort Hospice nursing along with Center Staff Nurses to assess and manage symptoms, comfort/pain, bowel function. Interview on 4/13/17 at 1:00 p.m. with Staff B (Director of Nurses) after review of Resident's #16's current facility and the hospice care plans Staff B revealed that the care plans did not include the frequency of services provided by the hospice agency for the skilled nurse, licensed nursing aide, social worker, and spiritual. Staff B confirmed that the facility's was unaware of all the services that the hospice was providing via the care plan. Staff B also confirmed that the facility's and the hospice care plans did not coordinated/integrated with each other. Resident #12 Review on 4/13/17 of Resident #12's care plan revealed a hospice care plan with a start date of 3/5/17. Under the intervention section it revealed the Hospice nursing assistant to compliment ADL care, provide comfort. Provide ADL support, companionship and other interventions as desired by pt (patient) to promote comfort. Hospice Nursing .to assess and manage symptoms comfort/pain, bowel function. Review on 4/13/17 of Resident #12's Hospice Team Care Plan revealed the following disciplines are visiting Resident #12: volunteer, social worker and a chaplain. The frequency of services were not present on the care plan for this hospice resident.",2020-09-01
89,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2017-04-13,280,D,0,1,K2IK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to update a care plan for 1 residents in a standard survey sample of 17 residents. (Resident identifier is #1.) Findings include: Resident #1 Review on 4/11/17 of Resident #1's Medication Administration Record [REDACTED]. Review on 4/11/17 of Resident #1's physician orders [REDACTED]. Further review of the medical record revealed a physician order [REDACTED].#1's DPOA and obtain permission for the DNR. Review on 4/11/17 of Resident #1's care plan completed on 3/31/2017 with a focus area of Advance directives is as follows: Resident has an established advanced directive that has been invoked, code status is full code. with a revision on 4/28/16. Interview on 4/11/17 at 3:30 p.m. with Staff B (Director of Nurses) confirmed that Resident #1's Advance directives care plans had not been updated since Resident #1's full code has been changed on 4/4/17 to a DNR. Staff B found the new order written on 4/4/17 to be a DNR.",2020-09-01
90,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2017-04-13,364,E,0,1,K2IK11,"Based on observation, interview, and resident council review, it was determined that the facility failed to assure that food is palatable, attractive and at the proper temperature to ensure resident's satisfaction. (Resident identifier is Resident #5.) Findings include: Observations on 4/13/17 at 7:37 a.m. of food service performed identified that the holding temperature on the steam table of the oatmeal prior to being served was 178 degrees Fahrenheit. The holding temperature of the scrambled eggs on the steam table prior to being served was 168 degrees Fahrenheit. A test tray was prepared at 7:45 a.m. and left the kitchen at 7:46 a.m. for the B Unit. The last tray was served to a resident at 7:59 a.m. and the test tray was pulled from the tray cart. At that time the oatmeal temperature of 149 degrees Fahrenheit and the scramble eggs had a temperature of 162 degrees Fahrenheit. The hot water for tea had a temperature of of 153 degrees Fahrenheit. The orange juice on the test tray had a temperature of 73 degrees Fahrenheit and did not maintain a cold temperature below 41 degrees Fahrenheit that was palatable, attractive and at the proper temperature to ensure resident's satisfaction. Interview on 4/13/17 at 1:15 p.m. with Resident #5 revealed that Resident #5 indicated the food is always the same chicken or fish, and is always cold. Resident #5 confirmed that for an alternate meal choices you can get peanut butter & jelly or grilled cheese as an alternate when you don't like the main menu, then stated their preference to have soup more. Interview on 4/12/17 at 10:00 a.m. with the resident council members revealed that several of the residents in attendance felt that the meals that they receive are often cold, especially on Unit B. When questioned, the residents responded that breakfast is frequently not hot enough. The residents did state that the staff would heat up a meal, but that it is not the same. Many residents stated that Unit A was always served before Unit B and that the kitchen frequently ran out of the first meal choice before Unit B was served. The residents reported that the food does not taste good, especially the scrambled eggs.",2020-09-01
91,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2017-04-13,441,D,0,1,K2IK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to follow infection control practice while providing care to 1 out of sample resident with a peripherally inserted central catheter in a survey sample of 17 residents. (Resident identifier is out of sample #19.) Findings include: Record review on 4/13/17 of the Medication Administration Record (MAR) for Resident #19 revealed an order for [REDACTED]. Observation on 4/13/17 with Staff C (Registered Nurse) at approximately 10:15 a.m. showed Staff C prepared the physician ordered medication Azireonam 1 GM (gram) intravenously (IV) for Resident #19. Staff C prepared the IV solution and intravenous tubing to attach to the IV pump. The double lumen Peripherally Inserted Central Catheter (PICC) was located on Resident #19's left upper chest. Staff C donned gloves and proceeded to cleanse each of the individual dual lumen ports with a separate alcohol wipe. One port was cleansed with a alcohol wipe and discarded on Resident #19's over the bed table. The second port was cleansed with a alcohol wipe and this was discarded on Resident #19's over the bed table. This over the bed table had multiple books and personal items of Resident #19. Further observation revealed as Staff C was connecting the IV tubing to the IV pump Staff C encountered air in the IV tubing. Staff C proceeded to disconnect the tubing from the pump and prime the tubing more to eliminate the air in the tubing. Staff C proceeded to attach the IV tubing to the pump. Staff C with donned gloves still in place proceeded to cleanse one of the PICC ports with one of the discarded used alcohol wipes. After cleansing Staff C discarded this alcohol wipe on the resident's over the bed table and picked up the second discarded used alcohol wipe and proceeded to cleanse the other PICC port with this used alcohol wipe and again discarded this wipe on the resident's over the bed table. Interview on 4/13/17 with Staff C confirmed the above listed findings that aseptic technique was not maintained to prevent cross contamination by using the individual discarded alcohol wipes a second time to cleanse each individual PICC line port for Resident #19.",2020-09-01
92,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2017-04-13,456,D,0,1,K2IK11,"Based on observation, manufacturer's instruction for use and interview, it was determined that the facility failed to follow manufacturer's instructions for dating glucometer testing solutions opened for 2 of 5 medication carts and cleaning of 1 anticoagulation meter. Findings include: Observation on 4/11/17 at approximately 9:30 a.m. of the opened glucometer quality control high and low testing solutions on 2 of the 2 A wing unit medication carts, it was revealed that the high and low quality control testing solutions were not dated with either the open date of the solutions or the discard date of the solutions. Manufacturer's instructions dated 06/01/96, state under section titled, Storage and handling the following directions, Do not use if the expiration date has passed. Discard any unused control solution 90 days after first opening or after the expiration date. Interview on 4/11/17 at approximately 9:45 a.m. with Staff B (Director of Nursing/Registered Nurse) who confirmed the control solutions were not dated when they were opened. Observation on 4/11/17 at approximately 9:35 a.m. of the anticoagulation meter on the A wing, revealed a dried brown substance on the right hand side of the meter and a 1 inch by 2 inch piece of clear plastic tape with the writing in blue pen, Unit A on the back of the meter. Interview on 4/11/17 at approximately 9:37 a.m. with Staff B regarding the cleaning of this meter, Staff B stated that the meter is cleaned with the bleach wipes after each use. Staff B agreed that the meter did have a dried brown substance on the right hand side of the meter. Staff B also agreed that the tape on the back of the meter precluded the machine from being cleaned effectively to ensure no transmission of infection could occur.",2020-09-01
93,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2017-04-13,516,D,0,1,K2IK11,"Based on observation and interview it was revealed that the facility failed to safeguard resident information on 1 of 7 medication cart computers. Findings include: Observation on 4/12/17 at approximately 11:30 a.m. revealed an unattended medication cart on Unit [NAME] The medication cart had a computer on top of it. The screen on the computer was still open with pictures of residents, as well as their medication information. This information was easily accessible to anyone. After approximately 5 minutes, Staff C (Licensed Practical Nurse) came over to the medication cart and stated that she forgot to lock the screen, and locked it. Observation on 4/12/17 at approximately 11:55 a.m. revealed the same medication cart, again unattended, with the computer screen open with resident information. After approximately 3 minutes, Staff C came over to the medication cart and asked if she had forgotten to lock it again. Staff C stated that she would just log out and that would ensure that it would be locked. Interview on 4/13/17 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that the medication cart computer screens should always be locked when not in attendance.",2020-09-01
94,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2019-07-11,580,D,0,1,NENQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to notify the resident's physician and/or representative when treatment has been discontinued or delayed for 2 residents in a final sample of 20 residents (Resident identifiers are #22 and #183). Findings include: Resident #183 Interview on 7/8/19 at 12:38 p.m. with Resident #183 revealed the resident was admitted on [DATE] and had not received all of their prescribed pain medications and the resident was upset because they were having constant moderate to severe pain. Review on 7/10/19 of Resident #183's Medication Administration Record [REDACTED]. There were notes for the first 10 administration times that indicated the medication was not given because it was not available from the pharmacy. There was no documentation of notification of the missed administration to Resident #182's physician. Resident #183 received [MEDICATION NAME] starting on 7/9/19. Interview on 7/10/19 at 12:00 p.m. with Staff A (Director of Nursing) confirmed there was no documentation that the physician was notified in the delay of Resident #183 receiving the above medication. Resident #22 Interview on 7/8/19 at approximately 12:10 p.m. with Resident #22's DPOA (Durable Power of Attorney) revealed that the facility had stopped Resident #22's orders for medications, and that they needed to be restarted as Resident #22 had some health issues, in particular acid reflux, without the medications. Resident #22's DPOA stated that they were not aware that the medications were being discontinued and that when they realized it, they asked to have them restarted. Review on 7/10/19 of Resident #22's Physician order [REDACTED]. Review on 7/10/19 of Resident #22's (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 7/11/19 of the facility policy, titled, Communication of Health Status, last reviewed on 3/1/16, revealed that it was the facility's policy to .Advise patient and /or health care decision maker of any change in his/her medical condition, medication orders or treatment orders . Interview on 7/11/19 at approximately 10:35 p.m. with Staff B (Unit Manager) confirmed that some of Resident #22's medications were discontinued, because they were on Hospice, and that their DPOA was not notified of the discontinuation. Staff B confirmed that when they found out, they asked that the medications be restarted. Staff B also confirmed that the DPOA should have been notified of the medication change.",2020-09-01
95,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2019-07-11,658,D,0,1,NENQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to follow professional standards to ensure that a resident did not receive 4 times the dose ordered for a medication used to treat CAD ([MEDICAL CONDITION]) for 1 resident in a final survey sample of 30 residents. (Resident identifier is #43.) Findings include: Professional reference: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 7/9/19 at approximately 7:43 a.m. during medication pass revealed that Staff C (Licensed Practical Nurse) popped a [MEDICATION NAME] 40 mg (milligram) tablet from a medication card into a medicine cup. After popping the medication into the cup, Staff C put the medication card back into the medication cart drawer. Review on 7/9/19 at approximately 7:43 a.m. of Resident #43's Medication Administration Record [REDACTED]. The review also revealed that Resident #43 did not have an order for [REDACTED].>Interview on 7/9/19 at approximately 7:50 a.m. with Staff C revealed that they said that they had taken the [MEDICATION NAME] 40 mg from another resident's medication card in error. Observation on 7/9/19 at approximately 7:50 a.m. of Resident #43's medication cup revealed that Staff C, after being interviewed, reached into the medication cup and removed the [MEDICATION NAME] tablet and discarded it. Staff C then went back into the medication cart drawer and removed Resident #43's [MEDICATION NAME] 10 mg from the correct medication card and popped it into the medication cup. Interview on 7/9/19 at approximately 9:20 a.m. with Staff A (Director of Nursing) confirmed that Staff C should have been more careful in taking the right medications for each resident.",2020-09-01
96,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2018-10-16,641,B,1,0,4FNO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, it was determined that the facility failed to accurately reflect the resident's status using the Resident Assessment Instrument (RAI) for 2 residents reviewed with wander alarms in a survey sample of 6 residents. (Resident identifiers are #4 and #5.) Findings include: Resident #4 Record review on 10/16/18 at approximately 11:30 a.m. revealed Resident #4 had a physician order [REDACTED]. Review on 10/16/18 of Resident #4's Minimum Data Set (MDS) Annual assessment on 8/17/18 and Quarterly assessments on 5/18/18, 3/6/18, and 12/14/17 revealed in Section P (Restraints and Alarms) that wander/elopement alarms were not used. Interview on 10/16/18 at approximately 11:45 a.m. with Staff B (Director of Nursing) confirmed the above findings and revealed that the MDS should have reflected that wander/elopement alarms were used daily. Observation on 10/16/18 at approximately 1:00 p.m. revealed that Resident #4 had a wander alarm on their right ankle. Review of the medical record of Resident #5 on 10/16/18 at approximately 10:45 am revealed an order dated 9/14/18 for placement of a Wander-Guard wander/elopment device (a device used to protect residents from elopment/leaving the building unattended) on the ankle of Resident #5 due to poor safety awareness. Interview with Staff B, (DON) on 10/16/18 at approximately 11:00 am revealed that the Wander-Guard security device was placed on Resident #5's ankle on 9/14/18. Further record review on 10/16/18 at 11:15 am revealed that the last quarterly MDS (Minimum Data Set)comprehensive assessment was performed on 9/18/18. The MDS dated [DATE] under Section P (Restraints and Alarms); Item E: (Wandering/elopment Alarm): stated that there was no wandering/elopment alarm in use for Resident #5. An interview on 10/16/18 with Staff B at approximately 11:30 am revealed that the MDS assessment was not coded correctly and should have reflected that Resident #5 was wearing the Wander-Guard wander/elopment device.",2020-09-01
97,MAPLE LEAF HEALTH CARE CENTER,305030,198 PEARL STREET,MANCHESTER,NH,3104,2018-03-16,880,B,0,1,OZ7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement an infection prevention practice to prevent the potential transmission of influenza for 1 out of 2 residents who received nasal swabs for influenza during the standard survey. (Resident identifier is #61.) Findings include: Observation on 3/14/18 at approximately 10:00 a.m. of Resident #61 revealed that Resident #61 was short of breath and had frequent coughing. Review on 3/15/18 of Resident #61's nurses notes, dated 3/14/18, revealed that Resident #61 .complained of 'not feeling well' .non prod (non productive) cough .had a temperature of 100.2. Review on 3/15/18 of Resident #61's Physician Telephone Orders, dated 3/14/18, revealed an order for [REDACTED].>Review on 3/15/18 of Resident #61's nurses notes, dated 3/14/18, revealed a note which documented .Flu Swab A & B collected. Observation on 3/15/18 at approximately 3:00 p.m. of Resident #61's room revealed that there was nothing indicating that Resident #61 was placed on precautions. Interview on 3/15/18 at approximately 3:00 p.m. with Staff A (Registered Nurse, Unit Manager) confirmed that Resident #61 had not been placed on precautions. Review on 3/16/18 of the facility's Infection Control Manual, dated 12-98, revised 10-1-08, revealed that In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for a patient known or suspected to be infected with microorganisms transmitted by droplets .that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures . Interview on 3/16/18 at approximately 12:00 p.m. with Staff B (Licensed Practical Nurse, Infection Control) confirmed that Resident #61 should have been placed on Droplet Precautions when Resident #61 was suspected of having influenza.",2020-09-01
98,MAPLE LEAF HEALTH CARE CENTER,305030,198 PEARL STREET,MANCHESTER,NH,3104,2019-05-03,658,D,0,1,2O0511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of physicians orders, manufacturers instructions and it was determined that the facility failed to follow physicians orders for 1 out of 4 residents observed during medication administration and 1 of 3 residents reviewed for pain in a final sample of 23. (Resident identifier is #17 and #57.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #57 Observation on 5/1/19 at approximately 8:20 a.m. with Staff A, Licensed Practical Nurse (LPN) during medication pass with Resident #57 revealed that Resident #57 had a [MEDICATION NAME] adhered to the lower back dated 4/30. Review on 5/1/19 of Resident #57's physicians orders revealed the following: (pronoun omitted) [MEDICATION NAME] 4% adhesive patch. Apply 1 patch topically to low back (remove after 8 hours). Apply 8 a.m. and remove 4 p.m. Interview on 5/1/19 at approximately 8:25 a.m. with Staff A revealed that the [MEDICATION NAME] should have been removed at 4:00 p.m. on 4/30. Review on 5/2/19 of the manufacturer's instructions for (pronoun omitted) [MEDICATION NAME] 4% adhesive patch revealed: . Directions . Remove patch from the skin at most 8-hour application Resident #17 Review on 5/3/19 of Resident #17's physician orders [REDACTED]. Review on 5/3/19 of Resident #17's Medication Administration Record [REDACTED]. Interview on 5/3/19 at 12:48 p.m. with Staff B (Unit Manager) confirmed the it was not documented that Resident #17's patch was removed on 4/10/19 and 4/24/19.",2020-09-01
99,MAPLE LEAF HEALTH CARE CENTER,305030,198 PEARL STREET,MANCHESTER,NH,3104,2019-05-03,880,E,0,1,2O0511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed establish and follow written policies and procedures for standard and transmission-based precautions and when and how isolations should be used for a resident for 4 of 4 residents observed on precautions. (Resident identifiers are #18, #53, #99, #205.) Findings include: Resident #18 Observation on 4/30/19 at 9:40 a.m. revealed a precaution sign outside of room [ROOM NUMBER]. Interview on 4/30/19 at approximately 9:45 a.m. with Staff B (Unit Manager) revealed that Resident #18 in room [ROOM NUMBER] was on precautions for [MEDICAL CONDITION]. Observation on 4/30/19 at 10:20 a.m. revealed a staff changing Resident #18's bed with gown hanging off of the staff's shoulders. Observation on 4/30/19 at 10:50 a.m. revealed housekeeping cleaning room and mopping floor around Resident #18's bed not wearing a gown or gloves. Observation on 4/30/19 at 1:50 p.m. revealed two Licensed Nursing Assistants (LNA) in Resident #18's room not wearing a gown or gloves. Staff C (LNA) removed the garbage bag from the trash container that contained used gowns and took it down the hallway to the soiled utility room. Observation on 5/1/19 at 8:30 a.m. revealed staff went to deliver food to Resident #18. Staff put food on top of the precaution cart in the hallway and put on a mask and brought the tray into Resident #18 who was in bed. Review on 5/3/19 of Resident #18's care plan dated 4/29/19 revealed that the resident is on contact precautions. Review on 5/3/19 of Resident #18's physician orders [REDACTED]. Interview 5/3/19 at 12:50 p.m. with Staff D (Infection Preventionist) revealed that for some residents on contact precautions, staff only need wear gloves and gowns during direct care, that residents can attend activities and dining and some residents would need to stay in their room and require staff to wear gloves and gowns whenever they enter the resident's room. Staff D revealed the differences in procedure is not reflected in facility policy, on signs, or in the resident's care plan. Staff D revealed that a mask is not a recommendation for contact precautions but is available for use if staff want to wear one. Resident #99 Interview on 4/30/19 at approximately 8:55 a.m. with Staff B (Registered Nurse) revealed that there is a question of bed bugs in Resident #99's room, and the room has been treated for [REDACTED]. Observation on 4/30/19 at 10:22 a.m. of this room revealed there is a precaution cabinet outside the room with PPE (personal protective equipment), but there is no precautions signage or Stop/see Nurse signage at the room entrance. Interview on 4/30/19 at approximately 9:15 a.m. with Staff I (clinical) revealed that instruction was to wear gown and gloves to go into the room. Observation on 4/30/19 at 10:50 a.m. revealed a visitor, without donning any personal protective equipment (PPE), walked into the room and spoke with Resident #99, then carried 2 framed pictures, one at a time, out of the room into the hallway, showing them to people in the hall, then returning the pictures to the room. Interview on 4/30/19 at approximately noon with Staff B revealed gown and gloves indicated when contacting linens/residents, the room was treated for [REDACTED]. Interview on 5/3/19 in the afternoon with Staff G (Director of Nursing) revealed the bed bugs were for Resident #99, they found a couple live bed bugs that Staff G thinks may have come in with Resident #99, he has one treatment to go. Interview on 5/3/19 at 2:04 p.m. with Staff J (clinical) confirmed Resident #99 has one treatment to go. Observation on 5/3/19 at approximately 12:43 p.m. revealed there was a Stop signage at the doorway to Resident #99''s room, there was still a PPE cabinet outside the room but no precaution sign on the PPE cabinet. Resident #205 Interview on 4/30/19 at approximately 8:55 a.m. with Staff B (Registered Nurse) revealed that Resident #205 is on precautions for [MEDICAL CONDITION]. Observation on 4/30/19 at 11:12 a.m. revealed a precaution cabinet outside of Resident #205's room with Contact Precautions signage and a Stop sign at the doorway. Staff K (clinical) was observed at this time in the room near the doorway without PPE on. Staff K exited the room and interview at that time with Staff K revealed Staff K had a mask on as they were only talking to the resident, and they had just removed it, Staff K related gloves are only needed if touching/doing care, if entering the room and only talking just need a mask. Observation on 4/30/19 until 11:24 a.m. revealed, after Staff K exited the room, a visitor was observed in the room with Resident #205, the resident was not visualized as they were behind a pulled curtain. The visitor came into view, and was observed wearing a mask and gloves but no gown. The visitor was touching things in the room including a grasping tool. Interview on 4/30/19 at approximately noon with Staff B revealed that for Resident #205, one should wear gown and gloves when contacting linens, the resident; and a mask is not needed in the room. Interview on 5/1/19 at approximately 1:54 p.m. with the resident's daughter revealed Resident #205 is presently on precautions for [DIAGNOSES REDACTED] ([MEDICAL CONDITION]); after staff finish care the staff discard their gown/gloves in the trash then remove the liner and replace it; after the resident uses the bedside commode the staff puts the contents in a bag and removes it. Observation of the room at time of this interview revealed the bathroom in the room is located on the roommate's side of the room, by the room entrance. There is only one sink in the room which is not in the bathroom but is in the room itself, again on the roommate's side. Resident #205's bed is at the far side of the room, by the window, separated from the roommate by a pulled curtain. There is a portable commode located between Resident #205's bed and the window wall, and the waste basket, which has a plastic liner, is also adjacent to the window wall. Record review on 5/2/19 at 9:22 a.m. of Resident #205's Discharge Summary for Date of Service 4/15/19 reveals Metabolic [MEDICAL CONDITION] due to [DIAGNOSES REDACTED] and secondary active [DIAGNOSES REDACTED]. Record review on 5/2/19 at 12:27 p.m. of the Admission Minimum Data Set assessment dated [DATE] revealed that that Resident #205 has frequent incontinence of urine and bowel, and Section I codes [DIAGNOSES REDACTED]. Interview on 5/3/19 at 9:37 a.m. with Staff B revealed Staff usually have bags with them that they put their PPE into when they are done, and then take the bag out of the room; similarly after commode use, the liner with waste is taken out of the room to the dirty utility. Record review on 5/3/19 at 12:24 p.m. of Resident #205's physician's orders [REDACTED]. Record review of the facility's [DIAGNOSES REDACTED]icile-Contact Precautions sheet, provided on survey, and dated 5/1/18, reveals, in part, that gloves are to be used When giving direct care. Also, The use of gowns when giving direct care will depend on site of infection and residents sign & symptoms. Resident #53 Observation on 4/30/19 at approximately 9:30 a.m. of Resident #53 revealed Resident #53 was sitting in a common area of the 3rd floor wing. There was a precautions cart and a sign identifying that the purpose for the cart was Droplet Precautions. The cart was located outside of a room that had four resident occupants. Staff was queried as to whom the precautions were for, the staff identified Resident #53 who was sitting in the common area. At the same time that the observation was taking place, a member of the Laundry staff delivered laundry items to the room in question. Laundry staff did not don Personal Protection Equipment prior to entering the room. Interview on 4/30/19 at 10:15 with Staff H (3rd floor Unit Manager) revealed that Resident #53 had Upper Respiratory Infection (URI) symptoms. Resident #53 was given an influenza test that resulted negative. Observations that occured at 9:30 a.m. were revealed to Staff H. Staff H responded that the concerns would be addressed. Interview on 5/3/19 at 12:10 PM with Staff D (Infection Preventionist) and Staff G, Registered Nurse, revealed that facility staff is empowered to initiate precautions if it is suspected by staff that infection prevention is needed. Staff D revealed that Resident #53 was suspected of requiring droplet precautions and that unit staff were finding it difficult to keep a mask on her or monitoring Resident #53's movements in the hallway.",2020-09-01
100,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2017-03-02,225,D,0,1,O8XB11,"Based on resident group interview, and review of facility generated reports, it was determined that the facility failed to report misappropriation of property to the state agency as required by regulation. Findings include: Interview on 3/1/17 at 10:30 a.m. with the resident group, revealed residents had complaints regarding items going missing such as jewelry, and money. Review of the grievance log from 5/20/16 to 3/2/17 revealed that there were no reports of jewelry or money missing. There was Resident #21's cell phone that was recorded as missing on the grievance log on 2/12/17. Interview on 3/2/17 at approximately 9:30 a.m. with Staff A (Social Worker) confirmed that missing items on the grievance log had not been reported to the state. Interview on 3/2/17 at approximately 10:45 a.m. Staff A stated, We ask the resident if they want us to call the police department. If they do not want us to call the police, then we don't. If we don't call the police then we don't notify the State(of NH). Staff A further stated: If the resident is alert and oriented and making their own decisions we do not continue to search if the resident says they misplaced it (the object).",2020-09-01
101,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2017-03-02,241,E,0,1,O8XB11,"Based on observation and interview, it was determined that the facility failed to provide dining assistance to residents in ways that promote residents' dignity and respect for 1 of 4 units observed. Findings include: Observation on 2/28/17 and 3/2/17 at approximately 11:30 a.m. of the dining rooms on the 2nd floor revealed residents who required assistance were being fed by staff. The staff that were assisting residents with eating were doing so by standing next to the resident and giving 1 bite to the resident and then the staff person would move on to the next resident and provide that resident with a bite. Interview on 3/2/17 at approximately 3:45 p.m. with Staff C (Administrator), Staff C stated she/he was not aware that staff were standing and feeding residents. Observation on 3/1/17 at 8:30 a.m. of breakfast on the 2nd floor dining area (closest to the elevator) revealed that there was a staff to resident ratio of 2-16. At 8:30 a.m., several residents were noted to have food in front of them and that these residents were not actively participating in feeding themselves. Staff B (Unit Manager) was going from resident to resident giving a bite and then moving to another table to give another resident a bite of food. Staff B stood during the entire meal while assisting. Observation on 3/1/17 at 1:30 p.m. in the assisted dining area revealed there were 8 residents noted to be in the 2nd floor dining area (closest to the nursing station). There were no staff present. Resident #22 was noted to have a full plate of food and drink on the table in front of them. Staff B arrived in the room at 1:40 p.m. and removed the plate of food. Interview on 3/1/17 at 1:40 p.m. with Staff B reviewed the above observation, Staff B stated that the Resident #22 should be assisted/supervised with all meals.",2020-09-01
102,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2017-03-02,280,D,0,1,O8XB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 1 resident in a standard survey sample of 17 residents. (Resident identifier is #12.) Findings include: Observation on 3/2/17 at 11:46 a.m. of meal time revealed Resident #12 had 3 covered bowls in front of him/her and was eating from a 4th bowl with plastic silverware. Review of Resident #12's current care plan revealed there was no mention of why Resident #12 was eating from bowls or using plastic silverware. During interview on 3/2/17 at approximately 4 p.m. with Staff C (Administrator), Staff C stated that the dietician made the recommendation for Resident #12 to use bowls due to a [DIAGNOSES REDACTED]. Staff C stated that Resident #12 uses plastic silverware because he/she has demonstrated unsafe behavior towards others with metal silverware. Record review of the dietician note(s) confirmed the above interview finding for use of bowls, as the dietitican put in their notes to use bowls to slow eating for safe swallowing. Review of the above care plan revealed the use of plastic silverware due to demonstrated unsafe behavior towards others with metal silverware, was not address in the care plan.",2020-09-01
103,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2017-03-02,281,D,0,1,O8XB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop an interim care plan at the time of admission for 1 of 1 residents in a survey sample of 17 residents. (Resident identifier is #11.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 269 relates under Planning Nursing Care, You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals .The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care .A correctly formulated nursing care plan makes it easy to continue care from one nurse to another. Review on 3/2/17 of Resident #11's medical record revealed an admission [DIAGNOSES REDACTED].#11. Review of the History and Physical note dated 1/25/17 revealed that Resident #11 had a left AV (arterio-vascular) fistula created on 9/9/16 and was not matured. Due to this fistula not being matured, Resident #11 was receiving [MEDICAL TREATMENT] treatment 3 times a week thru a right Tessio Catheter scheduled at the time of admission to the facility. No documented evidence in the facility admission care plan could be found regarding the [MEDICAL TREATMENT] treatments, Tessio Catheter or the non matured left AV fistula care for Resident #11. Interview on 3/2/17 at approximately 12:45 p.m. with Staff B ( Registered Nurse), reviewed the facility admission care plan and. Staff B verified that there was no documentation on this admission care plan for [MEDICAL TREATMENT] treatments, Tessio Catheter and AV Fistula care for Resident #11.",2020-09-01
104,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2017-03-02,441,D,0,1,O8XB11,"Based on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment in the Rehabilitation Gym, and proper hand hygiene for 1 resident, to prevent transmission of possible disease and infection. Findings include: Observation on 3/2/17 at approximately 2 p.m. of a dressing change done by Staff D (Nurse) to a resident's upper back revealed Staff D had placed a clean hand towel over the resident's overbed table to create a clean work station for the clean dressings and other supplies to complete the dressing change. Upon entering the room a white hand towel was observed to be covering an overbed table. Staff D did not wash their hands prior to putting on gloves to remove the old dressing and they did not wash their hands when they changed their gloves to clean the wound and then apply a clean dressing to the wound. Staff D cleared the items off the white hand towel and then picked up the white hand towel and tucked it under his/her left arm up against his/her uniform. Interview on 3/2/17 at approximately 2:20 p.m. with Staff D, reviewed their failure to perform hand hygiene when donning gloves and placing contaminated linens up against their uniform. Observation on 2/28/17 at approximately 9:30 a.m. of the Rehabilitation Gym revealed that the two padded office stools which are used in the patient care area had tears down the side seam exposing the foam inside. Breaches in the integrity of the stools can prevent proper cleaning and infection control prevention. Interview on 2/28/17 at approximately 9:30 a.m. with Staff B (Director of Rehabilitation), Staff B confirmed the above finding.",2020-09-01
105,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2019-05-17,656,D,0,1,LRKD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive care plan for 1 resident in a survey sample of 17 residents. (Resident identifier is #23.) Findings include: Dining observation on 5/15/19 at approximately 12:11 p.m. revealed Resident #23 seated at a table with a place setting of regular utensils and Resident #23 was receiving limited assistance to eat. Dining observation on 5/16/19 at approximately 12:30 p.m. revealed Resident #23 seated at a table with a place setting of regular utensils. Resident #23 was served a meal on a lip plate. Interview on 5/16/19 at approximately 12:35 p.m. with Staff C (Licensed Nursing Assistant) stated that Resident #23 sometimes has built up utensils and sometimes does not. Review on 5/15/19 at approximately 1:35 p.m. of Resident #23's medical record revealed a nutrition assessment dated [DATE] stating Resident #23 has lost 3 pounds in 30 days and receives the house supplement cup two times per day. Nutrition assessment also states Resident enjoys meals in the MDR (Main Dining Room) using built up utensils and lip plate dependent on assistance. Further review of Resident #23's comprehensive care plan revealed that there is no nutrition care plan. Interview on 5/17/19 at approximately 2:30 p.m. with Staff A (Unit Manager) confirmed that Resident #23 does need built up utensils to eat and is monitored by the dietician and should have a nutrition care plan in place and does not.",2020-09-01
106,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2018-07-11,812,D,0,1,472Y11,"Based on observation and interview during the initial tour of the facility's kitchen it was determined that the facility failed to clean equipment to prevent contamination from food objects, and also failed to maintain equipment in safe operating condition according to manufacturer's specifications, and discard foods after 7 days from the use by date. Findings include: Observation and interview on 7/9/18 at 9:27 a.m. during the initial tour it was observed that the meat slicer was covered with food debris and ready for use with a plastic bag covering it as stated by Staff A (Head Cook). Staff A at time of finding, broke down the meat slicer to be cleaned. Also during tour of the facilities' refigerator kitchenette on the[NAME]unit a plastic zip lock bag with several bananas and apples where found. The date on the bag was 6/25/18, 6 days beyond the 7 day discard date and all the fruit inside the bag were black and rotten. This finding was shown to Staff A who discarded the items at time of finding. Interview on 7/10/18 at 10:23 a.m. with Staff B (Director of food services) was asked by surveyor about the three compartment sink and questioned if the dish machine went down how would you wash your pots and pans? Staff B said they would remove the cooking sheets that are placed over the three compartment sink and use it. Staff B was asked if they have had to do that recently Staff B stated no, then Staff C (Kitchen Staff) stated that the sink itself does not work, the water was shut off and the drains leak. At this time Staff B was asked by surveyor to see if the water was working, Staff B tried both the hot and cold water and both were shut off. Staff C then stated they were to have this whole area (dish room) torn apart and fixed due to the above concerns but it's been several months now.",2020-09-01
107,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2018-07-11,825,D,0,1,472Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview it was determined that the facility failed to provide ongoing services that were coordinated and consistent with the specialized rehabilitative services to maintain residents goals and to prevent decline in the resident's level of function for 1 of 1 Resident in the finial sample of 21. (Resident identifier is #38) Findings include: Interview on 7/9/18 at 10:05 a.m. Resident #38 stated that last (MONTH) or (MONTH) they sustained a fall and had been admitted to the facility to do rehabilitation servieces with a goal to return home, but since being transferred to a new unit on 6/22/18 they have not walked ever since. Review of Resident #38's medical record revealed that they were admitted to the facility on [DATE] at 3:41 p.m. due to a fall that occurred at their local post office causing a right intertrochanteric femoral fracture. Resident #38 underwent an ORIF (Open Reduction Internal fixation) on 3/2/18 and was discharged from the hospital on [DATE]. On 7/10/18 interview with Staff D (Director of Rehabilitation) said Resident #38 was ambulating prior to being discharged from services on 6/22/18, but the rehabilitation department after discharge do not set up any type of ambulation program once discharged , nor was there any staff education on how to ambulate Resident #38 once discharged . Review on 7/11/18 of Resident #38 medical record revealed that they were admitted to the Livingston unit on 3/22/18 for skilled rehabilitation services and once Resident #38 maxed out on services, was transferred to Derryfield unit on 6/22/18. Review of the discharge paperwork from therapy provided by Staff D, revealed, Patient will safely ambulate on level surfaces up to 500 feet using a Rolling Walker with supervision with activity modifications, with adaptive devices and with tactile cues to return to prior living setting, to increase independence within facility and to reduce risk for falls. On 7/11/18 Staff [NAME] (Unit Manger) was asked to provide Resident #38's care plan since being transferred to the Derryfield unit. The care plan read's under goal (Resident #38), once standing, will be able to walk at least 50 feet and make two turns with set-up . On 7/11/18 Staff [NAME] was asked for the Kard Ex which is a quick reference for staff to provide care to the resident. On review of the Kard Ex under Ambulation/Mobility/Transfers the care areas are as follows: 1) Bed rail(s) used as an enabler. 2) Provide resident with limited assist of 1 for bed mobility. 3) Provide resident with limited assist of two for transfers using a pivot transfer. There is no mention of what is needed on the Kard Ex for Resident #38 to ambulate or what assistive devices are needed to ambulate. Review on 7/11/18 of Resident #38's ADL (Actives of Daily Living) flow sheets since Resident #38 was transferred to the Derryfield unit it's documented under Walk in corridor (Hallway) and Walk in room as 8-97 which is 8-ACTIVITY DID NOT [NAME]CUR 97-NOT APPLICABLE.",2020-09-01
108,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2019-02-01,625,C,0,1,6ULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to provide written information to residents in regards to notice of bed-hold policy and return before a transfer for 3 out of 3 residents who were transferred out of the facility. (Resident identifiers are #24, #69, and #96.) Findings include: Review on 1/31/19 of Resident #24's progress notes revealed that on 11/1/18 Resident #24 was transferred to the hospital for unresponsiveness and cyanosis. Review on 1/31/19 of Resident #24's chart records revealed that there were no written notice of the facility's bed-hold policy upon transfer to the hospital on [DATE] or thereafter. Review on 1/31/19 of Resident #24's progress notes revealed that there were no documentation that Resident #24 was provided with a written notice of the facility's bed-hold policy upon transfer to the hospital on [DATE] or thereafter Interview on 1/31/19 at 1:49 p.m. with Staff A (Social Service Director) confirmed the above findings. Staff A states that they have never done a written notice of bed-hold policy to any resident upon transfer and that it was given to the residents on admission in the admission packet. Staff A stated that It was not required in New Hampshire to give residents a written notice of bed-hold policy upon transfer. Resident #96. Review on 1/31/19 of Resident #96 medical record revealed that Resident #96 was transferred and admitted to the hospital on [DATE]. Further review of this medical record showed no documented evidence of notification to Resident #96 of the facility bed hold policy at the time of transfer to the hospital on [DATE]. Interview on 2/1/19 at approximately 8:20 a.m. with Staff A (Licensed Certified Social Worker) confirmed that there was no documented evidence of notification to Resident #96 of the facility bed hold policy at the time of transfer to the hospital on [DATE]. Resident #69 Review on 1/31/19 of Resident #69's progress notes revealed that on 11/27/18 Resident #69 was transferred to the hospital. Review on 1/31/19 of Resident #69's chart records revealed that there was no documentation that the resident was provided with a written notice of the facility's bed hold policy upon transfer to the hospital on [DATE] or thereafter. Interview on 1/31/19 at 8:20 a.m. with Staff D (LPN/Unit Manager) revealed that there was no written bed-hold policy given to Resident #69 or to his DPOA (Durable Power of Attorney). Staff D stated that years ago the nurses completed the bed hold policy form and gave it to the resident or DPOA at the time of a transfer but this is no longer done. Staff D stated that he/she was told that there was no regulation in New Hampshire to provide a bed hold policy notice and this is why the bed hold policy form is no longer completed and provided to the resident or DPO[NAME]",2020-09-01
109,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2019-02-01,689,E,0,1,6ULX11,"Based on observation and interview it was determined that the facility failed to ensure a safe environment on the Medical Surgical Unit to prevent burn and fire hazards. Findings include: Observation on 1/29/19 at approximately 11:30 a.m. on the MSU unit (Medical Surgical Unit) showed Staff I (kitchen aide) serving hot food from two individual portable counter top hot water warmers. Following the meal service Staff I placed stainless steel covers on top of each of the individual hot water warmers after removing the hot food. Staff I proceeded to leave the MSU unit leaving the warming units unattended. The two individual portable hot water warmers are positioned on the kitchen counter located on the MSU unit in the open dinning/kitchen/common area where residents eat, watch TV, sit for leisure activities and visit with family and staff members all times of the day. Interview on 1/29/19 at the time of this observation, Staff I confirmed that the two individual portable hot water warmers remain on the kitchen counter top. Staff I reported that the two units are turned on to heat 1/2 to 3/4 hour before meals are served. Observation on 1/29/19 at approximately 1:30 p.m, with Staff I revealed that the two hot water units were on the kitchen counter hot to touch.The covers were lifted from the containers and steam vapors were visible. Staff I confirmed, during this observation, that the two warmers were hot to touch and that steam was visible when lids were lifted and that both of these warming units were accessible to any resident or individual in this common area. Observation on 1/30/19 at approximately 8:40 p.m. showed Staff J (kitchen aide) preparing eggs to order for residents in a skillet on top of an electric unit located on the counter beneath the wall mounted kitchen cabinets on the MSU unit. Staff J also served hot food from the two individual portable hot water warmers located on the kitchen counter. Interview on 1/30/19 following the meal observation listed above with Staff J, confirmed that the two individual portable hot water warmers are turned off and stainless steel covers placed on the containers. Staff J confirmed that these units are left unattended on the counter for the next meal Staff J confirmed that the portable electric unit is also left on the kitchen counter. Interview on 1/31/19 at approximately 2:30 p.m. with Staff H (food service manager) confirmed that food is served from the two individual portable hot water warmers which are located on the MSU unit. Staff H reported that a portable barrier is placed in front of the two portable hot water warmers in a locked position after serving meals by the kitchen staff to prevent access to the hot warmers. Staff H was informed that Staff I and Staff J left the MSU unit on 1/29/19 and 1/30/19 following serving the meal and the two hot water warmers were unattended and no barrier was in place to prevent individuals from accessing the hot warmers.",2020-09-01
110,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2019-02-01,757,D,0,1,6ULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview and review of policy and procedures it was determined that the facility failed to keep 1 resident free from unnecessary medications out of a final survey sample of 27 residents. (Resident identifier is #41.) Findings include: Observation on 1/30/19 at approximately 7:50 a.m. during medication pass with Staff B (Licensed Practical Nurse) revealed the following physicians order in Resident #41's MAR (Medication Administration Record): [MEDICATION NAME] Tablet 25 mg (milligram). Give 25 mg by mouth 2 times a day related to CHRONIC [MEDICAL CONDITION] FIBRILLATION, hold if systolic blood pressure less than 100. Take blood pressure on lower arm manually. Order date, 4/19/18. Observation on 1/30/19 of medication pass with Staff B did not reveal the blood pressure being taken. Staff B was stopped prior to Staff B administering the medication to confirm that the blood pressure was not taken. Interview on 1/30/19 at approximately 7:50 a.m. with Staff B confirmed that the blood pressure was not taken. This must be a new order, I never check the blood pressure. Review on 1/30/19 at approximately 9:30 a.m. of Resident #41's record of blood pressures taken since 4/19/18. Review of the blood pressure log revealed that from 4/19/18 through 1/30/19 Resident #41's blood pressure was taken 34 times. Review on 1/30/19 of the facility policy and procedure titled, Medication Administration, Revised on (MONTH) 2008 revealed: Resident medications are administered in an accurate, safe, timely and sanitary manner physician's orders [REDACTED]. 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route 5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose. e.g., pulse with [MEDICATION NAME], blood pressure with anti-hypertensive, etc",2020-09-01
111,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2019-02-01,761,D,0,1,6ULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to ensure medication was locked and not accessible to unauthorized individuals. Findings include: Observation on 1/29/19 at approximately 12:20 p.m. on the MSU (Medical Surgical Unit) unit showed that the top drawer of the Emergency Code Cart located in the resident hallway adjacent to the common area was easily opened revealing an intact box of [MEDICATION NAME] Injection, Autoinjector 3mg (milligrams)/ml (milliliters) - 3ml solution. Interview on1/29/19 at approximately 12:20 p.m. with Staff G (Registered Nurse) confirmed that the top drawer of the MSU Emergency Code Cart located in the resident common hallway containing the medication listed above was not securely locked and could be easily opened by unauthorized individuals.",2020-09-01
112,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2019-02-01,880,D,0,1,6ULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, review of facility policy and procedure it was determined that the facility failed to have hair covered when serving food in the common area on the Medical Surgical Unit, failed to maintain infection control practices in 1 out of 3 food steam tables and wear gloves to 1 resident while administering eye drops . (Resident identifier is #27.) Findings include: Observation on 1/29/19 at approximately 11;30 a.m. on the MSU (Medical Surgical Unit) unit showed Staff I (kitchen aide) serving lunch food from the two individual portable hot water warmers and cold food containers with a baseball cap in place not fully covering head hair. Staff I had no head hair covering and no facial hair covering exposed beard. Interview on 2/1/19 at approximately 1:00 p.m. with Staff H (Food Service Manager) confirmed that when serving food staff must wear a hair net and that facial hair must be covered . Observation on 1/29/19 at approximately 9:00 a.m. in the West Unit dining area of the food serving line after breakfast of the glass above the steam tables and around the serving area revealed that there was a visible substance adhered to it. When the glass and area on the steam table was touched there was a substance that was dried on the glass and on the steam tables was a greasy substance. Observation on 1/29/19 at approximately 11:30 a.m. prior to lunch of the glass above the steam tables and around the serving area revealed that there was a visible substance that was adhered to the glass and area on the steam table. When the glass and area on the steam table was touched there was a substance that was dried on the glass and on the steam tables was a greasy substance. Observation on 1/30/19 at approximately 8:31 a.m. prior to breakfast of the glass above the steam tables and around the serving area revealed that there was a visible substance that was adhered to the glass and area on the steam table. When the glass and area on the steam table was touched there was a substance that was dried on the glass and on the steam tables was a greasy substance. Observation on 1/30/19 at approximately 11:00 a.m. prior to lunch of the glass above the steam tables and around the serving area revealed that there was a visible substance that was adhered to the glass and area on the steam table. When the glass and area on the steam table were touched there was a substance that was dried on the glass and on the steam tables was a greasy substance. Observation on 1/30/19 at approximately 1:30 p.m. after lunch of the glass above the steam tables and around the serving area revealed that there was a visible substance that was adhered to the glass and area on the steam table. When the glass and area on the steam table was touched there was a substance that was dried on the glass and on the steam tables was a greasy substance. Interview on 1/30/19 at approximately 2:00 p.m. with Staff [NAME] (Unit Manager) confirmed that the area had a substance adhered to the glass and then Staff [NAME] touched the area on the steam table around the serving area and stated, This needs to be cleaned. Review on 1/31/19 of the facility policy and procedure titled, Equipment, Revised date 9/2017 revealed: Policy Statement All food service equipment will be clean, sanitary, and in proper working order 3. All food contact equipment will be cleaned and sanitized after every use Resident #27 Observation on 1/30/19 at approximately 7:45 a.m. in the West unit dining area revealed Staff C (Licensed Practical Nurse) administering eye drops to Resident #27 without gloves on. Interview on 1/30/19 at approximately 8:15 a.m. with Staff C revealed that Staff C does not wear gloves while administering eye drops unless the resident has [MEDICAL CONDITION]. Review on 1/31/19 of facility policy and procedure titled Eye Drop administration, dated 2019 revealed: Eyedrop Administration . Put on gloves",2020-09-01
113,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2020-02-24,689,D,0,1,9C7G11,"Based on medical record review, policy and procedure review and interview, it was determined that the facility failed to prevent a fall for 1 out of 4 residents reviewed for falls in a final sample of 27 residents. (Resident identifier is #62.) Findings include: Review on 2/24/20 of Resident #62's nursing notes revealed the following nurses note dated, 1/25/20 06:05:00: Fall was witnessed by LNA (Licensed Nursing Assistant) during attempt to transfer from the wheelchair to the toilet with the slide board. A slipper sock was applied to (pronoun omitted) foot as it was not on at the time of the fall. Review on 2/24/20 of Resident #62's care plans revealed the following: Focus (pronoun omitted) is at risk for falls r/t (related to) increase weakness, decreased strength, balance, functional mobility history of falls at home and use of prosthetic LLE (left lower extremity) dated 1/15/20. Interventions Ensure that (pronoun omitted) is wearing appropriate non skid footwear, date initiated 1/15/20. Review on 2/24/20 of the facility policy and procedure titled, Fall Management System, dated (YEAR) revealed the following: Policy The facility assist each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, adaptive devices. A care plan is developed and implemented, based on this evaluation, with ongoing review. Interview on 2/25/20 at approximately 10:00 a.m. by telephone with Staff [NAME] and Staff G (Administrator) revealed that the LNA was attempting to transfer Resident #62 without any footwear on when the fall occurred on 1/25/20.",2020-09-01
114,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2020-02-24,692,D,0,1,9C7G11,"Based on interview and medical record review, it was determined that the facility failed to obtain weights as needed to monitor weight loss for 2 of 5 residents reviewed for nurtrician in a final survey sample of 27 residents. (Resident identifiers are #61 and #67.) Findings include: Review on 2/24/20 of the facility policy, titled Weight Management, last revised (MONTH) (YEAR), revealed that .As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are re-weighed within 48 hours. Weight variances include: a. Weight change of 5 lbs. (pounds); or b. Weight change of 3 lbs. if weight less than 100 lbs . Resident #61 Review on 2/21/20 of Resident #61's weight summary sheet revealed that Resident #61's admission weight was 167 lbs. on 10/15/19. On 11/2/19, it was documented that Resident #61 weighed 164.8 lbs. The next weight documented for Resident #61 was on 11/6/19, which was 135.2 lbs, which represented a 29.6 lb weight loss in 4 days. Resident #61's weight was not rechecked until 11/13/20 where it was documented that Resident #61 weighed 138.6 lbs. Review on 2/21/20 of Resident #61's weight summary sheet revealed that on 1/30/20 Resident #61 had a documented weight of 148 lbs. The next documented weight for Resident #61 was on 2/5/20 which was 136.6 lbs. This represented a weight loss of 11.4 lbs in 6 days. The next documented weight for Resident #61 was on 2/13/20 which was 136 lbs. Interview on 2/24/20 at approximately 1:50 p.m. with Staff [NAME] (Director of Nursing) confirmed that re-weights were not done and should have been obtained on Resident #61 within 48 hours after their weights on 11/6/19 and on 2/5/20. Resident #67 Review on 2/21/20 of Resident #67's weight summary sheet revealed that on 10/1/19 Resident #67 had a documented weight of 130.6 lbs. The next documented weight for Resident #67 was on 11/1/19, which was 120 lbs. This represented a 10.6 lb weight loss in 1 month. The next documented weight for Resident #67 was on 11/13/19 which was 120.6 lbs. Review on 2/21/20 of Resident #67's vitals note, dated 11/5/19, revealed that Staff F (Registered Dietitian) documented a note that read .Request recheck of WT (weight) . Interview on 2/24/20 at approximately 1:50 p.m. with Staff [NAME] confirmed that a re-weight was not done and should have been obtained on Resident #67 within 48 hours after their weight on 11/1/19.",2020-09-01
115,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2020-02-24,756,D,0,1,9C7G11,"Based on medical record review and interview, it was determined that the facility has failed to act on a drug regimen review for 1 of 4 residents triggered for unnecessary medications in a final survey sample of 27 residents. (Resident identifier is #48.) Findings include: Review on 2/24/20 of Resident #48's monthly drug regimen review was completed on 2/7/20 revealed the following: Recommendations were made and emailed to facility leadership and included in the monthly Pharmacy Consultant Report. Interview on 2/24/20 at 12:15 p.m. with Staff [NAME] (Director of Nurseing) revealed Staff [NAME] was unaware of any pharmacy recommendations and was unable to provide a report.",2020-09-01
116,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2020-02-24,761,E,0,1,9C7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of manufacturer's instructions and facility policy and procedure, it was determined that the facility failed to ensure that drugs used in the facility must be labeled with the expiration date when applicable on 3 out of 3 nursing units observed. (The Medical Surgical Unit, East and West Units.) Findings include: West Unit Observation on 2/20/20 at approximately 9:30 a.m. with Staff B (Licensed Practical Nurse) on the West unit south medication cart revealed the following opened insulins without an opening or expiration date on them: Resident #90 [MEDICATION NAME] pen Resident #64 [MEDICATION NAME] pen Interview on 2/20/20 at approximately 9:30 a.m. with Staff B confirmed that the 2 insulin pens had no date of expiration or opening labeled on them. South Unit Observation on 2/20/20 at approximately 9:45 a.m. with Staff C (LPN) on the East unit south medication cart revealed the following expired medications: [REDACTED] Resident #34 [MEDICATION NAME] injectable expiration date (MONTH) 2020 Interview on 2/20/20 with Staff C confirmed that the [MEDICATION NAME] injectable expiration date was (MONTH) 2020. Review on 2/21/20 of the manufacturer's instructions for [MEDICATION NAME] injection, revision date 7/2016 revealed: . How should I store [MEDICATION NAME] injection, auto injector? . Your [MEDICATION NAME] injection, has an expiration date. Replace it before the expiration date. MSU (Medical Surgical Unit) Observation on 2/20/20 at approximately 10:00 a.m. with Staff D (Registered Nurse) on the MSU (Medical Surgical Unit) south medication cart revealed the following opened insulins with incorrect dates of expiration on them: Resident #79 [MEDICATION NAME] date opened 1/29 do not use after 3/9. Resident #79 [MEDICATION NAME] date opened 2/16/20 do not use after 3/16. Interview on 2/20/20 at approximately 10:00 a.m. with Staff D confirmed the above [MEDICATION NAME] open exirpation dates were mislabeled . Review on 2/20/20 of the facility's insulin storage recommendations from the pharmacy, revision date (MONTH) 31,2017 revealed: [MEDICATION NAME] pen opened expires 28 days after opening [MEDICATION NAME] pen opened expires 42 days after opening Review on 2/20/20 of the facility's policy and procedure titled, 5.3 Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, revision date 10/28/19 revealed: .4. Facility should ensure that medications and biological's that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines . Review on 2/20/20 of the facility's policy and procedure titled, 8.2 Disposal/Destruction of Expired or Discontinued Medications, revision date 3/28/19 revealed: Procedure .4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.",2020-09-01
117,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-06-02,225,D,1,0,YEK311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of facility documentation, it was determined that the facility failed to ensure that all investigations of alleged violations are reported immediately and within 5 working days with the results of the investigation to the state survey and certification agency for 2 residents of a complaint survey sample of 6 residents. (Resident identifiers are #1 and #2.) Findings include: Resident #1 Review on 6/2/17 of the facility's investigation documentation dated 3/11/17 reveals the initiation of an alleged elopement investigation of Resident #1. The initial investigation documentation was submitted on 3/13/17 to the state survey and certification agency. No follow up investigation was submitted after the incident on 3/11/17 to the state survey and certification agency. Interview on 6/2/17 at approximately 1:18 p.m. with Staff A (Director of Nursing) and Staff B (Administrator) both confirmed that the initial investigation was submitted to the state on 3/13/17 and the final investigation report was not sent to the state survey and certification agency because Resident #1 went to the hospital on [DATE] after Resident #1 was returned to the facility via the local police. Resident #2 Review on 6/2/17 of the facility's investigation documentation revealed that Resident #2 had a fall on 4/21/17 resulting in a right [MEDICAL CONDITION]. The initial investigation documentation was submitted to the State survey and certification agency on 4/24/17. The final investigation was submitted on 5/4/17 at 2:57 p.m. to State survey and certification agency. Staff B provided the above documentation.",2020-09-01
118,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-06-02,281,D,1,0,YEK311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, it was determined that the facility failed to follow physicians orders by not administering medications to a newly admitted resident as ordered for 1 resident out of a complaint survey sample of 6 residents. (Resident identifier is #4.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications in Nursing Practice, on page 336, reveals Physician orders [REDACTED]. Nurses follow physicians orders unless they believe the orders are in error or harm clients. On pg. 708, Medication Administration it reveals Give all routinely ordered medications within 60 minutes of the time ordered (30 minutes before or 30 minutes after the prescribed time). Resident #4 Review on 6/2/17 of Resident #4's medical record revealed that this resident was admitted on [DATE] at 8:23 p.m. and the following medication orders were received on 1/19/17 at 1946 (7:36 p.m.) and were not administered as ordered: Dexamethosone 4 mg (milligram) every 8 hours for pain management; scheduled for 0600, 1400 and 2200 - this medication was first administered on 1/20/17 at 1400. Resident #4 missed the 2200 dose on 1/19/17 and the 0600 dose on 1/20/17. Interview on 6/2/17 at approximately 3:15 p.m. with Staff A (Director of Nursing), confirmed that Resident #4 had missed two doses of her/his ordered and scheduled pain medication as referenced above.",2020-09-01
119,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-06-02,323,D,1,0,YEK311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Incident/Accident report, medical record review and interview, it was determined that the facility failed to provide the appropriate level of supervision for 1 resident in a complaint survey sample of 6 residents. (Resident identifier is #1.) Findings include: Resident #1 Review on 6/2/17 of the facility's initial Incident/Accident report dated 3/11/17 revealed the following: On 3/11/17 during dinner meal service preparation the nurse could not locate the resident on the unit. The MSU (Medical Surgical Unit) nurse immediately initiated the facility missing person protocol and the facility was searched. unable to locate the resident. The Administrator, DPOA (Durable Power of Attorney), nursing Director and (local police) were contacted immediately. The resident was located at a friends home in . The resident was safe but confused and stated . 'was going to (pronoun omitted) adult day program.' Resident has a secondary psychiatric diagnosis. The DPOA met the resident at the apartment and the (local police) escorted (pronoun omitted) back from the apartment to the facility. Upon arrival back, the resident was safe, comfortable and calm but not able to make clear statements about why (pronoun omitted) left the facility. Discussion with the DPOA held and decision was made to transport the resident to the (local hospital) for a psychiatric/medical evaluation. Review on 6/2/17 of the facility's TIMELINE-Incident 3/11/17 report, which was not dated but signed by Staff A (Director of Nurses) revealed the following: At 2:45 p.m.was resting in (pronoun omitted) at that time. Staff C (Licensed Pracitcal Nurse) left the MSU to work on the West unit. At approximately 3:40 PM Staff D (Occupational Therapist), stated that they observed 'someone who looked so much like Resident#1 walk out the door. Staff D stated he/she was wearing a white cap and a light blue [NAME]et. At 4:45 p.m. staff identified that the resident was missing and initiated missing person protocol Staff started to search Resident #1's room, and found the safety wander-guard anklet in the closet under some clothes. The anklet bracelet had been split in half. Review on 6/2/17 of the facility's TIMELINE-Incident 3/11/17 report, which was not dated but signed by Staff A revealed the following: The community search was completed by staff within a 2 miles radius of the facility. Review on 6/2/17 of the facility's TIMELINE-Incident 3/11/17 report, which was not dated but signed by Staff A revealed the following: Resident #1's personal journal was found which contained a list of telephone numbers. Calls were made to the various numbers. At 5:45 p.m. Resident #1 answered one of the phone numbers. The DPOA called and spoke with Resident #1 while the (local police) arrived and escorted Resident #1 back to the facility. A discussion between the DPOA and Staff A occurred about the incident and Resident #1's mental status and the plan to transport Resident #1 to the local hospital was made. The decision was made to transport to the local behavioral unit. At 6:45 p.m. Resident #1 resting comfortably on the unit. Resident #1 is calm but pleasantly confused. Resident #1 is oriented to time and person only. Review on 6/2/17 of the Resident #1's Brief Interview for Mental Status (BIMS) dated 3/3/17 revealed a score of 8 indicating moderately impaired. Review of Resident #1's Elopement Risk dated 3/2/17 revealed a score of 8 indicating not at risk. Review on 6/2/17 of Resident #1's PASARR (Preadmission Screening and Resident Review) screening that was completed on 3/2/17, prior to Resident #1 being admitted to the facility on [DATE] revealed that Resident #1 was admitted to a local hospital behavioral health unit after becoming more anxious and depressed. pt (patient) has been unsteady on (pronoun omitted) and is unable to recall (pronoun omitted) last name, date and address.'' pt has unsteady gait, impaired memory and at times impaired orientation. pt requires constant supervision. Review on 6/2/17 of Resident #1's care plan titled Nursing Plan of Care with an effective date of 3/2/17 revealed under the Focus section .is an elopement risk r/t (related/to) adjustment to nursing home, Impaired safety awareness. Review of the Goal section revealed . will not leave facility unattended through the review date. Review of Interventions revealed the following: Check placement and function of safety monitoring device every shift. Review on 6/2/17 of Resident #1's medical record revealed a nursing daily skilled note for 3/7/17, wanderguard in place, in functional, continue 15 minute checks call bell in reach. Review on 6/2/17 of Resident #1's medical record revealed a nursing daily skilled note for 3/10/17, wanderguard in place, in functional, continue 15 minute checks call bell in reach. Review of Resident #1's physician monthly orders for March; signed 3/26/17 by the physician revealed that Resident #1 had the following order: Check Wander- guard for proper functioning daily. every day shift for Safety Review of Resident #1's physician monthly orders for March; signed 3/26/17 by the physician revealed that Resident #1 had the following order: Monitor Wander- guard placement every shift (L) ankle every shift for Safety initiated on 3/2/17. Review of Resident #1's TAR (Treatment Administration Record) for March; revealed that Resident #1 had the following order: Monitor Wander- guard placement every shift (L) (left) ankle every shift for Safety, in which on (MONTH) 10th and 11th, at 1500 (3 p.m.) it is not marked as being checked. Interview on 6/2/17 at 1:18 p.m. with Staff A explained that although Resident #1's BIMS was 8 and Resident #1 was not at risk for elopement, Resident #1 had a Wanderguard, had a DPOA and the facility staff were still getting to know Resident #1. Interview on 6/2/17 at 1:45 p.m. with Staff A revealed that on 3/11/17 Resident #1 took a taxi to DPOA's house. When questioned where did (pronoun omitted) call a taxi from, Staff A answered by cell phone. Staff A also revealed that after interviewing various people Resident #1 had made statements that Resident #1 was not going to stay at the facility prior to Resident #1 eloping.",2020-09-01
120,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2017-07-13,155,D,0,1,UBZH11,"Based on interview, policy review and observation, it was determined that the facility failed to ensure that documented choices and treatment decisions regarding code status are communicated to the interdisciplinary team. Findings include: Observation on 7/12/17 of resident rooms on the Winnisquam unit revealed smiley face stickers on residents' closet doors. Interview on 7/13/17 at 11:00 a.m. with Staff B (Registered Nurse) revealed that the unit's policy for a full code is a smiley face sticker placed on resident closet doors. Staff H (Licensed Practical Nurse) who was present during this interview stated that she was unaware of what the smiley face meant. Interview on 7/13/17 at 11:15 a.m. with Staff I (Certified Nursing Assistant) revealed that they thought that the smiley face was to indicate code status, but were not sure if it meant that the resident was full code or DNR (Do No Resuscitate); however, they thought it was probably full code. Interview on 7/13/17 at 11:30 a.m. with Staff J (Certified Nursing Assistant) revealed that she thought that the code status of residents was posted outside the resident's room on the door. Staff J explained that the LNA (Licensed Nursing Assistant) training instructor had taught them in class that is where it would be, but that no one in the facility had oriented Staff J regarding where to find a resident's code status at the facility. Interview on 7/13/17 at 1:30 p.m. with Staff M (Registered Nurse) revealed where to find code status is different on each unit and that Staff M was unaware of the facility's code status policy, but would find out. On 7/13/17 at 2:20 p.m. Staff M returned to discuss Staff M's findings and stated that the entire facility policy would be to utilize the smiley face stickers in residents' rooms. Review of the facility's policy titled, Cardiac and/or Respiratory Arrest with a revision date of 12/8/14 revealed that the policy does not provide guidance on smiley face stickers in residents' rooms in regards to code status. Policy reviewed procedure for the code, but did not state where staff where to look to determine the residents' code status.",2020-09-01
121,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2017-07-13,271,D,1,1,UBZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility investigation findings it was determined that the facility failed to ensure that there were physician's orders [REDACTED]. (Resident identifier is #15). Findings include: Review of Resident #15's record on 6/13/17 revealed that this resident was admitted to the facility on [DATE]. Staff E, RN (Registered nurse) was the admitting nurse resopnsible for transcribing the instructions from the discharge summary, and calling the physician to confirm the instructions that would then become physician's orders [REDACTED]. The discharge summary sent from the hospital had the following directions: [MEDICATION NAME] 7.5 mg QD (every day) [MEDICATION NAME] 100 mg SC (subcutaneously/injected under the skin) BID (twice per day) until [MEDICATION NAME] levels are therapeutic. Therapeutic goal is INR of 2.0-3.0, as well as other medications listed. There were several different medication lists sent from the hospital with the discharge summary paperwork, as well as other paperwork. Interview with Staff C, DON (Director of Nursing), review of the facility's investigation, and record review revealed that Staff E, RN did not call the physician to clarify which of the instructions on the various discharge summaries and paperwork were the most current, and to be confirmed as orders for patient care. The Hospital Discharge Summary was not signed by a physician, but was signed by a physician's assistant. No paperwork that was sent from the hospital at the time of this patient's admission was signed by a physician, either electronically or with writing instrument. On 5/31/17 Staff F, LPN (Licensed Practical Nurse) performed a chart check of this resident's medical record. During the chart check, Staff F made note of several medications that were not transcribed, or were not transcribed properly. There was no evidence that Staff F called the physician to verify or clarify orders for this patient. Because the physician was not contacted during the admission process for verification or clarification of orders, there were no orders for patient care from 5/30/17 until 6/2/17, when Staff G (Physician) entered the facility, reviewed the transcribed instrutions and signed them as orders.",2020-09-01
122,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2017-07-13,279,E,0,1,UBZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to develop comprehensive care plans for nutritional status, cognitive loss and [MEDICAL CONDITION] drug use, for 3 residents in a survey sample of 24 residents. (Resident identifiers are #3, #12, and #18.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 269: You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals .The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care . Resident #3 Review on 7/12/17 of Resident #3's Weight Summary revealed that Resident #3 had a weight loss from 161.4 lbs (pounds) on 1/4/17 to 144.8 lbs on 7/5/17. This was a 16.6 lb weight loss which was 10.2% in 6 months. Review on 7/12/17 of Resident #3's Dietitian Nutritional Assessment, dated 6/9/17, revealed that Resident #3 had a .significant 20# (pound) (12.1%) weight loss x past 6 months down to 145#. Review on 7/12/17 of Resident #3's MD (Medical Doctor) Narrative Progress Note, dated 6/27/17 revealed a note indicating an Overall since admission (5/9/16) approx. (approximately) 20 #(pound) weight loss. Review on 7/12/17 of Resident #3's MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 5/9/17 Section K 0300 Weight Loss - Loss of 5% or more in the last month or loss of 10% or more in last 6 months was coded Yes, not on physician-prescribed weight-loss regimen. Review on 7/12/17 of Resident #3's Care Plan revealed that there was no Care Plan for Nutritional status. Interview on 7/13/17 at approximately 2:00 p.m. with Staff C (Director of Nursing) confirmed that a Nutrition Care Plan should have been in place for Resident #3. Resident #12 Review on 7/12/17 of Resident #12's MDS with ARD of 5/3/17 Section I4200 revealed that Resident #12 had a [DIAGNOSES REDACTED].#12 had impairment in cognitive function. Review of Resident #12's Care Area Assessment indicated that Cognitive Loss/ Dementia - Functional Status would be addressed in the care plan. Review on 7/12/17 of Resident #3's Care Plan revealed that there was no Care Plan for Cognitive Loss. Interview on 7/13/17 at approximately 2:00 p.m. with Staff C (Director of Nursing) confirmed that a Cognitive Loss Care Plan should have been in place for Resident #12. Review on 7/12/17 of Resident #12's Medication Record for 7/1/17 through 7/31/17 revealed that Resident #12 received the antipsychotic medication [MEDICATION NAME]. Review on 7/12/17 of Resident #12's Care Plan for [MEDICAL CONDITION] Drug use indicated that Resident #12 was at risk for complications related to the use of [MEDICAL CONDITION] drugs. There were no documented interventions listed for monitoring and for follow up for side effects, specifically movement disorder, for the use of [MEDICATION NAME]. Interview on 7/13/17 at approximately 2:00 p.m. with Staff C confirmed that an intervention for monitoring side effects of [MEDICAL CONDITION] medication should have been in place on Resident #12's Care Plan. Resident #18 Review on 7/13/17 of Resident #18's Weight Summary revealed that Resident #18 had a weight loss from 140 lbs on 12/7/17 to 122.4 lbs on 6/7/17. This was a 17.6 lb weight loss which was 12.5% in 6 months. Review on 7/13/17 of Resident #18's Dietitian Nutritional Assessment, dated 5/16/17, revealed that Resident #18 had a .significant weight loss of 20# (13.8%) weight loss x past 6 months . Review on 7/13/17 of Resident #18's MDS with ARD of 5/12/17 Section K 0300 Weight Loss - Loss of 5% or more in the last month or loss of 10% or more in last 6 months was coded Yes, not on physician-prescribed weight-loss regimen. Review on 7/13/17 of Resident #18's Care Plan revealed that there was no Care Plan for Nutritional status. Interview on 7/13/17 at approximately 2:00 p.m. with Staff C confirmed that a Nutrition Care Plan should have been in place for Resident #18.",2020-09-01
123,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2017-07-13,281,D,1,1,UBZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and the professional standard of practice for following physician orders, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #4 and #15.) Findings include: Professional standard of practice referenced was: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Pages 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 713 .A registered nurse compares the list of medications on the MAR indicated [REDACTED].After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurses' notes. Resident #4 Review on [DATE] of Resident #4's (MONTH) (YEAR) s MAR (Medication Administration Record) revealed a physician's orders [REDACTED]. The medication record revealed that the medication had been given every day from [DATE] to [DATE]. This order did not indicate a route of administration. Review on [DATE] of Resident #4's (MONTH) (YEAR)'s MAR indicated [REDACTED]. Interview on [DATE] at 10:30 a.m. with Staff L (Licensed Practical Nurse) confirmed this transcription error and that the order for [MEDICATION NAME] should had been given daily. Review on [DATE] of Resident #4's MAR indicated [REDACTED] Resident #15 Review on [DATE] of Resident #15's medical record revealed that Resident #15 was admitted on [DATE] to the facility's Transitional Care Unit (TCU) from the hospital during the early part of the second shift (approximately 6:00 pm). Staff [NAME] (Registered Nurse) was the nurse who admitted Resident #15 to the TCU. The discharge summary dated [DATE] from the hospital stated: Plan of Care #2: Diagnosis/Problem: Factor V Leiden Mutation (a genetic clotting disorder), [MEDICAL CONDITION]([MEDICAL CONDITION]/blood clot). Goal: INR (International Normalized Ratio-a test to show speed of blood clotting) of 2XXX,[DATE].0. Instructions: Continue [MEDICATION NAME]. Bridge with [MEDICATION NAME] until INR is therapeutic. Review of Resident #15's physician's discharge summary dated [DATE] from the hospital stated: [MEDICATION NAME] 7.5 mg QD (every day). [MEDICATION NAME] 100 mg SC (sub-cutaneous/injected under the skin) BID (twice per day) until [MEDICATION NAME] levels are therapeutic. Therapeutic goal was INR of 2XXX,[DATE].0. There were several different medication lists sent from the hospital with the discharge paperwork. Investigation by the facility, and Interview on [DATE] with Staff C (Director of Nurses) and facility investigation confirmed that Staff [NAME] did not call the physician to clarify which orders were the most current/correct orders. Review of facility investigation revealed that on [DATE], Staff F (Licensed Practical Nurse) initiated a chart review of Resident #15's medical record. Staff F discovered that several medications that were ordered on the discharge summary from the hospital were missing from Resident #15's Medication Administration Record [REDACTED]. One dose of [MEDICATION NAME] ([MEDICATION NAME]) was not given and there was no order to hold the medication. After the chart audit by Staff F, the [MEDICATION NAME] order was added to the MAR but until INR levels are therapeutic was omitted from the order. Further review of Resident #15's discharge summary dated [DATE] listed but not transcribed, and therefore not given to the Resident #15, were the following medications: [REDACTED] [MEDICATION NAME] 0.5 mg by mouth Q am (in the morning); [MEDICATION NAME] 0.5 mg (2 tabs=1 mg) 2 tabs QHS (at bedtime); [MEDICATION NAME] 100 Units/ml, (for insulin dependent diabetes) give 36 Units SC (subcutaneously/injected under the skin) HS (at bedtime) adjust as needed; [MEDICATION NAME] 40 mg daily (no route was indicated); Potassium 10 mEq (milliequivalents) daily (no route was indicated); Review of Resident #15's discharge summary dated [DATE] also included lab listed that were not transcribed and therefore not performed are as follows: [DATE]: BMP (Basic Metabolic Panel) and BNP (Brain NatriureticPeptide) to be drawn on [DATE], and CBG (Capillary Blood Glucose) ,[DATE] times per day and treat if consistently over 150. Review of Resident #15's [MEDICATION NAME] flow sheets revealed on [DATE] the INR results were the following therapeutic levels achieved: [DATE] INR 2.3; [DATE] INR 2.7; [DATE] INR 3.0; [DATE] INR 3.2. The [MEDICATION NAME] was not discontinued once the INR results had reached the specified therapeutic level of 2XXX,[DATE].0, and were exceeding the specified therapeutic level as of [DATE]. Review of Resident #15's physician progress notes [REDACTED]. Staff G was notified of the medication transcription error for [MEDICATION NAME] as of [DATE]. As per review of the facility generated Event Summary Report, Staff G was notified of a missed dose of [MEDICATION NAME] on [DATE]. The report states that incorrectly transcribed admission orders [REDACTED]. Review of Resident #15's physician progress notes [REDACTED].Labs INR 3.2. Review of the facility's investigation report revealed on [DATE] the facility attempted to draw labs from Resident #15 and were unsuccessful. Staff G ordered that Resident #15 be sent to the nearby hospital for the labs to be drawn. Resident #15 was noted by staff to have a decline in medical status at this time (ie: clammy, short of breath, increased weakness with walking). The resident was transferred to this hospital. Resident #15 was diagnosed with [REDACTED].#15 had been discharged to the facility). A physician from the discharging hospital called the facility on [DATE] and reported that Resident #15 had an INR of 8.0 on arrival, had gone into [MEDICAL CONDITION] shortly after arrival, and CPR was initiated. There was also bleeding into the pericardium and the resident went into respiratory arrest, was incubated and was placed on a ventilator. Resident #15 did not return to the facility for rehabilitative services after this hospitalization . Interview on [DATE] with Staff C (Director of Nursing) reviewed the facility's investigation findings and confirmed the above findings.",2020-09-01
124,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2017-07-13,314,D,0,1,UBZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy review and interviews it was determined that the facility failed to provide appropriate care and services to aide in the prevention of an avoidable pressure ulcer for 1 of 3 residents with pressure ulcers in a survey sample of 24 residents. (Resident identifier is #2.) Findings include: Review on 7/11/17 of medical record revealed that Resident #2 returned to the facility on [DATE] at 10:30 p.m. following a non displaced femur fracture. Review of nursing notes revealed that the resident was placed on bed rest from 5/20/17 thru 5/23/17 without a physicians order. Review on 7/11/17 of the Nursing Assessment- Initial (Admission)v3 dated 5/20/17 revealed: Section 6, [NAME] Mobility (Braden) 4.) No limitations- changes position without assistance. Review on 7/11/17 of the Lift-Transfer Reposition assessment with a lock date of 5/21/17 section D revealed, resident is currently on bed rest due to non displaced left femur fracture. Review on 7/11/17 of Physician note dated 5/23/17 2:32 p.m. revealed, Decline since prior hospital admission. Review on 7/11/17 of the Nursing Assessment- Expanded (MDS Adm./Qtrly/Annual/Sig. Change) V-2 dated 5/24/17 revealed: Section 6, [NAME] Mobility (Braden) 2.) Very Limited- unable to make significant changes in position independently, needs extensive assistance. Review on 7/11/17 of the Braden Scale for Predicting Pressure Sore Risk Original dated 5/27/17 revealed Resident #2 Score of 14.0 (Moderate Risk). Review on 7/11/17 of the Skin-Pressure Ulcer v6 dated 6/14/17 revealed Resident #2 developed a pressure ulcer Stage 2 on coccyx, 2 cm (Centimeter) by 0.8 cm. Review on 7/11/17 of Resident #2 care plans revealed that no new interventions were initiated to assist in the prevention of developing a pressure ulcer when changes in resident's care level changed. Resident #2's careplans were as follows: Focus: Resident is at risk for skin breakdown as evidenced by limited mobility dated 3/2/17. Goal: The resident will not show signs of skin breakdown x_90_ days. Date initiated 3/2/17. Interventions: Evaluate for skin risk factors per protocol. date initiated 6/10/17. Monitor skin for signs and symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. date initiated 3/2/17. Weekly skin assessment by license nurse. date initiated 3/10/17. Review on 7/12/17 of the facility policy NSG236 Skin Integrity Management dated 11/28/16 revealed: Practice Standards 2. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated: 4.1 Implement pressure ulcer prevention for identified risk factors. Review on 7/13/17 of the facility policy Skin Integrity Care Delivery Process date 6/1/16 revealed under the pressure injury/ulcer prevention guideline: Risk Factor: Impaired/Decreased mobility/function-example of intervention /care plan consideration -individualized positioning and repositioning schedule, range of motion exercises. Under turning and repositioning, bed surfaces, seat surfaces: provide turning and repositioning to individuals at risk for pressure ulcers; specifically, those who have impaired mobility and or/ impaired sensation. Turning and repositioning plans are implemented regardless of bed surface. Interview on 7/12/17 at approximately 10:00 a.m. with Staff B (Registered Nurse) revealed that there was no evidence of any repositioning schedule for Resident #2 until 6/16/17. Staff B confirmed that there were no new interventions implemented for pressure ulcer prevention from 5/20/17 - 6/10/17. Interview on 7/12/17 at approximately 2:00 p.m. with Staff D (Regional) revealed that some interventions that would be put into place when a resident is at risk or has skin issues would be air mattress, off loading and repositioning. Interview on 7/13/17 at approximately 9:15 a.m. with Staff C (Director of Nurses) revealed that Resident #2's care plan was not individualized and that there were no new interventions initiated with Resident #2's change in mobility. Observation on 7/14/17 at approximately 7:30 a.m. with Staff N of Resident #2's dressing change to pressure ulcer on the coccyx area revealed that Resident #2 continues with a pressure ulcer. (3.4cm length x 2.1 cm width, 0.7 depth.)",2020-09-01
125,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2017-07-13,456,D,0,1,UBZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain patient care equipment in safe operating condition on 1 of 4 units. Findings include: Observation during tour on the Winnisquam Unit on 7/11/17 at approximately 7:30 a.m. of the PT/INR ([MEDICATION NAME] ratio and international normalized ratio) meter revealed the back of the PT/INR meter had an area with brown/red matter on it. Interview on 7/11/17 at approximately 7:35 a.m. with Staff A (Licensed Practical Nurse) revealed that the PT/INR meter was ready for use. Staff A stated the brown/red matter on the meter, Looks like blood.",2020-09-01
126,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,554,D,0,1,HYB111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview it was determined that the facility failed to determine safety and clinical appropriateness for self-administration of medication for 1 resident in a survey sample size of 27 residents. (Resident identifier is #8) Findings include: Resident #8 Observation on 8/29/18 at 11:14 a.m. revealed that Resident #8 reported to RN and was handed by the RN a glucometer and lancet from the medication cart, and performed their own glucose testing. Resident #8 reported to RN blood sugar result and was handed a [MEDICATION NAME] pen and self adjusted insulin dose then administered their own insulin. Record Review on 8/30/18 of Resident #8's physician orders [REDACTED]. Interview on 8/31/18 at 08:05 a.m. with Staff M (Director of Nursing) confirmed the above findings. Interview revealed that an assessment to self administer medication and perform their own glucose testing should be documented in computer and should have been done on admission and periodically thereafter.",2020-09-01
127,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,658,D,0,1,HYB111,"Based on observation, interview, and Policy & Procedure review it was determined that the facility failed to adhere to the standard required to administer medications via a feeding tube for 1 Resident out of 4 residents observed during medication administration. (Resident identifier is #53) Findings include: Potter, [NAME] [NAME], and Perry, Anne Griffin, Essentials for Nursing Practice. 9th ed. Stlouis, Missouri: Elsevier, 2019 Pg. 415; 'Administering Medications Through a Small-Bore Feeding Tube, Gastrostomy Tube, or Jejunostomy Tube'; Step 20, Irrigate Tubing a. Pinch or clamp enteral tube. Draw up 30 ml of water into irrigation syringe. Reinsert tip of syringe into tube, release clamp, and flush tubing. Clamp tube again and remove syringe. b. Using appropriate enteral connector, attach to enteral tube. Step 21. Remove bulb or plunger of syringe and reinsert syring into tip of feeding tube. Step 22. Administer dose of first liquid or disolved medication by pouring into syringe. Allow to flow by gravity. Review of Genesis Policy & Procedure Medication Administration: Enteral (Revision Date: 11/28/16) revealed in steps 7 to 11 the procedure to administer medications via a feeding tube: #7. Attach syringe to end of tube. #8. Instill tap water into the tube through the syringe, allow to flow by gravity. #9. Administer medications individually. #10. Reconnect tube or clamp as indicated. #11. Restart pump. Observation on 8/29/18 at approximately 7:34 AM, Staff N (Registered Nurse) gathered the scheduled medications for Resident #53. Staff N then prepared the medications for delivery via a feeding tube Resident #53 was receiving nutrition through. Staff N entered the room and went to the bed of Resident #53. Staff N paused the feeding pump currently in use, disconnected the feeding tube, attached the 60 cc syringe to the end of the tube leading in to Resident #53. Staff N then instilled the medications via pushing the medications into the feeding tube using the syringe as a whole unit, barrel and plunger. At no time was it observed that the medications were instilled via gravity flow. Interview with Staff N after medications were instilled into the feeding tube, Staff N was asked if that was how Staff N administered medications via feeding tubes and Staff N replied that it was how Staff N administered medications via feeding tubes. Interview on 8/29/18 at approximately 10:20 AM, Staff I (Unit Manager) was made aware of the observation of the medication administration for Resident #53. Staff I revealed that there were two options for administering medications via a feeding tube; gravity and syringe push. When Staff I was asked if Staff I reviewed the policy regarding the administration of medication via a feeding tube Staff I replied that they had reviewed it. Interview on 8/29/18 at approximately 1:00 PM with Staff M revealed Staff M was aware of the medication pass observation and agreed that the Genesis policy for medication pass via enteral method was not being followed.",2020-09-01
128,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,732,B,0,1,HYB111,"Based on observation and interview it was determined that the facility failed to post the nurse staffing information on a daily basis at the beginning of each shift for the day observed and the 3 previous days. Findings include: Observation on 8/30/18 at 8:10 a.m. revealed that the nurse staffing information (total number and actual hours worked by nursing staff) which was found near the business office, was dated 8/26/18. No other nurse staffing information was found posted at the facility. Interview with Staff B (Scheduling Manager) on 8/30/18 at 8:25 a.m. confirmed the above finding. Interview revealed that Staff B was posting nurse staffing information days later after corrections were made and not at a daily basis and at beginning of each shift.",2020-09-01
129,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,809,B,0,1,HYB111,"Based on observation and interview it was determined that the facility failed to provide meals at scheduled meal times for 1 out of 5 dining rooms observed. Findings include: Review on 8/31/18 of the facility's meal time scheduled for Winnisquam unit revealed that breakfast tray preparation and delivery starts at 8:15 a.m. Observation on 8/29/18 at 7:49 a.m. revealed that Resident #44 was wheeled down from room for breakfast in the Gathering room on the Winnisquam unit. Observation also revealed that LNA (License Nursing Assistant) wheeling resident stated to another employee that Resident #44 did not want to get up this morning and that LNA told Resident #44 that (pronoun omitted) needed to get up for breakfast. During interview on 8/29/18 at 9:00 a.m. with Staff L (License Practical Nurse) on Winnisquam unit, Staff L states that breakfast usually arrives on the unit for the assisted dining room around 9:15 or 9:30 am. Observation on 8/29/18 at 9:30 a.m. revealed Resident #44 continued to wait for breakfast from observation on 8/29/18 at 7:49 a.m. until 8/29/18 at 9:37 a.m. Interview on 8/29/18 at 11:02 a.m. with Resident Council revealed complaints of meals not served on time, specifically breakfast is served late to rooms/units around 9:30 a.m. Interview on 8/31/18 at 9:03 a.m. with Staff K (Kitchen Aide) revealed that there was a schedule on the wall that showed tray preparation and delivery for Winnisquam to start at 8:15 a.m. Interview with Staff K also revealed that tray service to Winnisquam unit was just started on 8/31/18 at 9:03 a.m. Interview on 8/31/18 at 9:15 a.m. with Staff H (License Practical Nurse) revealed yesterday breakfast came about 9:30 a.m. Interview also revealed that breakfast is frequently late.",2020-09-01
130,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,812,E,0,1,HYB111,"Based on observation, record review and interview it was determined that the facility failed to store and prepare food in accordance to professional standard for food service safety in 3 out of 4 kitchenettes and the kitchen. Findings include: Observation on 8/28/18 at 8:50 a.m. revealed that on the Winnisquam unit kitchenette there were two opened nectar thickened juice with no open date on carton in the refrigerator. Review of the carton revealed thickener is good for seven days when opened. Observation also revealed that the bottom of the ice scoop holder was covered with pink film. Observation on 8/28/18 at 8:55 a.m. revealed that on the Opeeche unit kitchenette there was one opened nectar thickened juice with no open date on carton and one nectar thickened juice with 8/9 written on carton in the refrigerator. Observation on 8/28/18 at 8:57 a.m. revealed that on the TCU (Transitional Care Unit) unit kitchenette there were eleven mighty shakes with printed label dated 8/27/18 on carton. Observation on 8/28/18 at 8:57 a.m. also revealed that the ice machine filter was covered with dust. Observation on 8/28/18 at 8:57 a.m. further revealed that lettuce had visible brown discoloration in a container covered with saran wrap with date 8/28/18. Interview on 8/28/18 at 9:02 a.m. with Staff C (Kitchen Aide) confirmed the above findings. Interview with Staff C revealed that Staff C had thawed the mighty shakes on 8/24/18. Interview further revealed that the date on container with lettuce are date of preparation/date of use. Observation on 8/31/18 at 10:06 a.m. revealed that the dish room fan was covered with dust and blowing directly on the dishwasher and clean dishes. Observation on 8/31/18 at 10:08 a.m. revealed visible dust on pipes behind and in front of the dish room fan. Observation further revealed clean serving bowls stacked wet, dry cups tossed in wet bucket for storage and 3 flies in dish room. Interview on 08/31/18 at 10:22 a.m. with Staff D (Dietician) confirmed the above finding of the dish room fan covered with dust blowing directly on washer and clean dishes, and visible dust on pipes behind and in front of fan.",2020-09-01
131,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,842,B,0,1,HYB111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review it was determined that the facility failed to accurately document medical record in accordance with accepted professional standard and practices in regards to behavior monitoring and intervention, monitoring tesio catheter, oxygen orders, and catheter care of 6 residents in a survey sample size of 27 residents. (Resident identifiers are #21, #4, #49, #115, #30, and #72) Findings Include: Policy: Review of facility policy for Catheter:Indwelling Urinary- Care of, revision date: 01/02/14, revealed .Document: Catheter care . Resident #21 Review on 8/30/18 of Resident #21's Electronic Medication Administration Record [REDACTED].document behaviors in behavior log. Record review of behavior monitoring in EMAR revealed that behaviors were observed by nurses on (MONTH) 5, 8, 13, 14, 15, 18, 26, 27, 28. Record review also revealed blank entries on (MONTH) 7, 20 and 22 for any free of or observed behaviors. Review on 8/30/18 of Resident #21's Behavior Monitoring and Interventions log for (MONTH) (YEAR) revealed behaviors, intervention, and response on (MONTH) 2, 4, 7-10, 13, 14, 18, 19, 26, 27, 28 and 29 which did not match the EMAR. Interview on 8/31/18 at 8:30 a.m. with Staff [NAME] (Licensed Practical Nurse) confirmed the above findings and was not able to explain discrepancy of records. Resident #4 Review on 8/31/18 of Resident #4's physician orders [REDACTED]. Further review of physician orders [REDACTED]. Interview on 8/31/18 at 2:16 p.m. with both Staff [NAME] (Licensed Practical Nurse) and Staff G (Respiratory Therapist) confirmed the above findings. Interview with Staff [NAME] revealed that there should be an amount of liters per minute to administer, route of administration and parameters for oxygen titration. Interview on 8/31/18 at 3:16 p.m. with both Staff [NAME] (License Practical Nurse) and Staff I (Unit Manager) confirmed the their were no orders for amount of liters per minute to administer, route of administration and parameters of oxygen titration. Interview with Staff I revealed that Resident #4's oxygen orders were transferred over from Opeeche unit and should have been reviewed similar to receiving a new admission. Resident #49 Review on 8/30/18 of Resident #49's Electronic Treatment Administration Record (ETAR) for (MONTH) (YEAR) revealed that Resident #49's tesio catheter on R (right) chest were to be monitored for placement and sign/symptoms of complications check two times a day. Further review of ETAR revealed missing documentation for (MONTH) 4, 21, 23, and 27. Review on 8/30/18 of Resident #49's current [MEDICAL TREATMENT] care plan revealed intervention to monitor tesio catheter qshift (every shift) and PRN (as needed). Interview on 8/31/18 at 8:30 a.m. with Staff [NAME] (License Practical Nurse) confirmed the above findings and was not able to provide explanations of discrepancy. Resident #115 Review on 8/31/18 of Resident 115's current indwelling catheter care plan revealed intervention for catheter care twice a day and PRN (as needed). No documentation of catheter care found in computer record nor paper record. Interview on 8/31/18 at 2:53 p.m. with Staff [NAME] (License Practical Nurse) confirmed the above finding. Interview on 8/31/18 at 3:16 p.m. with Staff I (Unit Manager) confirmed that there were no catheter care documented. Interview with Staff I revealed that catheter care should have been documented. Resident #30 Observation on 8/29/18 at 8:11 a.m. revealed that Resident #30 was swearing and waving their fist at another resident. The altercation de-escalated itself after approximately 1 minute, and Staff O (Medication Nurse Aide) witnessed the altercation. Interview on 8/31/18 at 8:45 a.m. with Staff H (License Practical Nurse) revealed that behaviors that were monitored were cursing at others and threatening others, and would be recorded on the Behavior Monitoring and Interventions log. Review on 8/31/18 of Resident #30's Behavior Monitoring and Interventions log for the month of (MONTH) (YEAR) revealed no documentation of cursing at other and threatening others. Resident #72 Observation on 8/28/18 at 11:05 a.m. revealed Resident #72 was lying in bed and yelling out for pants. Observation on 8/28/18 at approximately 11:30 a.m. revealed Resident #72 yelling out during care. Review on 8/31/18 of Resident # 72's current care plan revealed that the facility will document behavior interventions and responses. Review on 8/31/18 at 7:43 a.m. of Resident # 72's Behavior Monitoring and Intervention log revealed no behavior with interventions or response recorded on 8/28/18.",2020-09-01
132,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,880,D,0,1,HYB111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review it was determined that the facility failed to maintain infection control practices in regards to respiratory equipment and indwelling catheter for 3 residents in a survey sample size of 27 residents. (Resident identifiers #4, #115 and # 37) Findings include: Policy: Review on 8/30/18 of the facility's policy for Respiratory Equipment/Supply Cleaning/Disinfection, revision date: 10/01/12, revealed that .Scheduled for Supply Change .oxygen delivery devices frequency every 7 days and PRN (as needed) for soiling .Nebulizers/Aerosols/Humidifiers frequency every 7 days and PRN for soiling . Review on 8/30/18 of the facility's policy for Catheter:Indwelling Urinary- Care of, revision date: 01/02/14, revealed .Secure catheter tubing to keep drainage bag below the level of the patient's bladder and off the floor . Resident #4 Observation on 8/28/18 at 9:59 a.m. revealed that Resident #4 was using oxygen at 8 liter per minute, nares and nasal cannula tubing had red tinged stain (blood-like). Observation also revealed that oxygen concentrator had a humidifier bottle not hooked up to Resident #4. Observation further revealed that nasal cannula tubing with no date of tubing change, [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) face mask and tubings at the bedside table were uncovered and had whitish film around the face mask, and [MEDICAL CONDITION] oxygen tubing with 4/4/18 date. Observation on 8/28/18 at 1:30 p.m. revealed that Resident #4's [MEDICAL CONDITION] face mask and tubings was uncovered and whitish film around the face mask. Observation on 8/29/18 at 7:45 a.m. revealed Resident #4 nares and nasal cannula tubing had red tinged stain (blood-like), humidifier bottle not hooked up to Resident#4 and with no date, nasal cannula tubing with no date, [MEDICAL CONDITION] face mask and tubings at bedside table uncovered and whitish film around face mask. Interview on 8/29/18 at 8:55 a.m. with Staff [NAME] (Licensed Practical Nurse) confirmed the Resident #4 nares and nasal cannula tubings had red-tinged stain (blood-like), humidifier bottle was not hooked up to Resident #4 and should be in use and will change nasal cannula tubing. Interview with Staff [NAME] further revealed that nasal cannula tubings had no date, and that oxygen tubing for the [MEDICAL CONDITION] machine was not readable. Interview on 8/29/18 at 9:00 a.m. with Staff [NAME] revealed that oxygen tubing is change weekly and labeled with date using a tape. Interview with Staff [NAME] also revealed that humidifier is to be used continuously, change as needed, and did not need to be labeled. Interview with Staff [NAME] further revealed that the cleaning of [MEDICAL CONDITION] face mask and tubing is done by a nurse every day and has not yet been clean today (8/29/18). Review on 8/31/18 of Resident #4's Electronic Treatment Administration Record (ETAR) for (MONTH) (YEAR) revealed that oxygen tubing is to be change weekly and label each component with date and initials. ETAR further revealed that [MEDICAL CONDITION] mask, tubing, and wash daily with warm soapy water and air dry. Resident #115 Observation on 8/28/18 at 10:44 a.m. of Resident #115 revealed urinary catheter drainage bag covered with privacy bag hanging at the foot of the bed and half on the floor with bed in low position. Observation on 8/29/18 at 07:50 a.m. of Resident #115 revealed urinary catheter drainage bag covered with privacy bag hanging at the foot of the bed and half on the floor with bed in low position. Observation on 8/30/18 at 10:15 a.m. of Resident #115 revealed urinary catheter drainage bag covered with privacy hanging at the foot of the bed and half on the floor with bed in low position. Interview on 8/30/18 at 10:17 a.m. with Staff F (Licensed Nurse Aide) confirmed the above finding. Interview revealed that urinary bag was covered with the privacy bag and it was okay for the urinary catheter bag to be on the floor. Interview on 8/31/18 at 08:30 a.m. with Staff [NAME] (License Practical Nurse) revealed urinary catheter bag needs to be in a privacy bag and laid on top of a towel when bed is in low position. Review on 8/31/18 of Resident #115's current indwelling catheter care plan revealed intervention to Keep catheter off floor. Resident #37 Observation of the Winnisquam Unit on 8/29/18 at approximately 8:33 a.m. 10:12 a.m. and 1:30 p.m. of Resident # 37 lying in bed with catheter bag lying on the floor next to the bed. Observation on 8/31/18 at approximately 8:32 a.m. and again at 8:45 a.m. by another surveyor Resident # 37's catheter was observed to be lying on the floor next to the bed. Interview on 8/30/18 at approximately 12:28 p.m. with Staff H LPN (Licensed Practical Nurse) on the Winnisquam Unit confirmed that the facilities policy is to ensure that catheter bags are off the floor.",2020-09-01
133,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2018-08-30,908,B,0,1,HYB111,"Based on observation, interview, and policy & procedure reviewit was determined the facility failed to document if equipment utilized (glucometers) for monitoring of the facility's residents blood glucose was functioning in acceptable parameters on one (Lakeport Unit) out of seven glucometers in use in the facility. Findings include: Genesis Policy & Procedure: Glucose Meter; sections 3 through 5 (Revision date 3/16/17) . 3. Check expiration date on reagent strips package and control solution. Replace if outdated. 3.1 Calibrate the reagent strips with meter per manufacturer's instructions, if indicated. 3.2 Each time a new botle of control solution is opened, date the bottle. Bottle is to be discarded according to the manufacturer's recommended time frame (e.g., 30 days after opening solution). 4. Complete accuracy test according to manufacturer's instructions. 4.1 If equipment is not working properly, notify nursing supervisor. 5. Document testing on the Blood Glucose Meter Quality Control Results Log 5.1 Designated staff will audit quality control logs monthly for completion. Observation on 8/31/18 at 8:30 AM on the Lakeport Unit, revealed that the glucometer testing documentation had missing documentation for testing of the unit's glucometer for 12 dates out of the 31 dates during the month of August. In addition on 8/18/18 there was no recording of the test performed with a low range testing solution. On 8/26/18 a high range test result of 297 was noted and there was no documentation if the reading was reported to the Nursing Supervisor as required in the facility policy under section 4. There was no discard date for the control solutions documented at the heading of the log. Interview on 8/31/18 at 9:00 AM with Staff J, (Licensed Practical Nurse) Unit Leader. Staff J reviewed the log in question, noted the discrepencies, and revealed that testing was performed during the 11-7 shift on the Transitional Care Unit (TCU) and that the Lakeport log was maintained there. Staff J revealed that the log was not audited for accuracy and completion. Staff J revealed that the High & Low controls for glucometer testing is performed on the 11 PM to 7 AM shift each night.",2020-09-01
134,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2019-09-13,692,E,0,1,FZEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to maintain acceptable parameters of nutritional status due to not consistently using a method of weighing and re-weighing for 4 residents out of a final survey sample of 27 residents. (Resident identifiers are: #35, #81, #85, and #113.) Findings include: Resident #35 Review on 9/11/19 at 12:04 p.m. of Resident #35's medical record revealed an H&P (History and Physical) note dated 6/28/19 that states (Resident age and gender omitted) with extensive past medical history notably positive for [MEDICAL CONDITION] dysmobility status [REDACTED]. Review on 9/12/19 Resident #35's physician orders [REDACTED].x 4 weeks -Start Date 6/29/19 . On 7/28/19 when the last weight was taken Resident #35 weighed 131.6 lbs. (pounds), at that time Resident #35 was then transferred to another unit. The next weight taken was not until 8/11/19 at which time Resident #35 weighed 123 pounds showing a 8.6 lbs weight loss. A reweigh was not performed and a nutrition assessment was not completed until 8/18/19. Resident #81 Review on 9/13/19 of Resident #81's medical record revealed that a weight loss was triggered on 8/30/19 the record states, 7.5% change (comparison weight on 7/23/19, 143.4 lbs., -11.7%,-16.8 lbs) MDS (Minimum Data Set): -5.0% change over 30 days (Comparison Weight 8/3/19, 138.5 lbs, -8.6%, -11.9 lbs). Review of the weight logs revealed that on 7/27/19 Resident #81's weight was 143.6 lbs and on 8/3/19 Resident #81's weight was 138.5 lbs. showing a 5.1 lbs weight loss. A re-weigh was not performed nor was there a notification to the nutritionist. The weight loss wasn't addressed until 8/24/19 as written above. Interview on 9/13/19 at approximately 12:00 p.m. Staff [NAME] (Director of Nurses) revealed that reweighs are expected to be done if there is a 5 pound weight difference from the last weight obtained. Staff [NAME] also stated staff should be utilizing the same scale if possible when weighing residents. Staff [NAME] confirmed that the weight loss wasn't addressed until 8/24/19. Resident #85 Review on 9/11/19 of Resident #85's [DIAGNOSES REDACTED].#85 has acute on chronic [MEDICAL CONDITION] with [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), and heart failure. Review of Resident #85's care plan titled, Nutrition, revision date 8/21/19 revealed: Focus: (pronoun omitted) has increased nutrient need to support wound healing. Goal: . (pronoun omitted) will maintain a stabilized weight in the 190# range, during the next 90 days Interventions: . Monitor weight and alert dietician and physician to any significant weight loss or gain. Provide enteral feeding, as ordered. Review on 9/11/19 of Resident #85's weights from 8/7/19 to 9/9/19 revealed the following weights and the resident was not re-weighed to determine the accuracy of the discrepancy: 8/7/19 199.4 lbs. (Bath scale) 8/8/19 191.0 lbs. (Total lift scale) 8/10/19 194.8 lbs. (Total lift scale) 8/23/19 202.6 lbs. (Total lift scale) 8/24/19 196.4 lbs. (Total lift scale) 8/28/19 196.1 lbs. (Total lift scale) 8/29/19 215.5 lbs. (Total lift scale) 8/30/19 216.0 lbs. (Total lift scale) 8/31/19 196.0 lbs. (Bed scale) 9/4/19 193.4 lbs. (Total lift scale) 9/5/19 196.5 lbs. (Total lift scale) 9/8/19 191.4 lbs. (Total lift scale) 9/9/19 214.0 lbs. (Total lift scale) Interview on 9/13/19 at approximately 10:15 a.m. with Staff D (Dietician) revealed that Staff D expects a re-weigh to be obtained if weight fluctuates by 3 lbs. Interview on 9/13/19 at approximately 12:00 p.m. with Staff F (Unit Manager) revealed that Resident #85 requires the need to be [MEDICATION NAME] frequently due to fluid retention. Resident #113 Review on 9/11/19 of Resident #113's weights from 8/9/19 to 9/12/9 revealed the following weights and the resident was not re-weighed to determine the accuracy of the discrepancy: 8/9/19 156 lbs. (Total lift scale) 8/20/19 150.2 lbs. (Total lift scale) 8/27/19 151.2 lbs. (Bath scale) 9/10/19 159.8 lbs. (Bed scale) 9/12/19 153.8 lbs. (Total lift scale) Interview on 9/13/19 at approximately 12:00 p.m. with Staff [NAME] revealed that re-weighs are expected to be done if there is a 5 lbs. weight difference from the last weight obtained. Staff should be utilizing the same scale if possible when weighing residents. Staff [NAME] also stated that part of the decision on the rate of tube feeding orders are based upon a resident's weights. Review on 9/11/19 of Resident #113's care plan titled, Nutrition, revision date 9/11/19 revealed: Focus: (pronoun omitted) has increased nutrient needs to support wound healing Goal: . (pronoun omitted) will maintain a stabilized weight at 155-160# during the next 90 days Interventions: . Monitor weight and alert dietitician and physician to any significant weight loss or gain Provide enteral feeding as ordered Review on 9/13/19 of the facility policy and procedure titled, Weights and Heights, Revision date 3/5/19 revealed: 1. Obtaining and Documenting Weight: . 1.2 If a patient's weight is less than or greater than five pounds from the previous weight, the patient will be re-weighed and the weight verified by a licensed nurse to determine accuracy .",2020-09-01
135,LACONIA REHABILITATION CENTER,305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2019-09-13,761,E,0,1,FZEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility policy and procedure, review of the pharmacy insulin storage recommendations and review of the manufacturer's instructions, it was determined that the facility failed to label medications with an opening date for 1 out of 2 med rooms reviewed and for 2 out of 4 medication carts. (Resident identifiers are #75 and #99.) Findings include: Observation on 9/10/9 at approximately 8:00 a.m. in the Lakeport/Opechee medication room revealed 2 opened vials of [MEDICATION NAME] ([MEDICATION NAME] Purified Derivative) in the refrigerator that were not dated with an opening date or expiration date. Interview on 9/10/19 at approximately 8:00 a.m. with Staff A (Registered Nurse) confirmed that the 2 vials of [MEDICATION NAME] ([MEDICATION NAME] Purified Derivative) were not dated. Review on 9/10/19 at approximately 9:00 a.m. of the manufacturer's instructions for [MEDICATION NAME], undated revealed: . Storage . Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Resident #75 Observation on 9/10/19 at approximately 8:10 a.m. of the Lakeport medication cart revealed a Humalog Kwik-pen for Resident #75 was opened and not dated with an opening date or expiration date. Interview on 9/10/19 at approximately 8:10 a.m. with Staff B (Licensed Practical Nurse) confirmed that the Humalog insulin pen was not dated. Review on 9/10/19 at approximately 11:00 a.m. of the Humalog Kwik-pen manufacturer's instructions dated, (YEAR) revealed: . Storing your pen . In-use Pen . Throw away the Humalog Pen you are using after 28 days, even if it still has insulin in it. Resident #99 Observation on 9/10/19 at approximately 11:40 a.m. of the Transitional Care Unit medication cart revealed Resident #99 had 2 [MEDICATION NAME] flex pens opened and not dated with an opening date or expiration date and 1 Basaglar Kwik-pen opened and not dated with an opening date or expiration date. Interview on 9/10/19 at approximately 11:40 a.m. with Staff C (Registered Nurse) confirmed that the 3 insulin pens were opened and not dated. Review on 9/10/19 of the Pharmacy Insulin Storage recommendations revealed: [MEDICATION NAME] should be discarded 28 days after opening. Basaglar should be discarded 28 days after opening. Review on 9/11/9 of the facility policy and procedure titled 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, Revision last dated 10/31/16 revealed: . Procedure . 5. Once any medication or biological package is opened, Facility should follow manufacturers/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened.",2020-09-01
136,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2019-05-14,658,D,1,0,D7QZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to have a system in place for reconciliation and management of controlled drugs for 1 out of 5 narcotic books reviewed. (Resident identifiers are #1, #2, #3, #4 and #5.) Findings include: Reference for the professional standard of practice for medication documentation is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. page 688 Guidelines for Safe Narcotic Administration and Control . Store all narcotics in a locked, secure cabinet or container. (Computerized, locked cabinets are preferred.) . Narcotics are frequently counted. Usually counts are made on a continuous basis with the opening of narcotic drawers and/or at shift change. . Report discrepancies in narcotic counts immediately. . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted.` Review on 5/14/19 of the narcotic book and the resident's MAR (Medication Administration Record) revealed the following discrepancies: Resident #1 Review on 5/14/19 of Resident #1's (MONTH) 2019 MAR revealed the following physicians order: [MEDICATION NAME] 0.25 MG (Milligrams) by mouth at bedtime. Review on 5/14/19 of the above MAR and the narcotic book revealed that on 5/1/19 2 doses of [MEDICATION NAME] 0.25 MG were removed from the narcotic count at 20:30 while 1 dose was administered on the MAR. Resident #2 Review on 5/14/19 of Resident #2's (MONTH) 2019 MAR revealed the following physicians orders: [MEDICATION NAME] 0.5 MG by mouth at bed time. Review on 5/14/19 of the above MAR and the narcotic book revealed that on 4/23/19 2 doses of [MEDICATION NAME] 0.5 MG were removed from the narcotic count at 1900 hours and 2300 hours while 1 dose was administered on the MAR. Resident #3 Review on 5/14/19 of Resident #3's (MONTH) 2019 MAR revealed the following physicians orders: [MEDICATION NAME] 1MG by mouth twice daily. Review on 5/14/19 of the above MAR and the narcotic book revealed that on 5/8/19 3 doses of [MEDICATION NAME] 1MG were removed from the narcotic count at 0800 hours, 1400 hours and 1800 hours while 2 doses were administered on the MAR. Resident #4 Review on 5/14/19 of Resident #4's (MONTH) 2019 MAR revealed the following physicians order: [MEDICATION NAME] 2MG by mouth 4 times a day. Review on 5/14/19 of the narcotic book revealed that on 5/3/19 5 doses of [MEDICATION NAME] 2MG were removed from the narcotic count at 2200 hours, 0500 hours, 1045 hours, 1645 hours and 2030 hours. Which revealed that 1 dose was removed from the narcotic count and unaccounted for. Resident #5 Review on 5/14/19 of Resident #5's (MONTH) (YEAR) MAR revealed the following order: [MEDICATION NAME] 60MG by mouth twice daily. Review on 5/14/19 of the above MAR and the narcotic book revealed that on 9/24/18 2 doses of [MEDICATION NAME] 60MG were removed from the narcotic count at 1045 hours and 2000 hours while 1 dose was administered on the MAR. Review on 5/14/19 of Resident #5's (MONTH) (YEAR) MAR revealed the following order: [MEDICATION NAME] Immediate 15MG-1 tab by mouth every 6 hours as needed for pain. Review on 5/14/19 of the above MAR and the narcotic book revealed that on 9/10/18 6 doses of [MEDICATION NAME] Immediate 15MG were removed from the narcotic count at 0110, 0810, 1530, 2130, 2145 and 2200 while 3 doses were administered on the MAR. Interview on 5/14/19 at approximately 10:45 a.m. with Staff C stated, I am so glad that you are here and looking into all of this. Interview on 5/14/19 at approximately 1:30 p.m. with Staff A (Administrator) and Staff B (Director of Nurses) revealed that the facility has no system in place for monitoring any narcotics once they are logged in the narcotic book. We would check if there was a suspected issue. Review of the findings with Staff A and Staff B of the unaccounted narcotics that were signed out of the narcotic book and Staff B stated, Now it seems like we should have been checking them.",2020-09-01
137,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2019-05-14,732,C,1,0,D7QZ11,"> Based on observation and interview, it was determined that the facility failed to post nursing staffing data on a daily basis at the beginning of each shift. Findings include: Observation on 5/15/19 at approximately 10:00 a.m. revealed the nurse staffing data posted at the entrance to the 100's unit was dated 5/7/19 and the nurse staffing data posted at the entrance to the 200/300's unit was dated 5/7/19. Interview on 5/15/19 at approximately 10:05 a.m. with Staff A (Administrator) confirmed that the nurse staffing data posted was from 5/7/19, that the current staffing was not posted elsewhere at the facility and that it had not been posted since 5/7/19.",2020-09-01
138,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2017-07-26,279,D,0,1,6UZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop comprehensive care plans for 2 residents in a standard survey sample size of 15 residents. (Resident identifiers are #5 and #12.) Findings include: Resident #5 Review on 7/24/17 of Resident #5's medical record revealed that the resident returned from having a feeding tube placed on 6/12/17 at the hospital. Review of the MAR (Medication Administration Record) revealed that the resident's diet was NPO (nothing by mouth) as of 6/12/17. Review of Resident #5's care plans revealed: Focus Resident exhibits or is at risk for dehydration as evidence by insufficient intake/tube feed 6/13/17. Interventions . Offer small amounts of fluids frequently. Offer/encourage fluids of choice. Focus Resident exhibits or is at risk for impaired swallowing related to [MEDICAL CONDITION]. Interventions Resident will be at 90 degrees upright position/out of bed when swallowing food or drink. Encourage small sips/bites and cue as needed. Encourage resident to chew and swallow each bite. Focus Resident exhibits or is at risk for complications of infection related to aspiration pneumonia, Interventions . Encourage resident to consume all fluids during meals. Interview on 7/25/17 at approximately 1:00 p.m. with Staff B (DON) Director of Nurses confirmed that care plans were not updated/changed with placement of the feeding tube and diet order change to NPO. Resident #12 Review on 7/26/17 of Resident #12's medical record revealed that the resident had an order for [REDACTED].>Review on 7/26/17 of Resident #12's care plans revealed that there was not a palliative care plan initiated. Interview on 7/26/17 at approximately 10:45 a.m. with Staff B confirmed that Resident #12 did not have palliative care plan.",2020-09-01
139,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2017-07-26,281,D,0,1,6UZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to follow professional standards of care for 6 residents out of a survey sample of 15 residents. (Resident identifiers are #1, #2, #3, #4, #13 and #14.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Pages 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 713 .A registered nurse compares the list of medications on the MAR indicated [REDACTED].After administering a medication, record it immediately on the appropriate record form .After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurse's notes. Resident #3 Review on 7/25/17 of Resident #3's Medication Administration Record [REDACTED]=650 mg) to be given by mouth every 4 hours as needed for pain or fever; and, a PRN order for [MEDICATION NAME] HCl 50 mg tablet 1 tab by mouth every day as needed for pain. Because there are two orders for PRN (as needed) pain medications, there must be indications as to for what pain level/level of severity each medication would be used. Review of the reverse side of the PRN MAR indicated [REDACTED]. There was no documentation in the nurses notes or on the MAR indicated [REDACTED]. Interview with Staff B (Director of Nurses) confirmed that there should have been indications for when to administer the PRN pain meds, and that there should have been a post administration pain assessment to determine whether or not the PRN pain medication had reduced the pain level sufficiently for Resident #3. Resident #1 Review on 7/24/17 of Resident #1's scheduled medications as noted from Resident #1's physician's orders [REDACTED]. [MEDICATION NAME] 5% Patch: Apply 1 patch to right knee and right shoulder daily (on 6 am/off 6 p.m.)-Chronic Pain; Nicotine Patch Step 3, 7 Milligrams (MG)/24Hours (Hrs): Apply 1 patch daily; [MEDICATION NAME] NA 100 (Stool softener): 1 cap by mouth twice a day for constipation; [MEDICATION NAME] Outer 0.1mg/24hr Patch: Apply 1 patch and change every week for oppositional behaviors/withdrawal symptoms; [MEDICATION NAME] 5 mg: 1 tab by mouth 3 times a day. As needed medication (PRN) as noted from Resident #1's physician's orders [REDACTED]. Milk Of Magnesia (MOM): 30 Cubic Centimeters (CC) by mouth given if no stool in 48 hours (HRS)-Constipation; [MEDICATION NAME] Suppository: 1 rectally the following day if MOM ineffective-Constipation; Fleet Enema: If no stool in 72 hours if no results from [MEDICATION NAME] suppository-Constipation; Tap water enema the following day if no results from fleets-Constipation; Contact MD if no results from above regimen. Review of Medication Administration Record, [REDACTED] June 1st-Resident #1 had no record of having a bowel movement (BM). Resident #1 was offered MOM on three occasions and the resident refused. Resident #1 also refused two scheduled doses of [MEDICATION NAME] 100 mg and two scheduled doses of Senna 8.6mg. Physician was notified. June 2nd-Resident #1 had no record of having a BM. No documentation noted if any PRN medication was offered to alleviate the resident's constipation. In addition the resident also refused two scheduled doses of [MEDICATION NAME] 100 mg and two scheduled doses of Senna 8.6mg. No documentation noted that the physician was made aware of resident's refusal. June 3rd-Resident #1 had no documentation of having a BM. No documentation noted if any PRN medication was offered to alleviate the resident's constipation. In addition the resident also refused one scheduled dose of [MEDICATION NAME] 100 mg at 7pm and one scheduled dose of Senna 8.6mg at 7pm. No documentation that the physician was made aware of resident's refusal. June 4th-Resident #1 had no documentation of having a BM. No documentation noted if any PRN medication was offered to alleviate the resident's constipation. In addition the resident also refused one scheduled dose of [MEDICATION NAME] 100 mg at 7pm and one scheduled dose of Senna 8.6 mg at 7pm. No documentation that the physician was made aware of resident's refusal. June 5th- Resident #1 refused scheduled dose of [MEDICATION NAME] 100 mg at 7pm and two scheduled doses of Senna 8.6 mg at 9 am and 7pm. Resident also refused scheduled dose of [MEDICATION NAME] 5 mg at 12 PM. No documentation that the physician was made aware that the resident refused his scheduled medication. Resident did receive a Ducolax suppository and did have a BM. June 6th- Resident #1 refused one scheduled dose of [MEDICATION NAME] 100 mg at 7pm and two scheduled doses of Senna 8.6 mg. No documentation noted that the physician was made aware of the resident's refusal to take scheduled medication. June 10th-Resident #1 had no record of having a BM. No documentation noted if any PRN medication was offered to alleviate the resident's constipation. The resident also refused one scheduled dose of Senna 8.6 mg at 7pm. No documentation that the physician was made aware of resident's refusal. June 11th-Resident #1 had no record of having a BM. No documentation noted if any PRN medication was offered to alleviate the resident's constipation. No documentation that the physician was made aware of resident's refusal. June 16th-Resident #1 had no record of having a BM. No documentation noted if any PRN medication was offered to alleviate the resident's constipation. No documentation that the physician was made aware of resident's refusal. June17th-Resident #1 had no record of having a BM. MOM was offered to alleviate the resident's constipation. Resident refused. No documentation that the physician was made aware of resident's refusal. June 20th-Resident #1 had no record of having a BM. No documentation noted if any PRN medication was offered to alleviate the resident's constipation. In addition the resident also refused scheduled dose of a lidocane patch 5% at 8 am; Nicotine patch 7 mg at 9 am; [MEDICATION NAME] 100 mg at 7 PM; Senna 8.6 mg at 7 PM. No documentation that the physician was made aware of resident's refusal. June 21st-Resident #1 had no record of having a BM. No documentation noted if any medication was offered to alleviate the resident's constipation. No documentation that the physician was made aware of resident's refusal. June 22nd-Resident #1 had no record of having a BM. MOM was offered to alleviate the resident's constipation. Resident refused. No documentation that the physician was made aware of resident's refusal. June 23rd-Resident #1 had no record of having a BM. No documentation noted if any medication was offered to alleviate the resident's constipation. In addition the resident also refused scheduled dose of [MEDICATION NAME] 5 mg at 9 am; [MEDICATION NAME] 175 mg at bedtime. No documentation that the physician was made aware of resident's refusal. June 24th-Resident #1 had no record of having a BM. No documentation noted if any medication was offered to alleviate the resident's constipation. In addition the resident refused scheduled dose of [MEDICATION NAME] 1200 mg at 7 PM; [MEDICATION NAME] 175 mg at bedtime. No documentation that the physician was made aware of the resident's refusal. June 25th-Resident #1 had no record of having a BM. MOM was offered to alleviate the resident's canstipation. Resident refused. No documentation that the physician was made aware of the resident's refusal. June 26th-Resident #1 had no record of having a BM. No documentation noted if any medication was offered to alleviate the resident's constipation. No documentation that the physician was made aware of the resident's refusal. June 27th-Resident #1 had no record of having a BM. MOM was offered to alleviate the resident's constipation. Resident refused. [MEDICATION NAME] suppository was offered. Resident refused. No documentation that the physician was made aware of the resident's refusal. June 28th-Resident #1 had no record of having a BM. MOM was offered to alleviate the resident's constipation. Resident refused. Ducolax suppository was offered. Resident refused. In addition the resident refused scheduled dose of [MEDICATION NAME] 30 mg at 9 am; [MEDICATION NAME] 100 mg at 9 am; [MEDICATION NAME] 8.6 mg at 9 am. No documentation that the physician was made aware. Interview on 7/26/17 at approximately mid-morning with Staff D (Licensed Practical Nurse), Staff D was asked about physician notification when Resident #1 refuses medication for his constipation. Staff D replied when Resident #1 refuses the medication we offer, we just mark it refused because Resident #1 does it all the time Interview on 7/26/17 approximately 11:00 a.m. with Staff B (Director of Nursing), when it was asked if the physician is aware of Resident #1's refusal of medication that is scheduled or as needed on response to not having a BM, Staff B replied that, the doctor already knows. He mentioned it in his progress notes. I do not know why it is not documented in the nurses notes. When the physician progress notes [REDACTED].#1's refusal of bowel medication, Staff A indicated that the physician would be notified. Resident #14 Review on 7/26/17 at about 10:30am of Resident #14's chart revealed two pages of medication orders that had no resident identification, dates, or Physician signature. Interview on 7/26/17 at 10:40 a.m. with Staff [NAME] (Licensed Practical Nurse), when Staff [NAME] was questioned regarding the two pages of medication orders that were discovered in Resident #14's chart had no resident identification, dates, or Physician signature. Staff [NAME] replied The resident had a habit of checking into the Veteran's Hospital after [MEDICAL TREATMENT]. Maybe they were there for re-admission? Resident #2 Review on 7/25/17 of Resident #2's Medication Administration Record [REDACTED] Resident # 13 Review on 7/25/17 of Resident #13's MAR for 7/2017 revealed that the PRN order for [MEDICATION NAME] 3mg 1 tablet by mouth at bedtime for [MEDICAL CONDITION] was given on 7/21/17 with no documentation of results on the MAR indicated [REDACTED] Review on 7/25/17 of Resident #13's MAR for 7/2017 revealed that the PRN order for [MEDICATION NAME] 0.5 mg 1 tablet by mouth every 3 hours for [MEDICAL CONDITION]/mood was given on 7/13/17 and 7/21/17 with no documentation of results on the MAR indicated [REDACTED] Resident #7 Review on 7/25/17 of Resident #7's MAR for 7/2017 revealed that the PRN order for milk of magnesia 30 cc by mouth if no stool in 48 hours was given on 7/23/17 with no documentation of results on the MAR indicated [REDACTED] Review of resident #7's MAR for 7/2017 revealed that the PRN order for [MEDICATION NAME] 2 tablets by mouth every 12 hours for cough/congestion was given on 7/10/17 and 7/12/17 with no documentation of results on the MAR indicated [REDACTED] Review of resident #7's MAR for 7/2017 revealed that the order for [MEDICATION NAME] nebulizer 3 times a day for cough as needed was given on 7/22/17 with no documentation of results on the MAR indicated [REDACTED] Resident #8 Review of resident #8's MAR for 7/2017 revealed that the order for [MEDICATION NAME] 50 mg. by mouth every 6 hours as needed for a pain level of between 4-7 was given twice on 7/16/17 and one time on 7/17/17 with no documentation of results on the MAR indicated [REDACTED] Interview on 7/25/17 at approximatley 10:15 a.m. with Staff B (Director of Nursing) confirmed that there was no evidence of documentation of results for the administration of the above medications in the Resident's medical record or MAR's . Resident #4 Review on 7/24/17 of Resident #4's MAR indicated [REDACTED] [MEDICATION NAME] 0.4mg cap take 1 capsule by mouth daily. On 7/9/17 there was no documentation that Resident #4's [MEDICATION NAME] 0.4 mg had been administered at 8:00p.m. On 7/15, 7/16, 7/17 and 7/19 there was no documentation in the medical record that the order to monitor for constipation daily at 8:00p.m. had been followed. [MEDICATION NAME] 300mg take 1 capsule by mouth daily at bedtime. On 7/15 and 7/16 there was no documentation in the MAR indicated [REDACTED]. Resident #5 Review on 7/24/17 of Resident #5's MAR indicated [REDACTED] Neupro 8mg/24 hour patch daily. On 7/16/17 there was no documentation that Resident #4's Neupro 8 mg/24 hour patch had been applied at 8:00 a.m. [MEDICATION NAME] 150 mg twice a day On 7/20/17 there was no documentation that Resident #4's [MEDICATION NAME] 150 mg had been administered at 8:00 a.m. [MEDICATION NAME] 4 mg three time a day [MEDICATION NAME] 4 mg had been administered at 6:00 p.m. [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 25/250 mg seven times a day On 7/15, 7/21 and 7/29 there was no documentation that Resident #4's [MEDICATION NAME] 25/250 mg had been administered at 9:00 p.m. Review of Resident #5's MAR for (MONTH) and July's tube feed/[MEDICATION NAME] administration log revealed: [MEDICATION NAME] 1.2 over 1 hour 5x day 270ml/hour. In (MONTH) there is no documentation for [MEDICATION NAME] 1.2's administration 26 times. In (MONTH) there is no documentation for [MEDICATION NAME] 1.2's administration 11 times. Resident #11 Review on 7/26/17 of Resident #11's (MONTH) and (MONTH) (YEAR) (MAR) Medication Administration Record [REDACTED] On 6/2, 6/6, 6/10 a PRN (as needed) dose of [MEDICATION NAME] 0.4 mls (milliliters) was administered 1x daily for moaning without a follow up assessment documented in Resident #11's medical record for effect of medication. On 6/10 and 6/20 a PRN dose of Tylenol 1 GM (gram) was administered for pain relief without a follow up assessment documented in Resident #11's medical record for effect of medication. On 7/7/17 there was no documentation in the medication record or the MAR indicated [REDACTED] On 7/7/17 there was no documentation in the medication record or the MAR indicated [REDACTED]. On 7/18, 7/19 and 7/21 a PRN dose of [MEDICATION NAME] 0.4 mls was administered 1x daily for moaning without a follow up assessment documented in Resident #11's medical record for effect of medication. Resident #12 Review on 7/26/17 of Resident #12's (MONTH) (YEAR) MAR indicated [REDACTED] On 7/3, 7/8, and 7/13 twice a PRN [MEDICATION NAME] nebulizer treatment was administered for shortness of breath without a follow up assessment for effect of medication. On 7/13 twice a PRN Tylenol 650mg was administered for pain relief without a follow up assessment for effect of medication. Interview on 7/26/17 at approximately 10:00 a.m. with Staff B confirmed that the there was no evidence that Residents 4 and 5 medications and tube feeds were administered. The interview also confirmed that effects of PRN were not documented in the medical record for Resident #11 and #12.",2020-09-01
140,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2017-07-26,333,D,0,1,6UZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facility failed to ensure that 2 residents out of a survey sample of 15 residents were free from significant medication errors. (Resident identifiers are 4 and 8.) Findings include Resident #4 Review on 07/24/2017 of Resident #4's medical record revealed that Resident #4 was admitted to the facility on [DATE]. Resident #4 was discharged from the facility and admitted to the hospital on [DATE]. Review of the hospital discharge summary from (MONTH) 12, (YEAR) to (MONTH) 14, (YEAR) revealed that Resident #4 had a Cat Scan of the abdomen and pelvis without contrast at the hospital. Impression of Cat Scan: 3. Abundant fecal material is present throughout the large colon and within the rectal ampulla. Some degree of contipation/fecal impaction should be considered. Review of the discharge summary from the hospital revealed under Hospital Summary: Patient was noted to severely constipated on CAT Scan do abdomen/pelvis, did have a bowel movement with appropriate bowel regimen. Bowel movements needs to be monitored at nursing home. Review of the MAR indicated [REDACTED]. (MONTH) 14th-July 25th there were 6 days without documentation of staff monitoring constipation. (Dates not monitored-July 15,16,17,19,23 and 24. Review of the hospital discharge summary dated (MONTH) 14, (YEAR) revealed that under Discharge Medications for the following order: .[MEDICATION NAME] 17 gm powder pack, take 1 packet by mouth twice daily. Review on 07/25/17 of Resident #4's (MAR) Medication Administration Record [REDACTED] Polyethylene [MEDICATION NAME] 17 Grams by mouth twice daily. On the MAR indicated [REDACTED]. On another page of the MAR indicated [REDACTED]. That order was crossed out without a date or signature. Review of the medical record revealed that there was no physicians order to discontinue the scheduled Polyethylene [MEDICATION NAME] order. There was no physicians order to change the Polyethylene [MEDICATION NAME] to as needed. Interview on 07/26/17 at approximately 7:50 a.m. with Staff D (Licensed Practical Nurse) confirmed that the initial order dated 7/3/17, Polyethylene [MEDICATION NAME] 17 Grams by mouth twice daily was the only order for this medication. I don't know why someone do this and change it with out an order. Interview with Staff D (LPN) confirmed that there was no order to discontinue or change order to as needed to [MEDICATION NAME]. Staff D (LPN) also confirmed that there was no documentation that staff was monitoring for constipation on (MONTH) 15,16,17,19,23 and 24.",2020-09-01
141,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2017-07-26,371,D,0,1,6UZD11,"Based on observation, interview, and policy & procedure review, it was determined that the facility failed to do the following: properly date stored items in the main facility refrigerator. Findings include: Review on 7/25/17 of the facility's policy Food and Nutrition Services Use By Dating Guidelines (Rev.12/01/15) Section Refrigerator, Item section Frozen Shakes, under section Date With: Use by date of 14 days once thawed- use labels for individual items when removed from carton. Observation on 7/24/17 at 10:15 am, during the tour of the kitchen facility's main refrigerator, revealed there was a cardboard box located on a mid-level shelf that had containers of health shakes. There were no labels indicating the date when they had been removed from freezer storage or the date when they were to be consumed by. Interview on 7/24/17 during tour with Staff D (Dietary Services Director) when Staff D was questioned regarding the absence of 'use by' dating on the cartons, Staff D replied that the cartons are removed from the freezer for a specific resident use, thawed in the refrigerator, then labeled for a specific resident for a specific time. If refused or not consumed, the carton is returned, the label removed for dietician review, and the carton is thrown out.",2020-09-01
142,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2017-07-26,431,D,0,1,6UZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and review of the facility's policy and procedure, it was determined that the facility failed to have a system of medication records that enable periodic accurate reconciliation and accounting of all controlled medications for 2 residents in a survey sample size of 30 residents. (Resident identifiers are #1 and #16.) Findings include: Resident #1 Review on 7/25/17 of Resident #1's Physician order [REDACTED].>On 5/30/2017 an order was written for Oxycodone 10 milligrams (mg) Per Oral (PO) 1 tablet (tab) every 4 hours as needed (PRN) for pain 5-10. Review of facility Policy & Procedure titled Medication Administration: General (Revised 5/15/17); Section Practice Standards; Section 8 Document; Sub-Section 8.1 Administration of medication on Medication Administration Record [REDACTED]. Review of the instructions for documenting on the MAR; on the back of the MAR page; in the section marked Nurse's Medication Notes; instructions are typed for assigned staff administering medications; line D, PRN medication: 'Reason given should be noted on the nurse's notes'. For the months of (MONTH) and (MONTH) (YEAR), Resident #1 had orders for PRN use of Oxycodone for when Resident #1 was experiencing pain at a level of 5-10. For the month of June/2017, 105 entries were noted from Resident#1's narcotic ledger in which a dose of Oxycodone IR 10 mg. was withdrawn from the narcotic storage drawer for Resident #1's use. On the back of the MAR, only 86 entries were documented as to the reason Resident #1 was medicated with the Oxycodone IR 10 mg. and the effectiveness of the medication in regards to his pain. Dates and number of instances in which documentation of the reason for use of the Oxycodone IR 10 mg. and the effectiveness of the medication was omitted on the back of the MAR for the month of (MONTH) were the 1st (once), 6th (3 times), 7th (once), 8th (twice), 14th (once), 15th (3 times), 16th (once), 18th (twice), 23rd (once), 25th (twice), 26th (once), and the 28th (once). For the month of July/2017, up to 7/24/17, 87 entries were noted from Resident #1's narcotic ledger and only 73 entries were documented as to the reason Resident #1 was medicated with the Oxycodone IR 10 mg. and the effectiveness of the medication. Dates and number of instances in which documentation of the reason for use of the Oxycodone IR 10 mg. and the effectiveness of the medication was omitted on the back of the MAR for the month of (MONTH) were the 2nd (once), 3rd (once), 10th (3 times), 13th (once), 14th (twice), 15th (3 times), 17th (twice), 22nd (once). Resident #16 Review on 7/26/17 of Resident #16's medical record revealed a physicians order for: Oxycodone 7.5 mg (milligram) every 4 hours (PRN) as needed for pain. Review of Resident #16's MAR (Medication Administration Record) and reconcillliation with the Narcotic count book revealed that the following discrepancies: July 3- the p.rn. dose was documented in the MAR indicated [REDACTED]. July 5, 6, 10,11,12,13,16,17,18,and 19th -the p.rn. dose was removed from the narcotic count but not documented as administered on the MAR. Interview on 7/26/17 at approximately 3:00 p.m. with Staff A (Administrator) regarding the survey teams concerns with the discrepancies between the narcotic book and MAR.",2020-09-01
143,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2019-09-11,880,D,0,1,996R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during medication pass observations on 1 of 3 units. (Resident identifiers are #40, #23, #50 and #27.) Findings include: Resident #40 Observation on 9/9/19 at approximately 8:05 a.m., during medication pass, revealed that Staff A (Registered Nurse) administered medications to Resident #40. After administering Resident #40's medications, Staff A returned to the medication cart without washing their hands or using hand sanitizer and proceeded to prepare medications for Resident #23. Resident #23 Observation on 9/9/19 at approximately 8:10 a.m., during medication pass, revealed that Staff A coughed into their left hand as they were preparing a medication for Resident #23. Staff A did not wash their hands or use hand sanitizer after coughing into their hand and they proceeded to continue to prepare the medication for Resident #23. Resident #50 Observation on 9/9/19 at approximately 8:15 a.m., during medication pass, revealed that as Staff A was preparing medications for Resident #50, Staff A attempted to pop a [MEDICATION NAME] pill out of its blister pack but the pill got stuck in the blister pack, so Staff A used their bare fingers to remove the pill and put it into the medicine cup. Resident #27 Observation on 9/9/19 at approximately 8:20 a.m., during medication pass, revealed that Staff A was preparing medications for Resident #27. As Staff A was holding a bottle of [MEDICATION NAME] tablets, Staff A poured the tablets into the bottle's cover and several tablets fell into the cover. Staff A only needed 2 of the tablets, so Staff A put the extra tablets back into the bottle using their bare fingers. Observation on 9/9/19 at approximately 8:20 a.m., during medication pass, also revealed that as Staff A was holding a bottle of Senna Plus pills, they poured the pills into the bottle's cover and several pills went into the cover. Staff A only needed 2 of the pills, so Staff A put the extra pills back into the bottle using their bare fingers. Interview on 9/9/19 at approximately 8:30 a.m. with Staff A confirmed that they did not wash their hands or use hand sanitizer after administering medications to Resident #40 or after coughing into their hand. Staff A confirmed that they should have washed their hands or used hand sanitizer for both situations. Staff A also confirmed that they did touch several medications, with their bare hands, and that they should not have touched them.",2020-09-01
144,KENDAL AT HANOVER,305042,67 CUMMINGS ROAD,HANOVER,NH,3755,2017-06-12,156,C,0,1,TGI511,"Based on review of the facility admission packet and interview, it was determined that the facility failed to provide residents, on admission to the facility, information that the combined income of the resident and their spouse had special financial exceptions that would not negatively impact the spouse still living in the community (Spousal Impoverishment). Findings include: Review on 6/12/17 of the admission packet revealed that the information provided to prospective/on admission residents did not include information that the combined income of the resident and the spouse had special financial exceptions that would not negatively impact the spouse still living in the community. Interview on 6/12/17 at 1:45 PM with Staff B (Administrator), reviewed the missing spousal impoverishment information with Staff B. Staff B's response was that the facility was not set up so that a spouse would remain out in the community while only the resident in question would be admitted . For that reason, Staff B confirmed the facility did not have such information in the admission information packets. Interview at 3:00 PM on 6/12/17 with Staff C (Director of Nursing), reviewed this missing information was reviewed with Staff C. Staff B and C explained that the circumstances that would require the information to be included in the admission information was remote.",2020-09-01
145,KENDAL AT HANOVER,305042,67 CUMMINGS ROAD,HANOVER,NH,3755,2017-06-12,205,C,0,1,TGI511,"Based on admission packet review and interview, it was determined that the facility failed to provide residents, on admission to the facility, information regarding the holding of a resident's bed in the event of transfer to an acute care facility (bed hold notification). Findings include: Review on 6/12/17 of the admission packet revealed that the information provided to prospective/on admission residents did not include information that the resident's bed could be held open on transfer to an acute care facility pending return of the resident. Interview on 6/12/17 at 1:45 p.m. with Staff B (Administrator), reviewed the missing bed hold information was with Staff B. Staff B's response was that the facility was set up so residents could come and go as they wish. In fact some residents exited the facility for a period of time during the summer months and would return. For that reason, the facility had no bed hold policy or information for residents on admission. Interview on 6/12/17 at 3:00 p.m. with Staff C (Director of Nursing) and Staff B reviewed this missing information. Staff B and C explained that the circumstances that would require the information to be included in the admission information was remote.",2020-09-01
146,KENDAL AT HANOVER,305042,67 CUMMINGS ROAD,HANOVER,NH,3755,2017-06-12,456,B,0,1,TGI511,"Based on observation and interview, it was determined that the facility failed to maintain patient care equipment in safe operating conditions for 2 of 2 glucometer control solutions and 1 of 1 container of urinalysis testing strips. Findings include: Observation on 6/12/17 at approximately 12:45 p.m. of the emergency glucometer revealed that 2 bottles (high and low) testing solutions had expired on 5/2017. Observation on 6/12/17 at approximately 12:50 p.m. of the soiled utility room revealed a container of urinalysis testing strips had expired on 5/2017. Interview on 6/12/17 at approximately 12:50 with Staff A (Registered Nurse) confirmed that the glucometer testing solutions and the urinalysis testing strips had both expired 5/2017.",2020-09-01
147,WARDE HEALTH CENTER,305043,21 SEARLES ROAD,WINDHAM,NH,3087,2019-05-10,656,B,0,1,IR7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan for 2 residents in a final sample survey of 12 residents. (Resident identifiers are #4 and #23.) Findings include: Resident #23 Observation on 5/9/19 at 1:26 p.m. revealed that Resident #24 had a urinary drainage leg bag on their left thigh. Interview on 5/9/19 at 1:26 p.m. with Resident #23 revealed that Resident #23 had an indwelling catheter inserted on 4/29/19 at the urologist's office. Interview on 5/9/19 at 1:30 p.m. with Staff B (Licensed Nursing Assistant) revealed that Staff B had been assigned to Resident #23 for morning care and Staff B had stated that they had emptied Resident #23's urinary drainage bag. Staff B also stated that they would change Resident #23's urinary drainage bag to a urinary leg bag in the morning and empty the urinary leg bag or urinary drainage bag after every shift or when full. Review on 5/9/19 of Resident #23's electronic treatment administration record for (MONTH) 2019 and (MONTH) 2019 revealed no treatments for Resident #23's urinary indwelling catheter maintenance. Review on 5/9/19 of Resident #23's current care plan revealed no care plan related to Resident #23's use and maintenance for the indwelling catheter. Review on 5/9/19 of Resident #23's urology consult note dated 4/29/19 revealed that Resident #23 had [MEDICAL CONDITION] and Resident #23 had an indwelling catheter inserted. Review on 5/9/19 of Resident #23's nurses note dated 5/1/19 revealed that Resident #23 was concerned about placement of bag on their leg and prompt emptying of the urinary drainage bag. Review on 5/9/19 of Resident #23's nurses note dated 5/4/19 at 5:17 p.m. revealed that Resident #23 was frustrated and that Resident #23 stated that nobody came to check on my Foley bag (urinary drainage bag) all day today. Interview on 5/9/19 at 1:35 p.m. with Staff A (Director of Nursing) confirmed that Resident #23 had no care plan for Resident #23's use and care for the indwelling catheter. Staff A stated that there should be a care plan for Resident #23's use and maintenance for the indwelling catheter. Staff A also stated that the nursing staff would empty the urinary drainage bag after every shift. Resident #4 On 5/9/19 at 1:26 p.m. review of Resident #4's Electronic Medical Record (EMR) reveals that resident was placed on Hospice care on 8/2/18. Review of CHAT Biography (Facility's name for what is known as a CARE PLAN) in EMR reveals no determination of services to be provided by the Hospice provider to Resident #4 at the facility. On 5/10/19 at 9:30 a.m. review of Resident #4's Hospice Ledger reveals a specific care plan for Hospice care to be provided to Resident #4. There is no coordination with the CHAT biography in the EMR. On 5/10/19 at 11:24 a.m. interview with Staff A (Registered Nurse) confirmed the above findings.",2020-09-01
148,WARDE HEALTH CENTER,305043,21 SEARLES ROAD,WINDHAM,NH,3087,2018-07-26,578,D,0,1,151G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to accurately document the resident choice of advance directive for 1 resident in a survey sample of 12 residents. (Resident identifiers is #176.) Findings include: Review on 7/24/18 of Resident #176's Advance Directive file, revealed that Resident #176 has signed a Portable DNR (Do Not Resuscitate) form on 7/17/18 Review on 7/24/18 of Resident #176's (MONTH) (YEAR) Physician order [REDACTED]. Review on 7/25/18 of Resident #176's Chat Biography, Advance Care Planning, revealed that the question of My care decisions are: was answered with Full Code (staff initials) 7/19/18. Review on 7/25/18 of the facility report roster with all the resident names and room numbers had a notation on the top which read, ***Indicates A Full Code. Review revealed that *** was typed in on the roster next to Resident #176's name. Interview on 7/25/18 at approximately 8:28 a.m. with Staff N (Licensed Practical Nurse, Supervisor) regarding where Staff N would go to find what a resident's Advance Directives were, Staff N stated that they would go to the Advance Directive file, to see if there was a Portable DNR, but that if it was missing, they would look at the resident roster to see what the resident's Advance Directives were. Staff N confirmed that the Advance Directive information for Resident #176 was inaccurate on the Chat Biography and on the Resident Roster.",2020-09-01
149,WARDE HEALTH CENTER,305043,21 SEARLES ROAD,WINDHAM,NH,3087,2018-07-26,658,E,0,1,151G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #7, #13, and #14.) Findings include: Professional reference: Potter, [NAME] [NAME], and Perry, Anne Griffin. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #13 Review on 7/25/18 of Resident #13's Nutritional Assessment, dated 6/11/18 revealed that Resident #13 had a weight loss, and was not on a physician-prescribed weight-loss regimen. Review revealed that the weight loss was documented by the Registered Dietitian as >= 10% within 6 months. Review on 7/25/18 of Resident #13's Current Chat Biography, Dining and Nutrition, revealed that the question of My weight status is was answered with Weight Loss . Review on 7/25/18 of Resident #13's (MONTH) (YEAR) Treatment Sheets revealed an order to Weigh Resident by shift starting 4/23/18 . Interview on 7/25/18 at approximately 9:00 a.m. with Staff N (Licensed Practical Nurse, Supervisor) revealed that the order written as Weigh Resident By Shift meant that the resident was to have weekly weights. Review on 7/25/18 of the Facility's policy, titled Resident Weights, revised 3/21/11, revealed that .The LNA (Licensed Nursing Assistant) is responsible to immediately notify the nurse of any change in a resident's weight. Any increase or decrease of three (3) or more pounds must be reported .The licensed nurse is responsible for validating the reported weight change .If the resident's weight is plus or minus three (3) pounds from the previous weight, the resident must be reweighed within 24 hours and verified by the nurse .The following members of the interdisciplinary team are notified upon licensed nurse validation of significant weight change, Physician .If a resident cannot be weighed, there must be a documented medical reason that prevents the resident from being weighed .Notify physician . Review on 7/25/18 of Resident #13's Weight Listing sheet revealed that Resident #13 had a documented weight on 6/26/18 of 110 pounds. The next weight documented for Resident #13 was on 7/10/18, which was 102 pounds. This was an 8 pound, 7.2 %, weight loss in 14 days. There was no documented reweight on the 7/10/18 weight. The next documented weight was on 7/16/18, which was 6 days later. The documented weight on 7/16/18 was 99.10. This was another 2.9 pound loss in 6 days making the total loss of 9.9% in 20 days. Review on 7/25/18 of Resident #13's nurses notes revealed that there was no documented evidence that Resident #13's physician was notified of their weight loss or that Resident #13 was not weighed weekly, as ordered. Resident #14 Review on 7/25/18 of Resident #14's Current Chat Biography, Dining and Nutrition, revealed that the question of My weight status is was answered with Weight Loss. Review on 7/25/18 of Resident #14's (MONTH) (YEAR) Treatment Sheets revealed an order to Weigh Resident by shift starting 6/11/18 . Review on 7/25/18 of Resident #14's Weight Listing sheet revealed that Resident #14 had a documented weight on 4/9/18 of 147.4 pounds. Review revealed that Resident #14 had a documented weight on 5/1/18 of 129.8 pounds. This was a 17.6 pound, 11.9 %, weight loss in 22 days. There was no documented reweight on the 5/1/18 weight. The next documented weight was not until 5/8/18, which was 7 days later. Review on 7/25/18 of Resident #14's Weight Listing sheet revealed that Resident #14 had a documented weight on 5/29/18 and the next documented weight was not until 7/9/18, which was 6 weeks later. Review on 7/25/18 of Resident #14's nurses notes revealed that there was no documented evidence that Resident #14's physician was notified that Resident #14 was not weighed weekly, as ordered. Resident #7 Review on 7/25/18 of Resident #7's Nutritional Assessment, dated 5/16/18 revealed that Resident #7 had a weight loss, and was not on a physician-prescribed weight-loss regimen. Review revealed that the weight loss was documented by the Registered Dietitian as >= 5% weight change in 30 days. Review on 7/25/18 of Resident #7's Current Chat Biography, Dining and Nutrition, revealed that the question of My weight status is was answered with Weight Loss. Review on 7/25/18 of Resident #7's (MONTH) (YEAR) Treatment Sheets revealed an order to Weigh Resident by shift starting 4/23/18 . Review on 7/25/18 of Resident #7's Weight Listing sheet revealed that Resident #7 had a documented weight on 4/27/18 of 136.1 pounds. The next weight documented for Resident #7 was on 5/11/18, which was 110 pounds. This was a 26.18 pound, 19.18 %, weight loss in 14 days. There was no documented verification of the 5/11/18 weight until 5/16/18, which was 5 days later. Review on 7/25/18 of Resident #7's Weight Listing sheet revealed that Resident #7 had a documented weight on 6/15/18 of 113.2 pounds. The next weight documented for Resident #7 was on 6/30/18, which was 106.4 pounds. This was a 6.8 pound, 6.01 %, weight loss in 15 days. There was no documented verification of the 6/30/18 weight until 7/6/18, which was 6 days later. Review on 7/25/18 of Resident #7's nurses notes revealed that there was no documented evidence that Resident #7's physician was notified that Resident #7 was not weighed weekly, as ordered. Interview on 7/26/18 at approximately 11:00 a.m. with Staff B (Director of Nursing) confirmed that all 3 residents had orders for weekly weights, that if they were not weighed weekly their physicians should have been notified and that the weight discrepancies should have been verified within 24 hours.",2020-09-01
150,WARDE HEALTH CENTER,305043,21 SEARLES ROAD,WINDHAM,NH,3087,2018-07-26,880,D,0,1,151G11,"Based on observation, policy & procedure review, and interview, it was determined that the facility failed to prevent the possible spread of pathogens between two residents during an observation of medication administration between two residents. (Resident identifiers are #19 and #10) Findings include: Potter, [NAME] [NAME], and Perry, Anne Griffin. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Page 719-Administering Oral Medications; Step 7: Prepare medications; line a, Perform hand hygiene. Review of the facility policy Medication Administration General Guidelines (2007) page 4, section 11, Hands are washed with soap and water again after administration and with any resident contact. Observation on 7/25/18 at approximately 8:30 a.m. of a medication pass with Staff M, Registered Nurse, revealed that Staff M had completed administering medications to Resident #19. It was observed that Staff M did not perform hand hygiene prior to assembling the medications for Resident #10. Interview on 7/25/18 at 8:40 a.m. with Staff M at the end of Resident #10's medication pass. Observation of the lack of hand hygiene between residents was revealed to Staff M. Staff M's reply was that it only, had to be done after every 3rd resident unless the resident was physically contacted. Interview on 7/26/18 at approximately 3 p.m. with Staff B, Director of Nursing, the findings of the lack of hand washing between residents and the comments by Staff M were discussed. Staff B's reply was that the facility policies and procedures needed to be updated.",2020-09-01
151,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2019-01-17,756,B,0,1,RCLF11,"Based on record review and interviewit was determined the facility failed to ensure that a monthly pharmacy drug regimen review was done for 6 residents in a survey sample of 20 residents. (Resident identifiers are #4, #6, #15, #19, #22 and #60.) Findings include: Resident #4 Review on 1/14/19 of Resident #4's medical record revealed no documented evidence of a (MONTH) (YEAR) pharmacy drug regimen review done for Resident #4. Resident #6 Review on 1/14/19 of Resident #6's medical record revealed no documented evidence of a (MONTH) (YEAR) pharmacy drug regimen review done for Resident #6. Resident #15 Review on 1/14/19 of Resident #15's medical record revealed no documented evidence of a (MONTH) (YEAR) pharmacy drug regimen review done for Resident #15. Resident #19 Review on 1/14/19 of Resident #19's medical record revealed no documented evidence of a (MONTH) (YEAR) pharmacy drug regimen review done for Resident #19. Resident #22 Review on 1/14/19 of Resident #22's medical record revealed no documented evidence of a (MONTH) (YEAR) pharmacy drug regimen review done for Resident #22. Resident #60 Review on 1/14/19 of Resident #60's medical record revealed no documented evidence of a (MONTH) (YEAR) pharmacy drug regimen review done for Resident #60. Interview on 1/15/19 at approximately 10:00 a.m. with Staff A (Registered Nurse) confirmed, following review of the above listed residents' pharmacy drug regimen reviews, that there was no documented evidence in the medical record that the (MONTH) (YEAR) drug regimen review was done for Resident #4, #6, #11, #15, #19, #22 and #60.",2020-09-01
152,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2018-02-15,655,D,0,1,LUA911,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement an interim care plan for 1 resident (#220) out of 20 residents in the finalized facility sample. Findings include: It was reported from initial tour by another team surveyor that resident (#220) had PPE inside the room they resided in. The team member was informed that Resident #220 was on precautions. Sign indicating precautions was also posted on the doorway. On 2/15/18 a visit to resident #220's room confirmed the observation previously noted by survey team member. Review of Resident #220's Electronic Medical Record (EMR) revealed a lab result of a sputum sample collected on 1/28/18. The sputum sample was collected while Resident #220 was a patient at an acute care hospital from 1/27/18 to 2/5/18. Results reported were Moderate [MEDICAL CONDITION]-Resistant Staphylococcus aureus (MRSA). Review of Resident #220's care plan revealed no indication that a baseline or comprehensive care plan was developed for respiratory precautions when resident was readmitted to the facility on [DATE]. Interview with Staff A Registered Nurse (RN) on 2/15/18 at 1:15 PM validated with the above findings.,2020-09-01
153,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2018-02-15,697,D,0,1,LUA911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure adequate pain management to 1 resident in a standard survey sample of 20 residents. (Resident identifier is #4.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 699 .Prescribers must document the diagnosis, condition, or need for use for each medication ordered .When administering medications, document the assessment made and the time of medication administration. Make frequent evaluation of the effectiveness of the medication, and record findings in the appropriate record . Page 1082 .If you evaluate that a client continues to have discomfort after an intervention, use a new approach . Interview on 2/13/18 at approximately 8:45 a.m. with Resident #4 revealed that Resident #4 had frequent pain. When asked if the facility was generally managing their pain well with medications or other interventions, Resident #4 stated that they were not. Review on 2/14/18 of Resident #4's Medication Administration History, dated 2/1/18 - 2/14/18, revealed that Resident #4 received [MEDICATION NAME] 325 mg (milligrams) 2 tablets by mouth on 2/2/18 at 4:41 p.m. for shoulder and neck pain, 7/10 (7 out of 10 pain level.) Review revealed that the PRN (as needed) result which was documented on 2/2/18 at approximately 10:31 p.m. was .Not effective. Comment: res (resident) cstated (sig) (pronoun) was still in a lot of pain when checked at 10pm . Review on 2/14/18 of Resident #4's Medication Administration History, dated 1/1/18 - 1/31/18 and 2/1/18 - 2/14/18, revealed that Resident #4 received PRN [MEDICATION NAME] 325 mg (milligrams) 2 tablets by mouth on 1/12/18 at 5:49 a.m. for 5/10 general pain, on 1/13/18 at 10:21 p.m. for 5/10 general pain and on 2/3/18 at 9:59 p.m. for generalized pain. Review revealed that the PRN result which was documented for these three doses was Somewhat effective. Review on 2/14/18 of Resident #4's current care plan for pain revealed an intervention .Repositioning and ice sometimes help control my pain .Notify my doctor if my pain is not controlled with current treatment plan . Review on 2/14/18 of Resident #4's Nursing Progress Notes revealed that there was no documented evidence of any other interventions being tried on the date that Resident #4's PRN pain medication results were not effective. There was also no documented evidence that Resident #4's physician was notified of these results. Review on 2/14/18 of Resident #4's Doctor's Progress Notes, dated 1/15/18, revealed a note written by Resident #4's physician that read .DJD ([MEDICAL CONDITION] Joint Disease) no c/o (complaints of) pain . Review on 2/14/18 of the facility's Pain management Policy, dated 3/1/05, latest revision date 10/20/17, revealed that, .The resident or guests' response to pain medication/non-pharmacological interventions will be documented in the electronic medical record. If the resident pain is above their acceptable level after medication/non-medication interventions have been instituted the nurse will notify the physician. Interview on 2/15/18 at approximately 12:00 p.m. with Staff D (Registered Nurse) confirmed that there was no evidence of any documentation of any other attempted interventions or physician notification, for Resident #4's pain medication results. Staff D confirmed that there should have been attempted interventions, as well as documentation of the attempted interventions and of the physician notification.",2020-09-01
154,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2018-02-15,761,D,0,1,LUA911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17 Observation on 2/12/18 at approximately 9:45 a.m. during the facility tour on the Pines Unit during an interview with Resident #17 in their room revealed that Resident #17 had a medicine cup on the bedside table with 2 nickel sized, yellow in color medications in the cup. Resident #17 was unable to effectively communicate during the interview. There weren't any staff present in the room when the medication was observed on the bedside table. Interview and observation on 2/12/18 at approximately 9:50 a.m. with Staff B, LPN (Licensed Practical Nurse) confirmed that there were 2 Calcium [MEDICATION NAME] (Over the Counter) tablets in a medication cup on Resident #17's bedside table. No other staff was present in the room. Staff B stated, Well I didn't give these today, they (medication) must be from last night. Review on 2/14/18 of Resident #17's Medication Administration Record, [REDACTED]. Resident #17 does not have a physicians order to independently take medications. Review on 2/15/18 of the facility's Policy and Procedure titled, Medication Administration Procedures, Revision Date 11/17 revealed: Policy: Medication Administration will be administered according to current standards of practice by staff licensed and trained in medication administration. Procedure: . 11. The nurse must remain with the resident until the medication has been taken. The exception is if a resident has a physician order [REDACTED]. Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were secure and unavailable to unauthorized staff and residents and failed to date, when opened, one multidose vial of Insulin on 1 out of 3 nursing units. (Resident identifiers are #17 and #35.) Findings include: Resident #35 Observation on 2/13/18 at approximately 11:30 a.m. of the Medication Cart on the Pines Unit revealed an opened multidose vial of Humalog Insulin with Resident #35's name on it. There was no opened date written on the vial of Insulin or on the medication container that the vial was stored in. Interview on 2/13/18 at approximately 11:30 a.m. with Staff D (Registered Nurse) confirmed that there should have been a date put on the vial when it was opened. Review on 2/14/18 of the facility policy Labeling of Medications with Shortened Expiration Dates, dated 11/17, revealed that .The licensed staff opening the medication with the shortened expiration date will write the date the medication was opened on the label and store in accordance with manufacturer recommendations .Insulin Storage Recommendations at Room Temperature .Humalog Vial 28 days .",2020-09-01
155,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2017-03-08,281,D,0,1,4JXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure complete physician orders [REDACTED]. (Resident identifiers are #9 and #14.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 3/7/17 of Resident #9's Physician order [REDACTED].# 9 had an order for [REDACTED]. (by mouth) PRN (as needed) for pain management of 1-3 (pain level). Not to exceed 3000mg/day. There were no instructions for how often this PRN (as needed) medication could be given. Review on 3/8/17 of Resident #14's Physician order [REDACTED].#9 had an order for [REDACTED]. Interview on 3/7/17 and 3/8/17 with Staff [NAME] (Registered Nurse, Unit Manager) confirmed that the above orders were missing instructions for how often the medications could be given.",2020-09-01
156,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2017-03-08,371,E,0,1,4JXU11,"Based on observation, record review and interview, it was determined that the facility failed maintain the dishwasher rinse temperature to ensure sanitary conditions, failed to store supplemental shakes according to manufacturer's instructions, and failed to properly sanitize dishes using the 3 bay sink. Findings include: Observation in the kitchen on 3/6/17 at approximately 9 a.m. revealed that the high temperature dish machine reached a maximum rinse temperature of 171 degrees Fahrenheit ( F) during the 5 cycles observed (162 F, 168 F, 171 F, 160 F and 168 F). Review of the manufacturer's instructions for the high temperature dish machine titled High Temperature Dish Machine, Operation and HACCP Guidelines revealed the final rinse should reach a minimum temperature of 180 F. Interview with Staff F (Head Cook) on 3/6/17 at approximately 9:30 a.m. confirmed the manufacturer requires the rinse temperature to reach 180 F for proper sanitation. Staff F shut down the high temp dish machine and switched to manually washing dishes in the 3 bay sink. Observation in the kitchen on 3/6/17 at approximately 11:00 a.m. of kitchen staff performing manual dish washing in the 3 bay sink revealed Staff G (Dishwasher) dipped several cups for 1-2 seconds into the sanitizer in the 3rd bay and then placed then on the drying rack. Review of the manufacturer's instructions for the 3 bay sink titled Three Bay Sink Dishwasher Procedure revealed the dishwashing procedure states to Submerge in sanitize sink for 1-2 minutes. Interview with Staff F on 3/6/17 at approximately 11:00 a.m. confirmed that staff G dipped the cups in the sanitizer for 1-2 seconds and that dishes need to be submerged in the sanitize sink for 1-2 minutes Review of the kitchen logs for the high temperature dishwasher and the testing of the sanitizer sink from 12/1/16 to 3/6/17 revealed that kitchen staff record a check mark instead of actual temperatures for the wash temperature, rinse temperature. Kitchen staff also recorded a check mark instead of a value for Parts Per Million (PPM) when testing the sanitizer sink. Interview with Staff I (Director of Food Services) on 3/6/17 at 10:40 a.m. confirmed that kitchen staff record check marks instead of temperatures for the high temperature dishwasher and instead of a value when testing the sanitizer sink. Interview revealed that the check mark would indicate that the temperature or value was acceptable. On 3/6/17, there was a check mark, but the temperature was not acceptable. Observation on 3/6/17 at approximately 9:15 a.m. in the main kitchen revealed approximately 60 undated thawed supplemental shakes in the refrigerator. Review of the supplemental shake carton revealed the following instructions: After thawing, keep refrigerated. Use within 14 days after thawing. Interview on 3/6/17 at approximately 9:20 a.m. with Staff H (Dining Assistant) confirmed the thawed supplemental shakes were not dated with either the date thawed or the 14 day thawed expiration date.",2020-09-01
157,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2017-03-08,505,D,0,1,4JXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to promptly notify the physician of lab results for 1 resident in a standard survey sample of 16 residents. (Resident identifier is #4.) Findings include: Review on 3/7/17 of Resident #4's medical record revealed that Resident #4 had Chemistry lab work drawn on 2/6/17 at 6:07am. The final results, with a print date of 2/6/17 at 1:53:40 PM, showed abnormal lab values that included a Glucose level of 423 (normal range 70-120.) Resident #4 had a [DIAGNOSES REDACTED]. There was no documented indication that when results were known, the physician was notified of these lab results. Resident #4 was seen by the physician on 2/23/17. There was no indication in the physician's progress note written on 2/23/17 that the physician was aware of the abnormal labs and the labs results page was not signed or initialed by the physician. Interview on 3/7/17 at approximately 10:00am with Staff A (Registered Nurse, Unit Manager) revealed that the physician had not been notified of the abnormal lab results. Staff A indicated that when a physician sees the lab results they initial them. Interview with Staff A also revealed that Staff A called Resident #4's physician on 3/7/17 and that the physician ordered a HgA1c to be done on Resident #4.",2020-09-01
158,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-01-09,600,D,1,0,8TGP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, it was determined that the facility failed to ensure that a resident has the right to be free from abuse for 1 resident in a complaint survey of 2 residents. (Resident identifier is #1.) Findings include: Review on 1/9/19 of Resident#1's medical record reveals that Resident #1 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's MDS (Minimum Data Set) indicated that Resident #1's BIMS (Brief Interview for Mental Status) currently is a 15: meaning that Resident #1 is cognitively intact. DPOA (Durable Power of Attorney) was not activated. Review on 1/9/19 of Resident #1's progress notes revealed that on 11/17/18 Resident #1 reported an allegation of abuse to oncoming morning staff at 7:30 a.m Staff documented that pt (patient) reports being punched in stomach, poked in right eye and having left wrist grabbed. pt physically shaken when reporting incident. pt with skin tear to left wrist, 5 cm x 4 cm. skin unable to be approximated. wound bed red and moist. moderate amount of blood to sleeve of left arm and on pt bedding. right eye is red and swollen. pt denies pain to abdomen but abdomen slightly firm. pt sent (hospital name omitted) hospital for eval (evaluation) due to use of xeralto and skin tear. wound care was performed prior to transport to hospital. unit manager notified, DON (Director of Nursing) notified and (police department name omitted) PD (Police Department) notified. Review on 1/9/19 of Resident #1's progress notes reveals that on 11/17/18 Resident #1 is in good spirits and wanted to know if that man would be in the facility tonight. Was reassured that Staff A (License Practical Nurse) would not be. Review on 1/9/19 of Resident #1's emergency room discharge summary notes revealed that on 11/17/18 Resident #1 was evaluated for injuries sustained from an alleged assault from a staff member. Documentation revealed that looks like a slight bruise on (pronoun omitted) face.is on Eliquis. The skin physical exam reveals that minimal ecchymosis noted to the right lateral wrist. No ecchymosis to the abdomen, face. There are 2 skin tears to the posterior left forearm. One is approximately 1 cm. The other is 2 cm x 1 cm. Bleeding is well controlled. Review on 1/9/19 of the personnel file of Staff A, revealed that Staff A was a traveling LPN and Staff A received Elder Abuse training on 2/6/18. Staff A was terminated on 12/19/18 for physical abuse for the 11/16/18. Since Staff A was from a traveling nurse agency; the agency has placed a do not use for all nursing facilities in New England. Review on 1/9/19 of the investigation report on 11/17/18 revealed that Resident #1 reported to Staff B (License Nursing Assistant) that the tall skinny guy with glasses punched me in the gut, poked me in the eye, and grabbed my wrist. Staff B reported it immediately to Staff C (Registered Nurse) who assessed and provided care to Resident #1. The Administrator, DON, state agencies and local police were notified. Review on 1/24/19 of the incident report written by Staff A on 11/17/18 revealed that Resident #1 was pulling the curtain open in between Resident #1 and the roommate in an attempt to watch. Staff A was in the process of feeding the roommate via a [DEVICE] (Gastrostomy tube). Resident #1 proceeded to tug at Staff A's shirt and tugging at Staff A's pants. By tugging at Staff A's pants it was pulling the pants down. Staff A attempted to hold Resident #1's arm to stop it and pull the pants back up. At which time Resident #1 stated Staff A hit Resident #1. Staff A gave report to the oncoming nurse about Resident #1 claim of Staff A hitting Resident #1. Interview on 1/9/19 at 11:45 a.m. with Staff B revealed that Resident #1 told Staff B that the weasel with glasses punched me in the gut, poked me in the eye, and grabbed my wrist. Staff B immediately reported it to Staff C. Interview on 1/9/19 at 11:50 a.m. with Staff C revealed that Staff C completed wound care prior to the hospital transfer and that Resident #1 stated the weasel poke my eye, punched my stomach, and pointed to my wrist. Blood was on the bed sheets. Staff C revealed that Staff C interviewed other residents that have now been discharged and stated Staff A is a hot head and can be snippy. Interview on 1/9/19 at 2:00 p.m. with Staff D (Administrator) revealed that the incident was consider a sentinel event and it went to QAPI (Quality Assurance and Performance Improvement ). Staff were re-educated on elder abuse. Interview with Resident #1 on 1/9/19 at 10:30 a.m. revealed that the staff are wonderful at the this facility and that Resident #1 has no issues with the staff.",2020-09-01
159,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2018-02-26,656,B,0,1,ODTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive person-centered care plan for 5 of residents in a sample size of 36 residents. (Resident identifiers #20, #37, #43, #148, and #152.) Findings include: Resident #37 Interview on 2/21/18 11:20 a.m. with Resident #37 revealed the resident current has chronic pain regularly. Interview on 2/23/18 at 12:20 p.m. with Staff A (Director of Nursing) confirmed Resident #37 has chronic pain regularly. Interview revealed that Resident #37's care plan did not include interventions for pain. Review on 2/26/18 8:03 a.m. of Resident #37's [DIAGNOSES REDACTED]. Resident #152 Review on 2/23/18 1:02 p.m. of Resident #152's progress notes revealed a follow up note from 2/20/18 that stated the resident had [MEDICAL CONDITIONS] exacerbation, had a course of antibiotics that started on 2/12/18, and continued on cough syrup and [MEDICATION NAME] treatments three times a day for 14 days. Review of Resident #152's current care plan revealed it did not include interventions for [MEDICAL CONDITION] or respiratory complications. Interview on 2/23/18 at 12:20 p.m. with Staff A confirmed the above findings for Resident #152. Resident #20 Review on 2/23/18 of Resident #20's care plans revealed that Resident #20's discharge plan: Resident #20 is expected to be discharged related to: admission for skilled-short term stay. Review on 2/23/18 of Resident #20's medical record revealed that Resident #20 discharge plan changed on 2/10/17 to resident being a long term care resident. Interview on 2/23/18 at approximately 1:15 p.m. with Staff D, Unit Manager confirmed that the discharge care plan was incorrect for Resident #20 and had not been changed. Resident #43 Review on 2/21/18 of Resident #43's medical record revealed that Resident #43 had a 19.14% weight loss over 6 months. Review on 2/21/18 of Resident #43's care plans revealed that there was no nutrition care plan for Resident #43. Interview on 2/23/18 at approximately 8:00 a.m. with Staff B, Dietician confirmed that there was no nutrition care plan for Resident #43. Resident #148 Observation on 2/21/18 at approximately 8:45 a.m. during tour of the unit revealed Resident #148 had a sling on the right arm. Review on 2/23/18 of Resident #148's medical record revealed that a sling was ordered on [DATE] for the right arm. Review on 2/23/18 of Resident #148's care plans revealed that Resident #148 did not have a care plan for a sling to the right arm. Interview on 2/23/18 at approximately 1:00 p.m. with Staff Unit Manager confirmed that there was no care plan for the sling.",2020-09-01
160,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2018-02-26,842,D,0,1,ODTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, [MEDICAL TREATMENT] communication book review, facility policy and procedure review, and interview it was determined that the facility failed to complete ongoing assessment and oversight of the resident before, during and after [MEDICAL TREATMENT] treatments, including monitoring the resident's condition during treatments for 1 resident (#20), and based on record review and interview the facility failed to accurately record the special services received by 1 resident (#46), out of 32 residents in the finalized facility sample. Findings include: Resident #20 Review on 2/23/18 at approximately 9:00 a.m. of Resident #20's [MEDICAL TREATMENT] communication book revealed that the last communication note from the [MEDICAL TREATMENT] center and the facility was on 1/20/18. Review on 2/23/18 of Resident #20's medical record revealed that there was no evidence of Resident #20 being assessed before and after [MEDICAL TREATMENT] at the facility. There was no evidence in the record/communication book of Resident #20's monitoring while at the [MEDICAL TREATMENT] center. Interview on 2/23/18 at approximately 9:30 a.m. with Staff C, Licensed Practical Nurse revealed that the [MEDICAL TREATMENT] communication book goes with Resident #20 to [MEDICAL TREATMENT] and the book is used to communicate with the [MEDICAL TREATMENT] center. Review on 2/26/18 of the facility's policy and procedure titled, NSG253 [MEDICAL TREATMENT] Communication and Documentation, effective date 5/1/16 revealed: Policy Center staff will communicate with the [MEDICAL TREATMENT] center prior to sending a patient for [MEDICAL TREATMENT] by completing the [MEDICAL TREATMENT] Communication Record . or other state required form and sending it with the patient. The form will also be completed upon return of the patient from the [MEDICAL TREATMENT] center. 1. Prior to a patient leaving the center for outpatient [MEDICAL TREATMENT] treatment, a licensed nurse will complete the top portion of the [MEDICAL TREATMENT] Communication Record or the state required form and send with the patient to his/her out-patient [MEDICAL TREATMENT] center visit. 2. Following completion of the out-patient [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] nurse should complete the form and return it or other communication to the center with the patient. 3. Upon return of the patient to the center, a licensed nurse will: 3.1 Review the [MEDICAL TREATMENT] center communication . 3.3 Document the evaluation/observation on the [MEDICAL TREATMENT] Communication Record or state required form. Interview on 2/22/18 at approximately 12:15 p.m. with Staff A (Director of Nurses revealed that the [MEDICAL TREATMENT] center refused to use the facility's communication sheet. Resident #46 Record review of Hospice Nursing Facility Admit/Discharge notice from hospice agency dated 12/20/16 states that Resident #46 was admitted to hospice services on 12/20/16 and to be discharged on [DATE]. Review of resident #46's medical record reveals no order by provider discharging reident #46 from hospice services. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE]; Section O (Special Treatments, Procedures, and Programs); Question 0100; Section K Hospice Care response is noted as 'Yes'. Review of the Annual MDS dated [DATE]; reveals Section O ; Question 0100; Section K Hospice Care response is noted as 'Yes'. Interview 2/26/18 at about 9:45 am with Staff F Registered Nurse (RN), Nurse Manager stated that the above findings were correct and that resident was no longer receiving Hospice services.",2020-09-01
161,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,552,D,1,1,O04V11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to fully inform residents of the risk of treatment from antipsychotic medications for 2 residents reviewed in a final survey sample of 41 residents. (Resident identifiers are #3 and #44.) Findings include: Resident #44. Review on 4/2/19 at approximately 1:00 P.M. of Resident #44's medical record revealed that Resident #44 had a physician's orders [REDACTED]. Further review of this medical record revealed no documented evidence to show that the facility had informed Resident #44's activated power of attorney about the use and side effects of the ABH gel before administering the ABH gel to Resident #44. Interview on 4/2/19 at approximately 1:00 P.M. with Staff H (Registered Nurse) reviewed the above findings and confirmed that there was no documented evidence of informed consent for the physician ordered ABH gel medication for Resident #44. Resident #3 Review on 4/2/19 of Resident #3's current physician orders [REDACTED]. Review on 4/2/19 of Resident #3's [MEDICAL CONDITION] consent forms revealed no consents for [MEDICATION NAME] and [MEDICATION NAME]. Interview on 4/2/19 at 11:45 a.m. with Staff F (Unit Manager) revealed that Resident #3 makes their own medical decision and that there was no activation for DPOAH (Durable Power of Attorney for Health) for Resident #3. Staff F also revealed that when a resident has a new [MEDICAL CONDITION] medication order then a [MEDICAL CONDITION] consent form needed to be signed by the resident or DPOAH. Interview on 4/3/19 at 11:45 a.m. with Resident #3 revealed that Resident #3 makes their own medical decision. Resident #3 stated that they were not aware or told that they were on [MEDICATION NAME] and [MEDICATION NAME]. Interview on 4/3/19 at 11:45 a.m. with Staff F confirmed that there were no [MEDICAL CONDITION] consents for Resident #3's [MEDICATION NAME] and [MEDICATION NAME] in both the paper and electronic medical records. Staff F was unable to provide more information about Resident #3 giving consent to the use of [MEDICAL CONDITION] as listed above. Staff F stated that they will discuss with Resident #3 regarding the [MEDICAL CONDITION] medications use and its side effects.,2020-09-01
162,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,600,D,1,1,O04V11,"> Based on observation, medical record review and interview, it was determined that the facility failed to ensure that residents were free from neglect for 1 resident out of a final survey sample of 41 residents. (Resident identifier is #112) Findings include: Observation on 3/27/19 at approximately 10:45 a.m. revealed Resident #112's fingernails on both hands were over an inch long, they were thick and yellow and brown in color. Review on 3/27/19 of Resident #112's nurses notes and consultation notes for dates 12/1/18 through 3/29/19 revealed Resident #112 has not received nail care to include cutting, trimming or filing during these dates. Interview on 3/27/19 at approximately 2:25 p.m. with Resident #112's sibling and cousin revealed they were dissatisfied that the residents fingernails were very long, thick and filthy. Resident #112's sibling stated that he/she has brought many of his/her concerns, including the lack of fingernail care, to the attention of Staff E, (RN/Unit Manager) and he/she stated that nothing has been done since I brought these concerns to the Unit Manager about 2 weeks ago. Interview with Resident #112 on 3/27/19 at approximately 2:35 p.m. revealed complaints of pain when he/she bumps his/her nails or puts any kind of pressure on his/her fingernails. He/she stated, I have asked and asked and asked for staff to cut my fingernails or send me to a doctor who can, but they just won't do it. Interview on 3/29/19 at approximately 1:30 p.m. with Staff E, confirmed that the resident has not seen a doctor or had care provided to his/her fingernails because he/she has behaviors and has refused these services. There are no nurses notes or physician notes that support care has been offered or attempted regarding nail care for this resident. Staff [NAME] confirmed the he/she could not locate any notes to support the offerings or attempts to provide nail care to Resident #112.",2020-09-01
163,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,641,B,1,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined that the facility failed to accurately code the Minimum Data Set (MDS) of 4 residents out of a final survey sample of 41 residents. (Resident identifiers are #4, #85, #110, and #112) Findings include: Resident #112 Interview on 3/27/19 at approximately 9:30 a.m. with Staff [NAME] (Unit Manager/RN) revealed that Resident #112 would not be a good person to interview due to of her/his ongoing behaviors of throwing things at people and her/his verbal aggressiveness. Interview on 3/28/19 at approximately 8:30 a.m. with Staff T (LPN) revealed that Resident #112 can be difficult to provide care to because of Resident #112 can have verbal behavior and sometimes physical behaviors. Resident #112 often times will refuse medications and staff re-approach later in the day sometimes with positive results. Review on 4/2/19 of Resident #112's medical record revealed a current care plan specific to a psychiatric [DIAGNOSES REDACTED]. Included in Resident #112's medical record were Behavior Monitoring and Intervention sheets for the months of January, (MONTH) and (MONTH) of 2019 which contained no documented evidence of any behaviors. Review on 4/2/19 of Resident #112's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/6/19 revealed in Section's E0200 Behavior Symptom - Presence & Frequency, Section E0300 Overall Presence of Behavior Symptoms, Section E0500 Impact on Resident, Section E0600 Impact on Others and Section 0800 Rejection of Care - Presence & Frequency were not coded accurately to reflect Resident #112's behaviors. Interview on 4/2/19 at approximately 2:30 p.m. with Staff [NAME] revealed that the Behavior Monitoring and Interventions sheets were not completed. Staff [NAME] revealed that the sheets were not correctly showing Resident #112's verbal and aggressive behaviors for the months of January, (MONTH) and (MONTH) 2019 as the resident has had and continues to have behaviors that should be documented on the behavior sheets. Staff [NAME] confirmed the MDS that was completed on 3/6/19 also did not accurately reflect the Resident #112's behaviors. Resident #85 Review on 4/2/19 at approximately 2:00 p.m. of Resident #85's current medical record revealed that Resident # 85 was admitted to hospice services on 8/3/18 and discharged from hospice services on 3/29/19. Review of Resident #85's 2/8/19 Quarterly MDS (Minimum Data Set) assessment revealed that section O was coded No for hospice. Interview on 4/2/19 at approximately 2:10 p.m. with Staff P (Clinical Reimbursement Coordinator) confirmed that the 2/8/19 Quarterly MDS was coded No for hospice services when Resident #85 was receiving hospice services. Resident #4 Interview on 3/27/19 at approximately 10:30 a.m. with Staff [NAME] (Unit Manager) revealed that Resident #4 had a pressure ulcer on their left medial heel. Review on 4/1/19 of Resident #4's Skin Integrity Report, revealed that the left medial heel pressure ulcer on Resident #4 was staged as Unstageable on 1/5/19 when it was first identified. Review on 4/1/19 of Resident #4's Annual MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/16/19 revealed that Section M0300C1 was coded a 1 indicating that Resident #4 had 1 Stage 3 pressure ulcer. Section M0300E1 was coded as a 0 indicating that Resident #4 had no unstageable pressure ulcers. Interview on 4/2/19 at approximately 11:10 a.m. with Staff P (Clinical Reimbursement Coordinator) confirmed that Resident #4's MDS was coded incorrectly and should have indicated that Resident #4 had an unstageable pressure ulcer, not a Stage 3 pressure ulcer. Resident #110 Review on 4/2/19 of Resident #110's hospice records revealed Resident #110 was admitted to hospice on 2/27/19. Review on 4/2/19 of Resident #110's significant change MDS (Minimum Data Sheet) dated on 3/5/19 revealed that section J .J1400. Prognosis .does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . was coded as .0. No . and section O .O0100 special treatments, procedure and programs .K. Hospice . was coded as .2 .performed while a resident of this facility and within last 14 days . Interview on 4/2/19 at 8:39 a.m. with Staff G (MDS coordinator) confirmed the above findings. Staff G stated they would correct the MDS dated [DATE] section J1400.",2020-09-01
164,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,656,B,0,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to develop comprehensive care plans with accurate information about pressure sores and oxygen use for 3 residents in a final survey sample of 41 residents. (Resident identifiers are #32, #87, and #116.) Findings include: Resident #32 Observation on 4/1/19 at approximately 11:15 a.m. revealed that Resident #32 had a pressure ulcer on their right heel. Review on 4/1/19 of Resident #32's Skin Integrity Report, revealed that the pressure ulcer on Resident #32's heel was staged as Unstageable on 2/19/19 when it was first identified. Review on 4/2/19 of Resident #32's current care plan revealed that Resident #32's right heel pressure ulcer was documented as a .Stage IV (4) with a DTI (Deep Tissue Injury) area to site . Interview on 4/2/19 at approximately 8:35 a.m. with Staff [NAME] (Unit Manager) confirmed that Resident #32's right heel pressure ulcer was unstageable and should have been documented that way on their care plan. Resident #87 Observation on 4/1/19 at approximately 11:30 a.m. revealed that Resident #87 had a pressure ulcer on their sacrum. Review on 4/1/19 of Resident #87's Skin Integrity Report, revealed that the pressure ulcer on Resident #87's sacrum was staged as Stage 4 on 8/19/18 when it was first identified. Review on 4/2/19 of Resident #87's current care plan revealed that Resident #87's sacrum pressure ulcer was documented as a .Stage II (2) . Interview on 4/2/19 at approximately 8:35 a.m. with Staff [NAME] confirmed that Resident #87's sacrum pressure ulcer was a Stage 4 and should have been documented that way on their care plan. Resident #116 Observation on 3/29/19 at 10:30 a.m. of Resident #116 revealed the resident was using oxygen (O2) via nasal cannula and a concentrator, with no date noted on the oxygen tubing. Interview with Resident #116 at this time revealed the tubing hasn't been changed since Resident #116 came in/admission. Review of Resident #116's active orders on 4/1/19 revealed an order to CONTINUE TO WEAN PT (patient) OFF OF OXYGEN >92% N[NAME]TURNAL O2 2L (liters) >92% Interview on 4/2/19 at approximately 8:30 a.m. with Staff H (Registered Nurse) revealed they do O2 tubing changes on Sunday night, and that Staff H cannot see a date on the tubing for Resident #116 presently on the O2 concentrator. Observation at this time revealed there was a piece of tape on the tubing but it was blank. Review on 4/3/19 of Resident #116's (MONTH) 2019 Medication Administration Record (MAR) revealed his/her [DIAGNOSES REDACTED]. Review on 4/3/19 of Resident #116's care plans revealed an intervention to Monitor and report O2 Sats (saturations) levels . with no intervention for oxygen administration or to change oxygen tubing. Review on 4/3/19 at 2:25 p.m. of the (MONTH) 2019 MAR and Treatment Administration Record revealed no O2 sats recorded and no tracking for O2 sats or oxygen administration.",2020-09-01
165,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,660,D,1,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to develop a discharge care plan with identified goals for 1 of 1 discharged resident in a final survey sample of 41 residents. (Resident identifier is #132.) Findings include: Review on 4/3/19 at approximately 12:45 p.m. of Resident #132's medical record revealed the following Diagnosis: [REDACTED]. Review on 4/3/19 of the Progress Note with Late Entry Effective Date: 3/18/2019 Care Plan Meeting for Resident #132 revealed the following goals that Resident #132 would have to meet in order for Resident #132 to be discharged back to the assisted living group home: 1. the Foley catheter would have to be discontinued prior to discharge 2. needs to be able to ambulate household distances 3. toilet and dress (himself/herself) . Interview on 4/3/19 at approximately 12:45 p.m. with Staff I (Director of Social Services) after review of the comprehensive care plan and the findings listed above, Staff I confirmed that the discharge care plan was not individualized and did not identify the goals Resident #132 needed to meet in order to be discharged back to the assisted living group home.",2020-09-01
166,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,677,D,0,1,O04V11,"Based on observation, medical record review and interview, it was determined that the facility failed to ensure care was provided for a resident in a manner that maintains his/her dignity for 1 resident out of a final survey sample of 41 residents. (Resident identifier is #112.) Findings include: Observation on 3/27/19 at approximately 10:45 a.m. revealed Resident #112's thumb nails on both hands extended over the end of the finger longer than the nail bed itself and they were thick and yellow and brown in color. Review on 3/27/19 of Resident #112's nurses notes and all consultation notes dated 12/1/18 through 3/29/19 did not include any documentation specific to Resident #112's nail condition and there was no documentation of nail care to include cutting, trimming or filing during these dates. There are no nurses notes or physician notes that support care has been offered or attempted regarding nail care to this resident. Interview on 3/27/19 at approximately 2:25 p.m. with Resident #112's sibling and cousin revealed dissatisfaction that Resident #112's fingernails were very long, thick and filthy. Resident #112's sibling stated that he/she has brought his/her concerns to the attention of Staff E, (RN/Unit Manager) and he/she stated that nothing has changed since his/her concerns were reported approximately 2 weeks prior to the date of this interview. Interview with Resident #112 on 3/27/19 at approximately 2:35 p.m. revealed complaints of pain when he/she bumps his/her nails or puts any kind of pressure on his/her fingernails. He/she stated, I have asked and asked and asked for staff to cut my fingernails or send me to a doctor who can but they just won't do it. Interview on 3/29/19 at approximately 1:30 p.m. with Staff E, reviewed the above findings and Staff [NAME] confirmed that Resident #112 has not seen a doctor or had care provided to his/her fingernails because he/she has behaviors and has refused these services. Staff [NAME] confirmed the she/he could not locate any notes to support the offering or attempt to provide nail care to Resident #112. Staff [NAME] was unable to provide documentation that supported Resident #112'2 behaviors were being documented. Staff [NAME] was able to provide Behavior Monitoring Sheets, however there was no documentation of any behaviors for the above reviewed time period of 12/1/19 through 3/29/19.",2020-09-01
167,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,684,G,1,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page ,[DATE]-Vital Signs .Vital signs are a quick and efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention. When you learn the physiological variables influencing vital signs and recognize the relationship of vital sign changes to other physical assessment findings, you can make precise determinations of the clients health problems .the health care provider will order a minimum frequency of vital sign measurements for each client .As a clients physical condition worsens, it is often necessary to monitor vital signs as often as every ,[DATE] minutes. The nurse is responsible for judging whether more frequent assessments are necessary . Resident #647 Interview on [DATE] at 3:06 p.m. with Staff J (Nurse Practitioner) revealed that when ever a resident sustains a fall the facility's fall protocol is indicated, which would include neurological and vitals. Staff J stated that each unit has a sheet of paper that shows which steps are to be started and an order is not needed, it is expected to be provided by staff. Interview on [DATE] at 3:15 p.m. with Staff N (Medical Director) which was conducted by phone confirmed that the facility would follow the falls protocol but did not know the specifics of the policy because it was not right in front of them. Staff N was asked if they would expect the facility to do neurological and vitals on a resident who fell hit there head, Staff N responded Yes. Review of the facility's FALLS CARE DELIVERY PR[NAME]ESS with a revision date of [DATE] page 3 under RESPONSE TO A PATIENT FALL 1. Evaluate and monitor patient for 72 hours after the falls. Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury. Review of facility policy titled NSG204 Assessment: Neurological states .When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed: * every 30 minutes x two hours, then * every one hour x four hours, then * every four hours x 24 hours. Review on [DATE] of a nurses note dated [DATE] revealed 1630 Resident found sitting on floor, Resident stated that (they) fell and hit (their) head on foot of bed .Res (Resident) had lump on back of head d/t (due to) fall .Neuros started 1635 BP (Blood Pressure) ,[DATE] p (Pulse) 67, 1640 called NP (Nurse Practitioner) .1700 checked on resident asked if (they) would like a cold compress for head, (resident) stated yes. 1725 check on res asked if (he/she) wanted Tylenol res declined pain medication. 1800 resident sitting in wheel chair watching TV. 1845 LNA stated that (resident) needs help, found resident on bed non responsive with eyes opened and moving side to side .Called NP (Nurse Practitioner) and than called 911 . On (MONTH) 15, 2019 a clarification note was written that was completed by Staff B (Director of Nurses) after contacting Staff O (Licensed Nursing Assistant). Staff O was the person who was caring for Resident #647 at the time of the event. The facility's investigation revealed .Staff O stated that (they) entered the room of Resident #647 at around 4:30 p.m., and Resident #647 was on the floor. Staff O obtained vitals immediately and got the nurse to assess (resident) .Staff O went back to the room a little while later to see if (he/she) wanted to go to the dining room, and Resident #647 told Staff O Resident #647 wanted to eat in (their) room. Staff O states that when (they) went back into Resident #647 room after dinner to collect trays, that Resident #647 was 'not looking good', 'lying across the bed' Resident #647 arm was deep purple, and Resident #647 told Staff O 'I have a horrible headache. Staff O stated she got Resident #647 vital sings right away and 'I will never forget that her blood pressure was over 200'. 'I got the nurse right away and we sent Resident #647 by 911. Review of the NEUROLOGICAL ASSESSMENT FLOW SHEET for instructions states Document the date and time of each assessment, then proceed as follows: LEVEL OF CONSCIOUSNESS - check the appropriate response PUPIL RESPONSE - check PERL if applicable or enter the appropriate code for each eye. MOTOR FUNCTIONS-HAND GRASPS - Enter the appropriate code EXTREMITIES - Check the appropriate column(s) PAIN RESPONSE - Check the appropriate column VITALS - Record blood pressure, temperature, pulse and respiration in the appropriate columns. Use the OBSERVATION column to note the presence or absence of specific resident conditions . Review of the NEUROLOGICAL ASSESSMENT FLOW SHEET revealed on [DATE] at 4:30 p.m. Resident #647 vitals showed BP (blood pressure) ,[DATE], TEMP (temperature) 97.7 P (pulse) 67 R (respirations) 16 and none of the other assessments were completed as written above. The next documented entry on the neurological assessment flow sheet was at 5 p.m. with just the word dinner with no assessments completed. Then the next entry which was document at 6 p.m. showed vitals of BP ,[DATE] TEMP 97.7, P71, R 16. Review of the hospital notes dated [DATE] revealed that when Resident #647 was emergently brought to have CT (CAT scan) performed which revealed a large right-sided subdural hematoma with midline shift. On [DATE] at around 2:38 p.m. Resident #647's family decided to terminally extubate Resident #647 and Resident #647 expired rapidly. Based on all the clinical information written above, it was determined that the facility failed to perform neurological assessments and vitals to monitor Resident #647's condition from 4:30 p.m. to approximately 6:15 p.m. at which time Resident #647 was found on their bed non responsive with eyes opened moving side to side and assessed by Nurse Practioner. Based on medical record review and interview, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 residents out of a final survey sample of 41 residents. (Resident identifier is #17, #112, and #647) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page ,[DATE]-Vital Signs .Vital signs are a quick and efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention. When you learn the physiological variables influencing vital signs and recognize the relationship of vital sign changes to other physical assessment findings, you can make precise determinations of the clients health problems .the health care provider will order a minimum frequency of vital sign measurements for each client .As a clients physical condition worsens, it is often necessary to monitor vital signs as often as every ,[DATE] minutes. The nurse is responsible for judging whether more frequent assessments are necessary . Review on [DATE] of the the facility's falls protocol titled, Falls Care Delivery Process with a revision date of [DATE], page 3, Response to a Patient Fall 1. Evaluate and monitor patient for 72 hours after the fall. Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury. Review of facility policy titled NSG204 Assessment: Neurological reveals .When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed: * every 30 minutes x two hours, then * every one hour x four hours, then * every four hours x 24 hours. Review of the Neurological Assessment Flow Sheet for instructions reveals Document the date and time of each assessment, then proceed as follows: LEVEL OF CONSCIOUSNESS - check the appropriate response PUPIL RESPONSE - check PERL (Pupil Equal and Reactive to Light) if applicable or enter the appropriate code for each eye. MOTOR FUNCTIONS-HAND GRASPS - Enter the appropriate code EXTREMITIES - Check the appropriate column(s) PAIN RESPONSE - Check the appropriate column VITALS - Record blood pressure, temperature, pulse and respiration in the appropriate columns. Use the OBSERVATION column to note the presence or absence of specific resident conditions . Resident #17 Review of Resident #17's falls documentation of unwitnessed falls in the facility revealed the following: [DATE] and [DATE]. The Neurological Assessment Flow Sheet was started for each of these falls but none of them were complete based on the facility's falls protocol as listed below. Each of the above listed falls either was not completed for 3 full days or was missing vital sign assessments during the 3 day required assessment period or was missing the neurological part of the assessment or a combination of the above. Interview on [DATE] at approximately 2:10 p.m. with Staff [NAME] (Unit Manager/RN) confirmed there were missing entries on each of the falls listed above which means the falls protocol was not followed correctly. Resident #112 Review on [DATE] of Resident #112's falls documentation unwitnessed falls in the facility are as follows: [DATE], [DATE], [DATE], [DATE], and [DATE]. The Neurological Assessment Flow Sheet was started for each of these falls but none of them were complete based on the facility's falls protocol as listed below. Each of the above listed falls either was not completed for 3 full days or was missing vital sign assessments during the 3 day required assessment period or was missing the neurological part of the assessment or a combination of the above. Interview on [DATE] at approximately 2:15 p.m. with Staff [NAME] confirmed there were missing entries on each of the falls listed above which means the falls protocol was not followed correctly. Interview on [DATE] at 3:06 p.m. with Staff J (Nurse Practitioner) revealed that when a resident sustains a fall the facility's fall protocol is implemented, which consists of vital signs and a neurological assessment. Staff J stated that each unit has the protocol at each nurses station for reference which lists the steps required for all unwitnessed falls and Staff J stated that a doctors order is not required to implement this process but that it is expected staff will carry out the steps of the protocol. Interview on [DATE] at 3:15 p.m. with Staff N (Medical Director) was conducted over the phone, confirmed that the facility would follow the falls protocol.",2020-09-01
168,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,689,G,1,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview it was determined that the facility failed to provide appropriate supervision which resulted in harm for 2 out of a final survey sample of 41 residents. (Resident identifiers are #7 and #92.) Findings include: Resident #7 Review on 4/3/19 of a facility reported incident revealed that on 3/20/19 Resident #7 fell from a shower chair after receiving a tub bath. Review of the facility's reportable form revealed Resident #7 needed Supervised for ambulation and for ADL (Activities of Daily Living) status also to be Supervised. Also under the care plan for ADL's under Interventions it states total care with bathing, grooming, bed mobility, incontinence, Assist with sitting her up during meal time. Resident #7 has a Focus care plan stating (Resident #7) requires assistance/is dependent of ADL care in bathing, grooming, personal hygiene, dressing, related to: cognitive loss. Review on 4/3/19 of the RMS (Risk Management System) Event Summary Report dated 3/20/19, it states Pt (patient) was observed in a shower mechanical lift after being given a shower. This nurse was called to examine pt's (patient's) right toe nails in which it was reported that LNA (Licensed Nursing Assistant) had cleaned feet and then a toenail came off of the 3rd digit. Instructed LNA's to place pt in bed and then this nurse would treat it. About 15 mins (minutes) later, this nurse was passing by room and observed pt on the floor at the same time LNA's were walking in. Pt was alert and breathing even/unlabored. Observed left foot bent under the bed in awkward position. Repositioned pt and placed back in hoyer lift to place in bed. Bilat ankles shows purplish - blue discoloration and [MEDICAL CONDITION]. Pt admitted that (he/she) had also hit her head with (they) fell , but no apparent injuries noted to skull or face. Pain level is 8/10. Ambulance called and pt transported to hospital for further eval. Review on 4/3/19 of the Hospital discharge notes dated 3/25/19, revealed Discharge Diagnosis: [REDACTED]. Interview on 4/3/19 at 8:20 a.m. with Resident #7 confirmed that he/she was left alone for a period of time in the shower chair and fell out of it have excruciating pain in both ankles. Resident #7 stated that he/she does not know why they left him/her there. Interview on 4/3/19 with Staff B (Director of Nurses) at 9:15 a.m. confirmed that staff had left Resident #7 alone due to lack of communication for a period of time and Resident #7 fell from the tub chair fracturing both ankles. Staff B was asked to show the tub chair Resident #7 was in when they fell . When observing the chair Staff B stated that a seat belt has been added to the chair so resident will not fall out. Resident #92 Review on 4/3/19 of a facility reported incident states that on 3/14/19 Resident #92 attended an activity in the mid morning on 3/14/19. As the activity concluded, (Resident #92) told the activities aide that they preferred to stay in the solarium/sun room .Shortly after that, (Resident #92) got up from wheelchair and was found on the floor in the hallway, and was sent out due to a question of a fracture . On review of the current care plan under Focus reveals (Resident #92) is at risk of elopement related to: (Resident #92) has made one or more attempts to leave the facility during this stay or previous stays in this or other facilities. Believes (his/her) mother is waiting for (him/her) downstairs . and under Interventions (Resident #92) is to be in a supervised area when up in w/c (wheelchair). Under Describe the circumstances of the event .(Resident #92) was found laying on the floor in the doorway of RM (room number omitted). It appeared (he/she) had walked from the sun lounge and left (his/her) w/c (wheelchair) in the sun lounge . (Resident #92) remained on the floor unmoved until 911 arrived Under the root cause/conclusion of the RMS (Risk Management System) Event Summary Report it states (Resident #92) was found on the floor inside the doorway of RM (room number omitted). (He/She) had been attending an activity in the sun lounge. It appeared (he/she) ambulated independently resulting in a fall. On the return to the facility on [DATE] the hospital discharge [DIAGNOSES REDACTED].Closed Fracture of left proximal humerus, closed fracture of left distal radius, Fracture of right iliac wing . Interview at 4/3/19 with the Staff B (Director of Nurses) confirmed that Resident #92 was left unattended and the activites director is new and did not know that Resident #92 could not be left alone.",2020-09-01
169,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,690,D,0,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure appropriate treatment for [REDACTED]. (Resident identifier is #120.) Findings include: Interview on 3/27/19 at approximately 10:10 a.m. with Resident #120 revealed that Resident #120 had an indwelling catheter and was waiting for a nurse to come in and flush it. Resident #120 also revealed that his/her catheter was flushed by nursing approximately 1 to 2 times per day. Review on 4/1/19 of Resident #120's current physician orders revealed that there was no order in place to flush Resident #120's indwelling catheter. Review on 4/1/19 of Resident #120's (MONTH) and (MONTH) 2019 Medication and Treatment Administration Records and Progress notes revealed that there was no documentation of Resident #120's catheter being flushed or any details associated with the flushes. Interview on 4/1/19 at approximately 11:00 a.m. with Staff Q (Licensed Practical Nurse) confirmed that nursing staff had been flushing Resident #120's indwelling catheter. Staff Q also confirmed that there was no physician order to flush it and that there was no documentation of the catheter flushes, and that there should have been orders for and documentation of flushes.",2020-09-01
170,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,692,E,0,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, it was determined that the facility failed to ensure acceptable parameters of nutritional status in regards to reweights and physician and dietician notification for 3 residents in a final survey sample of 41 residents. (Resident identifiers are #26, #64, and #136.) Findings include: Review on 4/2/19 of facility's policy titled, Weight and Heights, revision date 8/01/18, revealed that .if a patients weight is less than or greater than five pounds from previous weight, the patient will be reweighed and the weight verified by a licensed nurse to determine accuracy .significant weight changes will be reviewed by the licensed nurse for assessment .significant weight change is defined as .5% (percent) in one month .10% in six months .the licensed nurse will notify the physician/APN (Advanced Practice Nurse)/PA (Physician Assistant) and dietician of significant weight changes .document notification of physician/APN/PA and Dietician licensed nurse will notify the physician/APN/PA of the dietician recommendations notify family/health care decision maker of the weight change and dietician recommendations. Family notification will be documented .the interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight change . Resident #26 Review on 4/1/19 of Resident #26's weight records revealed that Resident #26's weights were 94.8 lbs. (pounds) dated 3/20/19, 97.4 lbs. dated 3/8/19, 105 lbs. dated 2/1/19, and no weight recorded for the month of (MONTH) 2019. Further review of Resident #26's weight record revealed a 10.2 lbs. weight loss on 3/20/19 compared to 2/1/19 weight. Review on 4/1/19 of Resident #26's (MONTH) 2019 physician orders [REDACTED]. Review on 4/1/19 of Resident #26's nutritional care plan with initiated date of 11/14/17 revealed interventions to weigh Resident #26 as indicated and alert dietician and physician to any significant loss or gain. Review on 4/1/19 of Resident #26's nutritional assessments revealed Resident #26 was last seen by the dietician on 1/4/19. Review on 4/1/19 of Resident #26's progress notes revealed no documented notification to physician, dietician, and resident representative of Resident #26's 10.2 lbs. weight loss on 3/20/19 compared to 2/1/19 weight. Further review of Resident #26's progress notes revealed no documented refusal of weight and reweights from Resident #26. Interview on 4/2/19 at 12:46 p.m. with Staff F (Unit Manager) confirmed the above findings. Staff F was unable to provide any explanation regarding the missing weight for the month of (MONTH) 2019. Staff F stated that Resident #26's weight on 3/20/19 should have prompted nurses to do a re-weight, notifying the dietician, physician, and resident then document in the Resident #26's progress notes. Staff F revealed that they should have reweighed resident on 3/20/19 or 3/21/19 and notified the dietician for further assessment and recommendations. Resident #136 Review on 3/29/19 of Resident #136's weight record revealed that Resident #136 weights were 157.6 lbs. dated 3/20/19, 170 lbs. dated 2/16/19 and 177.8 lbs. dated 11/14/18, respectively. Further review of Resident #136's weight records revealed that Resident #136 had a 12.4 lbs. weight loss on 3/20/19 compared with the 2/16/19 weight. Review on 4/2/19 of Resident #136's nutrition care plan dated 12/12/18 revealed to weigh Resident #136 per protocol and alert dietician and physician to any significant loss or gain. Review on 4/2/19 of Resident #136's nutritional assessments revealed that Resident #136's was last seen by dietician on 3/10/19. Further review of Resident #136's nutritional assessment by the dietician dated 3/10/19 revealed that Resident #136 was losing weight, awaiting march weight to see if trend loss continued. Review on 4/2/19 of Resident #136's progress notes revealed no documented notification of physician, dietician, and resident of Resident #136's 12.4 lbs. weight loss on 3/20/19 compared to 2/16/19 weight. Further review of Resident #136's progress notes revealed no documented refusal to be reweighed by Resident #136. Interview on 4/2/19 at 12:46 p.m. with Staff F (Unit Manager) confirmed the above findings. Staff F stated that they should have done a reweight on 3/20/19 or 3/21/19 and followed up with the dietician for any recommendations. Staff F revealed that they had reweighed Resident #136 on 4/2/19 with a weight of 152.4 lbs. and would be following up with the dietician on 4/2/19 for continued weight loss. Resident #64 Interview on 3/27/19 at approximately 9:45 a.m. with Resident #64 revealed that Resident #64 stated that they had lost weight. Review on 4/1/19 of Resident #64's Weights and Vitals Summary revealed that on 11/19/18 it was documented that Resident #64 had a weight of 134.6 pounds. The next documented weight was on 12/19/18, and it was documented as 118.8 pounds, which was a 15.8 pound or 11.7% loss in 1 month. The next documented weight was on 1/2/19 which was 115.4 pounds, which represented another 3.4 pound loss. Interview on 4/1/19 at approximately 10:00 a.m. with Staff B (Director of Nursing) revealed that if a resident had a weight discrepancy of 3 or more pounds, a reweight should be obtained within the next 48 hours. Interview on 4/2/19 at approximately 11:00 a.m. with Staff [NAME] (Unit Manager) confirmed that Resident #64 should have had reweighs done after the weight loss on 12/19/19 and after the weight loss on 1/2/19.",2020-09-01
171,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,695,E,0,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that the facility failed to ensure that residents requiring oxygen therapy received respiratory care consistent with professional standards of practice, for 6 residents in a final survey sample of 41 residents. (Resident identifiers are #68, #77, #101, #103, #116, and #209.) Findings include: Resident #77 Interview on 3/28/19 at 2:30 p.m. with Resident #77 reveals s/he was admitted on [DATE] for pneumonia, s/he was on antibiotic for that, and s/he had part of lung removed in the past. Interview also revealed Resident #77 uses oxygen 24/7 and has had outpatient procedures at a hospital Wednesday last week and Monday this week, and they have him/her on antibiotics for coverage from that. He/she has been using the same oxygen tubing here for at least 2 weeks, it's not dated but s/he can recognize it from the nooks and crannies; Resident #77 related they don't date the oxygen tubing here and they usually only change it if s/he requests it. Observation during interview reveals the resident has an occasional cough. Interview on 4/2/19 in the p.m. with Staff B (Director of Nurses) revealed that Resident #77's oxygen tubing was changed today, she doesn't know when it was changed last prior to today. Review on 4/3/19 at 10:29 a.m. of Resident #77's care plan reveals no interventions for oxygen (O2) use. Review of orders in the electronic medical record, including Discontinued and Completed orders, revealed no oxygen administration orders until Revision Date of 4/1/2019, and these orders were incomplete as they lack rates. Interview on 4/3/19 at 1:05 p.m. with Staff K (Assistant Clinical Nurse) confirmed the above order finding as s/he reviewed the electronic record. Interview on 4/3/19 at about 12:15 p.m. with Staff A (Administrator) revealed the nursing staff changes the oxygen tubing, she thinks at night, and they do not document when it was changed, and there is no policy that addresses oxygen tubing. Observation on 4/3/19 at about 12:35 p.m. of Resident #77 revealed the resident was sitting in a chair wearing his/her nasal cannula. Observation of the oxygen tubing revealed it was dated 4/2 on the tubing from the concentrator. Interview on 4/3/19 at about 12:35 p.m. with Resident #77 revealed they changed his/her oxygen tubing since a previous interview (e.g., see above). Prior to this change the only other change here was about 1 month ago when Resident #77 requested it be changed because it was kinked. Resident #77 could tell it was the same tubing after that change a month ago by feeling it, for nooks and crannies, and the tubing now does not have that same feel. Resident #103 Interview on 4/2/19 at approximately 8:30 a.m. with Staff H (Registered Nurse) revealed they do O2 tubing changes on Sunday night. Interview on 4/2/19 at about 9:40 a.m. with Resident #103 revealed the tubing was still the same as last week and not changed on Sunday night. Observation during interview reveals no date evident on oxygen tubing. Review on 4/3/19 at 10:54 a.m. of Resident #103's orders in the electronic medical record, including Discontinued and Completed orders, revealed no oxygen administration orders until Revision Date of 4/1/2019, and these orders were incomplete as they lack rates. Review of the care plan in the electronic record revealed an intervention to Administer Oxygen as ordered/indicated Initiated on 01/14/2019. Interview and record review on 4/3/19 at 12:45 p.m. with Staff K (Assistant Clinical Nurse) reveals Resident #103's current electronic Medical Administration Record (eMAR) has an order or oxygen but does not specify the rate, relating on the record O2 concentrator set to ________liters/min Interview on 4/3/19 at 1:22 p.m. with Staff H revealed Resident #103 does not use oxygen since Resident #103's admission to this facility, so no order for oxygen; the care plan intervention was triggered by his/her diagnoses, and the neb treatment machine looks like oxygen (to explain surveyor observation of oxygen tubing). However, subsequent interview with Staff H and Staff K (see below) does confirm Resident #103 has an active order for oxygen. Interview on 4/3/19 at 1:30 p.m. with Staff H and Staff K, regarding eMAR review reveals Resident #103 does have an order for [REDACTED]. Resident #116 Observation on 3/29/19 at 10:30 a.m. of Resident #116 revealed the resident is using oxygen (O2) via nasal cannula and a concentrator, and there was no date noted on the oxygen tubing. Interview with Resident #116 at this time revealed, per the resident, the tubing hasn't been changed since Resident #116 came in. Review on 4/1/19 of Resident #116's active orders revealed an order to CONTINUE TO WEAN PT (patient) OFF OF OXYGEN >92% N[NAME]TURNAL O2 2L (liters) >92% Interview on 4/2/19 at about 8:30 a.m. with Staff H revealed the facility does O2 tubing changes on Sunday night, and Staff H related they could not see a date on the tubing for Resident #116 presently on the O2 concentrator. Observation revealed there was a piece of tape on the tubing but it was blank. Review on 4/2/19 at 10:11 a.m. of Resident #116's 3/14/19 MDS (Minimum Data Set) revealed Section O is Yes for oxygen. Review on 4/3/19 of Resident #116's (MONTH) 2019 Medication Administration Record (MAR) revealed Resident #116's [DIAGNOSES REDACTED]. Review on 4/3/19 of Resident #116's care plans revealed an intervention to Monitor and report O2 Sats (saturations) levels . with no intervention for oxygen administration or to change oxygen tubing. Review on 4/3/19 at 2:25 p.m. of the (MONTH) 2019 MAR and Treatment Administration Record revealed no O2 sats recorded and no tracking for O2 sats or oxygen administration. Resident #209 Observation on 3/27/19 at 12:02 p.m. revealed Resident #209 is in a wheelchair using nasal O2, and no O2 signage on doorway to the room. Interview with the resident during observation revealed s/he has been using oxygen for years. Observation and interview on 4/2/19 at 12:00 p.m. with Resident #209 revealed Resident #209 was observed with nasal cannula on with O2 concentrator running, no date on tubing noted, and no oxygen signage on doorway to room. When asked when the tubing was last changed, Resident #209 didn't know. Interview on 4/2/19 at 12:09 p.m. with Staff L (Licensed Practical Nurse) revealed, when told no oxygen signage on door Staff L related that he should have it. Staff L doesn't know when O2 tubing changed but it's supposed to be changed on Sundays by the nurse. Review on 4/3/19 at 10:54 a.m. of Resident #209's orders in the electronic record, including Discontinued and Completed orders, reveals no oxygen administration orders until Revision Date of 3/27/2019, with Start Date 3/27/2019 20:00 with order for Oxygen at 3 L/min via Nasal Cannula, continuously. Review of the electronic record reveals no care plan interventions for oxygen administration, there is an intervention in the ADL (activities of daily living) care plan for Monitor for SOB, fatigue and/or change in condition Interview on 4/3/19 at about 12:57 p.m. with Staff K reveals Resident #209 was admitted on [DATE]. Review on 4/3/19 at 3:19 p.m. of Resident #209's Nursing Documentation Note dated 3/20/2019 17:10 reveals it relates: . Patient was admitted /readmitted Medication List reconciled and verified with provider and no issues were identified Interview on 4/3/19 at about 12:15 p.m. with Staff A (Administrator) revealed the nursing staff changes the oxygen tubing, s/he thinks at night, and they do not document when it was changed. Staff A related there is no policy that addresses oxygen tubing. Resident # 68 Observation on 4/1/19 at approximately 9:00 a.m. of Resident # 68's room revealed a [MEDICAL CONDITION]/[MEDICAL CONDITION] (Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure) machine with oxygen attached. Review on 4/1/19 at approximately 10:30 a.m. of Resident 68's care plan revealed Resident #68 has a [MEDICAL CONDITION]/[MEDICAL CONDITION] (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) machine. Further review of the physician's orders [REDACTED]. Review of Resident #68's Nursing Documentation Note revealed a Daily Skilled Note dated 3/27/19 that states respiration even and unlabored with oxygen on at 3LPM through [MEDICAL CONDITION]. Interview on 4/1/19 at approximately 9:00 a.m. with Resident #68 revealed that the [MEDICAL CONDITION]/[MEDICAL CONDITION] is worn every night and is utilized with the oxygen. Interview on 4/1/19 at approximately 11:14 a.m. with Staff H (second floor unit manager) confirmed that there is no physicians order for the [MEDICAL CONDITION]/[MEDICAL CONDITION] or for the oxygen, and there is no care plan for the oxygen. Resident #101 Observation on 3/27/19 at approximately 10:00 a.m. of Resident #101 revealed that Resident #101 was sitting in their wheelchair in their room. An oxygen concentrator, which was running, had oxygen tubing with a nasal cannula attached to it. The nasal cannula was resting on the floor. There was also an oxygen tank, in a holder, attached to the back of Resident #101's wheelchair. It also had an oxygen tubing with a nasal cannula attached to it. That nasal cannula was also on the floor. Resident #101 was not using any oxygen. Interview on 3/27/19 at approximately 10:00 a.m. with Resident #101 revealed that Resident #101 stated that they change their own nasal cannula and that they should have been using one or the other. Observation on 3/27/19 at approximately 2:20 p.m. of Resident #101's room revealed that Resident #101 was not in their room. Observation also revealed that Resident #101's oxygen concentrator was running, and that it had oxygen tubing with a nasal cannula, that was resting on the floor, attached to it. Review on 4/1/19 of Resident #101's current care plan revealed that there was no documentation in the care plan that Resident #101 chose to apply their oxygen on their own, or that Resident #101 left their nasal cannulas on the floor. Review on 4/1/19 of Resident #101's progress notes revealed that there was no documented evidence that Resident #101 was educated on the importance of not leaving nasal cannulas on the floor, when not in use. Interview on 4/1/19 at approximately 11:00 a.m. with Staff Q (Licensed Practical Nurse) confirmed that Resident #101 needed continuous oxygen and that Resident #101 chose to change their oxygen cannulas on their own. Staff Q also confirmed that Resident #101's choices should have been documented on their care plan. Staff Q also confirmed that there was no documented evidence of education about proper storage of nasal cannulas with Resident #101 and that there should have been.",2020-09-01
172,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,758,D,1,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to ensure that residents with PRN orders for antipsychotic medications are evaluated and have a duration in the medical record for the PRN antipsychotic medication ordered for 3 residents' and failed to maintain behavior monitoring for 1 resident receiving antipsychotic medications in a final survey sample of 41 residents. (Resident identifier are #3, #28 and #44.) Findings include: Resident #44 Review on 4/2/19 at approximately 1:00 p.m. of Resident #44's medical record revealed that Resident #44 had a physician's orders [REDACTED]. Review on 4/2/19 at approximately 3:15 p.m. of Resident #44's (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 4/2/19 at approximately 3:15 p.m. of Resident #44's Behavior Monitoring records revealed that the record for (MONTH) 2019 was not completed to indicate behaviors and medication and no Behavior Monitoring record could be found for the month of (MONTH) 2019. Interview on 4/2/19 at approximately 3:15 p.m. with Staff I (Director of Social Service) confirmed, after review of the medical record and the above listed findings that there was no duration for the PRN ABH order, no evaluation for the appropriateness of the ABH for Resident #44 and that the (MONTH) 2019 Behavior Monitoring record was not completed and that there was no Behavior Monitoring record for (MONTH) 2019 for Resident #44. Resident #3 Review on 4/2/1 of Resident #3's physician ordes from (MONTH) (YEAR) revealed a order for [MEDICATION NAME] (anti-anxiety/anticonvulsant) 0.5 mg (milligram) 1 tablet by mouth everyday as needed (PRN) for severe anxiety with start date dated 12/24/18. Further review of the [MEDICATION NAME] PRN order revealed no end date. Review on 4/2/19 of Resident #3's physician orders [REDACTED]. Further review of Resident #3's physician orders [REDACTED]. Review on 4/2/19 of Resident #3's Medication Administration Record [REDACTED]. Review on 4/2/19 of Resident #3's physician progress notes [REDACTED]. Review on 4/2/19 of Resident #3's psychiatric progress notes from (MONTH) to (MONTH) 2019 revealed no documented end date and rationale for the [MEDICATION NAME] PRN order. Review on 4/2/19 of Resident #3's behavior monitoring sheets for the month of (MONTH) 2019 revealed no behavior symptom documented to be monitored. Interview on 4/2/19 at 11:45 a.m. with Staff F (Unit Manager) confirmed the above findings. Staff F was not aware the [MEDICAL CONDITION] PRN orders needed an end date. Staff F stated that they would follow up with the psychiatrist to evaluate the PRN [MEDICATION NAME] for Resident #3. Staff F also stated that the behavior monitoring sheets are charted by exception and should have documented behavior symptoms to be monitored.",2020-09-01
173,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-04-03,842,E,0,1,O04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that the facility failed to ensure that clinical records were complete and accurately maintained for 7 residents in a final survey sample of 41 residents. (Resident identifiers are #30, #62, #101, #106, #116, #127, and #137.) Findings include: Resident #116 Review on 3/29/19 at 11:04 a.m. of Resident #116's medical record reveals that the resident was DNR/DNI (do not resuscitate/do not intubate) on the physician's orders [REDACTED]. Review on 3/29/19 at 11:58 a.m. of the electronic medical record reveals a care plan focus that (Resident #116) . has an established advanced directive and is a full code. Date Initiated: 03/28/2019 . Created by: (Staff I (Social Services)) . and the target date listed under goal is 04/22/2019. Review on 3/29/19 at about 3:05 p.m. of the Resident #116's Medical Administration Record (MAR) for 3/1-31/19 charting reveals in the block for ADVANCE DIRECTIVES that the resident is DNR/DNI. Interview on 3/29/19 at about 3:10 p.m. with Staff H (Registered Nurse) and Staff I revealed the care plan/meeting note (see 3/29/19 Progress Notes below) was an error by Staff I, Resident #116 is a DNR and the paper MAR has him/her listed as a DNR, and staff confirmed with him/her today that s/he wants to be a DNR. An interview with Staff H revealed if a resident wants a change from DNR to full code they would have to get a physician order [REDACTED]. Review on 3/29/19 at about 3:15 p.m. of the 3/29/19 Progress Notes by Staff I . reveals . (Resident #116) has an established advanced directive and is a full code. Review on 3/29/19 at 3:46 p.m. of the electronic record now reveals a focus . established an advanced directive and is DNR. Date Initiated: 03/28/2019 Created on: 03/28/2019 Created by: (Staff I) . (Social Services) Revision on: 03/29/2019 Revision by: (Staff I) . (Social Services) Resident #101 Review on 3/28/19 of Resident #101's current physician orders [REDACTED].#101 had an order for [REDACTED]. Review on 3/28/19 of Resident #101's current care plan revealed that Resident #101 wished to be a DNR (Do Not Resuscitate). Review on 3/28/19 of Resident #101's admission physician orders, dated 6/25/18, revealed that Resident #101 had a physician order [REDACTED]. Interview on 3/28/19 at approximately 11:40 a.m. with Staff [NAME] (Unit Manager) confirmed that Resident #101 had confirmed that they wished to be a DNR and that a Portable DNR order form was to be done. Staff [NAME] also confirmed that the order for Full Code was written in error. Resident #127 Observation on 3/28/19 at approximately 8:25 a.m. revealed that Resident #127 was administered [MEDICATION NAME] ER (Extended Release) 100 mg (milligrams) by Staff Q (Licensed Practical Nurse). Review on 3/28/19 of Resident #127's (MONTH) Administration Record revealed that the physician's orders [REDACTED]. It was also signed off as being given at 8:00 p.m. on 3/26/19 and 3/27/19. Interview on 3/28/19 at approximately 11:00 a.m. with Staff Q confirmed that the order that was in the computer and written as 150 mg was transcribed incorrectly. After confirming the physician order, Staff Q revealed that the facility had recently switched from paper Medication Administration Records to electronic Medication Administration Records and that the dose of 150 mg was transcribed in error into the computer. Staff Q confirmed that the correct order was for [MEDICATION NAME] ER 100 mg twice daily. Resident #30 Observation and review on 3/28/19 at 8:30 a.m. with Staff C (Medication Nursing Assistant) of the medication administration for Resident #30 revealed that the Electronic Medication Administration Record (EMAR) showed to give Resident #30 [MEDICATION NAME] (antihypertensive) 25 mg (milligram) give 1 tablet by mouth every 12 hours. Resident #30's medication card for [MEDICATION NAME] 25 mg revealed to be 1/2 tablets with an instruction to give 12.5 mg (1/2 tablet) by mouth every 12 hours. Staff C looked at Resident #30's physician orders [REDACTED]. Interview on 3/28/19 at 8:35 a.m. with Staff C confirmed the above observation. Staff C stated that they were familiar with Resident #30's morning medication pass and noticed that the [MEDICATION NAME] order in the EMAR was different than what they normally gave Resident #30 in the morning which prompted them to check the order in Resident #30's chart. Staff C also stated that the facility started utilizing the EMAR on 3/26/19 and was previously utilizing the Medication Administration Record (MAR). Staff C went to Staff D (Licensed Practical Nurse) to have the [MEDICATION NAME] order corrected in the EMAR. Review on 3/28/19 of Resident #30's (MONTH) 2019 MAR revealed [MEDICATION NAME] 25 mg give 1/2 tablet (12.5 mg) by mouth every 12 hours signed off as given from (MONTH) 1 to 25, 2019. Review on 3/28/19 of Resident #30's (MONTH) 2019 EMAR revealed that [MEDICATION NAME] 25 mg give 1 tab by mouth every 12 hours was signed off as given on 3/26/19 and 3/27/19. Resident #137 Observation on 3/28/19 at 10:30 a.m. at the 3rd floor nurse's station revealed that Staff C spoke to Staff D regarding two entries in the EMAR for the same medication for Resident #137. Interview on 3/28/19 at 12:15 p.m. with Staff C revealed that Staff C noticed two entries in the EMAR for Resident #137's Duloxetine (antidepressant) medication and that they had looked at the physician order [REDACTED]. Observation and review on 3/28/19 at 12:15 p.m. with Staff C revealed that the EMAR for Resident #137 showed Duloxetine HCL Capsule Release particles alternating dose: 30 mg give alternating dose of 30 mg \ 60 mg by mouth one time a day every other day which was scheduled to be given on 3/28/19 and Duloxetine HCL Capsule Release particles alternating dose: 60 mg give alternating dose of 30 mg \ 60 mg by mouth one time a day every other day which was scheduled to be given on 3/28/19. Interview on 3/28/19 at 12:15 p.m. with Staff C stated they gave Resident #137 Duloxetine 30 mg during 3/28/19 morning medication pass. Review on 3/28/19 of Resident #137's (MONTH) 2019 physician orders [REDACTED]. Review on 3/28/19 of Resident #137's (MONTH) 2019 MAR revealed Duloxetine 60 mg signed off as given on 3/24 and 3/26 and Duloxetine 30 mg signed off as given on 3/25/19. Review on 3/28/19 of Resident #137's (MONTH) 2019 EMAR revealed Duloxetine 30 mg and 60 mg were signed off as given on 3/26/19, Duloxetine 60 mg was signed off as given on 3/27/19 and Duloxetine 30 mg was signed off as given on 3/28/19. Interview on 3/28/19 at 2:00 p.m. with Staff B (Director of Nursing) confirmed the above observations and findings for Resident #30 and Resident #137. Staff B stated that the facility started the transition from paper MAR to EMAR on 3/26/19. Staff B revealed that assigned staffs were given the task to enter physician orders [REDACTED]. Staff B stated that when they started the EMAR on 3/26/19 nursing staff giving medications were to reconcile the EMAR with the paper MAR that was readily available in the med cart and any discrepancy would be corrected. Staff B also stated that as they just started the transition to utilizing the EMAR for medication pass that glitches would be expected. Staff B also stated that they will educate the nursing staff that were giving medication to reconcile the EMAR with the paper MAR and correct any discrepancies. Resident #106 Review on 4/1/19 of Resident #106's Electronic Medical Record (EMR) revealed that Resident #106 had a discharge date of [DATE]. Review on 4/1/19 of Resident #106's progress notes revealed no documentation of discharge or transfer out of the facility on 3/31/19 and last documented progress note was dated 3/18/19. Interview on 4/1/19 at 1:05 p.m. with Staff C confirmed the above findings. Staff C revealed that Resident #106 was admitted to the hospital for [MEDICAL CONDITION] and chest pain on 3/31/19. Staff C stated Resident #106 was transferred to the hospital on [DATE] 11-7 shift. Staff C also revealed that a late entry note would be done on 4/1/19. Resident #62 Observation on 4/3/19 at 12:10 p.m. with Staff [NAME] (Unit Manager) and Staff J (Advance Practice Registered Nurse) of Resident #62's wound dressing change revealed that Resident #62 had a [MEDICATION NAME] wound dressing on right ear. Staff J states that they have been treating the wound on right ear with daily dry dressing and to continue daily dry dressing. Staff J revealed dry dressing can be a foam dressing, border dressing or a [MEDICATION NAME] dressing. Staff J states that the [MEDICATION NAME] dressing was better to use as the dressing would not fall off easily as Resident #62 favors and leans to their right side. Review on 4/3/19 of Resident #62's skin integrity report revealed that Resident #62 had a pressure ulcer on right ear that was first observed on 1/3/19. Review on 4/3/19 of Resident #62's physician orders [REDACTED].#62's wound on the right ear. Review on 4/3/19 of Resident #62's Treatment Administration Record (TAR) for the month of (MONTH) and (MONTH) 2019 revealed no treatment for [REDACTED]. Review on 4/3/19 of Resident #62's Electronic Treatment Administration Record (ETAR) for the month of (MONTH) 2019 and (MONTH) 2019 revealed no treatment for [REDACTED]. Interview on 4/3/19 at 12:15 p.m. with Staff [NAME] confirmed the above observation and findings. Staff [NAME] was unable to explain why there was no treatment orders for Resident #62's right ear wound in the ETAR, paper TAR, and the physician order [REDACTED].",2020-09-01
174,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2018-05-02,607,D,1,0,GEL411,"> Based on record review and interview, it was determined that the facility failed to implement written policies and procedures for investigating allegations of abuse for 1 of 1 allegation of abuse reviewed. (Resident identifier is #1.) Findings include: Review on 5/2/18 at 10:15 a.m. of the facility's policy titles OPS300 Abuse Prohibition, revised 3/1/18 revealed the following procedure: Process: .6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following: .6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation was made .6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: .6.7.2 clinical examination for signs of injuries, if indicated. Interview on 5/2/18 at approximately 1:15 p.m. with Staff H (Licensed Practical Nurse) revealed an allegation of sexual abuse was reported to Staff H on 4/29/18 (Sunday) after breakfast by Resident #1 and Resident #1's husband and Resident #4 (a friend). Staff H revealed that Staff H immediately reported the allegation to Staff I (Weekend Supervisor). Staff H revealed that Staff I did speak with the resident and resident's husband following the report. Staff H revealed when Staff H reported to work the next morning (4/30/18, Monday), Staff H realized that the allegation had not been reported to the Director of Nursing or Administrator and did so immediately. Review on 5/2/18 at 9:45 a.m. revealed no record of the allegation on 4/29/18 or that any interventions were performed to examine the resident, to contact the designated provider, or to contact the facility administration. Review on 5/2/18 at approximately 9:45 a.m. of Residents #1's hospital inpatient summary records dated 5/2/18 revealed the resident was admitted to the emergency department on 4/30/18 at approximately 12:12 p.m. Interview on 5/2/18 at approximately 1:20 p.m. with Staff A (Director of Nursing) confirmed that the allegation from Resident #1 of sexual abuse had not been reported to Staff A until the morning on 4/30/18 nor had clinical examination for signs of injuries been performed until 4/30/18.",2020-09-01
175,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2018-05-02,608,D,1,0,GEL411,"> Based on record review and interview, it was determined that the facility failed to report in an appropriate timeframe to the State Agency and one or more law enforcement entities a suspicion of sexual abuse against a resident at the facility for 1 of 1 allegations of abuse reviewed. (Resident identifier is #1.) Findings include: Review on 5/2/18 at 10:15 a.m. of the facility's policy titled OPS300 Abuse Prohibition, revised 3/1/18 revealed the following procedure: Process: .6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following: .6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required. Interview on 5/2/18 at approximately 1:15 p.m. with Staff H (Licensed Practical Nurse) revealed that Resident #1, Resident #1's husband, and Resident #1's friend (Resident #4) came to Staff H after breakfast on 4/29/18 and alleged that Resident #1 had been the victim of sexual abuse. Review of the fax confirmation for the initial report of the allegation of sexual abuse for Resident #1 to the State Agency revealed the State Agency was notified on 4/30/18 at 1:43 p.m. Interview on 5/2/18 at approximately 1:20 p.m. with Staff A (Director of Nursing) confirmed the above information and revealed that the allegation from Resident #1 of sexual abuse from the morning of 4/29/18 had not been reported to the police until after reported to Staff A on the morning of 4/30/18 and Resident #1 was admitted to the hospital.",2020-09-01
176,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2018-07-03,658,D,1,0,4R9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined that the facility failed to ensure that services being provided meet professional standards of quality for 1 resident in a survey sample of 5 residents. (Resident identifier is #1.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 16 Nursing Assessment, page 243-Data Documentation Data documentation is the last part of a complete assessment. The timely, thorough and accurate documentation of facts is necessary when recording client data . If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client. If there is not specific information, the reader is left with only general impressions. Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Chapter 35 Medication Administration Page 699-Prescriber's Role Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 706-709-Standards The prescriber often gives specific instructions about when to administer a medication Page 713-Recording Medication Administration .A registered nurse compares the list of medications on the MAR indicated [REDACTED].After administering a medication, record it immediately on the appropriate record form .After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurse's notes. Review on 7/3/18 of Resident #1's Physician orders [REDACTED].). Review on 7/3/18 of Resident #1's Medication Administration Record [REDACTED]. Review on 7/3/18 of Resident #1's MAR for (MONTH) revealed the medication was not given at 8:00 a.m. for the days of 6/7/18 and 6/8/18, as well as the days of 6/10/18, 6/12/18 through 6/14/18. For the scheduled dose at 8 p.m. the medication was not given on 6/5/18 and 6/9/18 through 6/13/18. Review of the progress notes and the back pages of the MAR's of (MONTH) and (MONTH) reveal no indication as to why medication was not administered at those times. Review on 7/3/18 of Resident #1's medical record revealed a finding of a Carvedilol order that was incorrectly posted to Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's MAR for the month of (MONTH) and the month of (MONTH) was conducted. From the review of the documents, it was determined that Resident #1 only received one dose in the mornings of each day from 5/18/18 to 6/14/18. There is no documentation of a second dose being administered during the reviewed time frame. Review on 7/3/18 of Resident #1's medical record revealed a [MEDICATION NAME] order that read [MEDICATION NAME] ([MEDICATION NAME]) 1 mg 1-3 tabs PO as directed dated 5/17/18. Subsequent review of Resident #1's MAR for the month of (MONTH) revealed a note, in the documentation section for the administration of the drug [MEDICATION NAME], to see flowsheet. Resident #1's dedicated flowsheet for the administration of [MEDICATION NAME] in the month of (MONTH) revealed no entries for the time period 5/17/18 to 5/21/18. Review on 7/3/18 of Resident #1's medical record revealed a physician order [REDACTED]. Subsequent review of the medical record reveals no documentation of the fluid I & O totals of Resident#1 from the date of the order 6/23/18 to 7/2/18. Interview on 7/3/18 at 11:15 AM with Staff A (Director of Nursing) confirmed the above findings.",2020-09-01
177,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2018-11-15,842,B,1,0,0LPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to provide documentation of occurrences and/or assessments related to resident falls and medication administration for 3 of 7 residents reviewed. (Resident identifiers are #5, #6, and #7.) Findings include: Resident #5 Review on 11/14/18 of Resident #5's progress notes revealed a progress note dated 9/15/18 that referred to a fall on 9/14/18 that resulted in a [MEDICAL CONDITION]. There was no documentation on 9/14/18 of a fall, an assessment after a fall, any treatments initiated, or notification of responsible parties. Interview on 11/14/18 at approximately 2:00 p.m. with Staff A (Director of Nursing) revealed that Resident #5 did have a fall that resulted in a [MEDICAL CONDITION] and Resident #5 was transported to the hospital via ambulance. Staff A provided an Event Summary Report dated 9/14/18. Review on 11/14/18 of the Event Summary Report dated 9/14/18 revealed Resident #5 had an unwitnessed fall on 9/14/18 that resulted in bleeding from the resident's head. The resident was transported to the hospital via ambulance. There was no documentation of an assessment after the fall, any treatments initiated, or notification of the responsible parties. Resident #6 Resident #6 complained that on the evening of (MONTH) 16, (YEAR) at approximately 9:30 pm the resident had a fall that was witnessed by Staff B, Nurse on duty. Review on 11/14/18 of Resident #6's electronic record revealed that there was no evidence of documentation of a witnessed fall that had taken place on (MONTH) 16, (YEAR) at approximately 9:30 pm. There was also no evidence of documentation to support that Resident #6 was assessed after the fall by Staff B the nurse on duty at the time of the fall, and no evidence of documentation to support that Staff B had reported the fall and assessment to the physician and other responsible parties as required by the facility's Policy and Procedures for falls, Fall Response Protocol, and Guidelines for Managing a Fall. An interview with Staff A on 11/14/18 at approximately 2:00 pm confirmed the above findings. Resident #7 Review on 11/14/18 of Resident #7's physician orders [REDACTED]. Review on 11/14/18 of Resident #7's Medication Administration Record [REDACTED]. Review on 11/14/18 of Resident #7's Event Summary Report, dated 6/24/18 indicates that Resident #7 received [MEDICATION NAME] before being transferred to the hospital for a suspected overdose of opioids. Interview with Staff A on 11/14/18 at approximately 2 p.m. confirmed the above findings and revealed there was no documented evidence of an investigation of Resident #7's suspected overdose.",2020-09-01
178,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,550,D,0,1,BFLK11,"Based on observations and interview, it was determined that the facility failed to ensure that each resident's dignity is maintained for 3 residents out of a final survey sample of 40 residents. (Resident identifiers are #26, #114 and #338.) Findings include: Observation on 11/12/19 at approximately 1:20 p.m. of the lunch meal in the third floor main dinning room revealed Resident #26 sitting in a wheelchair positioned at a table who was self propelling back and forth in a wheelchair. Resident #26 appeared agitated and visibly distraught sobbing and crying out loudly for her babies, stating I want to die and I'm going to kill myself. Resident #26 continued this behavior in the presence of approximately 20 other residents eating lunch with no staff intervention. Other residents present at this dining observation appeared upset by this behavior. One resident at another table walked over to Resident #26 and spoke to Resident #26 in a low comforting voice and proceeded to rub Resident #26's back in a comforting manner. This behavior continued for approximately 10 minutes from 1:20 p.m. to 1:30 p.m. before a staff member intervened and sat down calmly redirecting Resident #26 to the lunch meal. Resident #338 Observation on 11/12/19 at approximately 12:10 p.m. of Resident #338's room revealed Resident #338 had a catheter drainage bag without a privacy bag that was visible from the doorway. Observation on 11/12/19 at approximately 12:30 p.m. in the dining room revealed that Resident #338 had a visible catheter drainage bag without a privacy bag. Observation on 11/13/19 at approximately 10:30 a.m. of Resident #338's room revealed Resident #338 had a catheter drainage bag without a privacy bag that was visible from the doorway. Interview on 11/13/19 at approximately 10:30 a.m. with Staff C (Unit Manager) confirmed that Resident #338's catheter did not have a privacy bag and was visible from the doorway. Resident #114 Observation on 11/12/19 at approximately 12:20 p.m. of Resident #114's room revealed that Resident #114 had a catheter drainage bag that was touching the floor and without a privacy bag that was visible from the doorway. Observation on 11/13/19 at approximately 10:35 a.m. of Resident #114's room revealed that Resident #114 had a catheter drainage bag that was touching the floor without a privacy bag that was visible from the doorway. Interview on 11/13/19 at approximately 10:35 a.m. with Staff C, (Unit Manager) confirmed that Resident #114's catheter bag was touching the floor and without a privacy bag that was visible from the doorway.",2020-09-01
179,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,656,B,0,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview and review of the facility Bi-level Positive Airway Pressure ([MEDICAL CONDITION]) /Continuous Positive Airway Pressure ([MEDICAL CONDITION]) policy and procedure, it was determined that the facility failed to develop and implement care plans for 3 residents out of a final survey sample of 40 residents. ( Resident identifiers are #20, #34 and #53.) Findings include: Review on 11/15/19 of the facility Bi-level Positive Airway Pressure ([MEDICAL CONDITION])/Continuous Positive Airway Pressure ([MEDICAL CONDITION]) policy and procedure with a Revision Date: 11/01/19 revealed the following: . 9. Cleaning the system: 9.1 Clean the unit weekly . 10. Document: 10.1 Settings; 10.2 Mask size; 10.3 Date and time [MEDICAL CONDITION]/[MEDICAL CONDITION] initiated; 10.4 Supplemental oxygen, if applicable; 10.5 Humidification, if applicable; 10.6 Tolerance of [MEDICAL CONDITION]/[MEDICAL CONDITION] and mask; 10.7 Education of the patient, staff, and family; 10.8 Patient evaluation; 10.9 Skin irritation, if applicable; and 10.10 Notification of physician/mid-level provider, if applicable. Resident #20 Observation on 11/12/19 at approximately 9:00 a.m. revealed a [MEDICAL CONDITION] (Continuous Positive Airway Pressure) machine, hose and mask on Resident #20's bedside stand. At the time of the observation, Resident #20 indicated that the [MEDICAL CONDITION] machine is used by Resident #20 at bedtime to help me sleep. Review on 11/15/19 of the TREATMENT ADMINISTRATION RECORD (TAR) for Resident #20 dated 11/1/2019 - 11/30/2019 revealed the following: Resident on [MEDICAL CONDITION] 10 cm (centimeter) at bedtime. Review on 11/15/19 of Resident #20's care plan revealed a [DIAGNOSES REDACTED]. Further review of this care plan revealed no documented evidence of a [MEDICAL CONDITION] care plan for Resident #20. Interview on 11/15/19 at approximately 11:45 a.m. with Staff D (Registered Nurse) and review of the TAR, care plan and nursing progress notes confirmed that Resident #20 has a [MEDICAL CONDITION] machine at bedtime and confirmed the following; 1. That there was no documented evidence to show that the [MEDICAL CONDITION] was cleaned weekly 2. That there was no documented evidence of a [MEDICAL CONDITION] Care Plan 3. That there was no documented evidence of mask size, date & time [MEDICAL CONDITION] initiated, tolerance of [MEDICAL CONDITION] mask, patient education, patient evaluation and/or skin evaluation for Resident #20. Resident #34 Review on 11/15/19 of Resident #34's PROGRESS NOTE dated 11/15/2019 revealed a Stage IV pressure ulcer to the sacrum. Review on 11/15/19 of Resident #34's care plan revealed no documented evidence of a care plan for the Stage IV sacral ulcer with goals and interventions. Interview on 11/15/19 at approximately 11:30 am with Staff D (Registered Nurse) confirmed that there was no documented evidence of a care plan for Resident #34's Stage IV sacral ulcer with goals and interventions. Resident #53 Review on 11/13/19 of Resident #53's (MONTH) 2019 Medication Administration Record [REDACTED]. The review also revealed that Resident #53 had an order for [REDACTED].#53 also had an order for [REDACTED]. Review on 11/14/19 of Resident #53's current care plan revealed that there was no care plan in place for Resident #53's use of [MEDICAL CONDITION] medications. Interview on 11/15/19 at approximately 10:45 a.m. with Staff M (Regional Clinical Manager) confirmed that Resident #53 did not have a care plan in place for their use of [MEDICAL CONDITION] medications. Staff M also confirmed that a care plan should have been in place for these medications.",2020-09-01
180,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,658,E,1,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to follow the professional standard of practice for following physician orders [REDACTED]. (Resident identifiers are #1, #8, #21, #34, #52, #55, #63,#74, #88, #94, #114,#119, #230 and #383.) Findings include: Reference for the professional standard of practice is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 708 The prescriber often gives specific instructions about when to administer a medication Page 713 .A registered nurse compares the list of medications on the MAR against the original orders for accuracy and thoroughness . After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurses notes. Review on 11/13/19 of the facility's liberalized medication pass schedule, no revision date, revealed that .The liberalized medication pass program is currently under review as well as personalized medication schedules . .frequency .options .in the morning .7a-12p (7:00 a.m. to 12:00 p.m.) . .in the evening .4p-7p (4:00 p.m. to 7:00 p.m.) .two times a day .7a-12p/4p-10p (7:00 a.m. to 12:00 p.m., 4:00 p.m. to 7:00 p.m.) . .three times s day .7-10a,2-3p, 7-10p (7:00 a.m. to 10:00 a.m., 2:00 p.m. to 3:00 p.m., 7:00 p.m. to 10:00 p.m.) . Interview on 11/13/19 at 12:15 p.m. with Staff I (Licensed Practical Nurse), who worked at the fourth floor unit, revealed that the facility was understaffed. Staff I was responsible for 2 medication carts, 30-40 residents medication administration, resident assessments, blood sugar checks for the diabetic residents on the fourth floor unit, and documentation.Staff I also stated that they would pass morning scheduled medication until 2:00 p.m.-3:00 p.m. Resident #34 Observation on 11/15/19 at approximately 7:00 a.m. during wound rounds with Staff D (Registered Nurse) and Staff L (Nurse Practitioner) revealed a dressing change and wound measurements of a Stage IV pressure ulcer to the sacrum for Resident #34. Review on 11/15/19 of Resident #34's physician orders [REDACTED]. Review of this MAR and nursing notes for 11/15/19 showed no documented evidence that [MEDICATION NAME] 25 mg by mouth was given to Resident #34 one hour prior to the 7:00 a.m. wound care treatment observed on 11/15/19. Interview on 11/15/19 at approximately 11:30 a.m. with Staff D confirmed that there was no documented evidence on the MAR and nursing notes listed above on 11/15/19 to show that Resident #34 was given the pain medication of [MEDICATION NAME] 25 mg by mouth one hour prior to the wound care done on 11/15/19. Resident #230 Review on 11/15/19 of Resident #230 MAR (Medication Administration Record) revealed an order written [REDACTED]. Also a PRN (as needed) order was written as follows: [MEDICATION NAME] Tablet 500 MG Give 2 tablet by mouth every 6 hours as needed for pain. Review on 11/15/19 of the MAR revealed on 11/5/19 [MEDICATION NAME] 75 MG was given, but not until 11:44 p.m. almost 2 hours outside the scheduled time. Resident #230 also needed to receive [MEDICATION NAME] 1000 MG at 11:51 p.m. due to a pain level of 5. Resident #74 Review on 11/15/19 of Resident #74's medication audit report revealed that Resident #74's Tylenol 500 mg (milligram) give 2 tablets by mouth three times a day for pain was scheduled for 7:00 a.m. to 10:00 a.m. and was given on 11/11/19 at 11:40 a.m. Resident #74's [MEDICATION NAME] (anti-epileptic/nerve pain) 100 mg give 1 tablet by mouth three times a day for anxiety and was scheduled for 7:00 a.m. to 10:00 a.m. was given on 11/11/19 at 11:39 a.m. Resident #94 Review on 11/15/19 of Resident #94's medication audit report revealed that Resident #94's Quetiapine [MEDICATION NAME] (antipsychotic) 25 mg give 0.5 tablet by mouth in the morning was scheduled for 7:00 a.m. to 12:00 p.m. and was given on 11/2/19 at 2:49 p.m., 11/4/19 at 2:15 p.m., 11/5/19 at 1:50 p.m., 11/7/19 at 3:21 p.m., 11/11/19 at 2:14 p.m., 11/13/19 at 3:21 p.m., and 11/14/19 at 1:49 p.m. [MEDICATION NAME] (benzodiazapine) 5 mg give 2 tablets by mouth two times a day related to anxiety disorder was scheduled for 7:00 a.m. to 12:00 p.m. and was given on 11/2/18 at 2:48 p.m., 11/4/19 at 2:15 p.m., 11/5/19 at 1:44 p.m., 11/7/19 at 1:21 p.m., 11/11/19 at 2:13 p.m., 11/13/19 at 3:21 p.m., and 11/14/19 at 1:49 p.m. [MEDICATION NAME] (anticonvulsant) 1000 mg give 1 tablet by mouth two times a day was scheduled for 7:00 a.m. to 12:00 p.m. and was given on 11/4/19 at 2:15 p.m., 11/5/19 at 1:45 p.m., 11/7/19 at 3:21 p.m., 11/11/19 at 2:14 p.m., 11/13/19 at 3:21 p.m., and 11/14/19 at 1:49 p.m. Review on 11/15/19 of the facility's Medication Administration Report (MAR) from 11/1/19 through 11/15/19 revealed that scheduled medications were administered greater than 1 hour of the scheduled administration times. Resident #63 Review on 11/15/19 of Resident #63's MAR revealed that Resident #63 was scheduled to receive [MEDICATION NAME] 0.5 MG (milligram) tablet on 11/4/19 at 8:00 a.m., it was administered at 2:51 p.m. Resident #8 Review on 11/15/19 of Resident #8's MAR revealed that Resident #8 was scheduled to receive [MEDICATION NAME] HCI tablet 500 Milligrams. Give 1 tablet by mouth three times a day. This review revealed: [MEDICATION NAME] 500 MG (milligram) tablet on 11/1/19 at 8:00 a.m. it was administered at 11:29 a.m. [MEDICATION NAME] 500 MG tablet on 11/2/19 at 8:00 a.m. it was administered at 2:05 p.m. [MEDICATION NAME] 500 MG tablet on 11/3/19 at 12:00 p.m. it was administered at 3:06 p.m. [MEDICATION NAME] 500 MG tablet on 11/4/19 at 8:00 a.m. it was administered at 12:10 p.m. [MEDICATION NAME] 500 MG tablet on 11/4/19 at 12:00 p.m. it was administered at 3:02 p.m. [MEDICATION NAME] 500 MG tablet on 11/5/19 at 8:00 a.m. it was administered at 10:26 a.m. [MEDICATION NAME] 500 MG tablet on 11/5/19 at 12:00 p.m. it was administered at 2:13 p.m. [MEDICATION NAME] 500 MG tablet on 11/6/19 at 8:00 a.m. it was administered at 12:29 p.m. [MEDICATION NAME] 500 MG tablet on 11/7/19 at 8:00 a.m. it was administered at 3:14 p.m. [MEDICATION NAME] 500 MG tablet on 11/7/19 at 8:00 a.m. it was administered at 10:33 a.m. [MEDICATION NAME] 500 MG tablet on 11/7/19 at 12:00 p.m. it was administered at 3:15 p.m. [MEDICATION NAME] 500 MG tablet on 11/8/19 at 8:00 a.m. it was administered at 11:13 a.m. [MEDICATION NAME] 500 MG tablet on 11/8/19 at 12:00 p.m. it was administered at 3:02 p.m. [MEDICATION NAME] 500 MG tablet on 11/9/19 at 12:00 p.m. it was administered at 2:35 p.m. [MEDICATION NAME] 500 MG tablet on 11/10/19 at 8:00 a.m. it was administered at 10:19 a.m. [MEDICATION NAME] 500 MG tablet on 11/10/19 at 12:00 p.m. it was administered at 1:44 p.m. [MEDICATION NAME] 500 MG tablet on 11/11/19 at 8:00 a.m. it was administered at 12:26 p.m. [MEDICATION NAME] 500 MG tablet on 11/12/19 at 8:00 a.m. it was administered at 3:02 p.m. [MEDICATION NAME] 500 MG tablet on 11/12/19 at 12:00 p.m. it was administered at 3:02 p.m. [MEDICATION NAME] 500 MG tablet on 11/13/19 at 8:00 a.m. it was administered at 11:04 a.m. [MEDICATION NAME] 500 MG tablet on 11/14/19 at 8:00 a.m. it was administered at 11:26 a.m. [MEDICATION NAME] 500 MG tablet on 11/15/19 at 8:00 a.m. it was administered at 10:58 a.m. Review on 11/15/19 of Resident #8's MAR revealed that Resident #8 was scheduled to receive Tylenol tablet 325 Milligrams. Give 2 tablets by mouth three times a day. This review revealed: Tylenol 325 MG tablet on 11/1/19 at 8:00 a.m. it was administered at 11:29 a.m. Tylenol 325 MG tablet on 11/2/19 at 8:00 a.m. it was administered at 2:05 p.m. Tylenol 325 MG tablet on 11/4/19 at 8:00 a.m. it was administered at 12:10 p.m. Tylenol 325 MG tablet on 11/6/19 at 8:00 a.m. it was administered at 12:29 p.m. Tylenol 325 MG tablet on 11/7/19 at 8:00 a.m. it was administered at 3:14 p.m. Tylenol 325 MG tablet on 11/9/19 at 8:00 a.m. it was administered at 11:13 p.m. Tylenol 325 MG tablet on 11/11/19 at 8:00 a.m. it was administered at 12:27 p.m. Tylenol 325 MG tablet on 11/12/19 at 8:00 a.m. it was administered at 3:02 p.m. Tylenol 325 MG tablet on 11/13/19 at 8:00 a.m. it was administered at 11:04 p.m. Tylenol 325 MG tablet on 11/14/19 at 8:00 a.m. it was administered at 11:26 a.m. Tylenol 325 MG tablet on 11/15/19 at 8:00 a.m. it was administered at 11:03 p.m. Resident #114 Review on 11/15/19 of Resident #114's MAR revealed that Resident #114 was scheduled to receive [MEDICATION NAME] HCI tablet 2 Milligrams. Give 2 tablets by mouth every 8 hours. This review revealed: [MEDICATION NAME] 2 MG tablet on 11/4/19 at 12:00 a.m. it was administered at 03:50 a.m. [MEDICATION NAME] 2 MG tablet on 11/10/19 at 12:00 a.m. it was administered at 02:43 a.m. Insulin [MEDICATION NAME] to be administered before meals on 11/12/19 at 4:30 p.m. it was administered at 6:10 p.m. Insulin [MEDICATION NAME] to be administered before meals on 11/4/19 at 7:30 a.m. it was administered at 9:02 a.m. Resident #1 Review on 11/15/19 of Resident #1's (MONTH) 2019 Medication Administration Record revealed that Resident #1 had an order for [REDACTED]. Give 5 mg at noon with food. Review on 11/15/19 of Resident #1's Medication Admin (Administration) Report revealed the following: On 10/1/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 1:43 p.m. On 10/6/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 1:39 p.m. On 10/16/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 1:46 p.m. On 10/18/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 1:46 p.m. On 10/19/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 3:17 p.m. On 10/22/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 2:49 p.m. On 10/24/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 1:56 p.m. On 10/25/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 10:15 p.m. On 10/26/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 2:34 p.m. On 10/27/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 2:37 p.m. On 10/28/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 1:49 p.m. On 11/1/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 1:48 p.m. On 11/6/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 3:29 p.m. On 11/8/19, it was documented that Resident #1 received [MEDICATION NAME] 5 mg at 2:46 p.m. Interview on 11/15/19 at approximately 1:15 p.m. with Staff M (Regional Clinical Manager) confirmed that medications ordered at a specific time, with food, should be administered at that time. Resident #21 Review on 11/25/19 of Resident #21's MAR revealed that Resident #21 was scheduled to receive Humalog insulin Inject as per sliding scale subcutaneously before meals and at HS. This review revealed: On 11/12/19 dose scheduled for 8:00 a.m. was administered at 11:15 a.m. On 11/7/19 dose scheduled for 8:00 a.m. was administered at 12:50 p.m. On 11/7/19 dose scheduled for 11:30 a.m. was administered at 2:00 p.m. On 11/6/19 dose scheduled for 8:00 a.m. was administered at 11:33 a.m. On 11/6/19 dose scheduled for 11:30 a.m. was administered at 2:59 p.m. On 11/6/19 dose scheduled for 4:30 p.m. was administered at 6:42 p.m. On 11/5/19 dose scheduled for 4:30 p.m. was administered at 6:12 p.m. by On 11/3/19 dose scheduled for 8:00 a.m. was administered at 12:37 p.m. On 11/2/19 dose scheduled for 8:00 a.m. was administered at 11:24 a.m. Resident #21's MAR revealed that Resident #21 was scheduled to receive Tylenol Extra Strength Tablet(500 mg) give 2 tablets by mouth tree times a day. This review revealed: On 11/14/19 dose scheduled for 8:00 a.m. was administered at 11:06 On 11/12/19 dose scheduled for 8:00 a.m. was administered at 11:15 a.m. On 11/8/19 dose scheduled for 12:00 noon was administered at 2:22 p.m. On 11/7/19 dose scheduled for 8:00 a.m. was administered at 12:54 p.m. On 11/6/19 dose scheduled for Noon was administered at 2:59 p.m. On 11/6/19 dose scheduled for 8:00 a.m. was administered at 11:34 a.m. On 11/4/19 dose scheduled for 8:00 a.m. was administered at 11:25 a.m. Resident #21's MAR revealed that Resident #21 was scheduled to receive [MEDICATION NAME] 100 mg give by mouth every 8 hours for pain. This review revealed: On 11/9/19 dose scheduled for 5:00 a.m. was administered at 8:34 a.m. Resident #21's MAR revealed that Resident #21 was scheduled to receive [MEDICATION NAME] 40 mg by mouth in the morning. This review revealed: On 11/7/19 dose scheduled for 8:00 a.m. was administered at 12:54 p.m. On 11/3/19 dose scheduled for 8:00 a.m. was administered at 12:25 p.m. Resident #52 Review on 11/25/19 of Resident #52's MAR revealed that Resident #52 was scheduled to receive [MEDICATION NAME] 12.5 mg by mouth two times a day. This review revealed: On 11/6/19 dose scheduled for 8:00 a.m. was administered at 12:09 p.m. Resident #55 Review on 11/25/19 of Resident #55's MAR revealed that that Resident #55 was scheduled to receive [MEDICATION NAME] 5 mg by mouth every 8 hours. This review revealed: On 11/15/19 dose scheduled for midnight was administered at 4:39 a.m. On 11/5/19 dose scheduled for 8:00 a.m. was administered at 10:43 p.m. On 11/4/19 dose scheduled for 4:00 p.m. was administered at 6:48 p.m. On 11/1/19 dose scheduled for midnight was administered at 3:36 a.m. Resident #88 Resident #88 was scheduled to receive: [MEDICATION NAME]to be administered before meals and at bedtime on 11/2/19 at 21:00, it was administered on 11/3/19 at 04:41. [MEDICATION NAME] HCL ([MEDICATION NAME]) 50 mg (milligram) on 11/4/19 at 20:00, it was administered on 11/5/19 at 02:13. [MEDICATION NAME] HCL 1.25 mg on 11/5/19 at 19:00, it was administered on 11/6/19 at 03:31. [MEDICATION NAME] 2 mg on 11/5/19 at 20:00, it was administered on 11/6/19 at 03:30. Tylenol 650 mg on 11/5/19 at 21:00, it was administered on 11/6/19 at 03:30. [MEDICATION NAME]to be administered before meals and at bedtime on 11/5/19 at 21:00, it was administered on 11/6/19 at 03:30. [MEDICATION NAME]to be administered before meals and at bedtime on 11/7/19 at 21:00, it was administered on 11/8/9 at 00:27. [MEDICATION NAME] 2 mg on 11/11/19 at 20:00, it was administered on 11/12/19 at 03:51. [MEDICATION NAME]to be administered before meals and at bedtime on 11/11/19 at 21:00, it was administered on 11/12/19 at 03:51. Resident #383 Resident #383 was scheduled to receive: Azteonam in [MEDICATION NAME] Solution 1 gm (gram) / 50 ml's (milliliters) every 8 hours for infection was to be administered at 11/8/19 at 16:00, it was administered on 11/8/19 at 17:52. Azteonam in [MEDICATION NAME] Solution 1 gm (gram) / 50 ml's (milliliters) every 8 hours for infection was to be administered at 11/10/19 at 00:00, it was administered on 11/10/19 at 02:37. Azteonam in [MEDICATION NAME] Solution 1 gm (gram) / 50 ml's (milliliters) every 8 hours for infection was to be administered at 11/11/19 at 00:00, it was administered on 11/10/19 at 02:16. Azteonam in [MEDICATION NAME] Solution 1 gm (gram) / 50 ml's (milliliters) every 8 hours for infection was to be administered at 11/12/19 at 00:00, it was administered on 11/12/19 at 06:36. Azteonam in [MEDICATION NAME] Solution 1 gm (gram) / 50 ml's (milliliters) every 8 hours for infection was to be administered at 11/12/19 at 08:00, it was administered on 11/12/19 at 10:33. Azteonam in [MEDICATION NAME] Solution 1 gm (gram) / 50 ml's (milliliters) every 8 hours for infection was to be administered at 11/15/19 at 00:00, it was administered on 11/15/19 at 04:45. Resident #119 Resident #119 was scheduled to receive: [MEDICATION NAME] ER (extended release) 12 hour abuse-deterrent 80 mg on 11/5/19 at 20:00, it was administered at 11/5/19 at 23:26. [MEDICATION NAME]to be administered before meals and at bedtime on 11/3/19 at 21:00, it was administered on 11/4/19 at 02:14. [MEDICATION NAME] ER (extended release) 12 hour abuse-deterrent 80 mg on 11/7/19 at 23:00, it was administered at 11/8/19 at 06:22.",2020-09-01
181,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,689,D,1,1,BFLK11,"> Based on a review of a facility accident and incident report and interview, it was determined that the facility failed to ensure that a resident received the necessary supervision to avoid sustaining a fall with injury for 1 resident out of a final survey sample of 40 residents. (Resident identifier is #111.) Findings include: Interview on 11/14/19 with Staff D (Unit Manager, RN) revealed that Resident #111 sustained a fall on 11/12/19 in the bathroom and was hospitalized . Review on 11/14/19 of a facility RMS Event Summary Report revealed Resident #111 was assisted to the bathroom by an LNA (Licensed Nursing Assistant) who then left Resident #111 alone in the bathroom to get towels. While out of this resident's bathroom the LNA heard a bang. Resident #111 was noted by this same report to be lying on .left side with .left hand behind .and right leg crossing over .left leg blood noted on floor under resident's left forehead. The RMS report continued by stating that Resident #111 yelled in pain when attempting to turn (pronoun omitted) over. The staff called 911 and (pronoun omitted) was transported to the hospital. Review of 11/14/19 Resident #111's comprehensive plan of care revealed that Resident #111 is a total assist with toileting and is not supposed to be left alone in the bathroom. Interview on 11/15/19 with Staff D review the above findings and Staff D confirmed Resident #111's care plan was not followed.",2020-09-01
182,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,690,D,0,1,BFLK11,"Based on medical record review and interview, it was determined that the facility failed to provide appropriate treatment and services for urinary incontinence and fecal incontinence to maintain continence as much as possible for 1 resident out of a final sample of 40 residents. (Resident identifier is #16.) Findings include: Review on 11/13/19 of Resident #16's care plans under Focus stated (Resident #16) is incontinent of bowel with potential for improved control or management of bowel elimination under Intervention Establish regular evacuation time based on documented date (e.g. usual time) Identify treatment based on the individual's usual habits. Review on 11/13/19 of Resident #16's care plans under Focus stated (Resident #16) is incontinent of urine with potential for improved control or management of urinary elimination under Intervention Complete an incontinence assessment at intervals according to policy and procedure Offer/assist (Resident #16) with urinal/commode as requested/needed. Interview on 11/15/19 at 1:04 p.m. with Staff C (Unit Manager) confirmed there is no bowel or bladder voiding assessments completed to improve Resident #16's bowel and bladder incontinence. Interview on 11/12/19 at 1:04 p.m. Resident #16 revealed Resident #16 stated for the past 2 weeks his/her call bell has been broken and during this time staff were not coming to his/her room to provide care to the point that Resident # 16 stated he/she was incontinent of both bowel and bladder. Resident #16 also stated that staff never came for over 5 hours and by that time his/her genital area became raw and was bleeding because he/she had to sit in his own bowel and bladder incontinence. Review on 11/13/19 of Resident #16 medical record revealed a skin assessment completed dated 11/11/19 called Skin Check -V3 under section B New Skin Injury/Wound #6 Moisture Associated Skin Damage 6a Location (genital area). Observation on 11/14/19 at 12:59 p.m. of Resident #16's wound on his/her genital area was found to be red and tender to the touch. At time of observation Resident #16's brief was fully soaked of urine and feces. Interview on 11/14/19 at approximately 1:00 p.m. during observation with a facility staff of the wound revealed that the last time Resident #16 was changed was when he/she was placed into his/her wheelchair at 5:00 a.m. Review of the P[NAME] (Point of Care) Response History Task for Toilet/Bladder/Bowel over a 14 day look back period shows as follows: 10/31/19 -06:53, 11/3/19 -02:40, 11/4/19-22:06, 11/5/19-06:59, and 14:46, 11/7/19-02:44, 11/8/19-06:59, 11/9/19-22:09, 11/10/19-22:59, 11/11/19-03:37, and 23:03, 11/12/19- 22:55, 11/13/19-06:06 Review on 11/14/19 at 1:08 p.m. of Resident # 16's care plan meeting notes dated 7/19/19 stated .Nursing: (Resident #16) states to have a sore and that (he/she) hasn't been changed promptly after waking up. Staff C (Unit Manger) stated that time delays are due to requiring 2 people for a Hoyer lift which can vary depending on staffing for the day .",2020-09-01
183,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,755,E,1,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and interview, it was determined that the facility failed to ensure the availability of the emergency insulin supply kit for the facility and for 1 resident in a standard survey sample of 40 residents. (Resident identifier is #279.) Findings include: Review on 11/12/19 of Resident #279's Medication Administration Record [REDACTED]. subcutaneously before meals for Diabetes Type II above 400 call MD and Insulin [MEDICATION NAME] Solution 100 UNIT/ML Inject 15 unit subcutaneously one time a day before breakfast. Interview on 11/12/19 at approximately 9:30 a.m. with Staff H (Licensed Practical Nurse) on the third floor confirmed that the medications listed above for Resident #279 were on order and that these two medications were not available in the facility Insulin Emergency kit and that the facility Insulin Emergency kit was not in the designated refrigerator located on the second floor medication room where all the facility emergency medications are stored. Observation on 11/12/19 at approximately 10:00 a.m. with Staff C (Unit Manager) on the second floor revealed that there was no Insulin Emergency kit in the designated refrigerator located on the second floor medication room where all the facility emergency medications are stored. Interview on 11/12/19 at approximately 10:00 a.m. with Staff C confirmed that the facility Insulin Emergency kit was not in the designated refrigerator located on the second floor medication room. Staff C reported that the Pharmacy had been called last week to replace the facility Insulin Emergency kit but could not remember the day or date and had no documentation to show that the pharmacy had been notified. Observation and interview on 11/12/19 at approximately 10:10 a.m. with Staff [NAME] (Unit Manager) fourth floor confirmed that the facility Insulin Emergency kit was not in the fourth floor medication room. Staff [NAME] was not aware of any staff member needing the facility Insulin Emergency kit. Review on 11/13/19 of the pharmacy Shipment Summary document showed that one E-KIT REFRIGERATOR, HOUSE ST[NAME]K was delivered on 7/25/2019 3:37 PM to the second floor. Review on 11/13/19 of the facility Refrigerator Emergency Drug Kit form dated 8/19/2015 revealed the following medications are supplied in this Insulin Emergency Kit: - [MEDICATION NAME] (10 ml) U-100/1 ml - [MEDICATION NAME] Insulin Detemir (10 ml) U-100/1 ml - [MEDICATION NAME] 70/30 Insulin Human 70/30 (3ml) 70/30 U-100/1ml - [MEDICATION NAME] N Insulin Human NPH (3ml) U-100/1ml - [MEDICATION NAME] R Insulin Human Reg (3ml) U-100/1ml - Humalog Insulin [MEDICATION NAME] (3ml) U-100/1ml - [MEDICATION NAME] Supp [MEDICATION NAME] Supp 25 mg Interview on 11/13/19 at approximately 10:30 a.m. with Staff B (Director of Nursing) confirmed that the facility had no Insulin Emergency Kit in the facility. Staff B reported that she was unaware as to what happened since (MONTH) with the delivered Insulin Emergency Kit listed in the above findings. Staff B reported that the facility did not have a list of medications contained in this Insulin Emergency Kit. Staff B reported that the Kit would have to be opened to find a list of medications contained in the Insulin Emergency Kit.",2020-09-01
184,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,756,E,0,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure documentation of monthly drug regimen reviews for 4 residents in a final survey sample of 40 residents. (Resident identifiers are #74, #94, #53, and #22.) Findings include: Resident #53 Review on 11/13/19 of Resident #53's (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #53 also had an order for [REDACTED]. Review on 11/14/19 of Resident #53's Pharmacy Consultation Report revealed that the last documented pharmacy drug regimen review report for Resident #53 was on 9/23/19. Interview on 11/15/19 at approximately 1:15 p.m. with Staff M (Regional Clinical Manager) confirmed that the last documented pharmacy drug regimen review report for Resident #53 was on 9/23/19. Staff M also confirmed that there should have been a documented pharmacy drug regimen review for Resident #53 during the month of (MONTH) 2019. Resident #22 Review on 11/14/19 of Resident #22's Pharmacy Consultation Report revealed that the last documented pharmacy drug regimen review report for Resident #22 was on 9/23/19. Interview on 11/15/19 at approximately 1:15 p.m. with Staff M confirmed that the last documented pharmacy drug regimen review report for Resident #22 was on 9/23/19. Staff M also confirmed that there should have been a documented pharmacy drug regimen review for Resident #22 during the month of (MONTH) 2019. Resident #74 Review on 11/15/19 of Resident #74's Medication Regimen Review (MRR) from the month of (MONTH) 2019 to (MONTH) 2019 revealed that there were no MRR from the pharmacist for the month of (MONTH) 2019 and (MONTH) 2019 in Resident #74's chart or the electronic medical record. Resident #94 Review on 11/15/19 of Resident #94's MRR from the month of (MONTH) 2019 to (MONTH) 2019 revealed that Resident #94 had no MRR from the pharmacist for the month (MONTH) 2019 in Resident #94's chart or electronic medical record. Interview on 11/15/19 at 1:11 p.m. with Staff [NAME] (Unit Manager) confirmed the above findings for Resident #74 and #94. Staff [NAME] stated that they do not know where Resident #74's (MONTH) 2019 and (MONTH) 2019 MRR and also Resident #94's (MONTH) 2019 MRR. Staff [NAME] was unable to provide explanation for Resident #74 and #94 not being reviewed by the pharmacist on above said dates for their MRR. Review on 11/15/19 of the facility's pharmacy consultation report that was sent by the pharmacist on 11/15/19 revealed that Resident #74 was seen by the pharmacist on 8/21/19 and 10/23/19; and Resident #94 was seen by the pharmacist on 10/23/19. Interview on 11/15/19 at 2:38 p.m. with Staff A (Administrator) confirmed the above findings on the pharmacist consultation report. Staff A stated that based on the consultation report Resident #74 and #94 had no irregularities or recommendations for the above dates of their MRR. Staff A also stated that there should be documentation by the pharmacist in Resident #74 and #94's electronic medical record in the assessment tab for the above dates of their MRR which in this case there were no documentation from the pharmacist of medication being reviewed on above dates.",2020-09-01
185,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,758,D,0,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to limit the PRN (as needed) use of an antipsychotic medication to 14 days and to evaluate and give a rationale for their continued use for 1 of 7 resident reviewed out of a final survey sample of 40 residents. (Resident identifier is #53.) Findings include: Review on 11/13/19 of Resident #53's (MONTH) 2019 Medication Administration Record [REDACTED]. The review also revealed that Resident #53 received the [MEDICATION NAME] by mouth on 11/5/19, 11/8/19 and on 11/13/19. There were neither stop dates for the [MEDICATION NAME] nor documentation of evaluations every 14 days for the continued use of PRN [MEDICATION NAME]. Interview on 11/15/19 at approximately 10:45 a.m. with Staff M (Regional Clinical Manager) confirmed that there were no stop date orders or documented evaluations done every 14 days for Resident #53, with a documented rationale for the continued order for PRN [MEDICATION NAME]. Staff M confirmed that there should have been stop date orders and evaluations.",2020-09-01
186,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,761,E,0,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure that expired medication and medical supplies were stored in accordance to professional standards and medications were labeled in accordance to professional standards for 2 out of 2 medication rooms observed and 6 out of 9 medication carts observed. (Resident identifiers are #4, #9, #14,#22, #27, #43, #47, #49, #59, #64, #65, #83, #93, #98, #103, #109,#112, #116, #120, #123, #125 ) Findings include: Review on 11/13/19 of facility's policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revision date 10/31/16, revealed that .facility should ensure that medications and biologicals that have (sic): (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration date for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .facility should ensure that medications and biologicals for expired or discharges (sic) or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider . Review on 11/13/19 of facility's pharmacy policy titled, Insulin Storage Recommendations, revision date (MONTH) 2019, revealed that storage recommendation on room temperature for opened [MEDICATION NAME] vials is 28 days, opened Basaglar pens is 28 days, opened [MEDICATION NAME] vials is 28 days, and opened [MEDICATION NAME] pens is 28 days. Observation on 11/13/19 at 9:00 a.m. with Staff C (Unit Manager) on the second floor medication room revealed one culture swab with an expiration date of 12/2013, one ESwab (sic) with an expiration date of 09/2019, one Miniloc infusion set with an expiration date of 05/2016, one IV (intravenous) dressing change tray with an expiration date of 2/28/2019, one 3 ml (milliliter) [MEDICATION NAME] lock flush with an expiration date of 06/30/2016, nine 3 ml [MEDICATION NAME] lock flushes with an expiration date of 9/30/2017, six [MEDICATION NAME] lock flushes with an expiration date of 10/31/2017, one 3 ml [MEDICATION NAME] lock flush with an expiration date of 11/30/2017, four 3 ml [MEDICATION NAME] lock flushes with an expiration date of 2/28/2018, three 3 ml [MEDICATION NAME] lock flushes with an expiration date of 3/31/2018, six 3 ml [MEDICATION NAME] lock flushes with an expiration date of 10/31/2018, one 3 ml [MEDICATION NAME] lock flush with an expiration date of 7/31/2019, and five [MEDICATION NAME] lock flushes with an expiration date of 9/30/2019 that were found with the unexpired medication supplies in the second floor medication room. Interview on 11/13/19 at 9:10 a.m. with Staff C confirmed the above findings. Staff C stated that expired supplies and [MEDICATION NAME] lock flushes should have been discarded or returned to the pharmacy by placing in the return to pharmacy plastic container found in the medication room which the medications that was noted above were not in the pharmacy plastic container. Observation on 11/13/19 at 9:15 a.m. with Staff D (Unit Manager) of the third floor refrigerator in the medication room revealed that expired medications were found with unexpired medication. The expired medications were Resident #98 had one bottle of Compound medication of [MEDICATION NAME][MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME] liquid with an expiration date of 11/12/19, twelve suppositories of [MEDICATION NAME] Acetate ([MEDICATION NAME]) 20 mg (milligram) with an expiration date of 5/31/2019, and thirteen suppositories of [MEDICATION NAME] Acetate 20 mg with an expiration date of 10/2019. Interview on 11/13/19 at 9:18 a.m. with Staff D confirmed the above findings on the third floor medication room. Staff D stated that the expired medication should have been taken out of the refrigerator and placed in the return to pharmacy plastic container. Observation on 11/13/19 at 10:30 a.m. with Staff G (Licensed Practical Nurse) of the fourth floor west medication cart revealed that there were expired medications with the unexpired medications. The expired medications were Resident #59 had one used Basaglar insulin pen with an open date of 10/14/19 which the insulin pen had a label to discard after 28 days, Resident #64 had ten tablets of [MEDICATION NAME] (antihypertensive) 0.1 mg with an expiration date of 2/19/2019, Resident #64 had ten tablets of [MEDICATION NAME] 0.1 mg with an expiration date of 9/30/2019, Resident #64 had eight tablets of [MEDICATION NAME] (anti-infective) 1 Gm (gram) with an expiration date of 9/30/19, and Resident #120 had fifteen tablets of [MEDICATION NAME] (proton-pump inhibitor) 20 mg with an expiration date of 10/29/2018. Observation on 11/13/19 at 10:35 a.m. with Staff G of the fourth floor west medication cart overflow medication drawer revealed that there were expired medications with the unexpired medications. The expired medications were Resident #64's thirty tablets of [MEDICATION NAME] with an expiration date of 9/25/2019 and Resident #49 thirty tablets of [MEDICATION NAME] (proton-pump inhibitor) 20 mg with an expiration date of 3/31/2019. Interview on 11/13/19 at 10:38 a.m. with Staff G confirmed the above findings on the 4th floor west medication cart. Staff G stated that Resident #59's Basaglar insulin pen should have been used by 11/12/19 based on the facility pharmacy policy. Staff G also stated that there should be no expired medication in the medication cart and that expired medication should have been placed in the return to pharmacy plastic container located in the fourth floor medication room which the above medications were not in the pharmacy plastic container. Observation on 11/13/19 at 10:45 a.m. with Staff [NAME] (Unit Manager) on the fourth floor south medication cart revealed that there were expired medications with the unexpired medications. The expired medications were Resident #27's two tablets of [MEDICATION NAME] (anticoagulant) 7.5 mg with an expiration date of 9/28/2019 and 10/15/2019, respectively; Resident #65's eleven 1/2 tablets of [MEDICATION NAME] (antipsychotic) 0.25 mg with an expiration date of 8/30/2019, Resident #103's twenty-eight tablets of Atorvastatin (antihyperlipidemic) 10 mg with an expiration date of 8/31/2019, Resident #103's two tablets of Folic acid 1 mg with an expiration date of 10/31/2019, Resident #4's four tablets of [MEDICATION NAME] (antiemetic) 4 mg with an expiration date of 5/31/2019, Resident #103's one used bottle of [MEDICATION NAME] (insulin) 100 units/ml with an open date of 10/2/19 with the medication bottle labeled used within 28 days, Resident #4's one used bottle of [MEDICATION NAME] (insulin) 100 units/ml with an open date of 10/1/19 with the medication bottled labeled used within 28 days, Resident #22's two used [MEDICATION NAME]pen with no labeled open dates, Resident #93's ten tablets of [MEDICATION NAME] 4 mg with an expiration date of 5/31/19 and Resident #93's 10 tablets of [MEDICATION NAME] 4 mg with an expiration date of 6/30/19. Interview on 11/13/19 at 10:50 a.m. with Staff [NAME] confirmed the above findings on the fourth floor south medication cart. Staff [NAME] stated that expired medications should not have been in the medication cart and that expired medications should have been placed in the return to pharmacy plastic container located in the fourth floor medication room which the above medications were not in the pharmacy plastic container. Staff [NAME] also stated that Resident #103's [MEDICATION NAME] bottle should have been labeled used by 11/1/19, Resident #4's [MEDICATION NAME] bottle should have been labeled used by 10/31/19, and Resident #22's [MEDICATION NAME] pens should have been labeled with an open date when it was first used. Observation on 11/13/19 at 11:30 a.m. with Staff H (Licensed Practical Nurse) on the third floor north medication cart revealed Resident #43's thirteen tablets of [MEDICATION NAME] (antidiarrheal) 2 mg with an expiration date of 4/17/2019. Interview on 11/13/19 at 11:35 a.m. with Staff H confirmed the above findings on the third floor medication cart. Observation on 11/13/19 at 11:40 a.m. with Staff D on the third floor west medication cart revealed expired medications with the unexpired medications. The expired medications were a discharged resident's [MEDICATION NAME] emergency kit with an expiration date of 10/2019 and Resident #123's thirty tablets of [MEDICATION NAME] (proton-pump inhibitor) 150 mg with an expiration date of 9/30/2019. Interview on 11/13/19 at 11:42 a.m. with Staff D confirmed the above findings on the third floor west medication cart. Observation on 11/13/19 at 11:45 a.m. with Staff D of the third floor south medication cart revealed that there were expired medications with the unexpired medications. The expired medications were Resident #98's seven 1/2 tablets of [MEDICATION NAME] 3 mg with an expiration date of 7/28/2018, four 1/2 tablets of [MEDICATION NAME] 3 mg with an expiration date of 11/5/2019, sixteen 1/2 tablets of [MEDICATION NAME] 3 mg with an expiration date of 9/29/2019, and thirteen 1/2 tablets of [MEDICATION NAME] 3 mg with an expiration date of 8/14/2019. Observation also revealed expired medications for Resident #9's thirty tablets of Vitamin D (supplement) 400 units with an expiration date of 11/7/2019, thirty tablets of [MEDICATION NAME] (anti-diarrheal) 2 mg with an expiration date of 5/31/2019 and twenty-three tablets of [MEDICATION NAME] 2 mg with an expiration date of 9/30/2019. Observation also revealed expired medications for Resident #83's 30 tablets of [MEDICATION NAME] (diuretic) with an expiration date of 9/30/2019, thirty tablets of [MEDICATION NAME] with an expiration date of 7/31/2019, four tablets of [MEDICATION NAME] with an expiration date of 6/30/2019, and twenty-six tablets of [MEDICATION NAME] ([MEDICATION NAME]-2 Receptor Antagonist) 5 mg with an expiration date of 7/31/2019. Further observations revealed expired medications for Resident #14's twenty-seven tablets of [MEDICATION NAME] 2 mg with an expiration date of 5/31/2019, and Resident #116's twenty tablets of [MEDICATION NAME] (antiulcer) 20 mg with an expiration date of 6/30/2019. Interview on 11/13/2019 at 11:55 a.m. with Staff D confirmed the above findings on third floor south medication cart. Observation on 11/13/2019 at 12:10 a.m. with Staff I (Licensed Practical Nurse) of the fourth floor north medication cart revealed that there were expired medications with the unexpired medications. The expired medications were Resident #47's thirteen tablets of [MEDICATION NAME] 2 mg with an expiration date of 8/31/2019, Resident #109's fourteen tablets of [MEDICATION NAME] (muscle relaxant) 10 mg with an expiration date of 7/31/2019, and Resident #125's nine tablets of [MEDICATION NAME] 4 mg with an expiration date of 6/30/2019. Interview on 11/13/2019 with Staff I confirmed the above findings on the fourth floor north medication cart.",2020-09-01
187,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,809,E,0,1,BFLK11,"Based on dining observations made on 2 of 3 units, record review and interview, it was determined that the facility failed to deliver food either in a timely manner or with the necessary staff available for ensuring residents received the assistance they required to eat their meals. ( Resident identifiers are #53, #111 and #388.) Findings include: Third Floor Dining Observation on 11/12/19 of breakfast on the third floor revealed that this meal is posted on the unit to begin at 8 a.m., but residents in the dining room were not served until approximately 9:20 a.m. At 9:00 a.m. one tray was delivered to the third floor dining room and placed uncovered on a table in front of a seat where no one was sitting. An LNA (Licensed Nursing Assistant) was observed in the dining room during breakfast feeding an unidentified resident a piece of toast with the LNA using her bare hands instead of gloves. Resident #111 was observed not eating any breakfast during the entire meal and no staff member encouraged him/her to either eat the food or offered him/her any alternate foods. Lunch on the third floor is posted on the unit to begin at noon, but neither the dining room nor the three wings were served until approximately 1:00 p.m. In the dining room Resident #111 was observed wandering back and forth from his/her table but at no time during lunch did any staff member encourage this resident to eat the food served to him/her during the entire meal. Resident #111's tray was removed without him/her eating any lunch and no alternates were offered to him/her. A review of LNA documentation confirmed that Resident #111 had nothing to eat for breakfast and lunch on 11/12/19. Second Floor Dining Observation on 11/12/19 at approximately 12:00 p.m. on the second floor dining room revealed that the 12:00 p.m. meal did not start to be served in the dining room until 1:00 p.m. Interview on 11/12/19 12:30 p.m. with Resident #388 revealed, We can be waiting here some days until 1:30 for lunch. When one meal becomes late they all do for the rest of the day. Breakfast is anywhere between 7:30 in the morning until 10:30 in the morning. Resident #53 Interview on 11/12/19 at approximately 9:00 a.m. with Staff N (Licensed Practical Nurse) revealed that Resident #53 had a significant weight loss. Review on 11/13/19 of Resident #53's Weights and Vitals Summary report revealed that on 7/16/19, Resident #53 weighed 110.6 lbs and on 10/28/19, Resident #53 weighed 81.3 pounds which is a 26.4% loss in less than 4 months. Observation on 11/12/19 at approximately 9:05 a.m. of Resident #53 revealed that Resident #53 was laying in bed sleeping while their breakfast tray was on their bedside table (with no evidence that anyone had attempted to eat or drink any of the food or fluid.) Observation on 11/12/19 at approximately 10:30 a.m. of Resident #53 revealed that Resident #53 continued to lay in bed sleeping, in the same position, while their breakfast tray was on their bedside table, with no evidence that anyone had attempted to eat or drink any of the food or fluid. Observation on 11/12/19 at approximately 10:45 a.m. of Resident #53 revealed that Resident #53 continued to lay in bed sleeping, in the same position, and that their breakfast tray had been removed. Observation on 11/13/19 at approximately 9:30 a.m. of Resident #53 revealed that Resident #53 was laying in bed sleeping while their breakfast tray was on their bedside table, with no evidence that anyone had attempted to eat or drink any of the food or fluid. Observation on 11/13/19 at approximately 10:30 a.m. of Resident #53 revealed that Resident #53 continued to lay in bed sleeping, in the same position, while their breakfast tray was on their bedside table, with no evidence that anyone had attempted to eat or drink any of the food or fluid. Observation on 11/13/19 at approximately 11:00 a.m. of Resident #53 revealed that Resident #53 continued to lay in bed sleeping, in the same position, and that their breakfast tray had been removed. Observation on 11/13/19 at approximately 1:37 p.m. of Resident #53 revealed that Resident #53 was laying in bed sleeping while their lunch tray was on their bedside table, with no evidence that anyone had attempted to eat or drink any of the food or fluid. Observation on 11/13/19 at approximately 2:40 p.m. of Resident #53 revealed that Resident #53 continued to lay in bed sleeping, in the same position, while their lunch tray was on their bedside table, with no evidence that anyone had attempted to eat or drink any of the food or fluid. Review on 11/13/19 of Resident #53's current care plan revealed a goal for Resident #53 accepting at least 2 meals and eating equal to or greater than 50% on a daily basis. The care plan also included interventions of offering hand held items and encouraging fluids. Review on 11/13/19 of Resident #53's nutritional assessment, dated 9/19/19, revealed that Resident #53 had a significant weight loss and the dietitian recommended offering hand held items as needed when the resident won't sit for a meal. The dietitian also recommended that staff continue to encourage meals in the dining room to promote intakes. Interview on 11/13/19 at approximately 2:45 p.m. with Staff [NAME] (Unit Manager) confirmed that Resident #53 did have a weight loss and that staff should have been coming into the room periodically to encourage the resident to eat and drink. Third Floor Dining Observation on 11/12/19 in the third floor at approximately 12:00 noon revealed that the dining room doors were opened and residents moved to individual tables in the dining room. Residents were seated at individual tables with place settings, napkins and empty beverage glasses on a placemat in front of them. Observation on 11/12/19 in the third floor dining room area revealed a small adjacent room that goes from this dining room to the resident hallway with a food steam table from which residents are served their meals. There is one kitchen staff person behind the steam table plating food and a second staff person on the other side of the steam table preparing the individual resident meal tickets and preparing the individual resident meal trays according to the resident meal ticket preference. Observation on 11/12/19 in the third floor dining room at approximately 12:25 p.m. revealed a staff member with a paper menu going to a few residents seated at tables for their meal orders for the next day. One resident who was presented with the menu commented Why are you asking me what I want for tomorrow when I haven't gotten my lunch for today?. Observation on 11/12/19 in the third floor dining room at approximately 12:30 p.m. revealed two residents who got up from the table and left the dining room. During this time there was no staff present from 12:00 p.m. to 12:30 p.m. in this dining room. The residents commented where's the food. A second kitchen staff person appeared and asked the residents if they would like some music and turned a radio on. The residents had been seated in the dining room for half an hour with no staff present until 12:30 p.m. when this second kitchen person appeared, turned radio on and proceeded to bring a mobile beverage cart into the dining room and proceeded to serve beverages to residents per request at the individual tables. It should be noted that the residents had been seated at individual tables for lunch for approximately a half hour with no staff present, no beverages served and no stimulation to the point where a few of the residents were observed sleeping sitting in their chairs. Observation on 11/12/19 in the third floor dining room at approximately 12:40 p.m. revealed that the two staff plating & preparing the resident lunch meals had finished filling the meal trays and placed them on a delivery tray cart that was pushed out to the resident hallway for staff to deliver these trays to residents eating in their rooms. The residents in the dining room had not received their meals as of 12:40 p.m Observation on 11/12/19 in the third floor dining room at approximately 12:45 p.m revealed a second tray meal cart was being prepared to go to the resident hallway for residents eating in their rooms. A second staff member entered the dining room and started helping the kitchen person serving beverages to serve soup to the residents in the dining room at approximately 12:50 p.m Observation on 11/12/19 in the third floor restorative dining room at approximately 1:00 p.m. revealed the first resident was wheeled to third floor restorative dining room in a Broda chair positioned at a table and the staff person left to transport another resident needing assistance to this area. Observation on 11/12/19 in the third floor restorative dining room at approximately 1:00 p.m. revealed a staff member from the serving steam table placed a covered meal dish on a table with no residents present. This staff member asked one of the restorative staff where a specific resident sat and placed a covered meal plate in that identified spot. When a resident was positioned in that spot the restorative aide uncovered the meal. The meal was not the resident's, but was identified to belong to another resident. Observation on 11/12/19 in the third floor restorative dining room at approximately 1:05 p.m. revealed a staff member from the serving steam table placing two individual covered meal plates down on tables with no residents present. A few minutes later a staff member entered the restorative dining area and removed one of the covered meal plates stating resident is going to eat in their room. Confidential Interviews Confidential interviews on 11/12/19 during the initial tour of the third floor at approximately 9:30 a.m. with residents and staff revealed the following concern: meals are rarely on time, no matter if it is breakfast, lunch or dinner. Confidential staff interviews were performed with Staff AA, BB, CC, DD, EE, and FF over a four day period (11/12/19 thru 11/15/19) that expressed that only aides hand out meal trays and answer call bells, but when the State is here all staff provide the help.",2020-09-01
188,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,812,D,1,1,BFLK11,"> Based on observation and interview, it was determined that the facility failed to prevent cross contamination due to staff practices along with proper dating and maintaining of storage self equipment. Findings include: Observation on 11/12/19 at 8:34 a.m. while touring the main dish room in the kitchen revealed Staff K (dish washer) was scraping of plates covered with food debris and then came to the clean side without washing their hands. Staff K then started to pick up the clean utensils with their hands and placing them in holding racks. Interview on 11/12/19 at approximately 8;45 a.m. with Staff K during the above observation, Staff K was stopped at time of observation and asking if they had washed their hands before picking up the clean utensils. Staff K stated Yes. Observations revealed that dirty food debris was still on their hands from scraping off the dishes and this was pointed out to Staff K while in front of Staff J (Director of food services). Staff J confirmed that Staff K did not clean their hands after touching the dirty dishes and coming to the clean side of the dish machine. Staff K immediately went to the hand sink and washed their hands. Observation on 11/12/19 at 8:40 a.m. during the kitchen tour with Staff J revealed that the drying racks where the clean cups were sitting were rusted and unable to be properly cleaned due to the rust. Observation on 11/12/19 while touring the kitchenettes revealed that a one gallon of regular milk had a used by date of 11/12/19, but the expiration date for the milk was 11/10/19. Staff J was shown this finding who poured the milk out into the sink at time of finding.",2020-09-01
189,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,825,D,0,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to provide the rehabilitative services that followed a resident's transfer requirements for 1 resident out of a final survey sample of 40 residents. (Resident identifier is #230.) Findings include: Interview on 11/12/19 at 11:08 a.m. with Resident #230, revealed that Resident #230 stated, On 11/7/19 a therapist came to my room to give therapy. I told the therapist to use the gate belt, but instead took my gown and rolled it up in their fist making it so tight it hurt my chest were I had open heart surgery. At that time the pain was so bad they had to send me to the hospital. Review on 11/12/19 of Resident #230's therapy notes dated 11/6/19 under Transfers states Maximal Assistance (Max (A) x 2 with gait belt due to sternal Precautions also states Strict sternal precautions for eight weeks post-op (no push/pull/lift > 5-7 lbs.), no lifting arms over head, NO USE OF WALKER . Review of the Lift Transfer Reposition Assessment completed by the facility on 11/5/19 under Assessment 3a. GAIT/TRANSFER BELT required. Review on 11/13/19 of Resident #230's medical record revealed nurses notes dated 11/8/19 stated 18:09 C/O (complaint of ) Pain at surgical site periodically today and reported from last night .(Physician) ordered earlier to send to ER (emergency room ) if pain persists. (Resident #230) states I am ready to go to the ER now. When asked why (he/she) states 10/10 pain. Sent to (hospital) ER via lifeline. Review on 11/13/19 of Resident #230's hospital discharge summary note dated 11/9/19 stated, date of service (MONTH) 8, 2019 Patient seen at 2325 .the patient is a [AGE] year-old .with history of diabetes, [MEDICAL CONDITIONS] and other medial problems who was sent from . nursing facility for complaints of chest pain. The chest pain started yesterday morning, during a physical therapy session, in which the patient describes the physical therapist putting pressure over his/her chest. When the pain initially started he/she rated it beyond 10 out of 10. Currently it is an 8-9 out of 10. No [MEDICAL CONDITION] to the neck or down the arms. The chest pain radiates across the chest Hospital Course: .[MEDICATION NAME]es were applied to bilateral anterior chest. As well, (he/she) was given [MEDICATION NAME] and a dose of [MEDICATION NAME]. (His/her) chest discomfort feels a little better this morning.",2020-09-01
190,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,880,D,0,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to follow hand hygiene practices in two different areas that is consistent with accepted standards of practice and failed to provided proper signage for 1 of 3 residents rooms who were on contact precautions. Findings include: Observation on 11/13/19 at 10:30 a.m. revealed that there was a contact precaution cart in the middle of the hall between rooms [ROOM NUMBERS]. Staff R (License Piratical Nurse) went to enter room [ROOM NUMBER] when a staff member called out saying, you need to gowned up that resident is on contact precautions. Staff R was unaware that this room was a contact precaution room and stated, how come there is no sign letting me know. Review on 11/13/19 of the facility's policy and procedure titled IC301 Contact Precautions #2 stated Place a Stop. Please see nurse before entering room. sign on door. Observation on 11/12/19 at 8:34 a.m. while touring the main dish room in the kitchen revealed Staff K (dish washer) was scrapping of plates covered with food debris and then came to the clean side without washing their hands. Staff then started to pick up the clean utensils with their hands and placing them in holding racks. Interview on 11/12/19 at time of the observation with Staff K, Staff K was asked if they had washed their hands before picking up the clean utensils. Staff K stated Yes. Observations revealed that dirty food debris was still on their hands from scrapping off the dishes and this was pointed out to Staff K while in front of Staff J (Director of food services) who confirmed that Staff K did not clean their hands after touching the dirty dishes. Staff K immediately went to the hand sink and washed their hands. Observation on 11/13/19 at approximately 12:00 p.m. in resident room [ROOM NUMBER] revealed that the soap dispenser was not working or out of soap. Interview on 11/13/19 at approximately 12:05 p.m. with Staff F (Licensed Nurse Assistant) revealed, It happens all the time, we just use the bathroom by the elevator. Interview on 11/14/19 at approximately 9:30 a.m. with Staff A (Administrator) and Staff B (Director of Nurses) revealed the following audit findings of soap dispensers not working in the facility: 2nd floor - 4 rooms with non working soap dispensers 3rd floor - 3 rooms with non working soap dispensers 4th floor - 9 rooms with non working soap dispensers",2020-09-01
191,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2019-11-15,908,D,0,1,BFLK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain patient care equipment in safe operating condition for the care and treatment of [REDACTED]. (Resident identifier is #229.) Findings include: Review of the manufacture instruction for a wound vac unit that Resident #229 was using stated A flashing yellow LED appears when a significant leak condition exists. This alarm will be accompanied by a repeating audible tone. If the alarm is not resolved in approximately five minutes, therapy will be interrupted. Observation on 11/13/19 during wound care of a stage 4 pressure sore being treated using a wound vac it was noted that when Resident #229 was turned to their side the dressing was not attached to Resident #229 wound. Interview on 11/13/19 at the time of the observation with Staff R (Licensed Practical Nurse), Staff R was asked if there was an alarm to the unit and did they hear it sounding since the dressing was not intact. Staff R stated No. Staff R stated it would only take 2-3 hours for a new unit to be sent and they would call since it is not sound due to leak which it should do. Interview on 11/15/19 at 11:30 a.m. with Staff M (Regional Clinical Manger) revealed Staff M was asked to please follow up to see if the wound vac machine was replaced after findings on 11/13/19. Staff M disconnected the wound vac hose from the unit confirmed that the equipment was not replaced and still failed to alarm as designed. Staff M contacted the vender to have another unit sent to provide proper care for Resident #229's wound.",2020-09-01
192,ROCKINGHAM COUNTY NURSING HOME,305046,117 NORTH ROAD,BRENTWOOD,NH,3833,2017-02-24,371,E,0,1,1PZ511,"Based on observation and interview, it was determined that the facility failed to provide a sanitary environment in accordance with professional standards for food service safety. Findings include: Standard of Reference: Food Code, U.S. Public Health Service, FDA, 2013, page 174, 6-201.12 Floors, Walls, Ceilings, Utility Lines. (A) Utility service lines and pipes may not be unnecessarily exposed. Accessed from website on 3/7/17: https://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM 0.pdf Observation in the kitchen on 2/22/17 at approximately 9:00 a.m. revealed that there were approximately 300 square feet of ceiling tile missing in the area of the kitchen above the walk in milk cooler and the open space with access to the loading dock, dietician's office, dry storage, and main food preparation/service area. Observation in the kitchen on 2/22/17 at approximately 2:30 p.m. revealed kitchen staff preparing a cart with snacks underneath the exposed ceiling pipes. Interview on 2/22/17 at approximately 2:30 p.m. with Staff G (Maintenance) revealed the ceiling pipes had been exposed since (MONTH) (YEAR) when they needed repair. Interview on 2/24/17 at approximately 9:45 a.m. with Staff H (kitchen staff) revealed that carts used for serving snacks and milk are often stored below the exposed ceiling pipes. Interview also revealed that food was transported to storage from the delivery dock and to the kitchen from storage passing underneath the exposed ceiling pipes.",2020-09-01
193,ROCKINGHAM COUNTY NURSING HOME,305046,117 NORTH ROAD,BRENTWOOD,NH,3833,2017-02-24,514,B,0,1,1PZ511,"Based on record review, observation and interview, it was determined that the facility failed to maintain complete medical records for seat belt assessments for 4 out of 5 residents using seatbelts in a standard survey sample of 24 residents. (Resident identifiers are #1, # 16, # 17, and # 18.) Findings include: Review on 2/22/17 through 2/24/17 of Residents' Care Plans revealed that Residents #1, #16, #17 and #18 used self releasing seat belts when they were up in wheelchairs. Review of assessments and progress notes revealed that the facility failed to document assessments showing that these residents were able to self release the seat belts. Observation of Residents #16, #17 and #18 on 2/23/17 through 2/24/17 revealed that the residents were able to release their own seat belts when asked. Interview on 2/23/17 at approximately 2:00 p.m. with Staff C (Registered Nurse, Unit Manager) revealed that Resident #1 was able to release her seat belt upon request. Interview on 2/24/17 at approximately 2:45 p.m. with Staff F (Director of Nursing) revealed that seat belt assessments were done at least quarterly. Interview confirmed that there was no documentation for assessments showing that the residents were able to self release their seat belts when asked.",2020-09-01
194,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2017-04-07,281,D,0,1,TOLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, it was determined that the facility failed to meet professional standards by not following physician orders [REDACTED]. (Resident identifier is #10.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 4/7/17 at approximately 8:30 a.m. of Resident #10's Doctor's orders dated 4/3/17, revealed an order for [REDACTED].#10's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the Controlled Substance Book, page No. 177 for Resident #10 revealed a pharmacy label for Resident #10 with instructions for [MEDICATION NAME] tablet 15 mg 1 tab by mouth every 12 hours. Interview on 4/7/17 at approximately 11:30 a.m. with Staff C (Registered Nurse) and Staff [NAME] (Advanced Registered Nurse Practitioner) confirmed that the medication received from the pharmacy and administered to Resident #10 was for the short acting [MEDICATION NAME] as opposed to the longer acting [MEDICATION NAME] Contin.",2020-09-01
195,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2017-04-07,371,E,0,1,TOLC11,"Based on observation, medical record review, interview, and review of facility policy/procedure, it was determined that the facility failed to label and date items in the refrigerators with use by dates in the main kitchen and in 3 kitchenettes. Findings include: Observation on 4/5/17 in the morning of the facility kitchen refrigerators and the unit kitchenette refrigerators revealed the supplement shakes had no labeling of the date they were thawed nor had any use by dating marked on the cartons that were ready for distribution to the resident population. Interview 4/5/17 with Staff D (Food Service Manager) confirmed the containers were supposed to have 'used by' markings on each container. In the policy for the care of refrigerator items, it indicates that there is to be a four day window in which the product is consumed or discarded. Observation on 4/17/17 at approximately at 1:30 p.m. of unit 1B floor medication room refrigerator revealed an opened, outdated orange flavor thickener with a manufacturer use by date of 2/26/17. Interview on 4/7/17 at approximately at 1:30 p.m. with Staff B (Licensed Practical Nurse) revealed that Staff B used that thickener earlier in the day and had taken it out of the kitchenette. Observation on 4/17/17 at approximately at 1:45 p.m. of the kitchenette revealed an unopened orange flavor thickener with a manufacturer used by date of 11/29/16. Review on 4/7/17 at approximately at 1:45 p.m. of the manufacturer instructions on 4/7/17 on the carton, revealed See top of carton for use-by date. Shake well before using. Once opened, store at ambient temperatures for up to 8 hours or refrigerate for up to 7 days. Interview on 4/7/17 at approximately at 1:30 p.m. with Staff B confirmed that both the above orange thickeners were beyond the manufacturer's use by date. Observation on 4/5/17 at approximately 10:30 a.m. revealed that there was a pitcher containing orange juice in one of the kitchenettes on the second floor. The pitcher was not labeled or dated. Interview on 4/5/17 at approximately 10:30 a.m. with Staff C (Registered Nurse) confirmed that the juice was for residents and that it should have been labeled and dated.",2020-09-01
196,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2017-04-07,431,D,0,1,TOLC11,"Based on observation and interview, it was determined that the facility failed to ensure and identify the hazard of not securing the facility's contaminated sharp containers from unauthorized personnel. Findings include: Observation on 4/6/17 at approximately 7:15 a.m. during the initial tour of the Hyder House revealed a locked dirty utility room that contained a biohazard box that container one full contaminated sharps container. This room also contained a bin that contained bags of dirty laundry. Interview on 4/6/17 at approximately 7:15 a.m. with Staff A (Registered Nurse, Hyder House Manager) confirmed that the dirty laundry is picked up daily by the prisoners from the dirty utility room where the filled contaminated sharps container are placed. Staff A is unaware where the prison guard is at the time of pick up but the room is too small for every one to be in the room at the same time.",2020-09-01
197,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2017-04-07,441,D,0,1,TOLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that the facility failed to ensure infection control practices were maintained to minimize the risk of potential infection transmission, on three of seven units in the facility. (Resident identifiers are #2, #11, and #28.) Findings include: Observation on [DATE] of Unit 1A with Staff J (Licensed Nursing Assistant), revealed that were four ice packs in the kitchenette refrigerator freezer. Interview on [DATE] at the time of the observation with Staff J revealed that Staff J did not know what these ice packs were for, but regarding the one that was labeled for a particular resident, Staff J related that resident is expired. Interview on [DATE] with Staff L (nurse) revealed that the cold packs in the refrigerator on [DATE] were for employees to ice their own shoulders between feeding residents. Observation on [DATE] during tour of Unit 1B with Staff H (Registered Nurse), revealed that were 2 blue gloves containing frozen contents in the kitchenette freezer. Later in the morning on [DATE] a subsequent observation of the kitchenette freezer with Staff I (charge nurse) again revealed two blue gloves containing frozen contents in the freezer. Staff I related they were probably for Resident #38's cheek, and they would discard them after use, and Staff I was observed to put them in the sink. Residents #2 & #38 Observation on [DATE] during tour of Unit 1B with Staff H and then Staff I, revealed that there was a precaution sign at the doorway to Resident #38's room, and there was no precaution sign at the doorway to Resident #2's room although there was a cart with PPE (personal protective equipment) positioned near the entrance to the latter's room. Interview on [DATE] during tour with Staff I established that Resident #2 is on ([DIAGNOSES REDACTED].#2 should have a precaution sign on the door for blood with incontinence. Staff I confirmed that Resident #38 has or had a cheek infection, and was on contact precautions for history of MRSA (Methicillin-Resistant Staph Aureus), but Staff I related that Resident #38 is not on precautions. Observation on [DATE] during tour of Unit 1B with Staff I, revealed in the clean utility room that there were one or more red sheet on the floor and also on a foot stool, and there were also one or more johnnies on the floor. Interview with Staff I at time of observation revealed that the red sheets are put on the bed if the patient has bled out, and they're supposed to be in plastic container. Staff I was observed to put the red sheet(s) from the floor onto the foot stool. Resident #11 Review of Resident #11's Order Summary Report for Date [DATE] reveals an active order for Do not do TB ([DIAGNOSES REDACTED]) skin test. Interview on [DATE] with Staff K (Registered Nurse) revealed that a 2-step skin test is done upon admission, and if the resident refused they would have a conversation and do an annual questionnaire. Interview on [DATE] with Staff L (charge nurse) revealed that this resident has no history of TB and refused the PPD (purified protein derivative) in 2009 upon admission, and due to oversight the facility never did the follow-up questionnaire. Observation on [DATE] at approximately 2:30 p.m. of two linen carts on Unit 3 revealed that they were both uncovered with the protective front cover pulled up on top. Both carts had a pillow holding the protective front cover up. One linen cart was in the hallway and the other cart was in the tub room, in close proximity to the tub. Interview on [DATE] at approximately 2;45 p.m. Staff G (Medication Nursing Assistant) confirmed that the carts should have had the protective cover pulled down, and the cart in the tub room was in too close proximity to the tub, where water could have splashed on it. Staff G was not sure if the pillows on top were clean or if they had been used by a resident.",2020-09-01
198,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2017-04-07,456,D,0,1,TOLC11,"Based on observation, interview, and record review, it was determined that the facility failed to ensure patient care equipment for oxygen administration adhered to safe operating conditions, for 7 out-of-sample residents in a standard survey sample of 30 residents, and failed to ensure that refrigerator temperatures were monitored for one resident care unit. (Resident identifiers are #31, #32, #33, #34, #35, #36, #37.) Findings include: Resident #36 Observation during tour on 4/5/17 of Unit 1B with Staff H (Registered Nurse) and then Staff I (charge nurse), revealed that Resident #36 was using oxygen. When staff went to read the date on the oxygen tubing, it was discovered that the tubing lacked a date. In addition, there was no sign at the doorway to this resident's room to indicate that oxygen was in use. Interview on 4/5/17 during tour with Staff I revealed that the tubing was just put on yesterday, that Resident #36 was on as needed oxygen until yesterday, and now is on continuous oxygen. Resident #37 Observation on 4/5/17 during tour of Unit 1B with Staff H, revealed that Resident #37 was using oxygen. Staff H checked the date on the oxygen tubing at surveyor's request, and related it read 3/25/17 (11 days prior to date of tour), and Staff H also related that this resident is a smoker. Interview on 4/7/17 with Staff K (Registered Nurse) revealed that whoever changes the oxygen tubing is supposed to put their initials and date on it. Observation on 4/5/17 at approximately 10:30 a.m. revealed that there were 2 refrigerators in 2 different kitchenettes on the second floor. Both refrigerators had an untitled document taped to the front of them which read ALL REFRIGERATOR TEMPERATURES NEED TO BE AT 41*OR LESS. ALL FREEZER TEMPORATURES (sic) NEED TO BE 0* OR LESS. IF TEMPERATURES RISE ABOVE THESE LEVELS, PLEASE CONTACT MAINTENANCE FOR REPAIR ASAP. The documents were labeled (MONTH) (YEAR). All of the spaces where the daily temperatures would have been documented, were blank. Interview on 4/5/17 at approximately 10:30 a.m. with Staff C (Registered Nurse) confirmed that there were no daily temperatures documented for either of these refrigerators. Review of the Facility's Policy And Procedure Oxygen Therapy, Revised 3/08, revealed that Oxygen (O2) tubing was to be changed weekly. Resident #31 Observation on 4/5/17 at approximately 10:00 a.m. revealed that Resident #31 had an O2 concentrator in the room with O2 tubing attached to it. There was no date on the O2 tubing. Resident #32 Observation on 4/5/17 at approximately 10:00 a.m. revealed that Resident #32 was getting O2 via an O2 tank. The O2 tubing had no date on it. Observation of Resident #32's room revealed an O2 concentrator with O2 tubing attached to it. The date written on the tubing was 3/25/17 indicating that it should have been changed on 4/1/17. Resident #33 Observation on 4/5/17 at approximately 10:00 a.m. revealed that Resident #33 was getting O2 via an O2 concentrator. The date written on the tubing was 3/25/17 indicating that it should have been changed on 4/1/17. Resident #34 Observation on 4/5/17 at approximately 10:00 a.m. revealed that Resident #34 was getting O2 via an O2 concentrator. There was no date on the O2 tubing. Resident #35 Observation on 4/5/17 at approximately 10:00 a.m. revealed that Resident #35 was getting O2 via an O2 concentrator. The date written on the tubing was 3/25/17 indicating that it should have been changed on 4/1/17. Interview on 4/5/17 at approximately 10:00 a.m. with Staff C (Registered Nurse) confirmed that O2 tubing was either not dated or beyond the date of when they were supposed to be changed.",2020-09-01
199,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2017-04-07,465,D,0,1,TOLC11,"Based on observation, record review and interview, it was determined that the facility failed to provide a safe environment for 1 of 7 nursing units. Findings include: Observation on 4/5/17 at approximately 10:30 a.m. revealed an unlocked dirty utility room on Unit 2. Hanging on a handrail bar with easy accessibility in the utility room were 7 spray bottles containing sanitizer/cleaning solution. Interview on 4/5/17 at approximately 10:30 a.m. with Staff C (Registered Nurse) confirmed that the bottles contained sanitizing/cleaning solution to clean and sanitize the dining room tables and the wheelchairs. Observation on 4/7/17 at approximately 12:30 p.m. of the same utility room revealed that it was again unlocked and the 7 spray bottles were hanging on the hand rail bar. Three of the spray bottles had writing on them that said Table Cleaner. Two of the spray bottles had writing on them that said Table Sanitizer. Two of the spray bottles had writing on them that said Wheelchair Cleaner. Interview on 4/7/17 at approximately 12:30 p.m. with Staff D (Licensed Practical Nurse) confirmed that the bottles contained sanitizing/cleaning solution and that the door to the utility room should have been locked. Interview on 4/7/17 T approximately 1:00 p.m. with Staff F (Assistant Director of Nursing) confirmed that the spray bottles should have been kept behind locked doors. Review on 4/7/17 at approximately 2:00 p.m. of the Material Safety Data Sheets for both the cleaning and sanitizing solutions revealed that in the case of accidental contact, medical attention should be sought.",2020-09-01
200,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2019-04-18,550,B,0,1,H0HX11,"Based on observation, interview and policy and procedure review, it was determined that the facility failed to promote dignity in 1 out of 8 dining areas observed. Findings include: Observation on 4/15/19 at approximately 11:45 a.m. in the 4th floor dining room revealed 3 staff members standing up and feeding residents. One staff member was feeding 3 residents (alternating bites between the 3 residents). Observation on 4/16/19 at approximately 11:30 a.m. in the 4th floor dining room revealed a total of 9 residents seated at dining tables. At one table there were 4 residents with meals in front of them being assisted with their meals and 1 staff member standing up and feeding 3 residents (alternating bites between the 3 residents). There was another resident seated at the table without a meal. The other 5 residents were seated at other tables waiting for their meals. Interview on 4/16/19 at approximately 11:30 a.m. with Staff A (Licensed Nursing Assistant) revealed that residents who require more assistance receive their trays approximately 15-20 minutes earlier than the other residents who don't require assistance. Staff A also revealed that while the residents that require more assistance are eating, the residents that require less assistance are waiting at tables for 15-20 minutes daily until their meals arrive. Observation on 4/18/19 at approximately 11:45 a.m. in the 4th floor dining room revealed 1 staff member standing and feeding 1 resident and 1 staff member standing and feeding 3 residents (alternating bites between the 3 residents). Review on 4/18/19 of the facility policy and procedure titled, Communication Tool for Optimizing Eating/Feeding at mealtimes, dated (MONTH) 1999 revealed: . To serve in an appropriate and appealing manner, staff must: . 6. Sit in a chair facing the resident during feeding .",2020-09-01
201,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2019-04-18,577,C,0,1,H0HX11,"Based on observation and interview, it was determined that the facility failed to post notice of availability of surveys and complaint investigations for 3 preceding years in a prominent place and accesable to the public. Findings include: Observation on 4/18/19 of the entrance to the facility revealed a survey book next to the elevator. This book contained only the (YEAR) survey results. There was no notice of availability for 5 complaint investigations over the last 3 years (8/17/18, 6/14/18, 9/21/18, 4/7/17, 10/6/16.) and there was no notice of availability for 2 out of 3 recertification surveys (4/7/17, 5/26/16.) Interview on 4/18/19 at approximately 2:19 p.m. with Staff B (Director of Nursing) confirmed that the (YEAR) survey results were the only ones posted in the survey book next to the elevator, and that there were no notices of availability for the complaint investigations or the recertification survey results.",2020-09-01
202,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2019-04-18,610,E,1,1,H0HX11,"> Based on review of a Facility Reported Incident and interview, it was determined that the facility failed to protect residents from potential abuse following an allegation of sexual misconduct by a staff member for 39 out of 41 residents living on the 4th floor of the facility. (Resident identifiers are: all residents on the 4th floor with the exception of Resident #12 and #15 (Resident #12's roommate).) Findings include: Review on 4/16/19 at approximately 9:00 a.m. of a Facility Reported Incident alleged that on 3/28/19, Resident #12 was the recipient of sexual misconduct by a Staff J (Licensed Nursing Assistant). The facility then allowed Staff J to remain on the floor and finish the scheduled shift, but was told to stay out of the room of Resident #12. Because Staff J was not immediately placed on administrative suspension pending investigation of the reported allegations, all the other residents on the floor were exposed to potential sexual abuse for the rest of the shift. Interview with Staff G (administrator) reviewed the investigation notes and Staff G confirmed that Staff J was allowed to remain on the floor for the remainder of the shift.",2020-09-01
203,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2019-04-18,689,E,0,1,H0HX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed perform an initial, scheduled, and as needed assessment for the safety of 4 residents out of a final sample of 45 residents. (Resident identifiers are #5, #40, #131 and #195.) Findings include: Resident #131 Interview on 4/15/19 at 8:48 a.m. with Resident #131 revealed that Resident #131's smoking supplies (cigarettes and lighter) were stored on the unit and Resident #131 said, I get my smokes and lighter from the nurses and go into that room. On the door of the room in question, is a sign that gives notification that the room is for the intended use of smoking. When questioned as to if any staff observe Resident #131 when Resident #13's smoking activity occurs, Resident #131 replied Nobody comes in with me and nobody watches me. Observation on 4/15/19 at 9:30 a.m. revealed a dedicated room in close proximity of the 3rd floor nursing station that consists of chairs, table, and cigarette butt receptacles. On the door of the room is notification that the room is for the intended use of smoking. Times are listed on the door in which residents may enter the room for the activity of smoking. There is also ventilation fans to expel cigarette smoke from the designated smoking room. They were in operation. There were no devices available for staff to observe room activities from a remote location. Review on 4/17/19 at 1:15 p.m. of Resident #131's medical record revealed that resident has poor safety awareness, falls, mild cognitive impairment, dementia, and depression. It was also revealed that the last time a smoking assessment was conducted was in (MONTH) of (YEAR). A progress note dated 10/13/18 revealed that Resident #131 was found smoking in personal room. A progress note dated 11/17/18 revealed a second occasion that a Licensed Nursing Aid (LNA) discovered Resident #131 was smoking in his/her room. A progress note dated 11/19/18 revealed that staff discovered 4 matchbooks Resident #131 had in Resident #131's room. A progress note dated 1/6/19 revealed that staff discovered Resident #131 attempting to light a cigarette with the facility toaster. Review on 4/18/19 of Resident #131's care plan revealed a focus for Resident #131 to be independent with smoking. One intervention noted is as needed (PRN) smoking assessment. Resident #195 Interview on 4/16/19 at 9:45 a.m. with Resident #195 revealed I am going to smoke outside. I am independent. When Resident #195 was questioned as to where Resident #195's smoking supplies (Cigarettes and lighter) were maintained, Resident #195 replied I lock my cigarettes and lighter in the top drawer of my bureau. Review on 4/17/19 of Resident #195's medical record revealed that resident was admitted on [DATE]. There is no evidence that a smoking assessment was conducted. Resident #40 Observation on 4/15/19 at approximately 10:35 a.m. in the 4th floor smoking room revealed Resident #40, Resident #41 and Resident #149 were smoking in the smoking room without a staff member present. Interview on 4/15/19 at approximately 10:37 a.m. with Staff C ( Licensed Nurse Assistant) stated, I had to leave for a minute to answer someone's question. Review on 4/15/19 of Resident #40's smoking assessment revealed the following: Focus: (pronoun omitted) requires supervised smoking, revision date of 1/28/19. Goal: (pronoun omitted) will smoke only with proper supervision Interventions: (pronoun omitted) requires 1:1 supervision with smoking. (pronoun omitted) will use a cigarette holder. (pronoun omitted) will wear smoking apron. Review on 4/17/19 of Resident #40's smoking incident reports revealed the following: 11/7/18 Resident #40 sustained a 3.2 cm (centimeter) by 1.9 cm. fluid filled blister/burn on left thigh. 2/4/19 Resident #40 revealed that Resident #40 was taking apron off and burning chair with a cigarette on purpose. 3/28/19 Resident #40 sustained [MEDICAL CONDITION] right thumb, pointer and index finger. Review on 4/18/19 of Resident #40's nursing notes revealed the following: 10/6/18 Resident dropped .lit cigarette on .lap while smoking it and came out in the hallway for help. The resident did have a smoking apron on. Upon inspection [MEDICAL CONDITION] on resident, just (pronoun omitted) pants. 11/30/18 Staff noted resident having right thumb padding burn, 2nd and 3rd finger [MEDICAL CONDITION] top and bottom of fingers. Wounds are at various stages of healing. 2/3/19 Staff reports resident having some tiny burn areas on (pronoun omitted) pants. 3/26/19 Resident has light brown discolorations to right hand 3rd finger from smoking. Had cigarette holder which has been lost. Emailed case management (pronouns omitted) to get resident another holder. Review on 4/18/19 of Resident #40's smoking evaluation, dated 10/10/18 revealed: Cognitive 1. Does resident have a cognitive loss- Yes. 1a. Resident is alert and oriented and can consistently perform safe smoking techniques-No. . 1c. Resident is able to communicate effectively-No. Dexterity 3. Does resident have fine motor skills needed to securely hold cigarette-No. . Safety . Resident need for adaptive equipment 7a. Smoking apron 7.b Cigarette Holder . 7.d One-on-One assistance . 10. Resident smokes safely-No. 11. Resident utilizes ashtray safely-No. 12. Resident is able to extinguish cigarettes safely-No. . Interview on 4/18/19 at approximately 10:30 a.m. with Staff B (Director of Nurses) revealed that Resident #40 was assessed for smoking on 10/10/18. There have been no other smoking assessments done with Resident #40 to address safety with smoking. Staff B confirmed that on 4/15/19 when Resident #40 was smoking that a staff member should have been present. Resident #5 Interview on 4/15/19 at 11:03 a.m. with Resident #5 revealed that Resident #5 currently smokes and keeps their cigars and lighter with themselves and in their bedside drawer. Resident #5 stated that they independently smoke and are supervised by staff when going to the designated smoking area outside of the facility for a smoke break. Observation on 4/15/19 at 11:03 a.m. in Resident #5 room with Resident #5 revealed that Resident #5 had a box of cigars were kept in their bedside drawers and a lighter in Resident #5's pants pocket. Review on 4/18/19 of Resident #5's smoking evaluation revealed a smoking evaluation dated 4/18/19 which was blank. Further review of Resident #5's smoking evaluation revealed no other smoking evaluation prior to 4/18/19 in Resident #5's chart or Electronic Health Record. Interview on 4/18/19 at 12:36 p.m. with Staff D (Unit Manager) confirmed the above findings and observations. Staff D stated that Resident #5 independently smoked and was supervised when outside of facility at the designated smoking area. Staff D also stated that smoking evaluation was done on admission and as needed. Staff D further stated that the smoking evaluation was done by the social worker and documented in the Electronic Health Record. Staff D was not able to provide a smoking evaluation prior to 4/18/19.",2020-09-01
204,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2019-04-18,692,D,0,1,H0HX11,"Based on interview, record review, and policy review, it was determined that the facility failed to ensure acceptable parameters of nutritional status in regards to reweighs and notification to dietician and physician of weight loss for 1 resident out of a final survey sample of 45 residents. (Resident identifier is #52.) Findings include: Review on 4/18/19 of the facility's policy titled, Weighing Resident, revision date 7/18, revealed that .License nurse .assess the resident status and notifies the physician of significant weight loss .notifies dietician or weight loss .when weighing a resident and there's a 5 lbs. (pounds) difference and/or decrease from the previous week, the resident needs to be reweighed . Review on 4/18/19 of Resident #52's weight records revealed that Resident #52's weights were 137 lbs. on 4/16/19, 138 lbs. on 4/8/19, 140.4 lbs. on 4/1/19, 146 lbs. on 3/25/19, and 145.9 lbs. on 3/11/19. Further review on Resident #52's weight records revealed that Resident #52 had a 5.6 lbs. weight loss on 4/1/19 compared to 3/25/19 weight. Review on 4/18/19 of Resident #52's nurses notes revealed no documentation that the dietician and physician were notified of the weight loss or if Resident #52 refused to be reweighed. Review on 4/18/19 of Resident #52's dietician notes revealed that Resident #52's last documented dietician note was dated 1/31/19. Interview on 4/18/19 at 1:15 p.m. with Staff H (Licensed Practical Nurse) confirmed the above findings. Staff H stated that Resident #52 should have been reweighed on 4/1/19. Staff H also stated that residents are reweighed if there is a 5 lbs. weight loss or gain and that it should be documented on the nurses notes. Staff H further stated that the dietician and physician should have been notified and notification should have been documented in the nurses notes. Interview on 4/18/19 at 1:26 p.m. with Staff I (Assistant Dietician) revealed that they were not aware of Resident #52's weight loss on 4/1/19. Staff I stated that Resident #52 should have been reweighed on 4/1/19 and that residents should be reweighed if there was a 3 lb. weight difference from previous weight. Staff I further revealed that Resident #52 had greater than 5% (percent) weight loss on 4/16/19 compared to 3/11/19 weight which was a significant weight loss. Staff I stated that they will evaluate Resident #52. Interview 4/18/19 1:40 p.m. with Staff [NAME] (Unit Manager) revealed that Resident #52 was scheduled to be weighed weekly on 3-11 shift and that the Resident #52 should have been reweighed if there is a 5 lbs. weight difference from the previous weight and the dietician and physician notified by the 3-11 nurses. Staff [NAME] stated that they will reweigh Resident #52.",2020-09-01
205,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2019-04-18,926,B,0,1,H0HX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, it was determined that the facility failed to establish policies regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents and implement their smoking policies for 3 residents out of a final sample size of 45 residents. (Resident identifiers are #5, #131, and #195.) Findings include: Review on 4/18/19 of the facility policy titled, Riverside Rest Home Resident Smoking Policy, updated 4/17/19, revealed that .Resident, upon admission, will have a smoking assessment . reassessment of smoking practices will be done quarterly .All residents admitted will relinquish all smoking materials to the nurse's station whether independent or supervision needed .This includes cigarettes, matches, lighter and e-cigarettes . Resident #5 Observation on 4/15/19 at 11:03 a.m. in Resident #5 room with Resident #5 revealed that Resident #5 had a box of cigars kept in their bedside drawers and a lighter in Resident #5's pants pocket. Review on 4/18/19 of Resident #5's smoking evaluation revealed a smoking evaluation dated 4/18/19 which was blank. Further review of Resident #5's chart and Electronic Health Record revealed no other smoking evaluation prior to 4/18/19. Interview on 4/18/19 at 12:36 p.m. with Staff D (Unit Manager) confirmed the above findings and observations. Staff Staff D revealed that there were no smoking evaluation on Resident #5's chart. Staff D was unable to provide any other smoking evaluation prior to the 4/18/19 smoking evaluation for Resident #5. Staff D also stated that smoking evaluation was supposed to be done on admission and as needed. Resident #131 Interview on 4/15/19 at 8:48 a.m. with Resident #131 revealed when questioned where Resident #131's smoking supplies (cigarettes and lighter) were stored, Resident #131 replied I get my smokes and lighter from the nurses and go into that room. On the door of the room in question, is sign that gives notification that the room is for the intended use of smoking. When questioned as to if any staff observes Resident #131 when Resident #13's smoking activity occurs, Resident #131 replied Nobody comes in with me and nobody watches me. Observation on 4/15/19 at 9:30 a.m. revealed a dedicated room in close proximity of the 3rd floor nursing station that consists of chairs, table, and cigarette butt receptacles. On the door of the room is notification that the room is for the intended use of smoking. Times are listed on the door in which residents may enter the room for the activity of smoking. There is also ventilation fans to expel cigarette smoke from the designated smoking room. They were in operation. There were no viewing devices available for staff to observe room activities from a remote location. Review on 4/17/19 of resident #131's medical records revealed that resident has poor safety awareness, falls, mild cognitive impairment, dementia, and depression. It was also revealed that the last time a smoking assessment was conducted was in (MONTH) of (YEAR). A progress notes dated 10/13/18 reveals that Resident #131 was found smoking in his/her room. A progress note dated 11/17/18 revealed a second occasion that a Licensed Nursing Aid (LNA) discovered Resident #131 was smoking in his/her room. A progress note dated 11/19/18 revealed that staff discovered 4 matchbooks Resident #131 had in Resident #131's room. A progress note dated 1/6/19 revealed that staff discovered resident attempting to light a cigarette with the facility toaster. Review on 4/18/19 of Resident #131's care plan revealed a focus for Resident #131 to be independent with smoking. One intervention noted is as needed (PRN) smoking assessment. Resident #195 Interview on 4/16/19 at 9:45 a.m. with Resident #195 revealed, I am going to smoke outside. I am independent. When Resident #195 was questioned as to where Resident #195's smoking supplies (Cigarettes and lighter) were maintained, Resident #195 replied, I lock my cigarettes and lighter in the top drawer of my bureau. Review on 4/17/19 of Resident #195's medical record revealed that resident was admitted on [DATE]. There is no evidence that a smoking assessment was conducted.",2020-09-01
206,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2018-08-17,658,D,1,0,Z5E111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a record review and interview, it was determined that the facility failed to properly transcribe physician orders [REDACTED]. (Resident identifier is #1) Findings include: Review on 8/17/18 of Resident #1 medical record revealed that they were sent to the hospital on [DATE] due to chest pain at which time a cardiac catheterization was performed. During this procedure, a stent was placed in the right coronary artery during the procedure and then Resident #1 was transferred to the ICU. Resident #1 was discharged on [DATE] back to the facility. On 6/20/18 Resident #1 had a follow up visit with the cardiologist who noticed the medication (Brilinta 90mg twice daily) failed to get transcribed onto the MAR (Medication Administration Record). The revised orders were sent to the facility on [DATE], and the medication was administered to Resident #1 as ordered with no ill effect. Interview on 8/17/18 with Staff A (Director of Nurses) confirmed that a medication transcription error had occurred and the facility since has placed a corrective action plan in place to prevent any type of transcription errors from occurring.",2020-09-01
207,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2017-07-20,431,E,0,1,BRJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure that multi-dose medication bottles are labeled with the expiration date and that medications are not used after the expiration date on 3 of 7 units. (Resident identifiers are #31, #35, #36, #37, #38, #39, #40) Findings include: Review of the the document provided by the facility titled Insulin Storage Recommendations, dated [DATE], revealed the following opened room temperature expirations dates: Humalog-28 days, Lantus-28 days, Levemir-42 days, Novolin-42 days, Novolog-28 days. Review of the facility's policy titled 6.0 General Dose Preparation and Medication Administration, effective [DATE], page 1, section 3.11 revealed Facility staff should enter the date opened on the label of medication with the shortened expiration dates (e.g., insulins, irrigation solutions, etc). Resident #37 Observation on [DATE] at 10:00 a.m. on unit A2 of the Back medication cart revealed a bottle of Levemir Solution belonging to Resident #37. The bottle was labeled Do not use after ,[DATE]. The bottle was not labeled with an opened date. Review on [DATE] of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Observation on [DATE] at 10:00 a.m. on unit A2 of the Back medication cart revealed a bottle of HumaLOG Solution belonging to Resident #37. The bottle was labeled Do not use after ,[DATE]. The bottle was not labeled with an opened date. Review on [DATE] of the (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview on [DATE] at 10:00 a.m. with Staff H (Licensed Practical Nurse) confirmed the confirmed the open expirations dates labeled on the above bottles for Resident #37 and revealed that the above bottles were the bottles currently in use. Resident #38 Observation on [DATE] at 10:20 a.m. on unit A2 of the Front medication cart revealed a bottle of Lantus Solution belonging to Resident #38. The bottle was labeled Opened [DATE]. The bottle was not labeled with an opened expiration date or Do not use after date. Review on [DATE] of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident#39 Observation on [DATE] at 10:20 a.m. on unit A2 of the Front medication cart revealed a bottle of NovoLOG Solution belonging to Resident #39. The bottle was labeled Opened [DATE]. The bottle was not labeled with an opened expiration date or Do not use after date. Review on [DATE] of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Observation on [DATE] at 10:20 a.m. on unit A2 of the Front medication cart revealed a bottle of Levemir Solution belonging to Resident #39. The bottle was labeled Opened [DATE]. The bottle was not labeled with an opened expiration date or Do not use after date. Review on [DATE] of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident #40 Observation on [DATE] at 10:20 a.m. on unit A2 of the Front medication cart revealed a bottle of HumaLOG Solution belonging to Resident #40. The bottle was labeled Opened [DATE] and Do not use after [DATE]. Review on [DATE] of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview on [DATE] at 10:20 a.m. with Staff I (Registered Nurse) confirmed the open expirations dates labeled on the above bottles for Resident #38, Resident #39, and Resident #40 and revealed that the above bottles were the bottles currently in use. Resident #35 Observation on [DATE] at approximately 9:30 a.m. of the C3 Unit medication cart 1 revealed Resident # 35's Lantus insulin opened on [DATE] had expired prior to the date of survey. Review on [DATE] of Resident #35's medical record revealed that the resident had an active order for Lantus insulin 100 unit/ml (insulin glargine). Inject 18 unit subcutaneously one time a day. Review of the insulin administration record revealed that Resident #35 had been administered 9 doses of the expired insulin in (MONTH) (YEAR). Interview on [DATE] at approximately 9:30 a.m. with Staff D (LPN) Licensed Practical Nurse confirmed that Resident #35's Lantus insulin in medication cart 1 had expired on [DATE]. Resident #36 Observation on [DATE] at approximately 9:40 a.m. of C3 Unit medication cart 2 revealed for Resident #36, Humalog insulin opened on [DATE] had expired prior to the date of survey. Review on [DATE] of Resident #36's medical record revealed that the resident had an active order for Humalog insulin 100 unit/ml (insulin lispro (Human)). Humalog insulin order is based on a sliding scale prior to meals and bed time. Review of the insulin administration record revealed that Resident #36 had been administered 23 doses of expired insulin in (MONTH) (YEAR) and 39 doses of expired insulin in (MONTH) (YEAR). Interview on [DATE] at approximately 9:45 a.m. with Staff [NAME] (RN) Registered Nurse confirmed that Resident #36's Humalog insulin in medication cart 2 had expired on [DATE]. Resident #31 Observation on [DATE] at approximately 9:30 a.m. of the CRU unit medication cart Staff B, RN revealed an undated open vial of Humalog for Resident #31. Interview with Staff B at this time confirmed that Staff B had no knowledge of when it was opened. Review on [DATE] at approximately 11:00 a.m. of the June's and July's Medication Administration Records for Resident #31 revealed the following orders: HumaLOG Solution 100 unit/1ML (milliliter) vial- (Insulin Lispro) Inject 3 unit subcutaneously one time only for CBG (Capillary blood glucose) 219 until [DATE]. HumaLOG Solution 100 unit/1ML (milliliter) vial- (Insulin Lispro) Inject per sliding scale: .subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus without Complications. Interview on [DATE] at approximately 9:30 a.m. with Staff A and Staff B confirmed that the open vial of HumaLOG Solution had no date when opened.",2020-09-01
208,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2017-07-20,441,D,0,1,BRJ611,"Based on observation and interview, it was determined that the facility failed to ensure proper infection control practices were adhered to for cleaning of the blood glucose meters on 2 of 7 units. Findings include: Interview on 7/18/17 at approximately 9:30 a.m. during tour of the CRU unit Staff B (RN) revealed that Staff B cleans the glucometer on the medication cart with alcohol wipes before and after each blood glucose test that Staff B does. Observation on 7/18/17 at approximately 9:30 a.m. with Staff B confirmed that alcohol wipe that are used by displaying them. Interview on 7/18/17 at approximately 10:45 a.m. during tour of the A2 unit Staff C (Licensed Practical Nurse)revealed that Staff C cleans the glucometer on the medication cart with alcohol wipes after each blood glucose test that Staff C does. Observation on 7/18/17 at approximately 10:45 a.m. with Staff C also confirmed by displaying the alcohol wipes that Staff C uses.",2020-09-01
209,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2017-07-20,514,D,0,1,BRJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to maintain accurate, and complete medical records for 2 resident out of a sample of 30 residents. (Resident identifiers are #9 and #15.) Findings include: Review on 7/19/17 of the facility policy and procedure, Intake and Output, 7/2017 revealed: Purpose: 1. To keep an accurate record of resident's hydration and liquid elimination Fluid Intake includes: 1. All fluids taken by mouth . Fluid Output includes: 1. All urine (whether by voiding or catheter drainage) . Statement: 1. Intake and output will be recorded every shift according to procedure on all residents. a. who have an indwelling catheter . c. who are on fluid restrictions Procedure: 1. All fluid intake and output is recorded in milliliters/cubic centimeters. 2. Intake and output is recorded and measured when so directed by the physician and/or head/charge nurse. 3. Each person having contact with the resident on Intake and Output is responsible for recording fluids known to them. 4. Intake and Output are recorded in the Electronic Medical Record. Resident #15 Review on 7/19/17 of Resident #15's medical record (care plan section, start date 4/13/16) revealed that the resident was on a 2,000 ml. (milliliter) fluid restriction for - potential for fluid imbalance due to diuretic therapy/fluid overload. Intervention on care plan for urinary tract infection was to monitor intake and output. Review of the diet on the (MONTH) Medication Administration Record [REDACTED]. fluid restriction. Review on 7/19/17 of Resident #15's intake and output record revealed the following: Intake and output record for 5/20/17 thru 7/18/17: 26 shift entries marked na (not applicable) 32 shift omissions (no entries at all). Interview on 7/19/17 at approximately 9:50 a.m. with Staff G, LNA (Licensed Nursing Assistant) revealed that the intake and output is to be entered by the LNA every shift for a resident on intake and output. Resident #9 Review on 7/19/17 of Resident #9's medical record (care plan section, start date 4/3/17) revealed that the resident was on a 2,000 ml fluid restriction for - potential for fluid imbalance due to weight changes. Intervention on care plan was to monitor intake and output. Review of the diet on nutrition care plan (start date 4/3/17) revealed diet was no added sodium diet, 2000 ml. fluid restriction. Review on 7/19/17 of Resident #9's medical record of the physician orders [REDACTED]. Review on 7/19/17 of Resident #9's intake and output record revealed the following: Intake and output record for 4/3 thru 6/9/17: 79 shift entries marked na 4 Resident not available 21 shift omissions (no entries at all).",2020-09-01
210,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2018-09-11,759,B,0,1,QH0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure that the medication error rate was not greater than 5% during 32 medication pass observations. (Resident identifier is #217.) Findings include: Resident #217 Observation on 9/6/18 at approximately 11:06 a.m. during medication pass revealed that Resident #217 received the following scheduled 9:00 [NAME]M. medications; Aspirin 81 mg (milligrams) (1 tablet) by mouth one time a day, [MEDICATION NAME] 40 mg (1 tablet) by mouth one time a day, ROPINIRole HCI 1 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 100 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 25 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] 50 mg by mouth (two times a day), and Micro-K Extended Release 10 MEQ (milliequivalents) 2 capsule by mouth two times a day. Review on 9/6/18 of Resident #217's (MONTH) (YEAR) Medication Administration Record [REDACTED] Interview on 9/6/18 at approximately 11:10 a.m. with Staff D(Licensed Practical Nurse) confirmed that Staff D had administered Aspirin 81 mg (milligrams) (1 tablet) by mouth one time a day, [MEDICATION NAME] 40 mg (1 tablet) by mouth one time a day, ROPINIRole HCI 1 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 100 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 25 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] 50 mg by mouth (two times a day), and Micro-K Extended Release10 MEQ (milliequivalents) 2 capsule by mouth two times a day 2 hours after the scheduled prescribed time. In total there were 7 medication errors, 1 for Resident #217, out of a total of 32 medication pass opportunities resulting in a 21.87% error rate.",2020-09-01
211,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2018-09-11,842,B,0,1,QH0Y11,"Based on record review and interview, it was determined that the facility failed to to maintain medical records for pressure ulcers that are complete for 2 of 4 residents with pressure ulcers in a final sample of 36 residents. (Resident identifiers are #230 and #288.) Findings include: Resident #230 Review on 9/7/18 at 12:21 p.m. of Resident #230's progress notes dated 8/30/18 revealed Resident #230 had a non-healing stage 4 pressure ulcer on their coccyx. Review on 9/11/18 at 8:37 a.m. of Resident #230's skin notes from (MONTH) and (MONTH) (YEAR) revealed that the most recent pressure ulcer measurement was dated 8/21/18. Interview on 9/11/18 at 8:46 a.m. with Staff B (A2 Unit Manager) revealed that the wound team had discontinued wound measurements on Resident #230's coccyx wound on 8/21/18. Interview on 9/11/18 at approximately 2:00 p.m. with Staff C (Wound Nurse) confirmed that Resident #230's coccyx wound was no longer being measured. Resident #288 Review on 9/7/18 at 09:02 a.m. of Resident #288's skin note dated 8/23/18 revealed Resident #288 had an unstageable left heel pressure wound with no measurements. Further review of skin notes revealed that Resident #288's most recent assessment wound measurement was documented in the skin note dated 8/14/18. Review of Resident #288's progress note dated 8/23/18 revealed that Resident #288 was to be discharged from wound rounds by the wound team and would be assessed by facility unit staff. Interview 9/11/18 at approximately 2:00 p.m. with Staff C confirmed that Resident #288's left heel wound is no longer being measured.",2020-09-01
212,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2018-09-11,880,D,0,1,QH0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review it is determine that the facility failed to maintain infection control practices in regards to wound dressing change, Personal Protective Equipment (PPE) and handwashing for 1 out of 4 residents observed during wound dressing changes. (Resident identifier is #209) Findings include: Policy: Review on 9/11/18 of the facility's policy on Personal Protective Equipment (PPE) revision date was on 8/14 revealed that .Gloves: .2. Handwashing to be done before and after wearing gloves .4. Gloves are worn when it is reasonably anticipated that employees will have direct contact with patients, blood, bodily fluids . Review on 9/11/18 of the facility's policy on Skin and Wound Care Management revision date was on 3/17 revealed that .Basic Treatment Guidelines: .4. Apply gloves. Change gloves as needed if gloves become soiled during the dressing change . (Page 5). Review on 9/11/18 of the facility's policy on Handwashing revision date was on 5/11, revealed that .Healthcare Personnel Handwashing and Hand Antisepsis: Hands must be washed under the following conditions: .g. After removing gloves .The following is a list of some situations that require hand hygiene: .i. Before and after changing a dressing .r. After removing gloves or aprons . Observation on 9/11/18 at 11:00 a.m. of Resident #209's wound dressing change revealed that Staff A (Registered Nurse) obtained gloves from the medication cart and placed the gloves in their pocket with medication cart keys and proceeded to obtain Santyl ointment and an unopened package of cotton swabs from the medication cart. Observation on 9/11/18 at 11:03 a.m. of Resident #209's wound dressing change revealed that Staff A obtained a half opened package of [MEDICATION NAME] dressing and cleansing spray from Resident #209's shelf and placed the supplies on Resident #209's bedside table. Staff A donned gloves from their pocket, removed Resident #209's pants and adult brief, then proceeded to remove Resident #209's wound dressing. Staff A removed their gloves and washed their hands with soap and water then dried their hands with paper towel. Staff A obtained gauze pads from Resident #209's shelf and proceeded to cleansed the wound with cleansing spray and patted the wound dry with gauze pads. Staff A removed their gloves then obtained scissors from their pocket and proceeded to cut one-third of [MEDICATION NAME] dressing from the opened package. Staff A applied Santyl to wound with cotton swabs from the unopened package then covered the wound with the one-third [MEDICATION NAME] dressing and transparent film dressing with their bare hands. Staff A's bare hands were touching the resident's surrounding skin and the adhesive side of the transparent film dressing. Interview on 9/11/18 at 11:10 a.m. with Staff A revealed that Staff A removes their gloves when applying transparent film dressing because the gloves stick to the transparent film dressing and is difficult to apply on skin. Staff A confirmed that this is their standard practice for wound dressing changes.",2020-09-01
213,RIVERWOODS AT EXETER,305049,7 RIVERWOODS DRIVE,EXETER,NH,3833,2017-06-07,281,D,0,1,XFZS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to assess the need for as needed (PRN) medication and the resulting resident level of comfort after receiving medication, for two residents in a survey of 15 residents (Resident identifiers are #5 and #10). Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 699 Prescribers must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 1070 Nurses administer and monitor interventions ordered by primary health care providers (HCPs) for pain relief Resident #5 Review on 6/6/17 of Resident #5's Medication Administration Records for 5/1/17 through 5/31/17 and for 6/1/17 through 6/30/17 revealed that Resident #5 had orders for [MEDICATION NAME] 0.5 MG (milligram) 1 TAB (tablet) by mouth every day as needed for severe agitation. Further review revealed that Resident #5 also had an order for [REDACTED]. Review of Resident #5's (MONTH) and (MONTH) (YEAR) nurses' notes revealed that Resident #5 received as needed [MEDICATION NAME] on 5/7/17, 5/8/17, 5/12/17, 5/13/17, 5/14/17, 5/15/17, 5/22/17, 5/28/17, 5/31/17, 6/1/17, 6/3/17, 6/4/17 and 6/6/17. The behaviors documented in the nurses' notes for the indicated use of the [MEDICATION NAME] included agitation, aggression, anxiety, yelling out for a family member, attempting to climb out of bed and wheelchair, restlessness, pulling off clothes, ripping at clothes, looking for a piece of clothing that Resident #5 could not find, anxiously asking about an unseen flood that Resident #5 needed to help with, anxiety related to rug shampooing and air blowing machines, and tossing bedding around. Review of Resident #5's (MONTH) and (MONTH) (YEAR) nurses' notes revealed that Resident #5 received as needed Quetiapine [MEDICATION NAME] on 5/7/17, 5/8/17, 5/14/17, 5/15/17, 5/16/17, 5/31/17, 6/2/17, and 6/3/17. The behaviors documented in the nurses' notes for the indicated use of the Quetiapine [MEDICATION NAME] included agitation, restlessness, yelling out, yelling out for a family member, trying to climb out of wheelchair and bed, combative with staff, and throwing bedding. Interview on 6/6/17 At approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed that the two different medications were given for the same behaviors and that there was no clear indication of when to administer which medication to Resident #5. Resident #10 Review on 6/7/17 of Resident #10's medical record and Medication Administration Record (MAR) revealed that the facility failed to document pre and post numeric assessments for PRN (as needed) pain medications. Review of the facility policy and procedure Pain assessment dated ,[DATE] revealed under the Procedure sections #3 and #6: #3. An appropriate pain scale, numeric 0-10 or Wong-Baker Faces 0-10, based on resident assessment will be documented on the MAR. #6. Resident's response to PRN pain medication will be documented on the back of the MAR. Review of Resident #10's 4 months of MAR's and nursing notes revealed the following: 3/17- 6 PRN doses of Tylenol were given for pain without pre and post numerical pain assessments. 4/17-11 PRN doses of Tylenol were given for pain without pre and post numerical pain assessments. 5/17-20 PRN doses of Tylenol and [MEDICATION NAME] were given for pain without pre and post numerical pain assessments. 6/17-7 PRN doses of [MEDICATION NAME] were given for pain without pre and post numerical pain assessments. Review on 6/7/17 of the nursing notes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that there were some notes that included some pre and some post numerical assessments. These notes were not consistent with the doses that were administered. Interview on 6/7/17 at approximately 9:00 a.m. with Staff A (Registered Nurse) revealed that pre and post numerical assessments should be documented with all PRN pain medication administration.",2020-09-01
214,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2019-07-03,645,D,0,1,HZAU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that a resident with a mental disorder received a PASARR (Pre Admission Screening and Resident Review) for 1 resident in a final survey sample of 21 residents. (Resident identifier is #19.) Findings include: Review on 7/3/19 of Resident #19's PASARR level 1 dated 7/7/16 revealed that Section 2 titled Screening for Mental Illness (MI) was checked Yes for the question Has the individual been diagnosed with [REDACTED].? Section 2B. is checked for easily upset/anxious, Section 2C. is checked for serious difficulty concentrating and requires assistance with tasks in which the individual should be physically capable of performing. Section 2D. is checked for agitation due to adaptation to changes and judicial intervention due to increased symptoms. Section 6 is checked for hospital discharge exemption which states that the attending physician certifies that the individual is likely to require nursing facility services for less that 30 days, and that if the nursing facility stay is 30 days or longer a new PASARR and resident review must be performed within 40 calendar days. Review on 7/3/19 of Resident #19's Electronic Health Record revealed a primary medical [DIAGNOSES REDACTED]. Interview on 7/3/19 at approximately 10:00 a.m. with Staff H (Director of Social Services) confirmed that the PASARR level I dated 7/7/16 was for a hospital discharge exemption, and that Resident #19 remained in the facility past 30 days. Interview on 7/3/19 at approximately 9:09 a.m. with Staff I (2nd Floor Social Worker) confirmed that Resident #19 is followed by the facility's behavioral health service, but often refuses to speak to them, and does demonstrate illogical thinking process and distortions of thought content, specifically delusions and persecutory accusations; and these behaviors are included in his/her care plan.",2020-09-01
215,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2019-07-03,658,D,0,1,HZAU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, it was determined that the facility failed to ensure that medication administration were followed according to professional standards for 10 out of 25 observed medication administrations. (Resident identifier is #50.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 707 To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation Review on 7/2/19 of facility's policy titled, Medication: Administration: General, revision date 7/1/19, revealed that .medications will be administered as soon as possible .document: administration of medication on Medication Administration Record [REDACTED] Review on 7/2/19 of facility's policy titled, Medication Administration: Oral, revision date 5/4/15, revealed that .1. Prepare for administration of medication .2.1 verify medication order on MAR indicated [REDACTED].patient .drug .route .time .pour medications .administer medication document: administration of medication Interview on 6/30/19 at 8:00 p.m. with Staff A (Registered Nurse) revealed that they completed their evening medication pass. Interview on 6/30/19 at 8:31 p.m. with Staff A revealed that Resident #50 requested a PRN (as needed) Tylenol. Observation on 6/30/19 at 8:31 p.m. with Staff A revealed that Staff A was on the medication cart and had used the ABHR (Alcohol Based Hand Rub) on their hands then poured 2 tablets of Tylenol 500 mg (milligram) into a medication cup and proceeded to Resident #50's room. Staff A gave Resident #50 the 2 tablets of Tylenol 500 mg which Resident #50 took. Resident #50, after taking the 2 tablets Tylenol 500 mg, asked Staff where their evening medications were. Staff A told Resident #50 that they will be back for the [MEDICATION NAME] (anticoagulant) due at 9:00 p.m. Staff A left Resident #50's room and went back to the medication cart, used the ABHR on their hands and proceeded to do another task. Interview on 6/30/19 at 8:35 p.m. with Staff A confirmed that Staff A did not verify right resident, medication, dose, route, frequency and documentation in the Electronic Medication Administration Record [REDACTED]. Review on 6/30/19 at 8:35 p.m. with Staff A of Resident #50's EMAR revealed that there were no PRN Tylenol order. Further review of Resident #50's EMAR revealed that medications: [REDACTED] Interview on 6/30/19 at 8:35 p.m. with Staff A revealed that Staff A would sign off medications in the EMAR as given and then give the medication later to the resident. Interview on 6/30/19 at 8:36 p.m. with Staff D (Unit Manager) revealed that Staff D would verify right resident, medication, route, dose, frequency on EMAR with resident medication supply when giving the medication and not sign medications off prior to giving the medications. Interview on 6/30/19 at 9:16 p.m. with Staff B (Day Unit Manager) revealed that Staff B would verify right resident, medication, route, dose, frequency on EMAR with resident medication supply when giving the medication and not sign medications off prior to giving the medications. Interview on 6/30/19 at 9:16 p.m. with Staff [NAME] (Registered Nurse) revealed that Staff [NAME] would verify right resident, medication, route, dose, frequency on EMAR with resident medication supply when giving the medication and not sign medications off prior to giving the medications. Observation on 6/30/19 at 9:16 p.m. with Staff A on Resident #50's evening medication administration revealed that EMAR had red marked and yellow marked on the evening medications which were Atorvastatin 40 mg, [MEDICATION NAME] 30 mg, Latanoprost 0.005%, [MEDICATION NAME] 3 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 160-4.5 mcg/act, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 25 mg, and [MEDICATION NAME] 120 mg which were marked as given during above observation. Staff A stated that the medications were signed off in error and were not given. Staff A stated that the red mark meant medications are overdue and yellow mark meant medications are currently due. Staff A proceeded to give the Atorvastatin 40 mg, [MEDICATION NAME] 30 mg, Latanoprost 0.005%, [MEDICATION NAME] 3 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 160-4.5 mcg/act, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 25 mg, and [MEDICATION NAME] 120 mg. Interview on 7/1/19 at 8:52 a.m. with Staff C (Director of Nursing) confirmed the above observations. Staff C stated that Staff A should have verify medications prior to giving the medication and documenting on the EMAR right after medications were given.",2020-09-01
216,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2019-07-03,812,F,0,1,HZAU11,"Based on observation and interview, it was determined that the facility failed to maintain a working environment to prevent Food Contamination by means of unintended presence of potentially harmful substances, including, but not limited to microorganisms, while touring the kitchen. Findings include: Observation on 6/30/19 at 8 p.m. while doing the initial brief tour of the kitchen revealed that the floors were dirty with food product and stains throughout the floors from spilled products, along with a strong smell of waste coming from the dish room. Lighting could not be found in this area so these concerns will need to be further inspected when the Director of food services in the morning. Interview on 7/01/19 at 9:14 a.m. with Staff G (Director of Food Services) was told of what was observed last night in regards to the floors Staff G stated that the facility run out of cleaning solutions and the floors have not been cleaned at time of interview. The floors were still in the same condition dirty with food product and stains throughout the floors from spilled product. Observation on 7/1/19 at 9:14 a.m. while touring the kitchen with Staff G that same smell of waste that was smelt the day before was coming from the dish room. When entering the dish room all the floor tiles were lifted with water pooling under the tiles. The walls throughout the area were covered with a black substance like material (mold like) and under the tiles that were lifted it was observed that the same black substance like material (mold like). These finding were shown to Staff G at time of finding who stated that this area has been like this for a long time. Staff G went on to say that the facility has tried to clean it before but the mold comes right back. Staff G also was asked about the smell of waste stating that they have used expansion foam on the main drain due to water coming up from it eliminating the air gap. Staff G said the facility is planning something but not until the middle of the summer with no date identified. Observation on 7/1/19 at approximately 9:45 a.m. of the dish room in the kitchen revealed a foul smell upon entering the kitchen area. Upon entering the dish room, the floor tiles were wet and very slippery when walked on and were not attached to the floor and there was a black substance that pushed up around the tiles when the tiles were stepped on. Interview on 7/1/19 at approximately 9:50 a.m. with Staff G (Food Service Director) revealed that on several occasions has made administrative staff aware of these above noted issues. Staff G explained that a plan to overhaul the dish room was in the works for sometime around the middle of the summer. Interview on 7/1/19 at approximately 10:15 a.m. with Staff C (Director of Nursing) revealed that Staff C had identified on 6/27/19 that the mold in the dish room was worse than it has ever been and the kitchen staff were directed to bleach the dish room twice a week instead of once a week. Observation on 7/1/19 at approximately 10:30 a.m. of the dish room in the kitchen revealed a strong septic smell and wet floor with the tiles broken and lifting in multiple places. There was a black mold like substance underneath the tiles that was being tracked through the dishroom floor. The walls behind and under the counters were covered with a black mold like substance that started at floor level and continued up the walls to eye level. Interview on 7/3/19 at 11:30 a.m. with Staff C (Director of Nursing) and Staff F (Registered Nurse) during the infection control task interview revealed that Staff C and Staff F would do monthly environmental rounds that would include the kitchen to check for sanitation of the kitchen and infection control practices. Staff C was unable to provide documentation of said monthly rounds for the kitchen. Staff C and Staff F were not able to provide any information regarding results of their walking rounds from (MONTH) (YEAR) to (MONTH) 2019, however there were no staff and resident illnesses found from (MONTH) (YEAR) to (MONTH) 2019.",2020-09-01
217,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2017-08-09,279,D,0,1,HU2011,"Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 1 resident in a survey sample of 21 residents. (Resident identifier is #6.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 269 You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals .The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care . Review on 8//8/17 of Resident #6's hospital discharge summary, dated 3/16/17, revealed that Resident #6 had a pacemaker. Review on 8/8/17 of Resident #6's Comprehensive Care Plan, initiated on 3/16/17, revealed that there was no documented care plan for the pacemaker. Interview on 8/9/17 at approximately 10:00 a.m. with Staff D (Registered Nurse, Unit Manager) confirmed the above findings.",2020-09-01
218,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2017-08-09,281,E,0,1,HU2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure complete physician orders [REDACTED].#6 and #21) document effectiveness of pain medication for 2 residents (Resident identifiers #6 and #18), notify physician of missed medication (Resident identifier #7 and#21), develop an appropriate interim care plan for 1 resident (Resident identifier #3) and appropriately administer medications to 1 resident (Resident identifier #8) in a standard survey sample of 21 residents. Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary Page 699 Prescribers must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 720 To prepare tablets or capsules from a floor stock bottle, pour required number into bottle cap and transfer medication to medication cup. Do not touch medication with fingers . Page 721 Do not leave medications unattended. Page 1063 One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity Page 1082 Evaluation of pain is one of many nursing responsibilities that require critical thinking .Evaluating the effectiveness of a pain intervention requires you to evaluate the client after an appropriate period of time . Resident #6 Review on 8/8/17 of Resident #6's Medication Record, dated 8/1/17 through 8/31/17, revealed that Resident #6 had an order for [REDACTED].#6's Medication Record, dated 8/1/17 through 8/31/17, revealed that Resident #6 also had an order for [REDACTED]. Interview on 8/9/17 at approximately 10:00 a.m. with Staff D (Registered Nurse, Unit Manager) confirmed that there was no clear indication of whether to administer Tylenol or [MEDICATION NAME] to Resident #6 for pain. Review on 8/8/17 of Resident #6's Medication Records, dated 7/1/17 through 7/31/17 and 8/1/17 through 8/31/17, revealed that Resident #6 received [MEDICATION NAME] for pain with no documentation of the effect of the medication on 7/2/17 at 10:45 p.m., 7/4/17 at 11:00 p.m., 7/6/17 at 11:00 p.m., 7/13/17 (time illegible,) 7/15/17 (time illegible,) 7/26/17 at 10:30 p.m., 7/29/17 at 9:00 p.m., and 8/4/17 at 10:00 p.m. Interview on 8/9/17 at approximately 9:00 a.m. with Staff D confirmed that there was no documentation of the evaluation for the effectiveness of the above pain interventions. Resident #18 Review on 8/8/17 of Resident #6's Medication Records, dated 7/1/17 through 7/31/17 revealed that Resident #6 had an order for [REDACTED].#18 received [MEDICATION NAME] for pain with no documentation of the effect of the medication on 7/15/17 at 1:25 p.m. and on 7/17/17 at 7:30 a.m. Interview on 8/9/17 at approximately 9:00 a.m. with Staff D confirmed that there was no documentation of the evaluation for the effectiveness of the above pain interventions. Observation on 8/8/17 at approximately 7:40 a.m. with Staff G (Registered Nurse) of the medication task review revealed medications being picked up out of medication cup with Staff G's fingers and being administered to Resident #8. During this observation at approximately 7:45 a.m. Staff G was observed leaving the medication cart unlocked and with medications in a medication cup, eye drops and an inhaler on top of the medication cart to wash hands in bathroom at the nursing station. Interview on 8/8/17 at approximately 7:55 a.m. with Staff G confirmed that the pills in the medication cup were picked out of a medication cup with bare fingers. It was also confirmed that Staff G left the medication cart unlocked and unattended. Resident #3 [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 269 relates under Planning Nursing Care, You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care A correctly formulated nursing care plan makes it easy to continue care from one nurse to another. Review on 8/21/17 of this resident's current care plan reveals that Resident #3 was admitted on [DATE]. Review of Skin Integrity Reports reveals that on 7/29/17 the resident had Pressure Wounds identified on the posterior heel (Stage I), inner left lower extremity (Stage II), and outer left lower extremity (Stage II). An interim care plan for this resident was initiated on 7/29/17 with focus on . potential for discharge, or is expected to be discharged , related to: Admission for skilled short-term stay and . at risk for distressed/fluctuating mood symptoms related to: history of depression and . requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to: MVC with multiple fractures and . advanced directive and has a Full code in place. This interim care plan did not specifically address actual skin issues or pressure ulcer risk. Interview on 8/9/17 with Staff A (Registered Nurse), revealed that Resident #3 had acquired an in-house, Stage two, upper sacrum pressure ulcer that was now healed. Resident #21 Review on 8/9/17 of a physician's orders [REDACTED]. Review on 8/7/17 of Resident #7's medical record revealed that Resident #7 had an active order for [MEDICATION NAME] 40,000 units solution- inject subcutaneous once a week on Thursdays. Review on 8/7/17 of Resident #7's MAR (medication administration record) revealed that on (MONTH) 6th and (MONTH) 13th that the [MEDICATION NAME] had not been administered. Nursing initials were circled in the MAR indicated [REDACTED]. There was no entry for the (MONTH) 13th dose on the back of the MAR. Review on 8/8/17 of the facility's policy and procedure 7.0 Medication Shortages/Drugs Not Available dated 12/15/08 under Policy section revealed: When medication orders are not received or unavailable, the licensed nurse will immediately initiate action in cooperation with the attending physician and the pharmacy provider. All medication orders unavailable to the patient will be managed with urgency. Under Process section it relates: . 4.1 Obtain alternate physician orders, as necessary. Interview on 8/8/17 at approximately 9:20 a.m. with Staff A (Licensed Practical Nurse) confirmed that the physician had not been notified of the two missed [MEDICATION NAME] doses.",2020-09-01
219,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2017-08-09,323,D,0,1,HU2011,"Based on observation and interview, it was determined that the facility failed to ensure a resident environment free of accident hazards for 1 out of 3 kitchenettes. Findings include: Observation on 8/7/17 during the initial tour at approximately 10:00 a.m. of the Overlook Cafe kitchenette revealed an unlocked cabinet with bleach wipes and stainless steel cleanser, and an unlocked drawer with a can of cooking spray. Interview on 8/7/17 at approximately 10:00 a.m. with Staff C (Dining Services Director) confirmed the above findings and revealed that residents have access to this unlocked kitchenette. Observation on 8/8/17 at approximately 10:40 a.m. of the Overlook Cafe kitchenette revealed an unattended griddle that was on the counter and in the on position set at 300 degrees. A red light on the griddle was noted to be on. Placing a hand over the top of the griddle revealed that it was hot. A can of cooking spray was observed approximately 5 inches away from the hot griddle. Review on 8/8/17 at approximately 10:40 a.m. of the cooking spray manufacturer's instructions revealed a warning on the can, Flammable .Can may burst if left .or near heat source . Observation on 8/8/17 at approximately 10:40 a.m. of the Overlook Cafe kitchenette revealed that the bleach wipes and the stainless steel cleaner were still in the unlocked cabinet. Interview on 8/8/17 at approximately 10:45 a.m. with Staff [NAME] (Registered Nurse, Unit Manager) confirmed the above findings.",2020-09-01
220,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2017-08-09,371,E,0,1,HU2011,"Based on observation, interview, and review of manufacturer's instructions, it was determined that the facility failed to date thickened juice when opened, and to cover and date food when opened in 2 of 3 kitchenettes. Findings include: Observation on 8/7/17 during the initial tour at approximately 10:00 a.m. of the Garden View kitchenette revealed an open container of thickened cranberry juice with no date on it. Review on 8/7/17 of the Manufacturer's instructions for the thickened juice revealed that it should be discarded 7 days after opening. Observation on 8/7/17 during the initial tour at approximately 10:00 a.m. of the Overlook Cafe kitchenette revealed a tray of jello cups containing jello with whipped topping. There was no covering or documented date on them. Observation on 8/7/17 during the initial tour at approximately 10:00 a.m. of the Overlook Cafe kitchenette revealed a plastic container of hot dogs with no documented date on the container. Observation on 8/7/17 during the initial tour at approximately 10:00 a.m. of the Overlook Cafe kitchenette revealed 3 trays of juice and milk in individual cups. Two of the trays were dated as being opened on 8/6/17 and one tray was dated as being opened on 7/13/17. Observation on 8/7/17 during the initial tour at approximately 10:00 a.m. of the Overlook Cafe kitchenette revealed 2 open packages of donuts. One package was dated as being opened on 7/31/17 and the other was not dated. Interview on 8/7/17 at approximately 10:00 a.m. with Staff C (Dining Services Director) confirmed the above findings.",2020-09-01
221,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2018-08-31,554,B,0,1,SFDM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, it was determined that the facility failed to stay with a resident for an ordered medication without a self administration medication assessment. (Resident identifier is #3.) Findings include: Resident #3 Observation on 8/29/18 at approximately 8:10 a.m., during the medication pass, revealed that Staff [NAME] (Medical Assistant Nurse) walked away from Resident #3 after Resident #3 drank only a portion of the ordered [MEDICATION NAME]. Resident #3 indicated to Staff [NAME] that Resident #3 will drink the remainder of the [MEDICATION NAME] later. Review on 8/30/18 of Resident #3's medical record revealed no self administer medication assessments. Interview on 8/29/18 at approximately 8:15 a.m. with Staff [NAME] confirmed that the Miralx was left unattended with Resident #3 and that Resident #3 did not have an order to self administer medication. Staff [NAME] indicated that is how that Resident #3 had been receiving the [MEDICATION NAME] because Resident #3 can be difficult patient.",2020-09-01
222,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2018-08-31,584,D,0,1,SFDM11,"Based on observation, interview and review of the dining committee notes dated 4/3/18 it was determined that the facility failed to maintain a clean and homelike environment on 1 out of 2 nursing units. (Resident identifier is #40.) Findings include: Observation on 8/28/18 at approximately 1:15 p.m. revealed in the sitting/activity room directly across from the nursing station on the second floor that there were 10 out 16 chairs noted to have large visible dark soiled/stained areas on the seating area of the chairs. 2 out of the 16 chairs had visible tears noted in the chairs on the back rest. Resident #40's broda chair had tears in both arms. Observation on 8/28/18 at approximately 2:09 p.m. revealed in the dining room on the second floor that 9 out of 9 chairs were noted to have large visible dark soiled/stained areas noted on the seating area of the chairs. Observation on 8/28/18 at approximately 2:10 p.m. revealed in the dining room on the second floor the floor heating vent closest to the refrigerator was noted to have a large brown/red in color substance adhered to it. Observation on 8/29/18 at approximately 8:21 a.m. revealed that the floor heating vent closest to the refrigerator in the second floor dining room continued to have the large brown/red in color substance adhered to it from 8/28/18. Observation on 8/30/18 at approximately 8:30 a.m. revealed that the floor heating vent closest to the refrigerator in the second floor dining room continued to have the large brown/red in color substance adhered to it from 8/28/18. Interview on 8/30/18 at approximately 8:36 a.m. with Staff A (Director of Nursing) confirmed that the vent had the large brown/red in color substance adhered to it. Staff A also confirmed that the chairs in both the dining room and sitting/activity room on the second floor, had large visibly soiled/stained areas. Staff A confirmed that Resident #40's broda chair was in need of repair. Review on 8/31/18 of the facility dining committee notes dated 4/3/18 revealed that the chairs were identified as needing to be replaced.",2020-09-01
223,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2018-08-31,697,D,0,1,SFDM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined that the facility failed to ensure adequate pain management for 2 residents in a standard survey sample of 23 residents. (Resident identifiers are #46 and #64.) Findings include: Resident #46 Interview on 8/28/18 at approximately 11:40 a.m. with Resident #46 revealed that Resident #46 stated that they did not get adequate relief from pain medications administered for their pain. Review on 8/29/18 of Resident #46's (MONTH) Medication Administration Record [REDACTED]. Resident #46 also received PRN [MEDICATION NAME] on 8/19/18 at 9:58 p.m. The follow up pain level was documented at 11:42 p.m. as ineffective and was documented at level 7 on a 1-10 scale. Resident #46 also received PRN [MEDICATION NAME] on 8/23/18 at 9:38 a.m. The follow up pain level was documented at 10:38 p.m. as ineffective and was documented at level 8 on a 1-10 scale. Review on 8/29/18 of Resident #46's nurses notes revealed that there was no documentation of any other interventions attempted to relieve Resident #46's pain or any physician notification of the ineffective results of the pain medication. Review on 8/31/18 of Resident #46's Nursing assessment dated [DATE] revealed that on a scale of 1-10, Resident #46's acceptable level of pain was a 2 out of 10. Resident #64 Interview on 8/28/18 at approximately 12:10 p.m. with Resident #64 revealed that Resident #64 stated that they did not get adequate relief from pain medications administered for their back pain. Review on 8/29/18 of Resident #64's (MONTH) Medication Administration Record [REDACTED]. Resident #64 also received PRN [MEDICATION NAME] on 8/10/18 at 6:10 p.m. The follow up pain level was documented as ineffective and was documented at 6:23 p.m. at level 6 on a 1-10 scale. Resident #64 also received PRN [MEDICATION NAME] on 8/19/18 at 1:24 a.m. The follow up pain level was documented at 4:59 a.m. as ineffective and was documented at level 5 on a 1-10 scale. Review on 8/29/18 of Resident #64's nurses notes revealed that there was no documentation of any other interventions attempted to relieve Resident #64's back pain or any physician notification of the ineffective results of the pain medication. Review on 8/31/18 of Resident #64's Nursing assessment dated [DATE] revealed that on a scale of 1-10, Resident #64's acceptable level of pain was a 3 out of 10. Review on 8/31/18 of the Facility's Policy, titled Pain Management, last revised on 3/1/18, revealed that . Patients receiving interventions for pain will be monitored for the effectiveness and side effects .in providing pain relief. Document: 8.1 Non-pharmacological interventions and effectiveness; 8.2 Effectiveness of PRN medications. 8.3 Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/APP (Advanced Practice Provider) notification . Interview on 8/31/18 at approximately 9:45 a.m. with Staff B (Unit Manager) confirmed that when Resident #46 and Resident #64 reported that the results of their pain medication was ineffective, other non pharmacological interventions, such as ice, massage, or application of pain relieving cream should have been tried and documented and that there should have been documentation of physician notification.",2020-09-01
224,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2018-08-31,761,D,0,1,SFDM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to follow expiration dates for multidose bottles of eye drops found on 2 of 3 medication carts on the first floor and to follow manufacturer's guidelines for refrigerating a medication found on 1 of 2 medication carts on the second floor. Findings include: Observation on [DATE] at approximately 8:30 a.m. during medication cart review of the Wildlife Medication cart on the first floor revealed a bottle of Latanoprost eye drops, which was inside a brown plastic pharmacy container used to hold the bottle of eye drops. Observation of the opened bottle revealed that there was not a date opened written on the bottle. There were stickers attached to the outside plastic pharmacy container. One pink sticker read Refrigerate Until Opened. The other sticker read Date opened_______. After opening do not use after 42 days. The line where the date opened was to be filled in was left blank. Interview on [DATE] at approximately 8:35 a.m. with Staff C (Registered Nurse) confirmed that the open date should have been written on the space on the sticker. Staff C also confirmed that without the date written in, there was no way to tell if the medication had expired. Observation on [DATE] at approximately 10:00 a.m. during medication cart review of the Wildlife Ridge Medication cart on the first floor revealed a bottle of Latanoprost eye drops, which was inside a cardboard container used to hold the bottle of eye drops. Observation of the opened bottle revealed that there was not a date opened written on the bottle. Observation of the cardboard box revealed that there was an opened date written in on the box which was [DATE]. Interview on [DATE] at approximately 10:05 a.m. with Staff D (Medication Nursing Assistant) confirmed that the eye drops had expired. Staff D, looking at the Medication Administration Record, [REDACTED]. Review on [DATE] of the Facility Policy titled Storage and Expiration Dating of Medications . last revised (MONTH) 31, (YEAR), revealed that .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .Latanoprost Refrigerate until opened, may be used for 42 days after opening . Observation on [DATE] at approximately 8:43 a.m. of the medication cart revealed an opened bottle of Acidophilus on one of the two medication carts on the 2 floor. This bottle of Acidophilus once opened should be stored in the refrigerator. Interview on [DATE] at approximately 8:43 a.m. with Staff E, (Medical Assistant Nurse), confirmed that the Acidophilus should have been stored in the refrigerator after being opened per manufacturer's instructions.",2020-09-01
225,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2018-08-31,880,D,0,1,SFDM11,"Based on observation, interview, and facility policy review, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases for 1 resident in a standard survey sample of 23 residents. (Resident identifier is #75.) Findings include: Observation on 8/28/18 at approximately 10:30 a.m. of the container of PPE (Personal Protective Equipment) outside of Resident #75's room revealed that Resident #75 was on precautions. Interview on 8/28/18 at approximately 10:45 a.m. with Staff D (Medication Nursing Assistant) revealed that Resident #75 was on contact precautions and that a gown and gloves needed to be worn when in their room. Observation on 8/28/18 at approximately 3:00 p.m. revealed that the trash container for used PPE was located outside of Resident #75's room, in the hallway. Observation on 8/29/18 at approximately 11:28 a.m. revealed that the trash container for PPE was located outside of Resident #75's room, in the hallway. Observation also revealed that a yellow gown was in the trash container. The lid was closed on the trash container and the gown was laying approximately half inside the trash container and approximately half outside the trash container. Interview on 8/29/18 at approximately 11:30 a.m. with Staff A (Director of Nursing) confirmed that the trash container for used PPE was not to be outside of the room, in the hallway. Staff A confirmed that it should have been located in the room, so that PPE could be discarded before leaving the room. Staff A also confirmed that used PPE should not be hanging on the outside of the trash container. Review on 8/30/18 of the Facility Policy, titled Contact Precautions, last revision date 11/28/17, revealed .Before exiting room, remove and bag gown and gloves and wash hands upon exiting room .",2020-09-01
226,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2018-08-31,908,B,0,1,SFDM11,"Based on observation, interview and record reviews it was determined that the facility failed to ensure that the high temperature commercial dishwasher was consistently displaying accurate wash and rinse temperatures on its digital display. Findings include: On interview 8/28/18 at approximately 9:30 a.m., on the initial tour of the main kitchen, Staff F (Director of Dining Services) stated that the dishwasher had been run earlier but had been idle for several minutes before this attempt to resume dishwashing operations. Review of Investigational Guidelines at 483.60(i)(1)(2) reveals, in part, the following recommendations according to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code: High Temperature Dishwasher (heat sanitization): Wash- 150 - 165 degrees F. Final Rinse- 180 degrees F. Low Temperature Dishwasher (chemical sanitation) Wash- 120 degrees F. and Final Rinse- 50 ppm hypochlorite (chlorine) on dish surface in final rinse. Observation on 8/28/18 revealed that the commercial dishwasher attained 142.0 degrees F. on this first attempt. The minimum required operating temperature is 150 degrees F. or greater during the wash cycle. This machine was observed at this time to require 6 wash cycles to be run before attaining 150 degrees F. after which it held the temperature for 4 wash cycles and then dropped to 148.0 degrees F. Review of the dishwasher wash / rinse temperature tracking logs for June, (MONTH) and (MONTH) (YEAR) revealed the recorded wash temperatures ranged from 150 to 165 degrees F. Further observation revealed that the rinse temperature read-out was 255 degrees F. a reading well above the norm. Review of the dishwasher wash / rinse temperature tracking logs for June, (MONTH) and (MONTH) (YEAR) revealed the recorded rinse temperatures ranged from 180 to 186 degrees F. Interview on 8/28/18 at approximately 10:00 a.m. with Staff F confirmed that the digital read-out temperature gauge on the dishwasher indicated the temperature had fallen below 150 degrees F. On interview Staff F stated they should switch the operation of the dishwasher to a low temperature wash followed by a chemical sanitization and call their commercial appliance repair service to arrange a service call. Review of the commercial appliance repair service report dated 8/29/18 at 1:59 p.m. revealed in part: (circuit) board on the machine was not reading the temps correctly . and the board was not working correctly and (I) ordered parts for the machine. The commercial appliance repair service Technician also wrote: I did test the waters with my dish thermometer and found the wash cycle was ranging from 156-161 degrees and the rinse was a steady 185 degrees",2020-09-01
227,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2019-12-12,658,D,1,0,35Y211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure each resident had a sufficient amount of medications for 1 resident with scheduled medication used to treat pain out of 2 residents observed for medication administration. (Resident identifier is #1.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 12/20/19 an article 'Neither a Borrower Nor a Lender Be' When Drugs Are Involved, written by Matthew Grissinger RPh, on 2013 Mar; 38 (3) FASCP (Registered Pharmacist fell owship in the American Society of Consultant Pharmacists) revealed that staff should understand the risks involved with borrowing medications and and delays in receiving medications should be reported. Review on 12/12/19 of Resident #1's (MONTH) (MAR) Medication Administration Record [REDACTED] Observation on 12/12/19 during medication pass at approximately 10:00 a.m. with Staff D (Registered Nurse) revealed there was no [MEDICATION NAME] Patch 5% for Resident #1 in the medication cart. Staff D then checked the Omni Cell medication dispensing system and there was no [MEDICATION NAME] Patch 5% available. Staff D then approached Staff B (LPN (Licensed Practical Nurse)) and told Staff B that Resident #1 did not have any [MEDICATION NAME] 5% Patches and there were no [MEDICATION NAME] 5% Patches in the Omni Cell medication dispensing system. Staff B indicated that Resident #2 had the same [MEDICATION NAME] Patch 5% and that the order for Resident #2 was discontinue on 12/11/19. Staff B told Staff D to use a [MEDICATION NAME] Patch 5% from Resident #2. Staff D went back to the medication cart and took the [MEDICATION NAME] 5% patch out of Resident #2's supply and placed it on Resident #1's right shoulder. Interview on 12/12/19 at approximately 10:30 a.m. with Staff B revealed that it is not normal practice to borrow from another resident but in this case Resident #2 was no longer using the [MEDICATION NAME] Patch and Resident #1 had chronic pain. Staff B also indicated that the discontinued box should have been placed in the medication room. Review on 12/12/19 of the Facility's Policy titled Medication Shortages/ Unavailable Medications, dated 12/1/07 and revised 1/1/13, revealed that .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy . The policy review also revealed that .If the medication is unavailable from Pharmacy or a Third Party Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary .If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for orders/ direction, making sure to explain the circumstances of the medication shortage .When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) and in the nurse's notes per Facility policy. Such documentation should include the following information: .A description of the circumstances of the medication shortage; A description of Pharmacy's response upon notification; and .Action(s) taken. Interview on 12/12/19 at approximately 2:30 p.m. with Staff C (Center Nursing Executive) confirmed that should be no borrowing of medication.",2020-09-01
228,"LEBANON CENTER, GENESIS HEALTHCARE",305050,24 OLD ETNA ROAD,LEBANON,NH,3766,2019-12-16,689,D,1,0,8H4E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, it was determined that the facility failed to ensure the environment remained free of accident hazards due to smoking materials for 2 of 4 residents sampled. (Resident identifiers are #1 and #4.) Findings include: Observation on 12/16/19 at approximately 10:00 a.m. of Resident #1's shared bathroom revealed a substantially charred area approximately 5 inches by 3 inches on the tile floor. Interview on 12/16/19 at approximately 10:30 a.m. with Staff C (Unit Manager) revealed that Staff C was aware that Resident #1 did have a history of smoking prior to the current admission to the facility on [DATE]. Staff C had never seen and was not aware of Resident #1 smoking since that admission. Staff C did confirm that Resident #1's roommate, Resident #4 is a smoker. Interview on 12/16/19 at approximately 10:45 a.m. with Resident #4 revealed that Resident #4 stated that they kept their cigarettes and lighter with them until Resident #1 was smoking in the bathroom (12/11/19) and staff searched their room. Resident #4 also stated that they had never been asked by anyone at the facility to give their lighter or their cigarettes to staff before 12/11/19. Resident #4 had changed from cigarettes to vaping a few months back. Resident #4 was in the library during the incident and was unaware what happened to Resident #1 until Resident #4 arrived back to the room for the night. Resident #4 revealed that the facility found 2 old cigarettes and 4 lighters in the Resident #4's drawer during the search on the night of the incident. Resident #4 was unaware that the items were in there since Resident #4 has been vaping for awhile. Review on 12/16/19 at approximately 11:15 a.m. of Resident #1's care plan revealed a care plan focus for smoking with interventions for safe smoking initiated on 12/13/19. Review on 12/16/19 at approximately 11:25 a.m. of the RMS (Risk Management System) Report for 12/11/19 revealed that staff had been responding to the smell of smoke on 12/11/19 at about 9:30 p.m. and went from room to room looking for the source. Resident #1 was found in the bathroom smoking with singed hair and redden skin. He denied pain .Notified the DON, .the on call doctor .the patient's (spouse). Cigarette found in toilet and oxygen cannula found on ground. Both the physician and the spouse agreed not to send the patient out to the hospital but to continue to monitor. Patient is resting without any s/s (signs/symptoms) of acute distress. Inventions immediately after incident were the following: checked and removed room for lighters, cigarettes and other flammable items. Corrective actions were the following: Removed all flammable items and continue to educate patient. House rounds conducted to educate all staff and residents. Search conducted for smoking materials throughout the facility. QAPI (Quality Assurance Improvement Project) initiated related to smoking. Notices posted on family bulletin boards. Notice sent in mail to all family members. All residents who smoke were reassessed. Review on 12/16/19 at approximately 11:30 a.m. of Resident #1's medical record revealed a change of condition note was written on 12/12/19 at 12:42 a.m. for a smoking incident on 12/11/19 at 9:30 p.m. Resident #1 was found in the Resident #1's bathroom with burnt hair and red spots on face. Continued review of medical record revealed that physician and family were notified. Review of the Minimum Data Set (MDS) revealed that Resident #1, who has a Brief Interview Mental Status (BIMS) of 15 (cognitive intact) is his/her own person, refused to be transferred to the local hospital for evaluation. Review on 12/16/19 at approximately 11:30 a.m. of Resident #1's medical record revealed that Resident #1 was monitored for vital signs and that lung sounds were being completed every hour throughout 12/11/19-12/12/19. Resident #1 indicated to the staff that he/she does not remember how they came about having cigarettes. Review on 12/16/19 at approximately 11:30 a.m. of Resident #1's medical record revealed that Resident #1 [MEDICAL CONDITION] his neck, face, and head and Resident #1 wounds were being monitored. Resident #1's treatment orders were as follows: Silversorb, Xeroform, and wrap with gauze. Resident #1 was given two Extra Strength Pain Relief tablets ( Tylenol 500 milligrams) to manage pain. Review on 12/16/19 at approximately 11:30 a.m. of facility smoking policy titled Center Operations Policies and Procedures OPS137 Smoking with a revision date of 11/20/19, revealed in section #2 titled For Centers that allow smoking, section 2.6.1: If the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment. Section 2.6.2: Patients will not be allowed to maintain their own lighter, lighter fluid, or matches. Review on 12/16/19 at approximately 11:30 a.m. of the Facility Smoking Schedule updated 12/12/19 revealed ALL Staff are responsible for ensuring ALL lighters and smoking supplies are turned in after each episode. Interview on 12/16/19 at approximately 12:29 p.m. with Resident #1 revealed that Resident #1 don't have anything to say. Observation of Resident #1 at this time revealed that Resident #1 had a dressing on his neck and back area. Resident #1 was wearing a nasal cannula. Interview on 12/16/19 at approximately 1:00 p.m. with Staff A (Center Executive Officer) confirmed that Resident #1 was on oxygen and had a history of [REDACTED]. Staff A had never seen Resident #1 smoking since Resident #1's admission to the facility on [DATE]. Staff A revealed that the facility had holiday party the night of the incident and this was possibly where Resident #1 may have obtained smoking materials. Staff reported to Staff A that they did see Resident #1 with visitors during the party.",2020-09-01
229,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2018-06-21,880,D,0,1,N52K11,"Based on observation and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during 2 of 2 medication pass observations. (Resident identifiers are #18, #21, #40, #53, #56, and #69,.) Findings include: Observation on 6/18/18 at approximately 7:06 p.m. revealed that during the medication pass, Staff A (Licensed Practical Nurse,) administered medications to Resident #56. When Staff A was finished with that medication administration, Staff A did not wash their hands or use hand sanitizer before going on to prepare and administer medications to Resident #53. Observation on 6/18/18 at approximately 7:11 p.m. revealed that Staff A administered medications to Resident #53. After administering medications to Resident #53, Staff A removed Resident #53's shoes and placed them on the floor. Staff A also used Resident #53's recliner chair remote control to adjust Resident #53's recliner chair. When Staff A was finished with Resident #53, Staff A did not wash their hands or use hand sanitizer. Interview on 6/18/18 at approximately 7:20 p.m. with Staff A confirmed that Staff A did not wash their hands or use hand sanitizer between residents' medication administration and Staff A stated that they should have washed their hands or used hand sanitizer between residents. Observation on 6/18/18 at approximately 7:26 p.m. revealed that during the medication pass, Staff B (Licensed Practical Nurse,) administered medications to Resident #18. When Staff B was finished with that medication administration, Staff B did not wash their hands or use hand sanitizer before going on to prepare and administer medications to Resident #69. Observation on 6/18/18 at approximately 7:42 p.m. revealed that during the medication pass, Staff B administered medications to Resident #40. When Staff B was finished with that medication administration, Staff B went to the medication cart where a resident's hearing aide was sitting, in a cup, on top of the cart. Staff B did not wash their hands or use hand sanitizer, but Staff B put on a pair of gloves and picked up the hearing aide, placed it in a box and locked it in the medication cart. After removing the gloves, Staff B did not wash their hands or use hand sanitizer before going on to prepare and administer medications to Resident #21. Observation on 6/18/18 at approximately 7:53 p.m. revealed that during the medication pass, Staff B administered medications to Resident #21. When Staff B was finished with that medication administration, Staff B did not wash their hands or use hand sanitizer. Staff B stated that they needed to get chocolate milk from the refrigerator for the next resident's medication administration. Staff B went to the refrigerator and poured the chocolate milk into a cup and started to walk away with the chocolate milk, without washing their hands or using hand sanitizer. Interview on 6/18/18 at approximately 8:00 p.m. with Staff B confirmed that Staff B did not wash their hands or use hand sanitizer between residents' medication administration and Staff B stated that they should have washed their hands or used hand sanitizer between residents.",2020-09-01
230,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2019-07-25,812,E,0,1,P26Y11,"Based on observation during tour it was confirmed though interview, the facility failed by distribute food that could be called potentially hazardous foods, and maintain equipment in safe operating conditions to meet professional standards for food service and safety. Findings include: Observation on 7/23/19 at 9:35 a.m. with Staff A (Director of Food Services) while doing the initial tour of the kitchen revealed several nutritional supplements located in the reach in refrigerator revealed two labels on them one on top of the other. Interview with Staff A was asked what the discard date was for this product since it's only good for 14 days after being thawed, Staff A stated it was the date on far right side of label. When looking at the label the date was 7/27/19. At this time Staff A was asked if the label could be removed to see the prior label, Staff A stated yes and removed the label and the date written on the far right side of the label was 7/16/19 which would have been the discard date 14 days after thawing and not 7/27/19. This practice was seen on several supplemental shakes. Observation on 7/23/19 at 9:40 a.m. with Staff A (Director of Food Services) while doing the initial tour of the kitchen revealed that the dish machine temperature log for the month of (MONTH) had several temperatures below the required 180 degrees for a high temperature dish machine. Interview with Staff A revealed that the hot water tank is broken and because of this the dish machine does not hold its temperature. Staff A was asked how long this has been going on, Staff A stated about a month. Two kitchen staff members were at the dish machine doing the dishes during observation the first rack went though the dish machine the temperature showed 184 degrees then the second rack went through the dish machine and the temperature went down to 178 degrees. The two kitchen staff who were doing the dishes did not notice the temperature change and continued to use the dish machine, then a third rack went though and the temperature went down to 176 degrees and the fourth rack went through and the temperature went down to 167 degrees. Staff A was told of the temperature change and told the staff to stop doing the dishes and start to use chemical solution on the dish machine and to rerun the racks that went through at that time. Interview on 7/24/19 with Staff B (Director of Maintenance) confirmed that the hot water tank has been broken for some time now and at this time still has not been fixed. Review on 7/24/19 of the infection control logs shows no out breaks during this period of time. Observation on 7/23/19 at 9:50 a.m. with Staff A (Director of food Services) during the initial tour of the kitchen revealed that the can opener was in the ready to use position and when inspected, food build up on the cutting blade was observed. At this time the can opener was taken out of use by Staff A and placed in the dish machine. Observation on 07/23/19 at 9:45 a.m. with Staff A (Director of food Services) while doing the initial tour of the kitchen, both the walk in refrigerator and freezer floors were in poor condition being rusted making it a non cleanable surface. While touring the walk in refrigerator it was noted that the facility did not have pasteurized eggs, Staff A was asked what types of eggs are served to residents during breakfast, Staff A stated most get eggs over easy. Staff A was asked if the yokes are fully cooked and Staff A stated no.",2020-09-01
231,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2017-08-30,244,B,0,1,G2FP11,"Based on interview, observation, and resident council review, it was determined that the facility failed to act upon the views of the residents and changed the minutes of one of the Resident Council meetings. (Resident identifier is #25.) Finding include: Resident Council meeting on 8/29/17 at 10:30 a.m. with 15 residents in attendance revealed that residents were concerned that Administration does not always listen to their concerns or act upon them. They stated that the Resident Council minutes were changed by Staff [NAME] (Administrator) and that the Resident Council President refused to sign them. Resident Council meeting on 8/29/17 at 10:30 a.m. revealed that residents were also concerned with the size of the snacks that were served to them. They stated that when they ask for pudding or yogurt, the size had been changed a few months ago to such a small amount that they take one bite and it's done. Review on 8/29/17 of 2 copies of Resident Council Meeting Minutes: 6/29/17 given by Resident #25 revealed that the 2 copies were different. Much of the information on one copy was omitted. The changes were as follows: One copy was written as: Cookouts .Residents want to re-address this and would like changes to have them at least once a month (MONTH) - September. BBQ (barbecue) should be outside not inside with a very easy menu of hamburgers/hot dogs, chips and/or potato salad, drink and dessert .Nothing difficult. June's cookout was canceled, please make every effort to keep September's and plan for a rain date if needed. Second copy: This was omitted. One copy was written as: Why does change in Dietary from Keene Center with Genesis overseeing Dietary Dept. (department) matter just because HCS (Healthcare Services) took them over? Second copy: This was omitted. One copy was written as: Those nursing staff who are having bad days please don't take it out on the residents. Second copy was written as: Concern regarding LNA attitudes. One copy was written as: Some nursing staff are verbally conveying that they would rather just 'do the easy ones rather than the more difficult ones' which is being overheard by many residents. And that some staff continues to intentionally avoid certain residents that tend to be difficult .we are equals! Second copy: This was omitted One copy was written as: Residents noted that many of the 'older' LNA's seem to be burnt out .very concerned. Second copy: This was omitted. One copy was written as: Definitely not enough staff on hand on many days/nights to assist and care for the residents. Lights are on for long period of time and some often go unanswered. Falls are happening more .When will this be addressed? Second copy: This was omitted. Review on 8/29/17 of the Resident Council Minutes - Date: (MONTH) 29, (YEAR) .Signatures: Council President revealed a handwritten note saying Refusal 6/29/17 See (Name omitted.) Interview on 8/29/17 at approximately 1:00 p.m. with Resident #25 confirmed that one copy of the (MONTH) 29, (YEAR) minutes was the original copy that was given to Resident #25, right after the Resident Council meeting, by the staff member who had typed them. There was no signature page attached to this copy. Resident #25 stated that the second copy was one that was given to Resident #25 later, after it had been changed by Staff E. Resident #25 stated that Resident #25 refused to sign the Resident Council minutes signature page attached to the second copy because the minutes had been changed and much of the information and the concerns from residents had been removed. Interview on 8/30/17 at approximately 8:15 a.m. with Staff C (Receptionist) confirmed that Staff C wrote and typed the minutes for the (MONTH) 29, (YEAR) Resident Council meeting. Staff C confirmed that Staff C had handed a number of copies of the minutes, right after they were typed, to Resident #25. Staff C also confirmed that after handing the minutes to Resident #25, Staff C was approached by Staff [NAME] with changes to the minutes and was asked by Staff [NAME] to retype the minutes. Staff C stated that when asked to do this, Staff C felt uncomfortable about it and felt it was wrong. Staff C stated that Staff C reported what Staff C was asked to do to Staff D (Business Office Manager,) who is Staff C's supervisor. Staff C stated that Staff D implied that Staff D also felt that it was wrong. Staff C confirmed that when Resident #25 was asked to sign the minutes, Resident #25 refused to sign, as Resident #25 was upset about the changes. Interview on 8/30/17 at approximately 9:40 a.m. with Staff D (Business Office Manager) confirmed that Staff C had informed Staff D that Staff [NAME] had asked Staff C to retype the minutes of the Resident Council meeting. Staff D stated that Staff D did not recall what Staff D had instructed Staff C to do, but stated that Staff D also felt that retyping the minutes was wrong. Staff D did not remember whether Staff D had reported these concerns to Staff D's regional manager. Interview on 8/30/17 at approximately 4:30 p.m. with Staff [NAME] confirmed that Staff [NAME] had changed the minutes of the Resident Council meeting to shorten it and take out a lot of extra information. Staff [NAME] also confirmed that Staff [NAME] was not aware that the Resident Council President had a hand written note on the (MONTH) 29, (YEAR) Resident Council Minutes indicating a refusal to sign the minutes as written. During resident council on 8/29/17 residents voiced concerns about the portions that were being served for the pudding, applesauce, and yogurt, stating that it was one bite and it's done. Observation on 8/28/17 at approximately 10:00 a.m. during the initial tour of the kitchen with Staff G (Director of Food Services) of the 2nd and 3rd floor refrigerators in the kitchenettes, revealed that the pudding and applesauce that is provided for the residents as snacks are served in 2 ounce condiment cup containers, and yogurt is served in a 4 ounce condiment cup container. Interview on 8/30/17 at 10:30 a.m. with Staff G (Director of Food Services) confirmed that the pudding and applesauce that is provided as a snack for the residents is served in a 2 ounce condiment cup, and the yogurt is served in a 4 ounce condiment cup. Staff G stated that these food items are served in this manner as a convenience for the nursing staff to pass medications with.",2020-09-01
232,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2017-08-30,278,D,0,1,G2FP11,"Based on medical record review and interview, it was determined that the facility failed to accurately document information on the MDS (Minimum Data Set) for 1 resident in a survey sample of 21 residents. (Resident identifier is #1.) Findings include: Review on 8/29/17 of Resident #1's Significant Change/ 5 Day MDS (Minimum Data Assessment) with ARD (Assessment Reference Date) of 5/5/17 and Resident #1's Quarterly MDS with ARD of 6/28/17 revealed that some of the MDS questions were not assessed. The areas not assessed in both MDS's were Section B0700 (Makes Self Understood,) Section B0800 (Ability To Understand Others,) Section C (Mental Status,) Section D (Mood,) Section [NAME] (Behavior,) and Section Q (Participation In Assessment and Goal Setting.) Interview on 8/30/17 at 9:30 a.m. with Staff [NAME] (Administrator) confirmed that the above MDS sections had not been assessed and that they should have been assessed for Resident #1.",2020-09-01
233,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2017-08-30,281,D,0,1,G2FP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and the facility pain management policy and procedure, it was determined that the facility failed to ensure that medication administration for narcotics were properly documented for 1 resident, failed to have indications for medication administration and failed to document the effectiveness of as needed pain medication for 3 residents in a survey sample of 21 residents. (Resident identifiers are #1, #3, and #14. Findings include: Reference for the professional standard of practice for medication documentation is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. Box 35-1 Guidelines for Safe Narcotic Administration and Control . . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication, dose, and signature of nurse dispensing the medication. . If a nurse gives only part of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers . Pages 699 Prescribers must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 709 After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care . Page 713 .A registered nurse compares the list of medications on the MAR indicated [REDACTED].After administering a medication, record it immediately on the appropriate record form . Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurses' notes. Page 1063 .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity. . Although different clients prefer different pain scales, it is important for you to select and consistently use the same scale with a specific client. You do not use a pain scale to compare the pain of one client to that of another client. Review on 8/30/17 of the facility Pain Management policy and procedure with a revision date of 11/28/16 revealed the following: PURPOSE . To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. . To design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with patient directed goals. PRACTICE STANDARDS . 5. If PRN medications are given, document on the back of the MAR indicated [REDACTED]. 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document: 8.1 Effectiveness of PRN (as needed) medications. 8.2 Ineffectiveness of routine or PRN medications including interventions, follow up, and physician/APN/PA notification; . Resident #3 Review on 8/28/17 of Resident #3 MEDICATION RECORD (MAR) dated 8/1/17 through 8/31/17 revealed a physician order [REDACTED]. Further review of this MAR indicated [REDACTED]. Interview and review on 8/30/17 of the Narcotic log, page 14 for Resident #3 with Staff A (Registered Nurse) and Staff B (Licensed Practical Nurse) at approximately 2:45 p.m. showed that entries were made for the administration of [MEDICATION NAME] one 5 mg tab on 8/5, 8/9, 8/11 and 8/14 to Resident #3. Review of the back and front MAR for Resident #3 with Staff A and Staff B at this time revealed no documentation that [MEDICATION NAME] one 5 mg tab was administered to Resident #3 on 8/5, 8/9, 8/11 and 8/14 as documented on page 14 of the Narcotic log for Resident #3. Staff A and Staff B confirmed that there was no documentation on the MAR for the effectiveness of the PRN [MEDICATION NAME] given to Resident #3 for a total of 17 doses and that the Narcotic log, page 14, showed [MEDICATION NAME] was documented four times as given to Resident #3 with no matching documentation on the front or back sides of the MAR for Resident #3. Resident #1 Review on 8/29/17 of Resident #1's Medication Record dated 8/1/17 through 8/31/17 revealed that Resident #1 had an order for [REDACTED].#1 also had an order for [REDACTED]. Review on 8/29/17 of Resident #1's (MONTH) Nurse's Medication Notes revealed that Resident #1 received [MEDICATION NAME] on the following dates with no documentation of the effectiveness of the pain medication: 8/2/17 at 9:00 p.m., 8/3/17 at 8:45 a.m., 8/3/17 at 12:45 p.m., 8/5/17 at 8:40 p.m., 8/6/17 at 3:00 p.m., 8/8/17 at 10:45 a.m., 8/8/17 at 11:05 p.m., 8/9/17 at 8:00 a.m., 8/9/17 at 12:45 p.m., 8/11/17 at 6:30 a.m., 8/11/17 at 3:30 p.m., 8/11/17 at 9:25 p.m., 8/16/17 at 8:50 p.m., 8/17/17 at 8:50 p.m., 8/22/17 at 10:50 p.m., 8/23/17 at 9:50 p.m., 8/25/17 at 9:00 a.m., 8/25/17 at 2:30 p.m., 8/26/17 at 8:00 a.m., 8/26/17 at 2:30 p.m., and 8/27/17 at 6:50 a.m. Interview on 8/30/17 at approximately 9:00 a.m. with Staff F (Unit Manager) confirmed that there was no documented evidence of the effectiveness of these pain medication doses. Resident #14 Review on 8/29/17 of Resident #14's Medication Records dated 7/1/17 through 7/31/17 and 8/1/17 through 8/31/17 revealed that Resident #14 had an order for [REDACTED]. Review on 8/29/17 of Resident #14's (MONTH) and (MONTH) Nurse's Medication Notes revealed that Resident #14 received Tylenol on the following dates with no documentation of the effectiveness of the pain medication: 7/15/17 at 9:45 p.m. and 8/2/17 at 8:00 a.m. Interview on 8/30/17 at approximately 9:00 a.m. with Staff F confirmed that there was no documented evidence of the effectiveness of these pain medication doses.",2020-09-01
234,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2017-08-30,490,E,0,1,G2FP11,"Based on Resident Council meeting, family and resident interviews it was determined that the facility failed to attain the psychosocial well-being of the facility residents. Findings include: Review of the facility Resident Council meeting minutes, interviews with family members and residents revealed that the facility Administration failed to attain the psychosocial well-being of the facility residents. Interview on 8/30/17 at approximately 4:30 p.m. with Staff [NAME] (Administrator) revealed that Staff [NAME] was not aware that the Resident Council President had a handwritten note on the (MONTH) 29, (YEAR) Resident Council Minutes indicating a refusal to sign the minutes as written. The Resident Council President reported that the minutes had been changed and much of the resident concern information was removed from the original minutes. Cross reference F244.",2020-09-01
235,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2018-10-08,584,D,0,1,IQUI11,"Based on observation, interview and policy and procedure review, it was determined that the facility failed to maintain a clean and comfortable homelike environment on the 2nd floor (1 out of 3 floors). Findings include: Observation on 10/3/18 at approximately 9:00 a.m. on the second floor dining area revealed there was a portable vital sign machine plugged in. On the legs of the vital signs machine there was a dark brown substance adhered to it. Observation on 10/3/18 at approximately 9:30 a.m. on the second floor dining areas revealed the floors were noted to have visible food remnants scattered on them, under the tables had large circular spill areas noted. Walking on the floors in the 2 dining areas was noted to be sticky. Observation on 10/4/18 at approximately 7:30 a.m. of the second floor dining area revealed there was a portable vital sign machine plugged in. On the legs of the vital sign machine appeared to be the same dark brown substance adhered to it from the prior day. Observation on 10/4/18 at approximately 7:30 a.m. of the second floor dining areas revealed the floors were noted to have visible food remnants scattered on them, under the tables there were large circular spill areas noted which were observed the day prior. Walking on the floors in the 2 areas was noted to still be sticky. Interview on 10/4/18 at approximately 10:00 a.m. with Staff A (Licensed Nurse Assistant) revealed that housekeeping leaves the building around 3:00 p.m. and LNA's are suppose to dry mop the areas. Interview on 10/4/18 at approximately 10:30 a.m. with Staff B (Director of Housekeeping) confirmed the dining area floors were dirty and that housekeeping leaves the facility around 3:00 p.m. Interview on 10/4/18 at approximately 10:35 a.m. with Staff C (Unit Manager) revealed that resident care equipment should be wiped down with bleach wipes in between resident use. Staff C confirmed that the portable vital sign machine legs had a dark brown substance adhered to it and stated, I think they just wipe down the equipment that touches the residents. Review on 10/8/18 at approximately 1:00 p.m. of the facility's policy and procedure titled IC201 Cleaning and Disinfecting, revision date 7/24/18 revealed the following: . Purpose: . To ensure reusable medical equipment is cleaned and disinfected appropriately. Practice Standards . 1.3 Non-critical items are objects that do not come into contact with mucus membranes, but do come into contact with intact skin (e.g., blood pressure cuff, glucose meters, stethoscope, activity supplies, sensory manipulatives, craft supplies.) These items require cleaning between patient use 5.2 Multi-patient equipment must also be cleaned/disinfected after patient use 6. Clean environmental surfaces, floors, walls, furniture using Environmental Protection Agency registered disinfectant according to schedule and need. 6.1 Routine daily and periodic detail cleaning:",2020-09-01
236,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2018-10-08,695,B,0,1,IQUI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility failed to appropriately provide [MEDICAL CONDITION] (Continuous Positive Airway Pressure) treatments to 1 resident in a standard survey sample of 29 residents. (Resident identifier is #138.) Findings include: Observation on 10/3/18 at approximately 11:25 a.m. of Resident #138's room revealed that there was not a [MEDICAL CONDITION] machine in the room. Observation on 10/5/18 at approximately 3:25 p.m. of Resident #138's room revealed that there was not a [MEDICAL CONDITION] machine in the room. Interview on 10/5/18 at approximately 3:25 a.m. with Resident #138 revealed that Resident #138 stated that they have not used the [MEDICAL CONDITION] machine in about a month. Resident #138 stated that they needed a new mask and the one that was ordered, and came in, was not the right size. Review on 10/8/18 of Resident #138's current care plan revealed an intervention which read [MEDICAL CONDITION] as ordered. Review on 10/8/18 of Resident #138's (MONTH) (YEAR) Treatment Administration Record revealed that Resident #138 had an order for [REDACTED]. Review on 10/8/18 of Resident #138's Respiratory Treatment note, dated 9/18/18, revealed a note which read .Resident needs new Quattro Med (medium) full face mask, tubing and filters. (sic) Nurse manager aware and will call (Proper Noun omitted) . Review on 10/8/18 of Resident #138's Respiratory Treatment note, dated 10/2/18, revealed a note which read .Resident needs new Quattro Med full face mask, but when it came in it was the wrong mask . Review on 10/8/18 of Resident #138's nurses notes revealed that there was no documented evidence that Resident #138's physician was notified that Resident #138 was not using the [MEDICAL CONDITION] machine as ordered. Interview on 10/8/18 at approximately 10:00 a.m. with Staff [NAME] (Unit Manager) confirmed that Resident #138 had not been using the [MEDICAL CONDITION] machine and that it was sitting on their desk waiting for a new mask to arrive as the one ordered did not fit. Staff [NAME] confirmed that the nurses were documenting use of the [MEDICAL CONDITION] machine, when it was not in use. Staff [NAME] also confirmed that there was no documented evidence that the physician was notified and that the physician should have been notified that Resident #138 was not using the [MEDICAL CONDITION] machine.",2020-09-01
237,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2018-10-08,697,B,0,1,IQUI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined that the facility failed to ensure pain management for 1 resident in a standard survey sample of 29 residents. (Resident identifier is #52.) Findings include: Interview on 10/4/18 at approximately 7:45 a.m. with Resident #52 revealed that Resident #52 stated that they had pain and that the only thing ordered for them was Tylenol, which did not help. Resident #52 also stated that the physician indicated that there was nothing they could order for them, because the medication would be removed in [MEDICAL TREATMENT]. Interview on 10/4/18 at approximately 7:45 a.m. with Resident #52 revealed that Resident #52 attended [MEDICAL TREATMENT] on Monday, Wednesday and Friday every week. Review on 10/8/18 of Resident #52's current physician orders [REDACTED].#52 had an order for [REDACTED]. Review on 10/8/18 of the Facility Policy, titled Pain Management, last revised on 3/1/18, revealed that .Pain management that is consistent with professional standards of practice, the comprehensive person-centered plan, and the patient's goals and preferences is provided to patients who require such services .If the Nursing Assessment indicates pain: .Complete a pain evaluation .Document: .Ineffectiveness of routine or PRN (as needed) medications including interventions, follow-up, and physician/APP (advance practice provider) . Review on 10/8/18 of Resident #52's Nursing Assessment, dated 8/10/18, revealed that a pain assessment done for Resident #52 was incomplete. The Pain Goals section which asked .On a scale of 0-10, what is your acceptable level of pain? . was left unanswered, and the section which asked .Are you satisfied with your current level of pain? . was also left unanswered. Review on 10/8/18 of Resident #52's (MONTH) (YEAR) Medication Administration Record [REDACTED]. There was further documentation that on 9/10/18 at 6:46 p.m. the results of the Tylenol were Ineffective and that Resident #52's pain level was at 6 out of 10. Review on 10/8/18 of Resident #52's nurses notes on 9/10/18 revealed that there was no documented evidence that other interventions were attempted or that Resident #52's physician was notified of the ineffective results of the Tylenol. Interview on 10/8/18 at approximately 8:30 a.m. with Staff [NAME] (Unit Manager) confirmed that the pain assessment for Resident #52 should have been completed. Staff [NAME] also confirmed that there was no documented evidence of the physician being notified that Resident #52 did not get effective results with the Tylenol administration and that the physician should have been notified and that it should have been documented.",2020-09-01
238,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2018-10-08,698,B,0,1,IQUI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that a resident who attends [MEDICAL TREATMENT] receives the appropriate medications ordered because of [MEDICAL TREATMENT] for 1 resident in a standard survey sample of 29 residents. (Resident Identifier is #52.) Findings include: Interview on 10/4/18 at approximately 7:45 a.m. with Resident #52 revealed that Resident #52 attended [MEDICAL TREATMENT] on Monday, Wednesday and Friday every week and that he left at approximately 10:00 a.m. and returned mid afternoon. Resident #52 stated that they eat lunch at [MEDICAL TREATMENT] on those days. Review on 10/8/18 of Resident #52's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The administration record revealed that the medication was to be administered every day at 7:30 a.m., at 11:30 a.m. and at 4:30 p.m. The record also revealed that for the 11:30 a.m. dose on Monday, Wednesday and Friday nursing staff were documenting that the medication was not administered because Resident #52 was AW=Away from center. Interview on 10/8/18 at approximately 9:10 a.m. with Staff [NAME] (Unit Manager) confirmed that Resident #52 did not receive his 11:30 a.m. dose of Calcium Acetate on [MEDICAL TREATMENT] days. Staff [NAME] also confirmed that there was no physician order to hold the medication on those days, nor was there documentation of physician notification that the medication was not being administered, which there should have been.",2020-09-01
239,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2018-10-08,761,E,0,1,IQUI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and interview, it was determined that the facility failed to secure medications in a lock medication cart for 1 of 4 observed medication carts, ensure proper storage of expired medications and expired biologicals for 2 of 2 observed medication rooms and 1 of 4 observed medication carts, and ensure proper labeling of medications in accordance with currently accepted professional principle for 1 of 4 observed medication carts. (Resident identifiers are #40, #46, #61, #64, #72, #82, and #84.) Findings include: Policy: Review on 10/3/18 of facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, last revised on 10/31/16, revealed that .4. Facility should ensure that medications .that: (1) have an expired date on label .are stored separately from other medication until destroyed . Review on 10/3/18 of facility's policy titled 8.2 Disposal/Destruction of Expired or Discontinued Medication, last revised on 6/20/16, revealed that .4. Facility should place all discontinued or out-dated medication in a designated, secure location which is solely for discontinued medication or marked to identify the medication are discontinued and subject to destruction. Observation on 10/3/18 at 10:30 a.m. of the first floor medication room revealed that there was one flu swab (rapid diagnostic test for influenza) with an expired date of 02/2018 stored with the unexpired flu swabs. Further observation of the first floor medication room revealed that there were one sunscreen bottle with an expired date of 01/2018, one sterile 0.9% (percent) Normal Saline bottle with an expired date of 03/2018, and one [MEDICATION NAME] solution 70% laxative bottle with an expired date of 09/2018 that were stored with the unexpired treatment supplies and medications, respectively. Interview on 10/3/18 at 10:31 a.m. with Staff [NAME] (Unit Manager) confirmed the above findings. Staff [NAME] further revealed that the nurse staff check expired medications and expired biologicals daily and that any expired medications and biologicals were to be thrown out or taken out and placed in the pharmacy return bag to send back to the pharmacy. Resident #82 Observation on 10/3/18 at 10:32 a.m. of Resident #82's medication in the first floor medication room revealed that Resident #82 had 20 tablets of [MEDICATION NAME] 150 mg (milligram) (antibiotic) with an expired date of 9/18/18 that were stored with the unexpired medications. Interview on 10/3/18 at 10:32 a.m. with Staff [NAME] confirmed the above finding. Resident #84 Observation on 10/3/18 at 10:33 a.m. of Resident #84's medications in the first floor medication room revealed that Resident #84 had 30 tablets of [MEDICATION NAME] 25 mg (anti-hypertensive) with an expired date of 7/31/18 that were stored with the unexpired medications. Interview on 10/3/18 at 10:33 a.m. with Staff [NAME] confirmed the above finding. Resident #61 Observation on 10/3/18 at 10:34 a.m. of Resident #61's medications in the first floor medication room revealed that Resident #61 had 29 tablets of [MEDICATION NAME] 250 mg (antibiotic) with an expired date of 6/30/18 that were stored with the unexpired medications. Interview on 10/3/18 at 10:34 a.m. with Staff [NAME] confirmed the above finding. Resident #40 Observation on 10/3/18 at 10:35 a.m. of Resident #40's medication in the first floor medication room revealed that Resident #40 had an opened bottle, as indicated by a broken tamper seal, of [MEDICATION NAME] 0.4 mg ([MEDICATION NAME]) with an expired date of 05/2018 that was stored with the unexpired medications. Interview on 10/3/18 at 10:35 a.m. with Staff [NAME] confirmed the above finding. Staff [NAME] revealed that Resident #82, #84, #61, and #40's expired medications found in the first floor medication room were kept in the overflow medication box which holds the resident's unexpired medications to be use when the medication supply in the medication cart exhaust. Observation on 10/3/18 at 10:36 a.m. of the first floor medication room revealed that there were 2 unopened box of [MEDICATION NAME] Z 0.004% ophthalmic drops (medication to treat [MEDICAL CONDITION]) with an expired date of 07/2018 that were stored in the cabinet with the unexpired medications. Interview on 10/3/18 at 10:36 a.m. with Staff [NAME] confirmed that [MEDICATION NAME] Z 0.004% ophthalmic drops were expired and should have been taken out and placed in the pharmacy return bag to be destroyed. Observation on 10/3/18 at 10:40 a.m. of the first floor medication cart revealed that the medication cart was unlocked and unsupervised as indicated by easily opened medication cart drawers and accessible medications. Interview on 10/3/18 at 10:40 a.m. with Staff I (Licensed Practical Nurse) confirmed the above finding. Staff I further revealed that they thought it was okay to leave the medication cart. Resident #46 Observation on 10/3/18 at 10:45 a.m. of Resident #46's medications at the second floor medication room revealed that Resident #46's Firvanq (antibiotic) 50 mg/ml has a labeled open date of 8/29/18 and a labeled not to use after date of 9/12/18 stored in the refrigerator with unexpired medications. Interview on 10/3/18 at 10:45 a.m. with Staff J (Licensed Practical Nurse) confirmed the above finding. Staff J further revealed that expired medications in the medication room were checked daily by the nurse staff and that any expired medications were to be placed in the pharmacy return bag to be sent back to the pharmacy. Resident #72 Review on 10/3/18 of facility's drug information titled Omniview- Drug information .Humalog 100 units/ml vial ., last revised on (MONTH) (YEAR), revealed that .store all unopened insulin containers in the refrigerator .Throw away all insulin [MEDICATION NAME] (Humalog) in use after 28 days . Observation on 10/3/18 at 11:06 a.m. of Resident #72's medications at the third floor medication cart revealed that Resident #72's Humalog 100 units/ml vial had no cap on vial and no open date labeled on the vial nor the box. Interview on 10/3/18 at 11:06 a.m. with Staff L confirmed the above finding. Staff L revealed that the Humalog 100 units/ml vial was not used even though there was no cap on the Humalog vial. Staff L also revealed that the Humalog 100 units/ml vial should have been kept in the refrigerator and not in the medication cart. Interview on 10/3/18 at 2:00 p.m. with Staff H (Director of Nursing) confirmed that they use the Omniview Drug information to determine storage of medications for insulins. Resident #64 Observation on 10/3/18 at 11:10 a.m. of Resident #64's medications at the second floor south medication cart revealed that Resident #64's ER (emergency) [MEDICATION NAME] 1 mg kit had an expire date of 5/2018 that was stored with the unexpired medications. Interview on 10/3/18 at 11:10 a.m. with Staff J confirmed the above finding.",2020-09-01
240,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2018-10-08,842,B,0,1,IQUI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to accurately document treatment administration for 1 resident in a standard survey sample of 29 residents. (Resident identifier #138.) Findings include: Interview on 10/5/18 at approximately 3:25 a.m. with Resident #138 revealed that Resident #138 stated that they have not used the [MEDICAL CONDITION] (Continuous Positive Airway Pressure) machine in about a month. Resident #138 stated that they needed a new mask and the one that was ordered, and came in, was not the right size. Review on 10/8/18 of Resident #138's (MONTH) (YEAR) Treatment Administration Record revealed that there were nurses signatures with check marks indicating that the [MEDICAL CONDITION] had been applied on 10/1/18, 10/6/18 and 10/7/18. Interview on 10/8/18 at approximately 10:00 a.m. with Staff [NAME] (Unit Manager) revealed that the nurses were documenting use of the [MEDICAL CONDITION] machine, when it was not in use.",2020-09-01
241,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2018-10-08,880,D,0,1,IQUI11,"Based on observation, interview, record review and facility policy review, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases for 3 residents in a standard survey sample of 29 residents. (Resident identifiers are #27, #125 and #392.) Findings include: Observation on 10/3/18 at approximately 10:45 a.m. of the container of PPE (Personal Protective Equipment) outside of Resident #392's room revealed that Resident #392 was on precautions. Interview on 10/3/18 at approximately 10:45 a.m. with Staff [NAME] (Unit Manager) revealed that Resident #392 was on contact precautions for a MDRO (Multi drug resistant organism) in their urine and that a gown and gloves needed to be worn when in their room. Interview on 10/3/18 at approximately 10:50 a.m. with Resident #392 revealed that they have a suprapubic catheter. Observation on 10/3/18 at approximately 10:50 a.m. revealed that the uncovered trash container for used PPE was located right next to the toilet in the bathroom that was shared by Resident #392 and their roommate Resident #125. The trash container was overflowing with discarded gowns and gloves. Also in the bathroom, was a urinal, with a small amount of what looked like urine in it. The urinal was hanging on the hand rail located approximately 10-12 inches from the sink. Review on 10/3/18 at approximately 3:00 p.m. of Resident #125's MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/21/18 revealed that Resident #125 had a BIMS (Brief Interview for Mental Status) score of 9 out of 15 indicating that Resident #125 had some cognitive deficits. Observation on 10/4/18 at approximately 7:50 a.m. revealed that again the uncovered trash container was overflowing with discarded gowns and gloves and was still located next to the toilet in the bathroom. Also in the bathroom, was the urinal, with a small amount of what looked like urine in it,.hanging on the hand rail. Interview on 10/4/18 at approximately 10:50 a.m. with Staff F (Infection Control Nurse) and Staff G (Licensed Nursing Assistant) confirmed that the nursing staff used the urinal to empty Resident #392's urine from the catheter bag and then empty the urine into the toilet. Interview on 10/4/18 at approximately 10:55 a.m. with Staff F confirmed that the staff should not be leaving the used urinal in the bathroom, should not be leaving the trash container overflowing nor should it be located next to the toilet where another resident, especially some who had some confusion, could reach into it. Staff F also confirmed that staff should not be discarding the urine from the resident on precautions directly into the toilet. Review on 10/5/18 of the Facility Policy, titled Waste Management, last reviewed on 10/31/16, revealed that staff should .Dispose of non-regulated waste in appropriate, non combustible waste containers .When waste bags are 3/4 full, close bag and remove from area . Interview on 10/5/18 at approximately 2:00 p.m. with Staff H (Director of Nursing) revealed that the facility policy was for nursing staff to discard urine, that had a MDRO in it, into the toilet and then the nursing staff were to disinfect the toilet with bleach. When asked for a copy of this facility policy, Staff H confirmed that there was not a specific policy. Staff H also confirmed that there was no documented evidence of the nursing staff being inserviced on disinfecting a toilet after use for a resident with a MDRO. Resident #27 Observation on 10/3/18 at approximately 1:30 p.m. in Resident #27's room revealed that on Resident #27's bedside table was a urinal uncovered and had some yellow liquid, what appeared to be urine in it placed approximately 1-2 inches from Resident #27's lunch tray on bedside table. Interview on 10/3/18 at approximately 1:30 p.m. with Resident # 27 regarding the urinal being next to lunch on the bedside table, Resident #27 stated, They (staff) do that all the time.",2020-09-01
242,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2017-10-31,157,D,0,1,E3MK11,"Based on observation, record review, and interview, it was determined that the facility failed to consult with the resident's physician about a significant change in the resident's status, for one out-of-sample resident in a survey sample of 24 residents. (Resident identifier is #25.) Findings include: Resident #25 Observation on 10/30/17 at approximately 7:35 a.m. during medication pass with Staff G (Licensed Practical Nurse) revealed Resident #25's blood glucose level was 440. Resident #25 stated, I have been telling you all I have a UTI (Urinary Tract Infection) for days and nobody does anything about it, I know what it feels like and it has been burning for days. Review on 10/31/17 the facility's policy and procedure revealed: NSG Physician/Advanced Practice Provider Notification, Review Date 03/01/16 Policy Upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician/advanced practice provider. Interview on 10/30/17 at approximately 3:15 p.m. with Staff C UM (Unit Manager) revealed that the physician was in the facility on 10/30/17 and had not been notified of a resident with clinical concerns of burning with urination and elevated blood sugar.",2020-09-01
243,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2017-10-31,160,B,0,1,E3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident trust funds and interview, it was determined that the facility failed to convey resident funds within 30 days to the estate of the individual or probate jurisdiction administering the resident's estate for 5 of 5 sampled residents. (Resident identifiers are #29, #30, #31, #32, #33.) Findings include: On [DATE] at approximately 1:00 p.m. review of the resident trust fund revealed that the facility failed to convey 5 residents personal funds within 30 days of discharge from the facility. Review of the accounts revealed the following: Resident #29 had expired at the facility on [DATE] with $1,435.81 remaining in the account. The probate was filed on [DATE]. Which was 8 days late. Resident #30 had expired at the facility on [DATE] with $919.37 remaining in the account. The probate was filed on [DATE]. Which was 10 days late. Resident #31 had expired at the facility on [DATE] with $70.00 remaining in the account. The probate was filed on [DATE]. Which was 7 days late. Resident #32 had expired at the facility on [DATE] with $4,888.72 remaining in the account. The probate was filed on [DATE]. Which was 6 days late. Resident #33 had expired at the facility on [DATE] with $591.67 remaining in the account. The probate was filed on [DATE]. Which was 1 day late. Interview on [DATE] at approximately 5:00 p.m. with Staff I (Business Office Manager) confirmed that probate paperwork was not filed in thirty days on these 5 residents.",2020-09-01
244,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2017-10-31,241,D,1,1,E3MK11,"> Based on observation, interview, and record review, it was determined that the facility failed to ensure residents are treated in a manner and in an environment that promotes quality of life and each resident's rights, for three of three resident units. (Resident identifiers are #9, #17, and #25.) Findings include: During resident group interview on 10/30/17, where residents from the first and third floor units were in attendance, it was related that half the staff don't understand English, and staff answer rudely and give you a dirty look. It was mentioned the aides need training, examples given were that they don't rinse the urinal after emptying it, and they don't put the call bill within reach. It was related that staff want you in bed between 6 and 7, one resident got their sleeping pill at 4:30 p.m. on 10/29/17. Response to buzzer is very slow on the second and third shifts on the third floor, and very slow on the first shift on the first floor. One resident related that a week ago they had incontinence in bed due to no response to their call bell. Another resident related it happens to her/him self all the time. Review of Resident Council minutes for The Lodge, Oakwood Estates, and Applewood Acres, for July, August, and (MONTH) (YEAR), revealed, in part, resident concerns from one or more units with daily emptying of trash (July, August, September), housekeeping not cleaning all room (August), 1st floor often smells bad (August), and slow response to call bells (July, September). It was also related in the 10/30/17 group interview that resident rooms are only clean when there's a survey; they don't put your clothes away. And it was related that if you have an accident, e.g. catheter leakage, they leave it to clean up the next day. Resident #17 During interview with Resident #17, on 1031/17, the resident related they have been in the facility since (MONTH) (YEAR), and Resident #17 has multiple concerns: In (MONTH) he was choking after swallowing water, aspirated it, and couldn't catch his breath. He rang the call bell 15 minutes and yet staff hadn't come in, so he yelled help, help and they didn't come in, so he threw 2 coffee mugs at the door and a nurse came in. The nurse that responded to his throwing the coffee mugs at the door came in and left; then a second nurse came in and did his pulse and oxygen. He said if you leave now, I'll call 911. Aides are slow in responding and a lot of staff don't speak or understand English, mostly at nights and all weekend. He related an incident where staff started to give him the wrong medication so he made a formal complaint, he doesn't recall the medication or date of that incident. He was walking in (MONTH) (YEAR) with a cane, but relates that due to lack of or poor physical therapy he's no longer walking. They marked him down as refusal to cooperate so he lost his skilled care; he also had reached the end of his 100 days. His wheelchair doesn't fit, he needs a 15 inch wheelchair. He related he's now back on skilled care after going to the hospital last week. He watches TV in his room. They never tell him until after the fact about activities going on, he's visually impaired. Months ago, they brought a CD player with radio, but never showed him how to use it. The wheelchair provided to him is too painful, hurts his back, so he can't attend cocktail hour due to this. The food here tastes disgusting. He related he's not on a restricted diet. The vegetable are over steamed, they're mush. The two alternatives are an imported cat fish from China or pork, neither is tasty. Observation on 10/30/17 from approximately 12:26 p.m. to 12:33 p.m. revealed 3 nurses at the nurses station on the 3rd floor unit. The 3 nurses were engaged in personal conversations regarding vacation, alcohol and water aerobics. While these conversations were taking place there were call lights going off for resident assistance. At no point did any of the nurses answer any of the call lights. Observation on 10/30/17 from approximately 2:30 p.m. to 2:40 p.m. revealed 3 nurses at the nurses station on the 3rd floor were engaged personal conversations regarding, marriage and insurance. While these conversations were taking place there were call lights going off for resident assistance. At no point did any of the nurses answer any of the call lights. Resident #25 Observation on 10/30/17 at approximately 7:35 a.m. during medication pass with Staff G (Licensed Practical Nurse) revealed Resident #25's blood glucose level was 440. Resident #25 stated, I have been telling you all I have a UTI (Urinary Tract Infection) for days and nobody does anything about it, I know what it feels like and its been burning for days. Review on 10/31/17 the facility's policy and procedure revealed: NSG Physician/Advanced Practice Provider Notification, Review Date 03/01/16 Policy Upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician/advanced practice provider. Interview on 10/30/17 at approximately 3:15 p.m. with Staff C (Unit Manager) revealed that the physician was in the facility on 10/30/17b and had not been notified of a resident with clinical concerns of burning with urination and elevated blood sugar. Resident #9 Interview on 10/30/17 at approximately 1:00 p.m. with Resident #9 revealed concerns regarding communication between staff and residents, and that there was a definite difficulty with staff understanding resident's needs. The following incidents were reported during the interview: Resident #9 feels that personal belongings are thrown around by staff. Resident #9 stated that on a nightly basis the resident asks for personal belongings to be put away and not thrown in a pile on a chair in the resident's room. Observation on 10/30/17 at approximately 1:30 p.m. of Resident #9's room revealed that the chair had a pile of the resident's personal belongings on it. Interview on 10/30/17 at approximately 2:15 p.m. with Staff A (Unit Manager) in Resident #9's room confirmed that the personal belongings should be put away. Staff A began putting Resident #9's belongings away. I will take care of it. Resident #9 revealed concerns that staff do not understand when the residents speak to them, It must be the language thing, they say we are calling them stupid because we have to repeat ourselves over and over again and they still don't understand me! Observation on 10/31/17 at approximately 2:15 p.m. revealed the chair in Resident #9's room had a pile of belongings on it again. Interview on 10/30/17 at approximately 1:30 p.m.with Staff L, Unit Aide revealed that Staff L was unable to answer simple questions during an abuse interview due to a lack of understanding of questions that were asked.",2020-09-01
245,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2017-10-31,252,B,0,1,E3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure a clean and comfortable environment for residents. Findings include: During resident group interview on 10/30/17 in the morning, it was related that resident rooms are only clean when there's a survey, they don't put your clothes away. It was also related that if you have an accident, e.g. catheter leakage, they leave it to clean up the next day. There were 11 residents that participated in the group interview, representing the first and third floor units. Review of Resident Council minutes for The Lodge, Oakwood Estates, and Applewood Acres, for July, August, and (MONTH) (YEAR), revealed, in part, resident concerns from one or more units with daily emptying of trash (July, August, September), housekeeping not cleaning all room (August), 1st floor often smells bad (August), and nursing and/or call bell issues (July, August, September). Upon entrance by the health survey team into the facility on [DATE] at approximately 10:00 a.m., it was observed as a team consensus that there was a foul odor in the lobby. Subsequent observation on all days of survey (10/29-10/31/17) by survey team member(s), revealed that there was an on again, off again foul smell in the lobby area on the first floor, particularly to the right of the lobby in the vacinity of the candy cupboard.",2020-09-01
246,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2017-10-31,281,D,0,1,E3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility Medication Administration:General policy and procedure the facility failed to follow the professional standards of practice for following physician orders [REDACTED]. (Resident identifiers are #12, #13, #16 and #22.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 reveals: Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 708 reveals: The prescriber often gives specific instructions about when to administer a medication Page 713 reveals: .A registered nurse compares the list of medications on the MAR indicated [REDACTED].After administering a medication, record it immediately on the appropriate record form .After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurse's notes. .Recording Medication administration. After administering a medication, record it immediately on the appropriate record form . Never chart a medication before administering it. Recording immediately after administration prevents errors. The recording of a medication includes the name of the medication, dose, route and exact time of administration . If a client refuses a medication or is undergoing tests or procedure that result in a missed dose, explain the reason the medication was not given in the nurse's notes. Some agencies require the nurse to circle the prescribed administration on the medication record or to notify the physician when a client misses a dose. Be aware of the effects missing doses have on a client such as in hypertension or diabetes. Coordinating care with other services when testing or procedures are being completed helps ensure therapeutic control of the disease. Review of the facility Medication Administration: General policy with a revision date of 05/15/17 revealed the following: POLICY A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients. Accepted standards of practice will be followed. Medications will not be borrowed from another patient . PURPOSE To provide a safe, effective medication administration process. PRACTICE STANDARDS . 8. Document: 8.1 Administration of medication on Medication Administration Record [REDACTED] 8.2 Patient's response to medication; 8.2.1 Notification of physician?APN?PA, if applicable; 8.3 For medication refused by patient, circle your initials in the date and time space where that medication is ordered, and document patient's refusal of medication on the back of the MAR; 8.3.1 For Electronic Order Management (EOM) Centers, document refusal by entering the refusal code on the MAR. 8.4 Effectiveness of PRN (as needed) medication. Resident #22. Review on 10/31/17 of the MAR for Resident #22 dated 10/01/17 Through 10/31/17 revealed the following physician orders; TUMS 1 tablet BY MOUTH WITH EACH MEAL HUMALOG KIKPEN 100/ml INSULIN PEN GIVE ACCORDING TO SLIDING SCALE WITH MEALS CREON NEW FORMULATION . CAPSULE DR 2 CAPS BY MOUTH WITH MEALS [MEDICATION NAME] . 800 MG TABLET 2 TABS BY MOUTH WITH MEALS . [MEDICATION NAME] 17GM mix 1 PACKET IN FLUID OF CHOICE AND TAKE BY MOUTH DAILY. Review on 10/31/17 of the above listed MAR for Resident #22 revealed on the front of the MAR indicated [REDACTED]. The back of this MAR indicated [REDACTED]. No further documentation could be found for the 10/11 Tums not being given to Resident #22. Review on 10/31/17 of the above listed MAR for Resident #22 revealed on the front of the MAR indicated [REDACTED]. The back of this MAR indicated [REDACTED]. (Resident #22) went to [MEDICAL TREATMENT]. No further documentation could be found for the other 5 doses of Humalog not being given to Resident #22. Review on 10/31/17 of the above listed MAR for Resident #22 revealed on the front of the MAR indicated [REDACTED]. The back of this MAR indicated [REDACTED]. Review on 10/31/17 of the above listed MAR for Resident #22 revealed on the front of the MAR indicated [REDACTED]. The back of this MAR indicated [REDACTED]. No further documentation could be found for the other 3 doses of [MEDICATION NAME] not being given to Resident #22. Review on 10/31/17 of the above listed MAR for Resident #22 revealed on the front of the MAR indicated [REDACTED]. The back of this MAR indicated [REDACTED]. No documentation could be found for the doses not given on 10/10, 10/12, 10/13 to Resident #22. Interview and review of the above listed MAR indicated [REDACTED]. Staff C confirmed that Resident #22 is not back from [MEDICAL TREATMENT] to receive the scheduled 11:30 Tums, Humalog,[MEDICATION NAME] with meals. Staff C confirmed that the daily [MEDICATION NAME] was not given on the days listed above to Resident #22. The facility failed to notify the physician that the above listed medications were not given on [MEDICAL TREATMENT] days and that 7 doses of daily [MEDICATION NAME] were not given to Resident #22. Resident #12 Review on 10/30/17 of the Peritoneal Dislysis Record for (MONTH) (YEAR) revealed that the resident had [MEDICATION NAME] in the effulent after [MEDICAL TREATMENT] on the following mornings: 10/2/17, 10/3/17, 10/4/17, 10/5/17, 10/6/17, 10/7/17, 10/8/17, 10/9/17, 10/12/17,10/16/17, 10/17/18, 10/19/17, 10/20/17, 10/21/17, 10/22/17,10/25/17, 10/26/17, and 10/28/17. Review on 10/31/17 of Resident #12's Medical Adminsitration Record (MAR) revealed the following order: Inject 2500 units of [MEDICATION NAME] to each 5 L (liter) bag of diasylate (sic) if [MEDICATION NAME] present. Further review of the MAR indicated [REDACTED]. Review of the Resident #12's progress notes for (MONTH) (YEAR) revealed that the resident received [MEDICATION NAME] with treament (with each 5 L bag) on 10/2/17, 10/3/17, 10/5/17, 10/7/17, 10/8/17, 10/17/17, 10/20/17, and 10/22/17. Review of the Peritoneal Dislysis Record for (MONTH) (YEAR) revealed a note that [MEDICATION NAME] was given with treament on 10/16/17 and 10/29/17 (per resident's request). There was no evidence that [MEDICATION NAME] was adminsitered with treament on 10/4/17, 10/6/17, 10/12/17, 10/19/17, 10/26/17. Hepain was given with treatment on 10/29/17 when the effluent was clear, without a physican's order. Interview with Staff K (Registered Nurse) on 10/30/17 at 1:00 p.m. revealed if there was [MEDICATION NAME] in the effluaent after [MEDICAL TREATMENT] in the morning, then [MEDICATION NAME] would be administered with the next treatment. Interview with Staff F (Director of Nursing on 10/31/17 at approximately 2:00 p.m. cofirmed there was no documenation of [MEDICATION NAME] administration on the days mentioned above and there was no physican order for [REDACTED]. Resident #16 Review on 10/31/17 of Resident #16's [MEDICAL TREATMENT] communication book revealed a note to the facility on [DATE] from the [MEDICAL TREATMENT] center nurse that stated the resident should be taking Neprocaps. Review on 10/31/17 of Resident #16 (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with Staff J (Licensed Practical Nurse) on 10/31/17 at approximately 1:30 p.m. revealed the facility had contacted the provider for an order for [REDACTED]. Resident #13 Review on 10/30/17 of Resident #13's October's MAR (Medication Administration Record) revealed Resident #13 had an as needed order for [MEDICATION NAME] 10 milligrams by mouth every 6 hours for pain. The as needed medication was documented as being administered in the [DATE] times. Review on 10/30/17 of the Narcotic Count Book revealed that the medication had been documented as being administered 41 times during October. Review on 10/30/17 of the facility policy and procedure: Nursing Pain Management, Review Date 10/10/16 revealed: . 5. If as needed medications are given, document on the back of the MAR indicated [REDACTED]. Interview on 10/31/17 at approximately 12:45 p.m. with Staff A (Unit Manager) confirmed that the documentation in the Narcotic Count Book did not reflect the doses documenented in the MAR.",2020-09-01
247,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2017-10-31,431,E,0,1,E3MK11,"Based on observation, review of manufacturers instructions and interview it was determined that the facility failed to date opened multidose vials on 3 of 3 units. Findings include: Observation on 10/29/17 at approximately 10:30 a.m. of the Medication Room refrigerator on the 3rd Floor Unit, revealed an opened vial of Aplisol, Tuberculin Purified Protein Derivative, which was not dated. Interview on 10/29/17 at approximately 10:30 a.m. with Staff A (Unit Manager) confirmed that the opened vial of Aplisol was opened and not dated. Observation on 10/30/17 at approximately 7:45 a.m. of the Medication Room refrigerator on the 2nd Floor Unit, revealed an opened vial of Aplisol, Tuberculin Purified Protein Derivative, which was not dated. Interview on 10/30/17 at approximately 7:45 a.m. with Staff B (Medication Nurse Assistant) confirmed that the opened vial of Aplisol was opened and not dated. Observation on 10/30/17 at approximately 7:55 a.m. of the Medication Room refrigerator on the 1st Floor Unit, revealed an opened vial of Aplisol, Tuberculin Purified Protein Derivative, which was not dated. Interview on 10/30/17 at approximately 7:55 a.m. with Staff C (Unit Manager) confirmed that the opened vial of Aplisol was opened and not dated. Review on 10/30/17 of the Manufacturer's instructions for the Tuberculin Purified Protein Derivative revealed that A vial of Tubersol (Aplisol) which has been entered and in use for 30 days should be discarded.",2020-09-01
248,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2017-10-31,514,E,0,1,E3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to maintain complete medical records for seat belt assessments for 3 out of 3 residents using seatbelts in a standard survey sample of 24 residents, and for transcription of Physician orders [REDACTED]. (Resident identifiers are #14, #15, #16 and #26.) Findings include: Interview on 10/29/17 at approximately 10:30 a.m. during tour with Staff D (Weekend Supervisor) revealed that Resident #14, #15 and #16 utilized seat belts when in electric wheel chairs. Resident #14 Review on 10/30/17 of Resident #14's medical record revealed that the facility had not done any assessments for the ability to self release the seat belt being utilized. Interview on 10/30/17 at approximately 12:30 p.m. with Staff A (Unit Manager) confirmed that Resident #14 uses a seat belt when in electric wheel chair and the facility had not done any assessments with use of the seat belt. Resident #15 Review on 10/31/17 of Resident #15's medical record revealed that the faciltiy had not done any assessments for the ability to self release the seat belt being utilized. Interview on 10/31/17 at approximately 1:00 p.m. with Staff A (Unit Manager) confirmed that Resident #15 uses a seat belt when in electric wheel chair and the facility had not done any assessments with the use of the seat belt. Review on 10/31/17 of the facility's policy, NSG Restraints: Use of, Review Date 10/10/16 revealed: Policy . Patients will be evaluated for the use of restraints or protective devices during the nursing assessment process. If it is determined that a protective device is being used as an enabler, no further assessment is needed. Resident #26 Observation on 10/30/17 at approximately 1:30 p.m. during medication pass with Resident #26 revealed that physicians order did not include flushing instructions in the (MAR) Medication Administration Record. Review on 10/30/17 of the MAR indicated [REDACTED] Vancomyocin in normal saline 750 milligrams in 200 ML. The flushing orders were not checked off on the MAR. Interview on 10/30/17 at approximately 1:30 p.m. with Staff [NAME] (Licensed Practical Nurse) confirmed that the order was not transcribed with flushing orders. Review on 10/31/17 of the facility policy and procedure, Nursing Transcription of Orders, Review Date 3/1/16 revealed: Purpose: To communicate all practioner orders to caregivers regarding patient's care and treatment. Interview on 10/31/17 at approximately 11:30 a.m. Staff F (Director of Nursing) confirmed that the flushing orders were not transcribed. Resident #16 Interview during tour with Staff D on 10/29/17 at approximately 10:15 a.m. revealed that Resident #16 wears a seatbelt with in (pronoun removed) wheelchair. Review on 10/31/17 of Resident #16's assessments revealed no assessments for the ability to self release the seat belt the resident was utilizing. Interview on 10/31/17 at 1:45 p.m. with Staff J (Licensed Practical Nurse) confirmed Resident #16 had a seatbelt and the facility had not done any assessments with the use of the seat belt. Interview further revealed that Resident #16 had been using the seatbelt when in (pronoun removed) wheelchair for approximately 2 years.",2020-09-01
249,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,658,D,0,1,5OD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #24 and #429.) Findings include: Resident #429 Review on 10/31/19 of facility's nurse's procedure manual titled, 5.2 Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change, revision date 5/1/2016, revealed that .Considerations: 1. [MEDICAL CONDITION]'s include 1.1 PICC . .Guidance: . .for PICC's, upper arm circumference .upon admission then weekly .compare to baseline measurement to detect possible catheter-associated venous [MEDICAL CONDITION] . .Documentation in the medical record includes .date and time, site assessment, length of external catheter, reason for dressing change, patient response to procedure . Review on 10/31/19 of facility's nurse's procedure manual titled, [MEDICAL CONDITION] Flushing and Locking, revision date 5/1/2016, revealed that .Considerations: [MEDICAL CONDITION] include .PICC .Catheter patency must be verified prior to each access. To assess patency, aspirate the catheter to obtain positive blood return. The aspirate blood should have the color and consistency of whole blood .Procedure: Attach syringe filled with prescribed flushing agent to needless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency . Review on 10/30/19 of Resident #429's physician orders [REDACTED].#429 had an order to Change Catheter Site Transparent Dressing. Indicate external catheter and upper arm circumference .as needed . Observation on 10/30/19 at 12:10 p.m. with Staff A (Licensed Practical Nurse) revealed that Staff A went to Resident #429's room to change Resident #429 PICC line dressing on their right upper arm. Staff A did not obtain an arm circumference on Resident #429's right arm during the PICC line dressing change. When Staff A asked for Staff K's (Unit Manager) assistance to finish the PICC line dressing change; Staff K failed to aspirate for blood return when flushing the PICC line catheter with a 10 ml Normal Saline Flush as no red substance blood-like was noted when Staff K flushed Resident #429's PICC line catheter. Interview on 10/30/19 at 1:00 p.m. with Staff A confirmed above observation related to obtaining a arm circumference measurement on Resident #429. Staff A was unable to provide an explanation on above observations in regards to not obtaining arm circumference measurements. Staff A also confirmed that Resident #429 had an order to indicate upper arm circumference during a PICC line dressing change. Interview on 10/30/19 at 1:00 p.m. with Staff K confirmed above findings related to flushing Resident #429's PICC line catheter. Staff K was not able to provide an explanation on why no patency or blood return was assessed on the PICC line during PICC line dressing change. Interview on 10/31/19 at 6:10 a.m. with Staff L (Registered Nurse) revealed that Staff L observed blood on Resident #429's PICC line dressing and had placed a gauze over the insertion site for pressure and applied a new transparent dressing. Observation on 10/31/19 at 6:15 a.m. with Staff L revealed that Resident #429 had blood on their right upper arm and underneath the transparent PICC line dressing with a gauze covering the insertion site. The PICC line dressing was dated 10/31/19. Review on 10/31/19 and 11/1/19 of Resident #429's nurses notes and (MONTH) 2019's Electronic Medication Administration Record [REDACTED]. Interview on 11/01/19 at 1:59 p.m. with Staff J (Director of Nursing) confirmed above findings related to record review. Staff J stated that the nurses should have documented on the EMAR or nurses notes about the PICC line dressing changes performed on 10/30/19 and 10/31/19. Resident #24 Review on 10/30/19 at 1:13 p.m. of Resident #24's medical record revealed Resident # 24 is taking insulin. Review of the orders revealed two different orders written on 8/9/19. The first was Insulin [MEDICATION NAME] Solution 10 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION. Monitor CBG (Capillary Blood Glucose) BID (two times daily) fasting. Notify provider for CBG>250 for 3 consecutive times. Start Date 8/9/19. And the second was Fingerstick blood glucose Notify MD (Physician) if blood sugar greater than 400 if blood glucose is below 70 initiate hypoglycemic protocol Review on 10/30/19 of Resident #24's medical record shows that prior to 8/5/19 the facility was doing blood sugars BID but since the orders written on 8/5/19 no blood sugars have been done. Interview with Staff J (Director of Nurses) on 11/4/19 at 2:42 p.m. confirmed the above findings.",2020-09-01
250,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,684,D,0,1,5OD611,"Based on interview and record review, it was determined that the facility failed to provide time intervention during a hypoglycemic episode for 1 resident in a final survey sample of 31 residents. (Resident identifier is #382.) Findings include: Resident #382 Interview on 10/30/19 at approximately 10:40 a.m. with Resident #382 revealed that Resident #382 stated that the facility was short staffed and that they, at times, had to wait for their call light to be answered. Resident #382 revealed that a while back, they had to wait for approximately 1/2 hour for their call light to be answered. Resident #382 stated that it was a problem because when Resident #382 first put their light on, they felt that they were starting to have a hypoglycemic episode. By the time staff responded, Resident #382 stated that they were weak, sweating and had blurred vision. Review on 10/31/19 of Resident #382's nursing documentation note, dated 7/27/19, revealed that .CBG (Capillary Blood Glucose) at 0630=64, glass of OJ (orange juice) given with gram (graham) crackers, later pt (patient) requested a glass of apple juice. CBG rechecked=78 . Interview on 10/31/19 at approximately 2:00 p.m. with Resident #382 confirmed that the hypoglycemic episode was around the end of July. Resident #382 also confirmed that the interventions put in place were those listed in the 7/27/19 nursing documentation note. Interview on 11/4/19 at approximately 10:15 a.m. with Staff J (Director of Nursing) confirmed that Resident #382 did have an episode of low blood sugar and that it was possible that Resident #382 had to wait for 1/2 hour. Staff J also confirmed that Resident #382 should not have had to wait for 1/2 hour during a hypoglycemic episode.",2020-09-01
251,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,686,D,0,1,5OD611,"Based on record review, interview, and observation it was determined that the facility has failed to provided the necessary treatment and services, consistent with professional standards of practice for 1 resident in a standard survey sample of 31 residents. (Resident identifier is #3.) Findings include: Review on 10/30/19 at 1:03 p.m. of the facility matrix revealed Resident # 3 triggered for an facility aquired pressure sore. Review of the facility's skin assessments revealed on 10/7/19 right foot-blister right inner heel. Then on 10/21/19 Resident #3 skin assessment revealed Right medial malleolus ongoing with treatment. Review on 10/30/19 of Resident #3's Nurses notes dated 9/16/19 stated .Has intact blister right heel. TX (treatment) to skin prep and dressing daily . Nurses notes dated 9/30/19 state .Right great toe red and swollen . Nurses notes dated 10/7/19 .right foot-blister right inner heel Nurses notes dated 10/14/19 .Right medial malleolus ongoing with treatment Review of the physicians orders for the month of (MONTH) 2019 state Treatment to right inner hell blister. Apply non adherent pad cover with heel foam wrap with kerflix change every other day and PRN . Observation on 10/31/19 at 10:03 a.m. with Staff H (Unit Manager) revealed that Resident #3's heel had no dressing to the heel as ordered and what was observed was a black eschar to the heel per Staff (H). Interview on 11/04/19 at 12:11 p.m. with Staff I (Regional Compliance Manger) confirmed through observation that the area on Residents #3's right heel was still present.",2020-09-01
252,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,689,D,0,1,5OD611,"Based on observation, interview, and record review, the facility failed to esure the environment outside and in one of three dining areas were free from accident hazards. (Resident Identifier is #1.) Findings include: Observation 10/30/19 at 9:50 a.m. while touring the third floor kitchenette revealed that the 3 bay steam table had covers over the bays which were extremely hot and unable to be touched. At time of observation staff were in the area but at any time a resident could walk into the area and burn themselves. Interview at this time with Staff G (Director of food services) revealed it has been brought up before but Staff G thought nothing has been done. Resident #1 Interview on 10/30/19 at 9:18 a.m. with Resident #1 revealed that Resident #1 fell outside the facility while going out for a smoke as the sidewalk had cracks. Review on 10/31/19 of Resident #1's Einteract (sic) Change of Condition note dated 10/27/19 revealed that resident had a fall and obtained a left knee abrasion. Review on 11/1/19 of Resident #1's Event Summary Report dated 10/27/19 revealed that Resident #1 reported to staff that Resident #1 fell out of their wheelchair when Resident #1 hit an uneven area in the parking lot. Observation on 11/1/19 at 10:00 a.m. with Resident #1 at the back of the building revealed that on right hand side while exiting the building there was a 4 to 6 inches gaping holes between the transition from the cement to asphalt where Resident #1 stated they fell . Further observation on the right-hand side while exiting the back of the building also revealed an approximatley 2 feet (length) by 2 feet (wide) by 8 inches (depth) square hole on the cement walkway. Further observation of the left-hand side while exiting the back building also revealed that there were 3 patches that were broken with gaping cement on the cement walkway making it an uneven surface. Observation and interview on 11/1/19 at 10:16 a.m. with Staff [NAME] (Administrator) confirmed above observation on the back of the building. Observation on 11/1/19 at 11:45 a.m. revealed that Resident #1 was outside at the back of the building going back into the facility assisted by Staff F (Activities Director) when Resident #1 leaned forward almost out of their wheelchair while going between the 4-6 inches gap between the asphalt and cement, which Resident #1 identified on above observation on 11/1/19 at 10:00 a.m., and Staff F reached over preventing Resident #1 from falling of their wheelchair. Observation and interview on 11/1/19 at 12:00 p.m. with Staff [NAME] at the back of the building confirmed the above findings. Staff [NAME] stated that Resident #1 fell at the gaping hole found at the right hand side per Resident #1. Staff [NAME] stated that they should have had a orange cone on the square hole at the cement walkway and that Staff [NAME] had called for contractors to fix the gaps on the walkways. Staff [NAME] was unable to provide documentation related to contacting contractors to fix the cement walkway prior to 11/1/19.",2020-09-01
253,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,690,D,0,1,5OD611,"Based on interview and record review, it was determined that the facility failed to provide services to maintain urinary continence for 1 resident in a final survey sample of 31 residents. (Resident identifier is #128.) Findings include: Review on 11/4/19 of Resident #128's Three Day Continence Management Diary, dated 10/17/19, revealed that there were 40 documented entries made between 10/17/19 and 10/19/19. It was documented that Resident #128 was either continent of urine or dry on 39 of the documented checks and was incontinent of urine on 1 of the checks. Review on 11/4/19 of Resident #128's Urinary Incontinence Evaluation, dated 10/16/19, revealed that Resident #128 was to have scheduled toileting. Review on 11/4/19 of Resident #128's current care plan revealed that Resident #128 was incontinent of urine with the potential for improved control or management of urinary elimination. The care plan intervention that was documented was to assist the resident to the toilet upon rising, before meals, after meals, nightly and as needed. Review on 11/4/19 of Resident #128's nurses notes and LNA (Licensed Nursing Assistant) documentation revealed that there was no documented evidence that Resident #128 was toileted as scheduled or what the results of the toileting were. Interview on 11/4/19 at approximately 8:40 a.m. with Staff N (Unit Manager) confirmed that there was no documented plan in place for the LNA's to toilet Resident #128, nor was there documentation of the results of the toileting schedule. Staff N also confirmed that a documented plan should have been put in place.",2020-09-01
254,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,692,D,0,1,5OD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to provided early identification for 1 resident with impaired nutrition risk to allow the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise in a survey sample of 31 residents. (Resident identifier is #68.) Findings include: Review on 11/01/19 at 12:02 p.m. of Resident #68's weights reveal on admission on 6/8/19 Resident #68 was 172.0 pounds and on 10/29/19 had a weight of 151 pounds with a difference of 21 lbs over this period of time. Review of the facility policy named Weights and Heights with a effective date of 6/1/01 and a revision date of 11/1/19 under section 1. Obtaining and Documenting Weight: reveals 1.2 If a patient's weight is less than or greater than five pounds from the previous weight, the patient will be re-weighed and the weight verified by a licensed nurse to determine accuracy. Review of Resident #68's medical record under weights reveals the following entrees were made with no re-weights being provided:. weight on 6/8/19 - 172 lbs weight on 6/10/19-166.6 lbs which is a 5.4 lbs weight loss weight on 6/18/19 -166 lbs weight on 7/9/19 - 150 lbs which is a 16 lbs weight loss weight on 9/16/19 -144.6 lbs weight on 9/17/19 -152 lbs which is a 7.4 lbs weight gain. Review of Resident #68's the nutritional assessment dated [DATE] under Nutrition History: weight, diet dining habits reveals (Resident #68) was seen last week for weight loss. A new weight shows (Resident #68) has gained weight/no longer showing wt loss 9/17 152#, 9/16 144.6#, 9/2 144#, 8/19 145#. It is difficult to assess given fluctuations Interview on 11/1/19 with Staff H (Unit Manger) reviewed the weight sheets and Staff H confirmed that the staff have not re-weighed Resident #68 after a 5 pound weight loss/gain and nursing have not verified accuracy.",2020-09-01
255,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,697,D,0,1,5OD611,"Based on interview, record review and facility policy review, it was determined that the facility failed to ensure effective pain management for 1 resident in a final survey sample of 31 residents. (Resident identifier is #88.) Findings include: Interview on 10/30/19 at approximately 2:00 p.m. with Resident #88 revealed that Resident #88 stated that they do not always get adequate pain control with the pain medications that are administered to them. Review on 11/1/19 of Resident #88's (MONTH) 2019 Medication Administration Record [REDACTED] Review on 11/1/19 of Resident #88's nursing progress notes revealed that each time Resident #88 reported ineffective results from their pain medication, there was no documentation of any other interventions that were attempted or any physician notification of the ineffective results Review on 11/4/19 of the facility policy, titled Pain Management, last revised on 11/1/19, revealed that .Patients receiving interventions for pain will be monitored for the effectiveness and side effects (e.g., constipation, sedation) in providing pain relief. Document: 8.1 Non-pharmacological interventions and effectiveness; 8.2 Effectiveness of PRN (as needed) medications. 8.3 Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/APP (Advanced Practice Practitioner) notification . Interview on 11/4/19 at approximately 10:15 a.m. with Staff J (Director of Nursing) confirmed that there was no documentation of other interventions attempted for Resident #88's pain or any physician notification and Staff J confirmed that there should have been.",2020-09-01
256,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,732,B,0,1,5OD611,"Based on observation and interview, it was determined that the facility failed to post the daily staffing data. Findings include: Observation on 11/4/19 at approximately 9:00 a.m. of the bulletin board located in the main lobby where the staffing information was posted revealed a piece of paper clipped to the board with the number of nursing staff for the day listed on it. The date on the top of the paper was typed in and read 11/1/19. Interview on 11/4/19 at approximately 9:00 a.m. with Staff [NAME] (Administrator) confirmed that the current day's nursing staff information should have been posted on the bulletin board.",2020-09-01
257,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,761,E,0,1,5OD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure proper labeling of medications for 2 out of 4 medication carts observed and proper storage of expired treatment supplies for 1 out of 2 medication rooms observed. (Resident identifiers are #44, #48, #51, #53, #82 and #97.) Findings include: Observation on [DATE] at 12:30 p.m. with Staff A (Licensed Practical Nurse) revealed that Staff A went to the third floor medication room and grabbed an unopened package of intravenous securement device with an expiration date of [DATE] with the unexpired intravenous securement device to use for a PICC (Peripherally inserted Central Catheter) line dressing change. Interview on [DATE] at 12:31 p.m. with Staff A confirmed above findings. Staff A stated that they were unaware that the intravenous securement device was expired. Staff A also stated that they were almost going to use it for a dressing change. Interview on [DATE] at 1:53 p.m. with Staff B (Registered Nurse) revealed that all treatment supplies (i.e. tube feeding supplies and intravenous supplies) in the third floor medication cart were all ready for use. Observation on [DATE] at 1:53 p.m. with Staff B at the third floor medication room revealed that there were 1 unopened package of port access kit with an expiration date of [DATE] and 1 unopened irrigation tray with a piston syringe with an expiration date of [DATE] that was found with the unexpired treatment supplies. Interview on [DATE] at 1:55 p.m. with Staff B confirmed above findings on the third floor medication room. Staff B was unable to give any explanation why expired treatment supplies were found with the unexpired treatment supplies. Review on [DATE] of the facility policy, titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, last revised on [DATE] revealed that .Facility should ensure that medications and biologicals that : (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened Resident #53: Observation on [DATE] at approximately 9:08 a.m. of the second floor hallway revealed that Staff O (Licensed Practical Nurse) was ambulating in the hallway and Staff O was holding a Basaglar pen, a vial of [MEDICATION NAME] eye drops and a vial of Fluoromethalone eye drops, all labeled with Resident #53's name, in their hand, as Staff O had just administered medications to Resident #53. As Staff O reached the medication cart, Staff O placed the medications on the top of the medication cart and went to assist a resident who was ambulating independently in the hallway. Staff O left the medication cart with the medications on top of it, and went to escort the wandering resident into their own room, out of sight of the medication cart. Interview on [DATE] at approximately 9:10 a.m. with Staff O confirmed that Staff O stated that they should not have left the medications unattended on top of the cart. Resident #48 Observation on [DATE] at approximately 12:50 p.m. of the first floor medication cart #1 revealed a [MEDICATION NAME]pen for Resident #48. The plastic bag holding the pen had a sticker on it that read Refrigerate until open then room temp (temperature). Discard unused med (medication) after 28 days. Date opened . The date opened part of the sticker had a line to write in the date opened, but it was blank with no date entered. Interview on [DATE] at approximately 12:50 p.m. with Staff O confirmed that there was no date opened written for the [MEDICATION NAME] pen and that there should have been. Staff O also confirmed that Staff O had used that pen to administer insulin to Resident #48 earlier that day. Resident #51 Observation on [DATE] at approximately 12:50 p.m. of the first floor medication cart #1 revealed a Tresiba insulin pen for Resident #51. There was a sticker on the pen that read Date opened . There was a sticker on the plastic bag holding the pen that read Date opened .After opening do not use after 56 days . The date opened part of the stickers had a line to write in the date opened, but they were blank with no date entered. Interview on [DATE] at approximately 12:50 p.m. with Staff O confirmed that there was no date opened written for the Tresiba pen and that there should have been. Resident #97 Observation on [DATE] at approximately 12:50 p.m. of the first floor medication cart #1 revealed a vial of [MEDICATION NAME]for Resident #97. The box holding the vial had a sticker on it that read Refrigerate until opened. Discard unused med after 28 days. Date opened . The date opened part of the sticker had the date of [DATE] written on it. Interview on [DATE] at approximately 12:50 p.m. with Staff O confirmed that the [MEDICATION NAME] vial had expired and that it should not have been in the medication cart. Resident #44 Observation on [DATE] at approximately 1:22 p.m. of the third floor medication cart #1 revealed an Anoro Ellipta inhaler for Resident #44. There was a sticker on the plastic bag holding the inhaler that read .Room temp guard from moisture. Date opened . The date opened part of the sticker had a line to write in the date opened, but it was blank with no date entered. Interview on [DATE] at approximately 1:22 p.m. with Staff P (Registered Nurse) confirmed that there was no date opened written for the Anoro Ellipta inhaler and that there should have been. Resident #82 Observation on [DATE] at approximately 1:22 p.m. of the third floor medication cart #1 revealed a Breo Ellipta inhaler for Resident #82. There was a sticker on the plastic bag holding the inhaler that read .Discard as label instructions. Date opened . The date opened part of the sticker had a line to write in the date opened, but it was blank with no date entered. Interview on [DATE] at approximately 1:22 p.m. with Staff P confirmed that there was no date opened written for the Breo Ellipta inhaler and that there should have been.",2020-09-01
258,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,812,D,0,1,5OD611,"Based on observation, interview and record review it was determined that the facility failed to store, prepare, and distribute food and maintain equipment in accordance with professional standards for food service safety. Findings include: Observation on 10/30/19 at 9:00 a.m. while touring the main kitchen revealed the meat slicer sitting on the counter top uncovered. Staff G (Director of food services) was asked if the meat slicer was ready for use and Staff G stated Yes. On inspection of the slicer it was noted and shown to Staff G that food build up was on the cutting blade. Staff G observed the area confirming the finding. Observation on 10/30/19 at 9:10 a.m. of the upright reach in refrigerator revealed the temperature logs that were written for the month of (MONTH) had more then half the temperatures greater then 41 degrees. When inspecting the inside thermometer it showed an inside temperature of 43 degrees. Interview on 10/30/19 with Staff G stated the refrigerator is opened and closed so much its hard to maintain the temperature. Observation on 10/30/19 at 9:30 a.m. of the walk-in refrigerator revealed a bowel of chopped potatoes, and chopped eggs that were to be mixed together before serving. This bowl had cellophane covering over it but inside this bowl laying on top of the potatoes and eggs was another plastic bowl that held onion chunks to be added to the salad when served to residents who wanted them. Staff G was shown the finding and agreed that this bowl holding the onions should not be in direct contact with with a food product. Observation on 10/30/19 at 9:35 a.m. during tour revealed a table top mixer that had marked and chipped paint making it hard to clean and maintained. The under side of the mixer had food buildup stuck on it that was hard to remove due to the units condition. Staff G was shown the piece of equipment who agreed it was in need to repair but stated its the best mixer they have, even if its old.",2020-09-01
259,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,880,D,0,1,5OD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure sterile procedures were maintained during a PICC (Peripherally Inserted Central Catheter) dressing change for 1 resident out of a final sample size of 31 residents. (Resident identifier is #429.) Findings include: Review on 10/31/19 of the Center of Disease Control and Prevention website titled, Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011), last reviewed on 11/5/15, revealed that . Hand Hygiene and Aseptic Technique 1. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after .dressing an Intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained .Wear either clean or sterile gloves when changing the dressing on Intravascular catheters .Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs (Central Vascular Catheter), PICC's, or guidewire exchange . Review on 10/31/19 of facility's sterile dressing procedure, revision dated 1/2/14, revealed that .disinfect over=bed table .open sterile supplies and place onto sterile filed, taking care not to contaminate .apply sterile gloves. If it is necessary to place hand on patient, use non-dominant hand; keep dominant hand sterile . Review on 10/31/19 of facility's nurse's procedure manual titled, 5.2 Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change, revision date 5/1/2016, revealed that .Considerations: 1. [MEDICAL CONDITION]'s include 1.1 PICC . .Guidance: . .Sterile dressing change using transparent dressing change performed . .Procedure: . .Perform Hand hygiene . .Assemble equipment and supplies on clean work surfaces . .Don mask and clean gloves . .Remove old dressing/securement device. Remove gloves . .Perform hand hygiene at bedside using appropriate hand sanitizer . .Don sterile gloves . Observation on 10/30/19 at 12:10 p.m. with Staff A (Licensed Practical Nurse) revealed that Staff A went to Resident #429's room to change Resident #429 PICC line dressing on their right upper arm. Staff A placed the PICC line dressing kit on Resident #429's bedside table that had 2 remote controls, 1 Styrofoam cup and a telephone without performing hand hygiene and cleaning the surface of the bedside table. Staff A donned gloves and loosened the transparent PICC line dressing without completely removing the transparent dressing. Staff A removed the gloves, opened the PICC line dressing kit on Resident #429's bedside table without performing hand hygiene and cleaning the surface of the bedside table. Staff A donned on sterile gloves, removed a plastic trash bag on the PICC line dressing kit and set the plastic trash bag on Resident #429's bed with the sterile gloves touching the bed linens. Staff A grabbed the sterile drape from the PICC line dressing kit and laid it underneath Resident #429's arm with the sterile glove touching Resident #429's clothing and bed linens. Staff A removed the old transparent dressing on the PICC line. Staff A covered Resident #429's right arm with the sterile drape underneath Resident #429's right arm with the sterile gloves touching Resident #429's right arm, clothing and bed linens. Staff A removed sterile gloves and went back to the third floor medication room and got a securement device and a new PICC line dressing kit. Staff A went back to Resident #429's room set the new PICC line dressing kit on Resident #429's bedside table without cleaning the surface of the bedside table that had 2 remote controls, 1 Styrofoam cup and a telephone. Staff A donned gloves and opened the PICC line dressing kit package and securement device package. Staff A removed gloves and donned on sterile gloves. Staff A uncovered the drape that was covering Resident #429's PICC line catheter with the sterile gloves touching the drape, Resident #429's right arm, clothing and bed linens. Staff A cleansed the PICC line insertion site, around the PICC line insertion site and clips that was attached to the PICC line catheter with the sterile gloves that had been in contact with Resident #429's right arm, clothing and bed linens. Staff A called for Staff K (Unit Manager) to finish the PICC line dressing change. Staff K came in and finished doing the PICC line dressing change on Resident #429. Interview on 10/30/19 at 1:00 p.m. with Staff A confirmed above observation. Staff A stated that they should have cleaned the bedside table and that Staff A should have changed to new sterile gloves every time Staff A's sterile gloves touched Resident #429's right arm, clothing and bed linens as the sterile gloves was not sterile anymore. Interview on 10/31/19 at 9:00 a.m. with Staff M (Infection Control Preventionist) was unable to provide competency evaluation on Staff A's PICC line dressing change. Staff M stated that Staff A had a Central Venous Catheter Care training on (MONTH) 14, 2007. Staff M also stated that they would only do competency during orientation and as needed basis.",2020-09-01
260,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2019-11-04,919,B,1,1,5OD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined that the facility failed to ensure that the call light system were adequately equipped to allow residents to call for staff assistance to a centralized work area for 1 out of 3 units observed. Findings include: Observation on 10/31/19 at 6:19 a.m. at the third floor unit near the solarium revealed that there were beeping sounds heard but no visual light signal observed at the nurse's station call light system. Interview on 10/31/19 at 6:19 a.m. with Staff C (Medication Nursing Assistant) revealed that the beeping sound was the auditory signal for the third floor call light system. Observation on 10/31/19 at 7:00 a.m. at the third floor unit revealed that the call light system out of resident room [ROOM NUMBER]'s room had a visual light signal on but no visual light signal on at the nurse's station. Observation on 10/31/19 at 7:15 a.m. at the third floor unit revealed that the call light system out of resident room [ROOM NUMBER]'s room had a visual light signal on but no visual light signal on at the nurse's station. Interview on 10/31/19 at 7:20 a.m. with Staff C revealed that they were unaware that the visual light signal of the call light system in the nurse's station was not working appropriately. Observation on 10/31/19 at 7:25 a.m. revealed that Staff C had notified Staff D (Maintenance Director) that the visual light signal of the call light system at the nurse's station was not turning on when the visual light signal on the outside of some resident rooms and auditory signals of the call light system at the third floor unit was on. Record review on 11/1//19 at the call light system audit tool dated 10/31/19 revealed that there were 26 out of 52, which were resident rooms 301 A, 301 B, 302 A, 302 B, 303 A, 303 B, 304 A, 304 B, 307 A, 307 B, 308 A, 308 B, 310 A, 310 B, 312 A, 312 B, 313 A, 313 B, 315 A, 315 B, 317 A, 317 B, 318 A, 318 B, 319, and 320, of the visual light signal at the nurse's station that did not turn on when call light system was triggered in the resident rooms. Interview on 11/1/19 at 3:00 p.m. with Staff [NAME] (Administrator) confirmed the above findings of the call light system audit tool and that the visual light signal at the nurse's station of the third floor unit was not functional. Staff [NAME] revealed that they did an audit of the call light system and was working on getting the call light system fixed. Staff [NAME] also revealed that the call light system visual light signal at the nurse's station should be functional to aide staff in knowing when resident needs assistance along with the visual light signal outside the resident rooms and the auditory signal.",2020-09-01
261,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2020-02-07,580,D,1,1,MRF411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to immediately inform the resident representative of a medication error resulting in monitoring of the resident for side effects for 1 of 1 resident reviewed with a medication error in a final sample of 25 residents. (Resident identifier is #65.) Findings include: Review of nurses notes on 2/3/20 at approximately 1:30 p.m. from Saturday 2/1/20 evening shift medication pass revealed that while Staff D, Registered Nurse (RN) was preparing medication for administration to Resident #65, Staff D noticed a discrepancy between what was stated on the medication card for [MEDICATION NAME] 7.5 mg and the appearance of the tablets within the card. Staff D noted that the label on the medication card matched the MAR (Medication Administration Record); however, when Staff D put the medication into the dispenser cup, Staff D noted that the medication labeled as [MEDICATION NAME] 7.5 mg did not appear to have the characteristic size, color or shape of [MEDICATION NAME] tablets, and felt that the medication looked more like [MEDICATION NAME]. There were 23 doses missing from the medication card at this time. Staff D then notified Staff E (Supervisor) of the discovery. The on-call medical provider was called and an order was obtained to monitor Resident #65's blood sugars as needed (PRN) and assess for signs and symptoms of nausea and diarrhea. Interview on 2/4/20 at approximately 11:00 a.m. with Staff A (Director of Nursing) and Staff F (Administrator), and observation of medication card during interview revealed that the medication card for Resident #65 did state [MEDICATION NAME] on the front and [MEDICATION NAME] on the back. At the time of the examination of the packaging on 2/4/20 there were 23 doses missing from the medication card that had been administered to Resident #65. Review of Resident #65's MAR from [DATE] to 2/1/20 revealed that Resident #65 received 23 doses of [MEDICATION NAME] during that time period ([DATE] to 2/1/20). Interview on 2/4/20 at approximately 11:00 a.m. with Staff A confirmed that the [MEDICATION NAME] that had been administered instead of [MEDICATION NAME] during [DATE]-2/1/20 from the mismarked medication card. Interview on 2/6/20 at approximately 1:30 p.m. with Staff A revealed that the Activated Durable Power Of Attorney was not notified of the error until 2/6/20, which is 5 days after the error was discovered on 2/1/20.",2020-09-01
262,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2020-02-07,757,D,1,1,MRF411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure residents were free from unnecessary drugs for 1 of 7 residents reviewed for medications in a final sample of 25 residents. (Resident identifier is #65.) Findings include: Review on 2/3/20 at approximately 1:00 p.m. of Resident #65's medical record revealed that there was an order for [REDACTED].#65 was not diabetic and did not have an order to receive [MEDICATION NAME]. Review of nurses notes on 2/3/20 at approximately 1:30 p.m. from Saturday 2/1/20 evening shift medication pass revealed that while Staff D (Registered Nurse) was preparing medication for administration to Resident #65, Staff D noticed a discrepancy between what was stated on the medication card for [MEDICATION NAME] 7.5 mg and the appearance of the tablets within the card. Staff D noted that the label on the medication card matched the MAR (Medication Administration Record); however, when Staff D put the medication into the dispenser cup, Staff D noted that the medication labeled as [MEDICATION NAME] 7.5 mg did not appear to have the characteristic size, color or shape of [MEDICATION NAME] tablets, and felt that the medication looked more like [MEDICATION NAME]. There were 23 doses missing from the medication card at this time. Staff D then notified Staff E (Supervisor) of the discovery. The medication card was determined to contain [MEDICATION NAME] and had a label that read [MEDICATION NAME]. The medication was held from the resident and an investigation was initiated. The on-call medical provider was called and an order was obtained to monitor Resident #65's blood sugars as needed (PRN) and assess for signs and symptoms of nausea and diarrhea. Interview on 2/4/20 at approximately 11:00 a.m. with Staff A (Director of Nursing) and Staff F (Administrator), and review of medication card during interview, confirmed that the medication card for Resident #65 did state [MEDICATION NAME] on the front and [MEDICATION NAME] on the back. At the time of the examination of the packaging on 2/4/20 there were 23 doses missing from the medication card that had been administered to Resident #65. Review on 2/4/20 of Resident #65's MAR from [DATE] to 2/1/20 revealed that Resident #65 received 23 doses of [MEDICATION NAME] during that time period ([DATE] to 2/1/20). Interview on 2/4/20 at approximately 11:00 a.m. with Staff A confirmed that the [MEDICATION NAME] had been administered instead of [MEDICATION NAME] during [DATE]-2/1/20 from the mismarked medication card. Interview on 2/6/20 at approximately 1:30 p.m. with Staff A revealed that the Activated Durable Power Of Attorney was not notified of the error until 2/6/20, which is 5 days after the error was discovered on 2/1/20. Review on [DATE] of Resident #65's Medical Record revealed that there were no adverse effects evident for Resident #65 as a result of the medication error; however, notes reveal that Resident #65 did not achieve a decrease of symptoms of [MEDICAL CONDITION] for which the [MEDICATION NAME] was prescribed.",2020-09-01
263,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2020-02-07,761,D,0,1,MRF411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to date an insulin pen on 1 of 4 medication carts observed. (Resident identifier is #71.) Findings include: Observation on 2/5/20 at approximately 10:45 a.m. of the Meadow unit short medication cart revealed an opened [MEDICATION NAME] pen for Resident #71. The plastic bag holding the pen had a sticker on it that read Insulin Discard after 28 days. Discard date . with a line next to it for staff to write in the date to be discarded and that line was blank. There was no date written in on the pen itself. Interview on 2/5/20 at approximately 10:45 a.m. with Staff C (Registered Nurse) confirmed that the insulin pen did not have a date opened or a date to be discarded on it. Staff C also confirmed that the discard date should have been written on the sticker. Review on 2/7/20 of the facility policy titled Insulin Administration, dated 4/17/18, read .Stability of Common Insulin and Vials .[MEDICATION NAME] .Opened at Room or Refrigerator Temperature (days) .28 .",2020-09-01
264,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2020-02-07,811,D,0,1,MRF411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and policy review, it was determined that the facility failed to ensure that a feeding assistant provides dining assistance only for residents who have no complicated feeding problems for 3 out of 10 residents assisted by Paid Feeding Assistants (PFA's). (Resident identifiers are #19, #35 and #74.) Findings include: Review on 2/6/20 of facility's Paid Feeding Assistant Program, dated (MONTH) 2009, revealed that .who can a PFA not feed? .someone with tube or IV (intravenous) feeding, difficulty swallowing, recurrent aspirations .PFA's cannot feed residents with dysphagia .residents are not appropriate for feeding by a PFA if they are or have been observed having difficulty in initiating swallowing, reporting a feeling of obstruction as if food was stuck in their throat, pocketing food in mouth, regurgitating food through the nose, suffering from recurrent pneumonia Resident #35 Review on 2/6/20 of the facility's list of residents assisted by the paid feeding assistants revealed that Resident #35 was on the list. Review on 2/6/20 of Resident #35's medical [DIAGNOSES REDACTED].#35 has a [DIAGNOSES REDACTED]. Review on 2/6/20 of Resident #35's active diet order dated 1/21/20 revealed that Resident #35 was on cut up food texture and thin liquid consistency. Review on 2/6/20 of Resident #35's speech evaluation and plan of care dated 10/15/19 revealed that Resident #35 was seen by speech therapist for a choking episode and diet was down graded to a pureed texture diet. Review on 2/6/20 of Resident #35's care plan, revision dated 12/29/19, revealed that Resident #35 .was unable to be independent with eating .10/10/19 worked with therapy for eating .extensive assist diet pureed as (Resident #35) had trouble swallowing .12/29/19 (Resident #35) can drink thin liquids and eat cut up food Resident #74 Review on 2/6/20 of the facility's list of residents assisted by the paid feeding assistants revealed that Resident #74 was on the list. Review on 2/6/20 of Resident #74's medical [DIAGNOSES REDACTED].#74 has a [DIAGNOSES REDACTED]. Review on 2/6/20 of Resident #74's active diet order dated 4/4/18 revealed that Resident #74 was on mechanical soft texture diet. Review on 2/6/20 of Resident #74's current care plan dated 3/11/18 revealed that Resident #74 needed extensive assist with meals due to history of choking/coughing and right hand tremors. Resident #19 Review on 2/7/20 of the facility's list of residents assisted by the paid feeding assistants revealed that Resident #19 was on the list. Review on 2/7/20 of Resident #19's medical [DIAGNOSES REDACTED].#19 has a [DIAGNOSES REDACTED]. Review on 2/7/20 of Resident #19's active diet order dated 4/4/18 revealed that Resident #19 was on pureed texture diet. Review on 2/7/20 of Resident #19's current care plan, revision date 11/22/19, revealed that Resident #19 has a swallowing problem related [MEDICAL CONDITION] with dysphagia. Interview on 2/7/20 at 10:00 a.m. with Staff A (Director of Nursing) and Staff B (Staff Development/PFA instructor) confirmed above findings related to facility's list of residents assisted by PFA's, Resident #19, #35, and #74. Staff B was unable to provide explanation on why Resident #19, #35, and #74 were on the list of residents that PFA's can feed. Staff B stated that Resident #19, #35, and #74 should not be assisted by PFA during meals related to their [DIAGNOSES REDACTED].",2020-09-01
265,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2017-09-12,281,D,0,1,WPGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to clarify physician orders [REDACTED]. (Resident identifiers are #5, #13 and #22.) Findings include: Professional Reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary Page 708 The prescriber often gives specific instructions about when to administer a medication Resident #5 Review on 9/11/17 of Resident #5's Medication Record for (MONTH) (YEAR), revealed that Resident #5 had an order for [REDACTED].*1/2 Tablet (25 MG) by mouth every 8 hours as needed for Mod-Sev (Moderate-Severe) pain. Review on 9/11/17 of Resident #5's Medication Record for (MONTH) (YEAR), revealed that Resident #5 also had an order for [REDACTED].* Max (Maximum) APAP 3 GM (Grams)/ 24 HRS (hours.) Review on 9/11/17 of the Pain Scale . that was located on the top of the medication cart revealed that mild pain was pain level 1-4, moderate pain was pain level 5-6, and severe pain was pain level 7-10. Review on 9/11/17 of Resident #5's Medication Record for (MONTH) (YEAR) revealed that Resident #5 received [MEDICATION NAME] on 8/2/17, 8/9/17, 8/12/17, 8/18/17 and 8/31/17 all for a pain level of 5. Resident #5 received Tylenol on 8/2/17 for a pain level of 5. Interview on 9/11/17 at approximately 10:00 a.m. with Staff B (Licensed Practical Nurse) confirmed that the pain scale located on the medication cart is the one used by nursing staff at the facility when assessing pain. Interview on 9/11/17 at approximately 10:00 a.m. with Staff B also confirmed that there was no clear indication in the physician orders [REDACTED]. Tylenol for moderate pain to Resident #5. Review on 9/11/17 of Resident #5's Physician order [REDACTED].#5's physician. Review on 9/11/17 of Resident #5's Physician order [REDACTED].*APRN (Advanced Practice Registered Nurse) wrote order for mechanical soft. Review on 9/11/17 of Resident #5's Physician order [REDACTED].#5 was written as Regular. There was no documentation for the Mechanical Soft diet. Review on 9/11/17 of Resident #5's Medication Record for (MONTH) (YEAR) revealed that the diet for Resident #5 was written as Regular. There was no documentation for the Mechanical Soft diet. Interview on 9/11/17 at approximately 10:00 a.m. with Staff B confirmed that the diet order of Mechanical Soft diet should have been documented on the Physician order [REDACTED].#5. Resident #13 Review on 9/11/17 of Resident #13's Medication Record for (MONTH) (YEAR) and for (MONTH) (YEAR) revealed that Resident #13 had an order for [REDACTED]. Review on 9/11/17 of Resident #13's Medication Record for (MONTH) (YEAR) and for (MONTH) (YEAR) revealed that Resident #13 also had an order for [REDACTED].* Max (Maximum) APAP 3 GM (Grams)/ 24 HRS (hours.) Review on 9/11/17 of the Pain Scale . that was located on the top of the medication cart revealed that mild pain was pain level 1-4, moderate pain was pain level 5-6, and severe pain was pain level 7-10. Review on 9/11/17 of Resident #13's Medication Record for (MONTH) (YEAR) and for (MONTH) (YEAR) revealed that Resident #13 received Tylenol on 8/4/17 for no documented pain level, on 8/11/17 for no documented pain level, on 8/12/17 for no documented pain level, on 8/13/17 for a pain level of 6, on 8/14/17 for no documented pain level, and on 9/1/17 for a pain level of 7. Review on 9/11/17 of Resident #13's Medication Record for (MONTH) (YEAR) and for (MONTH) (YEAR) revealed that Resident #13 received [MEDICATION NAME] on 8/3/17 for a pain level of 5, on 8/4/17 for no documented pain level, on 8/5/17 for a pain level of 7, on 8/8/17 for no documented pain level, on 8/29/17 for a pain level of 6, and on 9/11/17 for a pain level of 8. Interview on 9/11/17 at approximately 10:00 a.m. with Staff B (Licensed Practical Nurse) confirmed that the pain scale located on the medication cart is the one used by nursing staff at the facility when assessing pain. Interview on 9/11/17 at approximately 10:00 a.m. with Staff B confirmed that there was no clear indication in the physician orders [REDACTED]. Tylenol for moderate pain to Resident #13. Resident #22 Review on 9/12/17 of Resident #22's MEDICATION RECORD (MAR) dated 9/6/17 THROUGH 9/30/17 revealed the following physician orders: [MEDICATION NAME] 5 mg one by mouth every 4 hours as needed mod (moderate) severe pain and [MEDICATION NAME] 325 mg 2 tabs by mouth every 4 hours PRN (as needed) mild/mod pain, fever not to exceed 3 grams 24 hours. Further review of this MEDICATION RECORD revealed that on 9/11/17 Resident #22 was administered [MEDICATION NAME] 5 mg for R (right) shoulder pain with a pain rating of 6/10 and on 9/12/17 was administered Tylenol 650 mg for pain rated at 6/10. Interview on 9/12/17 at approximately 12:30 p.m. with Staff A (Registered Nurse) confirmed that the two different PRN pain medications were given and that there was no clear indication of parameters or when to administer which PRN pain medication to Resident #22.",2020-09-01
266,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2017-09-12,356,D,0,1,WPGS11,"Based on observation and interview, it was determined that the facility failed to post the required staffing numbers for each shift. Findings include: Observation on 9/12/17 of the main reception area and all 4 nursing units revealed that the staffing numbers for the facility were not posted. Interview on 9/12/17 at approximately 10:45 a.m. with Staff C (Receptionist) confirmed that the staffing numbers were not posted and Staff C revealed that the newly hired scheduler was not aware of the requirement of posting the staffing numbers. Staff C said that the new scheduler had started employment on 8/16/17. Interview on 9/12/17 at approximately 11:00 a.m. with Staff D (Director of Nursing) confirmed that the staffing numbers were not posted in a prominent place.",2020-09-01
267,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-01-11,559,B,1,0,K40711,"> Based on record review and interview, it was determined that the facility failed to provide written notice, including the reason for the change, before a resident's room was changed for 3 of 3 residents reviewed with room changes in a survey sample of 5 residents. (Resident identifiers are #2, #4, and #5). Findings include: Resident #2 Review on 1/11/19 of the facility's bed change report dated 1/11/19 revealed that Resident #2 was transferred from room on 10/5/18. Review of 1/11/19 of Resident #2's medical record revealed no documentation of written notice to the resident of the room change. Resident #4 Review on 1/11/19 of the facility's bed change report dated 1/11/19 revealed that Resident #4 was transferred from room on 12/26/18. Review of 1/11/19 of Resident #4's medical record revealed no documentation of written notice to the resident of the room change. Resident #5 Review on 1/11/19 of the facility's bed change report dated 1/11/19 revealed that Resident #5 was transferred from room on 12/20/18. Review of 1/11/19 of Resident #5's medical record revealed no documentation of written notice to the resident of the room change. Interview on 1/11/19 at 12:40 p.m. with Staff C (Social Worker) revealed that when a resident's rooms is changed, room numbers, date, who was notified, and if the patient refused is documented in the medical record but there is not a written notice, including the reason, given to residents before the change. Staff C confirmed the above residents had their rooms changed without written notice provided.",2020-09-01
268,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-01-11,635,D,1,0,K40711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility investigation findings it was determined that the facility failed to ensure that there were incomplete admission physician's orders [REDACTED]. (Resident identifier is #1). Findings include: Resident #1 Review on 1/11/19 of Resident #1's medical record revealed that Resident #1 was admitted to the facility on [DATE]. Staff A, LPN (Licensed Practical Nurse) was the admitting nurse responsible for transcribing the instructions from the hospital discharge summary, and calling the primary physician to confirm the instructions that would then become physician's orders [REDACTED]. The discharge summary sent from the hospital on [DATE] had the following directions: [MEDICATION NAME] 5 mg (milligram) oral tablet : 1 tab(s)(tablet) orally once a day -orally once a day(sic) On the side of the hospital discharge orders under Testing after Discharge is a handwritten note to Mon add INR (International Normalize Ratio). Interview on 1/11/19 at 11:45 a.m. with Staff A RN (Registered Nurse/Unit Manager), revealed that the [MEDICATION NAME] flow sheet was started on the day of admission, which is great, but the physician order [REDACTED]. Review on 1/11/19 of Resident #1's medical record revealed a physician order [REDACTED]. Interview on 1/11/19 at 11:45 a.m.with Staff A, the physician was not contacted during the admission process for verification or clarification of orders, there were no orders for [MEDICATION NAME] from 1/5/19 until 1/7/19 when the verbal order for a recheck was initiated.",2020-09-01
269,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-01-11,757,D,1,0,K40711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that residents are free from receiving an excessive dose of drugs for 1 of 3 residents reviewed with anticoagulant therapy in a survey sample of 5 residents (Resident identifier is #2). Findings include: Review on 1/11/19 of Resident #2's physician orders [REDACTED]. Review on 1/11/19 of Resident #2's Medication Administration Record [REDACTED]. Review on 1/11/19 of Resident #2's progress notes revealed on 11/5/18 Resident # 2 was transported and admitted to the hospital related to altered mental status. Review on 1/11/19 of Resident #2's hospital discharge paperwork dated 11/9/18 revealed that when the resident was admitted to hospital on [DATE], the resident was diagnosed with [REDACTED]. Interview on 1/11/19 at approximately 1:30 p.m. with Staff D (Unit Manager) confirmed the above findings and revealed that the [MEDICATION NAME] amount was not transcribed in handwriting properly when a new MAR indicated [REDACTED].",2020-09-01
270,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,550,D,0,1,0FW611,"Based on observation and interview, it was determined that the facility failed to protect the right of a resident to have privacy during an ear examination for 1 resident in a final survey sample of 31 residents. (Resident identifier is #67.) Findings include: Observation on 1/22/20 at approximately 12:00 p.m. revealed that Resident #67 was sitting at a table in the Francoeur Unit dining room eating their lunch. There were other residents and some staff also present in the dining room. Staff L (Nurse Practitioner) approached Resident #67 and asked to look in their ears. Staff L took an otoscope and examined both of Resident #67's ears and then Staff L made a loud comment, which could be heard across the dining room, that Resident #67's ears were both full of soft wax. Interview on 1/22/20 at approximately 12:45 p.m. with Staff C (Unit Manager) confirmed that any resident examinations should be done in private and should not be done in a public area, including a dining room.",2020-09-01
271,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,553,D,0,1,0FW611,"Based on interview and record review, it was determined that the facility failed to notify residents or their representatives of care plan meetings for 3 residents of a final sample of 31 residents. (Resident identifiers are #84, #55, and #4.) Findings include: Resident #55 Interview on 1/23/20 at 9:53 a.m. with Resident #55 revealed Resident #55's stated I am never told about them. when asked about care plan meetings. Review on 1/24/20 at 10:37 a.m. of Resident #55's Electronic Medical Record (EMR) revealed no documentation of care plan meeting notifications to Resident #55. Resident #55 has a Brief Interview for Mental Status Score (BIMS) of 15 (Score range of 0-15 with 15 being the highest score) and Resident #55 is documented in the EMR to be responsible for self. Resident #55 would be the recipient for care plan meeting notifications. Resident #84 Interview on 2/27/20 at 1:00 p.m. with Resident #84's Durable Power of Attourney (DPOA) revealed the facility had not been providing Resdient #84 or their DPOA with notifications of scheduled care plan meetings for Resident #84. Interview on 1/24/20 at 12:01 p.m. with Staff M (Social Worker) revealed that there was no documentation in the EMR that documents notification of Resident #84's DPOA of care plan meetings, the care issues discussed, or discussion of revisions to the care plan. Staff M revealed that documentation of care issues are located in the social work notes of each resident in the EMR. Staff M did confirm that there was no notification of care plan meetings or an organized format in the EMR for documentation of care plan meetings for Resident #55 and Resident #84. Resident #4 Interview on 1/22/20 at approximately 10:30 a.m. with Resident #4's DPOA revealed that they did not get invited to care plan meetings quarterly. They stated that they think that they have only been invited to one meeting since Resident #4's admission on 7/27/18. Interview on 1/27/20 at approximately 10:15 a.m. with Staff M revealed that care plan meetings were held and Resident #4's DPOA attended them in (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019 and on 1/20/20. The interview with Staff M confirmed that care plan meetings were not done quarterly for Resident #4, just the dates above, and that they should have been held after every comprehensive assessment.",2020-09-01
272,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,656,D,0,1,0FW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement the smoking care plan for 2 of 4 residents who smoke out of a final survey sample of 31 residents. (Resident identifiers are #21 and #35.) Findings include: Resident #21 Review on 1/22/20 of Resident #21's smoking care plan revealed that Resident #21 may smoke independently and staff is to light cigarettes for resident. Resident #21 should not possess a lighter, lighters are to be locked at nurse station and should not be handled by the resident. Observations on 1/22/20 revealed Resident #21 smoking in the designated outside facility smoking area using a lighter from his/her person to independently light multiple cigarettes. Interview on 1/22/10 at 12:00 p.m. with Staff N (Administrator) and Staff A (Registered Nurse, Regional) confirmed that Resident #21's cigarettes are to be lit by staff and that Resident #21 should not handle or possess a lighter. Resident #35 Review on 1/22/20 of Resident #35's smoking care plan revealed that Resident #35 needs to have supervised smoking and staff is to light cigarette for resident. Resident should not possess lighter due to poor safety awareness, lighter to be locked at nurse station and should not be handled by resident. Review on 1/23/20 of Resident #35's Smoking Evaluation dated 12/22/2019 revealed that Resident #35 has history of fire setting or arson, history of unsafe smoking habits and history of sharing/selling cigarettes or smoking material and does not properly dispose of ashes or butts. Smoking evaluation also revealed that Supervised smoking is required due to Resident #35 .is smoking in room. (Resident #35) . lit a dollar bill to 'sage' . room. Review on 1/23/10 of Resident #35's Progress Notes revealed the following: - 11/21/19 .Lighter, cigarettes and a burnt dollar was removed from (Resident #35) room. Room and bathroom smelled of burnt material and cigarettes - 12/22/19 .(Resident #35) was smoking in .room again.also lit a $1 bill to 'sage' (his/her) room. - 1/5/20 . (Resident #35) went out of facility to smoke a cigarette. When resident came back .told nurse that .fell and landed on (pronoun omitted) bottom walking back into the building . No injuries status [REDACTED]. - 1/15/20 .(Resident #35) was seen to go outside and light a cigarette with a lighter that came out of .pocket (staff) went outside and told .(Resident #35) that .should not have lighter .(Resident #35) acknowledged that . should not have a lighter and quickly handed the lighter over. - 1/19/20 . notified resident had a lighter .spoke with resident and asked .if .(Resident #35) had a lighter .stated 'Yes I do' Interview on 1/22/10 at 12:00 p.m. with Staff N (Administrator) and Staff A (Registered Nurse, Regional) confirmed that Resident #35's cigarettes are to be lit by staff, that Resident #21 should not handle or possess a lighter and that Resident#35 should be supervised when smoking.",2020-09-01
273,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,689,E,0,1,0FW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to maintain exits free of obstructions when the facility failed to remove snow from facility designated exit gates resulting in the gates being inoperable during a potential evacuation. This deficient practice could affect 2 of 3 exits observed. The facility also failed to protect residents by ensuring safe smoking practices and using a designated smoking area in a public right of way for 2 of 4 residents that smoke cigarettes out of a final survey sample of 31 residents. (Resident identifiers are #21 and #35). Findings include: Observation on 1/22/20 during facility tour around 2 p.m. revealed that the designated exit door located on the Franceur unit near rooms [ROOM NUMBERS] exits out to a courtyard that has a gate (with a facility designated exit sign attached to it), opens to the street. During the observation, it was revealed that there was snow piled in front of the gate that would inhibit the opening of the gate, which would prevent egress through the gate during an emergency situation. Observation on 1/22/20 during facility tour around 2:15 p.m. revealed that the designated exit door located on the east wing near rooms [ROOM NUMBERS] that exits out to a courtyard that has a gate with a facility designated exit sign attached to, opens to the street. During the observation it was revealed that there was snow piled in front of the gate that would inhibit the opening of the gate, which would prevent egress through the gate during an emergency situation. Interview on 1/22/20 at approximately 2:15 p.m. with Staff A (Regional Clinical Quality Specialist) revealed that the gates are a designated exit. Staff A confirmed that there should not be snow piled in front of the gate that obstructs that operation of the gate. Review on 1/22/20 of the facility policy and procedure titled Smoking dated 11/20/19 revealed the following: POLICY For Centers that choose to have a smoke-free building or campus: - Smoking in any form through the use of tobacco products (pipes,cigars and cigarettes) or vaping with electronic cigarettes is prohibited; . - A smoke-free campus includes all Center property and premises including inside and outside of Center buildings, grounds, and parking areas including Center and personal vehicles in the parking area. For Centers that allow smoking, smoking (include the use of electronic cigarettes) will be permitted in designated areas only. Patients will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised. Smoking is defined as The inhalation of smoke from burning tobacco or any other substance encased in cigarettes, pipes, and cigars as well as any type of smokeless tobacco products including, but not limited to, electronic cigarettes. Supervised smoking is defined as The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. PURPOSE - To provide guidelines for smoke-free Centers/campuses. - To ensure that patients who choose to smoke will do so safely . PR[NAME]ESS 2. For Centers that allow smoking: 2.1 An area designated as a smoking area will be environmentally separate from all patient care areas (e.g., outdoors or smoking lounge), will be well ventilated, and, if outdoors, will protect patients from weather conditions. 2.1.4 Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances. 2.3 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. 2.5 A patient's smoking status - independent, supervised, or not permitted to smoke - will be documented in the care plan. 2.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. 2.6.1.1 Electronic cigarettes cannot simultaneously be locked and charged at the same time. For this reason, charging electronic cigarettes must take place at the nurse's station. 2.6.2 Patients will not be allowed to maintain their own lighter, lighter fluid or matches . Resident #21. Observation on 1/22/20 at approximately 10:30 a.m. revealed Resident #21 in a motorized wheelchair outside of the facility in the middle of a public road smoking a cigarette. This public road had snow bankings on either side of the road and an area of this road had ice build up extending from one side of the road to another. This patch of ice was adjacent to the facility designated off campus smoking area which in located within this public roadway. Observation on 1/22/20 at approximately 10:45 a.m. revealed Resident #21 in the same public roadway spot lighting a second cigarette and discarding the cigarette butts into the public road snow bank. Observation on 1/22/20 at approximately 10:45 a.m. revealed 3 cars exiting and entering this public road while Resident #21 was located in the middle of the road. Resident #21 relocated to another spot in the public road closer to the road snow bank following multiple cars having to go around Resident #21 into an oncoming road lane to avoid hitting Resident #21. Observation on 1/22/20 at approximately 11:00 a.m. of Resident #21, after speaking with Staff N (Administrator), Resident #21 was relocated with the assistance of Staff N to the facility designated off campus smoking area in the public road where a facility ashtray receptacle was located adjacent to the snow bank. Observation on 1/22/20 at approximately 12:00 p.m. of Resident #21 revealed Resident #21 lighting another cigarette with a hand held lighter. Observation on 1/22/20 at approximately 1:40 p.m. of Resident #21 revealed Resident #21 was accompanied by Staff N in the facility off campus smoking area. Resident #21 was unable to get across the above mentioned ice area on the public road and Staff N was observed lifting the back of the motorized wheelchair over the icy roadway patch for Resident #21. Review on 1/22/20 of Resident #21's Smoking Evaluation dated (12/24/19) revealed in the section under Smoking decision .Independent smoking is allowed .light pt (patient) cigarette for (his/her), keep lighter locked up Review on 1/23/20 of Resident #21's Progress Notes revealed the following: - 12/23/19 the pt and staff have been educated to keep .lighter locked up and light the cigarette when (he/she) wants one. pt cannot have a lighter in .possession . - 12/10/19 .Spoke with .(Resident #21) about smoking in front of the front entrance as (pronoun omitted) was outside smoking there .reminded .(Resident #21) that .needs to smoke across the street and off the grounds .will comply .also reminded .(Resident #21) the importance of keeping . lighter in the nurses cart and locked - 12/24/19 .Received a complaint from another residents family member that Resident #21 was sitting outside front entrance smoking a cigarette with another visitor .(Resident #21) was sitting in .motor wheelchair against the doors of the front entrance to stay out of the rain - 12/24/19 . (Resident #21) may smoke per smoking assessment .may smoke independently .staff is to light cigarette for resident .Resident should not possess lighter, lighter to be locked, and should not be handled by resident per smoking assessment - 1/6/20 . (Resident #21) was reminded not to have (pronoun omitted) lighter, SS (Social Service) removed it and gave to an LNA (Licensed Nursing Assistant) - 1/20/20 Resident seen lighting cigarette and smoking in parking lot at (Assisted Living) house .asked resident if (pronoun omitted) had a lighter and (he/she) said yes. re-educated resident Lighter given to administrator and updated. Interview on 1/22/20 at approximately 11:00 a.m. with Staff N confirmed that the facility is a non-smoking facility and that smokers must go off the facility campus to smoke. Staff N reported that a designated facility smoking area was located in the public road adjacent to the facility entrance road. Resident #35 Review on 1/23/20 of Resident #35's Smoking Evaluation dated 12/22/2019 revealed that Resident #35 has history of fire setting or arson, history of unsafe smoking habits and history of sharing/selling cigarettes or smoking material and does not properly dispose of ashes or butts. Smoking evaluation also revealed that Supervised smoking is required due to Resident #35 .is smoking in room. (Resident #35) . lit a dollar bill to 'sage' . room. Review on 1/23/10 of Resident #35's Progress Notes revealed the following: - 11/21/19 Lighter, cigarettes and a burnt dollar was removed from .(Resident #35) room. Room and bathroom smelled of burnt material and cigarettes .SS collected . second lighter from .bedroom and gave to the RN (Registered Nurse) to be locked up . - 12/22/19 . (Resident #35) was smoking in .room again. also lit a $1 bill to 'sage' (his/her) room. - 12/24/29 .(Resident #35) cannot use a lighter .due to incident on 12/22/29 .cigarettes, vape pen if (pronoun omitted) has one and lighter will continue to be held by staff but now staff need to light .cigarettes - 12/24/19 .(Resident #35) may smoke independently .staff is to light cigarette for resident. Resident should not possess lighter due to poor safety awareness, lighter to be locked and should not be handled by resident . Staff will also light the cigarettes for .(Resident #35) . not to have any lighters . - 1/5/20 . (Resident #35) went out of facility to smoke a cigarette. When resident came back . told nurse that . fell and landed on .bottom walking back into the building .No injuries .status [REDACTED]. - 1/15/20 .(Resident #35) was seen to go outside and light a cigarette with a lighter that came out of . pocket .(staff) went outside and told .(Resident #35) that .should not have lighter .(Resident #35) acknowledged that .should not have a lighter and quickly handed the lighter over. - 1/19/20 .notified resident had a lighter .spoke with resident and asked .if .(Resident #35) had a lighter . stated 'Yes I do' . 'where did you get it?' . (Resident #35) said . just went to the store and bought it. Observation on 1/22/20 at approximately 1:15 p.m. revealed Resident #35 in the facility designated public road smoking area without staff present using a lighter to independently light several cigarrettes to smoke. Interview on 1/23/20 with Staff A (Registered Nurse, Regional) confirmed the above listed findings and that Resident #35 had a fall on the ice when going outside to smoke.",2020-09-01
274,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,692,D,0,1,0FW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to obtain weights as needed to montior weight loss for 2 residents and to provide a therapeutic diet for 1 resident in a final survey sample of 31 residents. (Resident identifiers are #20, #51 and #75.) Findings include: Review on 1/24/20 of the facility policy, titled Weights and Heights, last revised on 11/1/19, revealed that .Patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team . Resident #20 Review on 1/23/20 of Resident #20's admission record revealed that Resident #20 was admitted to the facility on [DATE]. The review also revealed that Resident #20 was discharged to a geropsychiatric facility on 11/19/19 and returned to the facility on [DATE]. Review on 1/23/20 of Resident #20's weight summary sheet revealed that on 11/1/19, Resident #20 weighed 182.4 lbs (pounds.) The weight summary sheet also revealed that Resident #20 weighed 172.8 lbs on 11/15/20. This represented a 9.6 lb or 5.2% weight loss in 2 weeks. Review on 1/23/20 of Resident #20's weight summary sheet revealed that Resident #20's weight was documented as 177.8 lb on 12/13/19, which was the day after their return from the geropsychiatric facility. The weight summary sheet revealed that the next documented weight was on 1/3/20 which was 160.8 lb. This represented a 17 lb or 9.5% weight loss in 3 weeks. Review on 1/23/20 of Resident #20's weight summary sheet revealed that Resident #20's weight was documented as 160.8 lb on 1/3/20. The weight summary sheet revealed that the next documented weight was on 1/10/20 which was 156.2 lb. This represented another 4.6 lb or 2.8% weight loss in 1 week. The weight documented on 1/10/20 was the last documented weight for Resident #20. Review on 1/24/20 of Resident #20's nutritional assessment, dated 1/9/20, revealed that Staff F (Registered Dietitian) documented that Resident #20 had a 9.6% loss in one month. Review on 1/24/20 of Resident #20's current nutrition care plan revealed an intervention, dated 1/10/20, that read weekly weights set up for the next 4 weeks due to weight loss . Interview on 1/24/20 at approximately 1:00 p.m. with Staff C (Unit Manager) confirmed that there were no other weights documented for Resident #20 than those documented on the weight summary sheet. Staff C confirmed that Resident #20 should have had at least weekly weights after their admission on 11/1/19 until their discharge on 11/19/19 and again after their readmission weight which was taken on 12/13/19. Staff C also confirmed that Resident #20 should have had weekly weights after 1/10/20 as indicated on their care plan. Interview on 1/27/20 at approximately 2:20 p.m. with Staff F (Registered Dietitian) confirmed that Resident #20 should have had weights taken weekly. Resident #75 Review on 1/23/20 of Resident #75's admission record revealed that Resident #75 was admitted to the facility on [DATE]. Review on 1/23/20 of Resident #75's weight summary sheet revealed that the weights documented for Resident #75 after their admission were 214 lb on 3/19/19, 223 lb on 4/17/19, and 215.2 lb on 5/3/19. Review on 1/23/20 of Resident #75's weight summary sheet revealed that on 7/3/19, Resident #75 weighed 210.2 lbs. The weight summary sheet also revealed that Resident #75 weighed 178.6 lbs on 1/3/20. This represented a 31.6 lb or 15% weight loss. Review on 1/24/20 of Resident #75's nutritional assessment, dated 10/10/19, revealed that Staff F documented that Resident #75 had a 15% loss in six months. Staff F also documented that they recommended .weekly weight X4 (for 4) weeks for increased monitoring . Interview on 1/24/20 at approximately 1:00 p.m. with Staff C confirmed that there were no other weights documented for Resident #75 than those documented on the weight summary sheet. Staff C confirmed that Resident #75 should have had at least weekly weights after their admission on 3/19/19. Staff C also confirmed that Resident #75 should have had weekly weights after 10/10/19 when recommended by Staff F. Interview on 1/27/20 at approximately 2:20 p.m. with Staff F confirmed that Resident #75 should have been having weights taken at least weekly after their admission and after the recommendation was made on 10/10/19. Resident #51 Interview on 1/23/20 at approximately 8:45 a.m. with Resident #51 revealed that Resident #51 stated that they needed a special diabetic diet but that the facility was giving them sugary desserts. Resident #51 stated that they did not eat them, but that they also did not like the temptation. They stated that the facility was not sticking to their dietary needs. Review on 1/27/20 of Resident #51's current physician orders [REDACTED].#51 had an order for [REDACTED].>Review on 1/27/20 of Resident #51's diet ticket used by dietary staff read Regular diet. Interview on 1/27/20 at approximately 3:00 p.m. with Staff F confirmed that Resident #51 should have been receiving a consistent carbohydrate diet and not a regular diet. Interview on 1/27/20 at approximately 3:30 p.m. with Staff B (Food Service Supervisor) confirmed that the kitchen staff have been serving Resident #51 a regular diet and not a consistent carbohydrate diet.",2020-09-01
275,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,758,E,0,1,0FW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interview, the facility failed to document the behaviors of 2 residents (Resident identifiers are #36 and #67), failed to indicate a duration for PRN (as needed) use for 2 residents (Resident identifiers are #50 and #36) and failed to follow the recommendation of the Drug Regimen Review (DRR) for 1 resident (Resident identifier is #36) out of 10 residents reviewed for [MEDICAL CONDITION] medications a final sample of 31 residents. Findings include: Resident #59 Review on 1/24/20 at 11:32 a.m. of Resident #59's medical records revealed the resident exhibits verbal behaviors and paranoia. Resident #59's behaviors were being documented in a white binder that is located on the Medication cart. Interview on 1/27/20 at 9:45 with Staff D (Registered Nurse) revealed that Licensed Nursing Assistants document identified behavior in the white binder and report the behavior to the licensed staff at the end of their shift. At the end of the month a new set of behavior logs are placed in the behavior binder and the previous months logs are placed in the chart. Review on 1/27/20 at 3:11 p.m. of Resident #59's medical record revealed only the behavior charting logs for Resident #59 for the months of (MONTH) and October. There was a behavior charting document in the behavior binder located on the medication cart for the month of January. Behavior charting for the months of (MONTH) and (MONTH) are absent. January's log for Resident #59 revealed no behaviors observed. Interview on 1/27/20 at 3:30 p.m. with Staff D revealed that the behavior logs for the months of (MONTH) and (MONTH) for Resident #59 could not be produced. Resident #67 Review on 1/24/20 of Resident #67's (MONTH) Behavior Monitoring and Interventions sheet revealed that one of the behavior symptoms being monitored for Resident #67 was written in as 08. The behavior symptom code at the top of the page listed 08 as Other with a line next to it so that staff could write in the specific behavior. The line was left blank with no behavior written in. Review on 1/24/20 of Resident #67's (MONTH) Behavior Monitoring and Interventions sheet revealed that there was no documentation of any behaviors for Resident #67. Review on 1/27/20 of Resident #67's nurses notes revealed that Resident #67 received PRN (as needed) [MEDICATION NAME] on 1/16/20, 1/17/20, 1/20/20 and on 1/21/20. There were notes on 1/16/20 and on 1/20/20 indicating that Resident #67 was crying and stating that they wanted to go home. There was no documentation on 1/17/20 or on 1/21/20 indicating the reason why the [MEDICATION NAME] was administered. Interview on 1/27/20 at approximately 10:40 a.m. with Staff C (Unit Manager) and Staff D (Licensed Practical Nurse) confirmed that there should have been documentation on the behavior log for Resident #67 as Resident #67 has had behaviors during the month of January. Staff C and Staff D also confirmed that there should have been documentation in Resident #67's nurses notes indicating the reason that the [MEDICATION NAME] was administered. Resident #50 Review on 1/24/20 of Resident #50's pharmacy consultation report, dated 5/31/19, revealed that the pharmacist recommended a gradual dose reduction of Resident #50's [MEDICATION NAME] from 5 mg (milligrams) BID (twice a day) to 2.5 mg in the morning and 5 mg in the evening. Review on 1/24/20 of Resident #50's pharmacy consultation report, dated 5/31/19, revealed that Resident #50's physician accepted the recommendation on 6/12/19. Review on 1/24/20 of Resident #50's (MONTH) 2019 and (MONTH) 2020 Medication Administration Records (MAR) revealed that Resident #50 had been receiving [MEDICATION NAME] 5 mg since 3/20/19. There was no documented evidence that a gradual dose reduction was done for Resident #50. Interview on 1/24/20 at approximately 1:45 p.m. with Staff [NAME] (Director of Nursing) and Staff A (Regional Clinical Manager) confirmed that the pharmacy recommendation for Resident #50's gradual dose reduction was not done and they confirmed that it should have been. Review on 1/24/20 of Resident #50's (MONTH) 2019 and (MONTH) 2020 MAR's revealed that Resident #50 had an order for [REDACTED]. Review on 1/24/20 of the Pharmacy Consultation Report revealed that Resident #50 had a pharmacy review on 11/29/19 with no irregularities noted. Interview on 1/24/20 at approximately 1:45 p.m. with Staff [NAME] and Staff A confirmed that there should have been a recommendation for a stop date for Resident #50's [MEDICATION NAME] Resident #36 Review on 1/23/20 and 1/27/20 of Resident #36's medical record revealed that the resident was admitted on [DATE]. A pharmacy Drug Regimen Review (DRR) was found dated 11/29/2019. The recommendations were as follows: 1) (Resident #36) has a PRN (as needed) order for an antipsychotic without a stop date: [MEDICATION NAME] 2.5 mg (miligram) PRN, order written 11/20/19. 2) (Resident #36) receives Olanzapin which may cause involuntary movements including tardive dyskinesia (TD), but an Abnormal Involuntary Movement Scale (AIMS) or Dyskinesia Identification System, Condenser User Scale (DISCUS) assessment was not documented in the medial record within the previous 6 months. Interview on 1/27/20 at 11 a.m. with Staff [NAME] (Director of Nursing) confirmed that the pharmancy DRR recommendations had not been addressed.",2020-09-01
276,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,761,D,0,1,0FW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to label a medication when opened and failed to monitor freezer temperatures for a freezer that was being used to store dietary supplements in 2 out of 2 medication room refrigerators. Findings include: Observation on 1/23/20 at approximately 1:00 p.m. of the freezer in the East/West medication room revealed that there were 3 dietary supplements in the freezer. The manufactures instructions on the side of the containers read .Use within 14 days of thawing . Observation on 1/23/20 at approximately 1:10 p.m. of the (MONTH) 2019, (MONTH) 2019 and (MONTH) 2020 temperature log for the East/West medication room refrigerator and freezer revealed that there was no documentation of freezer temperatures for November, (MONTH) or January. Interview on 1/23/20 at approximately 1:10 p.m. with Staff K (Unit Manager) confirmed that the freezer temperatures had not been obtained. Staff K also confirmed that the temperatures should have been obtained and should have been documented. Review on 1/24/20 of the facility policy, titled Medication and Vaccine Refrigerator/ Freezer Temperatures . last reviewed on 11/15/19, read .Refrigerators and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day for proper temperatures . Observation on 1/23/20 at approximately 1:45 p.m. of the Tuck wing medication room refrigerator revealed a vial of [MEDICATION NAME] Purified Protein Derivative that had been opened. The box containing the vial had a sticker on it that read Date opened with a line next to it for staff to write in the date opened and that line was blank. The sticker also read Do not use after with a line next to it for staff to write in the date that the medication should be discarded and that line was also blank. Interview at approximately 1:50 p.m. with Staff J (Licensed Practical Nurse) confirmed that the vial had been opened. Staff J also confirmed that the date opened and the discard date should have been written on the stickers. Review on 1/24/20 of the facility policy .Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles last revised in 10/31/16 revealed that .Once any medication or biological is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility staff may record the calculated expiration date based on date opened on the medication container .[MEDICATION NAME] tests .Store in the refrigerator .Protect from light. Do not freeze. Date when opened and discard unused portion after 30 days .",2020-09-01
277,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,812,F,0,1,0FW611,"Based on observation and interview, it was determined that the facility failed to maintain the walk-in freezer in good working condition to keep frozen foods frozen solid and failed to maintain the freezer floor in good condition to be cleaned properly. Findings include: Observation on 01/22/20 at 09:07 a.m. during tour the facility's kitchen revealed that the items on the shelves of the freezer were found to be soft and not frozen. These items were as follows: -Packets of sliced pepperoni not frozen with a date received 11/6/19 -Packets of bologna and salami not frozen with a date received 1/16/20 -Mighty shakes not frozen with a received dated of 1/15/20 -Multiple boxes of Dixie cups ice creams not frozen with a received date of 1/15/20 -Nutrition ice cream treat dated 11/27/19 Observation on 1/22/20 at 9:15 a.m. revealed that the thermometer that was placed inside the freezer which staff read daily revealed that the temperature was reading 10 degrees. Interview on 1/22/20 at approximately 9:20 a.m. with Staff B (Director of Food Services), reviewed the above findings and placed two new thermometers one on the upper racks and one on the bottom racks which was done at 9:30. At 12:15 p.m. the thermometers were read by staff B, and both were reading between 30-32 degreases. Staff B discarded all unfrozen foods at time of finding. Observation on 1/23/20 at 10 a.m. of the freezer revealed a company had came and charged the unit. At this time the freezer is reading -5 degrees.",2020-09-01
278,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2020-01-27,883,E,0,1,0FW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facility failed to ensure documentation in the medical record of information/education provided regarding the benefits and risks of the Pneumococcal immunization and the administration or the refusal of or medical contraindications to the vaccine for 1 of 5 residents reviewed out of a final sample size of 31 residents. (Resident identifier is #69.) Findings include: Review on 1/27/20 of Resident #69's immunization status revealed that Resident #69 has a signed Pneumococcal Vaccine Informed Consent dated 10/4/19. Review of the facility infection control line listings revealed no pneumococcal vaccine given to Resident #69. Further record review revealed no physician order to give the pneumococcal vaccine to Resident #69 and no documentation to show that Resident #69 had received the pneumococcal vaccine after the consent was signed on 10/4/19 by Resident #69. Interview on 1/27/20 at approximately 4:30 p.m. with Staff A (Registered Nurse, Regional) and Staff O (Director of Nursing) confirmed that there was no physician order for [REDACTED].",2020-09-01
279,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,684,D,0,1,ZJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, it was determined that the facility failed to provide treatment for [REDACTED].#68.) and failed to provide services to maintain a resident's catheter for 1 of 2 residents reviewed with catheters in a final sample of 24 residents. (Resident identifier is #45.) Findings include: Resident #68 Review on 2/25/19 of Resident #68's medical record reveled an emergency room note dated 2/7/19 that states under subjective note I have been in rehab S/P (status [REDACTED]. When Resident was discharged from the emergency room they were given discharge instructions related to Fecal Impaction. Review on 2/25/19 of Resident #68's care plan with an initialted date of 8/20/14 reveals under Goal Resident will pass a soft formed stool (every) 3 days or bowel protocol will be instituted x 90 days. Review on 02/26/19 of Resident #68's Bowel Movement sheet with a run date from 2/1/19-2/25/19 shows that from 2/10/19-2/14/19 Resident #68 did not have a bowel movement. Review on 2/25/19 of Resident #68's nurses notes dated 2/14/19 revealed Resident was insistent that (he/she) be given a suppository to help (him/her) have a bowel movement this shift in spite of the fact that (he/she) hadn't tried to go today. (He/She) was educated on the dangers of relying on bowel meds and supps (suppository) and enema's. At 2200 this writer went in to give (him/her) a supp (suppository). When .brief was removed. there was a bm (bowel movement) agreed to stay on the bed pan and try to go on (his/her) own. Review on 2/25/19 of Resident # 68's medical record revealed a physicians bowel protocol with orders that are as follows: 1) If no bowel movement in 3 days give milk of magnesia 30 cc by mouth x-1 dose at bedtime. 2) If no bowel movement within next shift, give [MEDICATION NAME] suppository rectally x one. 3) If no bowel movement give fleet enema rectally in the evening. 4) If no results from fleet enema call Physician for further orders. Interview on 2/25/19 with Staff D (Director of Nurses) were shown the bowel sheets and the MAR (Medication Adminstration Record) during this period of time from 2/10/18-2/14/18 revealing that the PRN medications that were ordered for Resident #68 to take to prevent another fecal impaction were not given. Resident #45 Observation on 2/25/19 at 1:10 p.m. revealed that a transport company employee reported to the nurse's station on the dementia unit to bring Resident #45 to a urology appointment. At 1:20 p.m. the transport company employee left without Resident #45. Interview on 2/25/19 at 1:20 p.m. with Staff A (Unit Manager) revealed that the transport company required someone to accompany Resident #45 to the appointment and the facility could not send someone so they would reschedule the appointment. Interview on 2/25/19 at 2:00 p.m. with Staff D (Director of Nursing) revealed they arrange to send staff to an appointment with residents or arrange for a family member to accompany a resident when necessary. Review on 2/26/19 of Resident #45's nursing notes revealed no documentation of the missed appointment on 2/25/19, notifications to physician or family, or rescheduling. Review of Resident #45's admission records revealed the resident had a urinary track infection in (MONTH) when admitted . Review of Resident #45's emergency room (ER) visits revealed that Resident #45 went to theER on [DATE], on 2/5/19 and 2/7/19 for catheter replacement. The instructions after the 1/14/19 ER visit were to follow up with urology this week. The instructions after the 2/5/19 and 2/7/19 visits were to follow up with urology. Review of Resident #45's consult visits revealed no record of a urology appointment. Interview on 2/26/19 at 8:35 a.m. with Staff A (Unit Manager) revealed that appointments are recorded on the unit's calendar. Interview also revealed that Resident #45 had not been to the urologist after the 1/14/19 ER visit. Review on 2/26/19 of the unit's calendar revealed Resident #45 had an urology appointment scheduled on (MONTH) 25th with the notes that the resident needed to be accompanied to the visit. Further review revealed that Resident #45's appointment had been rescheduled for (MONTH) 8th with the notes that the resident needed to be accompanied to the visit. Review on 2/26/19 of Resident #45's Treatment Administration Record (TAR) revealed that the treatment of [REDACTED]. Further review revealed that the treatment to cleanse the proximal third of the catheter with soap and water was not performed twice a day on 10 of 25 days in (MONTH) 2019 (2/1/19, 2/2/19, 2/3/19, 2/5/19, 2/6/19, 2/7/19, 2/10/19, 2/16/19, 2/17/19, and 2/18/19).",2020-09-01
280,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,686,D,0,1,ZJEL11,"Based on medical record review, observation and interview, it was determined that the facility failed to provide the proper offloading device consistent with professional standards of practice for the healing of a DTI (Deep tissue Injury) for 1 of 3 in house acquired pressure sores in a survey sample of 24 residents. (Resident identifier is #36.) Findings include: Observation on 2/21/19 at 12:53 p.m. revealed Resident #36 was wearing a black type boot on their left foot. Interview with Staff J (Unit Manager) was asked about the boot who stated Resident #36 has a pressure area on their left heel facility acquired due to using their heels to propel themselves in their wheelchair. Further inspection of the boot that Resident #36 was wearing revealed it failed to have any off loading features for the healing of a pressure sore that is located on Resident #36's heal. Interview on 2/21/19 at 1:15 p.m. with Staff J revealed there was no order this was just a nursing measure and that they called down to the physical therapy department and this is what was given for Resident #36 to wear. Interview on 2/26/19 at 11:08 a.m. with Staff I (Director of Therapeutic Services) reviewed the product information provided by Staff I under features and Benefits 15 (degree) Wedge Sole effectively shifts body weight to the midfoot and heel. Reduces forefoot pressure by as much as 57%. And under Indications Wounds or ulcerations present under metatarsal heads and toes .Any situation that requires a pressure off-load of the forefoot. Review on 2/26/19 of Resident #36 facility skin sheets titled Skin-other Wound type v5 section [NAME] General describe (DTI) Date first observed (1/28/19). And under section G Measurements. 1. Length 2cm Width 3 cm. The last measurement was completed on 2/21/19 under section G Measurement. 1. Length 1.5cm Width 2.5 cm. This area was observed on 2/26/19 by surveyor with no change in measurement.",2020-09-01
281,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,689,E,0,1,ZJEL11,"Based on medical record review, facility policy, procedure review and interview, it was determined that the facility failed to ensure a safe environment to prevent accidental fire hazards on the facility's secured dementia unit where 28 residents reside. (Resident identifier is #15.) Findings include: Resident #15 Observation on 2/21/19 at approximately 9:45 a.m. of the accessible nursing station/room (does not have a lock or door on entrance) on the dementia unit revealed staff purses, bags and [NAME]ets that were unattended. Residents were also seen coming in and out of the room without staff being present or in line of sight of the room. Review on 2/25/19 of Resident #15's nursing notes revealed the following: nursing note, dated 11/26/18: This writer was notified by nursing staff, resident had been smoking in room. Nursing staff could smell smoke, entered residents room to find (pronoun omitted) holding a cup of water with 4 cigarette butts in water. Resident noted to be holding a pack of cigarettes and lighter. Nursing staff went through there own belongings, one of the nursing staff noticed a pack of cigarettes and lighter gone. Resident had gone into nursing staff purse and took them. nursing note, dated 12/15/18: . Resident pacing up and down the hallway, going into other residents rooms. nursing note, dated 12/31/18 . (pronoun omitted) attempts to grab objects out of the med cart. nurses will block cart with their body as they are doing med passes as patient will just attempt to go in cart continually. Interview on 2/25/19 at approximately 1:00 p.m. with Staff A (Unit Manager) revealed that Staff keep their personal belongings in the accessible nursing station/room (that does not have a lock or door). Interview on 2/25/19 at approximately 1:15 p.m. with Staff F (Licensed Practical Nurse) revealed that sometimes Staff F does have a lighter in (pronoun omitted) purse in the unsecured nursing room/station (that does not have a lock or a door). Interview on 2/25/19 at approximately 1:45 p.m. with Staff D (Director of Nurses) revealed that I thought a family member brought them in. Staff D read the nurses note dated, 11/26/18 and stated, I had no idea that this is what happened. Staff D revealed that Staff's personal belongings are supposed to be stored off the unit. Staff D revealed that there was no investigation done by the facility. Interview on 2/25/19 at approximately 2:15 p.m. with Staff C (LPN) (author of the 11/26/18 nursing note) revealed that Staff C educated staff at the time of incident to place their personal belongings up higher in the unsecured nursing station/room. Review on 2/26/19 of the facility's policy and procedure titled, Smoking, revision date 7/24/18 revealed: Policy Genesis HealthCare recognizes the myriad of health risks associated with tobacco use, both for smokers and for those exposed to secondhand smoke Smoking in any form through the use of tobacco products (pipes, cigars, and cigarettes) or vaping with electronic cigarettes is prohibited; . Purpose . To ensure that patients who choose to smoke will do safely. To ensure that patients who choose not to smoke are not exposed to smoke. Process For Centers that allow smoking: . 2.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nurses station 2.6.2 Patients will not be allowed to maintain their own lighter, lighter fluids, or matches Review on 2/26/19 of Resident #15's smoking assessment, dated 11/27/18 revealed the following: . B. 1. Does the resident have dementia? Yes 2. Does the resident have a poor memory? Yes 3. Is the resident unable to demonstrate the location of the designated smoking area? Yes . C 2. Does the resident have a history of unsafe smoking habits? Yes 3. Does the resident have a history of sharing/selling cigarettes or smoking material? Yes D. 1. Is the resident able to safely hold a cigarette? No 2. Does the resident have the ability to light a cigarette? Yes 3. Does the resident properly dispose of ashes or butts? No 4. Can the resident smoke safely without use of a smoking apron. No E. Smoking Decision 1. 3.)Resident not allowed to smoke. 1 a. Reason- Non smoking facility. Resident is unable to safely smoke Resident #63 Observation on 2/22/19 at 10:30 a.m. of the Francouer unit (dementia unit) revealed that the nurse's station had 1 entrance with no door, 1 unzipped purse on a table near the entrance, 1 purse on top of a shelf near the entrance, 1 ice coffee drink in a clear plastic container with a straw on a table near the entrance, and 1 box of pastry on top of a shelf near the entrance of the nurse's station. Observation on 2/22/19 at 11:00 a.m. of the Francouer unit revealed that Resident #63 went in the nurse's station with no nursing staff at the nurse's station or near the nurse's station. Resident #63 stood inside the nurse's station for a minute and was looking around the nurse's station, was tapping the table and reached and grabbed the top shelf then went out of the nurse's station. Observation on 2/22/19 at 11:15 a.m. of the Francouer unit revealed that Resident #63 went in the nurse's station with no nursing staff at the nurse's station. Resident #63 stood inside the nurse's station for a minute when Staff F (Licensed Practical Nurse) came and redirected Resident #63 out of the nurse's station. Interview on 2/22/19 at 11:30 a.m. with Staff A (Unit Manager) confirmed that the nurse's station entrance had no door, 2 purses one on the table and one on top of a shelf near the entrance, 1 ice coffee drink and the box of pastry. Staff A revealed that the box of pastry was brought in by family for staff, the ice coffee and 2 purses belonged to 2 of the nursing staff. Staff A states that they had a locked room on the unit and nursing staff should put their belongings in the room and not in the nurse's station as they had residents that occasionally wander in the nurse's station. Staff A also revealed that Resident #63 occasionally wandered in the nurse's station and other residents rooms.",2020-09-01
282,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,757,D,0,1,ZJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview it was determined that the facility failed to make sure each resident's drug regimen is free of unnecessary medications to cause adverse consequences for 1 of 1 resident receiving medications out of a standard survey sample of 24 residents (Resident identifier is #23.) Review on 2/26/19 at 09:24 a.m. of Resident #48's medical record revealed a nurse note dated 10/18/18 stating She complains today of constipation . Then on 10/23/18 nurses notes reveled .Change in condition Med (medication) error 10/18/18 in the morning . On 2/26/19 Staff D (Director of Nursing) was asked for the RMS (risk management system) Event Summary Report for the medication error and under Medication Error Investigation states Date of discovery 10/22/18, then Isolated error No then Multiple errors yes. This information was reviewed with Staff J (Unit manager) who stated the order was transcribed to Resident #23's MAR (Medication Administration Record) instead of Resident #48's MAR. On review of Resident #23's MAR, it shows that the [MEDICATION NAME] was given to them on the 19th, 20th, 21st, and 22nd but all these dates were circle as not given. On review of the back side of the MAR indicated [REDACTED]. The only nursing note found during this period of time was a note dated 10/22/18 at 14:30 A change in condition has been noted. The symptoms include: Diarrhea 10/22/2018 in the morning .Orders obtained include: d/c (discontinue) [MEDICATION NAME] increase oral fluids . Review on 2/26/19 of the next nurses' note dated 10/22/18 at 22:30 this is a follow-up note from the change in condition-medical that occurred on 10/22/18 .Resident alert and oriented. Able to make needs known. No c/o pain or discomfort. No loose stool noted .",2020-09-01
283,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,761,D,0,1,ZJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of manufacturer's instructions and facility policy procedure, it was determined that the facility failed to ensure that drugs used in facility must be labeled with the expiration date when applicable in 1 out of 2 medication storage rooms observed (The East/West medication room.) Findings include: Observation on 2/21/19 at approximately 11:10 a.m. of the East/West medication room refrigerator revealed 2 opened vials of [MEDICATION NAME] ([MEDICATION NAME] Purified Protein Derivative) and 1 opened vial of [MEDICATION NAME] Quadrivalent Influenza Vaccine with no date of openings on the vials. Interview on 2/21/19 at approximately 11:10 a.m. with Staff B (Licensed Medication Nurse Assistant) confirmed that the 3 vials were opened and did not have a date of opening on them. Review on 2/25/19 of the facilitys policy and procedure titled, Biologicals and Vaccines, Revision date 1/1/16 revealed: . Procedure . 2. In accordance with Applicable Law and the State Operations Manual, Facility should store and label (e.g. (for example) by auxillary labels) the biological or vaccine with appropriate information to ensure that the sterility and potency of the preperation is maintained until the biological or vaccine is actually injected Review on 2/25/19 of the facilitys policy and procedure titled, Storage and Expiration Dating of Drugs, Biologicals, Syringes, and Needles, Revision date 5/6/11 revealed: Policy Drugs, biologicals, syringes and needles are stored under proper conditions with regard to sanitation, temperature, light, moisture, ventilation, segregation, safety, security and expiration date as directed by state and federal regulations and manufacturer/supplier guidelines. Purpose To ensure the stability and quality of drugs, biologicals, syringes, and needles after they have left control Process . 3.1 Once any drug or biological package is opened, follow manufacturer/supplier guidelines for in use of expiration dating. Review on 2/25/19 of the manufacturer's instructions for [MEDICATION NAME] revealed that vials in use for more than 30 days should be discarded. Review on 2/25/19 of the manufacturer's instructions for [MEDICATION NAME] revealed that once the [MEDICATION NAME] of the multi-dose vial has been pierced the vial must be discarded within 28 days.",2020-09-01
284,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,812,E,0,1,ZJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety and ensure sanitary conditions of the kitchen for 1 observed kitchen and 2 of 3 observed unit refrigerators. Findings include: Review on [DATE] of the facility's policy titled, Labeling and Dating, (YEAR), revealed that .all foods should be dated upon receipt before being stored .food labels must include: the food item name, the date of preparation/receipt/removal from freezer, the use by date .items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from freezer and the use by date .leftovers must be labeled and dated with the date they are prepared and the use by date .Use by Dating Guidelines .the manufacturer's expiration date, when available, is the use by date for unopened items . Review on [DATE] of the facility's policy titled, Food: Safe Handling for Foods from Visitors, ,[DATE], revealed that .when food items are intended for later consumption, the responsible facility staff member will .label foods with the resident name and the current date . Observation on [DATE] at 9:29 a.m. of the kitchen initial tour revealed that the hood vents that were above the cooking grill and stove, which had a pot of soup that was boiling, had a thick coat of dust and grease when swiped with the bottom of a pen. Interview on [DATE] at 9:35 a.m. with Staff [NAME] (Food Manager) confirmed the above findings. Staff [NAME] revealed that the hood vents are cleaned and maintained every 6 months by an outside contracted vendor. Staff [NAME] states that the hood vents were last cleaned on [DATE]. Staff [NAME] also revealed that they do not clean the hood vents in between the 6 months maintenance and cleaning by the outside contracted vendor. Observation on [DATE] at 9:40 a.m. of the kitchen initial tour revealed that there was black debris and dust under the steam table. Further observation revealed there was black debris and dust under the sink, which Staff [NAME] states where they clean vegetable and thaw meat in water. Further observation also revealed that black debris, dust, napkin, and spoon were under the preparation table. Further observation also revealed that there was black debris, dust, empty packet of butter, spoon and knife under the table near the coffee machine and juice machine. Interview on [DATE] at 9:45 a.m. with Staff [NAME] confirmed the above findings that were observed under the steam table, sink, preparation table, and under the table near the coffee machine and juice machine. Staff [NAME] states that those areas were not cleaned and will be cleaned right away. Observation on [DATE] at 9:55 a.m. of the kitchen initial tour revealed that the refrigerator had a box of supplements with strawberry and vanilla flavor that had no expiration date, thaw date, or used by date labeled on the box or supplements. Further observation revealed 1 full tray of pudding in cups and 1 full tray of apple dessert in cups which were not covered or labeled with a use-by date. Interview on [DATE] at 9:57 a.m. with Staff [NAME] confirmed the above findings in the kitchen refrigerator. Staff [NAME] revealed that the trays of pudding and apple dessert should have been covered and labeled with a preparation date. Staff [NAME] also revealed that they do not date the supplements nor the box, where the supplements are placed, with use-by or thaw date and that the supplements were good for 14 days. Staff [NAME] was unable to provide an explanation of their process on identifying expired supplements from non-expired supplements. Observation on [DATE] at 10:00 a.m. of the kitchen initial tour with Staff [NAME] revealed that there was a 3-tray drying rack that was covered with dust on the bottom, middle, and top tray which had air-dried food containers. Interview on [DATE] at 10:00 a.m. with Staff [NAME] confirmed the above finding of the 3-tray drying rack. Staff [NAME] was unable to provide explanation and when the rack was cleaned. Observation on [DATE] at 10:05 a.m. of the Tuck unit refrigerator revealed 2 strawberry supplements with no use-by or thaw date. Interview on [DATE] at 10:05 a.m. with Staff [NAME] confirmed the above findings in the Tuck unit refrigerator. Staff [NAME] was unable to provide explanation if the 2 supplements were expired or not. Observation on [DATE] at 10:15 a.m. of the Francouer unit (dementia unit) refrigerator revealed a box of eggnog milk with an expired date of [DATE], 4 boxes of frozen microwavable mac and cheese with no resident name and use-by date. Observation on [DATE] at 10:20 a.m. of the Francouer unit kitchenette revealed 1 box of pound cake with expired date of [DATE] on top of an open cabinet and a microwave that had dried brown, yellow and red-like substance (food-like) inside the microwave. The inside of the microwave had rust on the top, side and bottom of it. Interview on [DATE] at 10:20 a.m. with Staff [NAME] confirmed the above findings in the Francouer unit kitchenette. Staff [NAME] was unable to provide explanation on why the expired food and milk had no residents names on them, which were food brought in by family. Staff [NAME] states the microwave needed to be thrown out and a new one put in.",2020-09-01
285,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,842,D,0,1,ZJEL11,"Based on medical record review, and interview, it was determined that the facility failed to have sufficient information in the record along with a comprehensive plan of care for services to be provided for 1 of 1 resident with a bone stimulator in the standard survey sample of 24 residents. (Resident identifier is #28.) Findings include: Interview on 2/21/19 at 12:21 p.m. with Resident #28 stated that she wants to walk. Resident #28 asked if she could be pushed out into the hall to do so. This information was bought to Staff J (Unit Manager) who revealed Resident #28 is unable to walk at this time due to having a non healing femoral fracture. Review on 2/26/19 at 11:52 a.m. of Resident #28's medical record revealed a physician note dated 1/29/19 and under Subjective .Date of surgery was 9/3/18 and this is 21 weeks, approximately .I had ordered a bone stimulator last time (Resident #28) was here, which (Resident #28) states (Resident #28) has used a couple of times and not more than this but cannot recall when this arrived or any other instructions at all . and under Plan Comments Attempts were made to call (facility) and we cannot find out any information is, is or is not, utilizing the bone stim later (sic) (stimulator) correctly or at all. However, this is a very vital component at this time as (Resident #28) has nonhealing bone to be used as directed Interview on 2/26/19 11:52 a.m. with Staff J (Unit Manager) was asked if Resident #28 has a bone stimulator and were is it located, since Resident #28 when asked did not know. Staff J showed surveyor the bone stimulator unit which was located in Resident #28's closet. Review on 2/26/19 of Resident#28's medical record failed to have any information about the bone stimulator except for the note that was written by the orthopedic surgeon who is an outside provided. There failed to be a care plan to address the use of a bone stimulator which has part of her care since admission. Review of Resident #28's medical record failed to have a physicians order for the use of [REDACTED]. On 2/26/19 at 2:01 p.m. Staff D got a phone order dated 2/26/19 at 12:45 p.m. that states u Clarification: Bone stimulator to be used R knee 1 x daily for 30 minutes at a time until next appointment.",2020-09-01
286,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2019-02-26,921,B,0,1,ZJEL11,"Based on observation and interview it was determined the the facility failed to provided a safe, functional, and comfortable environment for residents, staff and the public. Findings include: Observation while on the Francoeur unit on 2/21/19 at 11:45 a.m. and again on 02/25/19 at 1:44 p.m. revealed 19-20 residents were placed sitting in broda chairs and wheelchair's around the sitting area with no room for movement. The medication nurse was at the medication cart which was on the right side of the hallway, and residents in broada chairs and wheelchair's on the left side of the hallway leaving only two feet of floor space to walk through. A resident with a roller walker attempted to walk down the hall but was not able to due the the narrow space. Then at 1:10 p.m. on 2/25/19 a life plus staff member came to pick up a resident to go to a urology appointment but the life plus staff member could not get their wheel chair down the hall to get the resident due to all the residents in the hall and the medication cart blocking the area. At 1:20 p.m. Staff G (Administrator) and Staff H (Administrator in training) were asked to come to the unit by surveyor. Both Staff (G) and Staff (H) came to the unit and agreed with the findings written above. Staff G suggested moving the medication cart to the other side of the sitting area, but said the medication cart can not leave the area because we need a staff member to watch the residents while they all sit in the sitting area.",2020-09-01
287,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-16,655,E,0,1,AKV711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for the resident to receive quality care within 48 hours of admission for 3 residents in a standard survey sample of 21 residents. (Resident identifier are #76, #79 and #84.) Findings include: Resident #84 Review on 5/16/18 of Resident 84's medical record it reveal that Resident #84 was admitted to the facility on [DATE]. Review of the care plan section of the medical record identified that the first smoking care plan that had been developed for Resident #84 had been developed and initiated on 4/11/18. Review on 5/16/18 of Resident #84's smoking assessment was completed on 4/5/18. The smoking assessment revealed that Resident #84 was to be a supervised smoker. The care plan indicated that Resident #84 was to be an independent smoker. Review on 5/16/18 of Resident #84's nurse's notes revealed that Resident #84 was actively smoking on 4/2/18. Interview on 5/16/18 at approximately 11:30 a.m. with Staff G (Director of Nurses)confirmed that the smoking care plan was initiated on 4/11/18, 6 days after the smoking assessment was completed. In addition to being late this initial baseline care plan did not match the smoking assessment for the time period indicated. Review on 5/16/18 of Resident 84's medical record it reveal that Resident #84 was admitted to the facility on [DATE]. Review of the care plan section of the medical record revealed that the first smoking care plan that had been developed for Resident #84 had been developed and initiated on 4/11/18. A smoking assessment was completed on 4/5/18. The smoking assessment revealed that Resident #84 was to be a supervised smoker. The care plan indicated that Resident #84 was to be an independent smoker. Review on 5/16/18 of Resident #84's nurse's notes revealed that Resident #84 was actively smoking. Resident #79 Review on 5/16/18 of Resident #79's MDS (Minimum Data Set) revealed that Resident #79 was admitted to the facility on [DATE]. Review on 5/16/18 of Resident #79's current care plan revealed that there were three care plan entries made on 4/12/18. One entry was for Advanced Directive and/or DNR (Do Not Resuscitate) order in place, one for Resident is at risk for falls: [MEDICAL CONDITION] and one for Resident is at risk for skin breakdown as evidenced by limited mobility. The review also revealed that an entry for Resident/patient has potential LTC .(Long Term Care) was not entered until 4/16/18. The review also revealed that the next entry was made on 4/17/18 for While in the facility, resident states that it is important that she has the opportunity to engage in daily routines that are meaningful . The entry for Resident is at nutritional risk: r/t compromised skin integrity was also not entered until 4/17/18. The review further revealed that an entry for impaired decline in cognitive function . was not entered until 4/23/18, Further review of Resident #79's care plan revealed that no other care plan entries were made until 5/3/18 when an entry was made for Resident /Patient requires assistance/is dependent for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: Limited mobility . and an entry for Resident exhibits or is at risk for alterations in comfort related to [MEDICAL CONDITION]. Interview on 5/16/18 at approximately 9:30 a.m. with Staff J (Licensed Practical Nurse)confirmed that there had been no interim admission care plan in place within 48 hours of admission for Resident #79 for the following problems: Potential for LTC (Long Term Care), opportunity to engage in daily routines that are meaningful, nutritional risk related to compromised skin integrity, impaired decline in cognitive function, assistance with ADL (Activities of Daily Living), and alteration in comfort related to [MEDICAL CONDITION]. Resident #76 Review on 5/15/18 of Resident #76's Entry MDS (Minimum Data Set) revealed that Resident #76 was admitted to the facility on [DATE]. Review on 5/15/18 of Resident #76's care plan revealed that there were no care plan entries until 1/19/18 when an entry was made for Resident/patient has potential for long term care . The review revealed that the next entry was made on 1/26/18 for Resident/patient has impaired/decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION] . The review also revealed that no other risks or problems, including assistance with ADL's (Activities of Daily Living,) Advance Directives, Risk for dehydration, Risk for Dental care problems, Risk for falls, Risk for distressed mood, Risk for alterations in comfort, Risk related to [MEDICAL CONDITION] drug use, Risk for skin breakdown, and Incontinence were entered into the care plan until 1/30/18. Interview on 5/16/18 at approximately 8:15 a.m. with Staff B (Unit Manager) confirmed that there had been no interim admission care plan in place for Resident #76 and that there should have been one in place. Staff B also confirmed that most of the problems for Resident #76 were not care planned for until 1/30/18.",2020-09-01
288,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-16,656,E,0,1,AKV711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to develop and implement care plans for weight loss, pressure sores, behaviors, an intravenous line and isolation precautions for 4 residents in a standard survey sample of 21 residents. (Resident identifiers are #15, #76, #453 and #447.) Finding include: Resident #15 Interview on 5/14/18 at approximately 10:30 a.m. with Resident #15 revealed that Resident #15 had a pressure sore on their bottom. Observation on 5/14/18 at approximately 10:30 a.m. of Resident #15, while they were laying in bed, revealed that Resident #15's heels, which were visible because the top bed sheet was pulled back, were laying on the mattress with nothing to offload them. Review on 5/14/18 of Resident #15's Skin -Pressure Ulcer . form revealed that Resident #15 had a pressure sore on the coccyx that started on 2/14/18 as a Stage 2, but deteriorated to an unstageable area on 3/5/18. Review on 5/15/18 of Resident #15's current care plan revealed that Resident #15 had a care plan in place for Resident has actual skin breakdown related to fragile skin . The review revealed that there was no documentation in the care plan of what the breakdown was, where it was located or what the Stage of the breakdown was. Observation on 5/16/18 at approximately 8:15 a.m. of Resident #15 with Staff B (Unit Manager) present, revealed that Resident #15's heels were laying directly on the bed with no offloading. Interview on 5/16/18 at approximately 8:20 a.m. with Staff B confirmed that there were no details on Resident #15's care plan about the pressure sore and that there should have been. Resident #76 Interview on 5/14/18 at approximately 2:45 p.m. with Resident #76 revealed that Resident #76 had a weight loss. Review on 5/15/18 of Resident #76's weight summary form revealed that Resident #76 had a weight loss from 207.5 pounds on 3/22/18 to 160 pounds on 5/7/18. Review on 5/16/18 of Resident #76's Nutritional Assessment, dated 4/24/18, revealed that Resident #76 had a 23% weight loss in 1 month. Review on 5/16/18 of Resident #76's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 4/25/18 revealed that Section K0300 Weight Loss was checked for Yes, not on a physician-prescribed weight-loss regimen. Review on 5/16/18 of Resident #76's current care plan revealed that there was no care plan for either weight loss or nutrition for Resident #76. Interview on 5/16/18 at approximately 8:20 a.m. with Staff B confirmed that Resident #76 has had a significant weight loss and that there was no care plan in place for Resident #76's nutritional status. Staff B also confirmed that there should have been a care plan in place to address this issue for Resident #76. Resident #453 Observation on 5/14/18 at approximately 9:15 a.m. revealed a precautions cart outside of Resident #453's room. Interview on 5/14/18 at approximately 9:30 a.m. with Staff H (Unit Manager) revealed that Resident #453 was [MEDICAL CONDITION] precautions. Review on 5/15/18 of Resident #453's medical record in the [DIAGNOSES REDACTED].#453 was admitted on [DATE] [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aerus) bacteremia status [REDACTED].#453 also had a PICC (peripherally inserted central catheter) line in place for intravenous antibiotics. Care plans revealed that Resident #453 did not have a care plan [MEDICAL CONDITION] precautions or the PICC line. Interview on 5/16/18 at approximately 9:20 a.m. with Staff I (Licensed Practical Nurse) confirmed that there were no care plans for [MEDICAL CONDITION] or Picc line. Resident #447 Interview on 5/14/18 at approximately 9:15 a.m. with Staff H, revealed that Resident #447 had behaviors and would become agitated if interviewed. Observation on 5/14/18 while touring the unit throughout the day revealed Resident #447 yelling out frequently and exhibiting agitation. Review on 5/15/18 of Resident #447's medical record revealed the resident was admitted on [DATE] and that Resident #447 is followed by psychiatric services. Review on 5/15/18 of Resident #447's Medication Administration Record [REDACTED]. Review on 5/16/18 of Resident #447's care plans revealed that there were no care plans for behavioral/emotional or antipsychotic medication. Interview on 5/16/18 at approximately 9:40 a.m. with Staff G (Director of Nurses) confirmed that there were no care plans for behavioral/emotional or antipsychotic medication.",2020-09-01
289,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-16,761,E,0,1,AKV711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of manufacturer's instructions, it was determined that the facility failed to safely store and label medications on 2 out of 4 nursing units (West Unit and Tuck Unit) and 1 out of 2 medication rooms. (Resident identifiers are #10, #11, #16, #48, #66, and #88.) Findings include: Observation on [DATE] at approximately 1:20 p.m. of the medication room (medication room located between The West Unit and The Transitional Care) unit revealed the following medications were expired: In the refrigerator in the medication room were the following: Cephalaxin oral suspension, do not use beyond use date of [DATE] Cephalaxin oral suspension, do not use beyond use date of [DATE] Cephalaxin oral suspension, do not use beyond use date of [DATE] On the shelf in the medication room was the following: [MEDICATION NAME] oral suspension, do not use beyond use date of [DATE]. Interview on [DATE] at approximately 1:20 p.m. with Staff A (Licensed Practical Nurse) confirmed that the above medications were expired. Review on [DATE] of the manufacturer's instructions for Cephalaxin, revision date (MONTH) (YEAR), revealed: .Storage: .Discard any unused portion after 14 days. Observation on [DATE] at approximately 1:35 p.m. of the West Unit medication cart revealed the following undated and opened vials of insulin: 2 vials of Humalog 100 unit per milliliter insulin (Resident #66) 1 vial of [MEDICATION NAME] 100 unit per milliliter insulin (Resident #11) 2 vials of [MEDICATION NAME] 100 unit per milliliter insulin (Resident #48) 1 pen of [MEDICATION NAME] (Resident #10) Interview on [DATE] at approximately 1:40 p.m. with Staff D (Licensed Practical Nurse) confirmed that the above insulins were opened and undated. Staff D also confirmed that these vials of insulins were the ones being administered. Interview on [DATE] at approximately 1:45 with Staff [NAME] (Nurse Practice Educator) confirmed that the above insulins were opened and undated. Observation on [DATE] at approximately 1:50 p.m. of the Tuck Unit medication cart revealed the following insulins opened and not dated: 1 vial of Humalog 100 unit per milliliter insulin (Resident #88) 1 vial of [MEDICATION NAME] 100 unit per milliliter insulin (Resident #16) Interview on [DATE] at approximately 1:50 p.m. with Staff F (Registered Nurse) confirmed that the vials of insulin were opened and undated. Review on [DATE] of the manufacturer's instructions for Humalog insulin, revision date (MONTH) (YEAR), revealed: .Storage: .Throw away all insulin [MEDICATION NAME] in use after 28 days, even if there is insulin left. Review on [DATE] of the manufacturer's instruction for [MEDICATION NAME] insulin, revision date (MONTH) (YEAR) revealed: .Storage: .Throw away all insulin [MEDICATION NAME] in use after 28 days, even if there is insulin left. Review on [DATE] of the manufacturer's instruction for [MEDICATION NAME], revision date (MONTH) (YEAR) revealed: .Storage: .Discard all containers in use after 28 days, even if there is insulin left. Observation on [DATE] at approximately 7:30 a.m., during the medication pass, revealed that Staff C (Licensed Practical Nurse) walked away from the medication cart, which was located halfway down the West wing hallway, to look for a medication for a resident that was not in the medication cart. When Staff C walked away, a bottle of [MEDICATION NAME] nasal spray that was ordered for Resident #59 was left sitting on top of the medication cart. Staff C went to the medication room and was gone for approximately 5 minutes. Interview on [DATE] at approximately 7:35 a.m. with Staff C confirmed that the nasal spray was left unattended on top of the medication cart and that it should have been locked inside the medication cart.",2020-09-01
290,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-16,812,D,0,1,AKV711,"Based on observation and interview, it was determined that the facility failed to follow proper sanitization and food handling practices and failed to not commingle employee food with resident's food in one kitchenette. (Resident identifies is Resident #22.) Findings include: Observation on tour 5/14/18 at approximately 9:29 a.m. revealed an ice pack in the freezer on the Tuck Unit with the name for Resident # 22. Also, observed in the refrigerator was a lunch box with no name on it. Staff K asked Staff M, LPN (Licensed Practical Nurse) whose lunch box it was. Interview on 5/14/18 at approximately 10:00 a.m. with Staff K (Administrator) indicated that Staff K did not know whose lunch box was in the refrigerator and why the ice pack would be in the freezer. Staff K removed ice pack and lunch box. Staff K indicated the lunch box was a staff members and it should not be in the refrigerator on the floor but in the staff lounge refrigerator. Also, the ice pack should be in the rehabilitation freezer.",2020-09-01
291,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-16,880,D,0,1,AKV711,"Based on observation and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during 1 of 2 medication pass observations. (Resident identifiers are #56 and #59.) Findings include: Observation on 5/15/18 at approximately 7:40 a.m., during the medication pass observation, revealed that Staff C (Licensed Practical Nurse) administered medications to 2 different residents. Upon completion of the administration to the first resident, Resident #59, Staff C did not wash their hands or use hand sanitizer, but went on to administer medications to the second resident, Resident #56. Review on 5/16/18 of the facility's policy, titled .LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual ., dated 12/1/07, revised 1/1/13, revealed a procedure which read .Prior to preparing or administering medications, authorized and competent Facility staff should follow Facility's infection control policy (e.g., handwashing.) . Interview on 5/15/18 at approximately 7:50 a.m. with Staff C confirmed that Staff C had not washed their hands or used hand sanitizer between administering medications to 2 residents and that Staff C should have either washed their hands or used hand sanitizer.",2020-09-01
292,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2019-02-11,636,D,0,1,0R0111,"Based on interview and record review, it was determined that the facility failed to use assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified for 1 resident in a final survey sample of 45 residents. (Resident identifier is #5.) Findings include: Interview with Resident #5 on 2/6/19 at approximately 9:30 a.m. on the SCU (specialty Care Unit-a locked unit) revealed that Resident #5 was alert and oriented and able to answer all questions asked during the interview. When questioned about choices, Resident #5 verbalized an ongoing wish to leave the facility. Resident #5 stated that they had some issues at the time of his/her admission. Resident #5 was in agreement with the admission at the time, but since then, feels he/she has gotten much better and would like to be discharged from the facility and go back to living more independently. During the interview, Resident #5 was articulate and well spoken, and was able to demonstrate a calm, pleasant, and focused demeanor. Resident #5 verbalized appreciation of any efforts made that would focus on the discharge process. Resident #5 is assessed as independent with all ADL's (Activities of Daily Living) and at most, needs cueing or set up assistance. A record review was conducted on 2/11/19 at approximately 1:30 p.m. and it revealed that the most current MDS assessment which was completed on 1/23/19 demonstrates that the resident has a Brief Interview for Mental Status (BIMS) of 15 and has had no reported psychiatric behaviors. Section G, which focuses on the resident's ability to perform ADL's assesses the resident to be independent with most ADL's and a limited set up for several others. Further review (same date/time) of Resident #5's paper record revealed behavior monitoring sheets from October, (MONTH) and (MONTH) of (YEAR) that indicated that the resident had not demonstrated any adverse behaviors during that time. There was no documentation in the record to indicate that behavior monitoring was performed for this resident after (MONTH) of (YEAR). The Care Plan did not indicate updates to reflect the improvement in Resident #5's cognitive status, and the most current nurse's notes did not reflect Resident #5's cognitive, emotional and physical status. Interview on 2/11/19 at 1:00 p.m. with Staff B, (Unit Manager) Special Care Unit (SCU), revealed that Resident #5 was alert and oriented to person, place, and situation. Staff B stated that Resident #5's daughters had seen evidence that Resident #5 had improved to a point that they felt that Resident #5 could live outside the facility again, however, it was stated that Resident #5's son, who is currently the activated Durable Power of Attorney (DPOA), was not in agreement with the resident living more independently. This was verbally confirmed by Staff E, RN, SCU on 2/11/19 at approximately 2:15 p.m",2020-09-01
293,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2019-02-11,656,B,0,1,0R0111,"Based on medical record review and interview it was determined the facility failed to develop and implement a person-centered comprehensive care plan for 3 residents out of a final survey sample of 45 residents. (Resident identifiers are #10, #182, and #188.) Findings include: Resident #182 Review of the medical record revealed that hospice was started on 9/14/18 and the facility's hospice care plan states hospice visit as requested. The facility's hospice care plans did not establish which services will be provided to Resident #182. Review on 2/11/19 at 9:35 a.m. for Resident's #182's medical record revealed that the facility failed to show a coordinated plan of care as evidenced by not including or documenting the hospice goals and interventions in order to ensure that facility staff is providing consistent care when hospice staff are not scheduled in the facility. Interview on 2/11/19 at 1:30 p.m. with Staff I(Registered Nurse/Unit Manager) reviewed Resident #182's care plans and Staff I confirmed that the hospice care plans were not individualized with established services and the facility does not know when hospice services are coming or what disciplines are coming in for Resident #182. Staff I is unsure what hospice visit as requested. really means for an arrangements. Resident #188 Review on 2/7/19 at 11:09 a.m. of Resident #188's medical record revealed that Resident #188's care plan failed to be person centered. On review of Resident #188 care plan under Problem onset dated 1/4/19 states Long Term Goal (Hospice)--(----) under Goal it states (----) hospice team visits as directed by hospice level of care-During (-----) hospice LNA visit, LNA to tailor visit to resident's preferences that day-ongoing collaboration with interdisciplinary team and (-----) hospice staff to provide quality end of life care. Under Approaches it states Hospice visit as requested. Interview on 2/7/19 at 1:39 a.m. with Staff C (Unit Manger) reviewed the above information and Staff C stated Staff C has been adding in this information to the care plans but the hospice providers do not give any type of set times or services that they will be providing. Resident #10. Review on 2/11/19 of the Care Plan for Resident #10 revealed a generic hospice plan of care. Review of the hospice recertification plan of care dated 1/10/19 through 3/10/19 revealed no volunteer services provided for Resident #10. Review of the facility hospice care plan showed that Resident #10 was provided hospice volunteer services. Interview on 2/11/19 at approximately 2:30 p.m. with Staff G (Unit Manager) revealed that the facility staff are not aware when the hospice agency providing nursing services, aide services, social worker services and chaplin services are provided on a weekly basis to Resident #10. Staff G reported that facility staff would not know if the Hospice aide missed a scheduled time visit. Staff G reported that facility staff were not aware whether Resident #10 was receiving volunteer hospice services during this recertification period.",2020-09-01
294,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2018-03-23,623,B,0,1,PQAP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to notify the resident, resident representative, and the ombudsman of a transfer/discharge for 1 resident in a standard survey sample of 35 residents. (Resident identifier is#1.) Findings include: Review on 3/22/18 at approximately 9:00 am revealed that there was no notice of transfer/discharge in Resident #1's medical record. Interview on 3/22/18 at approximately 9:47 a.m. with Staff H (Director of Social Services) confirmed that the Notices of Transfer/Discharge have not been being done for any resident in the facility. Staff H also confirmed that a Notice of Transfer/Discharge was not provided to Resident #1, a family member or the Ombudsman prior to discharge to the hospital on [DATE].",2020-09-01
295,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2018-03-23,625,B,0,1,PQAP11,"Based on record review and interview, it was determined that the facility failed to notify the resident or resident representative of the bed hold policy before discharge to the hospital for 1 resident in a standard survey sample of 35 residents. (Resident identifier is #1.) Findings include: Review on 3/22/18 of Resident #1's medical record revealed that there was no documentation that the facility's bed hold policy had been given to Resident #1. Interview on 3/22/18 at approximately 9:47 a.m. with Staff H (Director of Social Services) confirmed that the bed hold policy had not been given to the resident or resident representative prior to hospitalization .",2020-09-01
296,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2018-03-23,689,G,0,1,PQAP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to provide an environment that was free of accidents with the use of assistive devices for 1 of 1 resident who fell and sustained injury in the standard survey sample of 35 residents. (Resident identifier is #210.) Findings include: Interview on 3/20/18 at 10:10 a.m. with Resident #210 revealed that they had a fall a couple of months ago. Resident #210 stated that during that day of the accident Resident #210 asked house keeping to clean the bathroom since it was dirty. Resident #210 said that evening they needed to use the bathroom so Resident #210 used the call bell and Staff [NAME] (Licensed nursing assistant) came to transfer Resident #210 onto the toilet seat, then left to get lotion for his/her shoulders and arms. Resident #210 stated as soon as I sat down on to the raised toilet seat it began to wobble and the raised toilet seat fell off the toilet throwing me to the ground. Review of Resident Incident Report dated 11/13/17 reveals: 2005 (8:05 p.m.) Responded to emergency bell in Resident's bathroom, upon arrival, Resident on floor on R (right) side, raised toilet seat on floor behind Resident's buttocks, ., LNA in attendance. Upon assessment, Resident with hematoma R head behind ear, skin tear on R jaw, c/o (complaining of) pain R shoulder and extreme pain R hip .Hematoma R side of head behind ear, skin tear R jaw line, R shoulder and hip pain (unable to move RLE (right lower extremity)). Review of the Hospital records titled history and physical examination [REDACTED].The patient although very physically frail, mostly in a wheelchair, but able to transfer with a walker and use the commode with a walker, is cognitively intact. (Resident #210) says that this evening (Resident #210) was on an elevated toilet seat, when (Resident #210) shifted in the toilet seat, slipped off the toilet, throwing (Resident #210) to the ground. Review of the hospital records titled INTERIM SUMMARY REPORT with a discharge date d of 11/24/17 reveals under ACTIVE [DIAGNOSES REDACTED]. Also within the notes it states The patient does need to have her cervical collar continued to be used for the next 2-3 months. There was some concern about inadequate p.o. (by mouth) intake due to this collar. Upon evaluation, it was felt that (Resident #210) may benefit from a PE[NAME] This is in place. (Resident #210) is currently on bolus feedings. Review of the manufacture's instruction for the 2-in-1 locking Raised Toilet Seat . under installation instructions under number (5) reveals Check for secure fit routinely before using product . Also under a section of the instruction manual it states CAUTION 1) Always be sure that the seat is correctly and securely locked in place before using. 2) Be sure that the adjustment knob in front of the seat is tight at all times, thus securing the seat to the toilet bowl. After reading these instruction Staff A (Director of Nurses) when asked if LNA staff are trained prior to transferring resident to check for stability of the raised toilet seat prior to transferring and Staff A stated No This same question was asked of Staff D (Assistant director of nursing) who also said No. Interview on 3/22/18 at 10:45 a.m. with Staff A was asked if the Staff B (house keeper) who cleaned Resident #210's bathroom (confirmed by facility staff) that day could be interviewed, Staff A stated they were no longer employed and could not be interviewed. Staff A was then asked since Staff B is no longer employed at the facility could a house keeping staff from another unit that has raised toilet seats be asked what they would do to clean the raised toilets. Interview on 3/22/18 at 10:50 a.m. with Staff A on unit 3B revealed that there were multiple raised toilet lifts. Staff C (house keeper) and Staff A were asked if when cleaning a resident's bathroom with a raised toilet seat and you see there is feces on the seat what would you do? Staff C stated they would remove the seat and wash the toilet, Staff C went on to say if it were a bubble raised toilet which is the one Resident # 210 was using which was confirmed by Staff A they would remove the device and put it back on when done cleaning the toilet. Interview on 3/22/18 at 11:05 a.m. with Staff F (Director of Quality Improvement) revealed that the raised toilet seat that was used by Resident #210 at the time of the accident was tested the next day to see if the equipment was broken. Staff F stated they locked it on the toilet and moved there body forward, backward, and side to side while sitting on the toilet seat and no mater how hard they tried they could not get the raised toilet seat to come off the toilet. Interview on 3/23/18 at 10 a.m. with Staff A and Staff F confirmed that the facility did a compete audit of all resident bathrooms and this type of raised toilet chair has been removed and replaced with a 4 legged free standing type of raised toilet seat taking away the potential for this to reoccur.",2020-09-01
297,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2018-03-23,842,D,0,1,PQAP11,"Based on observation, record review and interview, it was determined that the facility failed to complete an assessment for restraints for 1 resident out of 3 residents in a standard survey sample of 35 residents. (Resident identifier is #157.) Findings include: Observation on 3/21/18 at approximately 10:14 am revealed that the Resident #157 was seated in an electric wheelchair wearing a seatbelt. Review of medical record revealed that there have been no assessments completed for the seatbelt since admission on 11/18/16. Interview with Resident #157 revealed that the resident is able to self release the seat belt. Interview with Staff G (Licensed Practical Nurse) confirmed that assessments for restraints should be completed and that no assessments had been done since admission on 11/18/16.",2020-09-01
298,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2018-03-23,849,B,0,1,PQAP11,"Based on review of facility Hospice agreements and interview, it was determined that the facility failed to designate a member of the facility's interdisciplinary team to be responsible for working with the hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff, for 2 hospice contracts reviewed. Findings include: Review of the Hospice agreement which was entered into this first day of October, 2013 revealed under Responsibilities of Facility that . The Facility must designate in Interdisciplinary Team (IDT) Member who is responsible for working with Hospice representative to coordinate care to the residents. The individual must have a clinical background and have the ability to assess the resident or have access to a Facility staff member with the skill Review of the Hospice agreement which was entered into as of this the 23th day of May, (YEAR) did not reveal a documented Facility responsibility to designated an IDT member for working with the Hospice. Interview on 3/23/18 at approximately 1:00 p.m. with Staff D (Assistant Director of Nursing) and Staff I (Registered Nurse) revealed that there was no designated facility representative to coordinate Hospice services for a Hospice resident. Interview with Staff A (Director of Nursing) on 3/26/18 at approximately 12:00 p.m. revealed while the social worker was the point person for Hospice, there was no one formally designated as the facility representative to coordinate Hospice services.",2020-09-01
299,COURVILLE AT MANCHESTER,305057,44 WEST WEBSTER STREET,MANCHESTER,NH,3104,2019-03-13,554,B,0,1,QSLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record and facility policy review it was determined that the facility failed to assess 1 resident out of a final sample of 22 residents reviewed. (Resident identifier is #52.) Findings include: Observation on 3/10/19 at approximately 7:00 p.m. revealed that Resident #52 had a bottle of eye drops, for dry eye and a tube of [MEDICATION NAME] on the bedside table. Interview on 3/10/19 at approximately 7:00 p.m. with Resident #52 revealed that the resident self administers the 2 medications located on the bedside table, I have had these since I came here. I know when I need them and I just use them. Resident #52 also stated, Staff know that I have them, they are always here on my bedside table. Observation on 3/11/19 at approximately 11:00 a.m. of Resident #52's room revealed that the bottle of eye drops, and a tube of [MEDICATION NAME] were on the bedside table. Observation on 3/12/19 at approximately 10:45 a.m. of Resident #52's room revealed that the bottle of eye drops, and a tube of [MEDICATION NAME] were on the bedside table. Interview on 3/12/19 at approximately 10:50 a.m. with Staff C (Unit Manager) revealed that Resident #52 was not assessed for self medicating. Staff C had no knowledge of Resident #52 having medications at bedside. Review on 3/12/19 at approximately 11:00 a.m. of Resident #52's medical record revealed that there were no physician orders for the eye drops or the [MEDICATION NAME]. Interview on 3/12/19 at approximately 11:00 a.m. with Staff C confirmed that there were no physician orders for the 2 medications that were located on Resident #52's bedside table. Resident was admitted to the facility on [DATE]. Review on 3/12/19 of the facility policy and procedure titled, Self Administration of Medications, dated 2/15/13 revealed: .Residents shall be evaluated upon admission, quarterly and with any significant change in status for self administration of medications and/or per resident request Review on 3/12/19 of the facility policy and procedure titled, Medication Administration, revision date 11/17/17 revealed: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed Policy Interpretation and Implementation .3. Medications must be administered in accordance with the orders, including any required time frame (according to the nurse practice acts and facility policy.) . 17. Residents may self-administer their own medications only if the attending provider, in conjunction with the interdisciplinary team has determined that the resident has the decision making capability to do so safely",2020-09-01
300,COURVILLE AT MANCHESTER,305057,44 WEST WEBSTER STREET,MANCHESTER,NH,3104,2019-03-13,641,B,0,1,QSLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to complete MDS (Minimum Data Set) assessments with accurate information for falls, [DIAGNOSES REDACTED]. (Resident identifiers are #21, #28 and #61.) Findings include: Resident #28 Review on 3/11/19 of Resident #28's Progress Notes revealed that Resident #28 had a fall on 1/3/19 which resulted in a laceration to the back of Resident #28's head for which Resident #28 needed to go to the emergency room for evaluation and treatment. Review on 3/11/19 of Resident #28's Progress Notes revealed that Resident #28 had another fall on 1/5/19 that also resulted in Resident #28's need to be sent again to the emergency room for evaluation. Review on 3/12/19 of Resident #28's Quarterly MDS, with ARD (Assessment Reference Date) of 2/4/19, revealed that Section J1800, Any Falls Since Admission or Prior Assessment .whichever is more recent, was answered as No. The review also revealed that Resident #28's prior MDS assessment was a Quarterly assessment with an ARD of 11/7/19, without any admission assessments in between. Interview on 3/13/19 at approximately 9:50 a.m. with Staff [NAME] (MDS Coordinator) confirmed that Resident #28's 2/4/19 MDS was incorrectly documented and that the falls that Resident #28 experienced on 1/3/19 and 1/5/19 should have been on that MDS assessment. Resident #21 Review on 3/12/19 of Resident #21's (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 3/12/19 of Resident #21's Quarterly MDS with ARD of 2/15/19 revealed that Section II5950, [MEDICAL CONDITION] (other than [MEDICAL CONDITION],) was left unchecked. Interview on 3/13/19 at approximately 9:50 a.m. with Staff [NAME] confirmed that Resident #21's 2/15/19 MDS was incorrectly documented and that the [DIAGNOSES REDACTED]. Resident #61 Review on 3/12/19 of Resident #61's Minimum Data Set ((MDS) dated [DATE], section A2100: Discharge Status, revealed that acute hospital was selected. Review on 03/12/19 of Resident #61's progress notes revealed that Resident #61 was discharged home with services on 1/22/19. Interview on 3/12/19 at 2:30 p.m. with Staff D (Director of nursing) confirmed the above MDS was incorrect and Resident #61 was discharged home with services.",2020-09-01
301,COURVILLE AT MANCHESTER,305057,44 WEST WEBSTER STREET,MANCHESTER,NH,3104,2019-03-13,758,D,0,1,QSLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDRs) for 1 of 5 residents reviewed for unnecessary medications in a final sample of 22 residents (Resident identifier is #19). Findings include: Review on 3/13/19 of Resident #19's physician orders [REDACTED]. Review on 3/13/19 of Resident #19's pharmacy consultations reports revealed a recommendation dated 2/14/19 to attempt a GDR of [MEDICATION NAME] (Quetiapine). Further review the report also revealed the following THIS INDIVIDUAL DOES NOT MEET CRITERIA FOR GDR TO BE DEEMED 'CLINICALLY CONTRAINDICATED' BECAUSE A GDR HAS NOT YET BEEN ATTEMPTED IN THE FACILITY FOLLOWING THE MOST RECENT ADMISSION. Review on 3/13/19 of Resident #19's geriatric mental health progress notes dated 2/18/19 revealed there had been no noted concerns re (regarding) mood, behaviors, [MEDICAL CONDITION]., that there had been no nursing notes documented with behavioral disturbance, and Pharmacist recommend GDR [MEDICATION NAME]. Review on 3/13/19 of Resident #19's physician orders [REDACTED]., signed by the geriatric mental health provider. Review on 3/13/19 of Resident #19's pharmacy consultations reports dated 2/14/19 revealed a handwritten note on the report initialed by the unit manager dated 2/20/19 that Resident #19's guardian did not consent to the medication change recommended by the pharmacist. Review on 3/13/19 of Resident# 19's Medication Administration Record [REDACTED]. Interview on 3/13/19 at appropriately 11:15 a.m. with Staff D (Director of Nursing ) confirmed the pharmacy recommended a GDR, that the geriatric mental health provider agreed to the recommendation and ordered the GDR, but Resident #19's guardian did not agree to the medication change so the facility did not attempt to GDR the [MEDICATION NAME]. Review on 3/14/19 of Resident #19's geriatric mental health progress note provided by the facility post survey, dated 2/25/19, revealed the following documentation under facility staff reports section: no reported concerns re mood and behavior. Further review of the progress note revealed the following documentation under Impression/Plan section: 3-11 staff report (increased) behaviors and aggression this evening and playing in food. Guardian declines taper of [MEDICATION NAME] and (illegible) aggressive behaviors - will not taper [MEDICATION NAME].",2020-09-01
302,COURVILLE AT MANCHESTER,305057,44 WEST WEBSTER STREET,MANCHESTER,NH,3104,2019-03-13,761,D,0,1,QSLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of manufacturer's instructions and review of the facility policy and procedure it was determined that the facility failed to label an opened insulin vial with an expiration date and failed to remove expired medications out of the medication cart on 1 of 2 units observed (Second floor). (Resident identifiers are #5 and #34.) Findings include: Resident #34 Observation on 3/10/19 at approximately 6:00 p.m. of the medication cart (high numbered cart) on the second floor revealed an opened vial of [MEDICATION NAME] not labeled with an expiration date or opening date. Interview on 3/10/19 at approximately 6:00 p.m. with Staff A (Licensed Practical Nurse) confirmed that the [MEDICATION NAME] vial was not labeled with an expiration date or opening date. Review on 3/12/19 of the manufacturer's instructions for [MEDICATION NAME], revision date 11/18 revealed the following: .16.2 Storage .10 milliliter vial in use (opened) 28 days. Review on 3/12/19 of the facility policy and procedure titled, Medication Administration, revision date 11/17/17 revealed: .9. When opening a multi-dose vial, place the date on the container. Resident #5 Observation 3/11/19 at approximately 7:30 a.m. of Staff B, LPN during medication pass on the second floor revealed that Staff B poured Aspirin [MEDICATION NAME] Coated from a bottle with an expiration date of 1/19. Staff B was stopped prior to administering the expired medication to Resident #5. Interview on 3/11/19 at approximately 7:30 a.m. with Staff B confirmed that the bottle of aspirin [MEDICATION NAME] coated had expired 1/19. Observation on 3/11/19 at approximately 7:35 a.m. of the medication cart on the second floor revealed a bottle of multivitamins One Daily with an expiration date of 2/19 in the medication cart.",2020-09-01
303,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2020-01-03,658,E,0,1,R82J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, it was determined that the facility failed to follow a physician's order for 1 out of 26 medication administrations observed (Resident identifier is #61) and the facility failed to properly assess a resident after a fall with fracture for 1 resident of 3 residents with falls in a final survey sample of 19 residents (Resident identifier is #83). Findings include: Review on 1/2/20 of facility's policy titled, Medication Administration: General Guidelines, revision date 12/12, revealed that .page 3 of 6 . Medications are administered in accordance with written orders of the prescriber .obtain and record any vitals signs necessary prior to medication administration . [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 12/31/19 at 8:20 a.m. with Staff A (Licensed Practical Nurse) revealed that Staff A reviewed Resident #61's Electronic Medication Administration Record [REDACTED]. Further observation with Staff A revealed that Staff A poured 1 tablet of Resident #61's [MEDICATION NAME] 25 mg into a medicine cup along with the rest of Resident #61's scheduled morning medications. Staff A went to Resident #61's room and gave Resident #61 their 1 tablet of [MEDICATION NAME] 25 mg with the rest of the morning medications and left the room then Staff A signed off on the EMAR that the 1 tablet [MEDICATION NAME] 25 mg was given and no heart rate and blood pressure was documented. Interview on 12/31/19 at 8:25 a.m. with Staff A confirmed the above findings. Staff A stated that Staff A did not take Resident #61's blood pressure or heart rate before giving Resident #61 the 1 tablet of [MEDICATION NAME] 25 mg. Staff A also stated that they should have obtained Resident #61's blood pressure and heart rate prior to giving Resident #61 their [MEDICATION NAME] 25 mg. Review on 12/31/19 of Resident #61's physician orders revealed that Resident #61 had an order for [REDACTED]. Review on 12/31/19 of Resident #61's (MONTH) 2019 EMAR revealed that Resident #61 received [MEDICATION NAME] 25 mg twice a day from 12/3/19 to 12/31/19. Review on 12/31/19 of Resident #61's blood pressure and heart rate records for the month of (MONTH) 2019 revealed that Resident #61 blood pressures and heart rates were documented on 12/5/19 and 12/12/19. Review on 12/31/19 of Resident #61's nurses notes revealed no documentation of blood pressures or heart rates for the month of (MONTH) 2019. Interview on 12/31/19 at 8:35 a.m. with Staff B (Unit Manager) confirmed the above findings related to Resident #61's EMAR, blood pressure records, heart rate records and nurse's notes for the month of (MONTH) 2019. Staff B stated that if there were no documentation of blood pressure and heart rate other than 12/5/19 and 12/12/19 then the [MEDICATION NAME] 25 mg was given without checking Resident #61's blood pressure and heart rate. Staff B stated that Staff A and the other nurses should have obtained Resident #61's blood pressure and heart rate before giving the [MEDICATION NAME] 25 mg to determine if the medication should have been given or held based on the physician orders. Review of the Journal of Nursing, Post Fall Care Nursing Algorithm, accessed on 1/21/20 revealed the following professional standard: The general scheme of the algorithm is as follows: the post-fall algorithm begins with a decision diamond that requires the nurse to determine if loss of consciousness has occurred and, if so, the nurse must immediately check circulation, airway, and breathing and call rapid response as needed. If no loss of consciousness has occurred then the next step is to determine whether serious injury has occurred; in this case, serious injury is defined as an injury involving the neck or spine, or any other major trauma. The attending nurse should not move the patient, but should call for assistance from another nurse and immediately notify a physician. At this point a head-to-toe assessment is performed to obtain baseline information, including neurologic, cardiac, musculoskeletal, and integument assessment. The cardiac assessment requires the nurse to perform a baseline set of orthostatic vitals, including blood pressure, heart rate, oxygen saturations, temperature, and telemetry (if available). Neurologic assessment includes blood sugar and assessment of Glasgow coma scale (pupils, speech, sensation, and level of consciousness). The musculoskeletal system should be assessed for any deformities, pain, swelling, weakness, strength, and range of motion, and the should be assessed for any abrasions, lacerations, obvious bleeding, and/or hematomas. Review on 1/3/2020 of the facility policy and procedure titled SAFETY FALLS and Transfer to ED dated 3-8-18 revealed the following: POLICY: It is the policy of . Facility that residents experiencing a fall with obvious or probable injury will be transported to the Emergency Department for evaluation . PR[NAME]EDURE: . When a fall is discovered the nurse will immediately assess the resident for injury. . All extremities and head area are to be checked for Range of Motion (ROM) and signs of pain. If pain is present and/or ROM is limited (abnormal for the resident) they are not to be moved off the floor and the Ambulance is to be called. Review on 1/3/2020 of Resident #83's NURSING PROGRESS NOTE dated 11/30/2019 revealed the following: . Resident was found after this writer and 2 other staff members rushed to the W/C (wheel chair) alarm, sitting on the floor in front of her W/C, with shoes on and . (cushion) on W/C. Resident c/o (complained of) pain in the groin and states (he/she) hit (himself/herself) on the side of the head and that (he/she) twisted (his/her) left ankle . 3 staff transferred resident on to W/C. Currently being observed in front of the nurses station, until ambulance arrives to transfer to hospital. Manager alerted MD (Doctor of Medicine) and son aware. Review on 1/3/2020 of Resident 83's RESIDENT EVENT INVESTIGATION dated 11/30/19 revealed that Resident #83 had a pain level of 6 out of 10 and Refused ROM (range of motion) assessment. Review on 1/3/2020 of Resident #83's NURSING PROGRESS NOTE dated 11/30/2019 revealed the following: . resident in wc c/o left groin/leg pain yells out with movement s/p fall. MD updated and new order to send to ER (emergency room ) for eval . Review on 1/3/2020 of Resident #83's NURSING PROGRESS NOTE dated 11/20/2019 revealed the following: . Resident will be admitted for left hip fx (fracture) pt (patient) is scheduled for surgery tomorrow. Review on 1/3/2020 of Resident #83's Investigation/witness statement dated 11/30/19 revealed the following: {Resident) was A&O (alert & oriented) x 3, VSS (vital signs stable), neuros done, assessment attempted for ROM but resident refused. 3 staff transferred on to W/C . Review on 1/3/2020 of Resident #83's Investigation/witness statement dated 11/30/19 documented by LPN (Licensed Practical Nurse) revealed the following: I was told resident slid out of w/c when counting quarters in (his/her) room. I went to assess resident but was already in wc, primary nurse & LNA's put in wc. I asked resident what happened states (he/she) slid out of wc again while counting quarters states hit L (left) side head & c/o L (left) groin pain asked to lift leg and started yelling out in pain. Left in wc Order to send to ER (emergency room ) for eval (evaluation). Interview on 1/3/2020 at approximately 10:30 a.m. with Staff F (Registered Nurse, Director of Nursing) revealed that Resident #83 should not have been moved from the floor on 11/30/19 after a fall when resident complained of left groin pain. The facility failed to provide the appropriate care after the 11/30/19 fall by transferring Resident #83 to a wheelchair.",2020-09-01
304,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2020-01-03,800,D,0,1,R82J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to provide the necessary supplements identified as a dietary need for 1 of 3 residents reviewed for nutrition in a final sample size of 19 residents. (Resident identifier is #55.) Findings include: Review on 1/3/20 of Resident #55's nutrition care plan dated 12/6/19 revealed that Resident #55 had an intervention for mighty shakes QD (once daily). Review on 1/3/20 of Resident #55's weight records revealed that Resident #55's weight on 11/5/19 was 128.3 lbs. and on 12/5/19 Resident #55's weight was 113 lbs. which was a 15.3 lbs. weight loss in a month. Further review of Resident #55's weight records revealed that Resident #55's next recorded weight after 12/5/19 was on 12/20/19 which was 106 lbs. which was a 7 lbs. weight loss compared to the 12/5/19 weight. Review on 1/3/20 of Resident #55's Nutrition progress notes revealed that on 12/6/19 dietician recommended to start mighty shakes (supplement). Further review of Resident #55's nutrition progress notes revealed that on 12/13/19 and 12/27/19 Resident #55 was on mighty shakes and overall oral intake for Resident #55 was not great. Review on 1/3/20 of Resident #55's (MONTH) 2019 Electronic Medication Administration Record (EMAR) revealed that Resident #55 had no documentation to administer might shakes once daily. Review on 1/3/20 of Resident #55's current physician orders [REDACTED]. Review on 1/3/20 of Resident #55's nurses notes for (MONTH) 2019 revealed no documentation related to daily administration of mighty shakes. Interview on 1/3/20 at 9:50 a.m. with Staff C (Unit Manager) confirmed the above findings. Staff C stated that mighty shakes and supplements are put in the EMAR and administered by the nurses. Staff C also stated that Resident #55 did not received mighty shakes and that Staff C did not received any recommendations from the dietician regarding the mighty shake. Staff C also stated that if there were any recommendations, the recommendations were to be reviewed by the physician and were unlikely to be declined by the physician. Interview on 1/3/20 at 10:06 a.m. with Staff D (Dietician) confirmed that Resident #55 had a 7 lbs. weight loss on 12/20/19 compared to Resident #55 weight on 12/5/19 as listed above. Staff D also confirmed that Staff D had recommended Resident #55 to have mighty shakes once daily on 12/5/19. Staff D also confirmed that they wrote Resident #55's nutrition progress notes dated 12/13/19 and 12/27/19, and Staff D also confirmed that the nutrition care plan was updated on 12/6/19 by Staff D in regards to the mighty shake QD intervention. Staff D stated that they forgot to notify the nursing staff on the dietary recommendation for the mighty shakes.",2020-09-01
305,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-11-08,278,B,0,1,BQZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to provide accurate MDS (Minimum Data Set) assessments for 2 residents out of a standard survey sample of 20 residents. (Resident identifiers are #2 and #7.) Findings include: Resident #7 Review on 11/7/17-11/8/17 of Resident #7's medical record revealed that on 10/16/17, an MDS assessment was conducted for Resident #7. In section J1900, the MDS assessment reflected that Resident #7 had had a fall with a fracture during the current assessment period. In review of nursing notes and overall record review; however, any evidence of a fall with a fracture for Resident #7 remained unsupported. Interview was conducted with Staff B (MDS Coordinator) in which Staff B stated that there was an error on the MDS assessment in J1900, there was no recent fall with a fracture for this resident, and that the error reflected a fall with fracture that Resident #7 had sustained prior to the previous survey on 2/2/17. Resident #2 Review of Resident #2's MDS dated [DATE], section M0210 B1 revealed Resident #2 had 2 stage 2 pressure ulcers that were not present on admission. Section M0210 B3 revealed the date of the oldest pressure ulcer is 01/10/17. A nurses note dated 1/17/17 at 10A (sic) revealed the following entry: Stage 2 pressure areas coccyx + L (left) buttocks assessed by skin team. Areas have healed. Will continue to monitor. A nurses note dated 1/23/17 at 11:00 a.m. revealed the following entry: R (Right sic) BUTT[NAME]K area heald (sic) TX D/c. Interview on 11/8/17 at 10:25 a.m. with Staff D (Licensed Practical Nurse/Unit Manager), Staff D confirmed that the MDS was coded as is documented above and that Resident #2's pressure ulcers were both healed by 1/23/17. Interview on 11/8/17 at 10:35 a.m. with Staff B (Registered Nurse/MDS Coordinator), Staff B confirmed that the MDS as is documented above does show 2 stage 2 pressure ulcers. Staff B stated that she/he does not do that section of the MDS so is unable to confirm whether Section M0210 accurately reflects Resident #2's skin condition at that time. Interview on 11/8/17 at 10:48 a.m. with Staff [NAME] (RN/Director Of Nursing), Staff [NAME] confirmed that Resident #2 did not have any pressure ulcers at the time the above referenced MDS was completed.",2020-09-01
306,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-11-08,279,D,0,1,BQZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop comprehensive care plans for 2 residents in a survey sample of 20 residents. (Resident identifiers are #5 and #14.) Findings include: Resident #5 Review on 11/7/17 of Resident #5's Care Area Assessment (CAA) Summary, dated 10/30/17, revealed a note .Pressure Ulcers: (Resident #5) is at risk for skin breakdown r/t (related to) incontinence of bowel and bladder and needing some assist with bed mobility. (Resident #5) has no skin issues at this time. Will monitor for decline. Proceed. Review on 11/7/17 of Resident #5's care plan, initiated on 10/14/17 and revised on 11/6/17, revealed that there was no documented care plan in place for the prevention of pressure sores. Interview on 11/8/17 at approximately 1:00 p.m. with Staff A (Unit Manager) confirmed that there was no documented prevention of pressure sore care plan in place for Resident #5, who was at risk for developing pressure sores. Staff A confirmed that a care plan for the prevention of pressure sores should have been in place for Resident #5. Review on 11/7/17 of Resident #5's Medication Administration Record [REDACTED]. Start Date- 11/2/17 . Review on 11/7/17 of Resident #5's care plan, initiated on 10/14/17 and revised on 11/6/17, revealed that there was no documented care plan in place for the use of [MEDICAL CONDITION] medication. Interview on 11/8/17 at approximately 1:00 p.m. with Staff A (Unit Manager) confirmed that there was no documented [MEDICAL CONDITION] medication care plan in place for Resident #5. Staff A confirmed that a care plan for the use of [MEDICAL CONDITION] medication should have been in place for Resident #5. Resident #14 Observation on 11/6/17 at approximately 9:00 a.m. revealed that Resident #14 had a cast on Resident#14's left wrist. Review on 11/8/17 of Resident #14's care plan, initiated on 10/11/17 and revised on 11/7/17, revealed that Resident #14 had a .left ulna/radius fracture 2nd (secondary) to fall . There was no documentation on the care plan that Resident #14 had a cast. Interview on 11/8/17 at approximately 1:00 p.m. with Staff A (Unit Manager) confirmed that Resident #14 had a cast for a fracture of Resident #14's wrist and that there was no documentation on Resident #14's care plan that Resident #14 had a cast. Staff A confirmed that a care plan for the cast should have been in place for Resident #14.",2020-09-01
307,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-11-08,281,D,0,1,BQZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to provide parameters for PRN (as needed) pain medications for 3 residents in a standard survey sample of 20 residents. (Resident identifiers are #2, #9 and #17.) Findings include: Standards: Review of Fundamentals of Nursing, [NAME] [NAME] Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . On pages 699-713 . The prescriber must document the diagnosis, condition, or need for use for each medication ordered (page 699) .The prescriber often gives specific instructions about when to administer a medication (page 708) .This reference also relates on page 713 that a registered nurse compares the list of medications on the MAR indicated [REDACTED]. And After administering a medication, the nurse records it immediately on the appropriate record form .Recording immediately after administration prevents errors If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, the nurse explains the reason the medication was not given in the nurse's notes. Resident #2. Review of Resident #2's MAR (Medication Administration Record) revealed an order for [REDACTED]. [MEDICATION NAME] HCL 50 MG TABLET Give 50 mg orally every 6 hours as needed for PAIN Start Date 10/25/17 0700 Interview on 11/8/17 at approximately 10:25 a.m. with Staff D (Registered Nurse/Unit Manager), Staff D stated there is not a medication parameter for use for the [MEDICATION NAME]. Resident #9 Review of Resident #9's MAR (Medication Administration Record) revealed an order for [REDACTED]. [MEDICATION NAME] SULF (sic) 100 MG/5 ML (milliliter) Give 5 mg orally every 3 hours as needed for pain or respiratory distress related ENCOUNTER FOR PALLIATIVE CARE sublingual every 3 hours as needed Start Date 10/25/17 1715 The following order was noted to not be a correct order as Proair is not used for nausea/vomiting and is not administered via a suppository. PROAIR HFA 90 MCG (micrograms) INHALER 1 suppository inhale orally every 12 hours as needed for Nausea related to ENCOUNTER FOR PALLIATIVE CARE give one supp. (sic) rectally as needed for nausea/vomiting Start Date 10/25/17 1716 Interview on 11/8/17 at approximately 10:48 a.m. with Staff D (Registered Nurse/Unit Manager), Staff D stated there is not a medication parameter for use for the [MEDICATION NAME] and the Proair HFA is an incorrect order as the medication was not prescribed for nausea/vomiting and this medication is not given as a suppository. Resident #17 Review of Resident #9's MAR (Medication Administration Record) revealed the following orders with no indications for use: [MEDICATION NAME] 17.2 mg po (by mouth) @ (sic) bedtime prn (as needed) [MEDICATION NAME] 10 mg PR (per rectum) daily prn Interview on 11/8/17 at approximately 10:48 a.m. with Staff [NAME] (Director of Nurses), Staff [NAME] confirmed the medication parameters for use were missing for the [MEDICATION NAME] and [MEDICATION NAME] for Resident #17.",2020-09-01
308,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-11-08,282,B,0,1,BQZC11,"Based on interview and review of medical record, the facility failed to update the comprehensive care plan of 1 resident in a survey sampled of 20 residents. (Resident identifier is #4.) Findings include: Review on 11/7/17 of Resident #4's medical record revealed that there was no care plan in place which addressed Resident #4's stage two pressure sore on their right buttock. Review of Resident #4's nurses' notes revealed Resident #4 had developed this pressure sore on 10/30/17. Interview with Staff C (Assistant Director of Nurses) review the above finding and Staff C acknowledged adding this pressure sore to Resident #4's comprehensive care plan on 11/7/17 after it had been brought to the attention of facility staff.",2020-09-01
309,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-11-08,329,D,0,1,BQZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to perform an AIMS (Abnormal Involuntary Movement Scale) for residents on antipsychotic medications to monitor the effects of the medication for 2 residents of 7 sampled residents taking anitpsychotic medication in a standard survey sample of 20 residents. (Resident identifiers are #5 and #8) Findings include: Resident #8 Review of Resident #8's medical record revealed Resident #8 was receiving [MEDICATION NAME] 0.8 mg (milligrams) gel. Further review of Resident #8's medical record revealed there was not an AIMS done for Resident #8. Interview with Staff [NAME] (Director of Nurses) reviewed the above finding and Staff [NAME] confirmed that Resident #8 had not had an Abnormal Involuntary Movement Scale (AIMS) test to monitor the effects of this medication. Resident #5 Review on 11/7/17 of Resident #5's Medication Administration Record [REDACTED]. Start Date- 11/2/17 . Review on 11/7/17 of Resident #5's Assessment list revealed that there was no documented evidence that an assessment for abnormal involuntary movements was done for Resident #5. Interview on 11/8/17 at approximately 1:00 p.m. with Staff A (Unit Manager) confirmed that there was no documentation of an assessment for abnormal involuntary movements which should have been done for Resident #5.",2020-09-01
310,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-11-08,371,E,0,1,BQZC11,"Based on observation and interview, it was determined that the facility failed to properly label and date supplemental shakes in 3 of 3 nourishment kitchens, failed to properly store food, and failed to ensure proper sanitizing solution used in the kitchen's three compartment sink. Findings include: Observation on 11/6/17 at approximately 9:45 a.m. of the nourishment kitchen on the second floor revealed approximately 9 undated thawed supplemental shakes in the refrigerator. Interview on 11/6/17 at approximately 9:45 a.m. with Staff G (Unit manager for second floor west and east) confirmed the above findings. Review of the supplemental shake carton revealed the following instructions: After thawing, keep refrigerated. Use within 14 days after thawing. Observation on 11/6/17 at approximately 9:50 a.m. of the nourishment kitchen on the second floor revealed one container of egg salad dated 11/1/17 and one container of tuna or chicken salad with no date. Interview on 11/6/17 at approximately 10:30 a.m. with Staff F (Director of food Services) confirmed that all food products are dated with a use by date. Observation on 11/6/17 at approximately 9:00 a.m. of the pHydrion testing of the kitchen's three compartment sink performed by Staff H (Director of Facilities) revealed a result of 500 parts per million (ppm). Review of the manufacturers instructions for use of the sanitizing sink revealed that the sanitizing solution should be between 200-400 ppm. Observation on 11/6/17 at approximately 9:30 a.m. of the Rehab Unit kitchenette revealed 8 nutritional shakes in the refrigerator with no date on them and a bag with 6 bagels in it that had a sell by date of 10/26/17. Interview on 11/6/17 at approximately 9:30 a.m. with Staff A (Unit Manager) confirmed that the nutritional shakes should have been dated and that the bagels should no longer have been available for use. Observation on 11/6/17 at approximately 9:45 a.m. of the Third Floor kitchenette revealed 5 nutritional shakes in the refrigerator with no date on them and a creamer with an expiration date of 10/20/17. Observation on 11/6/17 at approximately 9:45 a.m. of the Third Floor kitchenette revealed a document on the front of the refrigerator titled Quarterly Temperature Logs . with spaces to fill in refrigerator and freezer temperatures. There was a freezer temperature for 11/1/17 and one for 11/2/17. There were no documented entries for the freezer temperature for 11/3/17-11/6/17 and no documented entries for the refrigerator temperature for 11/1/17-11/6/17. Observation on 11/6/17 at approximately 9:45 a.m. of the Third Floor kitchenette food freezer revealed 1 reusable ice pack with part of a resident name on it, and 2 commercial ice packs with no information on them. Interview on 11/6/17 at approximately 9:45 a.m. with Staff D (Unit Manager) revealed that the ice packs were for body use and should not have been stored in the food freezer. Staff D also confirmed that the nutritional shakes should have been dated, that the creamer should not have been available for use, and that the refrigerator/freezer temperatures should have been documented.",2020-09-01
311,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,558,D,0,1,KNHP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, it was determined that the facility failed to provide an appropriate assistive device for toileting for 1 of 1 resident reviewed for incontinence in a survey sample of 22 residents. (Resident identifier is #83.) Findings include: Interview on 11/28/18 at 10:15 a.m. with Resident #83 during resident council revealed that Resident #83 had been incontinent on multiple occasions because Resident #83 was unable to attach a high rise (assistive device for toileting) to the toilet in the resident's bathroom. Resident #83 said the resident's roommate did not use the device so the resident is not allowed to leave the device on the toilet. Interview on 11/29/18 at 9:30 a.m. with Resident #83 revealed Resident #83 had an episode of incontinence almost everyday last week because the resident was unable to put the high rise on the toilet and when the resident used the call bell they had to wait for help from facility staff. The resident also revealed they have a bowel disease and they have to go when have to go. Resident #83 also said that Resident #83 was able to self-toilet but it has become to hard to put high rise on and they can no longer do it by themselves. Observation during interview of Resident #83's bathroom revealed a high rise assistive device for toileting laying on the floor next to the toilet. Interview on 11/29/18 at 9:40 a.m. with Staff J (Licensed Nursing Assistant (LNA)) and Staff K (LNA) revealed Resident #83 was able to self-toilet during the day, but sometimes needed a one person assist. Staff J and Staff K confirmed that Resident #83 is not able to put the high rise on the toilet themselves and that the high rise needs to come off because the roommate doesn't use it. Review on 11/29/18 of Resident #83's list of [DIAGNOSES REDACTED]. Review on 11/29/18 of Bowel Elimination and Urine Elimination Logs indicated an increase in episodes of incontinence.",2020-09-01
312,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,623,B,0,1,KNHP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to notify the resident, resident representative, and the ombudsman of a transfer/discharge for 1 resident in a standard survey sample of 22 residents. (Resident identifier is #96.) Findings include: Resident #96 Review on 11/29/18 at approximately 9:00 a.m. revealed that there was no notice of transfer/discharge in Resident #96's medical record. Interview on 11/29/18 at approximately 1:05 p.m. with Staff G (Social Worker) confirmed that the Notices of Transfer/Discharge have not been being done for any resident in the facility. Staff G also confirmed that a Notice of Transfer/Discharge was not provided to Resident #96, a family member or the Ombudsman prior to discharge to the hospital on [DATE].",2020-09-01
313,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,641,B,0,1,KNHP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that assessments accurately reflect the resident's status for 3 of 22 residents in a final survey sample. (Resident identifiers are #31, #43, and #34.) Findings include: Resident #31 Review on 11/29/18 of Resident #31's Minimum Data Set ((MDS) dated [DATE] and 9/21/18 revealed Section N 0410 Medications Received indicted that Resident #31 had received anticoagulants. Review on 11/29/18 of Resident #31's physician orders [REDACTED]. Interview on 11/29/18 at approximately 10:40 a.m.with Staff B (Minimum Data Set (MDS) Coordinator) confirmed the above findings and revealed the above MDS sections were completed in error. Resident #43 Review on 11/29/18 of Resident #43's MDS (Minimum Data Set) dated 8/19/18 and 9/24/18 revealed that under Section N, Medications, N0410. Medications Received, section [NAME] was marked 0 days that Resident #43 received an anticoagulant. Review on 11/29/18 of Resident #43's Novembers Medication Administration Record [REDACTED] Xarelto 20 milligrams daily (order dated 6/27/18). Interview on 11/29/18 at approximately 11:00 with Staff B (Minimum Data Set Nurse) revealed that the the MDS's dated 8/19/18 and 9/24/18 were marked 0 in error, Resident #43 had been on an anticoagulant since 6/27/18. Resident #34 Review on 11/29/18 of Resident #34's nurses notes from (MONTH) (YEAR) revealed that Resident #34 had a witnessed fall on 9/7/18 and was sent out to the emergency room for evaluation and came back on 9/8/18 with [DIAGNOSES REDACTED]. Review on 11/29/18 of Resident #34's MDS (Minimum Data Set) dated 9/12/2018 revealed that no falls was coded on section [NAME] Interview on 11/29/18 at 12:40 p.m. with Staff B confirmed that Resident #34 had a fall with fracture on 9/7/18 and that the fall was not coded on the MDS for 9/12/2018. Staff B revealed that a fall resulting to a bone fracture is considered a fall with major injury. Staff B also revealed that the fall with major injury should have been coded on 9/12/2018 MDS and that Staff B will correct the MDS.",2020-09-01
314,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,645,D,0,1,KNHP11,"Based on interview and record review, it was determined that the facility failed to obtain a Preadmission Screening for mental disorder or intellectual disability for 1 resident in a final survey sample of 22 residents. (Resident identifier is #19.) Findings include: Review on 11/28/18 of Resident #19's medical record revealed that there was no PASARR (Preadmission Screening and Resident Review) found in Resident #19's medical record. Interview on 11/29/18 at approximately 12:34 p.m. with Staff G (Social Worker) confirmed that there was no documented evidence that a PASARR was done for Resident #19. Staff G also confirmed that a PASARR screening for mental disorder or intellectual disability should have been done prior to their admission.",2020-09-01
315,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,655,D,0,1,KNHP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to develop a baseline care plan that addressed infection control precautions, for 1 resident in a survey sample of 22 residents. (Resident identifier is #48.) Findings include: Review on 12/17/18 of the facility's Policy and Procedure Title: Isolation Precautions issued on 10/22/18 reveals that Residents found to have contact, airborne, or droplet infections will be placed on Isolation precautions use contact precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indrect contact, such as handling environmental surfaces or resident-care items Obtain appropriate signage and post outside the door frame Observation on 11/27/18 a.m. of Resident #48's room revealed a supply of PPE (personal protective equipment) attached to the room door with no signage posted at this room entrance; there was no sign to alert persons to see nurse before entering or to indicate the resident is on precautions. Interview on 11/27/18 a.m. with Staff P (Licensed Practical Nurse) revealed the patient is on precautions for ESBL (extended spectrum beta lactamase) in the urine. A subsequent observation of Resident #48's room, later that morning, revealed signage to see nurse now on the doorway. Interview on 11/27/18 p.m. with Staff O (Registered Nurse) revealed that the patient is here for IV antibiotics for ESBL, and for therapy to strengthen, staff should wear gloves when touching the resident, and when helping the resident go to the bathroom they should wear gown and gloves, and after removing gloves should sanitize/wash hands in the bathroom. Review on 12/17/18 of Resident #48's Baseline Careplan Review and Summary dated 11/20/18 reveals the resident was admitted on [DATE] for IV Abx (intravenous antibiotics) due to ESBL UTI (urinary tract infection). This 4-page care plan lists what the patient does for him/herself as meds, walker, toileting but does not mention any infection control precautions, such as contact precautions. Review on 11/29/18 a.m. of this resident's comprehensive Careplan revealed a Focus area for .has a Urinary Tract infection ESBL. Interview on 11/30/18 a.m. with Staff O, revealed that the resident was put on contact precautions on day of admission but it's not in any care plan, baseline or current; that the resident's diarrhea started shortly after she got here, and an assist by one staff for toilet use was initiated on day of admission. The comprehensive Careplan was revised by the facility on 11/30/18, as review on 11/30/18 reveals there is now an Intervention, created on 11/30/18, for CONTACT PRECAUTIONS MAINTAINED. Review of the current care plan on 11/30/18 also revealed that the resident . has potential for impairment to skin integrity r/t (related to) urinary incontinence. This Focus area was initiated on 11/20/18. And an Activities of Daily Living focus area Intervention for TOILET USE, initiated on 11/20/18, relates . resident requires limited assistance by 1 staff for toileting.",2020-09-01
316,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,656,E,0,1,KNHP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility failed to develop a comprehensive person centered care plan for 4 residents in a final survey sample of 22 residents. (Resident identifiers are #19, #45, #59 and #61.) Findings include: Resident #19 Review on 11/29/18 of Resident #19's medical record revealed that Resident #19 had been admitted to Hospice Services on 5/22/18. Review on 11/29/18 of Resident #19's current care plan revealed that a facility care plan for Hospice Services was initiated on 5/23/18. The only intervention documented on the care plan was (Facility) team to collaborate with Hospice team to achieve effective symptom management (refer to individual focus area) . There was nothing documented in the care plan stating who from Hospice would be involved, when the visits would occur, or who would be providing specific care. Interview on 11/29/18 at approximately 9:45 a.m. with Staff F (Unit Manager) confirmed that the facility care plan did not contain the specific Hospice information that should have been on the care plan. Resident #45 Observation on 11/27/18 at approximately 10:15 a.m. of Resident #45 and their spouse, revealed that Resident #45 was very hard of hearing and that the spouse used a dry erase board to communicate with them. Interview on 11/27/18 at approximately 10:15 a.m. with Resident #45's spouse revealed that they had been using the dry erase board to communicate for some time. Review on 11/29/18 of Resident #45's current care plan did not indicate that Resident #45 used a dry erase board to communicate. Interview on 11/29/18 at approximately 9:30 a.m. with Staff F revealed that Staff F was not aware that Resident #45 used a dry erase board to communicate. Interview on 11/29/18 at approximately 9:45 a.m. with Staff H (Licensed Nursing Assistant), after they were asked about the dry erase board by Staff F, confirmed that the staff and Resident #45's spouse use a dry erase board to communicate with Resident #45. Interview on 11/29/18 at approximately 9:50 a.m. with Staff F confirmed that the communication with a dry erase board should have been on Resident #45's current care plan. Resident #61 Review on 11/27/18 of Resident #61's physician orders [REDACTED].#61 was admitted to hospice services on 11/2/18 for [MEDICAL CONDITIONS]. Review on 11/29/18 of Resident #61's current care plan revealed there was no care plan for hospice. Interview on 11/29/18 at 12:45 p.m. with Staff A (Assistant Director of Nursing) confirmed Resident #61 was receiving hospice services and Resident #61 did not have a facility care plan with a focus on hospice services. Resident #59 Interview on 11/30/18 at 9:15 a.m. with Staff D revealed that Resident #59 leaves the facility around 9:45 a.m. to go to the [MEDICAL TREATMENT] center and comes back to facility around 3:00 p.m. every Monday, Wednesday and Friday. Staff D also revealed that Resident #59 preferred not to eat any snack or lunch at the [MEDICAL TREATMENT] center and preferred to eat their lunch after [MEDICAL TREATMENT] and so no lunch or snack is sent with them. Review on 11/30/18 of Resident #59's current care plan revealed that there were no mention of Resident #59 not wanting lunch or snack at [MEDICAL TREATMENT] and preferred to eat at the facility after [MEDICAL TREATMENT]. Interview on 11/30/18 10:00 a.m. with Staff D confirmed that there was no care plan for Resident #59 not wanting to eat at [MEDICAL TREATMENT] and Staff D was unable to provide explanation on how staff would know to give Resident #59 their lunch when they got back from [MEDICAL TREATMENT].",2020-09-01
317,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,657,D,0,1,KNHP11,"Based on record review and interview, it was determined that the facility failed to revise care plans so that they are comprehensive to provide the greatest benefit to 2 residents out of a survey sample of 22 residents. (Resident identifiers are #21 and #53.) Findings include: Resident #21. Interview on 11/27/18 at 11:13 a.m. during the initial tour with Resident # 21 revealed that they were supposed to walk every day and they no longer do that. Review on 11/29/18 of Resident #21's medical record under the tab Physical Therapy a discharge summary was found referencing the services dates from 8/2/18-8/24/18 which states under, Patient /Caregiver Training since last Report pt/staff education for daily ambul (ambulation) program w (with) RW (roller walker) 100 feet w (with) CG (close guard) and wc (wheelchair) follow. Written program in place. Review on 11/29/18 of Resident # 21 care plan under ADL failed to have an intervention to address resident's need to ambulate. Interview on 11/29/18 at 12:16 p.m. with Staff A (Assistant Director of Nurses) stated that the ambulation care plan was D/Ced because the staff on the unit said they do not do it any more, there for Staff A removed it. Staff A stated that they are in the middle of implementing a restorative ambulation program since it is no longer being done. Resident #53 Review on 11/29/18 of Resident #53's advance directives revealed an advance care planning encounter stating, .No further reinsertations of feeding tube. If the feeding tube inadvertently comes out, the tube will not be re-inserted. The advance care planning was dated 10/16/18 and signed by the nurse practitioner on 10/16/18. Review on 11/29/18 of Resident #53's care plans, revealed that Resident #53's care plans did not include .No further reinsertations of feeding tube. If the feeding tube inadvertently comes out, the tube will not be re-inserted. Interview on 11/29/18 at approximately 11:15 a.m. with Staff F (Unit Manager) revealed that Resident #53's additional advance directives were to not reinsert Resident #53's feeding tube if it comes out. Interview on 11/29/18 at approximately 2:00 p.m. with Staff A (Assistant Director of Nurses) revealed that Resident #53's care plans did not have the above information in them.",2020-09-01
318,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,688,D,0,1,KNHP11,"Based on record review and interview it was determined that the facility failed to provided services to prevent avoidable decline in mobility for 2 residnets out of a standard survey sample of 22 residents. (Resident identifiers are #11 and #21.) Findings include: Resident #21 Interview on 11/27/18 at 11:13 a.m. during the initial tour with Resident # 21 revealed that they were supposed to walk every day and they no longer do that. Review on 11/29/18 of Resident #21's medical record under the tab Physical Therapy a discharge summary was found referencing the services dates from 8/2/18-8/24/18 which states under, Patient /Caregiver Training since last Report pt/staff education for daily ambul (ambulation) program w (with) RW (roller walker) 100 feet w (with) CG (close guard) and wc (wheelchair) follow. Written program in place. On review of the LNA flow sheets it shows under Daily Ambulation Program for the month of (MONTH) that Resident #21 was ambulated almost daily. Then for the month of (MONTH) out of 30 days Resident #21 was only ambulated 5 times, then for the month of (MONTH) out of 31 days Resident #21 was only ambulated 9 times, and for the mouth of (MONTH) out of 30 days Resident #21 was only ambulated 2 times. These finding were shown to Staff A (ADON) on 11/29/18 12:16 PM who stated that the staff on the unit said they do not ambulate Resident #21 any more but are working on implementing a new restorative ambulation program since it is no longer being done. Resident #11 Interview on 11/27/18 at approximately 11:00 a.m. with Resident #11 revealed that Resident #11 was supposed to ambulate with the staff every day. Resident #11 stated that this was not being done because the staff are too busy. Resident #11 stated that when they were discharged from Therapy, this ambulation plan was put into place. Review on 11/28/18 of Physical Therapy Discharge Instructions, dated 10/2/18, revealed a note that read .Daily ambul (sic) program w (with) RW (rolling walker) 100-250 feet w SBA (stand by assist) Mod I (moderate independence) w wc (wheelchair) mobility . Review on 11/29/18 of Resident #11's Licensed Nursing Assistance tasks for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a task titled, Daily Ambulation Program . There was only one time in (MONTH) that this task was documented on, which was on 10/5/18 at 10:16 p.m. when the documentation read NA (Not Applicable.) For the month of November, the documentation was as follows: N/A on 11/1/18, 11/10/18, 11/13/18, 11/16/18, 11/19/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/26/18 and 11/27/18. UN (unavailable) was documented on 11/5/18, 11/6/18, and 11/7/18. RR (resident refused) was documented on 11/11/18 and 11/21/18. 0 (indicating no ambulation) was documented on 11/28/18 and 11/29/18. On 11/2/18 there was no documentation. On the remaining 10 days, there was documentation that Resident #11 ambulated with assistance 50-100 feet. Interview on 11/29/18 at approximately 1:00 p.m. with Staff F (Unit Manager) confirmed that the staff have not been ambulating daily with Resident #11 as they should have been.",2020-09-01
319,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,838,C,0,1,KNHP11,"Based on interview and record review, it was determined that the facility failed to document a facility-wide assessment during their standard survey. Findings include: Review on 11/27/18 at approximately 9:30 a.m. of the Entrance Conference Worksheet with Staff I (Director of Nursing) and Staff A (Assistant Director of Nursing) revealed that the facility was asked to provide a copy of their Facility Assessment. Interview on 11/29/18 at approximately 11:00 a.m. revealed that the facility was unable to locate their Facility Assessment.",2020-09-01
320,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,842,D,0,1,KNHP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to maintain complete medical records for 5 residents out of a standard survey sampl of 22 residents. (Resident Identifiers are #9, #43, #45, #53 and #63.) Findings include: Resident #43 Review on 11/30/18 of Resident #43's nursing notes revealed the following note dated 11/23/18, 22:47: The system generated a possible drug allergy for the following order: Keflex 500 MG (milligrams) by mouth four times a day for UTI (Urinary Tract Infection) for 5 days. Review on 11/30/18 of Resident #43's MAR (Medication Administration Record) revealed that Resident #43 had an allergy to Keflex and that Resident #43 received Keflex 500 mg. from 11/24/18 thru 11/28/18. Review on 11/30/18 of Resident #43's physician progress notes [REDACTED].#43 was last seen on 11/20/18. Interview on 11/30/18 at approximately 10:30 a.m. with Staff D (Unit Manager) revealed that there was no documentation of the physician being notified of the possible drug allergy in the medical record. There was no evidence of the physician being notified of the possible allergy prior to the medication being admininistered. Resident #53 Review on 11/29/18 of Resident #53's MAR (Medication Administration Record) revealed the following physicians order: Enteral Feed Order every shift Check and record residuals Q (at) shift. Contact Physician if residual exceeds 150 ml's. (milliliters) Start Date 10/25/17. Review on 11/29/18 of Resident # 53's medical record revealed that there was no documentation of Resident #53's residuals being recorded. Interview on 11/29/18 at approximately 11:30 a.m. with Staff E, Licensed Practical Nurse confirmed that the residuals are not being recorded in the medical record. Resident #63 Review on 11/30/18 of Resident #63's MAR indicated [REDACTED] [MEDICATION NAME] (Concentrate) Solution 20MG/ ML. Give 0.25 ml sublingually every 6 hours for pain related to SPINAL STENOSIS, LUMBAR REGION WITHOUT [MEDICAL CONDITION] CLAUDICATION (M48.061) AND Give 0.25 ml sublingually every 6 hours as needed for pain/SOB (shortness of breath) related to SPINAL STENOSIS, LUMBAR REGION WITHOUT [MEDICAL CONDITION] CLAUDICATION (M48.061) dated, 11/15/08. Interview on 11/30/18 at approximately 10:30 a.m. with Staff D, Unit Manager revealed that there was no documentation of the physician being notified of the drug allergy in the medical record. Review on 11/30/18 of Resident #63's nursing notes revealed the following note of a drug interaction: [MEDICATION NAME] (Concentration) Solution 20MG/ML has the following interaction with [MEDICATION NAME]: Severity: Moderate, Interaction-Plasma concentrations of [MEDICATION NAME] 100 MG may be increased by [MEDICATION NAME] (Concentrate) Solution 20 MG/ML. The clinical significance of this interaction is not known. Interview on 11/30/18 at approximately 10:30 a.m. with Staff D, Unit Manager revealed that there was no documentation of the physician being notified of the possible drug interaction in the medical record. Resident #9 Review on 11/28/18 of Resident # 9's record revealedthat a Pre Admission Screening and Resident Review (PASRR) was done on 4/17/17. During review of this assessment it was found that the last page #8 under Attestation to accurate information that states I certify that this Level 1 screen information is accurate to the best of my knowledge Signature of medical professional (Credentials need to be a MD, APRN, or PA) Interview on 11/29/18 at 2:30 p.m with Staff G (Director of Social Services) reviewed the above findings and Staff G who stated that they are doing a complete audit of all PASRR's since several have been found to be incomplete. Resident #45 Interview on 11/27/18 at approximately 10:15 a.m. with Resident #45 and their spouse revealed that Resident #45 was very hard of hearing. Resident #45's spouse stated that they were told that Resident #45 had ear wax and they were not sure if anything was done about it. Review on 11/29/18 of Resident #45's MD (Medical Doctor) Appointment Communication Form, which was not dated, revealed that Resident #45 was seen by an Ear, Nose and Throat (ENT) physician for Hearing. It was documented on the Communication form that .Cerumen B/L (bilaterally) cleared . The section marked follow up read 6 months. Interview on 11/29/18 at approximately 9:45 a.m. with Staff F (Unit Manager) confirmed that there was no date written for the ENT visit. Staff F looked through Resident #45's nurses notes as well as through the facility's appointment calendar but was unable to find any documented evidence of Resident #45 having the physician visit or a follow up visit in 6 months. Staff F thought that they remembered Resident #45 refusing to go out for a follow up visit, but could not find any documentation about that. Staff F confirmed that the ENT visit should have a date on it, should have had documentation in the nurses notes indicating that the resident left the facility and should have had documentation of Resident #45's refusal of a follow up visit.",2020-09-01
321,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,880,D,0,1,KNHP11,"Based on observation, interview, and record review, it was determined that the facility failed to ensure sanitary conditions in two locations: for food service on the 2nd floor solarium, and for rehab services in the 2nd floor rehab center. (Resident identifier is #48.) Findings include: Review on 12/17/18 of the facility's Policy and Procedure Title: Isolation Precautions issued on 10/22/18 reveals that Residents found to have contact, airborne, or droplet infections will be placed on Isolation precautions use contact precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indrect contact, such as handling environmental surfaces or resident-care items Observation on 11/27/18 a.m. of Resident #48's room revealed a supply of PPE (personal protective equipment) attached to the room door with no signage posted at this room entrance; there was no sign to alert persons to see nurse before entering or to indicate the resident is on precautions. Interview with Staff P (Licensed Practical Nurse) revealed the patient is on precautions for ESBL (extended spectrum beta lactamase) in the urine. Interview on 11/27/18 p.m. with Staff O (Registered Nurse) revealed that the patient is here for IV antibiotics for ESBL, and for therapy to strengthen, staff should wear gloves when touching the resident, and when helping the resident go to the bathroom they should wear gown and gloves, and after removing gloves should sanitize/wash hands in the bathroom. Interview on 11/30/18 a.m. with Staff O revealed that the resident was put on contact precautions on day of admission but it's not in any care plan, baseline or current; that the resident's diarrhea started shortly after she got here, and an assist by one staff for toilet use was initiated on day of admission. Observation on 11/30/18 at about 10:31 a.m. revealed Resident #48 getting therapy to their lower and upper extremities with Staff M (physical therapy) in the rehab room; using a medicine ball for lower extremities, the resident rolling it about on the floor with their feet with shoes on, and then the resident placing pegs into a pegboard with upper extremities. Staff M is touching resident and moving about room, e.g. returning medicine ball to top of open ball bin and then getting pegs and pegboard out of closed cupboard, without doing hand hygiene, and returning to work with resident some more, having resident stand and instructing resident (e.g., re inserting the pegs into the pegboard). Interview on 11/30/18 at about 11:12 a.m. with Staff N (rehab director) revealed that Staff N's expectation is that Staff M should have sanitized the medicine ball that resident was rolling on the floor with their feet, before returning the medicine ball to the top of the ball bin where it was available for potential use with another resident. Observation on 11/29/18 at 11:50 a.m. while performing a test food tray task with Staff A (Director of Food Services) revealed that several residents trays were being taken out of the food cart by staff and served to residents. During this time one of the dirty trays came back to the food cart because the resident did not want their meal. One of the LNA's who were passing the food trays out placed the dirty tray back into the food cart were other residents clean trays were that have not been served yet. Also observed during this time was another LNA staff member placing a dirty food cover and empty milk carton into the clean cart. Both observation's where reviewed with Staff A who confirmed these had occurred Staff A stated these items should not be placed into the clean cart with the unserved food trays.",2020-09-01
322,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2018-11-30,921,D,0,1,KNHP11,"Based on observation and interview, it was determined that the facility failed to ensure a safe environment in regards to a readily accessible hot water faucet attached to the coffeemaker in 1 out of 2 kitchenettes observed. Findings include: Observation on 11/27/18 at approximately 9:20 a.m. in the second floor rehab unit kitchenette revealed that there was a readily accessible hot water faucet attached to the coffeemaker which Staff C (dietary manager) was able to pour hot water in a cup and tested with a thermometer which revealed a temperature of 177 degrees Fahrenheit. Further observation of the kitchenette revealed that there were 2 doors to access the kitchenette one door was closed and one door is open. Interview on 11/27/18 at approximately 9:20 a.m. with Staff C confirmed above findings. Staff C revealed that the kitchenette was accessible to residents, family members and staff and that the second floor rehab unit kitchenette is also used for residents who are in therapy and that the kitchenette was not locked. Staff C also revealed that there were wandering residents that goes in the second floor rehab unit kitchenette. Staff C stated that they were going to disable the hot water faucet. Observation on 11/29/18 at 9:45 a.m. of the second floor rehab unit kitchenette revealed that the hot water faucet attached to the coffeemaker was readily accessible as hot water was easily poured in a cup and temperature of the hot water was tested with a thermometer that read 185 degrees Fahrenheit. Interview on 11/29/18 at approximately 9:48 a.m. with Staff C confirmed the above findings observed on 11/29/18 at 9:45 a.m. and that Staff C will be contacting the coffeemaker company to disable the hot water faucet the day of 11/29/18. Observation on 11/29/18 at 3:00 p.m. of the second floor rehab unit kitchenette revealed that the hot water faucet attached to the coffeemaker was readily accessible as hot water was easily poured in a cup. Interview on 11/29/18 at 3:00 p.m. with Staff C confirmed the above findings on 11/29/18 at 3:00 p.m. and that Staff C was still trying to contact the coffeemaker company to disable the hot water faucet the day of 11/29/18. Interview on 11/30/18 at 8:10 a.m. with Staff C revealed that the coffeemaker company was not able to disable the hot water faucet attached to the coffeemaker on 11/29/18 due to staffing and was going to disable the hot water faucet on 11/30/18.",2020-09-01
323,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,550,B,0,1,XV1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy it was determined that the facility failed to have staff present with residents that were determined to need cueing and/or assistance with meals in 2 out of 3 dining areas. (Residents are: #4, #33, #35, #40, #51, #70, #71, #73 ,#81, and #92) Findings include: Observation on 01/25/18 at approximately 7:20 am of the second floor dining room revealed 4 residents seated in the dining room with no staff present. Residents waited for approximately 20 minutes to be served. There were two residents seated at one table and only one resident was served while the other resident sat and watched them eat their meal for approximately 15 minutes before being served his meal. The dining room floor was observed to be very dirty with left over food from the night before laying near a chair. Observation on 1/24/18 at approximately 7:55 a.m. to 8:20 a.m. of breakfast in the 2nd floor dining room revealed that there were 6 residents (Resident identifiers are #35, #40, #51, #70, #71 and #81.) in the dining room eating. There were no staff present in the dining room. Resident #40 was yelling out for assistance because he had dropped his fork on the floor. This surveyor had to leave the dining area to inform Staff I, Unit coordinator that Resident #40 needed assistance. Staff I, came in, assisted Resident #40 with another fork and left the dining area. Observation on 1/26/18 from approximately 7:35 a.m. through 7:50 a.m. of breakfast in the 2nd floor dining room revealed 5 residents present in the dining room eating. No staff were present in the dining area. Resident #35 was observed to have intermittent coughing episodes during breakfast. Resident #33 was noted to be encouraging Resident #51 to eat breakfast. Resident #33 was also assisting Resident #35 with peeling a banana. Observation on 1/26/18 at approximately 8:00 a.m. until 8:30 a.m. revealed Staff H, Licensed Nurse Assistant entered the dining room and asked Resident #35 if the resident was done with breakfast. Resident #35 responded, I don't like it. Staff H, LNA then removed the tray and did not offer Resident #35 an alternate breakfast. Review on 1/26/18 of care plans of the residents present in the dining room on the 2nd floor on 1/24/18 revealed 5 out of the 6 residents in the dining room required either cueing, supervision or assistance with meals: Resident #70's care plan revealed that meals in supervised area, created on 7/27/15. Resident #71's care plan revealed staff was to encourage resident to consume all fluids during meals. Resident #51's care plan revealed staff was to encourage resident to consume all fluids during meals. Resident #40's care plan revealed that Resident #40 exhibits or is at risk for impaired swallowing related [MEDICAL CONDITION](cerebro-vascular accident) with the following interventions: encourage resident to consume all fluids during meals, offer small amounts of fluids frequently, meals in supervised areas. Resident #81's care plan revealed that Resident #81 exhibits or is at risk for impaired swallowing related [MEDICAL CONDITION](cerebro-vascular accident) with the following interventions: encourage small sips/bites and cue as needed, encourage resident to chew and swallow each bite, encourage resident to consume all fluids during meals. Review on 1/26/18 of the facility policy and procedure titled, 3.12 Dining Service Standards, revision date 11/28/17 revealed: Policy, Patients/Residents are provided a positive meal experience. . Process . 2. Services provided are based on the needs of the patient/resident population assigned to dining location. Review on 1/26/18 of the facility policy and procedure titled, Meal Service in Dining Room, revision date 1/2/14 revealed: . 10. Assist patient with eating. . 10.2 Provide assistance/supervision based on patient's current level of self-performance in eating. Resident #4 Observation on 1/25/18 at approximately 8:30 a.m. of the 3rd floor dining room revealed that Resident #4 was sitting at a table in the dining room eating breakfast. Resident #92 arrived in the dining room, after staff reported that Resident #92 had eaten breakfast in the Main dining room. Resident #92 sat down at Resident #4's table and reached over and took the bowl of oatmeal in front of Resident #4, without Resident #4 offering it, and ate the bowl of oatmeal. Resident #92 then placed the empty bowl in front of Resident #4. Interview on 1/25/18 at approximately 8:45 a.m. with Staff [NAME] (Licensed Nursing Assistant), when Staff [NAME] came over to pick up the empty plate and bowl in front of Resident #4, confirmed that sometimes residents in this dining room will eat other residents' food. This surveyor informed Staff [NAME] that Resident #4 did not eat the oatmeal, but that Resident #92 did. Observation on 1/25/18 from approximately 8:45 a.m. until 9:00 a.m. revealed that Resident #4 was not offered another bowl of oatmeal. Resident #73 Observation on 1/26/18 at approximately 8:00 a.m. of the 3rd floor dining room revealed that Resident #73 had an overbed table placed in front of them, so that breakfast could be put on the table. Resident #73 was sitting in an upright positioned Broda chair against the wall away from other residents who were all sitting at tables. One table had 2 residents sitting at it with space enough for another resident. Interview on 1/26/18 at approximately 8:22 a.m. with Staff D (Unit Manager) confirmed that there was no particular reason that Resident #73 was using an overbed table and stated that it was probably because there was not enough space in the dining room.",2020-09-01
324,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,656,D,0,1,XV1Z11,"Based on record review, observation, and interview, it was determined that the facility failed to develop and implement a care plan for fall prevention and behaviors for 1 resident in a standard survey sample of 27 residents. (Resident identifier is #85.) Findings include: Observation on 1/24/18 at approximately 11:30 a.m. revealed Resident #85 ambulating independently in the hallway holding a folded incontinent brief, which visably contained feces on the inside of it. After ambulating in the hallway, with multiple staff walking by, Resident #85 went into Resident #85's room and placed the brief on Resident #85's overbed table. Resident #85 then picked the brief up again and was ambulating independently in the hallway, again ambulating past different staff members. A housekeeping staff member noticed and took the soiled brief from Resident #85, who then continued ambulating independently. Review on 1/25/18 throughout the day, revealed Resident #85 ambulating independently in the hallway, walking into other residents' rooms, with many different staff members walking by. Review on 1/25/18 of Resident #85's eInteract Change of Condition assessments revealed that Resident #85 had experienced 11 falls in the month of (MONTH) (YEAR). Review on 1/25/17 of Resident #85's current care plan revealed an intervention to Assist resident with ambulation providing one assist using a standard walker. The care plan also revealed that there was no care plan for Resident #85's wandering into other resident rooms or for Resident #85 picking up inappropriate items. Interview on 1/25/17 with Staff D (Unit Manager) confirmed that Resident #85 frequently ambulates independently and wanders into other residents' rooms. Staff D confirmed that at times Resident #85 picks up items from other areas and that this was not on the care plan.",2020-09-01
325,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,660,D,0,1,XV1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon a review of a closed record and a staff interview the facility failed to develop a discharge plan for 1 of 3 closed records in a suvey sample of 27 residents (Resident identifier is #98). Findings include: Resident #98 was admitted on [DATE] to the facility from an acute care hospital according to this resident's unsigned and undated facility Discharge Transition Plan form. This form noted that Resident #98 was at the facility from 1/5/17 until being discharged on [DATE]. This facility's Discharge Transition Plan resident's form noted under the section Recommendations at Discharge that Resident #98 should be on a regular, dysphagia advanced diet. Other than noting a recommendation for Resident #98's diet and the resident's height, weight, blood pressure, pulse and allergies [REDACTED]. Staff A (DON, Director of Nurses) during a 1/26/18 interview stated that the facility's Discharge Transition Plan form should have been completed by facility staff and was unable to provide any documentation from an interdisciplinary team to show that they had developed a discharge plan for Resident #98.",2020-09-01
326,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,661,D,0,1,XV1Z11,"Based upon record review the facility failed to document a discharge summary for 1 of 3 discharged residents in a survey sample of 27 residents. (Resident identifier #98). Findings include: Resident #98 according to the facility Discharge Transition Plan form was discharged from the facility on 10/31/17. A review of Resident #98's medical record revealed that there was no documentation of a discharge summary recapitulating this resident's stay including their course of illness, treatment or therapy while at the facility. There was no summation of Resident 98's medical status at the time of their 10/31/17 discharge or a reconciliation of Resident #98's pre-discharge and post-discharge medications. There was no documentation that the facility developed in collaboration with either Resident #98 or with Resident #98's legal representative a post-discharge plan of care for this resident. Resident #98's medical record did not address where Resident #98 would be living or the services both medical and non-medical Resident #98 needed for their follow up care.",2020-09-01
327,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,677,E,0,1,XV1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy it was determined that the facility failed to have staff present with residents that was determined to need cueing and/or assistance with meals in 1 out of 3 dining areas. (Residents are: #4, #33, #35, #40, #51, #70, #71, #73 ,#81, and #92) Findings include: Observation on 01/25/18 at approximately 7:20 am of the second floor dining room revealed 4 residents seated in the dining room with no staff present. Residents waited for approximately 20 minutes to be served. There were two residents seated at one table and only one resident was served while the other resident sat and watched them eat their meal for approximately 15 minutes before being served his meal. The dining room floor was observed to be very dirty with left over food from the night before laying near a chair. Observation on 1/24/18 at approximately 7:55 a.m. to 8:20 a.m. of breakfast in the 2nd floor dining room revealed that there were 6 residents (Resident identifiers are #35, 40, 51, 70, 71 and 81.) in the dining room eating. There were no staff present in the dining room. Resident #40 was yelling out for assistance because he had dropped his fork on the floor. This surveyor had to leave the dining area to inform Staff I, unit coordinator that Resident #40 needed assistance. Staff I, Unit Coordinator came in, assisted Resident #40 with another fork and left the dining area. Observation on 1/26/18 from approximately 7:35 a.m. through 7:50 a.m. of breakfast in the 2nd floor dining room revealed 5 residents present in the dining room eating. No staff were present in the dining area. Resident #35 was observed to have intermittent coughing episodes during breakfast. Resident #33 was noted to be encouraging Resident #51 to eat breakfast. Resident #33 was also assisting Resident #35 with peeling a banana. Observation on 1/26/18 at approximately 8:00 a.m. until 8:30 a.m. revealed Staff H, Licensed Nurse Assistant entered the dining room and asked Resident #35 if the resident was done with breakfast. Resident #35 responded, I don't like it. Staff H, LNA then removed the tray and did not offer Resident #35 an alternate breakfast. Review on 1/26/18 of care plans of the residents present in the dining room on the 2nd floor on 1/24/18 revealed 5 out of the 6 residents in the dining room required either cueing, supervision or assistance with meals: Resident #70's care plan revealed that meals in supervised area, created on 7/27/15. Resident #71's care plan revealed staff was to encourage resident to consume all fluids during meals. Resident #51's care plan revealed staff was to encourage resident to consume all fluids during meals. Resident #40's care plan revealed that Resident #40 exhibits or is at risk for impaired swallowing related [MEDICAL CONDITION](cerebro-vascular accident) with the following interventions: encourage resident to consume all fluids during meals, offer small amounts of fluids frequently, meals in supervised areas. Resident #81's care plan revealed that Resident #81 exhibits or is at risk for impaired swallowing related [MEDICAL CONDITION](cerebro-vascular accident) with the following interventions: encourage small sips/bites and cue as needed, encourage resident to chew and swallow each bite, encourage resident to consume all fluids during meals. Review on 1/26/18 of the facility policy and procedure titled, 3.12 Dining Service Standards, revision date 11/28/17 revealed: Policy, Patients/Residents are provided a positive meal experience. . Process . 2. Services provided are based on the needs of the patient/resident population assigned to dining location. Review on 1/26/18 of the facility policy and procedure titled, Meal Service in Dining Room, revision date 1/2/14 revealed: . 10. Assist patient with eating. . 10.2 Provide assistance/supervision based on patient's current level of self-performance in eating.",2020-09-01
328,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,686,D,0,1,XV1Z11,"Based on record review and interview, the facility failed to appropriately monitor and document the condition of a pressure ulcer for 1 resident in a standard survey sample of 4 residents with pressure sores. (Resident identifier is #73.) Findings include: Professional Reference: Per National Pressure Ulcer Advisory Panel (March 2014) The NPUAP Selected 'Quality of Care Regulations made easy . (See http://www.npuap.org/wp-content/uploads/2014/03/NPUAP-F-tag-final-March-2014.pdf accessed 1/29/2018) .Pressure Ulcers: With each dressing change or at least weekly .an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and: -Location and staging -Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; -Exudate, if present: type (such as purulent/serous) , color, odor and approximate amount; -Pain, if present: nature and frequency (e.g., whether episodic or continuous); -Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and -Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate . Review on 1/26/18 of Resident #73's Skin-Pressure Ulcer v (version) 6, dated 1/3/18, documentation form revealed that Resident #73 had an unstageable pressure area due to suspected deep tissue injury to Resident #73's right heel, which was first observed on 10/22/17. Weekly documentation was done from 10/22/17 until 1/3/18 on the Skin-Pressure Ulcer v 6 form including documentation of the location and staging, size, exudate, pain, wound bed and description of wound edges and surrounding tissue. There was no evidence of this documentation form being done after 1/3/18. Review on 1/26/18 of Resident #73's Skin check-v 2, dated 1/11/18, 1/18/18, and 1/25/18, documentation form revealed the evidence of a pressure sore to Resident #73's right heel, without the other recommended information, including wound staging, size, exudate, pain, wound bed and wound edges. Interview on 1/26/17 at approximately 1:00 p.m. with Staff D (Unit manager) confirmed that Resident #73 continued to have a pressure sore on the right heel. Staff D also confirmed that there was no documentation of details on the condition of Resident #73's pressure sore after 1/3/18 and that there should have been weekly documentation of the wound specifics.",2020-09-01
329,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,697,D,0,1,XV1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that the facility failed to adequately assess a resident and to provide pain medication to 1 resident in a standard survey sample of 27 residents. (Resident identifier is #24.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 699 .Prescribers must document the diagnosis, condition, or need for use for each medication ordered .When administering medications, document the assessment made and the time of medication administration. Make frequent evaluation of the effectiveness of the medication, and record findings in the appropriate record . Page 708 .The prescriber often gives specific instructions about when to administer a medication . Page 1063 .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity . Observation on 1/24/18 at approximately 8:30 a.m. of Resident #24 revealed that Resident #24 was continuously rubbing the left arm with the right hand. Interview on 1/24/18 at approximately 8:30 a.m. with Resident #24 revealed that Resident #24 complained of pain as being awful, and that rubbing the arm was to help with the pain. Resident #24 also revealed that the pain medications given to Resident #24 were ineffective. Resident #24 stated that they did not always like taking the pain medication. Review on 1/24/18 of Resident #24's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/16/17 revealed that under Section J0400, Resident #24 answered the question of Pain Frequency as Constantly. Under Section J0600, Resident #24 answered the question of Pain Intensity as Severe. Review on 1/24/18 of Resident #24's (MONTH) (YEAR) Medication Administration Record [REDACTED]> (greater than) 100.0; Mild Pain . Review also revealed that Resident #24 also had an order for [REDACTED]. Review on 1/24/18 of Resident #24's Medication Administration Record [REDACTED]. Resident #24 also received [MEDICATION NAME]-[MEDICATION NAME] on 1/4/18, 1/9/18, 1/14/18, 1/15/18, 1/16/18, 1/20/18, 1/23/18, and 1/25/18. Review on 1/24/18 of Resident #24's PRN (as needed) Pain Management Flow Sheet, revealed that Resident #24 received [MEDICATION NAME]-[MEDICATION NAME] on 1/5/18, 1/9/18, 1/14/18, 1/15/18, 1/16/18, 1/20/18, 1/21/18 (not documented on Medication Administration Record,) 1/22/18 (not documented on Medication Administration Record,) 1/23/18, and 1/25/18. Review of the PRN Pain Management Flow Sheet also revealed that only the dose received on 1/16/18 showed an assessment for level of pain prior to receiving the dose and that the doses received on 1/5/18, 1/14/18, 1/15/18, 1/21/18, and 1/23/18 had no documentation of the level of pain after the medication was administered. Interview on 1/26/18 with Staff D (Unit Manager) confirmed that there was not clear direction of whether to give [MEDICATION NAME] or [MEDICATION NAME]-[MEDICATION NAME] for Resident #24's pain. Staff D also confirmed that there should have been documented assessments of Resident #24 pain level both before and after pain medication administration.",2020-09-01
330,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,711,D,0,1,XV1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow the physician orders [REDACTED]. (Resident identifiers are #34 and #73.) Findings include: Resident #34 Review on 1/26/18 on Resident #34 of MAR (Medication Administration Record) at approximately 11:00 a.m. revealed a January's physicians order as follows: ProAir HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albutaerol Sulfate HFA) 1 puff inhale orally two times a day related to unspecified asthma, uncomplicated, use with a spacer- with a start date of 1/9/2018. Review of the MAR indicated [REDACTED]. (MONTH) 13th-January 14th only one dose was given with no explanation why the second dose was not given. Interview on 1/26/18 at approximately 12:30 p.m. with Staff B, RN (Registered Nurse/Unit Manager) reviewed the January's MAR's and confirmed that the physician's orders [REDACTED]. Resident # 73 Review on 1/25/18 of Resident #73's RMS (Risk Management Solutions) Event Summary Report, dated 1/20/18, revealed that Resident #73 was given another resident's medications on 1/20/18 at 8:00 a.m. The medications that Resident #73 was given were [MEDICATION NAME] 80mg, [MEDICATION NAME] 5mg, and [MEDICATION NAME] 850mg. Interview on 1/26/17 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed that these were medication errors and that in the incident with Resident #73, it was determined by the facility that the very new nurse who administered the medications needed more supervision.",2020-09-01
331,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-01-26,759,D,0,1,XV1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation medication administration, review of medication administration, manufacturer's instruction, record review and interview it was determined that the facility failed to ensure the medication error rates less than 5%. (Resident identifiers are #37 and #74.) Findings include: Observation of medication pass on 1/25/18 and 1/26/18 revealed that there were 27 opportunities observed and 2 errors revealed. The facility medication error rate was at 7.4%. Resident #37 Observation on 1/25/18 at approximately 7:40 a.m. of medication administration revealed Staff G (LPN) Licensed Practical Nurse obtaining the blood pressure for Resident #37. There was no observation of a heart rate being obtained. Review of Resident #37s Medication Administration Record [REDACTED]. Interview with Staff G, LPN confirmed that the heart rate was not obtained by any staff member prior to administering the medication. Resident #74 Observation on 1/26/18 at approximately 12:15 p.m. of medication administration revealed Staff F (LPN) Licensed Practical Nurse pouring [MEDICATION NAME] Suspension into a medication. This surveyor observed Staff F remove the bottle of [MEDICATION NAME] from the medication cart and did not shake medication prior to pouring the medication into the medication cup and administering the medication. Review of Resident #74s Medication Administration Record [REDACTED]. Interview on 1/26/18 with Staff F at approximately 12:20 p.m. confirmed that the [MEDICATION NAME] Suspension was not shaken prior to administration. Review on 1/26/18 at approximately 1:30 p.m. of [MEDICATION NAME] Suspension, (pronoun omitted) Drug Information, Revised (MONTH) (YEAR) revealed: . How to use: . Shake this medication well before each dose.",2020-09-01
332,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2019-10-21,676,D,0,1,9BOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to give the appropriate treatment and services to maintain 1 of 1 resident's ambulation status by providing appropriate fitting shoes to be able to carry out their activities of daily living, in a final survey sample of 25 residents. (Resident identifier is #53). Findings include: Interview on 10/16/19 at 9:15 a.m. with Resident #53, revealed that due to her orthopedic fitted shoes not fitting correctly Resident #53 no longer is able to walk due to the pain when standing in them. Resident #53 went on to state that they have had the same pair of orthotic shoes for years and years. Record review on 10/16/19 at 10:00 a.m. revealed a nurses note dated 5/1/19 that states New DTI (Deep Tissue Injury) to tip of toe. At this time, resident continues to choose to wear shoes. Education provided related to potential for shearing and for continued decline of area . Review of Resident #53's medical record on 10/21/19 revealed several physician orders [REDACTED].>On 5/8/19 Please monitor (right) big toe for (increase) infection, redness, discharge and pain every shift. Please report to provider if (signs and symptoms) of infection occur. On 8/21/19 Redness, streaking, warmth to great left toe resident has pain to area, Infection suspected, localized. On 9/11/19 Podiatry consult for (left) great toe infection. Review of Resident #53's medical record on 10/18/19 revealed a podiatry note dated 7/29/19 which stated Resident #53 had an Ulcer on left toe measuring 0.1mm x 0.1 mm x 0.2mm. Under progress note it stated I recommend extra-depth shoes and custom-molded inserts due to the following condition(s):-History of previous foot ulceration: Poor circulation: Foot deformity: History of pre-ulceration callus . Review on 10/21/19 at 9:30 a.m. revealed Resident #53's medical record has a progress note/order written by an outside provider stating This must be completed by the patient's MD or DO on the date of the in-person visit the progress note also states: During 8/19/19 in-person visit addressing diabetes management. I reviewed a copy of the podiatric medical records and agree that the patient has the qualifying foot conditions which would render diabetic shoes and inserts a medical necessity because of the diabetes This progress note/order was not signed by the physician until 10/9/19 (approximately two months after the original request). Interview with Staff A (Administrator) on 10/22/19 confirmed the request for new shoes was made after the order was signed on 10/9/19 but it would still take another month before Resident #53 would have proper fitting shoes. Record review on 10/22/19 at 10:45 a.m., revealed that the facility assessment tool Skin Check-V3 revealed as of 10/17/19 under New Skin Injury/Wound(s) 9a. Bleachable redness to right 3rd, 4th, and 5th toes. Since the initial identification of a skin issue on 4/30/19, and as of the date of survey on 10/21/19, Resident #53 still had not received proper fitting shoes to prevent pressure as stated above and was still having ongoing issues with their shoes. Interview on 10/21/19 11:33 a.m. with Resident # 53 again confirmed that her ambulation had decreased due to the fact that her toes hurt so much she used her wheelchair in the room instead of ambulating which she used to do.",2020-09-01
333,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2019-10-21,742,D,0,1,9BOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to reassess a resident's psychosocial adjustment to the facility when the resident's service dog was removed from the facility for 1 resident out of a final sample of 25 residents. (Resident identifier is #234.) Findings include: Observation on 10/16/19 at approximately 11:00 a.m. of Resident #234 revealed the resident sobbing and crying. Interview on 10/16/19 at approximately 11:00 a.m. with Resident #234 revealed that Resident #234 had a service dog at the facility and it was removed on 10/15/19. Resident #234 was visually distraught and stated, This is when my dog knows to comfort me, if my dog sees me upset and crying like it crawls right up on me and makes me feel better. The only reason I came to this facility was because they told me I could have my service dog with me. I just had to send my company away because I can't even visit with them without crying. Review on 10/16/19 of Resident #234's medical [DIAGNOSES REDACTED]. Review on 10/18/19 of Resident #234's medical record revealed that Resident #234 was admitted on [DATE]. Review of Resident #234's behavior monitoring sheets revealed that Resident #234 was being monitored for verbalized depression and crying. The behavior sheet had documented crying on 10/16/19 and 10/17/19. No behaviors were exhibited prior to 10/16/19. There were no documented visits by social worker after the dog being removed. Interview on 10/18/19 at approximately 9:30 a.m. with Staff C (Social Worker) revealed that there were no documented visits by Staff C after the service dog was removed. Interview on 10/18/19 at approximately 11:45 a.m. with Staff D (Director of Nurses) revealed that the service dog was removed from the facility on 10/15/19 for several reasons. Resident #234 had fallen out of the wheelchair while attempting to take the dog to the bathroom outside. The dog was not house broken and also jumped onto other residents, including 1 resident with wounds on the lower extremities. This was discussed with Resident #234 and the resident voiced understanding. The caregiver for the service dog was encouraged to bring the dog to visit with Resident #234. Interview on 10/18/19 at approximately 12:15 p.m. with Staff A (Administrator) revealed that there was a verbal agreement that Resident #234 could have the service dog in the facility as long as the resident could care for the dog. Staff A confirmed that after the dog was removed from the facility that there were no assessments performed or new interventions put into place for Resident #234 psychosocial well being.",2020-09-01
334,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2019-10-21,812,E,0,1,9BOR11,"Based on observation and interview it was determined that the facility failed to maintain both the walk-in refrigerator and freezer in proper working order to prevent ice build up and maintain cleanliness of the equipment and environment. Findings include: Observation on 10/16/19 at 8:35 a.m. during the initial tour with Staff B (Director of Food Services) revealed that both the walk-in freezer and walk-in coolers were in need of repair. The freezer's door when entering the unit had large amounts of ice build up around it. The condenser in the back of the unit had large amounts of ice build up on it. During this observation it was noted that some of the food products and side shelf by the door had ice build up on them from the back of the freezer's condenser dripping. Observations were shown to Staff B. The door to the walk-in freezer was bent/separated from the front of the freezer box preventing the gasket to seal which caused ice build up on the outside of the freezer door. Observation on 10/16/19 at 8:45 a.m. revealed that the floors of the walk-in freezer unit in the kitchen were dirty and in poor condition. This observation was shown to Staff B who stated the floors are difficult to clean since there is a seam in the middle of the floor. When the floor is washed the water goes down into the seam and rust/brown material comes up through the seam. Observation during continuation of tour in the walk-in refrigerator revealed areas of rust that have built up and were unable to be cleaned. Observation on 10/16/19 at 8:50 a.m. revealed that the kitchen floor by the three compartment sink had a grease trap that was lifted above the floor making it a tripping hazard. The gap around the grease trap had silicone around the edges. Interview of 10/16/19 at 9:10 a.m. Staff B stated they use this after cleaning the trap, most of the silicone was missing which caused a gap around the grease trap making it an uneven surface/floor and unable to be cleaned.",2020-09-01
335,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-12-07,580,D,0,1,J2XK11,"Based on interview and record review, it was determined that the facility failed to notify a resident's physician and one DPOAH (Durable Power of Attorney for Health) of a decline in medical condition for 3 residents in a standard survey sample of 26 residents. (Resident identifiers are #53, #85 and #96.) Findings include: Resident #53 Review on 12/6/18 at approximately 11:40 a.m. of Resident #53's medical record reveals a note from the dietician dated 11/12/18 that Resident #53 triggered for a significant weight loss of -10.7% in one month. Review of Resident #53's 11/3/18 quarterly MDS (Minimum Data Set) reveals that section K 0300 is marked to indicate significant weight loss. Interview on 12/7/18 at approximately 8:40 a.m. with Staff F (Center Nurse Executive) confirms that Resident # 53's primary care physician was not notified of the significant weight loss. Staff F reviewed Resident #53's medical record and confirmed that there should have been documentation in the medical record that the physician was notified of Resident #53's significant weight loss and there was no documentation. Resident #85 Observation on 12/4/18 at 12:05 p.m. during the lunch meal time it was observed that Resident #85 was observed grimacing and pointing to Resident#85's mouth area while eating when asked if it was painful. Review on 12/4/18 of Resident #85's dental exam, dated 10/8/18, revealed that patient allowed exam today and that several teeth need to be extracted and that several teeth are in very poor shape. The only option would be to extract all of the upper teeth. Resident #85 is very difficult to communicate with. Further review of Resident #85's medical record revealed no documentation of notification to the DPOA to have this procedure completed. Interview on 12/7/18 at approximately 11:07 a.m. with Staff J (Unit Manager) confirmed that Resident #85's DPOA should have been been notified of Resident #85's need for dental work. Inteview with Staff J at 11:39 a.m. DPOA was made aware of Resident #85's dental needs and the DPOA requested the Resident #85 needs be met. Resident #96 Review on 12/5/18 of Resident #96's weight records revealed that on 11/6/18 weight recorded was 115 lbs. (pounds), 11/15/18 weight recorded was 104.2 lbs. and the next recorded weight was on 11/26/18 which was 99 lbs, respectively. Further review of Resident #96's weight record revealed that the weight on 11/15/18 which was 104.2 lbs. was 10.8 lbs. less than the weight on 11/6/18 which was 115 lbs. Review on 12/6/18 of Resident #96's dietician notes revealed that on 11/16/18 Staff [NAME] (Dietician) requested a reweigh to confirm triggered weight loss. Review on 12/6/18 of Resident #96's nurses notes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed that there were no nurses notes regarding notification of weight loss to the physician/APN/P[NAME] Review on 12/6/18 of Resident #96's physician and nurse practitioner notes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed that there were no physician or nurse practitioner notes regarding Resident #96's weight loss on 11/15/18. Interview on 12/7/18 at 9:45 a.m. with Staff B (Unit Manager) confirmed the above findings. Staff B revealed that there should have been a reweight on 11/15/18 and on 11/16/18 when dietician had requested for a reweight and the physician should have been notified. Interview on 12/7/18 at 9:52 a.m. with Staff [NAME] confirmed that reweight was not done on 11/15/18 and Staff [NAME] had requested a reweight on 11/16/18. Staff [NAME] revealed that the nurses staff were the ones that would notify the physician of any weight loss or weight gain.",2020-09-01
336,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-12-07,658,D,0,1,J2XK11,"Based on interview and record review, it was determined that the facility failed to follow physician's orders for 1 resident out of a final sample size of 26 residents. (Resident identifier is #96.) Findings include: Review on 12/6/18 of Resident #96's MD (Doctor of Medicine)/Nursing communication form dated 11/27/18 revealed that .Weight warning value: 99.0 .MDS (Minimum Data Set): -5.0% (percent) change over 30 days .response: ?IBW? (Ideal Body Weight) House supplement BID (twice a day), if underweight which was signed by Staff H (Advance Practice Registered Nurse) on 11/28/18. Interview on 12/6/18 at 2:04 p.m. with Staff C (Registered Nurse) revealed that the MD/Nursing communication form dated 11/27/18 was a weight warning for Resident #96, who had loss more than 5% over 30 days and that Resident #96's weight on 11/27/18 was 99 lbs. (pounds). Staff C also revealed that Staff H had ordered for Resident #96 to have a House supplement BID, if underweight, that was signed on 11/28/18 as response to the weight warning on 11/27/18. Review on 12/6/18 of Resident #96's weight record revealed that Resident #96's IBW was 120 lbs. Record review on 12/6/18 of Resident #96's (MONTH) and (MONTH) (YEAR) EMAR (Electronic Medical Administration Record) revealed that there was no order for House supplement entered in the EMAR to be given to Resident #96. Review on 12/6/18 of Resident #96's nurses notes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed that there were no nurses notes regarding the House supplement order on 11/28/18 by Staff H being followed through by nurses as to continue the House supplement as ordered, and if Resident #96 was underweight or not. Interview on 12/6/18 at 2:04 p.m. with Staff C confirmed that there was no order in place for Resident #96 to have House supplement BID since 11/28/18 nor were there nurses notes from 11/28/18 to 12/6/18 regarding Resident #96's House supplement BID order. Interview on 12/7/18 at 9:45 a.m. with Staff B (Unit Manager) confirmed that the House supplement BID for Resident #96 was not in the EMAR. Staff B revealed that the order for House supplement BID on 11/28/18 was supposed to be entered in the EMAR to be given to Resident #96.",2020-09-01
337,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-12-07,689,D,0,1,J2XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, it was determined that the facility failed to provide an environment that is free from accident hazards over which the facility has control and provides supervision for 3 residenets out of a final survey sample of 26. (Resident identifiers are #53, #77, and #149.) Findings include: Resident #149 Review on 12/4/18 of Resident #149 medical record revealed that they were admitted to the facility by family for respite care. At time of admission a care plan was created with a (Focus) area that states Resident is at risk for falls: cognitive loss, lack of safety awareness, history of falls. The (Interventions) are Maintain a clutter-free environment in the residents room and consistent furniture arrangement, and When resident is in bed, place all necessary personal items within reach . Review of Resident #149's nurses notes dated 12/4/18 at 13:33 state Residents wife asked this writer to look at (Resident #149) elbow at approximately 1300, left elbow has a 3.7cmx2cm skin tear with bruising around it . Resident has an abrasion 0.3cmx0.1cm on top of left hand, and a 0.2 cm x 0.2cm abrasion on right knee. Resident reports to this writer, that he fell , he asked his roommate for help, he stated he was able to crawl on the floor on his hands and knees but use unable to express how he got off the floor, resident unable to clearly state which day he fell , he stated 'it was a couple days ago'. Since this fall on 12/4/18 another (Intervention) was added to the care plan which states Frequent safety checks while in room . Review on 12/5/18 at 03:33 Resident #149's nurses notes state Staff responding to noise found resident sitting on floor by bathroom door. resident alert, at baseline confusion, denied pain, no new injury noted. attempting to climb off floor. 2 assist off floor . On the same day at 13:52 nurses notes state .bruising observed to left eye Review on 12/4/18 of the Event Summary Report dated 12/5/18 under root cause/conclusion it states roommate keeps room black, with very poor lighting, poor furniture arrangement excessive clutter, personal items not within reach. Interview on 12/6/18 at 1:30 p.m. with Staff F (DON) was asked if Resident #149 is on Frequent safety checks while in room as part of there care and where do they document that this intervention being performed? Staff F stated they do not, they just look in the room when walking by. Staff F was asked if Frequent safety checks while in room are part of the care plan what is the frequency that was different then before when Resident #149 sustained a fall on 12/4/18 and Staff F stated There is no time just when aid's walk the halls they are to look into Resident #149's room. Also Staff F was asked why Resident #149's personal items were not in reach, along with poor furniture arrangement and excessive clutter, since this also was part of the care plan which could contribute to Resident #149's fall with injury on 12/5/18. Resident #53 Review on 12/6/18 of Resident #53's medical record reveals that resident #53 has had 13 falls from 10/9/18 to 12/2/18. Resident #53 has medical [DIAGNOSES REDACTED]. Review of Resident #53's Care Plan reveals a focus area of Resident is at risk for falls: cognitive loss, lack of saftey awareness and has an intervention in place that states Visual saftey checks as often as possible to ensure resident is not on floor that was initiated on 11/23/18. Inerview on 12/7/18 at approximately 10:00 a.m. with Staff J (Unit Manager) reveals that the facility does not have a system in place to document that Visual safety checks have been done by staff. Staff J states that the LNA's (Licensed Nursing Assistants) know if a Resident is on Visual safety checks if it is listed on the Kardex, but there is no system in place to document whether or not staff has actually done a Visual safety check. Resident identifier #77 Review on 12/6/18 of Resident #77's elopement assessment dated [DATE] revealed that the resident was identified as an elopment risk as follows: 1. Yes, patient is able to ambulate or self-propel wheelchair independantly 4. Yes, patient has a history of actual elopement or attempted elopement. 5. Yes, patient has a history of wandering that places the patient at significant risk of getting to a potentially dangerous place, e.g., stairs, outside the facility 8. Yes, patient has expressed desire to leave; e.g., go home, talked about going on a trip, attempted to pack belongings 11a. Yes, patient exhibits one or more emotional state or behavior that may result in exit-seeking behavior: check all that apply (frustration, other.) 11b. Describe other from of above- historical from hospital stay;exit seeking. Interview on 12/7/18 at approximately 9:30 a.m. with Staff B (Unit Manager) revealed that the facility did not implement any interventions or plan of care for Resident #77's elopement risk.",2020-09-01
338,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-12-07,741,D,0,1,J2XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility failed to implement non-pharmacological interventions for 1 resident out of 1 resident reviewed with [MEDICAL CONDITION] in a standard survey of 26. (Resident identifier is #77.) Findings include: Review on 12/7/18 of Resident #77's medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review on 12/7/18 of the hospital Psychiatry Consult note, dated 9/11/18 revealed that the Psychiatry consult was requested for purpose of assessment of suicidal ideation and decision making capacity. Within this consult it revealed that (pronoun omitted) reported [MEDICAL CONDITION] on 9/11/18 to the psychiatrist and has had at least one possible attempt prior to this consult and 1 hospital stay in the past requiring a 10 day admission for [MEDICAL CONDITION]. Plan and recommendations were noted from Psychiatry 1. Environmental safety is a priority for this patient. No sharp objects should be within arm's reach of this patient. Medical equipment should be used with supervision (therapy bands) 3. Thirty minute checks for safety Review on 12/7/18 of nursing notes in Resident #77's medical record revealed that on 9/20/18 that Resident #77 had [MEDICAL CONDITION] with a plan requiring a hospital evaluation. Interview on 12/7/18 at approximately 10:00 a.m. with Staff B (Unit Manager) revealed that there was no plan of care for Resident #77's [MEDICAL CONDITION] and no interventions put into place for [MEDICAL CONDITION]. Observation on 12/7/18 at approximately 11:30 a.m. Resident #77 was unattended in the elevator and had nail clippers in hand. Interview on 12/7/18 at approximately 1:00 p.m. with Staff A (Social Worker) revealed that there was no documentation of Social Services following up with Resident #77 since the hospital evaluation on 9/20/18.",2020-09-01
339,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-12-07,790,D,0,1,J2XK11,"Based on medical record review, observation and interview it was determined that the facility failed to provide dental service within three days for 1 resident in a standard survey sample of 26 residents. (Resident identifier is #85.) Findings include: Observation on 12/4/18 at 12:05 p.m. during the lunch meal time it was observed that Resident #85 was observed grimacing and pointing to Resident #85's mouth area while eating when asked if it was painful. Review of the 8/24/18 Quarterly Minimum Data Set (MDS) revealed that Resident #85 has no natural teeth- broken loosely fitting full/partial denture. Review of the active care plan revealed the following intercventions for Resident #85 to monitor for change in fit or use of dentures, monitor for changes in nutritional /hydration status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and notify physician /food and nutrition as indicated dentures. Monitor for discomfort in mouth, broken or loose teeth. Resident #85 has an activated durable power of health care attorney.(DPOA) Review on 12/4/18 of Resident #85's dental exam, dated 10/8/18, revealed that patient allowed exam today and that several teeth need to be extracted and that several teeth are in very poor shape. The only option would be to extract all of the upper teeth. Resident #85 is very difficult to communicate with. Interview on 12/7/18 at 11:00 a.m. with Staff J (Unit Manager) revealed that the denture became missing on Sunday night, which was 8/5/18. No documentation that any dental referral or documentation to the DPOA was initiated when the dentures became missing. Review on 12/7/18 of Resident #85's dietary intake record revealed a slight declined in diet intake. Resident #85 has had a 5.59% decrease in weight in 5 months; with only 1% in one month. Interview on 12/7/18 at approximately 11:07 a.m. with Staff J (Unit Manager) confirmed that Resident #85's DPOA should have been been notified of Resident #85's need for dental work. Inteview with Staff J at 11:39 a.m. DPOA was made aware of Resident #85's dental needs and the DPOA requested the Resident #85 needs be met.",2020-09-01
340,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-12-07,812,E,0,1,J2XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure food was properly labeled and dated and that there were no expired foods in the kitchenettes for 2 out of 2 observed kitchenettes. (Resident identifier is #9.) Findings include: Policy review Review on [DATE] of facility's policy titled, Food and Nutrition Services Polices and Procedures, revision date [DATE], revealed that .25. Food that are marked with the manufacturer's used by date that are properly stored can be used until the date as long as the product has not been combined with any other food or prepared in any way including portioning . Review on [DATE] of facility's policy titled, Food and Nutrition Services Use By Dating Guidelines, revision date of [DATE], revealed that .The manufacturer's expiration date, when available, is the use by for unopened items. The manufacturer's instructions for use by date of opened items overrides these guidelines .Ready-to-eat .milk .cheese .thickened liquids . Use by date seven days after opening . Observation on [DATE] at 9:40 a.m. of the second floor kitchenette refrigerator with Staff D (Food Director) revealed that there was one opened nectar-thick cranberry juice that was half-full that had no open date or use by date on the carton. And per the manufacturer's instructions on the carton, the nectar-thick cranberry juice was good for seven days when opened. Observation of the second floor kitchenette refrigerator also revealed that there was an opened [MEDICATION NAME] milk with no open date or use by date on the carton and per manufacturer instructions on the carton, the [MEDICATION NAME] milk was good for seven days when opened. Further observation also revealed that there were pre-sliced cheese that had a use by date of ,[DATE] and an open container of milk-like substance with unreadable label and no date on the container. Interview on [DATE] at 9:40 a.m. with Staff D confirmed above findings. Staff D revealed that the nectar-thick cranberry juice and [MEDICATION NAME] milk should have been labeled with a use by date and that the pre-sliced cheese should have been removed. Staff D also revealed that they didn't know what was in the container with the milk-like substance. Interview on [DATE] at 9:45 a.m. with Staff B (Unit Manager) revealed that the container with the milk-like substance found in the second floor kitchenette was a tube feeding supplement for Resident #9. Staff B confirmed that the container with the milk-like substance had a tape on the cover of the container that was unreadable and no open or use by date. Observation on [DATE] at 9:47 a.m. of the third floor kitchenette refrigerator with Staff D revealed that there were two cartons of dairy pure product (milk) one with an expiration date of [DATE] and the other one with an expired date of [DATE]. Interview on [DATE] at 9:47 a.m. with Staff D confirmed the two expired dairy pure product. Observation on [DATE] at 9:03 a.m. on the second floor kitchenette refrigerator revealed that there was one half-and-half milk carton that was opened and no open date or use by date with a manufacturer's instruction that revealed that once opened the half-and-half milk was good for seven days. Interview on [DATE] at 9:03 a.m. with Staff G (Licensed Nursing Assistant) confirmed that the half-and-half milk carton was not labeled with an use by date. Staff G revealed that the half-and-half milk should have been labeled.",2020-09-01
341,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2018-12-07,842,B,0,1,J2XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to document finger stick blood glucose results on the resident records for 1 resident out of a final sample size of 26 residents. (Resident identifier is #68.) Findings include: Review on 12/7/18 of Resident #68's (MONTH) and (MONTH) (YEAR) EMAR (Electronic Medication Administration Record) revealed that Resident #68 had an order for [REDACTED]. Further record review revealed that there were only check marks and nurse's initial on the EMAR and no finger stick blood glucose results recorded. Review on 12/7/18 of Resident #68's diabetes care plan revealed an intervention to record blood glucose levels per physician orders. Review on 12/7/18 of Resident #68's blood sugar records revealed that the last recorded blood sugar was on 10/15/2018. Interview on 12/7/18 at 9:47 a.m. with Staff B (Unit Manager) confirmed the above findings. Staff B was unable to provide explanation as to why the blood sugar results were not documented.",2020-09-01
342,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,580,D,0,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to notify the resident's physician of a weight change for 1 of 1 resident with an orders to notify physician of weight changes in a final survey sample size of 34 (Resident identifier #295.) Findings include: Review on 1/7/19 of Resident #295's physician orders [REDACTED].>3 lbs (greater than 3 pounds) or more. Review on 1/7/19 of Resident #295's weight record revealed that on Wednesday 12/26/18 the resident's weight was documented as 175 and on Thursday 12/27/18 the resident's weight was recorded as 180.4. The weight difference is a 5.4 pound gain. Review on 1/7/19 of Resident #295's progress notes from 12/26/18 to 1/1/19 revealed there was no documentation of a notification to Resident #295's provider of the 5.4 pound weight gain between 12/26/18 and 12/27/18. Interview on 1/8/19 at 9:07 a.m. with Staff D (Director of Nursing) confirmed the above weight change and that there was no documentation of the change to the provider. Interview also revealed that there was no documentation of a notification to the provider of the weight change elsewhere.",2020-09-01
343,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,584,B,0,1,ZVIF11,"Based on observation, interview and review of facility policy and procedure it was determined that the facility failed to maintain a clean environment for 1 resident of 1 resident with a tube feeding in a final sample of 34 residents. (Resident identifier is #36.) Findings include: Observation on 1/2/19 at approximately 7:00 p.m. of Resident #36's room revealed that the tube feed pole had a substance that was tan/beige in color adhered to the base of the pole and the pole. The substance appeared to be tube feeding. Observation on 1/3/19 at approximately 2:00 p.m. of Resident #36's room revealed that the tube feed pole had the same substance that was tan/beige in color adhered to both the base of the pole and the pole. The substance appeared to be tube feeding. Observation on 1/4/19 at approximately 10:45 a.m. of Resident #36's room revealed that the tube feed pole had the same substance that was tan/beige in color adhered to both the base of the pole and the pole. The substance appeared to be tube feeding. Interview on 1/4/19 at approximately 11:00 a.m. with Staff [NAME] (Unit Manager) revealed that Staff [NAME] had been notified today of the dried tube feeding adhered to the pole. Staff [NAME] confirmed that the tube feed pole and base of the pole had dried tube feeding adhered to it. Staff [NAME] revealed that stationary patient equipment that is kept in a patient's room is cleaned as needed, weekly or when tubing is changed. Review on 1/4/19 of the facility policy and procedure titled, IC201 Cleaning and Disinfecting, revision date 7/24/18 revealed: .Purpose . To ensure reusable medical equipment is cleaned and disinfected appropriately. Practice Standards .5. Perform routine disinfection of items used in daily care practices with Environmental Protection Agency .",2020-09-01
344,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,610,D,1,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined that the facility failed to thoroughly investigate a bruise and a skin tear for 1 resident and to perform observations and education after a medication error for 1 resident in a final survey sample of 42 residents. (Resident identifiers are #62 and #70.) Resident #62 Review on 1/3/19 of the Facility Report to the Long Term Care Ombudsman . dated 11/13/18, revealed that Resident #62 received Levetiracetam, in error, instead of [MEDICATION NAME] on 11/4/18. The report also revealed that the facility planned to do a medication pass observation/education with the nurse who had made the error. Interview on 1/8/19 at approximately 2:00 p.m. with Staff G (Administrator) revealed that there was no documented evidence that a medication pass observation or education was done with the nurse who had made the medication error. Resident #70 Observation on 1/3/19 at approximately 8:45 a.m. of Resident #70's anterior right wrist revealed a 3 cm. (Centimeter) x 2.5 cm bruise that was purple with a greenish color noted. Resident is noted to be a poor historian. Resident #70 is dependant on staff with all activities of daily living and is unable to self propel broda-wheelchair. Interview on 1/3/19 at approximately 8:50 a.m. with Staff [NAME] (Unit Manager) revealed by Staff [NAME] looking at Resident #70's right forearm that Resident #70 had a bruise. Staff [NAME] revealed that there was no investigation to how Resident #70 obtained the bruise. Resident #70 said, I did not know that bruise was there. Review on 1/8/19 at approximately 9:00 a.m. with Staff D (Director of Nurses) revealed that the anterior right wrist bruise was not investigated. Review on 1/8/19 of skin checks performed weekly by nursing (date range from 11/24/18 - 1/2/19) did not identify the bruise on Resident #70. Review on 1/7/19 of the RMS (Risk Management System) dated, 10/29/18 revealed that Resident #70 obtained a skin tear on the left forearm that was unwitnessed. Resident #70 required 2 steri strips on 10/29/18 to the skin tear. Interview on 1/8/19 at approximately 1:00 p.m. with Staff D revealed that there was no investigation into the cause of Resident #70 obtaining this skin tear.",2020-09-01
345,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,625,B,0,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to provide the resident or resident's representative with written information about the bed hold policy in 2 of 4 residents reviewed with hospitalization s in a final survey sample of 34 residents. (Resident identifiers #27, and #295.) Findings include: Resident #295 Interview on 1/4/19 at approximately 1 p.m. with Staff B (Unit Manager) revealed that Resident #295 was transferred to the hospital that morning for respiratory distress. Interview on 1/7/19 at 11:00 a.m. with the Staff K (Social Worker) revealed that social services notifies the ombudsman of a resident's transfer or discharge but does not give written information about the bed hold policy to the resident or their representative. Interview on 1/7/19 at 11:06 a.m. with Staff J (Business Office Manager) revealed that Staff J does not give written information about the bed hold policy to residents or their representative at time of transfer to the hospital. Staff J will follow up with a call after a few days if looks like the resident will not return quickly to see if they want to hold their bed. Resident #47 Review on 1/7/19 of Resident #47's nursing progress notes revealed that Resident #47 was admitted to an acute care hospital on [DATE] and returned to the facility on [DATE]. There was no documented evidence that Resident #47 or their representative was offered a bed hold. Interview on 1/8/19 at approximately 12:30 p.m. with Staff I (Social Service Director) confirmed that there was no documented evidence that a bed hold was discussed with Resident #47 or their representative.",2020-09-01
346,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,655,D,0,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop a baseline care plan for [MEDICAL TREATMENT] and a care plan for the use of antipsychotic medication for 2 residents in a final survey sample of 34 residents. (Resident identifiers are #47 and #142.) Findings include: Resident #47 Interview on 1/3/19 at approximately 9:45 a.m. with Resident #47 revealed that Resident #47 went to [MEDICAL TREATMENT] 3 times per week and that they were on a fluid restriction. Interview on 1/8/19 at approximately 10:00 a.m. with Staff B (Unit Manager) confirmed that Resident #47 did go to [MEDICAL TREATMENT] 3 times per week, was on a fluid restriction and that they had a central venous catheter for [MEDICAL TREATMENT] access. Review on 1/8/19 of the current care plan for Resident #47 revealed that there was no [MEDICAL TREATMENT] care plan, no documentation of the fluid restriction on the care plan and no documentation on the care plan that Resident #47 had a central venous catheter. Interview on 1/8/19 at approximately 11:15 a.m. with Staff B confirmed that there was no care plan for [MEDICAL TREATMENT] for Resident #47 and that the fluid restriction and central venous catheter were not on the care plan. Staff B also confirmed that the current care plan should have included all of these areas. Resident #142 Review on 1/4/19 of Resident #142's (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 1/7/19 of Resident #142's current care plan revealed that there was no care plan in place for the use of the antipsychotic medication or interventions for monitoring potential side effects of [MEDICATION NAME]. Interview on 1/7/19 at approximately 1:00 p.m. with Staff [NAME] (Unit Manager) confirmed that there was no care plan in place for Resident #142's use of antipsychotic medication and that there should have been a care plan in place.",2020-09-01
347,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,658,E,0,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed failed to follow professional standards of quality and clarify provider's orders for 1 of 1 residents with nephrostomy care, and 2 of 2 residents who receive [MEDICAL TREATMENT] care, in a final sample of 34 residents (Resident identifiers are #47, #128 and #140.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 1/8/19 of Resident #128's physician orders [REDACTED]. There was no documentation of any other orders pertaining to dressing, nephrostomy site or skin care, and tube stabilization. Interview on 1/8/19 at 11:35 a.m. with Staff D (Director of Nursing) confirmed the above finding and revealed that the above order should be clarified to include dressing. Resident #140 Review on 1/7/19 at 11:24 a.m. of physician orders [REDACTED].#140 revealed an order for [REDACTED]. Interview on 1/7/19 at 12:10 p.m. with Staff B (Unit Manager) confirmed that Resident #140 goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 5:05 p.m. and revealed that Resident#140's family transports the resident and the resident takes a packed dinner to [MEDICAL TREATMENT] because they miss dinner. Interview also revealed that the physician had not been notified about the medications that are scheduled to be giving during [MEDICAL TREATMENT]. Interview also revealed that the resident does not receive the medications scheduled at the nursing home (NH) while at [MEDICAL TREATMENT]. Review on 1/7/19 of Resident #140's [MEDICAL TREATMENT] treatments revealed that since admission on 12/18/18, Resident #140 went to [MEDICAL TREATMENT] on 12/19/18, 12/22/18, 12/23/18, 12/26/18, 12/28/18, 12/30/18, 1/2/19, and 1/4/19. Review on 1/8/19 of Resident #140's Medication Administration Record [REDACTED] On 12/19/18 Resident #140 did not receive [MEDICATION NAME] at 5:30 p.m. because they were away from the center. On 12/23/18, Resident #140 did not receive [MEDICATION NAME] at 5:30 p.m. because the resident was away from the NH, received [MEDICATION NAME] at 8:42 p.m. (which was a time the resident was away from the NH), and the resident received [MEDICATION NAME] at 8:42 p.m. (which was a time the resident was away from the NH). On 12/26/18, Resident #140 did not receive [MEDICATION NAME] at 5:30 p.m. because the resident was away from the NH, the resident received [MEDICATION NAME] at 10:14 p.m. (which was over two hours late), and the resident received [MEDICATION NAME] at 10:14 p.m. (which was over two hours late). On 12/28/18, Resident #140 did not receive [MEDICATION NAME] at 5:30 p.m. because the resident was away from the NH, the resident received [MEDICATION NAME] at 9:21 p.m. (which was over an hour late), and the resident received [MEDICATION NAME] at 9:21 p.m. (which was over an hour late). On 12/30/18, Resident #140 did not received [MEDICATION NAME] at 5:30 p.m. because the resident was away from the NH, the resident receive [MEDICATION NAME] at 9:49 p.m. (which was over an hour late), and the resident received [MEDICATION NAME] at 9:49 p.m. (which was over an hour late). On 1/2/19, Resident #140 did not received [MEDICATION NAME] at 5:30 p.m. because the resident was away from the NH, receive [MEDICATION NAME] at 9:20 p.m. (which was over an hour late), and the resident received [MEDICATION NAME] at 9:13 p.m. (which was over an hour late). On 1/4/19, Resident #140 did not receive [MEDICATION NAME] at 5:30 p.m. because the resident was away from the NH, received [MEDICATION NAME] at 9:32 p.m. (which was over an hour late), and the resident received [MEDICATION NAME] at 9:32 p.m. (which was over an hour late). Resident #47 Interview on 1/3/19 at approximately 9:45 a.m. with Resident #47 revealed that they usually went to [MEDICAL TREATMENT] 3 times per week on Tuesday, Thursday and Saturday, except for 1/1/19. Resident #47 revealed that they left the facility at approximately 11:00 a.m. and returned at approximately 3:00 p.m. on those days. They stated that they ate lunch while at [MEDICAL TREATMENT]. Interview on 1/8/19 at approximately 10:00 a.m. with Staff B (Unit Manager) confirmed that Resident #47 went out to [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday from approximately 11:00 a.m. until approximately 3:00 p.m. Review on 1/8/19 of Resident #47's (MONTH) (YEAR) and (MONTH) 2019 Medication Administration Records revealed that Resident #47 had a physician order, which started on 12/24/18, for Humalog Insulin per sliding scale every day at 12:00 p.m. with meal The records revealed that on 12/27/18, 12/29/18, 12/31/18, 1/3/19, and 1/5/19 the documentation for those doses of Insulin was AW, which according to the facility charting codes meant Away from Center. There was no documented physician order [REDACTED]. Review on 1/8/19 of Resident #47's (MONTH) 2019 Medication Administration Records revealed that Resident #47 had a physician order, which started on 1/5/19, for Sevelamer [MEDICATION NAME] every day at 12:00 p.m. with meal The records revealed that on 1/5/19 the documentation for that dose was AW. There was no documented physician order [REDACTED]. Interview on 1/8/19 at approximately 10:30 a.m. with Staff B confirmed that Resident #47 did not receive the 12:00 p.m. dose of Insulin or Sevelamer on [MEDICAL TREATMENT] days. Staff B also confirmed that they were not given to Resident #47 at [MEDICAL TREATMENT] and that there should have been physician notification that these medications were being held and an order to hold them.",2020-09-01
348,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,689,D,0,1,ZVIF11,"Based on observation and interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards by using 2 space heaters in 1 resident room, on 1 unit out 4 units. (Resident identifiers are #29 and #39.) Findings include: Observation on 1/2/19 at approximately 7:15 p.m. of Resident #29 and Resident #39's room revealed 2 portable space heaters (1 on each side of the room) that were being used in their room. Interview on 1/2/19 at approximately 7:15 p.m. with Resident #29 revealed that the space heaters were provided to them a few weeks ago because the heating system was not working in their room. Resident #29 stated, They keep saying it will be fixed and all we do is wait. Interview on 1/2/19 at approximately 7:15 p.m. with Resident #39 confirmed what Resident #29 said about the heating system not working for the last few weeks. Interview on 1/2/19 at approximately 7:30 p.m. with Staff F (Registered Nurse) confirmed that the heat in that room has not been working for a few weeks. Interview on 1/2/19 at approximately 8:00 p.m. with Staff G (Administrator) revealed that there was no policy and procedure for the use of space heaters in the facility.",2020-09-01
349,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,725,E,0,1,ZVIF11,"Based on interview and review of the facility grievance log for the past year, it was determined that the facility failed to have sufficient staff available at all times in order to ensure residents safety and to attain or maintain the highest practicable physical, mental and psychosocial well being of the residents. Findings include: Interview on 1/3/19 at 1:00 p.m. with twenty-two residents representing three of the facility's four units revealed that a long term staffing shortage throughout (YEAR) and which according to residents remains ongoing was the resident's primary concern according to those who attended the resident's council meeting. Residents said that the shortage of staff becomes apparent when they ring their call lights requesting staff assistance. Residents reported that it often takes staff a half hour to an hour or longer to respond to their call lights. Also they stated that staff responding to call lights routinely say that they'll be right back to assist residents, but frequently never returned to provide the care and services that's essential to the resident's well being. Residents reported that they're tired of having to wait for long periods of time to be changed after having defecated or urinated in their adult diapers and clothing. Residents stated that because of the staff shortage they've filed grievances regarding missing their weekly baths or showers, having a catheter bag not being emptied in a timely manner, staff failing to get them up in time to attend activities or appointments and complained about going without receiving restorative assistance from LNA's (Licensing Nursing Assistant) who aren't available to aid them in ambulating. Residents said that during meals there's not enough staff to pass out the food and as a result cold food complaints have been made. Review of the resident's grievance log revealed that as early as (MONTH) of (YEAR) residents were complaining of poor staff responses to their call lights. Interview on 1/9/19 with Staff G (Administrator) she stated that staff responses to resident's call lights wasn't an issue until the summer of (YEAR) a review of the grievance log revealed that from (MONTH) to (MONTH) some eighteen grievance reports by residents citing poor staff responses to residents ringing their call lights had been documented. Residents filing grievances alleging unacceptable staff responses to their call lights began in (MONTH) (YEAR) and continued through every month of (YEAR). Staff G acknowledged during the 1/9/19 interview that in (YEAR) there were no inservices offered by the facility for the staff or retraining provided to them towards improving the staff's skills in responding to the multiple concerns of residents relative to the responses to call lights. Staff G stated that the facility had done a response to call lights study but also stated that there was no documentation of its findings. Resident #126 Interview on 1/2/19 at approximately 6:30 p.m. with Resident #126 revealed concerns of not enough staff to assist the residents. Resident #126 said, It can take up to an hour on the bed pan to get help, no one answers my call light. I have to have my roommate go to the hall to yell for someone to help me, I can hear staff saying he's not mine, I'm not going in. Resident #126's spouse was present during in the interview and confirmed that this happens frequently. Resident #126's spouse said, This is all the time here. There is not enough help. Resident #126 stated that sometimes they are unable to attend activities due to there not being enough staff to get Resident #126 out of bed. Resident #14 Interview on 1/2/19 at approximately 6:40 p.m. with Resident #14 (Resident #126's roommate) confirmed that Resident #14 has to go to the hallway a lot to get staff to assist Resident #126 when the call light is ringing. I help (pronoun omitted) as much as I can. Review on 1/8/19 of the facility Customer First Concern/Grievance Log revealed that Resident #126 and their spouse have filed 5 grievances over the last year regarding poor call light response time. Resident #111 Interview on 1/3/19 at approximately 8:10 a.m. with Resident #111 revealed that the wait time for call lights to be answered are up to 2 hours. They might come in and say they will be back when they get help, but that could take up to 2 hours. Resident #111 stated that sometimes activities are missed because there is not enough staff to transfer out of bed. Review on 1/8/19 of the facility Customer First Concern/Grievance Log revealed that Resident #111 filed 5 grievances over the last year regarding poor call light response time. Interview on 1/8/19 at approximately 10:00 a.m. with Staff H (Licensed Nurse Assistant) confirmed that call lights are going off for an extended amount of time, We are doing the best we can with the amount of staff we have. Staff H stated, I am sure the residents are suffering. When regular staff have the day off, the residents complain that they are not getting out of bed until 11:00 a.m. 12:00 p.m. Staff H stated that there is a safety issue with the amount of staff on the unit.",2020-09-01
350,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,755,D,1,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to maintain accurate narcotic records for 1 resident in final survey sample of 34 residents. (Resident identifier is #107.) Findings include: Review on 1/8/19 of the 'MEDICATION ADMINISTRATION RECORD (MAR) for Resident #107 dated 1/1/19 revealed a physician order [REDACTED]. Further review of this MAR showed no documentation on 1/3/19 to show that [MEDICATION NAME] 15 MG was given to Resident #107. Review on 1/8/19 of the Narcotic Book page #93 for Resident #107 revealed that one tablet of [MEDICATION NAME] 15 MG was given to Resident #107 on 1/3/19. Review on 1/8/19 of the Nurse Notes for Resident #107 revealed no documentation that [MEDICATION NAME] 15 MG was given to Resident #107 on 1/3/19. Interview on 1/8/19 with Staff C (Registered Nurse) confirmed that the Narcotic Book page #93 showed [MEDICATION NAME] 15 MG one tablet was given to Resident #107 on 1/3/19 and no documentation was found on the MAR and Nurse Notes to show that Resident #107 was given [MEDICATION NAME] 15 MG on 1/3/19.",2020-09-01
351,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,757,E,1,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to ensure that residents receive medications as ordered, not in excessive dose and not in the presence of potential allergies [REDACTED]. (Resident identifiers are #39, #47, #62 and #71.) Findings include: Resident #47 Review on 1/8/19 of Resident #47's (MONTH) (YEAR) and (MONTH) 2019 Medication Administration Records revealed that Resident #47 was receiving [MEDICATION NAME] 200 mg (milligrams) every morning and [MEDICATION NAME] 700 mg every evening, which was ordered on [DATE]. Prior to that, Resident #47 had been receiving [MEDICATION NAME] 200 mg in the morning and [MEDICATION NAME] 300 mg in the evening. Review on 1/8/19 of Resident #47's (MONTH) 27, (YEAR) Pharmacy Consultant Report revealed that the pharmacist wrote The Manufacturer recommends daily dosing and not to exceed 700 mg daily at this level of [MEDICAL CONDITION]. The pharmacist then recommended that the physician adjust the dose of [MEDICATION NAME] 700 mg by mouth at bedtime for pain . For the Physician's Response, section of the report, Staff L (Advanced Practice Registered Nurse) accepted the recommendation and signed it on 12/28/18. Interview on 1/8/19 at approximately 12:00 p.m. with Staff L confirmed that they said that they changed the evening dose of [MEDICATION NAME] to 700 mg, based on the pharmacy recommendation, but forgot to discontinue the morning dose of [MEDICATION NAME], which resulted in Resident #47 receiving more than the recommended dose of [MEDICATION NAME]. Resident #62 Review on 1/3/19 of the Facility Report to the Long Term Care Ombudsman . dated 11/13/18, revealed that Resident #62 received Levetiracetam, in error, instead of [MEDICATION NAME] on 11/4/18. Review on 1/7/19 of the Facility's Risk Management form for this medication error revealed that Resident #62 had received Levetiracetam instead of [MEDICATION NAME]. It also revealed that the error was discovered on 11/5/18. Interview on 1/7/19 at approximately 11:15 a.m. with Staff [NAME] (Unit Manager) confirmed that on 11/4/18, Resident #47 was given Levetiracetam, which they had no order for, instead of [MEDICATION NAME], in error. Resident #71. Review on 1/8/19 of Resident #71's Medication Administration Record [REDACTED]. Review on 1/8/19 of Resident #71's MAR indicated [REDACTED]. Interview on 1/8/19 with Staff [NAME] (Licensed Practical Nurse) confirmed that Resident #71 was given two doses of Lorazapam 0.5 MG on 11/19/18 in error due to the duplicate order. Interview on 1/8/19 at approximately 2:00 PM with Staff G (Administrator) confirmed that Resident #71 was given two doses of Lorazapam 0.5 MG on 11/19/18 due to duplicate order and that the MNA (Licensed Medication Nursing Assistant) should of clarified the duplicate order with a nurse before giving the two doses to Resident #71. Resident #39 Review on 1/7/19 of Resident #39's (MAR) Medication Administration Record [REDACTED]. Review on 1/7/19 of Resident #39's active physician orders [REDACTED]. Tylenol Tablet 325 MG (milligram) ([MEDICATION NAME]) Give 650 MG by mouth every 4 hours as needed for fever >100 or (1-3) pain NTE (not to exceed) 3 Grams from all sources in 24 hours, dated 12/29/17. [MEDICATION NAME] Tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) Give 0.5 tablet by mouth every 8 hours as needed for pain 6-10, dated 1/19/18. Review on 1/7/19 of Resident #39's MAR for (MONTH) (YEAR) and (MONTH) 2019 revealed that Resident #39 received medications with [MEDICATION NAME]: December (YEAR) [MEDICATION NAME] Tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) was administered 14 times. Tylenol 325 MG ([MEDICATION NAME]) was administered 5 times January 2019 [MEDICATION NAME] Tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) was administered 6 times. Tylenol 325 MG ([MEDICATION NAME]) was administered 2 times. Interview on 1/7/19 at approximately 11:00 a.m. with Staff D (Director of Nurses) revealed that there was no evidence that the physician was notified of the drug allergy. Staff D revealed that the facility nurse practitioner reviewed the allergy in the following progress note, dated 1/8/19: Patient has listed allergies [REDACTED]. These are intolerance causing anxiety. Patient has PRN (as needed) order for [MEDICATION NAME], has used without ill effect and is able to tolerate use on a PRN basis for pain.",2020-09-01
352,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,761,D,0,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, it was determined that the facility failed to ensure proper storage of expired treatment supplies and ensuring temperature logs were completed for 2 observed medication rooms out of 2 observed medication rooms and 1 observed code cart out of 2 observed code carts. Findings include: Review on [DATE] of the facility's policy titled, Storage and Expiration dating of Medication, Biologicals, Syringes, and Needles, revision date [DATE], revealed that .facility should ensure that medications and biologicals that : (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medication until destroyed or returned to the pharmacy or supplier . Review on [DATE] of the facility's policy, Medication and Vaccine Refrigerator/Freezer Temperatures, revision date [DATE], revealed that Refrigerator .use to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day . Observation on [DATE] at 9:10 a.m. of the Frost unit medication room with Staff A (Registered Nurse) revealed 1 Miniloc safety infusion set with a use by date of (YEAR)-06, 8 filter needles with expired date of (YEAR)-02, 5 filter needles with expired date of (YEAR)-06, 1 tube feed tubing with expired date of (YEAR)-02, 2 female Speci-Cath Kit with expired date of ,[DATE], one 1 ml (milliliter) syringe with expired date of ,[DATE], five purple top vacuettes with expired date of ,[DATE], and eight red top vacuettes with expired date of ,[DATE], and five nasopharayngeal sample collection kits for viruses with expired date of (YEAR)-05, that were stored with non expired treatment supplies. Observation of the Frost unit medication room refrigerator revealed that there were one box of influenza vaccine and 2 packets of Prevnar 13 vaccines. Review on [DATE] of the Frost unit refrigerator temperature logs for the month of (MONTH) 2019 revealed that temperature results were documented once a day for (MONTH) ,[DATE], 2019. Interview on [DATE] at 9:30 a.m. with Staff A confirmed the above findings. Staff A was unable to provided explanation regarding expired treatment supplies stored with non expired treatment supplies. Staff A states that medication, biologicals, and treatment supplies are checked weekly and any expired medication, biologicals, treatment supplies would be discarded. Staff A states refrigerator temperatures are checked once a day and documented on the temperature log. Interview on [DATE] at 9:35 a.m. with Staff B (Unit Manager) revealed that the refrigerator temperatures are checked once a day and documented on the Temperature log. Observation on [DATE] at 9:45 a.m. of the code cart on the Frost unit with Staff B revealed that there was one CPR (Cardiopulmonary Resuscitation)-D-pads attach to the AED (Automated External Defibrillator) with expired date of (YEAR)-,[DATE] and there were 3 lubricating jelly packets with expired date of (MONTH) (YEAR). Interview on [DATE] at 9:46 a.m. with Staff B confirmed above findings found on the Frost unit code cart. Observation on [DATE] at 10:15 a.m. with Staff C (Unit Manager) of the[NAME]unit medication room revealed that there were 22 1 ml syringes with expired date of ,[DATE], 36 microbleach wipes with expiration date of ,[DATE], and 1 [MEDICATION NAME]-iodine swab stick with expired date of ,[DATE] that were found on top of the medication room counter. Interview on [DATE] at 10:15 a.m. with Staff B confirmed above findings found on the[NAME]unit medication room. Staff C revealed that expired syringes, swab stick and bleach were ready for use and that Staff C was not aware that the supplies mentioned above can expire. Interview on [DATE] 01:42 p.m. with Staff D (Director of Nursing) confirmed that above finding regarding Frost unit refrigerator medication room temperature logs. Staff D was unable to provide explanation why temperatures were only checked once a day on ,[DATE]-,[DATE] rather than twice a day per facility policy.",2020-09-01
353,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,835,E,1,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews and a review of the facility grievance log, it was determined that the facility failed to be administered in a way permitting all residents to maintain or attain their highest practicable well being.(Resident identifiers are #29 and #39.) Findings include: Observations on 1/2/19 during tour in room [ROOM NUMBER] on the[NAME]Wing revealed the use of two portable space heaters one on each side of the room providing heat. Residents #29 and #39 were interviewed during the tour and revealed that the two space heaters had been used to provide heat in their room for weeks. Resident #29 and #39 stated that although the space heaters were being used for heating their room was still cold. It was determined that the space heaters are a fire hazard and by regulation prohibited from being used in any resident areas including their rooms. Interview on 1/2/19 with Staff G (Administrator) revealed that Staff G had no knowledge until 1/2/19 when the survey team brought it to her attention of the two space heaters being used in room [ROOM NUMBER] on the[NAME]Wing. Staff O (Director of Maintenance) said during a 1/2/19 interview that the space heaters found in room [ROOM NUMBER] were in their third week of being used. Staff O said they were unaware of the regulation prohibiting the use of space heaters in resident areas including resident rooms. Staff G and Staff O informed the survey team on 1/2/19 that the space heaters would be removed from room [ROOM NUMBER] and a secondary heating source used instead specifically the baseboard electrical heat that's been available and in working condition. According to Staff O during the 1/2/19 interview, but wasn't utilized until 1/2/19. Staff G and Staff O gave no reason why this secondary heating source wasn't used when the primary heating source didn't work in room [ROOM NUMBER]. Interview on 1/3/19 at 1:00 p.m. with twenty-two residents representing three of the facility's four units revealed that a long term staffing shortage throughout (YEAR) and which according to residents remains ongoing was the resident's primary concern according to those who attended the resident's council meeting. Residents said that the shortage of staff becomes apparent when they ring their call lights requesting staff assistance. Residents reported that it often takes staff a half hour to an hour or longer to respond to their call lights. Also they stated that staff responding to call lights routinely say that they'll be right back to assist residents, but frequently never returned to provide the care and services that's essential to the resident's well being. Residents reported that they're tired of having to wait for long periods of time to be changed after having defecated or urinated in their adult diapers and clothing. Residents stated that because of the staff shortage they've filed grievances regarding missing their weekly baths or showers, having a catheter bag not being emptied in a timely manner, staff failing to get them up in time to attend activities or appointments and complained about going without receiving restorative assistance from LNA's who aren't available to aid them in ambulating. Residents said that during meals there's not enough staff to pass out the food and as a result cold food complaints have been made. Review of the resident's grievance log revealed that as early as (MONTH) of (YEAR) residents were complaining of poor staff responses to their call lights. Interview on 1/9/19 with Staff G (Administrator) she stated that staff responses to resident's call lights wasn't an issue until the summer of (YEAR), a review of the grievance log revealed that from (MONTH) to (MONTH) some eighteen grievance reports by residents citing poor staff responses to residents ringing their call lights had been documented. Residents filing grievances alleging unacceptable staff responses to their call lights began in (MONTH) (YEAR) and continued through every month of (YEAR). Staff G acknowledged during the 1/9/19 interview that in (YEAR) there were no inservices offered by the facility for the staff or retraining provided to them towards improving the staff's skills in responding to the multiple concerns of residents relative to the responses to call lights. Staff G stated during the 1/9/19 interview that the facility had done a response to call lights study but also said that there was no documentation of its findings.",2020-09-01
354,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,842,E,1,1,ZVIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to ensure complete and accurate medical records for Foley catheter output, fluid intake, self administration of medications, [MEDICAL TREATMENT] treatments, a medication administration error, DPOA (Durable Power of Attorney) notification, and IV (Intravenous) administration for 7 residents in a final survey sample of 42 residents. (Resident identifiers are # 11, #57, #62, #69, #107, #140 and #295.) Resident #62 Review on 1/3/19 of the Facility Report to the Long Term Care Ombudsman . dated 11/13/18, revealed that Resident #62 received Levetiracetam, in error, instead of [MEDICATION NAME] on 11/4/18. Interview on 1/7/19 at approximately 11:15 a.m. with Staff [NAME] (Unit Manager) confirmed that on 11/4/18, Resident #47 was given Levetiracetam, which they had no order for, instead of [MEDICATION NAME], in error. Review on 1/7/19 at approximately 11:30 a.m. of Resident #62's nursing progress notes and Resident #62's assessments revealed that there was no documentation that Resident #62 had received any medication in error, nor was there any documentation that Resident #62's DPOA was notified of the error. Interview on 1/7/19 at approximately 11:40 a.m. with Staff [NAME] confirmed that there was no documented evidence in Resident #62's medical record that Resident #62 received the wrong medication or that Resident #62's DPOA was notified. Staff [NAME] confirmed that these should have been documented in the medical record. Resident #69 Interview on 1/3/19 at approximately 8:50 a.m. with Resident #69 revealed that Resident #69 was receiving [MEDICATION NAME] IV. Review on 1/7/19 of Resident #69's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The review also revealed that there was no documentation on the Medication Administration Record [REDACTED]. Review on 1/7/19 of Resident #69's nurses notes, dated 12/13/18 at 3:55 p.m. revealed a note that read .order to continue vanco ([MEDICATION NAME]) at 750 mg (milligrams) q12 (every 12 hours) intravenously .IV administration by supervisor . There was no documentation of the name of the supervisor, what time the medication was given or the dose of the medication given. Interview on 1/7/19 at approximately 1:40 p.m. with Staff M (Clinical Nurse Manager) confirmed that the medication administration documentation should have been done on the Medication Administration Record [REDACTED]. Resident #11 Review on 1/7/19 of Resident #11's Treatment Administration Record dated 1/1/19 showed Foley output every shift . No documentation could be found for the Foley output on 1/2/19 on the 11 to 7 shift and on 1/4/19 on the 3 to 11 shift. Interview on 1/7/19 at approximately 1:30 PM with Staff C (Registered Nurse) confirmed that there was no documentation of the Foley output on 1/2/19 for the 11 to 7 shift and on 1/4/19 for the 3 to 11 shift for Resident #11. Resident #107 Review on 1/7/19 of Resident #107's Treatment Administration Record dated 1/1/19 showed Foley output every shift. No documentation could be found for the Foley output on 1/2/19 on the 11 to 7 shift and on 1/4/19 on the 3 to 11 shift. Interview on 1/7/19 at approximately 1:30 PM with Staff C confirmed that there was no documentation of the Foley output on 1/2/19 for the 11 to 7 shift and on 1/4/19 for the 3 to 11 shift for Resident #107. Resident #57 Review on 1/7/19 of Resident #57's physician orders [REDACTED]. Interview on 1/7/19 at 10:35 a.m. with Resident #57 revealed that Resident #57 self administers [MEDICATION NAME] 4 times a day, and inhaler 2-3 times a week. Review on 1/7/19 of Resident #57's Medication Administration Record [REDACTED]. Resident #295 Review on 1/7/19 of Resident #295's MAR for 12/23/18 (admission) to 12/31/18 revealed that the recorded total fluid intake per day was not the sum of the fluid intake recorded for each shift that day for 9 of 9 days (12/23/18 to 12/31/18) Interview on 1/7/19 at 9:15 a.m. with Staff D (Director of Nursing) confirmed the above finding and revealed that the MAR indicated [REDACTED]. Resident #140 Review on 1/8/19 of Resident #140's [MEDICAL TREATMENT] treatments revealed that since admission on 12/18/18, Resident #140 went to [MEDICAL TREATMENT] on 12/19/18, 12/22/18, 12/23/18, 12/26/18, 12/28/18, 12/30/18, 1/2/19, and 1/4/19. Review on 1/8/19 of Resident #140's MAR for (MONTH) (YEAR) and (MONTH) 2019 revealed that the facility documented the resident went to [MEDICAL TREATMENT] on 12/19/18, 12/21/18, 12/24/18, 12/26/18, 12/28/18, 12/31/18, 1/2/19 and 1/4/19.",2020-09-01
355,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,867,D,1,1,ZVIF11,"> Based on interview and record review, it was determined that the facility failed to document on the Facility's quarterly QAPI (Quality Assurance and Performance Improvement) plan the implementation of a plan of action to address the identified problem of medication errors. Findings include: Interview on 1/3/19 at approximately 1:00 p.m. with residents at Resident Council revealed that the residents complained that medication errors have been ongoing and continue to be a problem at the facility. Review on 1/3/19 of the investigation survey done at the facility on 5/22/18 revealed that the facility received a deficiency for medication errors. Review on 1/8/19 of the facility's agenda for the quarterly QAPI meetings for 5/15/18, 8/21/18, and 11/20/18 revealed that Medication Error Reduction Plan was included on the 5/15/18 and the 8/21/18 agendas. Medication errors were not included on the 11/20/18 agenda. Interview on 1/8/19 at approximately 2:15 p.m. with Staff G (Administrator) and Staff N (Administrator in Training) confirmed that medication errors continued to be a problem area at the facility. Staff G also confirmed that the medication error reduction plan was not listed on the agenda for the 11/20/18 quarterly meeting.",2020-09-01
356,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-01-08,926,D,0,1,ZVIF11,"Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure that the facility addresses smoking safety by allowing residents to have lighters on their person for 1 resident in a final survey sample of 34 residents. (Resident identifier is #135.) Findings include: Observation on 1/4/19 at approximately 8:10 a.m. revealed that Resident #135 was outside to smoking on campus. Review on 1/7/19 of the facility policy titled Smoking last revised on 7/24/18, revealed that .Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station .If the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment .Patients will not be allowed to maintain their own lighter, lighter fluid, or matches . Interview on 1/7/19 at approximately 10:45 a.m. with Resident #135 revealed that Resident #135 stated that they kept their cigarettes and lighter with them. Resident #135 also stated that they had never been asked by anyone at the facility to give their lighter or their cigarettes to staff. Resident #135 stated that they would have given their lighter to staff, if they had been asked to. Interview on 1/7/19 at approximately 11:00 p.m. with Staff [NAME] (Unit Manager) confirmed that they had never read the facility's smoking policy and were not aware that residents were supposed to be asked for their lighters. Interview on 1/7/19 at approximately 1:00 p.m. with Staff [NAME] confirmed that they had just read the facility's smoking policy, and that after reading it they realized that Resident #135 should have been asked to give their lighter to staff.",2020-09-01
357,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2018-05-22,609,D,1,0,CHY811,"> Based on record review, observation and interview the facility failed to ensure that all alleged violations were reported to other state certification agencies in accordance with State law through established procedures and not following the facility's policies for 1 resident in a survey sample of 10 residents. (Resident identifier is #7.) Findings include: Resident #7 Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed nurses notes dated 4/5/18 at 9:00 a.m. a change of condition note,Other change in condition medication error 4/5/2018 in the morning. Orders obtained include: Frequent CBG (capillary blood glucose) checks, labwork d/t (due/to) using another using another patients pen, cross contamination Blood Tests Review on 5/22/18 of Resident #7's Event Summary Report revealed that Staff F (LPN nursing student) patient received 10 units of insulin that was meant for a different patient via insulin pen by 2 (pronoun omitted) LPN students. ARNP (Advanced Registered Nurse Practitioner) notified. DON (Director of Nursing) notified. Labs to be drawn on both patients involved d/t using another patients insulin pens cross contamination. Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed a condition follow up note written on 4/5/18 at 8 p.m. med error made with insulin No complications noted CBG 162/191 Review on 5/22/18 at 11:45 a.m. of the facility's policy titled Nursing Facility Reporting Requirements, with no date or update, Other Reportable Occurrences III Explained and/or witnessed incidents resulting injury (ie actual harm) caused by unusual circumstances, including environmental hazards, inadequate staffing, medication errors, etc. Interview on 5/22/18 at 1:00 p.m. with Staff B (Director of Nurses) revealed Staff B had contacted the facility's corporate regional personnel and it was felt that it was not a reportable event to the State Certification agency. The Administration will not allow nursing students to give insulin until the nursing school has addressed the following issue with the nursing student: verifing the patients prior to administering medication. Staff B indicated that the Staff F LPN nursing student did not verify the patient identification and that education needs to be completed. The facility did not report the above incident to the State Certification Agency.",2020-09-01
358,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2018-05-22,658,D,1,0,CHY811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure that medications were given as ordered for 3 residents in a survey sample of 10 residents. (Resident identifiers are #1, #6 and #7.) Findings include: Professional reference: Potter, [NAME] [NAME], and Perry, Anne Griffin. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary Resident #1 Review on 5/22/18 of the RMS (Risk Management System) Event Summary Report, dated 4/15/18, for Resident #1 revealed that on 4/15/18, the facility determined that on 4/14/18 at 8:00 p.m. Resident #1 was given 3 tablets of Oxy IR ([MEDICATION NAME] Immediate Release) instead of 3 tablets of [MEDICATION NAME]. Review on 5/22/18 of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED].) Review also revealed that Resident #1 had an order for [REDACTED]. Review on 5/22/18 of the facility's Controlled Substance Log book revealed that on 4/15/18, the facility documented that the count of Oxy IR and the count of [MEDICATION NAME] were incorrect and that there were 3 tablets of Oxy IR missing and that there were 3 extra tablets of [MEDICATION NAME]. Interview on 5/22/18 at approximately 2:10 p.m. with Staff B (Director of Nursing) revealed that this medication error should not have been made. Resident #7 Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed nurses notes dated 4/5/18 at 9:00 a.m. a change of condition note,Other change in condition medication error 4/5/2018 in the morning. Orders obtained include: Frequent CBG (capillary blood glucose) checks, labwork d/t (due/to) using another using another patients pen, cross contamination Blood Tests Review on 5/22/18 of Resident #7's Event Summary Report revealed that Staff F (LPN nursing student) patient received 10 units of insulin that was meant for a different patient via insulin pen by 2 (pronoun omitted) LPN students. ARNP (Advanced Registered Nurse Practitioner) notified. DON (Director of Nursing) notified. Labs to be drawn on both patients involved d/t using another patients insulin pens cross contamination. Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed a condition follow up note written on 4/5/18 at 8 p.m. med error made with insulin No complications noted CBG 162/191 Interview on 5/22/18 at 1:00 p.m. with Staff B (Director of Nurses) revealed Staff B had contacted the facility's corporate regional personnel and it was felt that it was not a reportable event to the State Certification agency. The Administration will not allow nursing students to give insulin until the nursing school has addressed the following issue with the nursing student: verifing the patients prior to administering medication. Resident #6 Review on 5/22/18 of Resident #6's medical record at 8:30 a.m. revealed nurses notes dated 3/27/18 at 12:00 p.m. a change of condition note,monitoring for [DIAGNOSES REDACTED] Review on 5/22/18 of Resident #6's Event Summary Report event ID 55 date/time 3/27/18 11:45 a.m. revealed that Staff C Licensed Practical Nurse (LPN) This nurse drew medication for a patient, secured it, and walked away to assist another staff member. Upon returning and administering medication it was discovered to be the wrong patient. Review of Resident #6's Medication Administration Record [REDACTED]. Resident #6's CBG's were 86 at 2:33 p.m. and 78 at 4:11 p.m. CBG's were monitored every half hour throughout the day until later that night. Interview on 5/22/18 at 11 a.m. with Staff B (Director of Nurses) revealed Staff B had contacted the facility's corporate regional personnel and it was felt that it was not a reportable event to the State agency. The Administration is trying signs as a pilot program and are a waiting for bracket to hang them from the medication cart. Staff B confirmed that Staff C administered the insulin to the wrong patient. Interview on 5/22/18 at approximately 11:30 a.m. with Resident #6 states that Resident #6 now checks all medication that Resident #6 receives and has turned away medications due to errors that have been made and has the nurses fix them at that time. Resident #6 states that the response from Staff B and Staff D (Administrator), was to have signs put up at the medication carts; but Resident #6 has noticed that not all the medication carts have the signs on them and not all floors have the signs on and feels that it was stated to appease Resident #6. Observation on 5/22/18 during medication pass at 7:30 a.m. to 8:30 a.m. revealed the do not disturb (the Nurse during Medication pass) sign was on the desk of the Webster Unit.",2020-09-01
359,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2018-05-22,759,E,1,0,CHY811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure that the medication error rate was not greater than 5% during 88 medication pass observations. (Resident identifiers are #2, #3, and #4.) Findings include: Resident #2 Observation on 5/22/18 at approximately 7:40 a.m. during medication pass revealed that there was a medicine cup on Resident #2's overbed table with a green tablet inside it. Resident #2 was sitting across the room from the overbed table. Interview on 5/22/18 at approximately 7:45 a.m. with Staff A (Licensed Practical Nurse) revealed that the pill inside the medicine cup was a Tums tablet 500 mg (milligram) that had been administered to Resident #2 by the 11-7 shift nurse. When asked, Staff A said that Resident #2 had a physician's order to self administer medications. Review on 5/22/18 of Resident #2's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The review revealed that this medication was to be administered at 6:00 a.m. and 6:00 p.m. Review on 5/22/18 of Resident #2's medical record revealed that there were no physician orders, assessment or care plan for self administration of medications. Interview on 5/22/18 at approximately 10:00 a.m. with Resident #2 revealed that Resident #2 said that they had chewed one of the Tums tablets, when it was administered at approximately 6:00 a.m., but that Resident #2 liked to save the other tablet for after they had coffee in the morning. Interview on 5/22/118 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that there were no documented orders or assessment for Resident#2's self administration of medications and that the tablets should not have been left unattended for Resident #2. Resident #3 Observation on 5/22/18 at approximately 7:46 a.m. during medication pass revealed that Resident #3 received Vitamin C 500 mg by mouth and Vitamin D 400 IU (International Units) by mouth. Review on 5/22/18 of Resident #3's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review on 5/22/18 of Resident #3's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview on 5/22/18 at approximately 10:00 a.m. with Staff A confirmed that Staff A had administered Vitamin C instead of [MEDICATION NAME] and had administered Vitamin D instead of Calcium-Vitamin D to Resident #3. Resident #4 Observation on 5/22/18 at approximately 8:04 a.m. during medication pass revealed that Resident #4 received [MEDICATION NAME] HCL ([MEDICATION NAME]) 37.5 mg by mouth and Vitamin D 400 I.U. by mouth. Observation also revealed that Resident #4 received [MEDICATION NAME] inhaler. The inhaler was removed from out of its box container by Staff A and the top flap of the box had been ripped off. No expiration date could be found on the inhaler or on the remains of the box it was held in. Review on 5/22/18 of Resident #4's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The review revealed that Resident #4 did not have an order for [REDACTED].>Review on 5/22/18 of Resident #4's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The review revealed that Resident #4 did not have an order for [REDACTED]. Interview on 5/22/18 at approximately 10:00 a.m. with Staff A confirmed that Staff A had administered the wrong dose of [MEDICATION NAME] HCL and the wrong dose of Vitamin D to Resident #4. After the error with the [MEDICATION NAME] HCL was pointed out to Staff A, they stated that they would be administering the remaining 112.5 mg of [MEDICATION NAME] HCL to Resident #4. The interview with Staff A also confirmed that there was no expiration date that could be found on the inhaler or on the inhaler box, and that it might have been on the part of the box that had been ripped off. Staff A confirmed that the medication should not have been administered without knowing the expiration date of the medication. In total there were 6 medication errors, 1 for Resident #2, 2 for Resident #3, and 2 for Resident #4, out of a total of 88 medication pass opportunities resulting in a 5.6% error rate.",2020-09-01
360,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2018-05-22,880,D,1,0,CHY811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record and facility policy review, and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during 1 of 3 medication pass observations and 1 of 11 record reviews. (Resident identifiers are #7 and #8.) Findings include: Resident #8 Observation on 5/22/18 at approximately 7:55 a.m. during medication pass revealed that Staff A (Licensed Practical Nurse) used a glucose meter to check Resident #8's blood sugar. After removing the test strip, with blood on it, from the glucose meter, Staff A placed the glucose meter, without cleaning it, in the left front pocket of their shirt. Interview on 5/22/18 at approximately 10:00 a.m. revealed that when asked, Staff A stated that the glucose meter was no longer in their pocket. Staff A said that they had removed the glucose meter from their pocket, cleaned it and placed it back in its holder. When asked what Staff A used to clean the glucose meter, Staff A pulled an alcohol prep pad out of the right front pocket of their shirt and said that they always use alcohol prep pads to clean the glucose meter between resident use. Review on 5/22/18 of the Facility's Policy titled Glucose Meter, dated 6/1/96, revised 3/16/17, revealed that the glucose meter is to be disinfected .before and after each patient use with .Environmental Protection Agency (EPA) approved disinfectant against [MEDICAL CONDITIONS](do NOT use an alcohol prep pad) . Interview on 5/22/18 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that the glucose meter should not have been placed in Staff A's pocket and that it should have been disinfected with Bleach wipes. Surveyor: Wyman, Debora [MI] Resident #7 Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed nurses notes dated 4/5/18 at 9:00 a.m. a change of condition note,Other change in condition medication error 4/5/2018 in the morning. Orders obtained include: Frequent CBG (capillary blood glucose) checks, labwork d/t (due/to) using another using another patients pen, cross contamination Blood Tests Review on 5/22/18 of Resident #7's Event Summary Report revealed that Staff F (LPN nursing student) patient received 10 units of insulin that was meant for a different patient via insulin pen by 2 (pronoun omitted) LPN students. ARNP (Advanced Registered Nurse Practitioner) notified. DON (Director of Nursing) notified. Labs to be drawn on both patients involved d/t using another patients insulin pens cross contamination. Review on 5/22/18 at 11:30 a.m. of Resident #7's medical record revealed a condition follow up note written on 4/5/18 at 8 p.m. med error made with insulin No complications noted CBG 162/191 Interview on 5/22/18 at 1:00 p.m. with Staff B (Director of Nurses) revealed Staff B had contacted the facility's corporate regional personnel and it was felt that it was not a reportable event to the State Certification agency. The Administration will not allow nursing students to give insulin until the nursing school has addressed the following issue with the nursing student: verifing the patients prior to administering medication. Staff B indicated that the Staff F (LPN nursing student) did not verify the patient identification and that education needs to be completed. The facility did not report the above incident to the State Certification Agency.",2020-09-01
361,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-06-06,658,D,1,0,7LRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to follow the professional standard of practice for physician orders [REDACTED]. (Resident identifier is #2.) Findings include: The reference for the professional standard of practice is the following: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 713 .A registered nurse compares the list of medications on the MAR indicated [REDACTED]. After administering a medication, record it immediately on the appropriate record form . Recording immediately after administration prevents errors. Review on 6/6/19 at approximately 10:00 a.m. of the physician's orders [REDACTED]. Review on 6/6/19 at approximately 10:00 a.m. of the 'Medication Administration Record [REDACTED] Potassium Chloride ER Tablet Extended Release 20 MEQ Give 1 tablet by mouth two times a day for [DIAGNOSES REDACTED]. Review on 6/6/19 at approximately 10:00 a.m. of the above listed MAR indicated [REDACTED] 20 meq one tablet twice a day for 8 days from 4/2/19 through 4/9/19 for a total of 16 doses. Review on 6/6/19 at approximately 10:00 a.m. of the potassium laboratory results for Resident #2 revealed the following: 4/2/19 potassium level 3.2 (indicating low level) 4/4/19 potassium level 4.5 (indicating within range) 4/10/19 potassium level 6.0 (indicating high level) Interview on 6/6/19 with Staff A (Registered Nurse) at approximately 1:00 p.m. confirmed that the physician was notified on 4/10/19 of the high potassium level for Resident #2 and at that time it was discovered that the 4/2/19 physician order [REDACTED].",2020-09-01
362,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-06-06,760,D,1,0,7LRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy and procedure, it was determined that the facility failed keep residents free from significant medication errors by not notifying the physician when medications were not available for 1 out of 2 residents reviewed. (Resident identifier is #1.) Findings include: Review on 6/6/19 of Resident #1's (MONTH) 2019 and (MONTH) 2019 MAR (Medication Administration Record) revealed the following medications NA (not available): April 2019 [MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME] Suspension; Give 5 Ml's (Milliliters) orally four times a day for thrush, order dated 4/12/19. 4/12/19 3 doses not available at 1200, 1600, and 2000. 4/13/19 3 doses not available at 1200, 1600, and 2000. Famciclovir Tablet 500 MG (Milligram); Give 1 tablet my mouth three times a day for [MEDICAL CONDITION] for 7 days, order dated 4/6/19. 4/6/19 1 dose not available at 1200. [MEDICATION NAME] Suspension 00 Unit/Ml; Give 5 Ml's by mouth four times a day for thrush related Candidal Stomatitis for 10 days, order dated 4/9/19. 4/14/19 2 doses not available at 0800 and 1200. 4/15/19 4 doses not available at 0800, 1200, 1600 and 2000. 4/16/19 3 doses not available at 0800, 1200 and 1600. [MEDICATION NAME] HCL ([MEDICATION NAME] Acid) Suspension; Give 250 MG's (Milligram) by mouth every 6 hours related to [MEDICATION NAME] due to [MEDICAL CONDITION] (C diff), order dated 4/3/19. 4/9/19 1 dose not available at 1200. May 2019 [MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME] Suspension; Give 5 Ml's orally four times a day for thrush, order dated 4/21/19. 5/13/19 4 doses not available at 0700, 1100, 1700 and 2000. Interview on 6/6/19 at approximately 12:15 p.m. with Staff A (Director of Nurses) revealed that there was no record of the physician being notified of the missed doses of medications. Review on 6/6/19 of the facility policy and procedure titled; NSG (Nursing) Medication Administration: General, Revision date 7/24/18 revealed: . Practice Standards . 5. If discrepancies, including medication not available, notify physician/advanced practice provider and or/pharmacy as indicated. .",2020-09-01
363,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-11,585,B,0,1,ECKJ11,"Based upon a Resident's Council group interview, staff interview and a review of the facility audits revealed that the facility failed to effectively respond to resident's grievances that staff do not answer the resident's call lights in a timely manner. Findings include: Interview on 10/12/19 at a Resident's Council meeting revealed that the facility staff were not either answering their call lights or responding to them in a timely manner. Residents revealed that staff unresponsiveness to call bells has remained an ongoing problem on three of four units since the last survey. A review of facility monthly audits involving only 3-9 residents rooms monitoring the response of staff to call lights ended in (MONTH) of 2019 even though residents, in the group interview, reaffirmed that this continues to be an unresolved problem. In the Initial Audit undated it's noted that a resident indicates that they're not always satisfied with the staff response to their call bell. Another resident stated that they're satisfied with staff response to their call light most but not all of the time. Review on 10/12/19 of the facility audits of responses to call lights revealed the audit was limited in March, (MONTH) and (MONTH) of 2019 to three resident's rooms each month and there was no audits after (MONTH) 2019. In a 10/12/19 interview with Staff A (Administrator) confirmed that the audits had stopped and stated that only three grievances a month were being made by residents who continued complaining about a lack of staff responsiveness to their call lights.",2020-09-01
364,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-11,689,D,0,1,ECKJ11,"Based on observation, record review and interview, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible by providing assessments to determine safety needs for 3 residents that smoke in a survey sample size of 27 residents. (Resident identifiers are: #110, #128 and #241). Findings include: Resident #241: Observation on 10/8/19 at approximately 10:00 a.m. revealed Resident #241 was smoking a cigarette outside the facility. An interview with Staff A, (Administrator) on 10/8/19 at approximately 9:00 a.m. revealed that the Facility is a smoke-free facility. An observation on 10/8/19 at approximately 3:00 p.m. of Resident #241 revealed that Resident #241 was sitting outside the front entrance of the facility smoking a cigarette. Staff A (Administrator) and Staff B (Corporate Representative of the facility) were immediately notified and went to the front entrance of the facility to observe Resident #241 smoking a cigarette. Review on 10/9/19 at approximately 10:30 a.m. of Resident #241's medical record revealed a care plan that stated that the resident was not going to smoke, and had started a smoking cessation program, (ie; donning a Nicotine Patch), but did not include any safety measures to implement that would cover the times when Resident #241 decided to go out to smoke. Further nurses notes documented on 10/3/19 and 10/8/19 revealed that Resident #241 regularly smokes 4-5 cigarettes per day on facility grounds. Interview on 10/9/19 at approximately 11:00 am with Resident #241 revealed that Resident #241 stated, the patch is not working and I want to try the pill, and other people are out there smoking and everyone knows it. Resident #241 also stated during this interview that he/she was approached by Staff A and Staff B, who told him he/she could not smoke, as this is a smoke-free facility. Resident #241 stated that he/she told them that he/she will quit smoking, but the patch doesn't work and he/she wants to try the pill. Resident #241 also said that they informed Staff A and Staff B that there are residents who are smokers in the building and they are smoking out front and everyone knows it. Resident #241 also stated that staff are also allowed to smoke on the premises, but they do not smoke out front with the residents. Interview on 10/9/19 with Staff A at approximately 11:30 a.m. confirmed that there are residents in the facility who smoke, and the residents had all signed a non-smoking agreement on admission. Staff A revealed that there were no smoking safety assessments performed for the residents who were regularly going outside to smoke. Staff A also acknowledged that there are staff members who also smoke on the premises. Resident #110 Interview on 10/9/19 at approximately 1:00 p.m. with Resident #110 revealed that Resident #110 has been smoking every day for the last 6 weeks. Resident #110 said that they smoke out in the front of the facility, they keep their own cigarettes and have kept their lighter hidden in the front of the facility. Resident #110 also said that no staff member had questioned them about smoking. Review on 10/10/19 of Resident #110's assessments revealed that there was no smoking assessment done for Resident#110. Interview on 10/10/19 at approximately 2:15 p.m. with Staff I (Licensed Practical Nurse) revealed that they said that they had heard that Resident #110 had been smoking but thought that it had been taken care of as the facility was a non-smoking facility. Interview on 10/11/19 at approximately 9:15 a.m. with Staff B (Regional Clinical Manager) confirmed that Resident #110 should have been assessed for their safety with independent smoking and that after the assessment, a care plan should have been developed. Resident #128 Interview on 10/9/19 at approximately 8:30 a.m. with Resident #128 revealed that Resident #128 stated that they smoked every day outside at the front of the facility. Resident #128 stated that they kept their cigarettes and their light in their fanny pack. Review on 10/10/19 of Resident #128's assessments revealed that there was no smoking assessment done for Resident #128. Interview on 10/10/19 at approximately 2:15 p.m. with Staff J (Licensed Nursing Assistant) revealed that they have smelled smoke on Resident #128 in the recent past. Interview on 10/11/19 at approximately 2:15 p.m. with Staff K (Registered Nurse) confirmed that they saw cigarettes and lighters in Resident #128's open fanny pack on 10/10/19. Interview on 10/11/19 at approximately 9:15 a.m. with Staff B confirmed that Resident #128 should have been assessed for their safety with independent smoking and that after the assessment, a care plan should have been developed.",2020-09-01
365,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-11,758,D,0,1,ECKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that a PRN (as needed) [MEDICAL CONDITION] drug was limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order, for 1 resident in a final sample size of 27 residents. (Resident identifier is #39.) Findings include: Review on 10/10/19 of Resident #39's current physician orders [REDACTED].#39 had an order for [REDACTED]. Review on 10/10/19 of Resident #39's (MONTH) to (MONTH) 2019 EMAR (Electronic Medication Administration Record) revealed that Resident #39 received PRN [MEDICATION NAME] 25 mg on 6/25/19, 6/28/19, 6/29/19, 7/5/19, 7/7/19, 7/12/19, 7/18/19, 7/21/19, 7/23/19, 7/27/19, 7/31/19, 8/1/19, 8/11/19, 8/30/19, 9/1/19, 9/8/19, 9/9/19, 9/30/19 and 10/4/19. Review on 10/11/19 of Resident #39's progress notes and chart between (MONTH) 2019 and (MONTH) 2019 revealed that Resident #39's in-house psychiatrist did not have documentation for the rationale and indication of duration for Resident #39's PRN [MEDICATION NAME] order that was started on 6/25/19. Review on 10/11/19 of Resident #39's APRN (Advanced Practice Registered Nurse) progress note dated 6/21/19 revealed that Resident #39's APRN had ordered for PRN [MEDICATION NAME] 25 mg but with no documented rationale and duration for the order. Further review of Resident #39's APRN progress notes revealed that Resident #39 had APRN progress notes dated 7/2/19, 7/8/19, 7/26/19, 8/1/19, 8/27/19, 9/4/19, 9/16/19 and 9/27/19 with no documented rationale and indication of duration for Resident #39's PRN [MEDICATION NAME] order that was started on 6/25/19. Interview on 10/11/19 at 10:00 a.m. with Staff G (Unit Manager) confirmed that above findings. Staff G stated that there should have been an ordered duration for the PRN [MEDICATION NAME] and documented rationale on Resident #39's medical record.",2020-09-01
366,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-11,880,D,0,1,ECKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide a sanitary environment for wound treatments for 2 residents in a final survey sample of 27 residents. (Resident identifiers are #128 and #396) Findings include: Resident #396 Interview on 10/8/19 at approximately 10:15 a.m. with Staff C (Unit Manager) revealed that Resident #396 had a Stage 4 pressure ulcer on their sacrum which was being treated with a wound vac. Staff C also revealed that Resident #396 was on contact precautions [MEDICAL CONDITIONS] in their blood and in the wounds that they had on their toes. Observation on 10/9/19 at approximately 9:55 a.m. of the wound vac dressing change to Resident #396's sacrum revealed that the supplies for the dressing change were placed on a tan overbed table by Staff C. The table had a laminated overlay and Staff C noticed that approximately 1/8 of the laminate was lifted exposing the underneath particle board, and the table also had multiple areas of torn laminate with tattered edges on the side of the table. Staff C initially cleaned the table with a bleach wipe, but then removed the table and said that it would be taken out of service due to its torn areas. Staff C then took another overbed table and it was noticed that this table also had multiple areas of torn laminate with tattered edges on the side of the table. Staff C wiped the table with a bleach wipe and then placed the dressing supplies on the overbed table. Staff C did not place a clean pad or towel on top of the table. Staff C did the wound vac dressing change using that overbed table to hold supplies. Observation on 10/9/19 of the overbed tables on the Frost Unit revealed that there were 19 overbed tables with the same tan laminate and that 13 of them had torn laminate on the sides, with tattered edges. Resident #128 Interview on 10/8/19 at approximately 10:15 a.m. with Staff C revealed that Resident #128 had a Stage 4 pressure ulcer on their sacrum. Observation on 10/9/19 at approximately 2:50 p.m. of the wound dressing change to Resident #128's sacrum revealed that Staff D (Registered Nurse) wiped an overbed table, that had multiple areas of torn laminate with tattered edges on the side of the table, with a bleach wipe. After the bleach dried, Staff D then placed the dressing supplies for Resident #128's dressing change on the overbed table. Staff D did the dressing change using that overbed table to hold supplies. Interview on 10/9/19 3:00 p.m. with Staff B (Regional Clinical Manager) and Staff [NAME] (Director of Nursing) confirmed that the overbed tables with the torn laminate sides should not have been used for treatments, as they could not be cleansed as they should be.",2020-09-01
367,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-24,550,D,1,0,8J3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and observation, it was determined that the facility failed to ensure that resident's right to refuse medication was supported by staff for 1 resident out of a survey sample of 3 residents with diabetes. (Resident identifier is #2.) Findings include: Review on 10/24/19 of a facility reported incident to the state agency on 10/15/19 revealed a medication error had occurred on 10/15/19 at approximately 9:20 p.m. involving Resident #2 receiving medication that was intended for another resident (Resident #1.) Review on 10/24/19 of Resident #2's medical record revealed that Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #2 has a BIMS (Brief Interview Mental Staus) of 13, which suggests an intact cognitition. Interview on 10/24/19 at approximately 10:00 a.m. with Resident #2, who has a BIMS (Brief Interview for Mental Status) of 13 and is alert and oriented, revealed that on 10/15/19 at approximately 9:20 p.m. Staff A (Travel nurse) entered Resident #2's room to administer insulin via [MEDICATION NAME] Solution Pen Injector. Resident #2 asked Staff A what the medication was. Staff A responded that it was insulin and Resident #2 informed Staff A that I don't take insulin. Resident #2 further stated that Staff A told Resident #2 that there were orders for Resident #2 to have insulin. Resident #2 stated that Staff A then injected the insulin: Jab, right in my stomach. Resident #2 stated Then they kept me up all night making me eat and checking my sugar. Phone interview on 10/31/19 at 12:51 p.m. with Staff A, (Registered Nurse travel) revealed that Staff A had no orientation and had many interruptions during the medication pass that evening and many supplies were missing. While getting the insulin pen ready for Resident #1 Staff A could not find a pen needle so Staff A took a syringe an withdraw 5 units from the insulin pen and injected (Resident #2) with it. If (Resident #2) had said something prior to Staff A injecting (Resident #2) then Staff A would have looked at the Mediciation Administriation Record. Staff A reported the incident after Resident #2 stated, I don't take insulin. Which was after Staff A had already injected (Resident 2); because Staff A is quick too give injections. Staff A revealed that Staff A found the pen needle after and then used the same insulin pen on Resident #1. Observation during interview on 10/24/19 at approximately 10:00 a.m. of Resident #2 revealed that Resident #2 was visibly upset and weepy when explaining the above incident. Interview on 10/24/19 at approximately 10:00 a.m. with Resident's Representative confirmed that Resident #2 was upset and concerned about receiving insulin and the continuous monitoring that was in place during the night. Resident #2's representative stated that they were notified of the medication error and arrived at the facility to be with Resident #2 while the monitoring was taking place and remained there until Resident #2 felt better. Review on 10/24/19 at approximately 10:30 a.m. of Resident #2's medical record revealed a progress note dated 10/15/19, that stated A change in condition has been noted. The symptoms include: Other change in condition med (medication) error wrong med (medication) 10/15/19 in the afternoon.",2020-09-01
368,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-24,552,D,1,0,8J3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to inform a resident of their health status for 1 resident out of a survey sample of 3 residents with diabetes. (Resident identifier is #1.) Findings include: Review on 10/24/19 of Resident #2's progress note, dated 10/15/19, revealed that there was a medication error where Resident #1's [MEDICATION NAME] Solution Pen Injector was used to administer insulin to another resident (Resident #2). Observation on 10/24/19 at 8:30 a.m. of the[NAME]Unit medication cart revealed a baggie that had a pharmacy label with Resident #1's name that contained one [MEDICATION NAME] Solution Pen Injector inside it. On the pharmacy label, it had an issue date of 10/4/19 in the right hand corner and a label to be discarded on 11/1/19. There was no date that stated when it was opened. Review on 10/24/19 at approximately 10:45 a.m. of Resident #1's medical record revealed that Resident #1's Durable Power of Attorney (DPOA) was activated. Further review revealed no notification of the resident's DPOA documented in the medical record. Interview on 10/24/19 at approximately 11:12 a.m. with Staff B (Center Nurse Executive) confirmed that Staff B did not notify Resident #1's activated DPOA that the resident's insulin pen had been used on Resident #2 on 10/15/19 and returned to the medication cart and since been used on Resident #1. Staff B revealed that no testing for infectious diseases had been offered to either Resident #1 or Resident #2.",2020-09-01
369,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-24,610,D,1,0,8J3T11,"> Based on record review and interview, it was determined that the facility failed to thoroughly investigate a medication error that resulted in immediate jeopardy for 1 resident in of a survey sample of 3 residents. (Resident identifier is #2.) Findings include: Review on 10/24/19 of a facility reported incident dated 10/15/19, revealed a medication error had occurred on 10/15/19 at approximately 9:20 p.m. involving Resident #2 receiving medication that was intended for another resident (Resident #1.) Interview on 10/24/19 at approximately 10:00 a.m. with Resident #2, who has a BIMS (Brief Interview for Mental Status) of 13 and is alert and oriented, revealed that on 10/15/19 at approximately 9:20 p.m. Staff A (Registered Nurse) entered Resident #2's room to administer insulin. Resident #2 asked Staff A what the medication was. Staff A responded that it was insulin and Resident #2 informed Staff A that I don't take insulin. Resident #2 further stated that Staff A told Resident #2 that there were orders for Resident #2 to have insulin. Resident #2 stated that Staff A then injected the insulin: Jab, right in my stomach. Resident #2 stated Then they kept me up all night making me eat and checking my sugar. Interview on 10/24/19 at approximately 11:15 a.m. with Staff B (Center Nurse Executive) confirmed that the only in-service that had been provided to staff was the Med administration/right patient in-service and that the facility did not report the incident to the Board of Nursing. Staff B had not discovered during their investigation an insulin pen had been use to draw up the insulin into a syringe and used on Resident #2, then the insulin pen was returned to the medication cart and has been used on the original resident (Resident #1) since. Staff B also had not informed the infection preventionist about the incident or informed the DPOA (Durable Power of Attorney) of Resident #1 that the resident's insulin pen had been used for another resident. Phone interview on 10/31/19 at 12:51 p.m. with Staff A revealed that Staff A had no orientation and had many interruptions with the medication pass that evening and many supplies were missing. While getting the insulin pen ready for Resident #1 Staff A could not find a pen needle so Staff A took a syringe and withdrew 5 units from the insulin pen and injected (Resident #2) with it. If (Resident #2) had said something prior to (Staff A) injecting (Resident #2) then (Staff A) would have looked at the Medication Administration Record. Staff A reported the incident after Resident #2 stated, I don't take insulin. Staff A revealed that Staff A found the pen needle after and then used the same insulin pen on Resident #1.",2020-09-01
370,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-24,760,D,1,0,8J3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that residents are free of significant medication errors by giving insulin that was not physician ordered to a resident who does not take insulin, placing that resident in Immediate Jeopardy for 1 resident out of 3 residents with diabetes in a survey sample. (Resident identifer is #2.) Findings include: Review of a facility generated report dated 10/15/19, revealed a medication error in which Resident #1's [MEDICATION NAME] Solution Pen Injector was used to administer insulin to Resident #2 which Resident #2 was not prescribed. Review on 10/24/19 at approximately 10:45 a.m. of Resident #2's (MONTH) Medication Administration Record [REDACTED]. Review on 10/24/19 of the change of condition report, dated 10/15/19, for Resident #2 revealed that on 10/15/19 at 9:40 p.m. Staff F (Nurse Practitioner) was notified that Resident #2 was administrated the wrong medication. New order to take CBG's (Capillary Blood Glucose) every two hours from midnight until 0800. NP (Nurse Practitioner) will follow up in the morning. Review of the CBG's report for Resident #2 revealed the CBG's were within normal limits throughout the night between the hours midnight and 8:00 a.m. Interview on 10/24/19 at approximately 11:12 a.m with Staff B (Center Nurse Executive) confirmed that Staff B did not know that Resident #2's medication error was from an insulin pen because the dose was 5 units. Staff B also revealed that Staff B did not inform Staff C, (Infection Preventionist) of the insulin medication error or throw the insulin pen away. Interview also confirmed that Resident #2 did not have an order for [REDACTED].>Review on 10/24/19 of the facility policy and procedure titled, Medication Administration, General Revised on 07/01/19 revealed: Do not reuse the same lancet, syringe, needle, pen or injection device (e.g., pre-filled, manufacturer, insulin or any other medication or biological) for more than one individual . If medication is refused by patient, discard medication and attempt to administer again at a later time",2020-09-01
371,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2019-10-24,880,J,1,0,8J3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure agency staff were accurately trained/oriented on the facility's policies for infection control for insulin pens, failed to identify infection control risks associated with insulin pens, and failed to protect a resident from and subsequently address potential cross contamination of blood borne pathogens for 1 of 3 residents with diabetes in a survey sample resulting in Immediate Jeopardy. (Resident identifier is #2.) Findings include: Immediate Jeopardy (IJ) was identified on 10/24/19 for failing to ensure that staff followed Center for Disease Control (CDC) guidelines for single patient use of insulin pens placing one resident at risk for exposure to the potential of blood borne pathogens when an insulin pen from one resident was used for another resident. Review on 10/25/19 of the CDC Clinical Reminder: Insulin Pens Must Never Be Used for More than One Person revealed that insulin pens not be used for more than one person because the potential of blood borne pathogens transmission risk is still present due to the regurgitation of blood into the insulin cartridge. Retrieved from https://www.cdc.gov/injectionsafety/clinical-reminders/insulin-pens.html accessed on 10/25/19 Review on 10/24/19 of the facility policy and procedure titled, Insulin Pens, date reviewed 3/1/19, revealed: Insulin pens containing multiple doses of insulin are meant for single patient use only and must never be used for more than one person, even when the needle is changed. Insulin pens will be clearly labeled with the patient name or other identifier to verify that the correct pen is used on the correct patient .To prevent risk of bloodborne pathogen exposure. Review of a facility generated report dated 10/15/19 revealed on 10/15/19, Staff A (Registered Nurse) used Resident #1's [MEDICATION NAME] Solution Pen Injector to administer insulin to Resident #2. Interview on 10/24/19 at approximately 10:00 a.m. with Resident #2 revealed that Resident #2 was aware that they had received insulin in error but was what not informed of any infection control risk related to the incident. Interview on 10/24/19 at approximately 11:15 a.m. with Staff B (Center Nurse Executive) revealed that Staff B had not realized during their investigation that another resident's insulin pen had been used on Resident #2 and put Resident #2 at risk for exposure to blood borne pathogens. Staff B also had not informed the infection preventionist about the incident. Interview also revealed that Resident #2 had not been informed that receiving insulin from another resident's pen could result in potential exposure to blood borne pathogens. Interview on 10/24/19 at approximately 11:35 a.m. with Staff C (Infection Preventionist) confirmed that Staff C had not been informed that Resident #2 had received insulin from another resident's insulin pen. Phone interview on 10/31/19 at 12:51 p.m. with Staff A, revealed that Staff A had no orientation as a agency nurse to the facility's polices and the facility's environment (where supplies are kept), had many interruptions with the medication pass that evening, and many supplies were missing from the medication cart. While getting the insulin pen ready for Resident #1, Staff A could not find a pen needle so Staff A took a syringe and withdraw 5 units from the insulin pen and injected (Resident #2) with it. Staff A did not think that the incident was an infection control issue.",2020-09-01
372,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2017-10-26,157,D,0,1,T5BJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately notify the resident's physician when the resident had an accident which resulted in an injury that had the potential for requiring physician intervention for 1 of 6 residents reviewed with falls (Resident identifier is #25). Findings include: Review on 10/26/17 of Resident #25's progress notes revealed on 6/3/17 at 5:45 a.m., Resident #25 had a fall and sustained a bump on the back of their head. Further review of progress notes revealed that the primary care physician was not notified until 9:30 a.m. when staff were unable to arouse the resident and the resident's pupils became dilated and non-reactive. Review on 10/26/17 of statements dated 6/4/17 concerning the above fall from Staff F (Licensed Nursing Assistant (LNA)) and Staff G (LNA) revealed after the fall the resident was placed in the resident's wheelchair and brought to the nurse's station for observation and the resident started vomiting and wanted to lay down. Review on 10/26/17 of Resident #25's physician orders [REDACTED]. [MEDICATION NAME] Tablet 75 MG - Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] [MEDICATION NAME] Aspirin Tablet 325 MG - Give 1 tablet by mouth one time a day for CAD ([MEDICAL CONDITION]) Interview with Staff B (Director of Nursing) on 10/26/17 at approximately 2:00 p.m. confirmed the above progress notes, LNA statements, and medications.",2020-09-01
373,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2017-10-26,281,B,0,1,T5BJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the professional standard of practice for 1 resident with pronouncement at the time of death, failed to complete an assessment after a fall for 2 residents in a survey sample of 24 residents and failed to ensure medication parameters for 4 residents in a survey sample of 24 residents. (Resident identfiers are #3, #4, #5, #6, #13, #22 and #23.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Pages 479 - 480 reveals: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care . Documentation of death provides a legal record of the event. Follow agency policies and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death . Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting . Documentation of End-of-Life Care . Time and date of death and all actions taken to respond to the impending death . Name of health care provider certifying the death . Persons notified of the death (e.g., health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death . Request for organ or tissue donations made and by whom . Special preparations of the body (e.g., desired or required religious/cultural rituals) . Medical tubes, devices, or lines left in or on the body . Personal articles left on and secured to the body . Personal items given to the family with description, date, time, to whom given . Location of body identification tags . Time of body transfer and destination . Any other relevant information or family requests that help clarify special circumstances. Page 336-Physicians' Orders reveals: The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Pages 699 reveals: Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 reveals: The prescriber often gives specific instructions about when to administer a medication Page 713 reveals: .A registered nurse compares the list of medications on the MAR indicated [REDACTED]. After administering a medication, record it immediately on the appropriate record form Recording immediately after administration prevents errors . If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurses' notes. Some agencies require the nurse to circle the prescribed administration time on the medication record or to notify the physician when client misses a dose. Page 1063 reveals: .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity . Although different clients prefer different pain scales, it is important for you to select and consistently use the same scale with a specific client. You do not use a pain scale to compare the pain of one client to that of another client. Pages ,[DATE] reveals: Evaluation of pain is one of many nursing responsibilities that require effective critical thinking .The client's behavioral responses to pain-relief interventions are not always obvious. Evaluating the effectiveness of a pain intervention requires you to evaluate the client after an appropriate period of time . Ask the client if the medication alleviated the pain when it is peaking . You need to continually assess whether the character of the client's pain changes and whether individual interventions are effective .You are successful in treating pain when the client's expectations of pain relief are met. Use evaluative criteria in determining the outcome of pain-relief interventions Effective communication of a client's assessment of pain and his or her response to intervention is facilitated by accurate and thorough documentation. This communication needs to happen from nurse to nurse, shift to shift and nurse to other HCPs. It is the professional responsibility of the nurse caring for the client to report what has been effective for managing the client's pain. A variety of tools such as pain flow sheet or diary will help centralize information about pain management. The client expects you to be sensitive to his or her pain and to be attentive in attempts to manage that pain. Effectively communicating with primary HCPs . will assist you in achieving optimal pain relief for clients. Resident #22 Review on [DATE] of Resident #22 paper record revealed a death certificate for [DATE]. Review on [DATE] of Resident #22's progress notes for [DATE] revealed no notes documenting the circumstances or pronouncement the resident's death. Interview with Staff B (Direction of Nursing) on [DATE] at 11:50 a.m. revealed Resident #22 passed away on [DATE] and confirmed there was no documentation of the circumstances or pronouncement of the Resident #22's death. Review on [DATE] of the facility policy titled Cardiac and/or Respiratory Arrest, revision date [DATE], revealed the following: #7. For all cardiac/respiratory arrests, document: 7.1 Time patient was found without pulse or spontaneous respirations in the patient's medical record; 7.2 Any significant clinical events proceeding the arrest; 7.3 Patient's DNR (Do Not Resuscitate) status; 7.4 Presence of end-stage, terminal, or advanced medical conditions(s); 7.5 Description of patient's condition upon discovery (e.g. absence of blood pressure, pulse, respirations, skin color, skin temperature, body stiffness, etc.); 7.6 Reason for decision to withhold CPR (Cardiopulmonary Resuscitation); 7.7 Notification of physician and time of notification; 7.8 Notification of family and time notified; 7.9 Transfer order/information on transfer sheet, if transferred; 7.10 Death pronouncement by licensed nurse or physician called, if applicable; 7.11 Name of funeral home and date and time of release of body, if applicable. Resident #4 Review on [DATE] of Resident #4's progress notes for [DATE] revealed the resident had transfered to the hospital due to a fall. There was no documentation of pertinent information describing the fall and immediate assessment in the medical record. Interview with Staff H (Unit Manager) on [DATE] at 12:00 p.m. confirmed that Resident #4 was transferred to the hospital due to a fall and there was no documentation of pertinent information describing the fall and immediate assessment in the medical record. Resident #13 Review on [DATE] of Resident #13's progress notes for [DATE] revealed the following note; At 4 am alarm sounded in pts (patient's) room resident was observed lying on the floor sm (small) amount of blood noted on pt (patient) forehead. Tylenol pm given safety maintained. There was no documentation of pertinent information describing the immediate assessment in the medical record. Interview with Staff B (Director of Nursing) on [DATE] at approximatley 9 a.m. confirmed there was no documentation of pertinent information describing the pertinent information and immediate assessment in the medical record. Review of the facility's policy titled Accidents/Incidents revised on [DATE], section 2. Assessment, Medical Assistance, Documentation, revealed the following instructions: 2.1.6.2 Document the accident /incident in the patient's chart; Documentation will include all pertinent information, date, time, place notifications, and intital and ongoing assessments; Resident #6 Review on [DATE] of Resident #6's Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet Give 500 mg (milligrams) by mouth as needed for Pain (sic) three times a day PRN (as needed) pain. [MEDICATION NAME] (sic) HCI Tablet 4 MG Give 2 tablet (sic) by mouth every 8 hours as needed for Pain (sic) scale ,[DATE]. [MEDICATION NAME] (sic) HCI Tablet 4 MG Give 2 tablet (sic) by mouth every 8 hours as needed for Pain (sic) scale ,[DATE]. During interview with Staff C (RN/Unit Manager) on [DATE] at 12:08 p.m. who confirmed the above findings and stated that the [MEDICATION NAME] should be used for pain of ,[DATE] on a pain scale of ,[DATE]. Resident #23 Review on [DATE] of Resident #23's Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet Give 650 mg (milligrams) by mouth every 8 hours as needed for pain ,[DATE]/fever >100.5 [MEDICATION NAME] (sic) HCI Tablet 10 MG Give 1 tablet (sic) by mouth every 4 hours as needed for pain ,[DATE] [MEDICATION NAME] (sic) HCI Tablet 10 MG Give 2 tablet (sic) by mouth every 4 hours as needed for pain ,[DATE] During interview with Staff C on [DATE] at 11:55 a.m. who confirmed the above findings. Staff C stated that the resident had another pain medication ordered that was to be utilized for pain between ,[DATE] on a pain scale of ,[DATE] however this medication had been discontinued and the pain medication list had not been updated. Resident #3 Review on [DATE] at approximately 9:00 a.m. of Resident #3's Medication Administration Record [REDACTED] [MEDICATION NAME] 50 MG (milligram) tablet by mouth as needed for pain twice daily. [MEDICATION NAME] Tablet 5 MG, give 1 tablet by mouth every 8 hours as needed for pain three times daily. Tylenol 325 MG, give 2 tablets by mouth every 6 hours as needed for pain/fever (scale,[DATE]). Interview on [DATE] at approximately 10:00 a.m. with Staff B (Director of Nurses) confirmed that the above orders did not have clear indications on which pain medication should be administered for pain Staff B, They should have a pain scale. Resident #5 Review on [DATE] at approximately 2:00 p.m. of Resident # 5's Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet 325 MG (milligrams) Give 2 tablets by mouth every 6 hours as needed for General Discomfort, Pain scale ,[DATE]. [MEDICATION NAME] 5 MG by mouth as needed every 2 hours for pain/restlessness. Pain scale ,[DATE]. Interview on [DATE] at approximately 10:0 a.m. with Staff B Director of Nurses confirmed that the current physicians order for the as needed pain medications did not cover the pain scale ,[DATE].",2020-09-01
374,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2017-10-26,431,E,0,1,T5BJ11,"Based on observation, interview, record review and policy review, the facility failed to ensure to ensure medications are not used after the expiration date for 2 residents and stock medications and supplies are not available for use after thier expiration date on 4 of 4 residential units. (Resident identifiers are #34 and #35.) Findings include: Resident #34 Observation on 10/24/17 at approximately 9:30 a.m. on the Homestead unit medication cart revealed a bottle of Lantus Solution belonging to Resident #34. The bottle was labeled Do not use after 10/22/17. Review on 10/25/17 of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident #35 Observation on 10/24/17 at approximately 9:30 a.m. on the Homestead unit medication cart revealed a bottle of Levemir Solution belonging to Resident #34. The bottle was labeled Do not use after 10/23/17. Review on 10/25/17 of the (MONTH) (YEAR) MAR for Resident #35 revealed that the resident received an injection of Levemir Solution from the above bottle in the morning on 10/24/17 after the do not use after date of 10/23/17 labeled on the bottle. Interview with Staff H (Unit Manager) confirmed the findings for the expired medications for Resident #34 and Resident #35 and they were the medication vials currently in use. During tour of the medication storage room on the Frost Unit with Staff C (RN/Unit Manager) it was revealed that a bottle of Naproxen that was available for resident use had expired 3/17. Interview with Staff C on 10/26/17 at 12:35 p.m. confirmed that the bottle of Naproxen had expired 3/17 and was available for resident use in the medication storage room. Observation on 10/24/17 in the AM, of the medication room located on the[NAME]Unit, in the presence of Staff [NAME] (Licensed Practical Nurse), revealed an unopened bottle of B-Complex vitamin on the medication storage shelf with an expiration date of 4/17. Interview at that time with Staff E, Staff [NAME] indicated that part of Staff E's monthly (Pierce Unit) audit examines for expired medication in the medication room and is unsure why the bottle of expired medication was on the shelf. Staff [NAME] indicated that the Medication Nurses do check for expiration dates prior to stocking the Medication Cart with medication from the medication room. Observation on 10/24/17 at approximately 9:30 a.m. during tour of the[NAME]Unit with Staff A (Unit Manager) revealed the following expired items/medications in the Medication Room: A Maxplus extension set with clear needles connector, expiration date 5/2017. A 22 gauge 1 inch needle, expiration date 9/2017. An Intravenous start kit, expiration date 8/2017. A vial of the Influenza vaccine vial opened, no date of opening in the medication refrigerator. A vial of Humulin Insulin 70/30 vial opened, not labeled with a resident name, open date 9/5/17, expired 10/3/17. Interview on 10/24/17 at approximately 9:40 a.m. with Staff A confirmed that the above medications and supplies were expired in the[NAME]Medication Room. Observation on 10/25/17 at approximately 7:30 a.m. of the Medication Room of the[NAME]Unit with Staff D (Licensed Practical Nurse) revealed: 4 culture swabs, expiration date 9/17. Interview on 10/25/17 at approximately 7:35 a.m. with Staff D (LPN) confirmed that the culture swabs were expired.",2020-09-01
375,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2017-10-26,456,B,0,1,T5BJ11,"Based on observation, interview and facility policy review, it was determined that the facility failed to maintain oxygen concentrators in sanitary operating condition for 5 out of 5 oxygen concentrators observed during tour of the[NAME]Unit. (Resident identifier's are #28, #30, #31, #32 and #33.) Findings include: Observation on 10/24/17 at approximately 9:30 a.m. on[NAME]Unit tour with Staff A (Unit Manager) revealed that Resident #28, #30, #31, #32 and Resident #33's oxygen concentrator filters had approximately 1/4 inch of dust and debris adhered to them. Staff B (Director of Nurses) was also present during part of the tour and was present for the findings of #28 and #30's oxygen concentrator filters that were observed. Interview on 10/24/17 at approximately 9:45 a.m. with Staff A confirmed that the filters had a visible amount of dust and debris adhered to them. Staff A stated, That is so bad, while observing Resident #32's oxygen concentrator filter. Review on 10/26/17 of the facility policy named Respiratory Equipment/Supply Cleaning/Disinfection Effective Date: 4/1/07 revealed in the section titled Routine cleaning of equipment in patient room: . 1.6.4 Oxygen Concentrators: Rinse and dry the external filter weekly and as needed when visibly dusty. Interview on 10/26/17 at approximately 1:00 p.m. with Staff B revealed that the Oxygen concentrator filters should be cleaned weekly.",2020-09-01
376,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2017-10-26,514,D,0,1,T5BJ11,"Based on record review and interview the facility failed to ensure that the medical record is complete and accurate for 1 resident in a survey sample of 24 residents and 1 out of sample resident. (Resident identifiers are #12 and #25.) Findings include: Resident #12. Review on 10/25/17 of Resident #12's NEUROLOGICAL ASSESSMENT FLOW SHEET revealed an incomplete flow sheet with no dates listed for 15 entries. A second NEUROLOGICAL ASSESSMENT FLOW SHEET for Resident #12 reviewed at this time revealed in the date section the following dates 5/16, 5/17, 5/18 and 5/19 with no year listed on this flow sheet. Interview on 10/25/17 at approximately 8:45 a.m. with Staff [NAME] (Registered Nurse) confirmed that the one NEUROLOGICAL ASSESSMENT FLOW SHEET listed above had no dates and the second NEUROLOGICAL ASSESSMENT FLOW SHEET had no year listed for Resident #12. Resident #25 Review on 10/26/17 of Resident #25's Neurological Assessment Flow Sheet from 6/3/17 revealed an incomplete flow sheet. At 6:20 a.m. and 6:50 a.m., the Level of Consciousness (L[NAME]), pupil response, motor function, temperature, pulse, respiration, and blood pressure were not recorded on the flow sheet. Interview with Staff B (Director of Nursing) on 10/26/17 at approximately 1:45 p.m. confirmed the above Neurological Assessment Flow Sheet was incomplete. Review of the facility's policy titled Assessment: Neurological, revision date 7/17/14, revealed the following 10 Document: 10.1 L[NAME], pupil reaction, motor function, temperature, pulse, respiration, and blood pressure on Neurological Assessment Flow Sheet.",2020-09-01
377,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2017-01-19,314,D,0,1,3B5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to perform pressure ulcer assessments consistent with professional standards of practice for 1 of 4 residents with pressure ulcers in a survey sample of 16 residents. (Resident identifier #1) Findings include: Review of National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014 revealed that pressure ulcer assessments should be performed at least weekly to provide an opportunity to detect complications and adjust treatments. (Accessed website on 1/27/17: http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf). Review of Resident #1's skin integrity reports from 10/19/16 to 1/18/16 revealed Resident #1 had an unstageable Deep Tissue Injury (DTI)/pressure ulcer on the lower left extremity - posterior. Further review of Resident #1's skin integrity reports revealed pressure ulcer assessments were performed on 10/28/16 and 11/17/16, which is 20 days between assessments. During that timeframe the measurement of length of the pressure ulcer went from 3 centimeters (cm) to 4.2 cm. Pressure ulcer assessments were performed on 12/30/16 and 1/17/17, which is 18 days between assessments. During that timeframe, the length of the pressure ulcer went from 1 cm to 6 cm. Interview with Staff B (Unit Manager) on 1/18/17 at 11:05 a.m. confirmed the findings from the review of skin integrity reports and revealed that there were no other pressure ulcer assessments for Resident #1 during the gaps in assessments identified above.",2020-09-01
378,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2018-04-23,609,D,0,1,7PZ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency within 24 hours for 1 of 2 residents investigated for abuse in a sample size of 18 residents (Resident identifier is #25). Findings include: Interview with Resident #25 on 4/19/18 at 11:54 am revealed the resident reported a staff member hurt the resident during care over the weekend and the resident had reported it to the facility. Interview with Staff B (Director Of Nursing) on 4/23/18 at 8:25 am revealed an allegation of abuse concerning rough treatment of [REDACTED]. Staff B revealed that the facility did not report the allegation to the State Agency. Staff B revealed that the investigation had not been completed.",2020-09-01
379,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2018-04-23,656,B,0,1,7PZ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 2 residents in a standard survey sample of 18 residents. (Resident identifiers are #21 and #68.) Findings include: Resident #21 Review on 4/23/18 at approximately 9:45 a.m. of Resident #21's medical record revealed a [DIAGNOSES REDACTED]. every 08 hours as needed for DNV (did not void). Review of Resident #21's care plan revealed that there was not a care plan in place for the physicians order to straight cath, or a care plan that addressed Resident #21's urinary incontinence. Interview on 4/23/18 at approximately 10:05 a.m. with Staff [NAME] (Unit Manager) confirmed that resident #21 did not have a care plan in place to straight cath, and that there was no care plan in place to address Resident #21's incontinence Resident #68 Interview on 4/19/18 at approximately 12:00 p.m. with Staff A (Unit Manager) revealed that Resident #68 had recent weight loss. Review on 4/23/18 of Resident #68's weights revealed that Resident #68 had a 5.62% weight loss since admission on 3/21/18. Resident #68's weight on 3/23/18 was 165.5 and on 4/17/18 was 151.2. Review on 4/23/18 of Resident #68's diet revealed that Resident #68's diet was regular/liberalized diet, dysphasia puree texture, nectar thick liquids. Review on 4/23/18 of Resident #68's care plans revealed that there was not a care plan for nutrition. Interview on 4/23/18 at approximately 10:45 a.m. with Staff A confirmed that there was no care plan for nutrition.",2020-09-01
380,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2019-05-03,552,D,0,1,2IYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined that the facility failed to document that they informed a resident's DPOA (Durable Power of Attorney) of the administration of antipsychotic medication to 1 resident in a final survey sample of 17 residents. (Resident identifier is #5.) Findings include: Review on 5/1/19 of Resident #5's current physician orders [REDACTED].#5 takes [MEDICATION NAME] (an antipsychotic medication) 0.5 mg (milligram) by mouth daily at bedtime, which was ordered on [DATE], the day of Resident #5's admission to the facility. Review on 5/2/19 of Resident #5's [MEDICAL CONDITION] Medication Administration Disclosure which was signed on 1/18/19, revealed that Resident #5's use of an antidepressant medication and their use of an anti-anxiety medication were circled on the form. There was no indication on the form that Resident #5 was taking an antipsychotic medication. Review on 5/2/19 of the Facility Policy, titled [MEDICAL CONDITION] Medication Use last revised on 11/28/16 revealed that .Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of [MEDICAL CONDITION] medications, per facility policy or applicable state regulations. Interview on 5/2/19 at approximately 1:30 p.m. with Staff F (Unit Manager) confirmed that there was no documented evidence that Resident #5's DPOA was notified of Resident #5's use of antipsychotic medication. Staff F also confirmed that Resident #5's DPOA should have been notified and that the notification should have been documented.",2020-09-01
381,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2019-05-03,584,E,0,1,2IYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain the walls, floors and residents' furniture in good repair to maintain a home-like environment throughout the facility. Findings include: Observation on 4/30/19 and 5/1/19 of the common area located as you enter through the front door of the facility revealed that the walls were all marked, scrapped and in need of repair. Also the baseboard heaters located towards the service corridors were scraped and broken. Observation on 4/30/19 and 5/1/19 while touring the 100's unit revealed the following: 1) The hallway radiator covers between rooms 110-112 and rooms 104-107 were bent and/or broken and paint was scraped off. 2) The door casings throughout the unit going into and out of resident's bedrooms and bathrooms were chipped, scraped and missing paint. 3) The floors throughout the unit were dirty and stained. All resident room floors were dirty and stained. 4) All resident room walls were in need of paint and sheetrock repair due to holes from hung items hitting the walls. 5) Resident room [ROOM NUMBER]'s wardrobes laminate was chipped and broken. This was a potential infection control issue due to it not being able to be cleaned completely. Observation on 4/30/19 and 5/1/19 while touring the 200's unit revealed the following: 1) Two radiator covers in the main hallway located by rooms 201-202 were bent, damaged and in need of paint due to scrapes. The radiator covers in the hallway by rooms 205-206 and 207-209 were bent, damaged and in need of paint due to scrapes. The radiator covers by the nurses' desk between the pantry room and room [ROOM NUMBER], and 211-213 were bent, damaged and in need of paint due to scrapes. 2) All the walls in the hallway of the 200's unit were in need of paint and repair due to damage to the sheet rock. 3) The nurses' station was in need of repair due to chipped and missing laminate along its sides. This was a potential infection control issue due to it not being able to be cleaned completely. 4) In almost all the resident rooms on the 200's unit their wardrobe closets were chipped and missing laminate. This was also seen around the sinks. This was a potential infection control issue and potential accident hazard due to sharp edges. 5) All door casings throughout the unit going into and out of resident's bedrooms and bathrooms were chipped, scraped and missing paint. 6) All the floors throughout the unit were dirty with stains. All resident room floors were dirty with stains. 7) All resident room walls were in need of paint and sheetrock repair due to holes from hung items that hit the walls. Observation on 4/30/19 and 5/1/19 while touring the 300's unit revealed the following: 1) In almost all the resident rooms on the 300's unit the wardrobe closets were chipped and missing laminate. This was also seen around the sinks. This was a potential infection control issue and a potential accident hazard due to sharp edges. 2) All door casings throughout the unit going into and out of resident's bedrooms and bathrooms were chipped, scraped and missing paint. 3) All the floors throughout the unit were dirty with stains. All resident room floors were dirty with stains. 4) All resident room walls were in need of paint and sheetrock repair due to holes from hung items and beds that hit the walls. Interview on 4/30/19 at 2:00 p.m. with resident council revealed that several of the resident council members felt that there was room for improvement and thankful that they were being asked about it. Interview on 5/3/19 at 2:21 p.m. with Staff G (Infection control) during the infection control interview, Staff G revealed that there was not really surveillance done on resident rooms. Staff G had noted residents' closets/wardrobe with the missing laminate and Staff G stated yes and it is definitely an issue. Interview on 4/30/19, 5/1/19, 5/2/19 and 5/3/19 during the end of day exit meeting with Staff [NAME] (Director of Nurses) reviewed the above environmental issues.",2020-09-01
382,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2019-05-03,656,B,0,1,2IYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to develop a care plan for the use of an indwelling catheter for 1 resident and for an advance directive choice for another resident in a final survey sample of 17 residents. (Resident identifiers are #42 and #66.) Findings include: Resident #66 Review on 5/3/19 of Resident #66's physician orders [REDACTED].#66 had an order for [REDACTED]. Review on 5/3/19 of Resident #66's care plan, dated 3/21/19, revealed that it read Resident has an established advanced directive and/or DNR (Do Not Resuscitate) order in place. Interview on 5/3/19 with Staff [NAME] (Director of Nursing) confirmed that Resident #66 had an order for [REDACTED].#66 returned from the hospital should have indicated that they no longer wanted to be a DNR but wanted to be a Full Code instead. Resident #42 Observation on 4/30/19 at 12:34 p.m. of Resident #42 revealed a urinary catheter drainage bag hanging on the foot of the bed. Review on 5/3/19 of Resident #42's current physician orders [REDACTED].#42 had orders to change Foley catheter (18 French with 10 milliliters balloon) for [MEDICAL CONDITION] bladder on the 27th every month, empty catheter drainage bag at least once every eight hours and as needed, perform Foley catheter care every day and evening shift and as needed, flush Foley catheter with 60 ml sterile water every 8 hours, and may use leg bag if desired when out of bed as needed. Review on 5/3/19 of Resident #42's current care plan revealed that Resident #42 is incontinent of urine with intervention to assist with perineal care as needed, use absorbent products as needed, and utilized appropriate continent product with initiated date of 2/8/19. Further review of Resident #42's current care plan revealed no care plan for Resident #42's Foley catheter use, interventions and goals. Interview on 5/3/19 at 1:00 p.m. with Staff [NAME] (Director of Nursing) confirmed the above findings. Staff [NAME] stated that Resident #42's care plan should show that Resident #42 was utilizing a Foley catheter and interventions that were in place for the care of the catheter and monitoring for skin breakdown and infections related to the Foley catheter. Interview on 5/3/19 at 2:00 p.m. with Staff D (Licensed Practical Nurse) revealed that Resident #42 was currently utilizing a Foley catheter for [MEDICAL CONDITION] bladder. Staff D stated that Resident #42 had a Foley catheter since their initial admission date of [DATE].",2020-09-01
383,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2019-05-03,658,D,0,1,2IYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy and procedure, it was determined that the facility failed to meet the professional standard of practice for the administration of medications for 1 resident out of 30 residents observed for medication administration. (Resident identifier is 58.) Findings include: Reference for the professional standard of practice are the following: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 688 Guidelines for Safe Narcotic Administration and Control . Store all narcotics in a locked, secure cabinet or container. . Narcotics are frequently counted. Usually counts are made on a continuous basis with the opening of narcotic drawers and/or at shift change. . Report discrepancies in narcotic counts immediately. . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. Page 713 .A registered nurse compares the list of medications on the MAR indicated [REDACTED]. .After administering a medication, record it immediately on the appropriate record form .After administering a medication, record it immediately on the appropriate record form. .Recording immediately after administration prevents errors. .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurses' notes. Page 1063 .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity. .Although different clients prefer different pain scales, it is important for you to select and consistently use the same scale with a specific client. You do not use a pain scale to compare the pain of one client to that of another client. Pages 1082-1083 Evaluation of pain is one of many nursing responsibilities that require effective critical thinking. .The client's behavioral responses to pain-relief interventions are not always obvious. Evaluating the effectiveness of a pain intervention requires you to evaluate the client after an appropriate period of time. .You need to continually assess whether the character of the client's pain changes and whether individual interventions are effective. .You are successful in treating pain when the client's expectations of pain relief are met. Use evaluative criteria in determining the outcome of pain-relief interventions. Effective communication of a client's assessment of pain and his or her response to intervention is facilitated by accurate and thorough documentation. This communication needs to happen from nurse to nurse, shift to shift, and nurse to other . It is the professional responsibility of the nurse caring for the client to report what has been effective for managing the client's pain. A variety of tools such as pain flow sheet or diary will help centralize information about pain management. The client expects you to be sensitive to his or her pain and to be attentive in attempts to manage that pain. Effectively communicating with primary . will assist you in achieving optimal pain relief for clients. Review of the facility policy and procedure titled PAIN MANAGEMENT with a revision date of 03/01/18 revealed the following: PURPOSE: . To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain . . 5. If PRN medications are given, document on the back of the MAR indicated [REDACTED]. 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects . in providing pain relief. Document: . 8.3 Effectiveness of PRN medications . Review on 5/3/19 at approximately 1:00 p.m. of the Medication Administration Record [REDACTED]. This MAR indicated [REDACTED]. Review on 5/3/19 at approximately 1:00 p.m. of the PRN PAIN MANAGEMENT FLOW SHEET for Resident #58 dated 3/1/19 revealed that the above listed medication was given on the following days: - 3/1 with Pain rating of 9 and the effectiveness of 3 - 3/4 with Pain rating of 6 and the effectiveness was blank - 3/5 with Pain rating of 8 and the effectiveness was blank - 3/7 with Pain rating of 5 and the effectiveness was blank - 3/22 with Pain rating of 9 and the effectiveness was blank. This documentation showed only 5 doses of PRN [MEDICATION NAME] 20 mg given to Resident #58 not the 18 doses listed on the MAR. Review on 5/3/19 at approximately 1:00 p.m. of the facility Narcotic log page #36 showed that Resident #58 was given PRN [MEDICATION NAME] Solution 20 mg on 3/13 and a second PRN dose on 3/14 and 3/21. The MAR, PRN PAIN MANAGEMENT FLOW SHEET and narcotic log dates of [MEDICATION NAME] 20 mg given to Resident #58 were not accurate and not consistent. Review on 5/3/19 at approximately 1:00 p.m. of the MAR for Resident #58 dated 4/1/2019 - 4/30/2019 revealed the following physician order for [REDACTED]. Review on 5/3/19 at approximately 1:00 p.m. of the PRN PAIN MANAGEMENT FLOW SHEET for Resident #58 dated 4/1/19 revealed that the above listed medication was given on the following days: - 4/1 with no pain rating and the effectiveness was blank - 4/11 with Pain rating of 10 and the effectiveness was 3 - 4/12 with Pain rating of 10 and the effectiveness was blank - 4/22 with Pain rating of 9 and the effectiveness was blank - 4/22 with Pain rating of 9 and the effectiveness was blank - 4/23 with Pain rating of 7 and the effectiveness was 2 - 4/26 with Pain rating of 10 and the effectiveness was 3 - 4/27 with Pain rating of 6 and the effectiveness was 3 - 4/29 with Pain rating of 9 and the effectiveness was 3. This documentation showed only 9 doses of PRN [MEDICATION NAME] 20 mg given to Resident #58 not the 17 doses listed on the MAR. Review on 5/3/19 at approximately 1:00 p.m. of the facility Narcotic log page #45, #46 and page #74 showed that Resident #58 was given PRN [MEDICATION NAME] Solution 20 mg on 4/3, 4/9 (twice), 4/22 and 4/23. The MAR, PRN MANAGEMENT FLOW SHEET and the narcotic log dates of [MEDICATION NAME] 20 mg given to Resident #58 were not accurate and not consistent. Interview on 5/3/19 at approximately 1:00 p.m. with Staff F (Registered Nurse) revealed, after Staff F reviewed the above listed findings, that the MAR, the PRN PAIN MANAGEMENT FLOW SHEET' and the narcotic logs were not accurate for the [MEDICATION NAME] 20 mg given to Resident #58 and that the professional standards of practice for the administration of PRN narcotic medication were not followed for Resident #58.",2020-09-01
384,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2019-05-03,758,D,0,1,2IYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that behaviors were monitored and documented for 1 resident; and PRN (as needed) orders for [MEDICAL CONDITION] drugs are limited to 14 days, except if the attending physician or prescribing practitioner believed that it is appropriate for the PRN order to be extended beyond 14 days, he or she should indicate the duration for the PRN order for 1 resident in a final survey sample of 17 residents. (Resident identifiers are #5 and #59.) Findings include: Resident #59 Review on 5/2/19 of Resident #59's current physician orders [REDACTED]. Review on 5/2/19 of Resident #59's (MONTH) 2019 Medication Administration Record [REDACTED]. Further review of Resident #59's (MONTH) 2019 MAR indicated [REDACTED]. Review on 5/2/19 of Resident #52's (MONTH) 2019 MAR indicated [REDACTED]. Further review of Resident #59's (MONTH) 2019 MAR indicated [REDACTED]. Review on 5/2/19 of Resident #59's (MONTH) 2019 MAR indicated [REDACTED]. Further review of Resident #59's (MONTH) 2019 revealed that Resident #59 did not received any PRN [MEDICATION NAME] 0.5 mg for that month. Review on 5/2/19 of Resident #59 (MONTH) 2019 MAR indicated [REDACTED]. Interview on 5/2/19 at 11:55 a.m. with Staff F (Unit Manager) confirmed the above findings. Staff F stated that Resident #59 was on PRN [MEDICATION NAME] since 7/5/18 then on 3/15/19 the PCP (Primary Care Physician) prescribed Resident #59 with a scheduled doses of [MEDICATION NAME] and continued the PRN [MEDICATION NAME] order. Staff F also stated that there should have been a duration of use on the [MEDICATION NAME] PRN orders (7/5/18 and 3/15/19 PRN [MEDICATION NAME] orders). Review on 5/3/19 of Resident #59's psychiatrist notes revealed that the last visit note was dated 5/30/18 and that no duration date for PRN [MEDICATION NAME] use. Review on 5/3/19 of Resident #59's physician/APRN notes from (MONTH) 2019 to (MONTH) 2019 revealed a APRN note on 3/6/19 that showed no duration was documented for the PRN [MEDICATION NAME] use. Interview on 5/3/19 at 11:38 a.m. with Staff [NAME] (Director of Nursing) confirmed that Resident #59's APRN note on 3/6/19 showed no documented duration of PRN [MEDICATION NAME] use. Resident #5 Review on 5/1/19 of Resident #5's current physician orders [REDACTED].#5 takes [MEDICATION NAME] (an antipsychotic medication) 0.5 mg (milligram) by mouth daily at bedtime, which was ordered on [DATE], the day of Resident #5's admission to the facility. Review on 5/3/19 of Resident #5's psychiatric consultation note, dated 4/11/19, revealed that Resident #5 was taking [MEDICATION NAME] for hallucinations, paranoia and delusions. Review on 5/3/19 of the Facility Policy, titled [MEDICAL CONDITION] Medication Use last revised on 11/28/16 revealed that .Facility staff should monitor the resident's behavior pursuant to facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving [MEDICAL CONDITION] medication for organic mental syndrome with agitated or psychotic behavior(s) .Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions . Review on 5/2/19 of Resident #5's (MONTH) 2019 Behavior Monitoring and Interventions form revealed that the behavior symptom that was being monitored for Resident #5 was Rejection of Care. There was no documented evidence that hallucinations, paranoia or delusions were being monitored. Interview on 5/3/19 at approximately 9:00 a.m. with Staff F (Unit Manager) confirmed that there was no documentation of Resident #5's hallucinations, paranoia and delusions and that these behaviors should have been included on the behavior monitoring form.",2020-09-01
385,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2019-05-03,812,E,0,1,2IYN11,"Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety for 2 out of 2 observed unit kitchenettes. Findings include: Review on 4/30/19 of facility's policy titled, Labeling and Dating version 3, revealed that .All Ready-To Eat/Temperature Control for Safety (TCS) foods that are held for more than 24 hours .will be labeled and dated with a .used by date (Day 7) Review on 4/30/10 of facility's policy titled, Use By Dating Guidelines, revision date 12/01/15, revealed that .Ready-to-eat/TCS foods include, but not limited to: .thickened liquids .date with .use by date seven days after opening Observation on 4/30/19 at 9:56 a.m. with Staff A (Food Service Director) at unit 1 kitchenette refrigerator revealed 1 opened carton of nectar-thick apple juice with labeled open date of 4/20/19 and 2 opened cartons of nectar-thick cranberry juice with labeled open date of 4/20/19. Further observation of the 3 opened cartons of nectar-thick juices revealed that on the juice carton a written manufacturer's instructions showed to discard the nectar thick juices after 7 days once opened. Observation on 4/30/19 at 10:00 a.m. with Staff A at unit 2 and 3 kitchenette refrigerator revealed 4 opened cartons of nectar-thick juices with no labeled open or used by date. Further observation of the 4 opened cartons of nectar-thick juices revealed that on the juice carton a written manufacturer's instructions showed to discard the nectar thick juices after 7 days once opened. Interview on 4/30/19 at 10:00 a.m. with Staff A confirmed the above observations. Staff A stated that the nectar-thick juices found in the unit 1 kitchenette refrigerator should have been discarded on 4/27/19 and the nectar-thick juices on unit 2 &3 kitchenette refrigerator should have had a label open date. Interview on 4/30/19 at 11:54 a.m. with Staff B (Licensed Nursing Assistant) revealed that nectar-thickened juices once opened would be labeled with an open date. Interview on 4/30/19 at 11:56 a.m. with Staff C (Licensed Nursing Assistant) revealed that nectar-thick juices once opened would be labeled with an open date. Staff C stated that if they open a carton of nectar-thick juices they would have to label the carton with an open date.",2020-09-01
386,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2017-08-30,281,B,0,1,6SU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facillity failed to meet professional standards of quality with as needed pain medication parameters for 2 residents, as needed anxiety medications with out specific indicators for administration for 1 resident and not implementing care plan interventions for 2 residents that have as needed anti-anxiety medications. (Resident Indicators are #1, #3, #8 and #12.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Pages 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #3 Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet 500 mg, 2 tablets every 8 hours via [DEVICE] (gastric tube) as needed for pain. NTE (not to exceed) 3 grams in 4 hours. [MEDICATION NAME] HCl tablet 50 mg, give 1 tablet every 8 hours via [DEVICE] as needed for pain. There were no written parameters, indications, or directions for what circumstances or pain levels these medications would be given. Resident #8 Review on 8/29/17 of Resident #8's MEDICATION ORDERS FOR [REDACTED] [MEDICATION NAME] 20 mg/ml (5mg) Per Oral (PO)/Sublingual (SL) every one hour as needed for pain or dyspnea. Order for Tylenol was also part of Resident #8's pain orders: [MEDICATION NAME] Suppository 650 mg. Insert 1 suppository rectally every 6 hours as needed for general discomfort. Notify physician/midlevel provider if discomfort persists. Do not exceed 3 grams/day. Interview with Staff B (DON) on 8/30/17 verified the above findings. Resident #1 Review on 8/28/17 of Resident #1's (MONTH) and (MONTH) (YEAR) MAR (Medication Administration Record) revealed that Resident #1 had the following active 2 physicians orders to be administered for anxiety PRN (as needed): [MEDICATION NAME] 0.25 MG (milligram) Give 1 tablet by mouth every 12 hours PRN for anxiety. [MEDICATION NAME] 0.5 MG give 2 tablets by mouth every 2 hours PRN for anxiety/agitation. In (MONTH) (YEAR) Resident # 1 was administered [MEDICATION NAME] 0.25 MG once and [MEDICATION NAME] 0.5 MG 4 times. In (MONTH) (YEAR) Resident #1 was administered [MEDICATION NAME] 0.25 MG 5 times. Interview on 8/28/17 at approximately 2:15 p.m. with Staff A (Registered Nurse) revealed that there were no specific indicators for administration with the 2 as needed antianxiety medications. Review on 8/28/17 of Resident #1's care plans revealed the following care plan dated 6/23/17, revised on 7/21/17: Focus: Resident is at risk for complications related to the use of [MEDICAL CONDITION] drugs, related to the use of [MEDICAL CONDITION] drugs, antianxiety. Interventions: Complete behavior monitoring flow sheet. Review on 8/28/17 of Resident #1's behavior monitoring flow sheet revealed that the flow sheets for (MONTH) and (MONTH) (YEAR) were not utilized. There was no evidence on the behavior monitoring flow sheets of any anxiety being exhibited, any non pharmalogical interventions or PRN's being administered in those months. Review of (MONTH) (YEAR)'s MAR indicated [REDACTED]. In (MONTH) (YEAR) Resident #1 was administered [MEDICATION NAME] 0.25 MG 5 times. Interview on 8/28/17 at approximately 2:15 p.m. with Staff A (Registered Nurse) confirmed that the (MONTH) and (MONTH) (YEAR)'s behavior monitoring flow sheets were not completed. Resident #12 Review on 8/30/17 of Resident #12's care plans revealed the following care plan dated 8/01/17, revised on 8/17/17: Focus: Resident is at risk for complications related to the use of [MEDICAL CONDITION] drugs, related to the use of [MEDICAL CONDITION] drugs, antianxiety. Interventions: Complete behavior monitoring flow sheet. Review of Resident #12's (MONTH) MAR indicated [REDACTED]. Review on 8/30/17 of Resident #12's behavior monitoring flow sheet revealed that the flow sheets for (MONTH) (YEAR) were not utilized. There was no evidence of any anxiety being exhibited or PRN's being administered. Interview on 8/30/17 at approximately 2:15 p.m. with Staff A (Registered Nurse) confirmed that the (MONTH) (YEAR)'s behavior monitoring flow sheets were not completed. Review on 8/30/17of the facility's policy and procedure: Behaviors: Management of symptoms, Effective date 8/01/99, Revision date 8/15/17 revealed: 4. Review Behavior Monitoring and Interventions Flow Record to identify patterns, possible causes, results of non-pharmalogical interventions, and side effects of medications, if present.",2020-09-01
387,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2018-10-23,757,D,0,1,L5F211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that resident's anticoagulant regimen was adequately monitored, that lab works was performed and documented as ordered, and that new orders were implemented accurately for 3 of 6 residents on [MEDICATION NAME] ([MEDICATION NAME]) which resulted in an excessive dose of [MEDICATION NAME], a delay in [MEDICATION NAME] treatment, and laboratory testing not being performed. (Resident identifiers are #4, #30, and #60.) Findings include: Resident #4 Review on 10/22/18 at 3:45 p.m. of Resident #4's physician orders [REDACTED]. Review of Resident #4's progress notes revealed no results of a PT/INR performed on 10/4/18. Review of Resident #4's physician orders [REDACTED]. Interview on 10/22/18 at 9:20 a.m. with Staff F (Director of Nursing) confirmed the above finding and was unable to provide documentation of a PT/INR result from 10/4/18. Interview on 10/22/18 at 4:00 PM with Staff F revealed a PT/INR was not done on 10/4/18 which resulted in no new [MEDICATION NAME] orders for Resident #4 and Resident #4 did not receive [MEDICATION NAME] for 2 days (10/4/18 and 10/5/18) until the error was discovered on 10/6/18. Review on 10/23/18 of Resident #4's Medication Administration Record [REDACTED]. Review on 10/23/18 of Resident #4's progress notes from 10/8/18 at 3:01 p.m. revealed a PT/INR result of 1.1. Review on 10/23/18 of the facility's policy titled PT/INR testing with Coagucheck XS and XS Plus monitoring system with a revision date of 7/1/15 revealed the following: 1.4 Therapeutic PT and/or INR range and parameters for physician notification. 1.4.1 For most indications, the recommendation INR is 2 to 3. 1.4.2 For patients who have prosthetic heart valves or recurrent systemi emboli, the INR should be maintained between 2.5 and 3.5. Interview with Staff H (Registered Nurse) on 10/23/18 at 11:00 a.m. via telephone confirmed Staff H performed a PT/INR on 10/4/18 and called the results to the physician but did not document the results in the clinical record. Resident #30 Review on 10/22/18 of Resident #30's physician orders [REDACTED]. [MEDICATION NAME] Sodium tablet 5 mg, give 1 tablet by mouth in the evening every Sunday, Tuesday, Thursday, Friday, and Saturday until 10/17/18. Review on 10/22/18 of Resident #30's Medication Administration Record [REDACTED]. Review on 10/22/18 of Resident #30's physician orders [REDACTED]. Review of Resident #30's progress notes revealed no results of a PT/INR performed on 10/11/18. Interview with Staff F (Director of Nursing ) on 10/22/18 at 9:20 a.m. revealed that the order for [MEDICATION NAME] was entered to the electronic MAR indicated [REDACTED]. [MEDICATION NAME] Sodium Tablet 2.5 mg, give 1 tablet by mouth in the evening every Sunday, Tuesday, Thursday, Friday, and Saturday until 10/17/18. Interview also revealed that a PT/INR was performed on 10/4/18 and it did not need to be repeated until 10/18/18. Staff F was unable to provide documentation to confirm the change PT/INR order. Interview also revealed that prior to 10/1/18, the facility used the [MEDICATION NAME] Clinic at the hospital to monitor anticoaguation therapy. After 10/1/18, the facility began monitoring anticoaguation therapy inhouse. Review on 10/23/18 of progress notes revealed the following note written on 10/22/18 by Staff G (Physician) for 10/4/18: Nurse (Name removed) communicated INR results of 1.6. Gave orders to continue current [MEDICATION NAME] dosing, and to repeat INR again on 10/8/18. Interview with Staff H (Registered Nurse) on 10/23/18 at 11:00 a.m. via telephone confirmed Staff H entered the [MEDICATION NAME] order into the electronic MAR indicated [REDACTED]. [MEDICATION NAME] Sodium Tablet 2.5 mg, give 1 tablet by mouth in the evening every Sunday, Tuesday, Thursday, Friday, and Saturday until 10/17/18. Interview revealed prior to 10/1/18 the facility used the hospital's [MEDICATION NAME] Clinic to follow anticoagution therapy. After 10/1/18, there was no education or training on how the facility would be monitoring anticoagution therapy inhouse. Resident #60 Review on 10/22/18 of Resident #60's electronic medical record and paper record revealed the following physician MEDICATION ORDERS FOR [REDACTED]. Review on 10/22/18 of Resident #60's nursing notes dated 9/6/18 showed an International Normalized Ratio (INR) result was 2.2 and to continue [MEDICATION NAME] 2.5 mg daily. A second entry in the nursing notes dated 9/6/18 for Resident #60 showed Next INR check is on 10/4/18. Interview and review of Resident #60's electronic medical record and paper record on 10/22/18 at approximately 4:30 p.m. and on 10/23/18 at approximately 10:00 a.m. with Staff F (Director of Nursing) revealed no documented evidence on 10/4/18 of the physician ordered INR results.",2020-09-01
388,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2018-10-23,760,D,0,1,L5F211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents on anticoagulant therapy ([MEDICATION NAME]/[MEDICATION NAME] Sodium). (Resident identifier is #30.) Findings include: Review on 10/22/18 of Resident #30's physician orders [REDACTED]. [MEDICATION NAME] Sodium Tablet 5 mg, give 1 tablet by mouth in the evening every Sunday, Tuesday, Thursday, Friday, Saturday until 10/17/18. Review on 10/22/18 of Resident #30's Medication Administration Record [REDACTED]. Review on 10/22/18 of Resident #30's progress notes for (MONTH) revealed the following nursing note on 10/14/18 at 11:26 a.m.: A change in condition has been noted. The symptoms include: Bleeding (other than GI (Gastrointestinal)) Other change in condition INR 7.6 10/14/18 in the morning. and Orders obtained include: Repeat INR Monday 10/15/18; Medicate with Vitamin K 5mg PO now. Review on 10/22/18 of Resident #30's MAR for (MONTH) revealed that Resident #30 received Vitamin K as ordered above on 10/14/18 for an INR of 7.6. Interview with Staff F (Director of Nursing ) on 10/22/18 at 9:20 a.m. revealed that the order for [MEDICATION NAME] was transcribed incorrectly on 10/4/18 and Resident #30 was supposed to receive the following: [MEDICATION NAME] Sodium Tablet 5 mg, give 1 tablet by mouth in the evening every Monday, Wednesday until 10/17/18. [MEDICATION NAME] Sodium Tablet 2.5 mg, give 1 tablet by mouth in the evening every Sunday, Tuesday, Thursday, Friday, Saturday until 10/17/18. Interview also revealed that prior to 10/1/18, the facility used the [MEDICATION NAME] Clinic at the hospital to monitor anticoaguation therapy. After 10/1/18, the facility began monitoring anticoaguation therapy inhouse. Review on 10/23/18 of progress notes revealed the following late note dated 10/4/18, written on 10/22/18 by Staff G (Physician): Nurse (Name removed) communicated INR results of 1.6. Gave orders to continue current [MEDICATION NAME] dosing, and to repeat INR again on 10/8/18. Interview with Staff H (Registered Nurse) on 10/23/18 at 11:00 a.m. via telephone confirmed Staff H entered the [MEDICATION NAME] order on 10/4/18 inaccurately. Interview revealed that Resident #30 was supposed to receive the following: [MEDICATION NAME] Sodium Tablet 5 mg, give 1 tablet by mouth in the evening every Monday, Wednesday until 10/17/18. [MEDICATION NAME] Sodium Tablet 2.5 mg, give 1 tablet by mouth in the evening every Sunday, Tuesday, Thursday, Friday, Saturday until 10/17/18. Staff H revealed that Staff H received counseling on taking and entering medication orders in the electronic medical record. Interview revealed prior to 10/1/18 the facility used the hospital's [MEDICATION NAME] Clinic to follow anticoagution therapy. After 10/1/18, there was no education or training on how the facility would be monitoring anticoagution therapy inhouse.",2020-09-01
389,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2018-10-23,770,B,0,1,L5F211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to have a Clinical Laboratory Improvement Admendments of 1988 (CLIA) Certificate of Waiver to perform its own laboratory testing in accordance with requirements for laboratories specified in part 493 of this chapter. Findings include: Observation on [DATE] at approximately 11:30 a.m. on the Evergreen unit revealed a point of care testing device to perform [MEDICATION NAME]/International Normalized Ratio (PT/INR) testing stored on the medication cart. Interview on [DATE] at approximately 11:30 a.m. with Staff H (Registered Nurse) confirmed that the facility performs PT/INR testing. Review on [DATE] of the facility's CLIA Certificate of Waiver revealed it expired on [DATE]. Review on [DATE] of the CLIA test complexity database revealed the Coagucheck XS the facility used to perform PT/INR testing is classified as waived complexity. Website accessed: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/Detail.cfm?ID= &NoClia=1 Interview [DATE] at 2:30 p.m. with Staff I (Administrator) confirmed that the CLIA Certificate of Waiver had expired and Staff I had applied for a new certificate but did not have it yet. Interview revealed that the facility was also performing waived glucose and urine dipstick testing.",2020-09-01
390,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2018-10-23,773,D,0,1,L5F211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to obtain/perform laboratory tests for anticoagulant monitoring when ordered by the physician for 2 of 6 residents on [MEDICATION NAME] ([MEDICATION NAME]) therapy. (Resident identifiers are #4 and #30.) Findings include: Resident #4 Review on 10/22/18 at 3:45 p.m. of Resident #4's physician orders [REDACTED].#4's progress notes revealed no results of a PT/INR performed on 10/4/18. Interview on 10/22/18 at 4:00 PM with Staff F (Director Of Nursing) confirmed the above findings. Interview revealed a PT/INR was not done on 10/4/18 which resulted in no new [MEDICATION NAME] orders for Resident #4 and Resident #4 did not receive [MEDICATION NAME] for 2 days (10/4/18 and 10/5/18) until the error was discovered on 10/6/18. Resident #30 Review on 10/22/18 09:00 AM of Resident #30's physician orders [REDACTED].#30's progress notes revealed no results of a PT/INR performed on 10/11/18. Interview on 10/22/18 at 9:20 a.m. with Staff F confirmed the above finding. Interview revealed that a PT/INR was performed on 10/4/18 and it did not need to be repeated for one month. Staff F was unable to provide documentation to confirm the change in order.",2020-09-01
391,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2018-10-23,812,E,0,1,L5F211,"Based on observation and interview, it was determined that the facility failed to ensure proper sanitation of the coffee cups and plate lids and obtain and maintain records of food temperatures for 1 observed kitchen and 1 observed meal service. Findings include: Review on 10/23/18 of the facility policy titled, Food and Nutrition Services Policies and Procedures, revision date on 12/01/15, revealed that .3. Food is tested throughout preparation and service to ensure the appropriate temperature is reached and maintained .3.2 Record the holding temperature of the foods being held for services on the Production Sheet. 3.3 Action is taken if food is not within identified ranges, prior to service . Record review on 10/18/18 of the facility's Service Line Checklist logs revealed that the food item names and food temperatures should be taken and recorded on the log prior to meal service for breakfast, lunch and dinner. The facility's Checklist Service line logs also revealed that the food temperatures for hot foods should be greater than or equal to 135 degrees F (Fahrenheit) and cold foods should be less than or equal to 41 degrees F. Record review on 10/18/18 of the facility's Service Line Checklist logs from 9/14-16/18 and 9/27/18 to 10/1/18 revealed that food temperatures were recorded for the dinner meal service and no food temperatures were recorded for breakfast and lunch meal service. Record review on 10/18/18 of the facility's Service line Checklist logs for the month of (MONTH) and (MONTH) (YEAR) revealed that there were no recorded food temperature for breakfast, lunch, and dinner from 9/1-9/18, 9/18-26/18, and 10/3/18 to 10/17/18. Record review on 10/18/18 of the facility's Service Line Checklist log for 9/17/18 revealed that the lunch main entree and main starch had a recorded food temperatures of 50 degrees F and the dessert food temperature for lunch was recorded at 45 degrees F. The Service Line Checklist log for 9/17/18 also revealed that there was no recorded corrective actions for the food temperatures recorded for 9/17/18 lunch main entree, main starch and dessert. Record review on 10/18/18 of the facility's Service Line Checklist log for 10/2/18 revealed that the alternate entree food temperature at lunch was recorded at 50 degrees F and the lunch dessert food temperature was recorded at 55 degrees F. The Service Line Checklist log for 10/2/18 had no corrective actions and food item names recorded for the food temperatures for 10/2/18's lunch alternate entree and dessert. Observation on 10/18/18 at 12:30 p.m. of the lunch meal service with Staff [NAME] (Regional Food Service Director) revealed that food temperatures from the steam tables in the main dining room were not obtained and recorded prior to meal service. Interview on 10/18/18 at 12:31 p.m. with Staff [NAME] confirmed the above findings and the incomplete food temperature logs from (MONTH) and (MONTH) (YEAR). Staff [NAME] was not able to provide any explanation and Staff [NAME] also revealed that food temperatures should be taken prior to meal service on a daily basis. Observation on 10/23/18 at 10:37 a.m. in the kitchen with Staff [NAME] (Regional Dietary Director) revealed that coffee cups were drying in a rack. Observation in the kitchen with Staff [NAME] also revealed that there were 4 coffee cups in the drying rack that left black debris when the inside of the cups were wiped with a white napkin. Further observation revealed that the plate lids were stacked wet on a cart and one plate lid had a white film (food-like) in the inside of the plate lid. Interview on 10/23/18 at 10:40 a.m. with Staff [NAME] at the time of observation confirmed the above findings and Staff [NAME] was unable to provide an explanation. Interview with Staff [NAME] revealed that the staff was going to be educated, coffee cups and plate lids will be rewashed with a different cleaning product, and dry on rack before stacking.",2020-09-01
392,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2018-10-23,926,B,0,1,L5F211,"Based on observation, interview, and policy review, it was determined that the facility failed to have smoking policies and procedures that reflect practices for 3 out of 3 residents reviewed who smoke. (Resident identifiers are #57, #328, and #16) Findings include: Policy: Review on 10/22/18 of facility's smoking policy, revision date of 7/24/18, revealed that .smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluids, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station .2.6.2 Patients will not be allowed to maintain their own lighter, lighter fluid or matches . Resident #57 Interview on 10/18/18 at 1:45 p.m. with Resident #57 revealed that Resident #57 kept their own cigarettes and lighter with them at all times. Observation at the time of the interview with Resident #57 revealed that they kept their cigarette and lighter in their sweatpant's pocket. Further observation of Resident #57's cigarettes and lighter revealed that there was no name, room and bed number labeled on the cigarette carton and lighter. Interview on 10/18/18 at 2:25 p.m. with Staff A (Unit Manager) revealed that resident's cigarettes and lighters are kept at the nurse's station. Observation on 10/19/18 at 12:21 p.m. revealed that Resident #57 kept their cigarette and lighter in their sweatpant's pocket. Interview on 10/22/18 at 1:19 p.m. with Staff C (Registered Nurse) confirmed that Resident #57 kept their own cigarettes and lighter with them. Resident #328 Interview on 10/18/18 at 11:51 a.m. with Resident #328 revealed that Resident #328 kept their own cigarettes and lighter with them at all times. Observation at the time of the interview with Resident #328 revealed that they kept their cigarette and lighter in their coat pocket. Further observation of Resident #328's cigarettes and lighter revealed that their was no name, room and bed number labeled on the cigarette carton and lighter. Observation on 10/19/18 at 11:58 a.m. revealed that Resident #328 kept their cigarette and lighter in their coat pocket. Interview on 10/22/18 at 1:20 p.m. with Staff C confirmed Resident #328 kept their own cigarettes and lighter with them. Resident #16 Interview on 10/18/18 at 12:22 p.m. with Resident #16 revealed that Resident #16 kept their own cigarettes and lighter with them all day and gave back the cigarettes and lighter to staff at night. Observation at the time of the interview with Resident #16 revealed that they kept their own cigarette and lighter in their fanny pack. Further observation of Resident #16's cigarettes and lighter revealed that their was no name, room and bed number labeled on the cigarette carton and lighter. Interview on 10/22/18 at 1:21 p.m. with Staff C confirmed the above finding. Staff C was unable to provide any explanation and revealed that the resident's smoking materials should be kept at the nurse's station.",2020-09-01
393,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2019-11-22,658,D,0,1,Y1CL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review it was determined that the facility failed to follow manufacturer's specifications regarding the preparation and administration of 1 resident observed receiving insulin with an insulin pen during medication pass (Resident identifier is #13) and failed to follow professional standards for prepared medications refused by the resident for 3 residents on 1 out of 3 units observed (lower level dementia unit). (Resident identifiers are #11, #45 and #58) Findings include: Resident #13 Observation on 11/22/19 at approximately 8:15 a.m. during medication pass with Staff [NAME] Licensed Practical Nurse revealed that Resident #13 had an order for [REDACTED]. Staff [NAME] was stopped prior to administering the 65 units, Staff [NAME] stated, I never knew that you needed to, is this something new? Review on 11/22/19 of Resident #13's November's MAR (Medication Administration Record) revealed that Resident #13 did have an order for [REDACTED].>Interview on 11/22/19 at approximately 8:15 a.m. with Staff [NAME] revealed that Staff [NAME] never primes insulin pens prior to administering doses of insulin. Review on 11/22/19 of the manufacturer's instructions titled [MEDICATION NAME] (insulin [MEDICATION NAME]) [MEDICATION NAME] pen, dated 2019 revealed: How to use your [MEDICATION NAME] (insulin [MEDICATION NAME] injection) 100 units/ml (milliliters) in 6 steps . Step 3. PERFORM A SAFETY TEST * Dial a test dose of 2 units. * Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. *Press the injection button all the way in and check to see that insulin comes out of the needle. .Always perform the safety test before each injection Residents #11, 45, and #58 Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 769 revealed the following: Nurses administer only medications that they prepare, and prepared medications are never left unattended. Observation on 11/20/19 at approximately 10:00 a.m. in the dementia medication cart revealed in the top drawer were 3 medication cups with medications crushed in them. Each of the 3 medication cups had names written on them. The following resident's names were written on medication cups: Resident #11 Resident #45 Resident #58 Interview on 11/20/19 at approximately 10:00 a.m. with Staff [NAME] Licensed Practical Nurse revealed that the medication cups had the 3 identified residents am medications crushed in seperate medication cups. Staff [NAME] stated, I didn't want to waste the medication, we have to reapproach them (the residents). Review on 11/21/19 of the facilitys policy and procedure titled, Medication Administration: General, revision date: 11/01/19 revealed: . 9. If medication is refused by patient, discard medication and attempt to administer again at a later time.",2020-09-01
394,PRESIDENTIAL OAKS,305063,200 PLEASANT STREET,CONCORD,NH,3301,2017-01-18,278,D,0,1,1W0U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to accurately reflect the resident's status on the MDS (Minimum Data Set) for 3 residents in a standard survey sample of of 13 residents. (Resident identifiers are #3, #7 and #9.) Findings include: Resident #9 Review on 1/18/17 of Resident #9's medical record revealed that Resident #9 had a physician's orders [REDACTED]. A significant change MDS was created on 2/17/16 and under section J Health Conditions under sub-section J1400 Prognosis it states: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) and the facility indicated no. In the MDS section O under Special Treatments, Procedures, and 0100, K Hospice Care this section is checked off. The CAA's (Care Area Assessments) were completed with the Significant change MDS and Hospice care had been activated. Interview on 1/18/17 at 9:00 a.m. with Staff A (Clinical Coordinator) revealed this Significant Change MDS was completed because the resident was put on hospice. Each MDS Quarterly that was completed on 5/18/16, 8/15/16, and 11/11/16 after the Significant change on 2/17/16 under the section J Health Conditions under sub-section J1400 Prognosis it states: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) the facility indicated no. In the MDS under section O Special Treatments, Procedures, and 0100, K Hospice Care this section is checked off on all three of the above MDS assessments. Interview on 1/18/17 at 9:00 a.m. with Staff A confirmed that sub-section J1400 should indicate a yes response to indicate that Resident #9 had a condition or chronic disease that may result in a life expectancy of less than 6 months in all 4 assessments. Resident #3 Review on 1/18/17 of Resident #3's medical record revealed that Resident #3 was admitted to this Facility on 2/2/16 and admitted to Hospice Care on 11/24/16. A significant change MDS was created on 12/7/16 and under section J Health Conditions under sub-section J1400 Prognosis it states: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) the facility indicated no. In the MDS under section O Special Treatments, Procedures, and 0100, K Hospice Care this section is checked off under column 2, indicating Hospice services were being provided after Resident #3 became a resident of this Facility. The CAA's were completed with the Significant change MDS and Hospice care had been activated. Interview on 1/18/17 at 12:16 p.m. with Staff A confirmed the significant change MDS created on 12/7/16 contained an MDS coding error (under section J Health Conditions at sub-section J1400 Prognosis) and should have had a yes response. Resident #7 Review on 1/18/17 of Resident #7's MDS with an ARD (Assessment Reference Date) of 12/15/16 revealed that under section J1400 Prognosis indicates that the resident has a condition or chronic disease that may result in a life expectancy of less than 6 months. (Requires physician documentation) The facility coded 0 which indicates that the resident did not have a life expectancy of less than 6 months. In the MDS under section O Special Treatments, Procedures, and 0100, K Hospice Care this section is coded to indicate that the resident does receive Hospice. Interview on 1/18/17 with Staff B, (Director of Nurses) confirmed that section J1400 should have been coded 1 for yes.",2020-09-01
395,PRESIDENTIAL OAKS,305063,200 PLEASANT STREET,CONCORD,NH,3301,2019-01-23,656,B,0,1,WGTG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #38 Review on 1/22/19 for Resident #38's medical record revealed that the facility failed to show a coordinated Plan of Care for hospice as evidenced by not including or documenting the hospice goals and interventions in order to ensure that facility's staff is providing consistent care when hospice staff are not scheduled in the facility. The hospice care plans do not establish which services will be provided to Resident #38. Interview on 1/23/19 at 2:00 p.m. with Staff D including review of Resident #38's care plan revealed and confirmed that Resident #38's hospice care plan is not an individualized with established services and that the goals and interventions were not listed with specific hospice disciplines and frequencies rendering care to Resident #38. Resident #40 Review on 1/23/19 for Resident #40's medical record revealed that Resident #40 is having increasing behaviors and delusional thoughts of the spouse having an affair. Resident #40 has a wanderguard in place; but has not been actively seeking an elopement. Review of Resident#40's care plan showed no plan of care for dementia and wandering with goals and interventions in order to ensure that facility's staff is providing consistent care when Resident #40 is having increasing behaviors and delusional thoughts. Interview on 1/23/19 at 2:00 p.m. with Staff D including review of Resident #40's, care plan revealed and confirmed that Resident #40's care plan is not individualized with established goals or interventions for Resident #40 for dementia or for wandering. Interview on 1/23/19 at 1:00 p.m. with Resident #40's family representative revealed that Resident #40 has a wanderguard on but has not been actively seeking to elope from the facility but Resident #40 will state they want to leave the facility. Resident #292 Review of Resident #292's medical record, care plan and physician's orders [REDACTED]. Interview on 1/23/19 at approximately 9:55 a.m. with Staff A (Registered Nurse) confirmed that the order for oxygen had not been added to Resident #292's plan of care. Resident #5 Observation on 1/22/19 at approximately 9:00 a.m. of Resident #5 in bed revealed that Resident #5 had audible wheezing. Interview on 1/22/19 at approximately 9:00 a.m. this surveyor informed Staff B, Clinical Coordinator of Resident #5's audible wheezing. Staff B revealed that Resident #5 had an order for [REDACTED]. Review on 1/23/19 of Resident #5's care plans revealed that Resident #5 did not have a care plan for respiratory or nebulizer treatments. Review on 1/23/19 of Resident #5's Medication Administration Record [REDACTED]. Interview on 1/23/19 at approximately 10:45 a.m. with Staff B confirmed that there was not a care plan for nebulizer treatments. Resident #7 Review on 1/22/19 of Resident #7's medical [DIAGNOSES REDACTED].#7 had a [DIAGNOSES REDACTED]. Review on 1/23/19 of Resident #7's care plans revealed that Resident #7 did not have a care plan for dementia. Interview on 1/23/19 at approximately 10:30 a.m. with Staff B confirmed that there was not a care plan for dementia. Resident #20 Observation on 1/22/19 at approximately 9:30 a.m. at the entrance to Resident #20's room revealed a precaution cart and sign to see nurse before entering. Interview on 1/22/19 at approximately 9:40 a.m. with Staff B revealed that Resident #20 was on precautions [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in the urine and ,[MEDICAL CONDITION].-Difficile. Review on 1/23/19 of Resident #20's [DIAGNOSES REDACTED].#20 was diagnosed with [REDACTED]. Review on 1/23/19 of Resident #20's care plans revealed that there were no care plans [MEDICAL CONDITION] or CDIFF. Interview on 1/23/19 at approximately 11:00 a.m. with Staff B confirmed that there were no care plans for CDIFF [MEDICAL CONDITION]. Based on observation, interview and record review, it was determined that the facility failed to develop comprehensive care plans for infection control precautions, hospice care, dementia care, wandering and respiratory care for 7 residents in a final survey sample of 16 residents. (Resident identifiers are #5, #7, #20, #32, #38, #40, and #292.) Findings include: Resident #32 Interview on 1/22/19 at approximately 11:00 a.m. with Staff C (Registered Nurse) revealed that Resident #32 was on contact precautions for [MEDICAL CONDITIONS]. Review on 1/23/19 of Resident #32's current care plan revealed that there was no documentation on the care plan that Resident #32 was on contact precautions for [MEDICAL CONDITION]., or any documentation on what personal protective equipment (PPE) was recommended for staff to wear when caring for Resident #32. Interview on 1/23/19 at approximately 10:00 a.m. with Staff B (Infection Control Nurse) and Staff D (Director of Nursing) confirmed that Resident #32's current care plan should have included that Resident #32 was on contact precautions and should have included how to do ADL's (Activities of Daily Living) and what PPE should have been worn when caring for Resident #32 while they were on contact precautions.",2020-09-01
396,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-02-27,656,E,1,0,GW2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to develop care plans for a resident's ruptured spleen and pressure ulcer, a resident's need for anti tippers on a wheelchair and a resident's need for padded side rails for 3 residents in a final sample of 8 residents. (Resident identifiers are #1, #2 and #3.) Findings include: Resident #1 Review on 2/27/19 of Resident #1's nurses notes revealed that Resident #1 had a fall on 1/8/19 and was sent to the hospital where they were treated for [REDACTED]. The notes also revealed that Resident #1 returned to the facility on [DATE]. Review on 2/27/19 of the Facility report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that Resident #1 had a fall on 1/8/19 that resulted in a ruptured spleen. Resident #1 was sent to the hospital on [DATE] and returned to the facility on [DATE] after they received treatment for [REDACTED]. Review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that the final report of the incident with Resident #1 read .Plan of care will be updated to reflect diagnosis . Review on 2/27/19 of Resident #1's current care plan revealed that Resident #1's [DIAGNOSES REDACTED]. Review on 2/27/19 of Resident #1's nurses note dated 1/21/19 revealed that Resident #1 had .a new open area to left gluteal fold area 1.3 X 0.5 slough, unstageable open area . Review on 2/27/19 of Resident #1's Skin assessment dated [DATE] revealed that Resident #1 had MASD (Moisture Associated Skin Damage) to the left gluteal fold. Review on 2/27/19 of Resident #1's current care plan revealed that Resident #1's MASD was not added to their comprehensive care plan until 1/31/19. Review on 2/27/19 of Resident #1's Skin - Pressure Ulcer assessment dated [DATE] revealed that Resident #1 had a Stage 2 Pressure ulcer on their left gluteal fold. Review on 2/27/19 of Resident #1's Skin - Pressure Ulcer assessment dated [DATE] also revealed that Resident #1 had a Stage 2 Pressure ulcer on their left gluteal fold. Review on 2/27/19 of Resident #1's current care plan revealed that Resident #1's left gluteal fold pressure ulcer was not on their comprehensive care plan. Resident #2 Review on 2/27/19 of the Facility's Work Order Report revealed that on 1/16/19 a work order was requested to put anti tippers on Resident #2's wheelchair. Interview on 2/27/18 at approximately 2:30 p.m. with Staff A (Director of Nursing) confirmed that Resident #2 was using anti tippers on their wheelchair. Review on 2/27/19 of Resident #2's current care plan revealed that there was no care plan in place for Resident #2's need for anti tippers on their wheelchair. Resident #3 Review on 2/27/19 of the Facility's Work Order Report revealed that on 2/13/19 a work order was requested to put padding on Resident #3's left side rail for protection. Interview on 2/27/18 at approximately 2:30 p.m. with Staff A confirmed that Resident #3's left side rail needed to be padded for protection. Review on 2/27/19 of Resident #3's current care plan revealed that there was no care plan in place for Resident #3's need for padding on their left side rail for protection. Interview on 2/27/19 at approximately 3:30 p.m. with Staff A confirmed that all of the above areas should have been on the care plans for Residents #1, #2 and #3.",2020-09-01
397,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-02-27,689,J,1,0,GW2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to prevent a fall from a mechanical lift that resulted in injury for 1 resident in a final survey sample of 8 residents who had falls and also needed equipment repairs. (Resident identifier is #1.) Findings include: Review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that on 1/8/19 at approximately 1:30 p.m., Resident #1 was being transferred using a mechanical lift and .while in the mechanical lift during a transfer from bed to chair, apparently a bolt became loose LNA's (Licensed Nursing Assistants) heard a 'crack' and the patient fell to the floor . Review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, also revealed that Resident #1 was sent to the hospital and was treated for [REDACTED]. Review on 2/27/19 of Resident #1's nurses notes revealed that Resident #1 had a fall on 1/8/19 and was sent to the hospital where they were treated for [REDACTED]. The nurses notes revealed that Resident #1 returned to the facility on [DATE]. The notes also revealed that Resident #1 is oriented to self only. Further review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that the facility did an investigation and found that .the locking nut on the mechanical lift was missing. It was identified that the screw was loose by the 3-11 shift (on 1/7/19.) Interview on 2/27/19 at approximately 3:00 p.m. with Staff A (Director of Nursing) and Staff B (Administrator) revealed that when the 3-11 shift staff, on 1/7/19, realized that the lift was broken, they put a sign on it that read Broken, Do Not Use, and removed the battery so that no staff would use it. Further review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that .the 11-7 LNA noted that the sign was on the lift indicating that it was 'broken' (pronoun for the LNA) identified that the battery was missing, (pronoun for the LNA) replaced it and reviewed all the functions of the lift and stated 'it worked' (pronoun for the LNA) removed the 'broken' sign. During the 7-3 shift (on 1/8/19) the LNAs attached the lift and sling appropriately, and subsequently lifted the patient according to protocol. However, the LNAs reported hearing a 'crack' while the patient was in the sling and the housing holding the patient slide (sic) out causing the housing and patient in the sling to fall to the floor . Review on 2/27/19 of the Facility Policy Titled Lock-Out/Tag-Out revised (MONTH) (YEAR), revealed that .All employees are responsible for complying with the requirements of the lock out/ tag-out procedures. Employees must never start, energize or use a piece of equipment locked/tagged for servicing or maintenance .When a tag is attached to any energy device, it must not be removed without authorization of the authorized person responsible for it . It also revealed that .In the case of a shift change when a lock-out/tag-out device is in use, specific procedures must be utilized to insure the continuity of the lock and tag-out protection, including the provision for the orderly transfer of lock-out and tag-out protection between off-going and oncoming employees . Interview on 2/27/19 at approximately 11:15 a.m. with Staff A revealed that at the time of Resident #1's incident, the Lock out cards were kept in the maintenance room, and not at the nurses station, so they were not as readily available to staff. Interview on 2/27/19 at approximately 3:00 p.m. with Staff A and Staff B confirmed that the mechanical lift was not used by any other residents, besides Resident #1, after the broken sign was removed on 1/8/19. Staff A also confirmed that the information regarding the broken mechanical lift was not passed on in the shift reports.",2020-09-01
398,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-07-11,554,D,0,1,85VC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, it was determined that the facility failed to ensure that a resident was clinically appropriate to self-administer their medications for 1 resident in a final sample size of 22 residents. (Resident identifier is #52.) Findings include: Review on 7/11/19 of facility's policy titled, medications: [REDACTED].patients who request to self-administer medication will be assessed for capability. If it is determined that the patient is able to self-administer: a physician/med-level (sic) provider order is required, self administration must be care planned, patient must be instructed in self-administration .periodic evaluation of capability must be performed . Interview on 7/11/19 at 11:32 a.m. with Resident #52 revealed that Resident #52 self-administers [MEDICATION NAME] (laxative) at least once daily and at times up to three times a day and nasal saline spray as needed for dry nares. Review on 7/11/19 of Resident #52's current physician order [REDACTED]. Review on 7/11/19 of Resident #52's clinical (i.e. self administration assessment) and nursing assessments revealed no self-administration assessments were found for Resident #52's [MEDICATION NAME] and saline nasal spray self-administration. Review on 7/11/19 of Resident #52's current care plan revealed no care plan for Resident #52's self-administration of [MEDICATION NAME] and saline nasal spray. Interview on 7/11/19 at 12:16 p.m. with Staff H (Director of Nursing) confirmed the above findings. Staff H stated that Resident #52's nasal saline spray order should have include a may self-administer in the order and that Resident #52 should have had a self-administration assessment completed and care planned for the self-administration of [MEDICATION NAME] and nasal saline spray. Staff H was unable to provide more information whether Resident #52 was educated on the [MEDICATION NAME] and nasal saline spray self-administration use. Staff H was also unable to provide more information whether the [MEDICATION NAME] and nasal saline spray was discussed with the IDT (Interdisciplinary Team) for self-administration.",2020-09-01
399,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-07-11,658,E,0,1,85VC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy and procedure review it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. (Resident identifiers are #16, #46, #164, #38, #59, #213, #44, #24, #52, #20, #60, #23, #28, #4, #12, #61, #35, #5 and #13.) Findings include: Standard of Practice. (Follow MD Order) The Potter-Perry, 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, (St. Louis, Missouri, Mosby, Inc., 2009), pg. 708, reveals Give all routinely ordered medications within 60 minutes of the times ordered (30 minutes before or 30 minutes after the prescribed time). [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, relates on page 708 The prescriber often gives specific instructions about when to administer a medication The text also relates on page 707 The six rights of medication administration include the following: . The right medication . The right dose . The right client . The right route . The right time . The right documentation Observation on 7/8/19 at approximately 10:00 a.m. in Resident #16's room revealed the following: Left elbow arm dressing was present, no date on dressing and dressing appeared saturated (blood visible through the [MEDICATION NAME] dressing). Right knee bandaid was present, no date on bandaid and bandaid appeared to have blood underneath (Blood visible through the bandaid.) Right foot, 2nd toe gauze dressing present, no date on the dressing. Interview on 7/9/19 with Staff H (Director of Nurses) confirmed that the 3 dressings that were applied to Resident #16 were not dated and there was no way to indicate when the dressings were applied. Review on 7/10/19 of Resident #16's medical record revealed that there were no physician's orders for any of the 3 dressings that were applied to Resident #16 and no documentation of when the 3 dressings were applied. There were no care plans for the 3 treatments observed. Interview on 7/10/19 at approximately 8:45 a.m. with Staff H (Director of Nurses) revealed that there were no physicians orders for any of the 3 dressings applied to Resident #16 and no notification to the physician of the injuries. There was no monitoring of the 3 areas that required dressings and no documentation on how Resident #16 obtained the injury to the left elbow/right knee. Review on 7/10/19 of the Resident #16's weekly skin assessments revealed the following: 4/23/19 skin assessment indicated that on Resident #16's right foot, 2nd toe there was a Category II. The Category II definition is: Partial tissue loss, Scant tissue loss 25% of [MEDICATION NAME] flap lost. 6/25/19 skin assessment indicated that Resident #16 had Scab right toes, mulitple bruises from previous falls. 7/2/19 skin assessment indicated that Resident #16 had Scab right toes, mulitple bruises from previous falls. Review on 7/11/19 of the facility policy and procedure titled, NSG241 Treatments, Revision date 11/28/17 revealed: Policy A licensed nurse or medical technician, per state regulations, will perform ordered treatments. Accepted standards of practice will be followed. . Practice Standards . 9. Document 9.1 Administration on Treatment Administration Record 9.2 Patient's response . 9.3 Notification of physician/advanced provider, if applicable. Review on 7/11/19 of the facility policy and procedure titled, OPS410 Taking Medication and Treatment Orders, Revision date 3/20/17 revealed: Policy Medication and treatment orders will be accepted only from authorized, credentialed physicians or from other authorized, credentialed practioners in accordance with state regulations regarding prescriptive privileges. Review on 7/11/19 of medications that were administered from 7/2/19 thru 7/9/19 and were out administered greater than 1 hour of the scheduled medication times revealed the following: Resident #46 Resident #46 was scheduled to receive: [MEDICATION NAME]to be administered before meals on 7/2/19 at 16:30, it was administered at 23:58. [MEDICATION NAME]to be administered before meals on 7/3/19 at 16:30, it was administered at 18:02. Resident #164 Resident #164 was scheduled to receive: [MEDICATION NAME] 100 MG (milligram) tablet on 7/2/19 at 0:800, it was administered at 11:34 a.m. [MEDICATION NAME] 100 MG tablet on 7/6/19 at 08:00, it was administered at 11:05 a.m. Insulin [MEDICATION NAME] to be administered before meals on 7/2/19 at 16:30, it was administered at 18:12. Insulin [MEDICATION NAME] on 7/2/19 at 20:00, it was administered on 7/3/19 at 00:56. Insulin [MEDICATION NAME] to be administered before meals on 7/3/19 at 16:30, it was administered at 21:23. Insulin [MEDICATION NAME] on 7/4/19 at 20:00, it was administered on 7/5/19 at 01:08. Resident #38 Resident #38 was scheduled to receive: Insulin [MEDICATION NAME] on 7/2/19 at 08:00, it was administered at 11:38. Humalog insulin to be administered with meals on 7/2/19 at 16:30, it was administered on 7/3/19 at 00:56. Humalog insulin to be administered with mealson 7/2/19 at 17:00, it was administered on 7/3/19 at 00:57. Insulin [MEDICATION NAME] on 7/2/19 at 20:00, it was administered on 7/3/19 at 00:58. Humalog insulin to be administered with mealson 7/2/19 at 21:30, it was administered on 7/3/19 at 00:58. Humalog insulin to be administered with mealson 7/3/19 at 16:30, it was administered at 18:04. Insulin [MEDICATION NAME] on 7/4/19 at 20:00, it was administered on 7/5/19 at 01:09. Humalog insulin to be administered with mealson 7/4/19 at 21:30, it was administered on 7/5/19 at 01:10. Resident #59 Resident #59 was scheduled to receive: [MEDICATION NAME]to be administered before meals on 7/2/19 at 11:30, it was administered at 13:23. [MEDICATION NAME]to be administered before mealson 7/3/19 at 11:30, it was administered at 13:16. [MEDICATION NAME]to be administered before mealson 7/6/19 at 11:30, it was administered at 13:33. Resident #213 Resident #213 was scheduled to receive: [MEDICATION NAME] 300 MG on 7/8/19 at 09:00, it was administered at 14:30. Resident #44 Resident #44 was scheduled to receive: [MEDICATION NAME] 200 MG on 7/2/19 at 20:00, it was administered on 7/3/19 at 00:04. [MEDICATION NAME] 200 MG on 7/9/19 at 20:00, it was administered on 7/10/19 at 00:09. Resident #24 Resident #24 was scheduled to receive: Insulin [MEDICATION NAME] to be administered at lunch on 7/6/19 at 11:30, it was administered at 13:40. Resident #52 Resident #52 was scheduled to receive: Insulin [MEDICATION NAME] on 7/8/19 at 07:30, it was administered at 09:41. [MEDICATION NAME]to be administered with meals on 7/8/19 at 08:00. it was administered at 12:53. [MEDICATION NAME]to be administered with meals on 78/19 at 12:00, it was administered at 15:01. Resident #20 Resident #20 was scheduled to receive: [MEDICATION NAME] 875/125 MG on 7/2/19 at 19:00, it was administered at on 7/3/19 01:19. [MEDICATION NAME] 875/125 MG on 7/4/19 at 19:00, it was administered on 7/5/19 at 00:44. [MEDICATION NAME] 875/125 MG on 7/6/19 at 07:00, it was administered at 12:24. [MEDICATION NAME] 875/125 MG on 7/8/19 at 19:00, it was administered on 7/9/19 at 00:30. Resident #60 Resident #60 was scheduled to receive: Humalog insulin on 7/2/19 to be administered before breakfast at 08:00, it was administered at 09:54. Humalog insulin on 7/3/19 to be administered before meals at 11:00, it was administered at 12:33. Humalog insulin on 7/5/19 to be administered before meals at 11:00, it was administered at 12:56. Humalog insulin on 7/8/19 to be administered before breakfast at 08:00, it was administered at 11:03. Humalog insulin on 7/8/19 to be administered before meals at 11:00, it was administered at 13:13. Humalog insulin on 7/9/19 to be administered before meals at 11:00, it was administered at 14:31. Resident #23 Resident #23 was scheduled to receive: [MEDICATION NAME]on 7/2/19 at 17:00, it was administered on 7/3/19 at 00:53. Insulin [MEDICATION NAME] on 7/2/19 at 20:00, it was administered on 7/3/19 at 00:54. [MEDICATION NAME]on 7/2/19 at 21:00, it was administered on 7/3/19 at 00:54. [MEDICATION NAME]on 7/5/19 at 21:00, it was administered on 7/6/19 at 00:11. Insulin [MEDICATION NAME] on 7/8/19 at 20:00, it was administered on 7/9/19 at 00:09. [MEDICATION NAME]on 7/9/19 at 21:00, it was administered on 7/10/19 at 00:10. Resident #28 Resident #28 was scheduled to receive: [MEDICATION NAME]to be administered with meals on 7/8/19 at 12:00, it was administered at 15:12. Resident #4 Resident #4 was scheduled to receive: [MEDICATION NAME] Sodium 3 MG tablet on 7/3/19 at 17:00, it was received on 7/4/19 at 00:53. Resident #12 Resident #12 was scheduled to receive: [MEDICATION NAME] 2.5 MG tablet on 7/2/19 at 20:00, it was administered on 7/3/19 at 00:00. [MEDICATION NAME] 2.5 MG tablet on 7/4/19 at 20:00, it was administered on 7/5/19 at 01:06. Resident #61 Resident #61 was scheduled to receive: Insulin [MEDICATION NAME] on 7/5/19 at 12:00, it was administered at 16:03. Humalog insulin on 7/4/19 at 20:00, it was administered on 7/5/19 at 00:40. Resident #35 Resident #35 was scheduled to receive: Humalog insulin to be administered with meals on 7/8/19 at 08:00, it was administered at 11:54. Humalog insulin to be administered with meals on 7/9/19 at 12:00, it was administered at 13:36. Resident #5 Resident #5 was scheduled to receive: [MEDICATION NAME]to be administered with meals on 7/5/19 at 12:00, it was administered at 13:38. [MEDICATION NAME]to be administered wtih meals on 7/8/19 at 12:00, it was administered at 15:04. Resident #13 Resident #13 was scheduled to receive: Humalog insulin to be administered before meals on 7/7/19 at 11:30, it was administered at 13:12. Humalog insulin to be administered before meals on 7/8/19 at 11:30, it was administered at 15:20.",2020-09-01
400,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-07-11,689,D,0,1,85VC11,"Based on observation, interview, record review and policy review, it was determined that the facility failed to ensure that resident received adequate assistance devices to prevent accidents for 1 resident in a final sample size of 22 residents. (Resident identifiers is #16.) Findings include: Observation on 7/9/19 at approximately 12:30 p.m. by the life safety surveyor revealed that Resident #16 was outside in front of the building in a wheelchair being pushed by Staff T a hospice LNA (Licensed Nursing Assistant). The LNA was pushing Resident #16 in the wheelchair when Resident #16's right foot was driven over by the front right wheel on the wheelchair. The LNA then pulled the chair backwards and then forward 4 times in a repetitive motion, going over Resident #16's foot 4 times. Resident #16's right sock came off and there was blood on Resident #16's right foot and the ground. Resident #16 did not have any foot pedals/leg rests while the LNA was pushing the wheelchair. Staff G (Regional Manager), Staff H (Director of Nurses) and Staff F (Administrator) were notified of in the incident. Staff H immediately went outside and assessed Resident #16 who incurred an abrasion to the right foot 2nd toe. Interview on 7/9/19 at approximately 12:30 p.m. with the Staff T revealed, I was told that (Resident 16) can't use foot pedals because it was considered a restraint. Review on 7/9/19 of Resident #16's medical record revealed that Resident #16's BIM's (Brief Interview Mental Status) score was a 99 (cognitively unable to participate in the assessment). Cognitively Resident #16 was unable to participate in the interview. Review on 7/9/19 of Resident #16's medical record revealed the following nursing note dated 7/9/19, Call out to (pronoun omitted) hospice; LNA took resident outside for lunch and inadvertently did not use leg rest which caused skin tear/abrasion to right second toe. Treatment obtained. Care provided. LNA educated with regards to use of leg rest. Reassurance provided to resident. Message left for DPOA (Durable Power of Attorney). Interview on 7/9/19 at approximately 12:45 p.m. with Staff H revealed that Resident #16 should have foot pedals on the wheelchair during transport. Review on 7/10/19 of the facility policy and procedure titled Activities of Daily Living, revision date 11/28/16 revealed: Policy . Assistive devices and adaptive equipment are provided as needed.",2020-09-01
401,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-07-11,725,F,0,1,85VC11,"Based on observation, interview and review of staffing records and meal time schedule, it was determined that the facility failed to provide adequate staffing to provide complete care to all residents at the facility. (Resident identifiers are #4, #5, #7, #9, #12, #13 #15, #21, #26, #38, #42, #52, #54, #55, #56, #60 and #61.) Findings include: Observation on 7/8/19 at approximately 11:40 a.m. revealed an enclosed serving cart outside the[NAME]Unit dining area. Review on 7/8/19 at approximately 9 a.m. of a facility document titled, Food Truck Delivery Times revealed the following information: Lunch Start Time- 11:15 am (cart to floor ) 1)[NAME]Unit 11:30 am. Two residents were observed sitting in the dining room at a table. At approximately 12:10 p.m. an Staff U (Licensed Nursing Assistant) opened the serving cart and began delivering trays to residents in their rooms. Shortly after the LNA began delivering trays an LPN (Licensed Practical Nurse) approached the serving cart and also started passing trays to residents in their rooms. There were no other staff assisting to pass trays on the[NAME]Unit during this observation. The[NAME]Unit has 13 resident beds rooms. Interview on 7/8/19 at approximately 2:30 p.m. with Staff K, revealed he/she has worked at this facility for several months and the facility is trying to provide enough staff to meet the needs of the residents. Staff K stated that passing trays is occasionally delayed due to call outs and staff availability. Interview on 7/9/19 at approximately 9:45 a.m. with Resident #164, revealed (pronoun omitted) eats in his/her room and often times he/she has to wait quite a while for his/her meal to be delivered. Observation on 7/8/19 at 11:40 a.m. of the[NAME]Unit meal service for lunch in the dining area revealed two residents in the dining area and the food cart sat approximately 15 minutes prior to being passed. A nursing assistant started passing the meal trays to the rooms first. One nurse started to help pass trays after approximately 10 minutes had passed. No other staff present to help pass trays at this time. Observation on 7/8/19 at 4:15 p.m. on the[NAME]Unit dinner meal service revealed that 3 residents were in the dining area waiting for the meal cart to arrive. All 3 residents were sitting at the same table. The meal cart arrived at 4:46 p.m. A resident was served at 4:50 p.m. in the dining room; while the other two residents waited to be served. The meal trays were being passed to the rooms at the same time. At 4:50 p.m. the Unit manager was assisting and the Administrator Assistant was also assisting with the passing trays at this time. The second nurse on the[NAME]floor started to assist with the passing of the trays at 4:51 p.m. The second meal tray was served at 4:59 p.m. and the third tray was next . Observation on the[NAME]Unit on 7/10/19 at 7:41 a.m. for the breakfast meal all the staff were present to pass the meal trays with the Administrator, DON (Director of Nursing), Administrator Assistant and the Unit manager passing meal trays. The Administrator left at 7:49 a.m. to go to another unit after he ordered a tray for a new admission and all the trays were passed. Observation on[NAME]Unit on 7/10/19 at 08:02 a.m. revealed dietary delivered a tray and placed it on top on the cart. A few minutes had passed and the charge nurse was questioning who put the tray there and whose tray it was. After a two minute discussion of who's tray is it and who put it there the nurse ordered the LNA (License Nursing Assistant) to go around and check all the new admissions and see who needed breakfast. At this point in time Staff S, an anonymous staff member made a comment at that time Administration can not just come swooping in and then leave. They have no idea what they are doing and how chaotic they just made this morning. Interview on 7/10/19 at 9:45 a.m. with Staff S this is not the usual behavior for passing of trays. If everyone wants to step up and help than do it all the time but this has not happen before. It would be great if it did it would be make sense. Interview on 7/9/19 at 11:05 a.m. at resident council meeting revealed that the group was in agreement that their was insufficient nursing staff during meal time especially lunch and dinner. The group had the following concerns: 1. Meals would be cold by the time they get it 2. The nursing staff gets busy passing the meal, answering call lights and feeding the residents and it is difficult to find nursing staff to ask for condiments or assistance. 3. Nursing staff seemed to be in a hurry. Group included Resident #4, #5, #7, #9, #12, #13, #15, #21, #26, #38, #52, #54, #55, #56, #60 and #61, who represented all 3 units ([NAME] unit, Folsom unit and[NAME]unit) of the facility. Interview on 7/10/19 at 8:00 a.m. with Staff Q (Licensed Nursing Assistant) revealed that Staff Q passed lunch to residents on the Folsom unit and assist residents in the main dining room. Staff Q stated that they sometimes need help during lunch and sometimes management assists with passing the meals and drinks but most of the time Licensed Nursing Assistant staff does it. Interview on 7/10/19 at 8:10 a.m. with Staff R (LNA) revealed that Staff R passed lunch to residents on the[NAME]unit and sometimes assists with meals in the main dining room. Staff R stated that they have not or not usually have management helping nursing staff during lunch. Staff R stated that they would pick up extra shifts when facility needs nursing staff and stay a couple hours after day shift (7:00 a.m. to 3:00 p.m.) to help with passing dinner meals to residents, assist meals, or answer call lights. Resident #60 Interview on 7/8/19 at approximately 10:00 an with Resident #60 revealed, I want to get out of bed everyday, I need 2 people to help me and sometimes there is not enough staff available at the time I want to get up. Resident #42 Interview on 7/8/19 at approximately 11:30 a.m. with Resident #42 revealed that the resident has not had a shower in 2 weeks. I keep asking and I still haven't gotten one. The staff are too busy to do it. Review on 7/10/19 of Resident #42's bathing record it revealed that the last shower/bath was on 6/28/19. Interview on 7/10/19 at approximately 8:15 a.m. with Staff C (Registered Nurse) confirmed that there was no documented shower/bath since 6/28/19. Interview on 7/8/19 at approximately 4:00 p.m. with Staff D (Licensed Practical Nurse) revealed that dinners were always late, The dining room usually starts at 5:45 p.m. Interview on 7/9/19 at approximately 7:15 a.m. with Resident #13 revealed, Food is served cold a lot of the time, trays sometimes take up to 20 minutes to be passed after they come on the unit. Interview on 7/9/19 at approximately 7:30 a.m. with Resident #5 revealed, Food is cold because we don't have enough staff. I can't remember the person's name but I have been told that there is only 1 LNA (Licensed Nurse Assistant) during meals. Interview on 7/10/19 at approximately 7:45 a.m. with Staff A, (Licensed Nurse Assistant) revealed, Staffing depends on the day. During meal times there is only 1 LNA on the floor to pass trays and answer call lights. Residents get frustrated when they are on the toilet waiting for us. Interview on 7/10/19 at approximately 8:00 a.m. with a Staff member who wishes to remain anonymous revealed, If management and people that are in their offices would come and help sometimes it would be better here. Interview on 7/10/19 at approximately 8:00 a.m. with Staff B, (Licensed Practical Nurse) revealed, At meal times we could use more hands on the floor. Staffing is a big issue here, I have worked at other facilities in the area and this facility is short staffed. Interview on 7/10/19 at approximately 8:10 a.m. with Staff C (Registered Nurse) revealed that the Unit Manager position on the Folsom Unit has been empty for a while.",2020-09-01
402,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-07-11,758,D,0,1,85VC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that PRN (as needed) order for [MEDICAL CONDITION] drugs are limited to 14 days, except if the attending physician believes that it is appropriate for the PRN order to be extended beyond 14 days, indicate the duration for the PRN order for 1 resident in a final sample size of 22 residents. (Resident identifier is #3.) Findings include: Review on 7/10/19 of Resident #3's current physician order [REDACTED]. Review on 7/10/19 of Resident #3's (MONTH) 2019 EMAR (Electronic Medication Administration Record) revealed that Resident #3 was given [MEDICATION NAME] PRN on 7/1/19, 7/2/19, 7/3/19, 7/4/19, 7/7/19, 7/9/19, 7/10/19. Review on 7/10/19 of Resident #3's (MONTH) 2019 EMAR revealed that Resident #3 received [MEDICATION NAME] PRN on 6/1/19, 6/2/19, 6/3/19, 6/4/19, 6/6/19, 6/8/19, 6/13/19, 6/14/19, 6/15/19, 6/16/19, 6/19/19, 6/23/19, 6/28/19, 6/29/19, 6/30/19. Review on 7/10/19 of Resident #3's nurses notes from 6/18/18 to 7/10/19 revealed no documentation that Resident #3's [MEDICATION NAME] PRN order was reviewed by the physician. Review on 7/10/19 of Resident #3's physician notes from 6/18/18 to 7/10/19 revealed no documentation of Resident #3's [MEDICATION NAME] PRN rationale for continuance and indication of duration. Review on 7/10/19 of Resident #3's MRR (Medication Regimen Review) dated 6/14/19 revealed that Resident #3 has a [MEDICATION NAME] PRN order in place for greater than 14 days without a stop date which the physician declined on 6/27/19 with rationale, will extend period, still required. Further review of Resident #3's MRR dated 6/14/19 revealed no duration documented for the rationale to extend the [MEDICATION NAME] PRN use. Interview on 710/19 at 11:36 a.m. with Staff H (Director of Nursing) confirmed above findings. Staff H stated that the physician should have specified a duration for Resident #3 [MEDICATION NAME] PRN.",2020-09-01
403,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-07-11,760,D,0,1,85VC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that a resident was free of significant medication error in regards to [MEDICATION NAME] order for 1 resident in a final sample size of 22 residents. (Resident identifier is #263.) Findings include: Review on 7/9/19 of Resident #263's INR (International Normalized Ratio) dated 7/8/19 revealed an INR of 1.84. Review on 7/9/19 of Resident #263's Anticoagulant Tacking Record (ATR) revealed that Resident #263' INR on 7/1/19 was 5.27 and [MEDICATION NAME] dose was held on 7/1/19 and 7/2/19. Further review of Resident #263's ATR revealed that on 7/3/19 Resident #263's INR was 3.01 and [MEDICATION NAME] dose was held on 7/3/19 and physician ordered to resumed [MEDICATION NAME] 2 mg once a day on 7/4/19 and recheck INR on 7/8/19 and no documentation was found for the 7/8/19 INR. Review of Resident #263's ATR revealed an INR goal range of 2-3. Review on 7/9/19 of Resident #263's EMAR (Electronic Medication Administration Record) for the month of (MONTH) 2019 revealed that Resident #263 received a dose of 2 mg (milligram) [MEDICATION NAME] (anticoagulant) from 7/4/19 to 7/7/19. Further review of Resident #263's (MONTH) 2019 EMAR revealed no order for [MEDICATION NAME] on 7/8/19 and 7/9/19. Review on 7/10/19 of Resident #263's (MONTH) 2019 EMAR revealed an order for [REDACTED]. Interview on 7/10/19 at 9:29 a.m. with Staff I (Unit Manager) confirmed the above findings. Staff I stated that Resident #263's INR result on 7/8/19 that was 1.84 was a subtherapeutic level and Resident #263's INR goal range was 2-3 indicated on Resident #263's ATR. Staff I also stated that nursing staff should have followed up with the physician on 7/8/19 for [MEDICATION NAME] dosing. Interview on 7/10/19 at 9:35 a.m. with Staff D (Licensed Practical Nurse) revealed that they missed to follow up with the physician on Resident #263's INR dated 7/8/19 for [MEDICATION NAME] dosing. Staff D also revealed that Resident #263 missed a [MEDICATION NAME] dose on 7/9/19 as the [MEDICATION NAME] order that was obtained on 7/9/19 was entered in the EMAR with the wrong start date as the [MEDICATION NAME] order did not indicate to start on 7/10/19 the [MEDICATION NAME] 2.5 mg should have been entered in the EMAR to be given on 7/9/19.",2020-09-01
404,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2019-07-11,880,D,0,1,85VC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, it was determined that the facility failed to maintain infection control program to help prevent the transmission of communicable diseases and infections in regards to contact precautions for 1 out of 1 resident on Transmission Based Precautions (TBP) and glucometers for 2 out of 3 units observed. (Resident identifier is #61.) Findings include: Resident #61 Review on 7/10/19 of facility's policy titled, Contact Precautions, revision date 6/15/19, revealed that .staff must use barrier precautions when entering the room .wear gown and gloves . Review on 7/10/19 of facility's policy titled, Discontinuing Transmission Based Precautions, revision date 11/28/16, revealed that .when discontinuing of transmission based precaution is appropriate: notify all departments .instruct patient and visitors that precautions are no longer needed .return patient to his/her room if a move to separate room occurred .inform the housekeeping department to perform discharge/turnover cleaning . Observation on 7/8/19 at 11:13 a.m. outside Resident #61's room revealed a transmission based precaution cart and a sign to see the nurses. Review on 7/8/19 of Resident #61's urinalysis dated 6/27/19 revealed that Resident #263 had ESBL (Extended Spectrum Beta Lactamase ). Review on 7/8/19 of Resident #61's Electronic Medication Administration Record [REDACTED]. Interview on 7/8/19 at 11:13 a.m. with Staff J (Licensed Practical Nurse) confirmed that Resident #61 was on [MEDICATION NAME] and contact precaution for Resident #61's positive ESBL in the urine. Staff J stated that visitors when not in contact with Resident #61 should wash their hands before entering and leaving the room, visitors in contact with resident should wash their hands, wear a gown and don gloves. Staff J also stated that staff providing care and in contact with Resident #61 should wash their hands, wear a gown and don gloves. Observation on 7/8/19 at 1:07 p.m. revealed that Staff P (Physical Therapist), Staff O (Personal Care Assistant), Staff L (Licensed Nursing Assistant) were in Resident #61's room with no gown or gloves, touching resident and doing slide board transfer teaching with Resident #61. Observation on 7/9/19 at 9:39 a.m. outside Resident #61's room revealed a transmission based precaution cart and a sign to see the nurses. Interview on 7/9/19 at 9:39 a.m. with Staff J revealed that Resident #61 continued to be on contact precaution for ESBL in the urine. Staff J stated that they are waiting for the physician to clear Resident #61 and discontinue the contact precaution. Interview on 7/9/19 at 1:00 a.m. with Resident #61 revealed that Resident #61 was looking for the physician to discuss discontinuing the contact precaution so they can return to their previous room. Observation on 7/9/19 at 1:36 p.m. revealed that Staff M (housekeeper) was in Resident #61's room cleaning and organizing Resident #61's belongings and bed side table with no gloves and gown. Observation on 7/10/19 at 8:13 a.m. outside Resident #61's room revealed a transmission based precaution cart and a sign to see the nurses. Interview on 7/10/19 at 12:48 a.m. with Staff H (Director of Nursing) revealed that Staff H stated that Resident #61 was not on contact precaution since 7/7/19 as Resident #61 completed their antibiotic regimen for the ESBL in the urine. Staff H was unable to provide any documentation that Resident #61 was taken off contact precaution per facility policy titled, Discontinuing Transmission Based Precautions. Observation on 7/11/19 8:05 a.m. outside Resident #61's room revealed a transmission based precaution cart and a sign to see the nurses. Interview on 7/11/19 at 8:11 a.m. with Staff H confirmed the above observation on 7/11/19. Staff H revealed that Resident #61's room has not been terminally clean and will be terminally clean on 7/11/19. Staff H stated that as Resident #61's room was not terminally cleaned so the contact precaution was in effect on 7/8/19 to 7/10/19 even though Resident #61's antibiotics were completed on 7/7/19. Observation on 7/11/19 at 11:00 a.m. revealed that Resident #61's room was terminally cleaned by the housekeeping staff. Observation on 07/10/19 at 10:57 a.m. of the glucometers on the[NAME]Unit it was observed both glucometers were labeled with a label to denote which side the glucometer belong too. The gluocometer was marked with a F1 label on the back of the meter and the other meter was labeled with F2 label on the back of the meter. Interview on 07/10/19 at 11:00 a.m. with Staff D, LPN (Licensed Practical Nurse) confirmed the above findings. Observation on 07/10/19 at 11:27 a.m. of the 4 glucometers on the[NAME]Unit it was observed that clear tape was on the back of each glucometer and was written on the back of them denoting which side the meter belong too. Interview on 07/10/19 at 11:27 a.m. with Staff D LPN confirmed the above findings. Interview on 07/10/19 at 11:30 a.m. with Staff C, RN (Registered Nurse) confirmed that labels should not be on the back of the glucometers. Staff C will have all the tape remove from the meters.",2020-09-01
405,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2017-08-03,157,B,0,1,M98S11,"Based on record review and interview the facility failed to inform a resident's Durable Power of Attorney (DPOA) when a change in health condition and treatment regimen occurred for 1 out of sample resident. (Resident identifier is #17) Findings include: Resident #17 Review on 8/2/17 of Resident #17's medical record revealed a grievance that was filed by the activated DPOA with Staff A (LPN) on 7/18/17 regarding his/her grandmother who developed cold symptoms on 7/14/17. An Event Investigation Interview Record form was completed by Staff C (LPN). Staff C documented that she/he had contacted the nurse practitioner who order a chest x-ray, breathing treatments and cough drops. Staff C did not document notifying the DPOA of the change in health status and the new physicians orders. Interview on 8/3/17 at approximately 1:15 p.m. with Staff B (Administrator), Staff B stated the documentation in the grievance was correctly documented.",2020-09-01
406,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2017-08-03,281,D,0,1,M98S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow the professional standard of care for the pronouncement of death for 1 discharge record in a survey sample of 16 residents. (Resident identifier is #14.) The facility also failed to ensure that residents were free from significant medication errors for 1 resident in a standard survey sample of 16 residents. (Resident identifier is #4.) Findings include: Resident #14 Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Pages 479 - 480 Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care .Documentation of a death provides a legal record of the event. Follow agency policies and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death .Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting .Documentation of End-of-Life Care . .Time and date of death and all actions taken to respond to the impending death .Name of health care provider certifying the death .Persons notified of the death (e.g., health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death .Request for organ or tissue donations made and by whom .Special preparations of the body (e.g., desired or required religious/cultural rituals) .Medical tubes, devices, or lines left in or on the body .Personal articles left on and secured to the body .Personal items given to the family with description, date, time, to whom given .Location of body identification tags .Time of body transfer and destination .Any other relevant information or family requests that help clarify special circumstances. Review on [DATE] of nursing progess notes for Resident #14 revealed the following documentation: Pt. deceased on assessment this shift. DPOA (Durable Power of Attorney) , notified in person immediatley as she was in the facility. On call practitioner notified and orders to pronounce and release obtained. Hospice notified by phone. Released to funeral director per DPOA choice. Review of the nursing progress notes revealed no evidence of an assessment for the pronouncement of death for Resident #14. Interview on [DATE] at approximatlely 1:30 p.m. with Staff A (Unit Manager) confirmed the above finding, and verified that there was no evidence of an assessment done for Resident #14 at the time of death. Resident #4 Findings include: Review on [DATE] of Resident #4's Medication Administration Record [REDACTED]. On [DATE] Resident #4 has a physician's orders [REDACTED]. On [DATE] at 2030 and on [DATE] at 0330 Staff N (Licensed Practical Nurse) documented on the electronic medical record that [MEDICATION NAME] HCL 5 mg. tablet was administered. Interview on [DATE] at approximatley 11:00 a.m. with Staff A (Licensed Practical Nurse) confirmed that the [MEDICATION NAME] was discontinued on [DATE], and that [MEDICATION NAME] HCL tablet 5 MG 1 tablet by mouth as needed for pain BID was administered on [DATE] and [DATE] without a physician's orders [REDACTED].>",2020-09-01
407,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2017-08-03,282,D,0,1,M98S11,"Based on record review and interview it was determined that the facility failed to follow a comprehensive care plan for a pacemaker for 1 resident out of a survey size of 16 residents. (Resident identifier is #12.) Findings include: Review on 8/3/17 of Resident #12's careplans dated 2/8/16, revision date 6/28/17 revealed that Resident #12 had a pacemaker. Care plan is as follows: Focus: Resident #12 is at risk of complications related to St Jude dual chamber pacemaker. Interventions: . Pacemaker checks as ordered/remote pacer check located in patients room. Review of the consultation from the cardiologist dated 6/9/16 revealed that the pacemaker was to have a remote follow up on 9/12/16 and the cardiologist would call and fax the results to the facility. No documentation of the remote follow up was found in the medical record. Review of nursing notes dated 7/14/17 from the cardiologist revealed that the facility had no knowledge of the remote pacemaker checks not being done from 6/9/16 until 7/14/17 and no remote pacemaker checks had been done and the resident had not been seen since 6/9/16. Interview on 8/3/17 at approximately 9:45 a.m. with Staff A (Licensed Practical Nurse) revealed that the facility had no knowledge that the remote pacemaker checks were not being done. Staff A (LPN) stated, Cardiology notifies us if there is an issue. Staff A (LPN) confirmed that there was no communication between the cardiologist and the facility from 6/9/16 to 7/14/17.",2020-09-01
408,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2017-08-03,364,B,0,1,M98S11,"Based on observation and interview it was determined that the facility failed to ensure safe and appetizing temperatures for food. Findings include: Interview on 8/2/17 at approximately 10:30 a.m. with Resident Council members revealed that 8 of the 13 members present stated that, food is always served cold, lunch and supper especially. They stated that the staff will heat the meal up in the microwave but they would have to heat up every individual meal because the 8 council members feel all the meals are cold. The members stated that this is throughout the facility. Review of the Resident Council Minutes for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed that food being served cold has been a topic of discussion at each meeting. Observation of a test tray on 8/3/17 at 12:30 p.m. on[NAME]Unit revealed that at approximately 1:00 p.m. the following temperatures were recorded. Beef and macaroni- 120 degrees Fahrenheit [NAME] slaw- 63 degrees Fahrenheit Garlic bread- 64 degrees Fahrenheit Salad dressing- 64 degrees Fahrenheit Interview on 8/3/17 at approximately 1:00 p.m. with Staff G (Director of Food Services) who recorded the above temperatures confirmed the above findings, and agreed that the temperatures did not fall into acceptable ranges.",2020-09-01
409,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2017-08-03,371,E,0,1,M98S11,"Based on observation and interview it was determined that the facility failed to prepare food under sanitary conditions. Findings Include: Observation on 8/1/17 at approximately 9:30 a.m. during initial tour of the kitchen with Staff G (Director of Food Services) revealed that the mixer was found to be covered and stored as cleaned and put away; however, upon removal of the cover and upon inspection of the mixer, the upper inside of the splash guard was observed to be covered with what looked like dried on batter. Interview on 8/1/17 at approximately 9:30 a.m. with Staff G (Director of Food Services) confirmed this by stating it looks like it hasn't been wiped down. On 8/2/17 at approximately 10:15 a.m. another inspection of the mixer with Staff G revealed that the mixer was again covered and stored as cleaned; however, the upper inside of the splash guard remained covered with what looked like dried on batter. Staff G stated, It still has not been cleaned. Observation on 8/1/17 at approximately 9:30 a.m. during initial tour of the kitchen, Staff F (Dietary Aide) was observed wearing a hair net that only covered the portion of hair that was pulled back into a bun. The rest of the head was free of a hair net. Observation on 8/2/17 at approximately 10:30 a.m. observation of Staff [NAME] (Dietary Aide) revealed that Staff [NAME] was not wearing a hair net or hat during preparation of food in the kitchen. On 8/3/17 at approximately 11:45 a.m. during kitchen observation Staff F (Dietary Aid) was observed serving food with a hair net that only partially covered the hair, and there were no gloves being worn while serving food. At 12:05 p.m. Staff D (Dietary Aide) was observed preparing food while not wearing gloves.",2020-09-01
410,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2017-08-03,431,D,0,1,M98S11,Based on record review and interview it was determined that the facility failed to correctly document and account for controlled medications for 1 resident in a standard survey sample of 16 residents. (Resident identifier is #4.) Findings include: Resident #4 Review on 8/2/17 at approximately 9:00 a.m. of Resident # 4's MAR (Medication Administration Record) revealed that on 7/1/17 at 2:47 a.m. Oxycodone HCL 5 mg. tablet was administered to Resident # 4. Review of the narcotic book revealed that no Oxycodone had been given on that date and time. Further review of the narcotic book revealed that on 7/25/17 an Oxycodone HCL 5 mg. tablet was signed out of the narcotic book twice but there was no documentation on the MAR indicated [REDACTED]. Interview on 8/2/17 at approximately 10:00 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings.,2020-09-01
411,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2018-09-20,658,B,0,1,ESXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #66) Findings include: Review on 9/20/18 of Resident #66's Electronic Medication Administration Report (EMAR) for (MONTH) (YEAR) revealed that Resident #66 has [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday with pick up time for transportation at 5:30 a.m. Review on 9/20/18 of Resident #66's EMAR for (MONTH) (YEAR) revealed the following physician orders [REDACTED]. Further review of Resident #66's EMAR for (MONTH) (YEAR) revealed that at 7:30 a.m. on 9/11/18 (Tuesday), 9/13/18 (Thursday), 9/15/18 (Saturday), 9/18/18 (Tuesday) and 9/20/18 (Thursday) Resident #66's Humalog was not given as indicated by the EMAR chart code documentation of AW (Away from the center). Interview on 9/20/18 at 11:20 a.m. with Staff D (Registered Nurse) confirmed that Resident #66 did not receive their Humalog Sliding Scale in the morning of 9/11/18, 9/13/18, 9/15/18, 9/18/18 and 9/20/18 because Resident #66 was at the [MEDICAL TREATMENT] center. Interview with Staff D revealed that Resident #66 ate breakfast in the facility at 5:00 a.m. every morning of the [MEDICAL TREATMENT] days and goes to the [MEDICAL TREATMENT] center with snacks. Review on 9/20/18 of Resident #66's EMAR for (MONTH) (YEAR) revealed that Resident #66 received [MEDICATION NAME] Proxetil 200 mg, which was scheduled for 8:00 a.m., on 9/11/18 (Tuesday) at 12:03 p.m. and on 9/13/18 (Thursday) at 11:46 a.m. Interview on 9/20/18 at 3:00 p.m. with Staff A (Director of Nursing) confirmed that Resident #66 did not have their blood sugar checked and did not receive their Humalog Sliding Scale on 9/11/18, 9/13/18, 9/15/18, 9/18/18 and 9/20/18. Interview with Staff A also confirmed that Resident #66 received the [MEDICATION NAME] Proxetil 200 mg medication approximately 3.5 hours late because Resident #66 was at the [MEDICAL TREATMENT] center. Interview on 9/20/18 at 3:10 p.m. with Staff [NAME] (License Practical Nurse) confirmed that Resident #66 did not have their blood sugar checked and did not received their Humalog Sliding Scale on 9/11/18, 9/13/18 and 9/18/18. Interview with Staff [NAME] revealed that Staff [NAME] does not check blood sugar and give Humalog Sliding Scale on [MEDICAL TREATMENT] days because clinically blood sugar is better high than low when being dialyzed.",2020-09-01
412,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2018-09-20,697,D,0,1,ESXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure adequate relief of pain for 1 resident in a standard survey sample of 17 residents. (Resident identifier is #61.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 1082 .If you evaluate that a client continues to have discomfort after an intervention, use a new approach . Observation on 9/17/18 at approximately 9:45 a.m. of Resident #61 revealed that Resident #61 was grimacing in pain sitting at the end of the Phillips Hallway with Resident #61's walker. Interview on 9/17/18 at approximately 9:45 a.m. with Resident #61 revealed that Resident #61 has physical therapy for the lower back area and had to stop because of the pain. Resident #61 did not received any extra pain medication prior to going to physical therapy. The pain medication does help when given. Interview on 9/17/18 at 9:50 a.m. with the daughter revealed that she could not understand why Resident #61 always had to ask for pain medications. Her opinion was to stay ahead of the pain and not play catch up. Review on 9/17/18 of Resident #61's Nurse's Notes revealed no notes written that the resident's pain management was discussed with the physician at all. Resident #61 has been taking prn (as needed) [MEDICATION NAME], since Resident #61 has arrived in the facility on 8/17/18 everyday three to four times a day. Review on 9/17/18 of Resident #61 of (MONTH) (YEAR)'s MAR (Medication Administration Record) revealed that Resident #61 received the following medications for pain management: [MEDICATION NAME] 72 hour 25 MCG/hr (microgram/hour) apply 1 patch [MEDICATION NAME] every 72 hours for pain management, [MEDICATION NAME] capsule 100 mg (milligrams), give 200 mg by mouth three times a day for pain management, biofreeze professional 5% gel 9 (topical [MEDICATION NAME]) apply to mid back topically every 8 hours as needed, [MEDICATION NAME] tablet 10-325 mg give 1 tablet by mouth every 4 hours as needed for moderate to severe pain and [MEDICATION NAME] tablet 325 mg give 2 tablets by mouth every 4 hours as needed for mild pain - more than 3 doses notify physician/advance practice provider (APP) Do not exceed 3g/day (gram/day). Review on 9/17/18 of Resident #61's (MONTH) (YEAR) MAR indicated [REDACTED] [MEDICATION NAME] tablet 325 2 tablets on 8/17, 8/20,8/22, 8/23, 8/24, 8/27, 8/28, x 2, [MEDICATION NAME] 10-325 mg 1 tablet on 8/18 x 3, 8/19 x 3, 8/20 x 3, 8/21 x 2, 8/22 x 1, 8/23 x 1, 8/24 x 3, 8/25 x 1, 8/26 x 3, 8/27 x 2, 8/28 x 2, 8/29 x 3, 8/30 x 1, 8/31 x 2. Review on 9/17/18 of Resident #61's (MONTH) (YEAR) MAR indicated [REDACTED]. Review on 9/17/18 of Resident #61's (MONTH) MAR indicated [REDACTED] [MEDICATION NAME] tablet 325 2 tablets on 9/1, 9/6, 9/7, 9/11 x 2, 9/12, 9/17, [MEDICATION NAME] 1 tablet 10-325 mg on 9/1 x 3, 9/2 x 3, 9/3 x 2, 9/4 x 3, 9/5 x 2, 9/6 x 3, 9/7 x 2, 9/8 x 3, 9/9 x 3, 9/10 x 2, 9/11 x 2, 9/12 x 1, 9/13 x 3, 9/14 x 3, 9/15 x 4, 9/16 x 2, 9/17 x 3, 9/18 x 1, 9/19 x 2, 9/20 x 1. Review on 9/17/18 of Resident #61's (MONTH) (YEAR) MAR indicated [REDACTED]. Review on 9/17/18 of Resident #61's (MONTH) (YEAR) MAR indicated [REDACTED]. Review on 9/17/18 of Resident #61's person-centered care plan with a initiated date of 8/20/18 revealed the goal would be Resident #61 will achieve acceptable level of pain control x 90 days and the intervention are: that Resident #61 would request pain medication before pain becomes severe, medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, reports to physician as indicated, monitor frequency of episodes of breakthrough pain to determine the need for pain med adjustment, monitor for non-verbal signs/symptoms of pain and medicate as ordered Interview on 9/20/18 at approximately 1:00 p.m. with Staff G (Registered Nurse) confirmed that Resident #61 should have a review of the pain medication regimen that Resident #61 is on. Interview on 9/20/18 at approximately 1:00 p.m. with Resident #61 and Staff G, Staff G confirmed with Resident #61 that less prn medications and a more even pain control throughout the day would be more effective and beneficial for Resident #61. Resident #61 stated that Resident #61 does not want to keep asking for pain medications. Interview on 9/20/18 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed that the staff were aware that Resident #61 was having pain, but because Resident #61 had the prn medications the pain medications were being effective at times the staff continued to give and not involve the doctor. Staff A will have the physician will reassess the medications.",2020-09-01
413,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2018-09-20,761,D,0,1,ESXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to follow expiration dates for medications on 2 out of 2 observed medication rooms and failed to follow labeling, expiration dates and or refrigeration for medications on 1 out of 3 observed medication carts. (Resident identifiers are #1, #5, #19, and #48.) Findings include: Observation on [DATE] at approximately 8:40 a.m. of the[NAME]Hall medication room revealed a house stock bottle of Vitamin B 6 pills that had a manufacturer's expiration date printed on the bottom of the bottle which read ,[DATE]. The side of the bottle also contained a hand written date which read ,[DATE]. Interview on [DATE] at approximately 8:40 a.m. with Staff [NAME] (Licensed Practical Nurse) confirmed that the expiration date of the medication was ,[DATE]. Staff [NAME] also confirmed that they were not sure of who had written the date of ,[DATE] on the bottle or why they had written it. Observation on [DATE] at approximately 9:00 a.m. of the[NAME]Hall back medication cart revealed a house stock bottle of Oyster Shell Calcium 500 mg (milligram) with a manufacturer's expiration date printed on the bottle which read ,[DATE]. Resident #48 Observation on [DATE] at approximately 9:00 a.m. of the[NAME]Hall back medication cart revealed a multidose vial of [MEDICATION NAME] Insulin for Resident #48. The multidose vial was inside a brown plastic pharmacy container used to hold the vial. There was no date written on the vial. There was one sticker on the brown container that read Refrigerate until opened. There was another sticker on the brown container that read Refrigerate until opened; discard unused med after 28 days Date opened [DATE]. Resident #5 Observation on [DATE] at approximately 9:00 a.m. of the[NAME]Hall back medication cart revealed a multidose vial of [MEDICATION NAME] for Resident #5. The multidose vial was inside a brown plastic pharmacy container used to hold the vial. There was no date written on the vial. There was one sticker on the brown container that read Refrigerate until opened. There was another sticker on the brown container that read Refrigerate until opened; discard unused med after 28 days Date opened _______. The date opened was not written in on the sticker. Resident #1 Observation on [DATE] at approximately 9:00 a.m. of the[NAME]Hall back medication cart revealed a [MEDICATION NAME] Insulin pen for Resident #1. It was inside a plastic bag used to hold it. There was a sticker on the plastic bag that read Refrigerate until opened. There was no opened date written on the pen or on the plastic bag. Resident #19 Observation on [DATE] at approximately 9:00 a.m. of the[NAME]Hall back medication cart revealed a [MEDICATION NAME] pen for Resident #19. It was inside a plastic bag used to hold it. There was a sticker on the plastic bag that read Refrigerate until opened. There was no opened date written on the pen or on the plastic bag. Interview on [DATE] at approximately 9:15 a.m. with Staff H (Registered Nurse) and Staff A (Director of Nursing) confirmed that the Oyster Shell Calcium and the multidose vial of [MEDICATION NAME] Insulin had expired. They also confirmed that the multidose vial of [MEDICATION NAME], the [MEDICATION NAME] Insulin pen and the [MEDICATION NAME] pen should have been dated when opened or left in the refrigerator until opened. Observation on [DATE] at approximately 9:25 a.m. of the Folsom[NAME]medication room revealed a multidose vial of [MEDICATION NAME] Purified Protein Derivative which was inside the cardboard box used to hold it. There was no date written on the vial. There was a sticker on the cardboard box which read Date opened [DATE] Do not use 30 days after above date. Interview on [DATE] at approximately 9:28 a.m. with Staff A confirmed that the multidose vial of [MEDICATION NAME] Purified Protein Derivative had expired and should have been discarded. Review on [DATE] of the Facility policy titled, Storage and Expiration Dating of Medications, Biologicals . last revised on [DATE], revealed that .facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier . It also revealed that .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened . The Facility policy also revealed the following Insulin Storage Recommendations .[MEDICATION NAME] vials .opened at room temperature 28 days, [MEDICATION NAME] vials .opened at room temperature 28 days, [MEDICATION NAME] pen .opened at room temperature 28 days, and [MEDICATION NAME] pen .opened at room temperature 28 days . The Facility policy also revealed the following Recommended Minimum Medication Storage Parameters .[MEDICATION NAME] Injection ([MEDICATION NAME] test) .Store in refrigerator .Date when opened and discard unused portion after 30 days .",2020-09-01
414,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2018-09-20,842,B,1,1,ESXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined that the facility failed to have complete medical records in regards to consent for antibiotic use, accuracy of actual fall notes, documentation on Electronic Medication Administration Records (EMAR) and Electronic Treatment Administration Record (ETAR), and inaccurate transcription for 4 residents in a final sample of 17 residents. (Resident identifiers are #6, #26, #64, and #169) Findings include: Resident #6 Review on 9/18/18 of Resident #6's physician orders [REDACTED]. which was ordered on [DATE]. Further review of Resident #6's physician orders [REDACTED].#6 was on [MEDICATION NAME] ointment (antibiotic) during the month of (MONTH) and (MONTH) (YEAR) and [MEDICATION NAME] (antibiotic) 500 mg during the month of (MONTH) (YEAR). Review on 9/19/18 of Resident #6's progress notes revealed that there were no notes found in regards to obtaining consent for antibiotic use from the DPOAH. Interview on 9/20/18 at 10:20 a.m. with Staff A (Director of Nursing) confirmed physician order [REDACTED]. Interview on 9/20/18 at 1:46 p.m. with Staff A revealed that Staff F (Registered Nurse) spoke to DPOAH on 9/20/18 at 12:18 p.m. via telephone and that the DPOAH was aware that Resident #6 was on [MEDICATION NAME] and [MEDICATION NAME] ointment. Interview with Staff A further revealed that clarification on antibiotic use was discussed with DPOAH and orders were changed on 9/20/18 at 2:20 p.m. to specify that DPOAH wished for no IV and PO (by mouth) antibiotics. Resident #26 Review on 9/18/18 of Resident #26's change in condition follow-up notes revealed that Resident #26 had falls on 6/15/18, 6/17/18, 7/14/18, 7/15/18, 7/16/18 and 7/18/18. Review of Resident #26's nurse's notes related to falls revealed that there were no falls on 6/17/18, 7/15/18, 7/16/18 and 7/18/18. Interview on 9/19/18 at 11:50 a.m. with Staff A confirmed that the change in condition follow-up notes regarding the falls were documented incorrectly. Interview with Staff A revealed that there were only 2 actual falls which were on 6/15/18 and 7/14/18. Interview with Staff A further revealed that the nurse's notes on 6/17/18, 7/15/18, 7/16/18 and 7/18/18 were follow up notes for the 6/15/18 and the 7/14/18 fall, respectively. Review on 9/19/18 of Resident #26's ETAR for (MONTH) (YEAR) revealed the following treatment order: assess resident's ability to remove Velcro lap belt when asked every day shift for safety. Review of Resident #26's ETAR for (MONTH) (YEAR) further revealed that there were no documentations that the resident was able or not able to remove the Velcro lap belt on 7/5/18, 7/7/18, 7/10/18, 7/12/18, 7/19/18, 7/20/18, 7/24/18 and 7/25/18 (8 days out of 31 days in the month of (MONTH) (YEAR).) Review on 9/19/18 of Resident #26's ETAR for (MONTH) (YEAR) revealed the following treatment orders: (MONTH) use Velcro seat belt when up in wheelchair due to advancing [MEDICAL CONDITION] .Release every two hours and as requested by resident for care and transfers every shift for safety. Review of Resident #26's ETAR for (MONTH) (YEAR) further revealed that there were no documentations that the Velcro seat belt was release every 2 hours and as requested by Resident #26 on 7/4/18, 7/5/18, 7/10/18, 7/12/18, 7/17-20/18, 7/24-25/18 (10 days out of 31 days in the month of (MONTH) (YEAR)). Interview on 9/19/18 at 1:00 p.m. with Staff A confirmed missing documentations on Resident #26's ETAR for (MONTH) (YEAR). Staff A was unable to provide reasons for missing documentations. Resident #64 Observation on 9/17/18 at 10:21 a.m. revealed that Resident #64 had a wander guard device on their right ankle. Review on 9/18/18 of Resident #64's physician orders [REDACTED].#64. Review on 9/18/18 of Resident #64's assessments revealed that there was no elopement assessment that was done for the use of the wander guard device. Review of Resident #64's assessments further revealed that there was no assessments done in regards to the use of the wander guard device since admission. Review on 9/18/18 of Resident #64's nurse's notes revealed that Resident #64 had attempted to exit the facility since Resident #64's admission. Further review of Resident #64's nurse's notes revealed that there were no notes found regarding consent from the DPOAH (Durable Power of Attorney for Health) to use the wander guard device. Review on 9/18/18 of Resident #64's current care plan revealed that Resident #64 is at risk for elopement and wander guard device was utilize and initiated on 8/27/18. Interview on 9/20/18 at 8:55 a.m. with Staff D (Registered Nurse) confirmed that Resident #64 has a wander guard device on their right ankle to prevent them from exiting the building. Interview with Staff D revealed that the use of a wander guard device needs a physician order [REDACTED]. Interview on 9/20/18 at 9:25 a.m. with Staff A confirmed that Resident #64 was using a wander guard device, no elopement assessment was found, and no nurse's note was found in regards to obtaining a consent from the DPOAH to use the wander guard device. Interview with Staff A revealed that the facility's process in utilizing a wander guard is to have an elopement assessment completed, update a resident current care plan, obtain a verbal consent from the DPOAH to use a wander guard device, and obtain a physician order [REDACTED]. Resident #169 Review on 9/18/18 of Resident #169's Minimum Data Set (MDS) revealed that Resident #169 was at the facility from 6/17/18 until 6/30/18 when they were discharged home. Review on 9/18/18 of Resident #169's Discharge Medication List from the hospital, dated 6/17/18, revealed that Resident #169 had received [MEDICATION NAME] 50 mcg (micrograms) by mouth very day while in the hospital and this order was to continue. Review on 9/18/18 of Resident #169's Physician order [REDACTED].#169 did not have an order for [REDACTED].>Review on 9/18/18 of Resident #169's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview on 9/18/18 at approximately 2:45 p.m. with Staff A (Director of Nursing) confirmed that a transcription error had occurred and that the nurse transcribing the admission orders [REDACTED].",2020-09-01
415,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2018-09-20,849,B,0,1,ESXU11,"Based on record review and interview, it was determined that the facility failed to designate a member of the facility's interdisciplinary team (IDT) in writing who is responsible for working with hospice representatives to coordinate care to the resident provided by the Long Term Care (LTC) facility staff and hospice staff for 1 out of 1 hospice resident reviewed. (Resident identifier is #53.) Findings include: Review on 9/19/18 of facility's hospice contract agreement with hospice provider revealed that there was no written designated member of the facility's IDT team to coordinate care between resident, facility staff, and hospice provider. Review on 9/19/18 of Resident #53's chart and hospice communication book with hospice provider revealed that there was no written designated member of the facility's IDT team to coordinate care between resident, facility staff, and hospice provider. Interview on 9/19/18 at 2:46 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview with Staff A revealed that the designated member of facility's IDT who is responsible for working with hospice representatives were the facility's Staff B (Social Worker) and Staff C (Social Worker). Interview on 9/19/18 at 3:00 p.m. with Staff B and Staff C confirmed that they were the designated member of the facility's IDT team who are responsible for working with hospice representatives to coordinate care to the resident provided by the Long Term Care (LTC) facility staff and hospice staff.",2020-09-01
416,APPLEWOOD CENTER,305065,8 SNOW ROAD,WINCHESTER,NH,3470,2016-11-03,159,B,0,1,2ZTU11,"Based on the review of the resident trust fund account and interview it was determined that the facility failed to notify residents when the amount in the resident's account reached $200 less than the SSI resource limit for the State of NH ($2500) as specified in section 1611(a)(3)(B) of the Act for 1 of 5 sampled residents. (Resident identifier is #16.) Findings include: Resident #16. Review on 11/3/16 of the Individual Statement for Resident #16 revealed that from 08/03/16-09/07/16 the balance continually exceeded $200 less than the SSI resource limit for the State of NH, in fact exceeding the $2500 limit the entire time. On 09/07/16 the balance was still within the $200.00 less than $2500.00. There was no documented evidence that the resident or their representative had been notified. Interview on 11/13/16 at the time of the review with Staff A (Business Office Manager), confirmed the above finding.",2020-09-01
417,APPLEWOOD CENTER,305065,8 SNOW ROAD,WINCHESTER,NH,3470,2016-11-03,456,D,0,1,2ZTU11,"Based on interview, facility policy and review of the manufacturer's instructions for the facility it was determined the facility failed to clean the glucometer and that the facility failed to date the test strips according to the manufacturer's instructions. Findings include: Review of the facility EVEN CARE G2 Blood Glucose Test Strips manufacturer's instruction revealed the following: WARNING AND PRECAUTIONS . Do not use test strips after their expiration date. Please check the expiration date on the test strip bottle. STORAGE AND HANDLING . Use within 6 months after first opening . Review of the facility Glucose Meter with an effective date of 06/01/96 and a revision date of 06/01/15 revealed the following .2. Disinfect meter before patient use. Observation of the medication pass on 11/1/16 at 4:10 p.m. with Staff B (Registered Nurse), revealed that Staff B obtained a blood glucose from Resident #7. Staff B removed the glucometer from the medication cart and removed one test strip from the test strip container and place the test strip on top of the glucose meter. After the blood glucose was obtained Staff B placed the glucose meter back into the medication cart without cleaning it. Observation and review Staff B (RN) verbally confirmed the above listed findings for not cleaning the glucose meter. Observation of the medication pass on 11/2/16 at 8:15 a.m. with Staff C (Licensed Practical Nurse) revealed 2 opened bottles of glucose test strips that were not dated with a date for the time of opening. During this observation and review Staff C (LPN) confirmed the above listed findings for the glucose test strips.",2020-09-01
418,SAINT VINCENT REHABILITATION & NURSING CENTER,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2017-06-23,431,D,0,1,83ZO11,Based on observation and interview it was determined that the facility failed to store all drugs and biologicals in locked compartments on 2 out of 3 nursing units. Findings include: Observation on 6/22/17 at approximately 7:15 a.m. during medication pass on the 1st floor with Staff A (Licensed Practical Nurse) revealed a bottle of Lactaid on top of the medication cart without any nursing staff in the area. Interview on 6/22/17 at approximately 7:30 a.m. with Staff A (LPN) confirmed that the bottle of Lactaid had pills in it and was on top of the medication cart without any nursing staff in the area of the medication. Observation on 6/22/17 at approximately 9:40 a.m. of the 3rd floor unlocked nurses station revealed 2 medication bottles D3 (cholecalciferol) 2000 IU (international units) and K2 (menaquinone) 100 milligrams on the desk without any nursing staff in the area. Interview on 6/22/17 at approximately 9:45 a.m. with Staff B (Registered Nurse) confirmed that the 2 medication bottles had pills in them and were on the desk without any nursing staff in the area. Observation on 6/22/17 at approximately 1:30 p.m. of the 1st floor nurses station revealed a bottle of Vitamin D (cholecalciferol) 1000 IU was on the counter at the nurses station without any nursing staff in the area of the medication. Interview on 6/22/17 at approximately 1:35 p.m. with Staff A (LPN) confirmed that the medication bottle had pills in it and was on the counter at the nurses station without any nursing staff in the area of the medication.,2020-09-01
419,SAINT VINCENT REHABILITATION & NURSING CENTER,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2019-07-19,550,D,0,1,7CFV11,"Based on interview and record review, it was determined that the facility failed to ensure residents rights were followed for 1 resident in a final survey sample of 22 residents. (Resident identifier is #26.) Resident #26 Interview on 7/17/19 at approximately 9:15 a.m. with Resident #26 revealed a concern that a nurse attempted to give Resident #26 more medication than was ordered. Resident #26 stated, the nurse attempted to give me 5 times the amount of my diabetes medication. Resident #26 went on to say that when Resident #26 tried to tell the nurse that this was too much medication the nurse responded with, this is what my computer is telling me that you get and you will take this medication. Resident #26 stated that they had to get stern with the nurse and tell the nurse that they were not going to take this medication because it is too much and it would give them diarrhea and put them in the hospital. Resident #26 then stated, the nurse told me I was being belligerent and then she left. Resident #26 stated that they had a care plan meeting to which they attended and did mention the above noted incident as being a concern of theirs. Resident #26 was asked in the care plan meeting if the person who attempted to give them too much medication was in the room and Resident #26 stated that the nurse was and they pointed to the nurse responsible for the above noted situation. Staff D was the nurse Resident #26 identified as being the nurse referenced above. Interview on 7/17/19 at approximately 1:30 p.m. with Staff A (Administrator), revealed that Staff A was not aware of the above situation and revealed that since they were not aware this incident had occurred, they had not reported it to the State of NH. Interview on 7/17/19 at approximately 1:40 p.m. with Staff C (Director of Nursing), confirmed the above situation had occurred and Staff C stated that additional education regarding resident rights were reviewed with Staff D.",2020-09-01
420,SAINT VINCENT REHABILITATION & NURSING CENTER,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2019-07-19,656,B,0,1,7CFV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to develop care plans for diabetes for 1 resident, dental issues for 1 resident, dysphagia for 1 resident, refusal of weights for 1 resident, tube feedings for 1 resident and a kidney transplant for 1 resident in a final survey sample of 22 residents. (Resident identifiers are #10, #19, #26, #47 and #53.) Findings include: Resident #19 Review on 7/18/19 of Resident #19's weight log revealed that Resident #19 had not had a documented weight since 5/8/19, which was 91.5 pounds. Review on 7/18/19 of Resident #19's Nutritional Assessment, dated 5/31/19, which was their most recent nutritional assessment, revealed that Resident #19 had weight fluctuations, both loss and gain in the past 90 days, and that the Nutrition Plan was to .monitor wt (weight) . Review on 7/19/19 of Resident #19's current care plan revealed that there was no documentation for the reason that Resident #19 had not had any weights documented since 5/8/19. Interview on 7/19/19 at approximately 10:00 a.m. with Staff C (Director of Nursing) revealed that Resident #19 had not had any weights taken since 5/8/19, because Resident #19 frequently refused them. Staff C confirmed that Resident #19's refusal of weights was not documented on their care plan and that it should have been. Resident #47 Review on 7/17/19 of Resident #47's active physician orders [REDACTED].#47 was NPO (Nothing By Mouth) and received all of their nourishment and medications through a feeding tube. Review on 7/18/19 of Resident #47's care plan revealed that the section titled Dining and Nutrition was blank without any information or interventions for Resident #47's feeding tube. Interview on 7/18/19 at approximately 9:00 a.m. with Staff B (Clinical Nurse Manager) revealed that documentation for feeding tubes should be found under the Dining and Nutrition Section. Interview on 7/18/19 at approximately 10:50 a.m. with Staff C confirmed that the Dining and Nutrition section of Resident #47's care plan was blank. Staff C also confirmed that information and interventions for the feeding tube should have been on the care plan. Resident #53 Review on 7/18/19 at approximately 11:24 a.m. of Resident #53's medical record revealed a [DIAGNOSES REDACTED]. Further review of Resident #53's physician orders [REDACTED].#53 takes [MEDICATION NAME], and [MEDICATION NAME] for [DIAGNOSES REDACTED]. Review on 7/18/19 at approximately 11:45 a.m. of Resident #53's care plan reveals that there is not a care plan for Diabetes and that there is no mention of the [DIAGNOSES REDACTED]. Interview on 7/18/19 at approximately 12:00 p.m. with Staff B (Clinical Nurse Manager) confirms that Resident #53 does not have a care plan for Diabetes.",2020-09-01
421,SAINT VINCENT REHABILITATION & NURSING CENTER,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2019-07-19,657,D,0,1,7CFV11,"Based on record review and interview, it was determined that the facility failed to update and revise the care plan for 3 resident in a final sample of 22 residents. (Resident identifier is #10, #42 and #49.) Findings include: Resident #10 Observation on 7/16/19 at 12:03 p.m. revealed Resident #10 sitting up in a recliner chair eating a ground meat with extra gravy meal. Interview on 7/16/19 at 12:03 p.m. with a family member revealed that Resident #10 is eating better with the present meal. The previous meal Resident #10 would always spit out. The family member was happy that Resident #10 was up in a recliner chair in not in bed eating that meal. Review on 7/18/19 revealed that Resident #10 has a dining and nutrition care plan to offer cut up meats but not a mechanically soft diet as recommended by the Staff E, SLP (Speech-Language Pathologists). Interview on 7/19/19 at approximately 10:30 a.m. with Staff C, Staff C confirmed that Resident #10 did not have a mechanically soft diet on the care plan. Resident #42 Review on 7/18/19 of Resident #42's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/17/19, revealed that it was documented in Section N0410, Medications, that Resident #42 had taken anticoagulation medications for 7 days. Review on 7/18/19 of Resident #42's current care plan revealed that there was no documentation on the care plan of Resident #42's use of anticoagulant and INR (International Normalized Ratio) levels should be or when the INR would be drawn. Interview on 7/19/19 at approximately 10:45 a.m. with Staff C, Staff C confirmed that Resident #42 did use anticoagulant medication and have INR drawn, that it was not on their care plan and that it should have been. Resident #49 Review on 7/18/19 of Resident #49's Significant Change MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/20/19, revealed that it was documented in Section N0410, Medications, that Resident #49 had taken anticoagulation medications for 5 days. Review on 7/18/19 of Resident #49's current care plan revealed that there was no documentation on the care plan of Resident #49's use of anticoagulant and INR levels should be, what happens when INR levels are high or when the INR would be drawn or redrawn. Interview on 7/19/19 at approximately 11:00 a.m. with Staff C, Staff C confirmed that Resident #49 did use anticoagulant medication and have INRs drawn or when INR levels are high, that it was not on their care plan and that it should have been or redrawn.",2020-09-01
422,SAINT VINCENT REHABILITATION & NURSING CENTER,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2019-07-19,791,B,0,1,7CFV11,"Based on observation and interview, it was determined that the facility failed to provide emergency dental services for 1 resident in a final survey sample of 22 residents. (Resident identifier is #26.) Findings include: Resident #26 Interview on 7/17/19 at approximately 9:15 a.m. with Resident #26 revealed that on or around (MONTH) 9, 2019 the resident's right tooth, adjacent to the front tooth, had broken down the middle from the gum line. Resident #26 was concerned, stating that he/she didn't know if his/her insurance would pay for it or if he/she would have to pay for it himself/herself. Resident #26 stated that he/she did not have an appointment yet for the consultation or repair. Resident #26 revealed that he/she wasn't having any pain from this broken tooth. Observation on 7/17/19 at approximately 9:16 a.m. of Resident #26's right tooth adjacent to the front tooth was noted to be broken from the gum line down and half of the tooth was missing. Interview on 7/17/19 at approximately 2:30 p.m. with Staff C (Director of Nursing) revealed that Resident #26 did have a broken tooth that occurred on 7/10/19 and that an appointment had been made for the resident the same day the tooth broke. Staff C stated that, (Resident #26) canceled the same day appointment, because it wasn't good enough for (Resident #26). Staff C was unable to provide any supporting documentation that an appointment had been made or that the resident had canceled it.",2020-09-01
423,SAINT VINCENT REHABILITATION & NURSING CENTER,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2019-07-19,842,D,0,1,7CFV11,"Based on record review and interview, it was determined that the facility failed to document free water flushes that were being administered to 1 resident in a final survey sample of 22 residents. (Resident identifier is #47.) Findings include: Review on 7/18/19 of Resident #47's Nutrition Assessment, dated 6/19/19, revealed that the dietitian recommended that Resident #47 was to receive free water flushes, through their feeding tube, of 150 cc (cubic centimeters) 4 times per day. Review on 7/18/19 of Resident #47's (MONTH) 2019 physician orders, revealed that Resident #47 had an order, dated 6/11/19, for Free water flush four times daily starting 6/11/19 . Review on 7/18/19 of Resident #47's (MONTH) and (MONTH) 2019 Medication Administration Records revealed that there was no documentation that Resident #47 had received the ordered free water flushes. Interview on 7/18/19 at approximately 10:50 a.m. with Staff C (Director of Nursing) confirmed that the free water flushes were not documented and that they should have been.",2020-09-01
424,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2017-05-11,155,E,0,1,692111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to accurately document the resident choice of advance directive for 2 residents in a survey sample of 21 residents. (Resident identifiers are #2 and #8.) Findings include: Resident #2 Review on [DATE] of Resident #2's medical record reveals a clinical note entry dated [DATE] which stated . residents son/DPOA (Durable Power of Attorney) signed DNR (Do Not Resuscitate) two pink sheets tonight . Review on [DATE] also revealed a pink Portable Do Not Attempt Resuscitation (P-DNR) Order with the box checked that says Do Not Attempt Resuscitation (DNR.) The form was signed on [DATE] by the Nurse Practitioner. This form was kept in a drawer at the nurses station. Review on [DATE] of Resident #2's current face sheet revealed that full code was documented in the box for advance directives. Review on [DATE] of Resident #2's (MONTH) (YEAR) Medication Report revealed that full code was documented in the box for advance directives. Interview on [DATE] at approximately 10:20 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. During the interview, Staff A was asked how Staff A would find out what the advanced directive was in the case of discovering that a resident had stopped breathing with cessation of heart beat. Staff A indicated that Staff A would go to the computer and look at the ribbon (the dark line at the top of the resident's page.) If the resident and/or representative had chosen DNR, it would be written in the ribbon. If the resident had chosen to be a full code, nothing would be written on the ribbon. Resident #2 had nothing written on the ribbon so Staff A indicated that the next step would be to go to the resident's Face Sheet. Resident #2's Face Sheet indicated that Resident #2 wished to be a full code. Staff A indicated that after seeing the full code written, Staff A would initiate CPR (Cardiopulmonary Resuscitation.) Interview on [DATE] at approximately 4:00 p.m. with Staff [NAME] (Director of Nursing) revealed that all nursing staff were educated at orientation on where to go to find a resident's current Advance Directives. Staff [NAME] indicated that they were instructed to go immediately to the drawer at the nurses station that held copies of each resident's Advance Directives. Staff [NAME] also indicated that, in light of the discrepancy with Resident #2's information, staff needed to be reeducated as to where to go first in order to get the correct information. Resident #8 Review on [DATE] of the audit dated [DATE] of advanced directives checked by the facility staff, revealed that Resident #8 had the letters FC (Full Code) documented under Resident #8's name. A notation was documented next to Resident #8's name indicating that the ribbon for Resident #8 had been corrected to DNR. Staff [NAME] confirmed that all the updates on the audit form had been done to indicate the correct advanced directive chosen by the resident or resident representative.",2020-09-01
425,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2017-05-11,278,B,0,1,692111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the MDS (Minimum Data Set) record was inaccurate for 2 residents in a survey sample of 21 residents. (Resident identifiers are #3 and #4.) Findings include: Resident #3 Review on 5/10/17 of Resident #3's Annual MDS with an ARD (Assessment Reference Date) of 12/6/16, and the Quarterly MDS with an ARD of 4/11/17, revealed they both coded the resident as having Moisture Associated Skin Damage (MASD) in Section M Skin Conditions. Review of the current Care Plan revealed no evidence of treatment for [REDACTED]. Interview on 5/10/17 with Staff B (Licensed Practical Nurse) revealed that Resident #3 has had no skin issues in the past 3 months. Interview on 5/20/17 with Staff I (MDS Coordinator) revealed that the MDS codings were incorrect and they should have be no for MASD. Resident #4 Review on 5/10/17 of Resident #4's Quarterly MDS with an ARD of 12/8/16, and the Significant Change MDS with an ARD of 3/8/17, revealed they both coded the resident as having Moisture Associated Skin Damage (MASD) in Section M Skin Conditions. Also, the MDS of 3/8/17 coded the resident in Section L Oral/Dental Status, as having natural teeth or tooth fragment(s). Review of the resident's current Care Plan revealed the resident has dentures. Interview on 5/10/17 with Staff G (Registered Nurse) revealed that the resident did have MASD in November, but not now, and Resident #4 only had it for about one week. Interview on 5/10/17 with Staff G revealed the resident has no teeth, and that the coding in Section L is an MDS error. Interview on 5/10/17 with Staff H (Clinical Assessment Manager), confirmed the MDS should be no for MASD.",2020-09-01
426,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2017-05-11,281,B,0,1,692111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure complete physician orders [REDACTED]. (Resident identifier are #20 and #4.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Pages 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 1063 One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity Resident #20 Review on 4/11/17 of Resident #20's (MONTH) (YEAR) Medications Report revealed that Resident #20 had an order for [REDACTED].>100.0. There was no indication for the interval between doses. Review on 4/11/17 of Resident #20's (MONTH) (YEAR) Medications Report also revealed that Resident #20 had an order for [REDACTED]. Interview on 4/11/17 at approximately 1:15 p.m. with Staff C (Licensed Practical Nurse) confirmed that the above orders were missing parameters for pain that would indicate when to administer which pain medication as well as the interval between doses. Resident #4 Review on 5/10/17 of Resident #4's (MONTH) (YEAR) MEDICATIONS list printed 5/10/17 revealed an order for [REDACTED]. The As Needed portion of this order does not provide any clinical indication for the medication's administration. The Q4H portion of this order reads like a scheduled medication which is inconsistent with the preceding As Needed instruction. Interview on 5/10/17 with Staff G (Registered Nurse) revealed they changed it in the MAR (Medication Administration Record).",2020-09-01
427,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2017-05-11,441,E,0,1,692111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to ensure two gel ice packs were stored in non-food freezers for 2 of 6 food refrigerators located on the resident units. Findings include: Observations on 5/9/17 at approximately 9:50 a.m., during the initial tour of the food preparation and storage areas revealed 2 gel packs to be in freezer compartments of 2 of the resident food refrigerators located in the kitchenettes on the second floor unit. The first gel pack was observed covered in a white terry cloth covering, the second was observed to be an uncovered gel pack. Interview on 5/9/17 at approximately 9:55 a.m. with Staff D (Director of Culinary Services), Staff D stated: These shouldn't be here. as he removed them from the food refrigerators. Observation on 3/11/17 at approximately 1:00 p.m. during tour of the 3rd floor medication room revealed a red substance on the front of the glucometer used for blood glucose testing. Interview on 3/11/17 at approximately 1:00 p.m. with Staff B (Licensed Practical Nurse) reviewed the above findings which revealed that the glucometer was used for multiple residents on the 3rd floor and did not know if the red substance on the front of the glucometer was consistent with blood. Interview on 3/11/17 at approximately 1:15 p.m. with Staff A (Licensed Practical Nurse), Staff A explained that it is the practice of the staff to disinfect the glucometer after using it and that the glucometer be put back into the nursing room to be ready for the next use. Observation on 5/9/17 at approximately 10:30 a.m. during tour of the second floor revealed that a dried brownish substance was on the top of the glucometer. Interview on 5/9/17 at approximately 10:30 a.m. with Staff J (Licensed Practical Nurse/Unit Manager) reviewed the above findings which revealed that the above instrument was used for multiple residents and Staff J stated she/he believed the dried brownish substance on the top of the glucometer to be blood. Staff J explained that it is the practice of staff to clean the glucometer with a bleach wipe after using it and that the meter was ready for use. Resident #3 Review on 5/10/17 of Resident #3's electronic Immunization record 5/10/17 revealed a two-step PPD (purified protein derivative - a screening skin test for [DIAGNOSES REDACTED]) was done in (MONTH) of (YEAR). The first step was placed on 3/14/16 and was read out as 0 mm (negative). The second step was placed on 3/21/16 but the electronic record is blank for how it was read out. Interview on 5/10/17 with Staff [NAME] (Registered Nurse) revealed that the result of that step two was nowhere in the record, and that Staff [NAME] put another PPD to be ordered in today.",2020-09-01
428,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2017-05-11,514,B,0,1,692111,"Based on record review and interview, it was determined that the facility failed to accurately document the resident choice of advance directive for 2 residents in a survey sample of 21 residents. (Resident identifiers are #2 and #8. ) Findings include: Resident #2 Review on 5/10/17 of Resident #2's medical record reveals a clinical note entry dated 2/3/17 which stated . residents son/DPOA (Durable Power of Attorney) signed DNR (Do Not Resuscitate) two pink sheets tonight . Review on 5/10/17 also revealed a pink Portable Do Not Attempt Resuscitation (P-DNR) Order with the box checked that says Do Not Attempt Resuscitation (DNR.) The form was signed on 2/2/17 by the Nurse Practitioner. This form was kept in a drawer at the nurses station. Review on 5/10/17 of Resident #2's current face sheet revealed that Full Code was documented in the box for Advance Directives. Review on 5/10/17 of Resident #2's (MONTH) (YEAR) Medication Report revealed that Full Code was documented in the box for Advance Directives. Interview on 5/10/17 at approximately 10:20 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Resident #8 Review on 5/11/17 of the audit dated 5/10/17 of Advanced Directives checked by the facility staff, revealed that Resident #8 had the letters FC (Full Code) documented under Resident #8's name. A notation was documented next to Resident #8's name indicating that the ribbon for Resident #8 had been corrected to DNR. Staff [NAME] confirmed that all the updates on the audit form had been done to indicate the correct Advanced Directive chosen by the resident or resident representative.",2020-09-01
429,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2019-06-28,658,D,0,1,RQG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy and procedure review it was determined that the facility failed to follow the manufacturer's specifications regarding the preparation and administration of 1 resident that was observed receiving insulin during medication pass. (Resident identifier is #73.) Findings include: Observation on 6/26/19 at approximately 7:40 a.m. during medication pass with Staff A, RN (Registered Nurse) revealed that Resident #73 had an order for [REDACTED]. Staff A was stopped prior to administering the 10 units, I never prime it before administering. I was not taught to do that. Interview on 6/26/19 at approximately 7:45 a.m. with Staff B (Unit Manager) revealed that Staff B does not turn the flex pen dose selector to 2 units prior to administering insulin, I only prime the pen if it is the first dose. Review on 6/26/19 of the manufacturer's instructions titled [MEDICATION NAME], dated 5/2015 revealed: . Instructions for Use . Giving the airshot before each injection Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. [NAME] Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear in the needle tip . Review on 6/26/19 of the facility policy and procedure titled, Medication Administration Subcutaneous Insulin, Section 7.23, dated 5/16 revealed: . Procedures . 5.Review manufacturer specific administration and storage instructions for pen devices. . 22 Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that the pen and needle work properly. removing air bubbles.",2020-09-01
430,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2019-06-28,842,B,0,1,RQG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility failed to maintain a complete medical record of medication administration and self administrations assessment for 1 of 1 resident who self-administer medications in a final sample of 27 residents (Resident identifier #104). Findings include: Observation on 6/25/19 at 10:52 a.m. of the Resident #104 in their room revealed 3 bottles of nasal spray ([MEDICATION NAME], and Afrin) on the night stand. Interview with Resident #104 during observation revealed that the resident self-administers nasal sprays each evening. Review on 6/27/19 of physician orders [REDACTED]. Instructions for orders indicate medication can be kept at bedside. Review on 6/27/19 of resident assessments revealed a Medication Self-Administration Evaluation performed on 5/2/19 that indicates the resident is fully able to administer medications but did not indicate which medications. Review on 6/27/19 of Resident 104's Medication Administration Record [REDACTED]. Further review revealed that the resident had orders for oral, suppository, intramuscular, intranasal, and topical medications. Observation on 6/27/19 at 1:05 p.m. with Staff C (Director of Nursing) revealed the above 3 nasal sprays in Resident #104's room. Interview with Resident #104 at that time revealed the resident has been using one nasal spray every night and the resident is not [MEDICATION NAME] longer. Interview on 6/27/19 at 1:35 p.m. with Staff C revealed that there was no record of Resident 104's self -administration of medications in (MONTH) or (MONTH) 2019.",2020-09-01
431,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2018-08-06,658,B,0,1,VO4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy and procedure review it was determined that the facility failed to follow professional standards of practice for expired medications in 1 out of 5 medication rooms. (Resident identifiers are #8 and #37.) Findings include: . It is important to know and stick to the expiration date on your medicine. Using expired medical products is risky and possibly harmful to your health Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength (https://www.fda.gov/Drugs/ResourcesForYou/SpecialFeatures/ucm 9.htm accessed on 8/14/18.) Observation on 8/3/18 at approximately 12:30 p.m. of the second floor medication storage room revealed the following expired medications: [REDACTED] Resident #8 Prevnar expiration date 3/18. Resident #37 [MEDICATION NAME] 20 mg (milligram) expiration date 7/31/18 Resident #37 Pioglitazone 45 mg expiration date 7/31/18 Resident #37 [MEDICATION NAME] Extended Release expiration date 6/7/18 Interview on 8/3/18 at approximately 12:30 p.m. with Staff A (UM) Unit Manager confirmed that the above medications were expired. Review on 8/7/18 of the facility's policy and procedure titled Disposal of Medications, Syringes and Needles. Disposal of Medications, dated (MONTH) 5, (YEAR) revealed: . Section 5.4 . 7. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy.",2020-09-01
432,MOUNT CARMEL REHABILITATION AND NURSING CENTER,305067,235 MYRTLE STREET,MANCHESTER,NH,3104,2018-08-06,760,D,0,1,VO4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy and procedure review it was determined that the facility failed to ensure that residents are free from significant medication errors and failed to dispose of an expired medication for 1 out of 7 medication carts. (Resident identifiers are #8 and #37.) Findings include: Observation on 8/3/18 at approximately 12:35 p.m. of the medication cart on the second floor revealed Resident #37's [MEDICATION NAME] Extended Release 75 mg had expired on 6/7/18. Interview on 8/3/18 at approximately 12:40 p.m. with Staff B Licensed Practical Nurse revealed that the expired [MEDICATION NAME] was administered on 8/3/18 to Resident #37. Interview on 8/3/18 at approximately 2:00 p.m. with Staff C (Director of Nurses) revealed that when the expired medication was brought to the facility's attention it was revealed that the expired medication had been administered to the Resident #37 by different staff members daily. Review on 8/7/18 of the facility's policy and procedure titled Disposal of Medications, Syringes and Needles. Disposal of Medications, dated (MONTH) 5, (YEAR) revealed: . Section 5.4 . 7. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy. Review on 8/7/18 of the facility's policy and procedure titled Medication Administration, General Guidelines, dated 12/12 revealed: . Medication Administration . 8. Check expiration date on package/container. No expired medications will be administered to a resident.",2020-09-01
433,THE ELMS CENTER,305068,71 ELM STREET,MILFORD,NH,3055,2018-03-16,761,D,0,1,MOQ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to ensure that medications were disposed of properly, to prevent potential unauthorized access, during observation of medication administration in a survey sample of 30 medications administered . Findings include: Observation on 3/15/18 at approximately 7:15 a.m. with Staff A, (RN) Registered Nurse revealed the following medications being disposed of in the trash receptacle on the side of the medication cart: 1. Tylenol 500 milligrams 2. Iron 325 milligrams 3. [MEDICATION NAME] 18 micrograms 4. Aspirin [MEDICATION NAME] Coated 81 milligrams Interview on 3/15/18 at approximately 7:30 a.m. with Staff A revealed that this is the everyday practice of medication disposal. Review of policy and procedure titled, 8.2 Disposal/Destruction of Refused, Discontinued, and Expired Medications. Revision date 3/1/11 revealed the following: Policy: The center adheres to all federal, state and local regulations regarding drug destruction when discarding any medication and/or medical waste. . Process: . 1.2 Immediately dispose of the dose by mixing the dose in water or alcohol to make unusable and dispose of dose in trash, sink drain, or toilet.",2020-09-01
434,THE ELMS CENTER,305068,71 ELM STREET,MILFORD,NH,3055,2019-03-22,550,B,0,1,X5O011,"Based on the resident council interview and staff interview, it was determined that the facility had failed to ensure that residents who wanted to vote were able to exercise that right during the (MONTH) (YEAR) midterm election. Findings include: Interview on 3/20/19 at 1:30 p.m. with twelve members of the Resident Council revealed that the resident council members present during this meeting had not been able to vote in the (MONTH) (YEAR) midterm election. The resident council residents stated that had the facility asked them, they would have participated by voting in this election. Interview on 3/21/19 following the resident council meeting with Staff D (Administrator) confirmed that the facility had failed to ensure that any of its residents were able to exercise their right to vote during the (MONTH) (YEAR) midterm election.",2020-09-01
435,THE ELMS CENTER,305068,71 ELM STREET,MILFORD,NH,3055,2019-03-22,761,B,0,1,X5O011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, it was determined that the facility failed to ensure proper storage and labeling of medications for 2 out of 2 medication carts observed. (Resident identifiers are #5, #7, #29, and #34.) Findings include: Review on 3/21/19 of facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revision date of 10/31/16, revealed that .facility should ensure that medications, and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier .Once any medications or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration date for open medications. Facility staff should record the date opened on the medications container when the medication has a shortened expiration date once opened . Observation on 3/21/19 at 9:20 a.m. with Staff C (Licensed Practical Nurse) of the east medication cart revealed Resident #34's 200 units spray medication container was labeled good for 35 days and no open date was labeled on the medication container or the Calcitonin-Salmon 200 units spray bottle. Observation also revealed Resident #7's [MEDICATION NAME] 10% (percent) medication manufacturer's guidelines on the bottle was labeled discard opened vial after 96 hours and the [MEDICATION NAME] 10% medication container was labeled with an open date of 3/13/19. Resident #7's [MEDICATION NAME] 10% medication revealed a loose top cap. Observation further revealed that Resident #29's C-ketocanozole cream/zinc oxide 1:1 cream with an expiration date of 2/23/19. The Calcitonin-Salmon 200 units spray, [MEDICATION NAME] 10 % bottle, and C-ketocanozole cream/zinc oxide 1:1 cream were stored with the unexpired medication in the east medication cart. Interview on 3/21/19 at 9:30 a.m. with Staff C confirmed the above observations. Staff C revealed that the bottle of Calcitonin-Salmon 200 unit spray should have been labeled and Staff C was unable to provide any explanation when the medication was opened. Staff C also revealed that they did not use the [MEDICATION NAME] 10 % bottle that was in the medication cart. Staff C stated that they opened a new bottle of [MEDICATION NAME] 10% on 3/21/19 that morning from the medication room refrigerator and had discarded the new bottle of [MEDICATION NAME] 10% after one use. Staff C further revealed the C-ketocanozole cream/zinc oxide 1:1 cream was an as needed medication and has not been used for Resident #29. Staff C stated that the Calcitonin-Salmon 200 units spray bottle should have been labeled with an open date on the medication bottle or container. Staff C also revealed that the above observations should have been removed from the medication cart. Observation on 3/21/19 at 9:35 a.m. with Staff B (Licensed Practical Nurse) of the west medication cart revealed an opened OTC (Over The Counter) Aspirin 325 mg (milligram) with an expired date of 1/19 which was stored with the unexpired OTC medications. The OTC Aspirin 325 mg had an open date labeled 2/19 on the bottle. Further observation revealed that Resident #5's [MEDICATION NAME] ER (extended release) 500 mg medication card had 4 tablets and was labeled with an expired date of 2/2019 which was stored with the unexpired medications. Interview on 3/21/19 at 9:45 a.m. with Staff B confirmed the above observations of the west medication cart. Staff B was unable to provide explanation if they had used the OTC Aspirin 325 mg from (MONTH) 2019 to (MONTH) 2019. Staff B also revealed that Resident #5's [MEDICATION NAME] ER 500 mg tablets was changed to a liquid source on (MONTH) 31, (YEAR) to make it easier to swallow for Resident #5. Staff B states that Resident #5's [MEDICATION NAME] ER 500 mg medication card should have been removed from the medication cart. Interview on 3/21/19 at 9:55 a.m. with Staff A (Chief Nurse Executive) confirmed the above observations of the east and west medication carts. Staff C revealed that expired and discontinued medications should have been removed from the medication cart and stored in the medication room to be destroyed or returned to the pharmacy.",2020-09-01
436,THE ELMS CENTER,305068,71 ELM STREET,MILFORD,NH,3055,2016-12-30,514,B,0,1,N4FL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow the professional standard of practice to show that the medical record for 1 resident in a standard survey sample of 12 residents was complete and accurate. (Resident identifier is #8.) Findings include: Record review on 12/30/16 for Resident #8 revealed the following diagnosis; End Stage [MEDICAL CONDITION] Chronic, Dependent on [MEDICAL TREATMENT] M (Monday)-W (Wednesday)-F (Friday), Essential Hypertension, Dementia with behavioral disturbance, Obesity, [MEDICAL CONDITIONS], Muscle Weakness, Alzheimers, Sleep Apnea and s/p (status [REDACTED]. Record review of the Medication Administration Record [REDACTED].Give 2 capsule by mouth with meals related to [MEDICAL CONDITION] STAGE IV .dated 7/5/16. Review of Resident #8's (YEAR) MAR's for October, November, and (MONTH) revealed that this medication is scheduled to be given at 7:30 a.m., 11:30 a.m. and 16:30 p.m. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. It should be noted that Resident #8 goes out to [MEDICAL TREATMENT] three days a week and is transported to the [MEDICAL TREATMENT] facility between 10:30 a.m. and 11:00 a.m. Review of Resident #8's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #8's (MONTH) (YEAR) MAR indicated [REDACTED]. Interview and review of the MARs, medication flow sheets and the nursing progress notes on 12/30/16 with Staff A (Registered Nurse) at approximately 1:40 p.m. revealed that the facility failed to document the reason why the medication Phoslo was encircled indicating that it was not administered and that no documentation was found to show that the physician was notified why this medication was not consistently administered on M-W-F for a total of 12 doses at 11:30 in (MONTH) and for 4 doses scheduled at 16:30 as listed above, for 13 doses at 11:30 in (MONTH) and 1 dose scheduled at 16:30,12 doses schedule at 11:30 in (MONTH) and 3 doses scheduled at 16:30 as listed above for Resident #8. The lack of documentation during the time periods listed above and no documentation to show that the physician was notified of this medication not being administered for these 3 months was verbally confirmed by Staff A during this review and interview.",2020-09-01
437,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2017-02-08,279,D,0,1,C0SJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to develop a comprehensive care plan which includes services to be furnished to achieve the highest level of well being for 2 residents in a standard survey sample of 10 residents. (Resident identifiers are #2 and # 7.) Findings include: Resident #2: Review of Resident #2's Bowel and Bladder assessment dated [DATE], revealed that the conclusion of the bladder assessment and actions needed was for the resident to have a scheduled toileting plan/habit training program. Review of the CHAT Biography (Plan of Care) revealed there was no toileting plan. The Resident Summary (Licensed Nursing Assistant (LNA) instruction sheet) stated the Resident's toileting program is to assist to toilet using walker and gait belt, toilet every 2 hours with assist. Interview with Staff A (Director of Nursing) on 2/8/17 at approximatley 4:20 p.m. confirmed the above findings. Resident #7: Review of Resident #7's Bowel and Bladder assessment dated [DATE] indicated total incontinence. Review of the Resident Summary (LNA instruction sheet) for Resident #7 revealed that Resident #7 was incontinent of urine, incontinent of bowel. Interview on 2/8/17 at 4:30 p.m. with Staff [NAME] (LNA) confirmed that there is no documented frequency, on this summary, for toileting or checking this Resident for incontinence. Review of the CHAT Biography (Plan of Care) for Resident #7, stated to monitor for toileting needs and keep clean and dry. There was no frequency specified. Review of Resident #7's Physician orders [REDACTED]. Review of Resident #7's CHAT Biography (Plan of Care) under Quality of Life Emotional Well Being on 2/8/17 revealed that there were no interventions for the use of the Antipsychotic medication, [MEDICATION NAME].",2020-09-01
438,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2018-04-06,658,D,0,1,TUZQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to administer pain medication to a resident in a timely manner for 1 resident in a standard survey sample of 14 residents. (Resident identifier is #243.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 1075 .Administer [MEDICATION NAME] as soon as pain occurs and before it increases in severity . Observation on 4/5/18 at approximately 8:00 a.m. revealed that Resident #243 was grimacing in pain and saying Ouch, Ouch, Ouch when Staff C RN (Registered Nurse) raised the head of Resident #243's bed in order to administer scheduled medications. Observation on 4/5/18 at approximately 8:00 a.m. revealed that Resident #243 told Staff C (Registered Nurse) that they had a pain level of 8 out of 10. When Staff C said that Staff C would give Resident #243 pain medication, Resident #243 said I will take it. Observation on 4/5/18 at approximately 8:05 a.m. revealed that after giving the scheduled medications to Resident #243, Staff C did not get the pain medication for Resident #243, but instead started to hand out breakfast trays to other residents and then stood at the medication cart to monitor three residents who were sitting in the common area, eating breakfast. Interview on 4/5/18 at approximately 8:05 a.m. with Staff C confirmed that Staff C stops the medication pass when trays come out in order to assist with passing out trays and monitoring residents while they are eating. Staff C stated that only in an emergency would Staff C administer medications to residents during this time. Observation on 4/5/18 at approximately 8:29 a.m. revealed Staff C administering pain medication to Resident #243. Review on 4/5/18 of Resident #243's (MONTH) (YEAR) Medications record revealed that Staff C documented administering [MEDICATION NAME] at 8:29 a.m. to Resident #243 for a documented pain level of 9. Interview on 4/5/18 at approximately 8:31 a.m. with Staff C confirmed that approximately 1/2 hour had passed from the time Resident #243 stated they were in pain and would take medication, to when the medication was administered. Interview on 4/5/18 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that Resident #243 should not have had to wait 1/2 hour for pain medication to be administered in order for trays to be passed and monitoring of residents eating to occur.",2020-09-01
439,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2018-04-06,880,D,0,1,TUZQ11,"Based on observation and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during 1 of 2 medication pass observations. Findings include: Observation on 4/5/18 at approximately 8:30 a.m. revealed that during the medication pass, Staff C (Registered Nurse) reached into the pocket in the front of their shirt and removed a tissue. Staff C then wiped their nose with the tissue and then put the tissue back in their shirt pocket. Staff C then went on to pour the next medication and did not wash their hands or use hand sanitizer before continuing with the medication pass. Interview on 4/5/18 at approximately 8:35 a.m. with Staff C confirmed that Staff C did not clean their hands after wiping their nose and that Staff C should have cleaned their hands before pouring the next medication.",2020-09-01
440,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2019-06-19,658,D,1,0,QBIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, it was determined that the facility failed to follow physician's orders for laboratory testing and professional standards for documenting medication administration for 1 of 3 residents reviewed on anticoagulation therapy. (Resident identifier is #1.) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 709: After administering the medication, indicate which medications were given on the client's MAR per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client Review on 6/19/19 of Resident #1's physician orders revealed the following orders: [MEDICATION NAME] 3 mg (milligram) tablet oral, One time daily for six days starting 4/27/19 (dated 4/26/19) and PT/INR ([MEDICATION NAME]/International Normalized Ratio) on 5/3/19. There was no order for [MEDICATION NAME] after 5/2/19. Review on 6/19/19 of Resident #1's laboratory reports revealed no PT/INR testing reports dated 5/3/19. Review on 6/19/19 of Resident #1's Medication Administration Record (MAR) revealed Resident #1 received [MEDICATION NAME] as ordered on between 4/27/19 to 5/2/19. Resident #1 did not receive [MEDICATION NAME] after 5/2/19. Review on 6/19/19 of Resident #1's clinical notes dated 5/8/19 at 11:27 a.m. revealed the resident had been discharged to the hospital. Review also revealed a late clinical note dated 5/8/19 at 7:23 p.m. that the resident received [MEDICATION NAME] 3 mg on 5/7/19 at 7:20 p.m. after a new order was received. Interview on 6/19/19 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview with Staff A further revealed that when the facility receives PT/INR results, they are called in to the physician and new [MEDICATION NAME] orders are obtained. Staff A also revealed that Resident #1's PT/INR specimen was not collected. Staff A confirmed that there no documentation of the medication administration of [MEDICATION NAME] on 5/7/19 on the MAR and that Resident #1 did not receive [MEDICATION NAME] between 5/3/19 and 5/7/19.",2020-09-01
441,SAINT FRANCIS REHABILITATION AND NURSING CENTER,305070,406 COURT STREET,LACONIA,NH,3246,2019-02-15,658,B,0,1,GKXN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, it was determined that the facility failed to clarify physician orders [REDACTED]. (Resident identifiers are #14 and #44.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the client suffers Resident #14 Observation during tour of the Birch Lane unit on 2/14/19 at about 10:56 a.m. revealed no oxygen sign on doorway to Resident #14's room, and there is an oxygen concentrator located in Resident #14's portion of the room. Interview on 2/14/19 at about 10:56 a.m. with Resident #14 revealed the Resident #14 uses an oxygen concentrator sometimes when they wash him/her up at night, not every night. Observation on 2/15/19 at about 9:05 a.m. revealed there is now an oxygen in use sign on the doorway to Resident #14's room. Review on 2/15/19 at approximately 9:44 a.m. of the physician orders [REDACTED].#14 has two active orders for oxygen, one for oxygen at 1 L/min (one liter per minute) per nc (nasal cannula), and another for same flow rate except as PRN (as needed) 3x/wk (three times per week), both orders are dated 9/23/18. Interview on 2/15/19 at about 11:50 a.m. with Staff C (Registered Nurse) confirmed that Resident #14 has 2 orders for oxygen; upon her record review, and Staff C related she put both orders in and she could discontinue the continuous oxygen order as Resident #14 uses it only prn and not every day, maybe a couple times a week. Resident #44 Observation on 2/14/19 at about 10:00 a.m. during tour of the Birch Lane unit revealed that there was an oxygen concentrator in Resident #44's room. There was no roommate residing in this room. The oxygen tubing on the concentrator was dated 2/8/19 (indicating a recent tubing change), and there was no oxygen in use signage on the doorway to the room. Interview on 2/14/19 at about 10:18 a.m. with Staff A (Licensed Medication Nursing Assistant) revealed that Resident #44 uses the oxygen (O2) concentrator sometimes, and he should probably have an oxygen sign on the door. Review on 2/14/19 of Resident 44's current CHAT Biography care plan reveals it relates . provide supplemental O2 if .(Resident #44's) O2 sat (saturation) is critically low with symptoms, . Observation on 2/15/19 at about 9:05 am. of Resident #44's room revealed there was now an oxygen in use sign on the doorway to the room. Interview on 2/15/19 at about 11:46 a.m. with Staff B (Licensed Nursing Assistant) revealed the resident has been using prn O2 for a couple months. Review on 2/15/19 of Resident #44's physician orders [REDACTED]. Interview on 2/15/19 at about 12:04 p.m. with Staff D (Licensed Nursing Assistant) revealed Resident #44 used oxygen after he came back from the hospital but he was not now using oxygen on days. Interview with Staff C revealed Resident #44 was in the hospital 1/10-1/14/19 [MEDICAL CONDITION] and URI (upper respiratory infection), and his O2 sats on room air have been good since return from hospital; Staff C related Resident #44 had a discharge order for oxygen from the hospital but Staff C does not see in nurses notes that Resident #44 has used oxygen since returning to the facility on on 1/14/19, and Staff C related she can't find an order in this facility's records for oxygen use in facility after return from hospital. Further interview on 2/15/19 at about 2 p.m. with Staff C revealed Staff C checked (e.g., with Staff B) if Resident #44 used any O2 since return from the hospital and he/she did not, so Staff C related the O2 concentrator and O2 sign were removed from room.",2020-09-01
442,SAINT FRANCIS REHABILITATION AND NURSING CENTER,305070,406 COURT STREET,LACONIA,NH,3246,2019-07-03,867,D,1,0,T91S11,"> Based on record review and interview, it was determined that the facility failed to implement an appropriate plan of action, education, for an error that occurred with accuracy of and confidentiality of resident medical information for 2 residents in a final survey sample of 11 residents. (Resident identifiers are #1 and #2.) Findings include: Review on 7/3/19 of the facility report, titled .Final Report Wrong Paperwork . dated 5/21/19 revealed that on 5/17/19, Resident #1, .who is a full code, was sent to the emergency room for evaluation. The Advance Directive paperwork sent with (Resident #1) was the DNR (Do Not Resuscitate) form of . roommate (Resident #2) . Review on 7/3/19 of the facility report, titled .Final Report Wrong Paperwork . dated 5/21/19 revealed that the plan was .There will be education for all nurses to remind them to always take the time to check if the paperwork they gather is for the correct resident . Review on 7/3/19 of the packet of information that the facility sent to Resident #1's daughter, on 6/20/19, regarding the error also included the statement that .There will be education for all nurses to remind them to always take the time to check if the paperwork they gather is for the correct resident . Review on 7/3/19 of the copies of the letters written by the facility administrator, dated 7/3/19, to Resident #2 and their DPOA (Durable Power of Attorney) revealed that .In response to the incident, we reviewed our process for protecting your personal information and will provide mandatory education to our staff to prevent this from happening again . Review on 7/3/19 of the facility list of licensed nurse who currently work at the facility revealed that there were 13 nurses. Review on 7/3/19 of the Inservice Sign In Sheet, with the topic of Transfer/D/C (discharge) sheets, double check that legal forms are accurate/correct . dated 5/20/19, revealed that of the 13 nurses listed, only 4 of them had signed the attendance sheet. Interview on 7/3/19 at approximately 1:00 p.m. with Staff A (Administrator) confirmed that only 4 of the 13 nurses had received education after the incident with Resident #1 and Resident #2. Staff A also confirmed that they had planned to send the letters that they had written to Resident #2 and their DPOA out on 7/3/19.",2020-09-01
443,SAINT FRANCIS REHABILITATION AND NURSING CENTER,305070,406 COURT STREET,LACONIA,NH,3246,2017-12-06,641,B,0,1,6DM211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the MDS (Minimum Data Set) Assessment was accurate for 2 residents in a sample survey of 14 residents. (Resident identifiers are #18 and #25.) Findings include: Resident #25 Review on 12/6/17 of Resident #25's Annual MDS Assessment with ARD (Assessment Reference Date) of 10/19/17, revealed that under Section O0400. (Therapies) that Resident #25 had received 50 minutes of group therapies, as stated in #3 (Group minutes), in the last 7 days; but under O0420 (Distinct Calendar Days of Therapy), the number 0 was listed correctly for the last 7 days (need at least 15 minutes to code as a day). Review on 12/6/17 of Resident #25's Quarterly MDS Assessment with ARD of 5/2/17, revealed that under Section O0400. (Therapies) that Resident #25 had received 50 minutes of group therapies, as stated in #3 (Group minutes), in the last 7 days; but under O0420 (Distinct Calendar Days of Therapy), the number 0 was listed correctly for the last 7 days. Interview on 12/6/17 at 10:16 a.m. with Staff A (MDS Coordinator) confirmed that the information in Section O0400 was incorrect on both the annual and quarterly MDS's and that the information Section O0400 was pulled forward from the previous MDS and Resident #25 did not have any group therapy during these two time periods. Interview on 12/6/17 at 10:16 a.m. with Staff B (Director of Therapy) also confirmed that Resident #25 was not in group therapy during these two time frames. Resident #18 Interview on 12/04/17 at 10:41 a.m. with Resident #18 revealed the following statement: . my teeth are falling out of my head and some of them are broken .sometimes staff help me brush them, but rarely . the dentist comes around about every 6 months to check teeth. A strong pungent odor was perceived on Resident #18's breath at the time of the interview. Review on 12/6/17 at approximately 10:00 a.m., of all available dental notes which ranged from 8/10/15 to 7/18/16, stated that the resident has had some broken teeth. Review of section L Oral/Dental Status on MDS (Minimum Data Set) assessment dated [DATE] has section Z: None of the above were present selected, where section D: Obvious or likely cavity or broken natural teeth should have been selected during the assessment to reflect the correct status of the Resident #18's teeth. Interview on 12/6/17 with Staff A (MDS Coordinator) revealed that item D was the proper assessment status for Resident #18.",2020-09-01
444,SAINT FRANCIS REHABILITATION AND NURSING CENTER,305070,406 COURT STREET,LACONIA,NH,3246,2016-12-20,371,D,0,1,R65I11,"Based on observation and interview, it was determined that the facility failed to prepare food under sanitary conditions. Findings include: Observation during the initial tour of the kitchen on 12/19/16 at approximately 9:00 a.m. with Staff A (Director of Food Services) and Staff B (Dietary Aid/Prep Cook) revealed that the food preparation area staff were not wearing either a hair net or other acceptable type of hair covering to prevent the hair from contacting exposed food. Interview at time of observation with Staff A (Food Service Director) confirmed the above finding.",2020-09-01
445,SAINT TERESA REHABILITATION & NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2019-02-22,584,C,1,0,XTJZ11,"> Based on interview and payroll record review, it was determined that the facility failed to ensure that there was nursing coverage available for a full 24 hours on the night of 2/15/19. Findings include: Interview on 2/22/19 at approximately 3:30 p.m. with Staff A (Administrator) and Staff B (Director of nursing) reviewed the original complaint being investigated. During this review, Staff A and Staff B revealed with full transparency about another unrelated issue that had occurred on the same night as the original complaint. Staff A and Staff B related the following: on the night of 2/15/19 during the 11-7 shift, there was one nurse on the schedule. This nurse, Staff C (Licensed Practical Nurse) told the LNAs (Licensed Nursing Assistants) that he/she had a sick animal at home and during his/her meal break he/she was going to go and check on it. Staff C's home was in view of the facility and he/she gave his/her cell number so he/she could be reached if needed. Staff C left the building at 3 a.m. and was was noted by one of the LNAs to be back at the facility at 3:25 a.m. having been out of the building from 5-25 minutes. The LNAs reported to Staff B not having any issues during this time requiring the nurse. Staff B and Staff C confirmed that the Board of Nursing had been notified regarding Staff C and that Staff C's employment has been terminated with the facility. Review on 2/22/19 of Staff C's payroll documentation confirmed the above findings.",2020-09-01
446,SAINT TERESA REHABILITATION & NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2019-06-06,880,D,0,1,FPB011,"Based on observation, interview, and policy and procedure review, it was determined that the facility failed to maintain infection control practices in regards to the use of Personal Protective Equipment (PPE) for one resident and handwashing between donning and doffing medical gloves during a dressing change for a wound for another resident, in a survey sample size of 13 residents. (Resident identifiers are: #19 and #25.) Findings include: Review on 6/6/19 of the facility's undated policy and procedure titled, NON-STERILE DRESSING PR[NAME]EDURE - CLEAN TECHNIQUE, revealed that .The responsibility of the nurse is to not add any more microbes to the wound than are already there. The following infection control measures should be taken to prevent cross-contamination .PR[NAME]EDURE .4.) Place trash bag at end of bed or within easy reach of working area. 5.) Wash hands and apply gloves .9.) Removed the soiled dressing and place it in the trash bag .10.) Remove gloves, wash hands and apply new gloves .12.) Clean the wound with normal saline or prescribed cleanser. 13.) Pat the tissue surrounding the wound dry with a 4 x 4. 14.) Remove gloves, wash hands and apply new gloves .19.) Apply wound dressing .22.) Discard gloves and all used supplies in trash bag. Remove equipment. 23.) Wash hands .25.) If there are multiple wounds, repeat this procedure for each wound. Review on 6/6/19 of the facility's policy and procedure on hand washing, dated 2012, titled HAND HYGIENE revealed that II. WHEN TO WASH HANDS (at a minimum) .Before and after each resident contact, After touching a resident or handling his or her belongings, Whenever hands are obviously soiled, After contact with any body fluids, After handling any contaminated items (linens, soiled diapers, garbage, etc.). Resident #25 Observation on 6/6/19 at approximately 1 p.m. of a dressing change to bilateral nephrostomy tubes that was performed by Staff C (Licensed Practical Nurse) for Resident #25 revealed, Staff C took 2 medical gloves from the right pocket of (pronoun omitted) scrub top and put one on each hand without performing hand hygiene. Staff C removed the old dressing from the residents left nephrostomy tube, opened the package of a new dressing and then applied the clean dressing to Resident #25's left neprostromy tube. Staff C then removed (pronoun omitted) gloves from both hands, picked up the removed dressing from the left nephrostomy tube and put the used gloves and removed dressing in the trash can at the left side of the residents bed. Staff C then took a second pair of gloves out of their right pocket of (pronoun omitted) scrub top and put one on each hand, again without performing hand hygiene. Again Staff C performed the same pratice on the right nephrosomy tube as they did on the left failing to change gloves between dirty and clean. Interview on 6/6/19 at approximately 1:20 p.m. with Staff C revealed (pronoun omitted) did not know what the facility's policy is regarding hand washing when changing a dressing. Interview on 6/6/19 at approximately 2:15 p.m. with Staff D (Director Of Nursing) revealed, based on description of above noted event, Staff C did not follow infection control guidelines specific to changing a non-sterile dressing with a clean technique. Staff D provided the above referenced policies and procedures for hand hygiene and non-sterile dressing procedure - clean technique to the survey team. Interview on 6/6/19 at approximately 2:16 p.m. with Staff [NAME] (Nurse Practice Education) revealed, based on description of above noted event, Staff C did not follow infection control guidelines specific to changing a non-sterile dressing with a clean technique or correct hand hygiene techniques. Resident #19 Observation on 6/4/19 at 9:30 a.m. while touring the unit revealed that Resident #19 had a sign outside there door stating See nurse before entering due to Resident #19 being on contact precautions. Observed during this time was Staff B (Laundry) standing on a ladder holding Resident #19's privacy curtain against their body failing to wear PPE (Personal Protective Equipment) while unclipping the privacy curtain from its track to be taken down to wash. At this time Staff A (Clinical Nurse Manager) was taken to Resident #19's room and was asked if Staff B should be wearing PPE and Staff A stated they should be. Staff A called Staff B to the door educated them on wearing proper PPE when in a room that is on precautions, and had them apply the appropriate PPE.",2020-09-01
447,SAINT TERESA REHABILITATION & NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2018-07-18,761,D,0,1,BFSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to date an Insulin pen which was found on 1 of 2 medication carts and failed to remove an expired [MEDICATION NAME] vial from 1 of 2 refrigerators in the 1 facility medication room. (Resident identifier is #39.) Findings include: Observation on [DATE] at approximately 8:42 a.m. of the Trinity Wing medication cart revealed a [MEDICATION NAME] pen for Resident #39 with no open date written on it. Observation revealed that the Insulin pen had already been used. Interview on [DATE] at approximately 8:42 a.m. with Staff [NAME] (Registered Nurse) confirmed that there was no date on the Insulin pen and that it was already in use. Staff [NAME] also confirmed that the date should have been written on the Insulin pen when its use began. Review on [DATE] of the Facility Policy titled Medications With Special Expiration Date Requirements dated ,[DATE], revealed that .After Opening and Dating both Package and Unit .[MEDICATION NAME] - 28 days (vial & pen) . Observation on [DATE] at approximately 9:22 a.m. of one of the two refrigerators in the medication room revealed a vial of [MEDICATION NAME] 5 units/ 0.1 ml vial. It was located in its box. There was no date written on the vial and the date hand written on the box was [DATE]. Interview on [DATE] at approximately 9:22 a.m. with Staff F (Unit Manager) confirmed that the only date written on the box was [DATE] and that the medication was beyond its expiration date. Review on [DATE] of the Facility Policy titled Medications With Special Expiration Date Requirements dated ,[DATE], revealed that .After Opening and Dating both Package and Unit .[MEDICATION NAME]/[MEDICATION NAME] .30 days .",2020-09-01
448,SAINT TERESA REHABILITATION & NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2018-07-18,880,D,0,1,BFSR11,"Based on observation, interview and facility policy review, it was determined that the facility failed to ensure the implementation of a program to help prevent the transmission of infection for 2 residents in a standard survey sample of 13 residents. (Resident identifiers are #197 and #198.) Findings include: Resident #198 Observation on 7/16/18 at approximately 10:05 a.m. of Resident #198 revealed that Resident #198 was on contact precautions. This was identified by a cart which was located right outside of the room that was used for holding personal protective equipment. Observation also revealed that Staff B (Certified Occupational Therapy Assistant) was in Resident #198's room conversing with them. Staff B, who was leaning against the footboard of the bed, was wearing gloves, but had no gown on. Interview on 7/16/18 at approximately 10:05 a.m. with Staff B revealed that Staff B stated that they only needed to wear a gown when providing care to Resident #198. When it was pointed out that Staff B was leaning against the footboard of the bed, Staff B confirmed that they should have had a gown on. Observation on 7/16/18 at approximately 10:10 a.m. of Resident #198 revealed that Staff B had returned to Resident #198's room with a cup of juice for Resident #198. Staff B was wearing gloves, but no gown. Staff B initially placed the cup on the windowsill, next to Resident #198, but then offered to move the overbed table closer to Resident #198 to make it easier to be able to reach the cup. Staff B leaned forward to move the table and as they were moving the table, it came so close to Staff B's shirt that it may have touched the front of their shirt. Review on 7/16/18 at approximately 10:45 a.m. of a piece of paper, titled Contact Precaution Guidelines located in the precaution unit outside of Resident #198's room revealed that Gloves are to be worn: -If your hands may possibly touch a surface - You are providing personal care to the resident .Gowns are to be worn: -If your clothing may come into contact with a surface - You are providing personal care to the resident. Observation on 7/16/18 at approximately 12:00 p.m. of Resident #198's room revealed that Resident #198 had 2 family members visiting. Neither of the family members were wearing gloves or gowns. The visitors both handled Resident #198's television remote as they tried to get a television station for Resident #198. One of the visitors was adjusting the footrest on Resident #198's wheelchair. The other visitor was sitting in a chair in Resident #198's room. Interview on 7/16/18 at approximately 12:05 p.m. with Resident #198's family members revealed, when asked, that they were not aware that they needed to wear anything over their street clothes when in Resident #198's room. They both said that nobody in the facility had discussed what, if anything, should should be worn. Observation on 7/16/18 at approximately 12:03 p.m. of Resident #198's room revealed that Staff C (Licensed Nursing Assistant) was in the room caring for Resident #198's roommate. Staff C, who was wearing a gown and gloves, was in the room at the same time that Resident #198's visitors were in the room. Interview on 7/16/18 at approximately 12:08 p.m. with Staff C revealed that when asked, Staff C stated that they did not say anything to Resident #198's visitors about wearing gowns and gloves. Staff C stated that they were only visiting and that people only need to wear gowns and gloves when providing care. Observation on 7/16/18 at approximately 12:45 p.m. of Resident #198 revealed that Staff D (Speech Therapist) entered Resident #198's room, wearing a gown and gloves. Staff D went over to the bed, as Resident #198 was laying in bed. Staff D got very close to the bed and leaned forward and asked Resident #198 what they wanted for lunch. Staff D then went to the doorway of the room and took off their gown and their gloves, but never entered the bathroom to wash their hands. Staff D then walked over to the food tray preparation area, which was located next to the restorative dining room, but never washed their hands. Interview on 7/16/18 at approximately 1:00 p.m. with Staff D confirmed that they did not wash their hands after removing their gown and gloves, and that they should have washed their hands. Resident #197 Observation on 7/16/18 at approximately 11:55 a.m. of Resident #197, who was Resident #198's roommate, revealed that Resident #197 was also on contact precautions. Review on 7/16/18 at approximately 10:45 a.m. of a piece of paper, titled Contact Precaution Guidelines located in the precaution unit outside of Resident #197's room revealed that Gloves are to be worn: -If your hands may possibly touch a surface - You are providing personal care to the resident .Gowns are to be worn: -If your clothing may come into contact with a surface - You are providing personal care to the resident. Interview on 7/16/18 at approximately 1:55 p.m. with Resident #197's family member, as they were sitting in the restorative dining room visiting Resident #197, revealed that, when asked, they stated that they were not aware that they needed to wear any personal protective equipment over their street clothes when in Resident #197's room. They said that nobody in the facility had discussed what, if anything, should should be worn. Review on 7/18/18 of the facility policy, titled .Contact Precautions dated 2012 revealed that .Gloves should be worn when entering the room and while providing care for the resident .Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately .After glove removal and hand hygiene, hands should not touch potentially contaminated environmental services or items .A gown should be donned prior to entering the room or resident's cubicle .The gown should be removed before leaving the resident's room .After removal of the gown, clothing should not contact potentially contaminated environmental surfaces . Observations on 7/16/18 at approximately 10:15 a.m., on 7/16/18 at approximately 11:55 a.m. and again on 7/17/18 at approximately 7:15 a.m. revealed that the bathroom shared by Resident #198 and Resident #197 had a sink for washing hands. On the wall to the left of the sink was a paper towel dispenser, which was empty. There was a shelf above the sink and on the shelf was a large roll of paper towels. The only way to remove a piece of the paper towel was to hold the whole roll and rip off a piece of paper towel. Interview on 7/17/18 at approximately 8:20 a.m. with Staff G (Director of Nursing) confirmed that the paper towel roll should not be left on the counter for people to rip off a piece, but should be in the dispenser. Interview on 7/18/18 at approximately 10:00 a.m. with Staff A (Assistant Director of Nursing, Infection Control Practitioner) confirmed that gowns and gloves should be worn when in the room of a resident on contact precautions, that staff should wash their hands after removing gowns and gloves, that visitors should be informed of what is recommended for contact precautions and that paper towels should be in paper towel dispensers.",2020-09-01
449,JAFFREY REHABILITATION AND NURSING CENTER,305072,20 PLANTATION DRIVE,JAFFREY,NH,3452,2017-08-24,279,D,0,1,WJET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan that meets a resident's identified medical needs for 1 resident in a standard sample size of 12 residents. (Resident identifier #3) Findings include: Review on 8/22/17 of Resident #3's list of [DIAGNOSES REDACTED].#3 had a [DIAGNOSES REDACTED]. Review on 8/22/17 of the current comprehensive care plan dated 8/16/17 for Resident #3 revealed that there was no plan for a cardiac pacemaker. Interview on 8/23/17 at 1:15 p.m. with Resident #3 confirmed that Resident #3 had a cardiac pacemaker. Interview on 8/23/17 at 1:40 p.m. with Staff B (Unit Manager) confirmed that Resident #3 had a cardiac pacemaker and that cardiac pacemaker was not mentioned in Resident #3's current comprehensive care plan.",2020-09-01
450,JAFFREY REHABILITATION AND NURSING CENTER,305072,20 PLANTATION DRIVE,JAFFREY,NH,3452,2017-08-24,425,E,1,1,WJET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that medications are provided to residents in a timely manner and administered according to physician order [REDACTED].#1, #2, #3, #4, #5, #9, and #10) Findings include: Resident #2 Review on 8/23/17 of Resident #2's (MONTH) (YEAR) MAR (Medication Administration Record) revealed that Resident #2 had an order for [REDACTED]. On 8/4/17 at 6:00 a.m. there was a note Resident's AP (Apical Pulse) 51 medication held .Not administered. On 8/5/17 at 6:00 a.m. there was a note AP 50-56 medication HELD. Not administered . There was no documented evidence that Resident #2's physician was notified of the medications being held. Interview on 8/24/17 at 9:15 a.m. with Staff B (Unit Manager) confirmed the above information and confirmed that Resident #2's physician should have been notified that the medication was held. Resident #4 Review on 8/23/17 of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED].ACUTE EMBOLISM .for 3 months. It was ordered to be given at Morning Medication Pass and Evening Medication Pass. On 8/16/17 there was a note awaiting arrival from pharmacy. Not administered . Review on 8/23/17 of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED].Dysphagia. On 8/9/17 at 4:30 p.m. and on 8/10/17 at 7:30 a.m. there were notes indicating that the medication was Not available from pharmacy at this time. Not administered . Interview on 8/23/17 at approximately 2:00 p.m. with Staff [NAME] (Registered Nurse) revealed that there has been an issue with receiving medications from the pharmacy. Staff [NAME] stated that the process for ordering medications had changed a few months ago and since the change they have not been receiving all of the resident medications in a timely manner. Review of Resident #5 Medical Administration Record (MAR) revealed a physician's orders [REDACTED]. The MAR indicated [REDACTED]. On 8/6/17 Resident #5's Medical Administration Record documented that Resident #5 did not receive Aricept, because the medication remained unavailable. Interview on 8/23/17 with Staff A (Administrator), Staff A confirmed that Resident #5's Aricept was unavailable on 8/3/17 and again on 8/6/17. Resident #3 Review on 8/23/17 of Resident #3's Medication Administration Record [REDACTED] Amiodarone 100 mg tablet (1) Tablet oral, order date 8/15/16 (morning medication pass) 8/16/17 awaiting pharm delivery. Iron ER 159 mg (45 mg iron) tablet, extended release (1) tablet, two times daily (order date 8/15/17) 8/16/17 awaiting pharm delivery (morning medication pass) 8/16/17 awaiting delivery (evening medication pass) 8/17/17 awaiting pharm delivery (morning medication pass) There was no indication if the medication was given during the evening medication pass on 8/15/17 Ranitidine 150 mg tablet (1) tablet oral, one time daily, order date 8/18/17 (morning medication pass) 8/19/17 no stock 8/20/17 no stock Interview on 8/23/17 at 1:45 p.m. with Staff B (Unit Manager), Staff B confirmed the above finding and revealed that the facility was having issues with getting medication timely from the pharmacy and the above medication were not given on the above days. Resident #10 Review on 8/24/17 of Resident #10's MAR indicated [REDACTED] Amindarone 200 mg tablet (1) tablet oral, two times daily starting 8/2/17 8/2/17 med not given, waiting for pharmacy delivery Calcium lactate 650 mg tablet (1) tablet oral, one time daily starting 8/3/17 8/3/17 Not given due to unavailable 8/4/17 Ordered 8/5/17 None available. Ordered. 8/6/17 None available. Ordered. 8/7/17 not given due to unavailable 8/8/17 None available 8/9/17 None available. 8/10/17 None available. 8/11/17 None available. Ordered. 8/12/17 None available. Ordered. 8/13/17 Not given due to unavailable 8/14/17 Not administered 8/15/17 None available. 8/16/17 None available. 8/17/17 None available. 8/18/17 None available. 8/19/17 None administered. 8/21/17 Medication on administered. Not available. 8/22/17 Not given due to unavailable Review of Resident #10's census revealed that Resident #10 was admitted on [DATE] and discharged home on[DATE]. Resident #10 did not receive calcium lactate during their stay at the facility. Interview on 8/14/17 at 11:25 a.m. with Staff C (License Medication Nursing Assistant), Staff C confirmed the above findings. Interview on 8/24/17 at 11:30 a.m. with Staff D (Registered Nurse) revealed that the facility was having issues with getting medications timely from the pharmacy. Resident #1 Review on 8/23/17 of Resident #1's Medication Administration Record [REDACTED] Magnesium Oxide 400 mg (1 TAB) oral, one tab daily to start on 7/31/2014, and a note written in the Non-PRN (as needed) Medication Notes section of the MAR for this medication stating: New order to place on hold due to awaiting delivery. Resident #9 Review on 8/24/17 of Resident #8's MAR indicated [REDACTED] Atropine 1% eye drops (2 drops/gtts) sublingual (under the tongue) 3 times daily starting 7/14/17, and a note written in the Non-PRN Medication Notes section of the MAR for this medication on 8/3/17 stating: not given due to unavailable. Lantanoprost 0.005% eye drops (1 drop) both eyes every day. Order date 7/16/2012. On 8/13/17 a note in the Non-PRN Medicaiton Notes section of the MAR for this medication stated: med not given waiting for pharmacy delivery. Interview on 8/24/17 with Staff A (administrator) revealed the following information: Staff A stated that the facility was aware of a process problem with ordering and re-ordering medications since the facility has updated its documentation methods to be totally on computer (paperless). Staff A stated that the former method or reordering medication involved faxing the order to the pharmacy. Currently, the administrating nurse will reorder through the MAR program in the patient's record. Staff A continued to explain that there are issues with the pharmacy when ordering with the current method. The issues are that if there is a pre-authorization on the medication being ordered, and the nurse orders earlier than the pre-authorization date, the re-order will be bumped out of the system, and the facility will be unaware. The pharmacy will not be able to retain the order , and therefore, it would be like the medication was never re-ordered in the system. Staff A stated that they were working with the pharmacy to correct the problem, but currently, the situation continues to exist, and residents are not being given medications due to the medications not being delivered in a timely fashion. Staff A stated that they don't keep many of the medications in question in their [NAME] Kit ( emergency medication supply kit ) currently, but would consider updating the system to include more medications.",2020-09-01
451,JAFFREY REHABILITATION AND NURSING CENTER,305072,20 PLANTATION DRIVE,JAFFREY,NH,3452,2017-08-24,514,D,0,1,WJET11,"Based on record review and interview, it was determined that the facility failed to maintain accurate medical records for 1 resident in a standard survey sample of 12 residents. (Resident identifier is #2.) Findings include: Professional References: Per the National Pressure Ulcer Advisory Panel (April 8-9, (YEAR)) .The updated staging system includes the following definitions .Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis .Granulation tissue, slough and eschar are not present . (See http://npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury accessed 9/1/2017.) Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 1282 You need to assess pressure ulcers at regular intervals using systematic parameters to evaluate wound healing, plan appropriate interventions, and evaluate progress . Review on 8/23/17 of Resident #2's Clinical Notes revealed a Clinical Note dated 7/20/17 at 1:03 p.m. that revealed that Resident #2 had a .New pressure area noted dorsal aspect of L (left) foot. OA (open area) 0.75cm (centimeters) X (by) 0.75 cm. Scant amounts of purulent drainage noted. Wound bed noted to have slough. Surrounding skin reddened, nonblanchable . Review on 8/23/17 of Resident #2's Weekly Pressure Ulcer Flow Sheet revealed that Resident #2's pressure ulcer staging was as follows: 7/20/17 Stage 2 with granulation checked off under Wound bed 7/25/17 Stage 2 with no tissue type checked off under wound bed No Date Stage 2 with no tissue type checked off under wound bed 8/7/17 Stage 2 with no tissue type checked off under wound bed 8/14/17 Stage 2 with no tissue type checked off under wound bed 8/21/17 No Stage checked off with slough checked off under wound bed Review on 8/23/17 of Resident #2's note by the APRN (Advanced Practice Registered Nurse) dated 7/29/17 revealed documentation that reads .Area about 1 cm that is 100% slough .Unstageable . Review on 8/23/17 of Resident #2's Wound Clinic report dated 8/1/17 revealed a note documenting that the area was an Unstageable ulcer dorsum L foot. Review on 8/23/17 of Resident #2's Chat Biography revealed a notation dated 8/2/17 .(Proper noun) has a Stage 2 pressure area to (pronoun) left foot. Interview on 8/24/17 with Staff B (Unit Manager) confirmed the above information and that there was a discrepancy in the Staging of Resident #2's pressure ulcer.",2020-09-01
452,JAFFREY REHABILITATION AND NURSING CENTER,305072,20 PLANTATION DRIVE,JAFFREY,NH,3452,2018-09-19,550,B,0,1,OL6E11,"Based on a resident council interview and staff interview, it was determined the facility failed to determine whether there were residents who wanted to exercise their right to vote during New Hampshire's 9/11/18 primary and/or offer any assistance to enable residents to participate in this election. Findings include: Interview on 9/18/18 of the resident council revealed that none of the residents present were asked whether they wanted to exercise their right to vote either prior to or during New Hampshire's 9/11/18 primary election. Some of the residents attending the 9/18/18 resident council meeting said they'd like to continue exercising their right to vote. Interview on 9/19/18 at 3:00 p.m. with Staff A (Administrator) confirmed that the facility's Activities Department had forgotten to follow through with the residents regarding their preferences for participating in this election.",2020-09-01
453,HOLY CROSS HEALTH CENTER,305074,357 ISLAND POND ROAD,MANCHESTER,NH,3109,2020-02-27,609,D,1,0,O6DC11,"> Based on review of facility reported incident, medical records, policy and procedures, witness statements and interviews, it was determined that the facility failed to report 4 of 4 allegations immediately to the facility administrator and failed to report to the State agency in a timely manner. (Resident identifiers are #1, #2, #3 and #4.) Findings include: Resident #1 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C (License Nursing Assistant). Review on 2/27/20 at approximately 9: 00 a.m. of Staff A's (License Practical Nurse) witness statement dated 2/5/20 revealed that Staff C was in Resident #1's room when Staff A heard Resident #1 yelling, checking with Staff C, Staff C indicated to Staff A that Resident #1 was trying to hit Staff C. Resident #1 who has dementia was unable to explain what was happening. Staff A spoke to Staff C about this incident, but did not report this to either Staff D (Director of Nurses) or Staff [NAME] (Administrator) at that time. Interview on 2/27/20 at approximately 8:30 a.m. with Resident #1 revealed that Resident #1 was not afraid of staff and could not recall any staff mistreating Resident #1. Review on 2/27/20 of Resident #1's medical record revealed the latest BIMS (Brief Interview For Mental Status) dated 12/13/19 was a 4, which means severe cognitive impact. Resident #2 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C. Review on 2/27/20 of Resident #2's medical record revealed the latest BIMS dated 12/24/19 was a 2, which means severe cognitive impact. Resident #3 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C. Review on 2/27/20 of Resident #3's medical record revealed the latest BIMS dated 1/16/20 was a 1, which means severe cognitive impact. Resident #4 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C. Review on 2/27/20 at approximately 9 :00 a.m. of Staff B's, (License Practical Nurse) witness statement dated 1/30/20 revealed Staff B over heard Staff C to pee in your diaper I will change you. if you ever call out for help again I will put you on your recliner. I am not bothered by your screaming, I've got kids at home. Staff C did transfer Resident #4 to the recliner in the middle of the night due to Resident #4 yelling out help help. when Staff B did notice that Resident #4 was in the recliner Staff B returned Resident #4 to bed. Review on 2/27/20 of Resident #4's medical record revealed the latest BIMS dated 12/12/19 was a 8, which means moderately cognitive impact. Interview on 2/27/20 at approximately 11:00 a.m. with Staff B by phone confirmed that Staff C was yelling Residents #1, #2, #3 and #4 at different times beginning at the end of (MONTH) and continuing into (MONTH) but did not report it to Staff D or E. Staff B was afraid to report the incidents to Staff D and E. Staff C could not give any specific dates other then the general month. Staff B, finally reported the occurrences on the morning of 1/30/20 to Staff D and E. Review of the facility's policy and procedure titled Abuse and Neglect- Clinical Protocol, revision date (MONTH) (YEAR) revealed: Reporting: . 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Protection of patients during investigations; and reporting of incidents, investigations, and center response of their investigations. Review of the facility's Policy and Procedure titled Reporting Abuse Protocol, revision date 1/2018 revealed: When investigating a report of abuse whether Resident-to -Resident or Staff to Resident, the following needs to be completed. 1. Intervene and ensure the residents well-being. 2. Report the incident to the Charge Nurse. Charge Nurse will: IMMEDIATELY 3. Remove the person involved to a private area and get their written statement. 4 Contact BOTH (Staff D Director of Nurses), (phone numbers omitted) AND (Staff [NAME] Administrator) , (phone numbers omitted). If you must leave a message, specify the time you called and that you need a call back ASAP (As soon as possible) regarding a complaint. Interview on 2/27/20 at approximately 11:30 a.m. with Staff [NAME] confirmed that the allegations were not reported to Staff [NAME] or to Staff D within 24 hours of the occurrences. Staff [NAME] revealed that Staff C was reported to the Board of Nursing on 2/6/20 and Staff C was terminated.",2020-09-01
454,HOLY CROSS HEALTH CENTER,305074,357 ISLAND POND ROAD,MANCHESTER,NH,3109,2017-03-29,281,D,0,1,EM5N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to meet professional standards of quality for the medication pass for 1 resident in a survey sample of 12 residents. (Resident identifier is #11.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 3/28/17 at 8:10 a.m. of medication pass task with Staff A (Licensed Practical Nurse) revealed Resident #11's physician order [REDACTED].= 75 mg) every day - hold for systolic BP (blood pressure) less than 90 or HR (Heart Rate) less than 60. Staff A did not check BP or HR during observation. Review on 3/28/17 of Resident #11's MAR (Medication Administration Record) revealed that the medication [MEDICATION NAME] had blood pressure parameters that had not been done prior to the medication administration. The BP and HR had a box indicated in the MAR for documenting the readings. These boxes were empty. In (MONTH) (YEAR) there were 12 BP omissions in the MAR and in (MONTH) (YEAR) there were 22 BP omissions in the MAR. Interview on 3/28/17 at approximately 8:15 a.m. with Staff A confirmed that Resident #11's BP and HR were not performed prior to medication administration on 3/28/17 during observation of medication administration. Interview on 3/28/17 at approximately 8:50 a.m. with Staff B (Assistant Director of Nurses) confirmed that there was no record of BP's or HR's in Resident #11's medical record.",2020-09-01
455,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-01-30,658,D,0,1,JM4711,"Based on medical record review, facility policy and procedure review and interview it was determined that the facility failed to meet professional standards of quality for 1 resident out of a standard sample size of 19 residents. (Resident identifier is #39.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 16 Nursing Assessment page 243. Data Documentation Data documentation is the last part of a complete assessment. The timely, thorough, and accurate documentation of facts is necessary when recording client data if you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client. If there is not specific information, the reader is left with only general impressions. Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. Review on 1/29/18 of Resident #39's medical record revealed that Resident #39 had a fall on 1/19/18. Review of Resident #39's medical record revealed that there was no assessment documented of the resident's condition or assessment after the fall. Interview on 1/29/18 at approximately 11:30 a.m. with Staff A, Director of Nursing confirmed that there was not a complete post fall assessment documented in the medical record or in RMS (Risk Management System). Review on 1/29/18 of the facility's policy and procedure titled, NSG215 Falls Management, revision date of 3/15/16 revealed: . Policy . Patients experiencing a fall will receive appropriate care and investigation of the cause . Purpose . To address injury and provide care for a fall . Practice Standards . 5.3 Document accident/incident 5.3.1 As a new event in the RMS . 5.3.4 Investigation using the Fall Investigation/QA and other appropriate tools in RMS . 5.6 The Center Executive Director and Center Nurse Executive will conduct a post fall review.",2020-09-01
456,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-01-30,690,D,0,1,JM4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their policy and procedure and care practices related to catheterization for 1 of 2 residents reviewed with indwelling catheters (Resident identifier #69). Findings include: Observation on 1/25/18 10:01 a.m. revealed Resident #69 had a catheter bag that was draining clear urine. The catheter bag was positioned in their lap, above his/her bladder, in a blue privacy bag. Observation on 1/26/18 11:45 a.m. revealed Resident #69 was sitting in their wheelchair in their room. He/She was observed to have their catheter bag sitting in their lap, above their bladder, in his/her wheelchair. Interview on 1/26/18 with Staff B (Licensed Medical Nursing Assistant) and Staff C (Licensed Practical Nurse) confirmed the placement of the catheter bag was in Resident #69's lap, above their bladder. Staff C stated that catheter bags need to be below the resident's bladder for it to drain correctly and not lead to an infection. Review of Physician orders [REDACTED].#69 to be transported to the emergency room due to the resident's indwelling catheter not draining. Review of Resident #69's nursing notes for (MONTH) (YEAR) through 1/24/18 revealed no notes educating the resident on the placement of their catheter bag. Review of Resident #69's occupational therapy notes for (MONTH) (YEAR) through 1/24/18 revealed no notes educating the resident on the placement of their catheter bag. Interview on 1/29/18 11:28 a.m. with Staff D (Director of Rehabilitation) confirmed that occupational therapy educated the resident three times in (MONTH) (YEAR) (10/16/17, 10/19/17, and 10/30/17) on the proper positioning of the resident's Foley bag. Interview also confined that there were no nursing notes regarding education of the resident regarding the correct positioning of Resident #69's catheter bag from (MONTH) (YEAR) to 1/24/18. Review on 1/29/18 of the emergency room and laboratory reports from 12/11/17 revealed the resident's catheter was changed because it had stopped draining on 12/10/17 and the resident had a Urinary Tract Infection [MEDICAL CONDITION]. The lab report revealed the organisms in the urine were [DIAGNOSES REDACTED] and Esherisha coli greater than 100,000 colony forming units each. Review on 1/29/18 of Resident #69's current care plan revealed no interventions for or mention of Resident #69's non-compliance with their catheter bag being kept about their bladder. Review of the facility's policy titled, Catheter: Indwelling Urinary - Care of effective 06/01/96, last revised on 01/02/14 section 10 stated the following: Secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. Position catheter for straight drainage.",2020-09-01
457,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-01-30,880,E,0,1,JM4711,"Based on observation and interview it was determined that the facility failed to provide a safe, sanitary and comfortable environment for 1 unit of 3 units. Observation on 1/24/18 11:35 a.m. of the tub room on the 200's unit revealed sheetrock dust all over the floor, whirlpool tub, shower area and the sink. There were 2 empty cardboard boxes next to the whirlpool tub, there were tools (wrench and a screw driver) sitting on the edge of the sink, the water in the sink was running on full blast and there was a handwritten sign taped to the mirror over the sink that asked people not to shut the water off in this sink to prevent the pipes from freezing. There were packages of incontinence products and a roll of toilet paper sitting in the shower stall on the floor. There was dried Joint Compound and paint all over the floor. Wires from the ceiling were hanging over the whirlpool tub and another grouping of wires were hanging from the ceiling to the left of the whirlpool tub. This tub room was still being used to give residents whirlpool baths as a resident was observed on 1/24/18 at approximately 11:30 a.m., being wheeled from this tub room wrapped in a bath blanket. Interview on 1/24/18 at 11:40 a.m. with Staff [NAME] (Maintenance) revealed that over the previous weekend, a pipe had frozen and broken in the tub room and there had been a lot of water damage to the tub room which is why the room looked like it did. Staff [NAME] stated that he/she posted the sign over the sink to keep the water running all the time until the possibility of the pipes freezing was over. Staff [NAME] stated he/she had been working in the tub room since the pipe broke replacing sheetrock that had been damaged, applying joint compound to the new sheetrock and painting of the new sheetrock. The hanging wires were observed to be covered individually with wire nuts and Staff [NAME] stated that he/she had turned the breakers that go to these hanging wires off so there was no electricity flowing through them. Staff [NAME] provided access to the electrical room to show that the breakers for this tub room were in the off positions. Observation on 1/24/18 at approximately 11:45 a.m. of the breaker box for this tub room revealed that all the breakers to this tub room were in the on position at 11:45 a.m. Staff [NAME] stated that none of the tub rooms lock and upon inspection, all the tub room doors were left in the open position allowing access to all residents. There was one door to access/exit this tub room. At 11:55 a.m. the tub room on the 100's unit revealed many broken and missing tiles around the whirlpool. The motion sensor light at the entrance was missing the protective sensor cover. There were paint chips on the floor that could be scraped with the finger nail off of the floor. Soiled linen (3) containers that were covered were noted in the alcove of the tub room and there was visibly soiled linens in these containers. There is one entry/exit to this tub room which is accessible to all residents as it does not lock. Interview on 1/24/18 at approximately 12 noon Staff [NAME] revealed that this tub room does not lock.",2020-09-01
458,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-01-30,921,E,0,1,JM4711,"Based on observation and interview the facility failed to ensure that the 200 Maple Wing tub area was maintained in a safe and sanitary manner. ( Resident identifier is #64.) Findings include: Observation on 1/24/18 during tour of the 200 Maple Wing at approximately 10:45 a.m. showed that the whirlpool tub area was under repair and revealed the following: . Resident #64 in wheelchair exiting the 200 Maple Wing tub area wrapped in a white bath blanket being pushed by Staff F (Licensed Nursing Assistant). . No secure locking mechanism on the 200 Maple Wing tub area door, indicating this room which is located at the end of the 200 Maple Wing resident hallway is accessible at any hour. . Multiple large pieces of sheetrock leaning against the tub room wall to the left of this doorway entrance. . A large open white plastic bucket of dry wall joint compound. . Tub room floor with white powder substance and chunks of white debris throughout the whole area. . On the floor adjacent to the toilet was an open box with exposed power tools and electrical cords. . Next to this box of tools was an empty brown cardboard box. On top of this box was an unwrapped roll of toilet paper. On the floor was a package of Depends. . Unlocked wall mounted cabinet with multiple bottles of hygiene products. . Multiple disassembled metal & plastic pieces of elongated lighting fixtures leaning against the wall adjacent to the toilet. . A paper hand written sign posted above the tub room sink with directions Keep water running during winter months. . Faucet water was running not dripping. . To the left of the sink water faucet handle was a a large metal wrench and a blue handle screwdriver. . To the right of the sink water faucet handle resting were two individual gray ceiling air duct covers with . The ceiling in this room had three uncovered open areas in the ceiling located above the tub and sink area large amounts of thick gray substance attached to these two air duct vents. . Hanging above the tub from the ceiling were two separate bunches of individual colored electrical wires with capped ends. Interview on 1/24/18 at approximately 11:00 a.m. with Staff F revealed that Resident #64 had just finished a whirlpool tub bath in the 200 Maple Wing tub room and that the facility has been utilizing this room with the above listed findings to render care to residents for about a week . Interview on 1/24/18 at approximately 11:15 a.m. with Staff [NAME] (Maintance Director) revealed that Staff [NAME] left the above listed box of tools, electrical cords, metal wrench and screwdriver in this tub room. At the time of this interview Staff [NAME] confirmed the above listed 200 Maple Wing tub room observations and that the facility staff have been rendering care while this room was under repair. Interview on 1/24/18 at approximately 3:45 p.m. with Staff G (Administrator) revealed that the 200 Maple Wing tub room should of been closed for resident care during repairs.",2020-09-01
459,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2019-03-15,760,D,1,0,7H8811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an investigation of a medication error requiring a clinical intervention, and review of the medical record, and interview, it was determined that the facility failed to implement effective measures to prevent further medication errors. (Complainant identifier is #1.) Findings include: On 2/26/19, during telephone interview, the complainant (#1) stated that during their stay they were given the wrong dose of a medication and the facility implemented every hour checks to make sure the complainant stayed awake. Review of the complainants medical record on 3/15/19, it was found that a Event Summary Report dated 2/16/19 revealed, During shift count at 2300 it was found that [MEDICATION NAME] was incorrect. It was determined that instead of being administered [MEDICATION NAME]& [MEDICATION NAME] as had been requested, the patient was given [MEDICATION NAME]. (---) gave orders to 'monitor vital signs every hour x 6 hours, pupil check every 2 hours x 6 hours & observe for elevated temp, pupil [MEDICATION NAME], headache, chest pain. If BP (Blood Pressure) up to 180 systolic, transfer to ED (Emergency Department) . Review on 3/15/19 of the RMS (Risk Management System) Event Summary Report under the section called Corrective Actions states Review with staff member regarding proper medication administration procedure with NPE (Nurse Practice Educator) . Monitor med (medication) pass. Interview on 3/15/19 with Staff A (Director of Nurses) was asked if they had the education documentation provided by the NPE along with the mediation pass that was performed with Staff B (Medication Nursing Assistant). Staff A stated that the education that was to be provided to Staff B was not done nor was the medication observation done.",2020-09-01
460,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-04-25,607,D,1,0,UH3M11,"> Based on review of facility policy, review of investigation file, and interview, it was determined that the facility failed to implement the facility's policy for the prevention and reporting of abuse by performing a complete investigation of an alleged sexual assault reported by a resident for 1 resident out a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Genesis Policy OPS300, Abuse Prohibition (Review date 1/25/18; Revision date 3/1/18); Section Process: 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property . 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following: . 6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required . 6.7 Initiate as investigation within 24 hours of an allegation of abuse that focuses on: . 6.7.2 clinical examination for signs of injuries, if indicated; 6.8 The investigation will be thoroughly documented within the RMS (Risk Management System). Ensure that documentation of witnessed interviews is included. 6.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. Review on 4/25/18 of the facility's investigation file for Resident #1's allegation of sexual assault revealed that there were: 1. No statements from the staff that worked the 11 p.m. to 7 a.m. at the time the alleged sexual assault occurred. 2. No copies of a complaint that was sent by the facility to the New Hampshire Board of Nursing. There was a copy of the Board's regulatory activity related to this incident in the file. Interview on 4/25/18 at 11:20 PM with Staff C (Nursing Home Administrator) and Staff D (Director of Nursing) revealed that no witness statements were obtained from the staff that worked the 11 p.m. to 7 a.m. on the night of the alleged sexual assault. When questioned if the alleged victim was either examined at the facility and/or sent for physical examination at a local healthcare setting, Staff C and Staff D replied that a post-incident exam was not performed.",2020-09-01
461,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-04-25,610,D,1,0,UH3M11,"> Based on review of the medical record and interview, it was determined that the facility failed to thoroughly investigate an allegation of sexual abuse for 1 resident in a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on 4/25/18 of the Facility's First report of incident, dated 3/28/18, revealed that Resident #1 states that male LNA (Licensed Nursing Assistant Staff B) touched (Resident #1) inappropriately this am (morning) while providing care, (Resident #1) is not injured .Full investigation to follow. Review on 4/25/18 of the Adult Protective Services Investigation Notification, dated 4/2/18, revealed that .It is alleged that on 03/28/18, (Staff B, Licensed Nursing Assistant) sexually abused (Resident #1,) in that (Staff B) fondled (Resident #1's) breasts and (Staff B) inserted (pronoun for Staff B's) finger into (Resident #1's) vagina while providing care to (Resident #1) . Review on 4/25/18 of the Facility's Event Detail Report, dated 3/28/18 revealed that the incident occurred at 4:42 a.m. on 3/28/18. Review on 4/25/18 of the Statement, dated 3/28/18, made by Staff A (Licensed Practical Nurse) revealed that at approximately 6:50 a.m. on 3/28/18 Staff A, who had arrived at work at approximately 6:30 a.m., witnessed Staff B enter Resident #1's room to provide care. Staff A also revealed in the statement that Resident #1 .isn't on the list for 11-7 aide to get ready in the am usually (Resident #1's) am care is completed by 7-3 shift. I am not sure of the circumstances as to why (Staff B) needed to provide care for this resident this am . Review on 4/25/18 of the (MONTH) (YEAR) LNA Documentation Report revealed that Staff B had documented at 4:42 a.m. on 3/28/18 that Staff B had provided care, including dressing and personal hygiene, to Resident #1, which was before the care was given. According to a witness statement by given by Staff A, Staff B did not provide care until approximately 6:50 a.m Review on 4/25/18 of the Facility's Report file of the alleged incident that occurred to Resident #1 on 3/28/18 revealed that there were no statements from the staff who had worked on the 11-7 shift on 3/28/18. Review on 4/25/18 of the Progress notes and the Skin Check sheets for Resident #1 revealed that there was no documented evidence that a skin check or assessment of Resident #1 was done on 3/28/18. Interview on 4/25/18 at approximately 2:30 p.m. with Staff C (Administrator) and Staff D (Director of Nursing) confirmed that no body assessment was done on Resident #1 on 3/28/18. The interview also revealed that the 11 p.m.-7 a.m. staff, who were working with Staff B on 3/28/18, were not interviewed regarding the allegation or questioned as to why Staff B provided care, including dressing and personal hygiene, to Resident #1 during the 11 a.m.-7 p.m. shift. Staff C and Staff D confirmed that there was a discrepancy in the timing of the incident between the statement given by Staff A and the Facility's Event Detail Report. Staff D confirmed that the timing of the incident was inaccurately listed as the time that Staff B documented in the computer, and that there was no investigation into when the alleged incident actually happened.",2020-09-01
462,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-04-25,745,D,1,0,UH3M11,"> Based on review of the medical record and interview, it was determined that the facility failed to provide social services to support a resident that alleged an incident of sexual abuse had occurred for 1 resident out of a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on 4/25/18 of the Facility's First report of incident, dated 3/28/18, revealed that Resident #1 states that male LNA (Staff B) touched (pronoun omitted) inappropriately this a.m. while providing care . Review on 4/25/18 of the social service progress notes for Resident #1 revealed that there were no documented social service notes for Resident #1 from before 3/28/18 or when Resident #1 had an allegation of sexual abuse, until Resident #1's discharge home on 4/11/18. Interview on 4/25/18 at approximately 2:30 p.m. with Staff C (Administrator) and Staff D (Director of Nursing) confirmed that there was no documented evidence that anyone met with Resident #1 to see if they were alright and to make sure that they felt safe. Staff C and Staff D confirmed that meetings to offer support to Resident #1 should have taken place and should have been documented.",2020-09-01
463,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-04-25,842,B,1,0,UH3M11,"> Based on review of the medical record and interview, it was determined that the facility failed to ensure that resident medical records are accurately documented on 1 resident out of a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on 4/25/18 of the (MONTH) (YEAR) LNA Documentation Report revealed that Staff B (Licensed Nursing Assistant) had documented at 4:42 a.m. on 3/28/18 that Staff B had provided care, including dressing and personal hygiene to Resident #1. This was before the care was given. According to a witness statement given by Staff A (Licensed Practical Nurse) Staff B did not provide care until approximately 6:50 a.m. Review on 4/25/18 of the (MONTH) (YEAR) LNA Documentation Report revealed that Staff B had documented provided care to Resident #1 on the following dates and times: 3/1/18 at 2:58 a.m., 3/2/18 at 3:13 a.m., 3/3/18 at 2:55 a.m., 3/6/18 at 2:53 a.m., 3/7/18 at 4:27 a.m., 3/8/18 at 4:27 a.m., 3/10/18 at 3:00 a.m., 3/11/18 at 12:40 a.m., 3/12/18 at 1:54 a.m., 3/13/18 at 2:58 a.m., 3/15/18 at 1:40 a.m., 3/16/18 at 4:12 a.m., 3/17/18 at 1:32 a.m., 3/20/18 at 4:36 a.m., 3/21/18 at 4:12 a.m., 3/24/18 at 5:02 a.m., 3/25/18 at 1:39 a.m., 3/26/18 at 1:19 a.m., 3/27/18 at 2:54 a.m. and 3/28/18 at 4:42 a.m. Interview on 4/25/18 at approximately 2:30 p.m. with Staff C (Administrator) and Staff D (Director of Nursing) confirmed that the documentation done by Staff B was not correct as it should have been done at the end of the 11 p.m. to 7 a.m. shift, after the care was given, instead of before providing care, to correctly reflect the care and assistance provided to Resident #1.",2020-09-01
464,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2019-10-04,558,D,0,1,9KDJ11,"Based on interview, observation, and record review, it was determined that the facility failed to provide services in accommodation of the resident's transfer needs for 1 of 3 residents reviewed for activities of daily living (ADL) in a final survey sample of 21 residents. (Resident identifier is #50.) Findings include: Interview on 10/1/19 at 9:36 a.m. with Resident #50 revealed Resident #50 complained that staff did not use the hoyer lift properly the day before (9/30/19) causing him/her pain and discomfort and physical therapy needed to reposition the resident in their wheelchair. Observation on 10/2/19 at 10:58 a.m. revealed Resident #50 was in the dining area crying quietly. Interview on 10/2/19 at 10:58 a.m. with Resident #50 revealed that Resident #50 stated that staff had used the wrong hoyer lift strap to transfer him/her today and was crying because the resident was in pain. The resident stated the facility should be using a split hoyer lift but had been using a full lift pad and the resident had told the staff but they would not listen. Review on 10/3/19 of Resident #50's lift transfer reposition assessment done 9/17/19 revealed that nursing recorded Resident #50 required a large full body lift pad. Interview on 10/4/19 at 10:53 a.m. with Staff D (physical therapist) revealed that the staff did use a full lift pad to transfer Resident #50 to their wheelchair on 9/30/19 and Staff D found Resident #50 uncomfortable in their wheelchair. Staff D revealed that they had recommended a split lift pad approximately two months ago at a care plan meeting and that a full lift pad negates the pressure relieving cushion on the resident's wheelchair. Interview on 10/4/19 at 12:15 p.m. with Staff A (Unit Manager) revealed there was no intervention to use a split pad with the hoyer lift on Resident #50's care plan and confirmed the lift transfer reposition assessment done in (MONTH) says to use a full pad but should say a split hoyer lift pad.",2020-09-01
465,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2019-10-04,656,B,0,1,9KDJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to develop care plans for smoking for 1 resident and for transmission based precautions for 1 resident, in a final survey sample of 21 residents. (Resident identifiers are #20 and #80.) Findings include: Resident #20 Interview on 10/2/19 at approximately 8:50 a.m. with Resident #20 revealed that Resident #20 usually smoked about one time a day. Review on 10/3/19 of Resident #20's current care plan revealed that there was no care plan for Resident #20's smoking. Interview on 10/3/19 at approximately 2:15 p.m. with Staff A (Unit Manager) confirmed that Resident #20 did smoke daily. Staff A also confirmed that there was no care plan for Resident #20's smoking and that there should have been a care plan in place for as long as Resident #20 continued to smoke. Resident #80 Interview on 10/1/19 at approximately 11:35 a.m. with Staff A revealed that Resident #80 was on contact precautions [MEDICAL CONDITIONS] in a wound. Review on 10/3/19 of Resident #80's [DIAGNOSES REDACTED].#80 had a [DIAGNOSES REDACTED]. that was categorized as Acute Infections. Review on 10/3/19 of Resident #80's current care plan revealed that there was no care plan for Resident #80'[MEDICAL CONDITION] or contact precautions. Interview on 10/4/19 at approximately 11:13 a.m. with Staff B (Nurse Practice Educator) confirmed that Resident #80 [MEDICAL CONDITION] and was on contact precautions and that there was no care plan in place for Resident #80'[MEDICAL CONDITION] or contact precautions, and that there should have been.",2020-09-01
466,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2019-10-04,690,D,0,1,9KDJ11,"Based on record review and interview, it was determined that the facility failed to identify a change in bowel incontinence, assess the resident and provide appropriate treatment and services to restore as much normal bowel function as possible for 1 resident out of a final survey sample of 21 residents. (Resident identifier is #45.) Findings include. Review on 10/3/19 at 12:49 p.m. of Resident #45's Quarterly MDS (Minimum Data Set) dated 6/3/19 under section H0400 Bowel revealed Always continent of bowel. Then on 9/3/19 a Quarterly MDS was completed and under section H0400 Resident #45 coded Frequently incontinent of bowel. On review of the facility's P[NAME] (Point of Care) response history as of 10/4/19 it shows that Resident #45 is still incontinent of bowel. Interview on 10/4/19 at 10:26 a.m. with Staff B (Nurse Practice Educator) confirmed the above, stating that the facility failed to perform a new bowel assessment and also failed to complete a care plan for both bowel and bladder.",2020-09-01
467,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2019-10-04,842,B,0,1,9KDJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to maintain complete and accurate medical records for medication administration for 2 residents in a final sample of 21 residents. (Resident identifiers are #22 and #78.) Findings include: Resident #78 Review on 10/4/19 of Resident #78's physician orders [REDACTED]. Review on 10/4/19 of Resident #78's narcotic administration record and Medication Administration Record [REDACTED]., 9/5/19 at 8:17 p.m., 9/7/19 at 4:07 p.m., 9/12/19 at 1:00 p.m., 9/17/19 at 6:05 a.m., 9/18/19 at 10:00 a.m., 9/19/19 at 9:13 a.m., 9/20/19 at 5:00 a.m., 9/23/19 at 10:20 p.m., 9/25/19 at 6:35 a.m., and 9/29/19 at 8:45 p.m. Resident #22 Review on 10/4/19 at 1:01 p.m. of Resident #22's medical record revealed Resident #22's orders for a scheduled Narcotic [MEDICATION NAME] HCI Liquid 1mg/ml Give 5 ml by mouth two times a day for pain management (5 mg). This order has no time written except for AM and PM. Resident #22 also has PRN (as needed) medication orders written [MEDICATION NAME] HCI Liquid 1mg/ml Give 5 ml by mouth every 4 hours as needed for Pain . On review of these two medications against the MAR (Medication Administration Record) and the narcotic book it showed the following: On 9/7/19, the MAR indicated [REDACTED]. On 9/8/19, the MAR indicated [REDACTED]. On 9/9/19, the MAR indicated [REDACTED]. On 9/12/19, the MAR indicated [REDACTED]. On 9/13/19, the MAR indicated [REDACTED]. On 9/22/19, the E-MAR (Electronic Medication Administration Record) showed the a.m. and p.m. dose given, but only the a.m. was in the narcotics book. Also on review of the narcotic book under Direction the facility failed to write what the orders were and only wrote See MAR, since both the Scheduled and PRN are the same dose with no times the medications can not be properly followed. Interview on 10/4/19 at 11:30 a.m. with Staff B (Nurse Practice Educator) reviewed the above findings.",2020-09-01
468,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2019-10-04,883,D,0,1,9KDJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to administer pneumococcal immunizations to 2 residents in a final survey sample of 21 residents. (Resident identifiers are #80 and #132.) Findings include: Resident #80 Review on 10/2/19 of Resident #80's Pneumococcal Vaccine Informed Consent, revealed that on 9/12/19 Resident #80 signed their permission to be administered the pneumococcal vaccination by the facility. Review on 10/2/19 of Resident #80's active physician orders, revealed a physician order [REDACTED]. Review on 10/2/19 of Resident #80's (MONTH) 2019 Medication Administration Records revealed that there was no documentation that Resident #80 had received the pneumococcal vaccination. Interview on 10/2/19 at approximately 11:15 a.m. with Staff B (Nurse Practice Educator) confirmed that Resident #80 had not received the pneumoccocal vaccination and that Resident #80 should have received it. Resident #132 Review on 10/4/19 of Resident #132's Pneumococcal Vaccine Informed Consent, revealed that on 9/23/19 Resident #132's Health Care Decision Maker had signed their permission for Resident #132 to be administered the pneumococcal vaccination. Review on 10/4/19 of Resident #132's active physician orders, revealed a physician order [REDACTED]. Review on 10/4/19 of Resident #132's (MONTH) 2019 Medication Administration Records revealed that there was no documentation that Resident #132 had received the pneumococcal vaccination. Interview on 10/4/19 at approximately 11:15 a.m. with Staff B (Nurse Practice Educator) confirmed that Resident #132 had not received the pneumoccocal vaccination and that Resident #132 should have received it.",2020-09-01
469,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2019-10-04,919,B,0,1,9KDJ11,"Based on observation and interview, it was determined that the facility failed to maintain the residents' call system volume at a level that could be heard. Findings include: Observation on 10/1/19 at 11:40 a.m. revealed that tape was placed over the speaker system at the nurses station lowering the sound so it could not be heard as designed. Interview on 10/1/19 at 11:45 a.m. with Staff C (Unit Manager) and Staff B (Nurse Practice Educator) reivewed the above finding of the tape covering the speaker to the call system which diminishing the audible tone. Staff C removed the tape and immediately the audible sound could be heard as designed.",2020-09-01
470,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2018-12-18,623,C,0,1,26VV11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to provide written notice of a transfer or discharge for 2 residents in a final survey sample of 20 residents. (Resident identifiers are #55 and #49.) Findings include: Resident #55 Review on 12/17/18 at approximately 9:49 a.m. of Resident #55's medical record revealed that Resident #55 was transferred to the hospital on [DATE]. Interview on 12/17/18 at approximately 10:13 a.m. with Staff A (business office manager) confirmed that she does not provide residents or resident representatives with a written notice of transfer or discharge form. She only sends a monthly list of residents who have transferred or discharged to the State Office of Long Term Care Ombudsman. Interview on 12/17/18 at approximately 10:00 a.m. with Staff B (Center Executive Director) confirms that the facility has not been providing written notice of transfer or discharge to residents or resident representatives. Resident #49 Review on 12/18/18 at approximately 1:00 p.m. of Resident #49's medical record revealed that Resident #49 was transferred to the hospital on [DATE] and again on 12/15/18. There was no written notice of transfer or discharge found in the resident's medical record for review. Interview on 12/18/18 at approximately 1:30 p.m. with Staff B confirmed that the facility has not been providing written notice of transfer or discharge to residents or residents representatives.,2020-09-01
471,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2017-05-10,157,D,0,1,J10T11,"Based on record review and interview it was determined that the facility failed to notify the physician of 2 accidents that occured with 1 resident out of a standard survey sample of 17 residents. (Resident identifier is #6.) Findings include: Review of Resident #6's medical record on 5/8/17 revealed a nurses note dated 2/23/17 at 3:08 p.m. that stated, while Resident #6 was outside, one of the facility's barn cats had clawed Resident #6's lower left arm. Review of nurses noted dated 2/25/17 at 1:44 p.m. revealed that Resident #6 was scratched in the middle of Resident #6's right stump by one of the facility's barn cats. Both of the incidents required a dressing be applied to the affected areas. There was no evidence in the medical record of the physician being notifed of the incidents. Interview on 5/9/17 at approximately 10:30 a.m. with Staff B, Registered Nurse, Unit Manager confirmed that the physician had not been notified of the incidents with the barn cats on 2/23/17 and 2/25/17. Interview on 5/9/17 at approximately 12:45 p.m. with Staff A, Director of Nursing revealed that Staff A had not been notified of the above 2 incidents.",2020-09-01
472,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2017-05-10,281,D,0,1,J10T11,"Based on record review and interview it was determined that the facility failed to obtain physician orders for two treatments administered to 1 resident out of a standard survey sample of 17 residents. (Resident Identifier is #6.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Pages 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Review of Resident #6's medical record on 5/8/17 revealed a nurses note dated 2/23/17 at 3:08 p.m. that stated, while Resident #6 was outside, one of the facility's barn cats had clawed Resident #6's lower left arm. Review of nurses noted dated 2/25/17 at 1:44 p.m. revealed that Resident #6 was scratched in the middle of Resident #6's right stump by one of the facility's barn cats. Both of the incidents required a dressing be applied to the affected areas. There were no physicians orders for the treatments that were administered. There was no evidence in the medical record of the physician being notifed of the incidents. Interview on 5/9/17 at approximately 10:30 a.m. with Staff B , Registered Nurse , Unit Manager confirmed that the physician had not been notified of the incidents with the barn cats on 2/23/17 and 2/25/17. Staff B confirmed that there were no physician orders for the treatments applied. Interview on 5/9/17 at approximately 12:45 p.m. with Staff A, Director of Nursing revealed that Staff A had not been notified of the above 2 incidents.",2020-09-01
473,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2018-05-23,600,J,1,0,7M4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined that the facility failed to ensure that a facility staff provided the intervention of CPR (Cardiopulmonary Resuscitation) to a full code resident at the time of their death resulting in neglect at a past non-compliance immediate jeopardy level for 1 resident out of a survey sample of 9 residents. (Resident identifier is #1.) Findings include: Review on [DATE] of Resident #1's medical record revealed a physician order [REDACTED]. Review of Resident #1's care plan for advance directives with a revision date of [DATE] revealed that Resident #1 wished to be a full code. In addition, Resident #1 had been full code prior to the revision date of [DATE]. Review on [DATE] of the facility's Description of incident or concerns; revealed, (Resident #1) was found by licensed nursing assistant (Staff E) and (Staff F , LNA) on [DATE] (death occurred on [DATE]; [DATE] was the day that the shift began) at 01:30 in bed and did not appear to be breathing, LNA (Staff E) immediately went to nurse (Staff C, Licensed Practical Nurse) who was caring for resident (Resident #1), and informed .(Staff C), while LNA (Staff F) grabbed vital sign pole (pole/cart to be used to check blood pressure, respirations, temperature, etc.), LPN (Staff C) stated .(Staff C) administered CPR, however, all evidence supports that CPR was not provided, code cart was undisturbed, employee statements support no CPR given, LPN (Staff C) admitted .(Staff C) did not check for conclusive signs of death, did not get code cart, did not notify physician, and did not intervene when .(Staff C) saw the resident (Resident #1) one hour before in distress. Review on [DATE] of facility interview on [DATE] at 3:15 p.m. with Staff [NAME] revealed, .About 01:15 .(Staff E) got .(Staff F) to help .(Staff E) with rounds and we went into .(Resident #1's) room we saw .(Resident #1) was pale and didn't think .(Resident #1) was breathing. (Staff E) went to get the nurse .(Staff C) who came down and locked (sic) at .(Resident #1) and asked .(Staff E) to get .(Staff G, Licensed Practical Nurse) the other nurse. (Staff E) walked to the nurse's station to get .(Staff G), and .(Staff F) got the vital sign pole and took it in the room. (Staff E) told .(Staff G) that .(Staff C) wanted .(Staff G) in .(Resident #1's) room and .(Staff G) went down there. (Staff E) did not see anything else .(Staff E) was not in the room. (Staff C) the nurse came out of the room about 2 minutes later and told us that .(Resident #1) passed and to go in and do post mortem care. During interview on [DATE] in the afternoon with Staff E, Staff E's interview dated [DATE] at 3:15 p.m. was reviewed. Staff [NAME] confirmed that what was documented was accurate to what Staff [NAME] had told the facility. Review on [DATE] of facility interview on [DATE] at 11:15 a.m. with Staff F revealed, On [DATE] .(Staff F) was helping .(Staff E) with rounds it was about 1:30 .(Staff F) think, we went into .(Resident #1's) room and .(Resident #1) looked dead, .(Resident #1) was cold on .(Resident #1's) hands and face, and pale .(Resident #1's) eyes were closed we told the nurse .(Staff C) and .(Staff C) went in and looked at .(Resident #1) then .(Staff C) called for .(Staff G) the other nurse and .(Staff C) went in the room, .(Staff F) went to get the vital sign pole because .(Staff F) thought they would need it. (Staff F) left to finish helping with rounds. Review on [DATE] of Staff G's written statement dated [DATE] revealed, On (MONTH) 10,2018 at 01:30 a.m.- .(Staff G) was at the nurses' station doing paperwork when .(Staff E) came up to .(Staff G) and said .(Staff C) needs you in .(Resident #1's) Rm (room). On arrival to Rm (room number omitted), .(Resident #1's) Rm .(Staff G) found .(Staff C) standing beside the bed, the nurse on the shift (Staff C) was there- .(Resident #1) was lying prone in bed, no respirations, color ashen, skin cool to touch eyes + mouth open slightly- .(Staff C) states, 'she's passed.' (Staff C) then walks out with (Staff G) to the nurse's station, .(Staff G) said .(Staff C) will have to call a RN in to pronounce. During interview on [DATE] in the afternoon with Staff G, Staff G's written statement dated [DATE] was reviewed and Staff G confirmed that it was accurate to what Staff G remembered happening. Review on [DATE] of Staff D's (Registered Nurse) written statement dated [DATE] revealed, (Staff D) was called at 0134 a.m. [DATE] by .(Staff C). (Staff C) stated, '(Resident #1) passed and .(Staff C) need someone to pronounce (Resident #1) as neither .(Staff G) nor (Staff C) can do that.' (Staff D) arrived at (facility) at 0200 and found .(Resident #1) in .(Resident #1's) bed lying flat, no audible respirations, no chest rise noted. (Staff D) listened to chest for 1 minute with stethoscope and no heart beats were noted. Resident was pronounced at 0200. During interview on [DATE] in the afternoon with Staff D, Staff D's written statement dated [DATE] was reviewed and Staff D confirmed that it was accurate to what Staff D remembered happening. Review on [DATE] of Staff C's written statement dated [DATE] revealed, (Staff C) was informed by LNA (Staff E) @ 0130 something was wrong c (with) .(Resident#1). (Staff C) had get to .(Resident #1's) room attempted v/s (vital signs) started to do CPR. looked around saw LNA told .(Staff E) to get .(Staff G). (Staff G) came in looked @ .(Resident #1) and said yes .(Resident #1) is passed-said a quick word to .(Resident #1)-looked @ .(Staff C) said .(Resident #1) is gone we need to call someone to pronounce .(Resident #1). During interview on [DATE] in the morning with Staff C, Staff C's written statement was reviewed and Staff C confirmed that it was accurate to what Staff C remembered happening. Review on [DATE] of facility interview notes dated [DATE] at 1:30 p.m. with Staff C, Staff H (Licensed Practical Nurse) and Staff B (Director of Nurses) present, revealed, (Staff B) read .(Staff C's) written statement back to .(Staff C) and .(Staff C) stated it was correct; (Staff B) then read (Staff C's) nurse's note and asked the following questions: 1.) Did .(Staff C) shake .(Resident #1) call .(Resident #1's) name or do a sternal rub? Answer No 2.) Did .(Staff C) check .(Resident #1's) pupils for a response? Answer No 3.) Did .(Staff C) look for .(Resident #1's) chest to rise and fall? Answer No 4.) Did .(Staff C) check .(Resident #1's) neck pulse (carotid pulse) or listen to .(Resident #1's) heart for ,[DATE] seconds? Answer No 5.) Did .(Staff C) attempt to obtain a blood pressure or temperature? Answer No 6.) Did .(Staff C) get the code cart? Answer No 7/) Did .(Staff C) call or ask anyone to call 911? Answer No 8.) When was the last time .(Staff C) saw this .(Resident #1) and what .(Resident #1) doing? Answer about one hour before What was .(Resident #1) doing? Answer .(Resident #1) was stoking (breathing characterized by rhythmic waxing and waning of depth of respiration) 9.) What did .(Staff C) do? Answer Nothing it was expected 10.) Did .(Staff C) you know .(Resident #1's) code status? Answer No unto until I saw the chart on the counter 11.) Did .(Staff C) call the provider? Answer No Review on [DATE] of Staff C's employee record revealed the following: Staff C had worked for the facility as an agency nurse for approximately a year prior to changing to a full time employee of the facility on [DATE]. Staff C was trained on the facility's policy regarding abuse and neglect prevention on [DATE]. Staff C was trained on conclusive signs of irreversible death on [DATE] when Staff C was working for the facility as an agency nurse. Staff C's nurse license was current and she had been trained in BLS (Basic Life Support) on [DATE]. Interview on [DATE] at 10:30 a.m. with Staff B (Director of Nurses) reviewed the above findings and confirmed that Staff C should have known Resident #1's code status as this information is available on the E-MAR (Electronic Medication Administration Record), on a red sticker for DNR (Do Not Resuscitate) on the paper chart if the resident had been a DNR and on the shift change sheet for each nurse's assignment. During interview on [DATE] at 1:45 p.m. with Staff A (Administrator) and Staff B the above findings were review. Staff A and Staff B confirmed that Staff C was negligent in her duties by not providing CPR for Resident #1 at the time of their death when Resident #1 wanted to be full code and had a physician's orders [REDACTED].#1 was a full code.",2020-09-01
474,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2018-05-23,656,D,1,0,7M4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined that the facility failed to ensure a facility staff implemented a care plan for advance directives which included full code for 1 resident out of a survey sample of 9 residents. (Resident identifier is #1.) Findings include: Review on [DATE] of Resident #1's care plan for advance directives and full code with the revision date of [DATE] revealed the following interventions: .Initiate CPR (Cardiopulmonary Resuscitation), Call 911, notify MD (Medical Doctor) and Guardian . In addition, Resident #1 had been full code prior to the revision date of [DATE]. Review on [DATE] of the facility's Description of incident or concerns; revealed, (Resident #1) . was found by licensed nursing assistant (Staff E) and (Staff F , LNA) on [DATE] at 01:30 in bed and did not appear to be breathing, LNA (Staff E) immediately went to nurse (Staff C, Licensed Practical Nurse) who was caring for resident (Resident #1), and informed .(Staff C), while LNA (Staff F) grabbed vital sign pole (pole/cart to be used to check blood pressure, respirations, temperature, etc.), LPN (Staff C) stated .(Staff C) administered CPR, however, all evidence supports that CPR was not provided, code cart was undisturbed, employee statements support no CPR given, LPN (Staff C) admitted .(Staff C) did not check for conclusive signs of death, did not get code cart, did not notify physician, and did not intervene when .(Staff C) saw the resident (Resident #1) one hour before in distress. Review on [DATE] of Staff C's employee record revealed the following: Staff C had worked for the facility as an agency nurse for approximately a year prior to changing to a full time employee of the facility on [DATE]. Staff C was trained on the facility's policy regarding abuse and neglect prevention on [DATE]. Staff C was trained on conclusive signs of irreversible death on [DATE] when Staff C was working for the facility as an agency nurse. Staff C's nurse license was current and she had been trained in BLS (Basic Life Support) on [DATE]. Interview on [DATE] at 10:30 a.m. with Staff B (Director of Nurses) reviewed the above findings and confirmed that Staff C did not implement the care plan for full code for Resident #1. Staff B revealed that Staff C should have known Resident #1's code status as this information is available on the E-MAR (Electronic Medication Administration Record), on a red sticker for DNR (Do Not Resuscitate) on the paper chart if the resident had been a DNR and on the shift change sheet for each nurse's assignment. The E-MAR, paper chart and shift change sheet were reviewed and did show that Resident #1 was a full code.",2020-09-01
475,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2019-06-03,658,D,0,1,QWJC11,"Based on observation and interview it was determined the facility failed to perform accepted professional standards while administering medications to 1 resident out of a sample size of 17 residents. (Resident identifier is #25). Findings include: Observation on 5/29/19 at 10:30 a.m. revealed Staff A (Licensed Practical Nurse) brought medications in three cups to Resident #25. Resident #25 at the time was participating in an activity. Staff A placed all three cups of medicine on the carpet beside the chair. Staff A then assessed Resident #25's Vital Signs (VS). Staff A then administered the medications. Interview on 5/29/19 at 10:40 a.m. with Staff A revealed that Resident #25 normally sits at one of the tables in the dining room and was not in that location today due to the activity. Interview on 5/31/19 at 1:35 P.M. with Staff B, (Registered Nurse) and Staff C (RN) the observation was brought forth. Staff B revealed that the incident was brought to Staff B's attention by Staff [NAME] Staff A replied to Staff B that Staff A was unsure why Staff A placed the cups of medicine on the floor. Observation on 5/29/19 at approximately 10:25 a.m. with Staff F (Licensed Practical Nurse) revealed that Staff F gave medications in medication cups to Staff [NAME] Staff A walked down the hall with the medications. Interview on 5/29/19 at approximately 10:25 a.m. with Staff A revealed that there were medications in the medication cups that were prepared by Staff F and Staff A was going to adminster the medication. (pronoun omitted) is only trying to help me out. Review on 5/30/19 of the facility policy and procedure titled; NSG 305 Medication: Administration: General, Revision date: 7/24/18 revealed: . Practice Standards . 4. Medications will be administered as soon as possible, but no more than two hours after doses are prepared, and will be administered by the same person who prepares the doses for administration. .",2020-09-01
476,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2019-06-03,761,E,0,1,QWJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of manufacturer's instructions and review of the facility policy procedure, it was determined that the facility failed to ensure that drugs used in the facility must be labeled with the expiration date and expired medications be stored away from medications being utilized when applicable for 1 out of 2 medication carts ([NAME]'s way) and the Birch medication room. (Resident identifier's are #15, #22, #37 and #250.) Findings include: Observation on 5/29/19 at approximately 10:15 a.m. in the Birch medication room refrigerator revealed 6 doses of [MEDICATION NAME] high dose vials with an expiration date of 4/25/19 and 1 opened [MEDICATION NAME] muti-dose vial with no date of opening on it. Interview on 5/29/19 at approximately 10:15 a.m. with Staff G RN (Registered Nurse) confirmed that the individual doses of [MEDICATION NAME] were expired and the multi-dose vial of [MEDICATION NAME] did not have a date of opening on it. Review on 5/31/19 of the manufacturer's instructions; dated (YEAR) revealed the following: [MEDICATION NAME] expires after 28 days of opening at room temperature. [MEDICATION NAME]flex pen expires after 28 days of opening at room termperature. [MEDICATION NAME] expires 28 days after opening. Observation on 5/29/19 at approximately 10:30 a.m. of the [NAME]'s way medication cart revealed the following: Resident #37 [MEDICATION NAME]flex pen with no opening date Resident #250 [MEDICATION NAME] labeled with a do not use after 4/15/19 date Resident #22 [MEDICATION NAME] labeled with a do not use after 5/9/19 date Resident #15 [MEDICATION NAME]flex pen with no opening date Interview on 5/29/19 at approximately 10:30 a.m. with Staff F LPN (Licensed Practical Nurse) confirmed that the insulin pens either did not have a date of opening or were expired. Interview on 5/31/19 at approximately 11:00 a.m. with Staff B DON (DIrector of Nurses) revealed that when medications are expired they are stored in the sink in the medication room. Review on 5/31/19 of the facility's policy and procedure titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles; Revision Date 10/31/16 revealed: . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medications or biological package is opened, Facility should follow manufacturers/supplier guidelines with respect to expiration for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. .",2020-09-01
477,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2017-06-27,371,D,0,1,XFGR11,"Based on observation, interview, and policy & procedure review, it was determined that the facility failed to properly date stored items in the main facility refrigerator. Findings include: Review on 6/27/17 of the facility policy for 'USE BY Dating Guidelines (Rev. 12/01/15), under the heading Frozen shakes related, Use by date of 14 days once thawed. Observation on 6/25/17 at 3:45 p.m., of the walk-in refrigerator revealed there was on a shelf, a tray that contained three thawed supplement shakes. None of the shakes was marked with a use by date. Interview on 6/27/17 at 10:00 a.m. with Staff D (Dietary Services Director) revealed that the frozen shakes are removed the day prior, for intended use, and thawed in the refrigerator. On the day of use, the shakes are labeled for the intended resident and sent to the units. If the shakes are not consumed by the resident, they are returned to the refrigerator, the labels removed, and reused. Staff D provided the above information on Dating Guidelines during this interview.",2020-09-01
478,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2017-06-27,431,D,0,1,XFGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview it was determined that the facility failed to discard expired and outdated insulin from 1 out of 6 medication carts. (Resident identifier is #16.) Findings include: Observation on [DATE] at approximately 4:25 p.m. during the medication pass on the Birch unit with Staff C (License Practical Nurse), Resident #16's blood sugar was obtained by Staff C and the value was 275. Resident #16 has an order for [REDACTED]. Staff C revealed an open vial of Novolin R (regular) insulin with an opened date of [DATE] to be discarded in 42 days. With a use by date of [DATE] in the medication cart. Staff C proceed to draw up 4 units of the Novolin R insulin for the afternoon coverage. This surveyor asked Staff C to look at the vial again just before Staff C was going to inject the Novolin R into Resident #16. Staff C obtained a new vial of Novolin R after checking the vial and checking the used by date and discovered it was expired. Review on [DATE] at approximately 4:45 p.m. of the Medication Administration Record [REDACTED] Novolin R 100 unit/1ML (milliliter) vial- INS (insulin) INJECT 4 units subcutaneously daily (at breakfast) Novolin R 100 unit/1ML vial- INS Give according to Sliding scale Before Lunch and Before Supper Only (inject SQ (subcutaneous) in Abdomen) Over 250=4 Units, Over 350= 8 Units, Over 450= 10 Units Lantus 100 Unit/1ML vial-INS 28 Units subcutaneously every morning. Observation on [DATE] of the Novolin R and the Lantus with Staff C, at approximately 4: 30 p.m. revealed that both had been opened on [DATE] and expired [DATE]. The label from the pharmacy on the vials stated to be discarded after 42 days after open. Review on [DATE] at approximately 4:45 p.m. of the Medication Administration Record [REDACTED]. Interview on [DATE] at approximately 4:45 p.m. with Staff C confirmed that the open vials of Novolin R and Lantus were expired on [DATE] and had been administered. Interview on [DATE] at approximately 6:30 p.m. with Staff B (Director of Nurses) confirmed that the open vials of Novolin R and Lantus were expired on [DATE] and did not understand why the vials would say 42 days instead of the manufacturer's recommended 28 days and had a call into the pharmacy.",2020-09-01
479,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2017-06-27,441,E,0,1,XFGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and review of facility's policy, it was determined that the facility failed to ensure proper infection control practices were adhered to for cleaning of both the blood glucose meter on 1 of 3 units and the PT/INR machine ([MEDICATION NAME] time and international normalized ratio) for the whole facility for two out of sample residents, and for medication administration for 2 Residents. (Resident identifiers are #16, #22, and #23.) Findings include: Resident #16 During observation on 6/25/17 at approximately 4:25 p.m. during the medication pass on the Birch unit with Staff C (Licensed Practical Nurse), Staff C was observed taking a blood glucose test with the blood glucose meter on Resident # 16 and cleaning the blood glucose meter with alcohol swab and placing the blood glucose meter back into the medication cart. Interview at approximately 4:30 p.m. with Staff C revealed that Staff C always uses alcohol swabs and nothing else to clean the blood glucose meter. Review of the facility's policy 6/26/17 at 8:30 a.m. revealed the following: IC201 Cleaning and Disinfecting with a revision date of 11/28/16. Policy Cleaning and disinfecting of patient care items and environment will be conducted based on risk of infection involved .3. Follow manufacturer's recommendations for product use and dwell time and safety precautions when using disinfectants, Wear gloves to avoid skin reactions and exposure to potentially harmful chemicals. Review of the manufacturer instructions that the approved alcohol wipes must be EPA registered which the observed wipes were not EPA registered Resident #23 Nursing Intervention and Clinical Skills Second Edition, by Elkin, Perry and Potter, Copywright 2000, Chapter 17: Administration of Non-[MEDICATION NAME] Medication; under the Implementation section, step #9, states the following: To prepare tablets or capsules from a floor stock bottle, pour the required number into the bottle cap and transfer the medication to the medication cup. Do not touch medication with fingers. Extra tablets may be returned to the bottle. On 6/26/17 at approximately 7:45, a.m. Staff A, MNA (Medication Technician) was observed during morning mediation pass. A multivitamin pill was due to be given to Resident #23. Staff A proceeded to open a bottle of vitamin pills. Once open, Staff A proceeded to pour the vitamin pill into the bottle cap. Three pills entered the cap during the pour, and Staff A attempted to shake 2 of the pills back into the bottle without success. Staff A then held two of the pills in the cap with her ungloved, bare thumb, shaking the remaining pill into the med cup. Staff A then poured the two pills that were held back in the cap, and then poured them back into the vitamin bottle. Interview with Staff B, DON (Director of Nursing), on 6/26/17 at approximately 9:45 am revealed that it is not the policy of this facility to touch resident's medication with bare hands at any time. Resident #22 Observation during tour on the Birch Unit on 6/25/17 at approximately 3:45 p.m. of the PT/INR ([MEDICATION NAME] ratio and international normalized ratio) meter revealed the back of the PT/INR meter had 3 areas with a dried brown/red matter on it. Interview on 6/25/17 at approximately 3:45 p.m.with Staff C, LPN (Licensed Practical Nurse) revealed, It should have been cleaned. It looks like it could be blood, but I am not saying that. Staff C, confirmed that the meter was considered ready for use. Observation on 6/26/17 at approximately 7:30 a.m. during medication pass with Resident #22 revealed Staff E, Licensed Practical Nurse dropped 2 pills out of the medication cup, onto the medication cart and picked the 2 pills up with bare hands and combined them with the other medications in the medication cup. Interview on 6/26/17 at approximately 7:35 a.m. with Staff [NAME] about dropped medications revealed that this is Staff E's normal routine with medications that fall on the medication cart. Staff [NAME] stated, I thought that this was fine as long as they didn't touch the floor? Interview with Staff B, DON (Director of Nursing), on 6/26/17 at approximately 9:45 am revealed that it is not the policy of this facility to touch resident's medication with bare hands at any time.",2020-09-01
480,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-01-12,221,D,0,1,XBFR11,"Based on observation, record review and interview, it was determined that the facility failed to ensure that 1 resident out of a survey sample size of 17 residents is free from physical restraints. (Resident identifier is #11.) Findings include: Record review on 1/11/17 of Resident #11's medical record revealed that an intervention on the care plan for falls indicated Self releasing Velcro reminder belt on broda chair. Evaluate ability to self release weekly. Review of Restraint Evaluation/Reduction assessment also indicates, Self releasing lap belt when up in wheelchair. resident to demonstrate (Resident) can release Q (every) week. Observation on 1/11/17 at 8:45 a.m. and 10:15 a.m. revealed Staff A, MNA, (Medication Nursing Assistant) instructing the Resident to remove Velcro reminder belt. Resident #11 was unable to follow instruction to release the belt. Observation on 1/12/17 at 7:45 a.m. and 7:55 a.m. Resident #11 being instructed by Staff B, LPN, (Licensed Practical Nurse) to remove Velcro reminder belt. Resident #11 was unable to follow instruction to release the Velcro reminder belt. Staff A and B confirmed the above. Interview on 1/11/17 at 2:30 p.m. with Staff C, RN, (Registered Nurse) confirmed that there was no documentation to prove that weekly self release checks were being done.",2020-09-01
481,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-01-12,279,D,0,1,XBFR11,"Based on record review and interview, it was determined that the facility failed to develop a care plan that included all planned concern areas, for one resident in a survey sample of 17 residents. (Resident identifier is #5.) Findings include: Review of Resident #5's Admission Minimum Data Set assessment with an Assessment Reference Date of 11/15/16 revealed that Resident #5 was coded as Frequently incontinent in section H0300. Urinary Continence. Review of the corresponding Care Area Assessment (CAA) for Urinary Incontinence and Indwelling Catheter confirmed that Resident #5 had incontinence and documented the facility's decision to care plan for this care area. Review of Resident #5's care plan revealed no care plan in place for urinary incontinence. Interview on 1/11/17 with Staff F (nurse), confirmed that a care plan for urinary incontinence had not been developed in response to the above CAA decision.",2020-09-01
482,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-01-12,282,D,0,1,XBFR11,"Based on record review and interview it was determined that the facility failed to ensure for 1 resident out of a sample size of 17 residents that services outlined in comprehensive care plan were met. There was no evidence that the comprehensive care plan interventions were being done. (Resident identifier is #11) Findings include: On 1/11/17 record review of Resident #11's record revealed that an intervention on the care plan indicated Self releasing Velcro reminder belt on broda chair. Evaluate ability to self release weekly. Review of Restraint Evaluation/Reduction assessment also indicates, Self releasing lap belt when up in wheelchair. resident to demonstrate (Resident) can release Q (every) week. Documentation did not reflect weekly release checks are being done. Interview with Staff C, RN (Registered Nurse) on 1/11/17 at 2:30 p.m. confirmed that there was no documentation to prove that weekly self release checks were being done.",2020-09-01
483,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-01-12,356,C,0,1,XBFR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to post in a prominent location, that was readily accesible to residents ad visitors, how many Licensed Nurses (Registered Nurses (RN) and Licensed Practical Nurses (LPN) and Licensed Nurse Aides (LNA)) were assigned on both of its resident care units for the survey date of 1/11/17. Findings include: Observation of the front lobby on 1/10/17 during the entry time of 8:15 am. there were no postings of staff (RN, LPN, LNA) that were scheduled to work in the facility. On reentry to the facility on [DATE] at 8 am, there were no postings of staff (RN, LPN, LNA) that were scheduled to work in the facility for that day as well. Observation of the third floor unit on 1/11/17 at 1:45 pm revealed no posted information of the RN, LPN, and LNA that were working on that shift. Interview occurred on 1/11/17 at 1:55pm. with Staff C (RN). Staff C indicated that assignment books contain the requested information as well as who is caring for each resident. Staff C was unable to point out the names in the book of the RN, LPN, LNA staff currently providing care on the unit. Staff C did indicate the information was available on request. Observation on 1/11/17 at 2pm of the second floor unit revealed no posted information of the RN, LPN, and LNA staff that were providing care. Interview with Staff D (RN), on 1/11/2017 occured at 14:05. Staff D confirmed me that no staffing information was available for public viewing on the unit. Observation of the facility lobby area revealed no information regarding staffing levels at the facility.",2020-09-01
484,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-01-12,371,D,0,1,XBFR11,"Based on observation and interview, it was determined that the facility failed to ensure that food was consistently prepared or stored in a safe/sanitary manner, in the main kitchen and in two kitchenettes. Findings include: Observation on 1/10/17 during morning tour in the main kitchen with Staff [NAME] (Dining Service Director) revealed a french fry cutter with the blade device in place with multiple bits of debris adhering to the blade surfaces. Interview with Staff [NAME] at time of the observation revealed that the french fry cutter was ready to use, and Staff [NAME] was observed as they removed the blade device from the french fry cutter. Also during this kitchen tour, interview with Staff [NAME] revealed that food is stored up to 3 to 5 days from date of preparation. Observation on 1/10/17 during morning tour of the 2nd floor kitchenette with Staff [NAME] revealed that entrance to the kitchen is by a push-button combination lock which Staff [NAME] unlocked to allow entrance to the kitchenette. Observation of the refrigerator in the kitchenette revealed an open container of electrolyte solution that was labeled for a resident, which did not have an open date logged on the container. Staff [NAME] was then observed to discard that container of solution. Observation of the freezer compartment revealed an open bag of waffles without any date, which Staff [NAME] then took and discarded. Also observed in the freezer was a frozen, covered bowl with no date. Upon interview with Staff [NAME] at this time, Staff [NAME] identified the item as tomato soup for a particular resident, and Staff [NAME] related it should have a date. Observation on 1/10/17 at 8:30 am during tour revealed the ice machine in the kitchenette located on the third floor was missing a secure holder for the ice scoop. The ice scoop was located in the ice in an up right position with the handle sticking out of the ice. An interview on 1/12/17 at 8:30 am with Staff A (MNA/LNA) revealed that there was an ice scoop holder at one time but it has been missing.",2020-09-01
485,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-01-12,431,D,0,1,XBFR11,"Based on observation and interview, it was determined that the facility failed to discard expired medications found in the medication room and medication cart on the 3rd floor hall low side to right side of nursing station. Findings include: Observation on 1/10/17 at 8:45 a.m. during medication room inspection revealed two bottles of Vitamin D 400 international units had an expiration date of 1/2016 and one bottle of Vitamin B 6 100 milligrams with an expiration date of 1/2016. Interview with Staff A, MNA, Medication Nursing Assistant on 1/10/17 at 8:45 a.m. confirmed the above. Observation on 1/11/17 at 7:15 a.m. during medication cart inspection on the 3rd floor, revealed a prescription container of sublingual Nitrostat 0.4 milligrams had an expiration date of 8/15/16 on the label. The bottle inside had an expiration date of 12/2016. Interview on 1/11/17 at 7:15 a.m. with Staff B, (LPN), Licensed Practical Nurse confirmed the above.",2020-09-01
486,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-01-12,514,D,0,1,XBFR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to provide pain medication parameters for 1 resident out of a survey sample of 23 residents (Resident identifer #1) and conduct proper bed against the wall assessments for 2 residents out of a survey sample of 17 residents (Resident identifers #5, and #9). Findings include: Resident #1 Review on 1/10/17 of Resident #1's pain medication (Tylenol and [MEDICATION NAME]) parameters in the physician orders [REDACTED]. The parameters for the use of the medication [MEDICATION NAME], for the month of December2016, and (MONTH) (YEAR), were not present. Staff D (RN), was interviewed on 1/10/17, late in the afternoon. Staff D indicated that it may of occurred when staff were performing month to month validation of the Resident's orders and did not notice the omission of the [MEDICATION NAME] parameters on the printed medication provided by Omnicare each month. Resident #9 Review of Resident #9's current care plans revealed an intervention for Bed against the wall assessment: Bed against the wall to provide more room for mobility, transfers, and ease movement in the room as recommended by the IDT (Interdisciplinary Team). During interview of Resident #9 in their room on 1/11/17, it was observed that Resident #9's bed is positioned with one side against the wall. Interview on 1/11/17 with Staff F (nurse) to determine if there was any documentation in the record (such as IDT notes) that addressed whether or not the bed against the wall impeded the resident's mobility in any way, revealed an intervention on Resident #9's care plan that related Most nights . prefers sleeping in . recliner with staff reminding . to position q2 hrs (every two hours). Staff F was unable to identify in the record any other documentation that addressed the results of an assessment to determine if the positioning of the bed compromised Resident #9's mobility getting in and out of bed. Resident #5 Review of Resident #5's current care plans revealed an intervention for Bed against the wall assessment: Bed against the wall to provide more room for mobility, transfers, and ease movement in the room as recommended by the IDT. Observation on 1/11/17 of Resident #5's room in the morning confirmed that the Resident #5's bed is positioned with one side against the wall. Staff F was interviewed during survey to determine if there was any documentation in the record that addressed whether or not the bed against the wall compromised Resident #5's mobility getting in and out of bed, and Staff F presented no such documentation.",2020-09-01
487,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-10-25,241,D,0,1,MWBR11,"Based on observation, interview and policy review, the facility failed to respect the privacy of residents during medication administration for 1 resident in a survey sample of 18 residents. (Resident identifier is #18.) Findings include: Observation on 10/24/17 at approximately 7:20 a.m. revealed Staff A (Licensed Practical Nurse) administering an Insulin injection into Resident #18's abdomen. Resident #18 was in the bed closest to the door of the room. Staff A entered the room and informed Resident #18 that Staff A needed to administer Resident #18's Insulin. Staff A asked Resident #18 if it was alright to give the administration in Resident#18's abdomen, to which Resident #18 agreed. Staff A then proceeded to lift the johnny that Resident #18 was wearing, which completely exposed Resident #18 from the upper abdomen down to Resident #18's feet, including the incontinent brief that Resident #18 was wearing. Resident #18 chooses not to use a blanket on the bed. Staff A did not pull the privacy curtain or close the door to administer the injection and Resident #18 was completely visible from the hallway. Interview on 10/24/17 at approximately 10:15 a.m. with Staff B (Registered Nurse) confirmed that the door should be closed or the privacy curtain pulled whenever administering an abdominal injection to a resident. Interview on 10/24/17 at approximately 10:30 a.m. with Staff A confirmed that Staff A was aware that Staff A should have closed the door or pulled the privacy curtain when administering an abdominal injection to Resident #18. Review on 10/25/17 of the facility policy titled Treatment: Considerate and Respectful .Revision Date: 9/1/13 revealed .1.8 Privacy: Maintain patient privacy of body including keeping patients sufficiently covered .",2020-09-01
488,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-10-25,281,D,0,1,MWBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #8 and #11.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 709 Right Documentation. Nurses and other health care providers use accurate documentation to communicate with each other. Many medication errors result from inaccurate documentation. Therefore ensure that accurate and appropriate documentation exists before and after giving medications. Verify inaccurate documentation before giving medications . Resident #11 Review on 10/24/17 of Resident #11's Medication Record for 10/9/17 through 10/31/17 revealed an order for [REDACTED]. Review on 10/24/17 of Resident #11's Treatment Record for 10/9/17 through 10/31/17 revealed that Resident #11 had wound vac changes to Resident #11's right foot on 10/11/17, 10/14/17, 10/15/17 and 10/18/17. Review on 10/25/17 of Resident #11's Controlled Medication Record for [MEDICATION NAME] revealed that Resident #11 received [MEDICATION NAME] 50mg on 10/11/17 and on 10/18/17. There was no documentation that Resident #11 received [MEDICATION NAME] on 10/14/17 or on 10/15/17 prior to wound vac changes. Review on 10/24/17 of Resident #11's Medication Record for 10/9/17 through 10/31/17 revealed an order received on 10/20/17 for Tylenol 1GM (Gram) po TID (Three times daily) scheduled for 8:00 a.m., 2:00 p.m. and HS (Hour of sleep.) There was documentation that Resident #11 received the Tylenol on 10/21/17 through 10/23/17 at 8:00 a.m. and at HS. There was no documentation that Resident #11 received Tylenol at 2:00 p.m. on 10/21/17, 10/22/17 or 10/23/17 nor was there a documented reason as to why the Tylenol was not administered on those days. Interview on 10/25/17 at approximately 9:30 a.m. with Staff C (Director of Nursing) confirmed that there was documentation that Resident #11 received the wrong dose of [MEDICATION NAME] on 10/11/17 and on 10/18/17 prior to wound vac changes and that there was no documentation that Resident #11 received any [MEDICATION NAME] prior to the wound vac changes on 10/14/17 and on 10/15/17. Staff C also confirmed that there was no documentation that Resident #11 received the scheduled 2:00 p.m. Tylenol on 10/21/17, 10/22/17 or 10/23/17. Resident #8 Review on 10/25/17 of Resident #8's Medication Record for 9/1/17 through 9/30/17 revealed an order for [REDACTED]. Review on 10/25/17 of Resident #8's Medication Record for 9/1/17 through 9/30/17 revealed that Resident #8 received [MEDICATION NAME] 0.5 ml on the following dates: 9/3, 9/4 (x2) incorrect documentation-back of Medication Record signed only, 9/7, 9/8 (x2), 9/15 (x2), 9/17 (x2) incorrect documentation-back of Medication Record signed only, 9/18, incorrect document only the front is signed with no effectiveness on the back of the medication record or in the nurse's notes,9/20, 9/21,9/22 (x2), 9/28 incorrect document only the front is signed with no effectiveness on the back of the medication record or in the nurse's notes, 9/29 and 9/30. Interview on 10/25/17 at approximately 9:30 a.m. with Staff D (Workplace Resident Life Coordinator) confirmed the documentation for Resident #8 for the [MEDICATION NAME] was inconsistent and did not always show effectiveness.",2020-09-01
489,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-10-25,282,D,0,1,MWBR11,"Based on record review and interview, the facility failed to update care plans for 1 resident in a survey sample of 18 residents. (Resident identifier is #10.) Findings include: Review on 10/23/17 of Resident #10's nursing notes revealed that Resident #10 had a fall with injury at the facility on 10/14/17. Resident #10's fall resulted in 2 fractures (Left humerus fracture and left distal humerus fracture). Review on 10/23/17 of Resident #10's progress note from (name omitted) Orthopaedics on 10/18/17 revealed that Resident #10 had the following orders: Sling. Non Weight Bearing to the Left Upper Extremity. Okay to remove sling and splint as needed for hygiene. Hold off on Range of Motion for now. Review of Resident #10's care plans revealed that they were not updated after the residents fall on 10/14/17. Resident #10's care plans were not updated with limitations ordered from the Orthopaedics appointment on 10/18/17. Review on 10/23/17 of the facility policy and procedure titled, NSG215 Falls Management revealed that under Practice Standards, . 5.4 Update care plan to reflect new interventions. Interview on 10/23/17 at approximately 12:00 p.m. with Staff D (Workplace Resident Life Coordinator) confirmed that Resident # 10's care plan was not updated.",2020-09-01
490,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-10-25,322,D,0,1,MWBR11,"Based on observation, interview and policy review, the facility failed to appropriately administer medications through a gastrostomy tube for 1 resident in a survey sample of 18 residents. (Resident identifier is #18.) Findings include: Observation on 10/24/17 at approximately 7:25 a.m. revealed Staff A (Licensed Practical Nurse) administering seven different medications to Resident #18 through Resident #18's gastrostomy tube. Staff A did not administer any water between each medication being administered. Review on 10/25/17 of the facility's policy Medication Administration: Enteral .Revision Date: 11/28/16 revealed that .9. Administer medications individually. 9.1 Flush with 5 ml (milliliter) tap water between each medication . Review on 10/25/17 of Resident #18's physician orders did not reveal any documented evidence that there was a physician order not to flush with water after each individual medication. Interview on 10/25/17 at approximately 9:30 a.m. with Staff B (Registered Nurse) confirmed that gastrostomy tubes should be flushed with water between each medication administered.",2020-09-01
491,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2017-10-25,514,D,0,1,MWBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the Facility failed to provide an accurate medical record for 1 resident in a survey sample of 18 residents. (Resident identifier is #13.) Findings include: Resident #13 Review on 10/24/17 of Resident #13 medical record revealed that Resident #13 was admitted on [DATE] with the following Diagnosis: [REDACTED]. Review on 10/24/17 of Resident #13's medical record revealed an AIM (Abnormal Involuntary Movement Scale) that was completed on 7/1/17 that had a score of 7. Where in section [NAME] (Facial and Oral Movements) had a score of 5. The 3 previous AIMS all had a scores of zeros. Review of Resident #13 medical record revealed a late entry nurses note with an effective date of 7/1/17, has a baseline lip-smacking and grimacing when (pronoun omitted) talks which is part of (pronoun omitted) personality and speech affect .currently being followed by med-ptions and (pronoun omitted) PCP (Primary Care Physician} at this time for other acute issues. Score from today is reflective of (pronoun omitted) true baseline and therefore we will continue to monitor at this time. Review of Resident #13 Medication Management Assessment completed on 7/5/17 for follow up of medication reduction and other ongoing behavioral problems with an onset prior to admission. The [MEDICATION NAME] was decreased from 20 mg (milligrams) PO (by mouth) BID (twice a day) to 10 mg PO BID on 4/27/17 to d/c (discontinued) the 10 mg a.m. leaving the 10 mg pm dose in place on 6/1/17. Continue review of the Medication Management Assessment form reveals that the section Review of the Systems was Not Assessed. Under the section Examination it revealed the following: Appearance WNL (Within Normal Limits), Behavior Restless/Inability to remain Still, Speech Pressured, Repetitive, racing thoughts. Review of Resident #13's care plan revealed one for complications related to the use of [MEDICAL CONDITION] drugs. Under the Intervention section the following interventions were listed: AIMS testing per protocol; monitor for changes in mental status and functional level and report to MD (Medical doctor) as indicated; Monitor for side effects and consult physician and/or pharmacist as needed. Review of the facility policy of Management of Symptoms with a revision date of 8/15/17 reveals .Who displays or is diagnosed with [REDACTED]. Interview on 10/25/17 with Staff A (Director of Nursing) and Staff D (Registered Nurse) at 11:15 a.m. indicated that lip-smacking and grimacing is the baseline for Resident #13 but could not find no other documentation to this effect. That the first few AIMS were incorrect.",2020-09-01
492,VILLA CREST,305079,1276 HANOVER STREET,MANCHESTER,NH,3104,2019-08-30,658,D,0,1,GSVQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that services being provided meet professional standards for 1 resident whose weights were not properly documented and for 1 resident for whom physicians' orders were not followed in a final survey sample of 29 residents. (Resident identifiers are #55 and #77.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 564: If the client has lost more than 5% of body weight in a month or 10% in 6 months, the loss is significant. You need to weigh clients at the same time of day, on the same scale, and in the same clothes to allow an objective comparison of subsequent weights. Accuracy of weight measurement is important because health care providers will base medical and nursing decisions . on changes [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the client suffers Resident #55 Review on 8/27/19 of Resident #55's medical record revealed under the vital sign section of the chart that the last weight that was done was on 8/22/19 showing 154.6 pounds. The prior weight done on Resident #55 was on 8/15/19 which was 167.7 pounds, a 7.8 % weight loss in one week. On 8/8/19 Resident #55's weight was 169.2 pounds, and on 8/1/19 was 163 pounds. Interview on 8/27/19 at 8:44 a.m. with Staff B (Unit Manager) who was shown the weight logs, Staff B stated Resident #55 had been ill for a short period of time, but felt that he never could have weighed 167.7 lbs (pounds) and was closer to weighing between 155 and 160 lbs. Staff B stated that she will get a reweigh which was performed and Resident #55's weight is 157.6 as of 8/27/19 at 2:30 p.m. Staff B also revealed that they did do a medication reduction of [MEDICATION NAME] which caused decrease in appetite and increase in behavior. Medications were reordered with a GDR (Gradual Drug Reduction) failure. Staff B went on to say the issue stems from the staff using different types of equipment when weighing residents and not deducting the equipment being used. Resident #77 Review on 8/30/19 Resident #77's MAR (Medication Administration Record) revealed a physician order [REDACTED]. [MEDICATION NAME] R Regular U-100 Insulin (insulin regular human) (OTC (over the counter)) solution; 100 unit/ml; Amount to Administer: Per Sliding Scale; If Blood Sugar is 0-180, give 0 units. If Blood Sugar is 181 to 240, give 2 Units. If Blood Sugar is 241 to 300, give 4 Units. If Blood Sugar is 301 to 350, give 6 Units. If Blood Sugar is 351 to 400, give 8 Units. If Blood Sugar is greater than 400, give 10 Units. If Blood sugar is greater than 400, call MD (physician). injection Further review of the MAR indicated [REDACTED]. Then the next scheduled time for Resident #77's Blood Sugar was at 11:00 a.m. with a charted date-time of 10:22 Not Administered: Due to Condition and no Blood Sugars were documented. Review on 8/30/19 at 10:02 a.m. of Resident #77 medical record revealed has a nurses note dated 8/4/19 that revealed 12 p.m. resident unresponsive. Clammy and pale. Blood sugar done: 23 [MEDICATION NAME] given IM (Intramuscularly) . 12:15 BS-49 12:15 [MEDICATION NAME] IM repeated. 12:30-BS-67 1:00 BS (Blood Sugar)-71 115 BS -131 1:30 BS-302. Resident alert and oriented. Had 100% of lunch. Used BR (bathroom) facilities. Lg (large) Void and med bm (bowel movement). No further hypoglycemic signs noted on this shift. Review on 8/30/19 of the MAR indicated [REDACTED].Amount to Administer: 1 mg; injection Resident #77 was administered this medication two times. Review on 8/30/19 of the MAR indicated [REDACTED]. If this occurs at meal time-order tray. Hold insulin dose and call provider. On review of the MAR for 8/25/19 at 6:20 a.m. Blood Sugar was at 51 mg and there was no documentation of administration of the above order. This also happened on 8/26/19 at 6:31 am with Blood Sugar at 58 mg. Review on 8/30/19 of the MAR indicated [REDACTED]. If Blood sugar is greater than 400, call MD. injection On review of the MAR for 8/4/19 at 7:33 p.m. Blood Sugar was at 415 mg and there was no documentation showing that the physician was called in the nurses notes or anywhere else in the chart. Interview on 8/30/19 at 1:30 p.m. with Staff A (Director of Nurses) who was shown all the information written above and Staff A confirmed the above findings.",2020-09-01
493,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2018-01-11,609,D,1,0,MY9U11,"> Based on record review and interview, it was determined that the facility failed to report to the State Survey Agency 2 incidents of inappropriate touching of residents (names unknown) by 1 resident. (Resident identifier is #1) Findings include: Review on 1/11/18 of Resident #1's Nurse's Notes, dated 10/6/17 at 2:45 p.m., revealed .Found sitting by 1 female rubbing her upper thigh while she was asleep . Review on 1/11/18 of Resident #1's Nurse's Notes, dated 10/9/17 at 10:30 a.m., revealed Reported by staff that worked the w/e (weekend) (Resident #1) needed to be escorted out of female bedrooms multiple times .caught inapprop (inappropriately) touching female res (resident) multiple times . Review on 1/11/18 of the Facility's Administrative Procedures Manual, original date 8/1/01, revised date 12/11/17 revealed .Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect, misappropriation of patient property or exploitation if it meets any of the following criteria: .6. Any complaint of sexual harassment, sexual coercion, sexual assault, or inappropriate touching . Review further revealed .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law . Interview on 1/11/18 at approximately 1:30 p.m. with Staff A (Director of Nursing) stated that the two allegations of inappropriate touching were not reported to the State Survey Agency and that they should have been reported.",2020-09-01
494,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2017-07-07,221,D,0,1,ERMS11,"Based on medical record review, observation, and interview, it was determined that the facility failed to do assessments of residents positioned in wheelchairs when unattended and seated at tables, and to obtain orders and consents if indicated if the assessments identified this positioning constituted a restraint, for 4 residents out of 16 observed residents. (Resident identifiers are #10, #16, #18, and #19.) Findings include: Observation on 7/5/17 at approximately 11:50 a.m. to 12:10 p.m. of the 1st floor dining room (closest to the nurses station) revealed 4 out of 16 residents in wheel chairs and scootchairs (specialized wheel chair to promote mobility) positioned at dining tables with wheelchair brakes locked for safety, with no meal or activity occurring on these tables. Resident #10 was in a scoot chair positioned at a dining table with 1 brake in the locked position. Review of Resident 10's care plan dated 4/17/17 under Falls revealed that the resident self propels scoot chair on unit. Also per falls care plan Resident 10 is able to get in and out of scoot chair independently. Resident #16 was in a wheelchair positioned at a dining table with 2 brakes in the locked position. Review of Resident #16's care plan dated 7/3/17 under Falls revealed that the resident self propels wheelchair. Resident 16 Ambulates hand held assist of 2. Resident #18 was in a scoot chair positioned at a dining table with 1 brake in the locked position. Review of Resident #18's care plan dated 5/22/17 under Falls revealed that the resident is out of bed to a scoot chair daily, able to get in and out of independently. Also per falls care plan Resident #18 transfers and ambulates with assist of 1-2, gait belt, and walker. Resident #19 was in a wheel chair positioned at a dining table with 1 brake on. Review of the 4 residents medical records revealed that there were no physician orders for restraints, restraint consents or restraint assessments. Interview on 7/5/17 at approximately 12:00 p.m. with Staff A (Licensed Nursing Assistant) confirmed that the brakes were in the locked positions on the above residents. Interview on 7/5/17 at approximately 12:05 p.m. with Staff B (Licensed Nursing Assistant) confirmed that Resident's #10, #16, and #18 self propel themselves in the chairs in the facility. Interview with Staff B (Licensed Nursing Assistant) revealed that Resident #19 self propelled wheelchair on the unit. Interview on 7/5/17 at approximately 1:30 p.m. with Staff C (Registered Nurse) revealed that Staff probably wanted them to stay safe and locked the chairs. Review of the facility's Use of Restraints policy dated (MONTH) 2007 under Policy Interpretation and Implementation revealed: 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and or/representative (sponsor). The order shall include the following: [NAME] The specific reason for the restraint (as it relates to the resident's medical symptom); B. How the restraint will be used to benefit the resident's medical symptom; C. The type of restraint, and period of time for the use of the restraint. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing symptom(s).",2020-09-01
495,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2017-07-07,441,D,0,1,ERMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to complete the first [DIAGNOSES REDACTED] (TB) test on 2 of 5 sampled employees prior to these employees having contact with residents as required by state regulation. Findings include: New Hampshire Code of Administrative Rules, Chapter He-P 800, Part He-P 803, New Hampshire Nursing Home Rules, effective 1/26/11, page 33, section 803.18 (i)(1) states Prior to having contact with clients, employees shall: (1) Submit to the licensee the results of a physical examination or a health screening preformed by a licensed nurse or a licensed practitioner and the results of a 2-step [DIAGNOSES REDACTED] (TB) test, Mantoux method or other method approved by the Centers for Disease Control .(2) Be allowed to work while waiting for the results of the second step of the TB when the results of the first step are negative for TB . Review on 7/7/17 of employee records revealed that Staff [NAME] (Licensed Nurse Assistant) had the first step of the TB test planted on 7/4/17 and read 7/7/17. Review of the facilities daily schedule for the survey period revealed Staff [NAME] worked on the 1st floor unit on 7/5/17 and 7/6/17. Interview on 7/7/17 at approximately 8:30 a.m. with Staff C (Minimum Data Set Coordinator) confirmed the above finding. Review on 7/7/17 of employee records revealed that Staff D (Dietary Aide) had the first step of the TB test planted on 3/25/17 and read on 3/27/17. Interview on 7/7/17 at 8:45 a.m. with Staff F (Human Resources) revealed that Staff D worked having contact with residents on 3/26/17.",2020-09-01
496,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2019-08-23,640,B,0,1,DM3I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to transmit the Minimum Data Set (MDS) within 14 days after completion for 5 of 28 residents reviewed for MDS assessments. (Resident identifiers are #2, #3, #4, #5, and #6.) Findings include: Review on 8/23/19 at 9:01 a.m. of MDS reports revealed that Resident #2's last transmission was an admission assessment dated [DATE], Resident #3's last transmission was a quarterly assessment dated [DATE], Resident #4's last transmission was a quarterly assessment dated [DATE], Resident #5's last transmission was an assessment dated [DATE], and Resident #6's last transmission was a quarterly assessment dated [DATE]. Interview on 8/23/19 at 9:32 a.m. with Staff A (MDS Coordinator) revealed that the above Resident's MDS assessments were due the first week in (MONTH) and were completed, but had not been uploaded/submitted until the time of survey on 8/22/19.",2020-09-01
497,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2019-08-23,656,D,0,1,DM3I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet 1 of 1 resident's mental and psychosocial needs in a standard survey sample of 23 residents. (Resident identifier is #83.) Findings include: Review on 8/23/19 of Resident #83's medical record revealed that on 5/2/19 Resident #83 was transferred to the hospital by the facility due to suicidal comments/ideation's. Resident #83 was then transferred from the local hospital to a second hospital on [DATE] and discharged on [DATE]. The summary from the second hospital states .admitted on (MONTH) 8, 2019 on transfer from (hospital) with depression and recent suicidal behavior. This is .(Resident #83) first . psychiatric admission, but one of multiple psychiatric hospitalization s .said .(Resident #83) couldn't stand it and drank some cleaning fluid, 'just a tiny teaspoon,' unable to drink more due to the taste. (Resident #83) did do this as a suicide attempt, but immediately told staff and was sent to (hospital) . Review on 8/23/19 of Resident #83's current care plan failed to have any needs written to address the above behavior since being readmitted to the facility after expressing the desire to commit suicide. Interview on 8/23/19 at 10 a.m. with Staff B (Director of Nurses) confirmed that the facility did not write a care plan to address the above event to help staff monitor and assess Resident #83's suicidal behavior for signs and symptoms.",2020-09-01
498,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2018-04-24,641,D,1,0,4KIA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that the MDS (Minimum Data Set) Assessments accurately reflect the skin integrity status of 1 resident out of a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on 4/24/18 of Resident #1's Skin Integrity Report, dated 1/12/18 revealed that Resident #1 had a Stage 2 pressure ulcer on their coccyx, which was present on their admission date of [DATE]. It also revealed that Resident #1 had a Stage 2 pressure ulcer on their right posterior lower extremity, which was present on admission. Review on 4/24/18 of Resident #1's MDSs with ARDs' (Assessment Reference Dates) of 1/18/18 and 1/28/18 Section M0300 B revealed that Resident #1 had 2 Stage 2 pressure sores that were present on admission. Review on 4/24/18 of Resident #1's Wound Care Center progress note, dated 2/9/18, revealed that Resident #1 now had a Stage 4 pressure sore on their right posterior leg and a Stage 3 pressure sore on their sacrum. Review on 4/24/18 of Resident #1's MDS with ARD of 2/12/18 Section M0300 B revealed documentation that Resident #1 still had 2 Stage 2 pressure sores that were present on admission and no other pressure sores at any higher stages. Review also revealed that in Section M0800, which questioned the number of worsening pressure ulcers since the prior assessment, which was 1/28/18, it was documented that there were none. Review on 4/24/18 of Resident #1's MDS with ARD of 3/14/18 Section M0300 B revealed documentation that Resident #1 still had 2 Stage 2 pressure sores that were present on admission and no other pressure sores at any higher stages. Review also revealed that in Section M0800, which questioned the number of worsening pressure ulcers since the prior assessment, which was 2/12/18, it was documented that there were none. Review on 4/24/18 of Resident #1's Wound Care Center progress note, dated 3/23/18, revealed that Resident #1's pressure sore on their right posterior leg was now a Stage 2 and the pressure sore on their sacrum was now a Stage 4. Review on 4/24/18 of Resident #1's Discharge, Return Anticipated MDS, with ARD of 3/27/18 Section M0300 F revealed documentation that Resident #1 had 1 Unstageable pressure sore that was present on admission and no other pressure sores at any higher stages. Review also revealed that in Section M0800, which questioned the number of worsening pressure ulcers since the prior assessment, which was 3/14/18, it was documented that there were none. Review on 4/24/18 of Resident #1's Entry MDS, with ARD of 3/29/18 revealed that Resident #1 returned to the facility on [DATE], after a discharge on 3/27/18 to an acute care hospital. Review on 4/24/18 of Resident #1's Wound Care Center progress note, dated 4/5/18, revealed that Resident #1 had a Stage 4 pressure sore on their sacrum. Review on 4/24/18 of Resident #1's MDS with ARD of 4/5/18 Section M0300 F revealed documentation that Resident #1 had 1 Unstageable pressure sore that was present on readmission, and no other pressure sores. Interview on 4/24/18 at approximately 2:30 p.m. with Staff A (Administrator) and Staff B (Unit Manager) confirmed that the pressure sore documentation on the MDSs and the pressure sore documentation on the weekly skin integrity reports, done by the facility staff, was not accurate and that it did not match the documentation done by the wound clinic. They also confirmed that accurate documentation should have been done.",2020-09-01
499,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2018-04-24,658,D,1,0,4KIA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #1.) Findings include: Professional reference: Potter, [NAME] [NAME], and Perry, Anne Griffin . Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 4/24/18 of Resident #1's Wound Care Center physician progress notes [REDACTED].#1 had a pressure ulcer on the sacral region. Review revealed that this pressure sore had declined from a Stage 2 pressure sore on 1/11/18 to a Stage 3 pressure sore on 2/9/18 to a Stage 4 pressure sore on 3/23/18. Review revealed an order, dated 4/5/18, for off-loading which read .Pressure release every 30 minutes while in chair . Review on 4/24/18 of Resident #1's current care plan revealed that Resident #1 required assistance with repositioning. Interview on 4/24/18 at approximately 1:00 p.m. with Resident #1, who was laying in bed, revealed that Resident #1 stated that they are up in the wheelchair every day for intervals of no longer than 2 hours. Resident #1 stated that staff do not assist them with repositioning or remind them to reposition in the chair every 30 minutes. Review on 4/24/18 of Resident #1's current care plan did not include any interventions to release pressure every 30 minutes when in a chair. Review of 4/24/18 Resident #1's medical record revealed no documented evidence that the staff are repositioning Resident #1 or reminding Resident #1 to reposition every 30 minutes when in a chair. Interview on 4/24/18 at approximately 2:30 p.m. with Staff A (Administrator) and Staff B (Unit Manager) confirmed that there was no documented evidence that Resident #1 was being repositioned in the wheelchair and that it should have been done and documented that it was done.",2020-09-01
500,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2018-04-24,755,D,1,0,4KIA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to provide a scheduled medication used to treat [MEDICAL CONDITION] for 1 resident out of a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on 4/24/18 of Resident #1's (MONTH) Medication Administration Record [REDACTED].Give 10 mg (milligram) by mouth every 12 hours for (medical diagnosis) . Review on 4/24/18 of Resident #1's (MONTH) Medication Administration Record [REDACTED]. dose on 3/2/18 until Resident #1 received it at 11:30 p.m. on 3/21/18. Interview on 4/24/18 at approximately 1:00 p.m. with Resident #1 revealed that Resident #1 stated that they did not get their medication for [MEDICAL CONDITION] for approximately 3 weeks. Resident #1 stated that they were only told by the staff that they were working on it. Resident #1 revealed that they feel that they had a decline in their function because of not getting the medication. Resident #1 stated that the most specific decline was in their ability to transfer to and from the wheelchair. Review on 4/24/18 of the Facility's Policy titled Medication Shortages/ Unavailable Medications, dated 12/1/07 and revised 1/1/13, revealed that .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy . The policy review also revealed that .If the medication is unavailable from Pharmacy or a Third Party Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary .If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for orders/ direction, making sure to explain the circumstances of the medication shortage .When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) and in the nurse's notes per Facility policy. Such documentation should include the following information: .A description of the circumstances of the medication shortage; A description of Pharmacy's response upon notification; and .Action(s) taken. Review on 4/24/18 of Resident #1's Skilled Nurses Note, dated 3/6/18, which was 4 days after the first missed dose of Ampyra, revealed a note that read .Ampyra not available, patient and NP (Nurse Practitioner) aware . Review on 4/24/18 of an email, dated 3/8/18, from the Center Nurse Executive to the Pharmacy revealed it read .The prescription you sent for (Proper Noun) was only for 6 pills, 3 day supply. Since (pronoun) will be here for a while can you please call (phone number) to authorize a month supply? Or for however many (resident) needs til (until) discharge . Review on 4/24/18 of Resident #1's Progress Note written by the APRN (Advanced Practice Registered Nurse,) dated 3/13/18 revealed a note that read .(Pronoun for Resident#1) feels that (pronoun for Resident #1) may be having a flare and will need steroids. (Pronoun) amypra (sic) was supposedly sent by pharmacy, but it has not arrived yet. DON (Director of Nursing) to f/u (follow up) on lack of amypry (sic) presence . Review on 4/24/18 of Resident #1's (MONTH) Administration Record revealed that there was no order for Steroid medication. Review on 4/24/18 of Resident #1's Skilled Nurses Note, dated 3/17/18, revealed a note that read .Ampyra still not not available NP made aware and DON made aware . Interview on 4/24/18 at approximately 2:30 p.m. with Staff A (Administrator) and Staff B (Unit Manager) confirmed that there was not enough documented evidence that the facility attempted to obtain the medication, or that other alternate orders were discussed. Review on 4/27/18 of Resident #1's Physical Therapy Treatment Encounter note, dated 3/14/18, revealed a note that read .Pt (patient) went to neurological appointment today and expressed frustration secondary to reporting no new interventions from neurologist . Review on 4/27/18 of Resident #1's General Nurses Note, dated 3/15/18, revealed that Resident #1 did go out to see neurologist, but there was no documentation indicating that the neurologist was notified that Resident #1 has not been receiving the Ampyra for [MEDICAL CONDITION]. Interview on 4/27/18 at approximately 2:30 p.m. with Staff A confirmed that there was no documented evidence that Resident #1's neurologist was notified that Resident #1 had not been receiving Ampyra.",2020-09-01
501,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2019-04-26,578,D,0,1,P14411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined that the facility failed to initiate a DNR (Do Not Resuscitate) order for 1 resident in a final survey sample of 20 residents. (Resident identifier is #264.) Findings include: Review on 4/23/19 of Resident #264's Entry Tracking MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 4/18/19 revealed that Resident #264 was readmitted to the facility on [DATE]. Review on 4/23/19 of Resident #264's Discharge Return Not Anticipated MDS with ARD of 4/16/19 revealed that Resident #264 had been discharged home after having been admitted to the facility on [DATE]. Review on 4/23/19 of Resident #264's current physician orders [REDACTED].#264. Review on 4/24/19 of Resident #264's physician orders [REDACTED].#264 had an order for [REDACTED]. Review on 4/24/19 of the Facility Policy titled, Health Care Decision Making last revised on 1/1/13, revealed that .Upon admission .the physician, in collaboration with designated Center staff, will meet with the patient or health care decision maker to complete or review advance directives . Interview on 4/24/19 at approximately 10:15 a.m. with Staff A (Unit Manager) confirmed that Resident #264 did not have orders for Code Status from their admission on 4/18/19 through 4/23/19. Staff A confirmed that the Code Status was discussed with Resident #264 on 4/24/19 and that Resident #264 wanted to be a DNR. Staff A also confirmed that without an order for [REDACTED].#264 at admission.",2020-09-01
502,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2019-04-26,697,D,0,1,P14411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined that the facility failed to document follow up assessments of the resident's pain relief after the administration of pain medication for 1 resident in a final survey sample of 20 residents. (Resident identifier is #39.) Findings include: Interview on 4/23/19 at approximately 9:45 a.m. with Resident #39 revealed that Resident #39 stated that they have pain in their back and their side. Resident #39 was unable to answer the question of whether or not they got relief from pain medications administered to them. Review on 4/25/19 of Resident #39's (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 4/25/19 of Resident #39's (MONTH) 2019 PRN (As Needed) Pain Management Flow Sheet . revealed that Resident #39 received [MEDICATION NAME] with no documented pain rating after administration on 4/2/19, 4/5/19, 4/7/19, 4/8/19, 4/10/19, 4/12/19, 4/16/19 and 4/21/19. Review on 4/25/19 of the Facility Policy titled Pain Management last revised on 3/1/18, revealed that .Patients receiving interventions for pain will be monitored for the effectiveness .in providing pain relief .Document: .Effectiveness of PRN medications . Interview 4/25/19 at approximately 1:45 p.m. with Staff A (Unit Manager) confirmed that the documentation for pain medication results was missing and that the nurses should have documented how much relief the resident had with each administration.",2020-09-01
503,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2019-04-26,758,D,0,1,P14411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined that the facility failed to document behavior monitoring for a resident who received antipsychotic medication for 1 resident in a final survey sample of 20 residents. (Resident identifier is #39.) Findings include: Review on 4/24/19 of Resident #39's (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 4/25/19 of Resident #39's (MONTH) 2019 Medication Administration Record [REDACTED]. Review on 4/25/19 of the Facility's Policy titled, Behaviors: Management of Symptoms . last revised on 8/15/17, revealed that .The Behavior Monitoring and Interventions Flow Record will be used for patients who: Exhibit behavioral symptoms .Are taking [MEDICAL CONDITION] medications that require monitoring . Interview on 4/25/19 at approximately 1:45 p.m. with Staff A (Unit Manager) revealed that residents who take antipsychotic medication are to have their behaviors documented using a behavior flow record. Staff A also confirmed that there was no behavior flow record for Resident #39 and that there should have been one.",2020-09-01
504,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2019-04-26,761,D,0,1,P14411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility policy and procedure and review of the pharmacy insulin storage recommendations it was determined that the facility failed to label 2 insulin pens and 2 insulin vials with no indication of opening dates or expiration dates on 1 of 4 medication carts observed. (Brown Cart A wing) Findings include: Observation on [DATE] at approximately 1:05 p.m. of the A wing medication cart (Brown Cart) revealed the following insulin vials/pens opened and not labeled with an expiration date: Resident #11 [MEDICATION NAME] flex pen Resident #11 [MEDICATION NAME] pen Resident #29 2 [MEDICATION NAME] vials Interview on [DATE] at approximately 1:10 p.m. with Staff D (Medication Nurse Assistant) confirmed that the insulins were opened and had no expiration dates on them. Review on [DATE] of the facility policy and procedure titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revision date [DATE] revealed: . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; . 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened Review on [DATE] of the pharmacy insulin storage recommendations dated ,[DATE] revealed the following: [MEDICATION NAME] at room temperature has a 42 day expiration date. [MEDICATION NAME] pen at room temperature has a 28 day expiration date. [MEDICATION NAME] pen at room temperature has a 28 day expiration date.",2020-09-01
505,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2019-04-26,842,D,0,1,P14411,"Based on interview and record review, it was determined that the facility failed to ensure complete resident records for a resident fall and progress notes after a physician visit for 2 residents in a final survey sample of 20 residents. (Resident identifiers are #30 and #55.) Findings include: Resident #55 Review on 4/24/19 of Resident #55's progress notes revealed a progress note, dated 4/8/19 at 11:08 a.m., which read (Resident #55) had an unplanned transfer. Contact person notified of transfer. Name: (Resident #55) .(Telephone number) . Review on 4/24/19 of Resident #55's progress notes revealed a progress note, dated 4/9/19 at 11:13 a.m., which read patient returned from (Noun omitted) Hospital after fall that occurred at 11:00 am. CT (Computerized [NAME]ography) scan results came back as negative. Patient arrived via ambulance on stretcher. EMT's (Emergency Medical Technicians) transferred (Resident #55) into bed. Patient is alert and medications were given as scheduled. NP (Nurse Practitioner) aware of return. No new orders at this time. Family notified. Review on 4/24/19 of Resident #55's progress notes revealed that there were no other progress notes with any information regarding the events prior to the fall, details of the fall, or the assessment immediately after the fall. Interview on 4/26/19 at approximately 9:45 a.m. with Staff B (Director of Nursing) confirmed that Resident #55's progress notes did not include details about Resident #55's fall. Staff A also confirmed that all of the information about the fall should have been included in Resident #55's progress notes. Resident #30 Interview on 4/24/19 at approximately 11:15 a.m. with Resident #30's father revealed that Resident #30 was late for an ultrasound appointment that morning because staff was not aware of the appointment. Interview on 4/25/19 at approximately 10:00 a.m. with Staff B, DON (Director of Nurses) confirmed that the facility was not aware of Resident #30's ultrasound appointment. Staff B revealed that Resident #30 was seen by a Cardiologist on 4/2/19 and there was no office visit report in Resident #30's medical record. Review on 4/25/19 at approximately 1:00 p.m. of the Cardiologist office note dated 4/2/19 revealed: . Plan . Check renal artery ultrasound to exclude renal artery stenosis. Interview on 4/25/19 at approximately 1:00 p.m. with Staff B also revealed that there was no process in the facility requesting physician office visits notes that are done outside of the facility to be obtained for residents medical records in the facility.",2020-09-01
506,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2019-04-26,880,D,0,1,P14411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy and procedure review, it was determined that the facility failed to adhere to infection control procedures with glucometer cleanings between residents and during medication pass observation for 1 resident out of 4 residents observed. (Resident Identifier is #11.) Findings include: Interview on 4/23/19 at approximately 10:00 a.m. with Staff E, LPN (Licensed Practical Nurse) revealed that Staff [NAME] uses alcohol prep pads to disinfect the glucometer between resident use. Review on 4/25/19 of the facility policy and procedure titled, Glucose Meter, Revision Date; 3/16/17 revealed the following: . 1.3 Environmental Protection Agency (EPA) approved disinfectant against [MEDICAL CONDITIONS](Human immunodeficiency Virus) (do NOT use an alcohol prep pad). 2. Disinfect meter before and after each patient use. Resident #11 Observation on 4/24/19 at approximately 8:10 a.m. revealed Staff F (Registered Nurse) preparing medications to administer to Resident #11. Staff F popped an [MEDICATION NAME] tablet from the blister pack directly into their hand without wearing a glove. Staff F stated that the tablet was small and they popped it into their hand so that there was less likelihood of it falling on the floor. Interview on 4/24/19 at approximately 8:20 a.m. with Staff F confirmed that they should have worn gloves if they needed to pop a medication directly into their hand. Interview on 4/24/19 at approximately 9:00 a.m. with Staff C (Senior Center Nurse Executive) confirmed that Staff F should have worn gloves if they needed to pop a medication directly into their hand.",2020-09-01
507,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2017-05-17,155,E,0,1,UJ9B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to establish mechanisms for documenting and communicating the resident's CPR (CardioPulmonary Resuscitation) and/or DNR (Do Not Resuscitate) choices for 3 residents in a survey sample of 17 residents. (Resident identifiers are #1, #13 and #17.) Findings include: Resident #1 Review on [DATE] of Resident #1's medical record revealed that Resident #1 had a physician telephone order dated [DATE] for the following: DO NOT RESUSCITATE (DNR). (DNI) (Do Not Intubate) Advance Directives. Invoke DPOA (Durable Power of Attorney) . (name omitted) for medical and financial. This order was stamped with the word DUPLICATE. Further review revealed that this telephone order was not dated and signed by the physician. Interview on [DATE] at approximately 10:30 a.m. with Staff B (Licensed Practical Nurse) confirmed that the above listed physician telephone order dated [DATE] stamped DUPLICATE was not signed and dated. Staff B also reported that Resident #1 had a signed and dated pink portable DNR consent form. This was not in the medical record at the time of review and Staff B was going to contact the hospital to see if it might of been left at the hospital. At the time of this interview Staff B was asked about the DPOA activation for Resident #1. Record review revealed that Resident #1 has a BIMS score of 15. Staff B verbalized that at the time of admission a discussion was held with Resident #1. Resident #1 indicated that a family member (sister) was who Resident #1 wanted to assist with health care and financial decisions even though Resident #1 was not deemed incapacitated to make these decisions. Interview on [DATE] with Staff F (Registered Nurse) revealed that in a resident emergent situation the staff member would look in the front of a resident's chart. The first page would be a plastic cover sleeve containing the Code Status for that individual resident. Staff F reported that if the medical record could not be located the staff member could go to the MAR (Medication Administration Record) to locate the individual resident Code Status. Interview on [DATE] with Staff G (Social Services) revealed that the Code Status was handled by the Admissions staff and/or the nursing staff. Interview on [DATE] with Staff B revealed that no documented evidence could be found to show that Resident #1 indicated that the family member (sister) was to make health care and financial decisions for Resident #1 even though Resident #1 was not deemed incapacitated to make those decisions. The facility was unable to locate the pink portable DNR consent form for Resident #1. Interview on [DATE] at 12:50 p.m. with Staff I (Admissions) revealed that advanced directives are reviewed or offered at admissions but code status is done by nursing staff. Interview on [DATE] at approximately 1:00 p.m. with Staff C (Unit Manager) revealed that nursing establishes code status with residents at admission but does not have a form to designate code status. Resident #13 Review on [DATE] of Resident #13's care plan revealed that Resident #13 had active advance directive care plans that were not accurate. Care plan dated [DATE] read: (Resident #13) has an established advanced directive and/or Do Not Resuscitate order in place. Review on [DATE] of the physician order [REDACTED].#13's current orders dated [DATE] for advance directives read: Full Code. Interview on [DATE] at approximately 8:50 a.m. with Staff C (Unit Manager) confirmed that the care plan for advance directives was not updated to full code with order change on [DATE]. Resident #17 Interview on [DATE] at approximately 10:00 a.m. with Staff B revealed that if an emergent situation took place that an employee would look in the front of a resident's chart to find out a resident's code status. Staff B took Resident #17's medical record to show where in the medical record the code status is located. There was no code status information in the medical record where staff would look in an emergent situation. Staff B confirmed that the code status should be located in the front of the chart.",2020-09-01
508,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2017-05-17,280,D,0,1,UJ9B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facility failed to review and revise a care plan with a change in code status for 1 resident out of a standard survey of 17 residents. (Resident identifier is #13.) Findings include: Review on 5/16/17 of Resident #13's care plan revealed that Resident #13 had active advance directive care plans that were not accurate. Care plan dated 5/8/17 read: Resident has an established advanced directive and/or DNR (Do Not Resuscitate) order in place. Review on 5/16/17 of Resident #13's physician order [REDACTED].#13's current orders dated 5/9/17 for advance directives read: Full Code. Interview on 5/16/17 at approximately 8:50 a.m. with Staff C, (Unit Manager) confirmed that the care plan for advance directives was not updated to full code with order change on 5/9/17.",2020-09-01
509,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2017-05-17,281,E,1,1,UJ9B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy and procedures titled Medication: Administration: General and Controlled Drugs: Management of it was determined that the facility failed to follow the professional standards of practice for physician orders being followed and the administration and documentation of narcotic medications for 3 residents in a survey sample of 14 residents. (Resident identifiers are #9, #10 and #11.) Findings include: Review of the facility policy titled Medication: Administration: General with a revision date of 05/15/17 revealed the following: PURPOSE To provide a safe, effective medication administration process. PRACTICE STANDARDS . 4. If discrepancies, including medication not available, notify physician/advanced practice nurse (APN)/physician assistant (PA) and/or pharmacy as indicated . 8. Document: 8.1 Administration of medication on Medication Administration Record (MAR); . 8.3 For medication refused by patient, circle your initials in the date and time space where that medication is ordered and document patient's refusal of medication on the back of the MAR. Review of the facility policy titled Controlled Drugs: Management of with a revision date of 05/01/16 revealed the following: POLICY . The management of controlled drugs - including the ordering, receipt, storage, administration, ongoing inventory and destruction - is conducted under the direction and ultimate responsibility of the Center Executive Director and Center Nurse Executive and follows safe practice and federal/state regulations . Ongoing inventory: A complete count of all Schedule II-IV controlled drugs is required at the change of shifts per state regulation or at any time which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses . Reference for the professional standard of practice for medication documentation is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009, which revealed the following: Page 709 After administering the medication, indicate which medications were given on the client's MAR per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care . ' Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines . Page 713 If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurses notes. Some agencies require the nurse to circle the prescribed administration time on the medication record or to notify the physician when a client misses a dose . Guidelines for Safe Narcotic Administration and Control . Store all narcotics in a locked, secure cabinet or container . . Narcotics are frequently counted. Usually counts are made on a continuous basis with the opening of narcotic drawers and/or at shift change. . Report discrepancies in narcotic counts immediately . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. . If a nurse gives only part of a pre-measured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers. Instead, flush wasted portions of the tablets down the toilet and wash liquids down the sink. Page 336 - Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #10 Review on 5/17/17 of Resident #10's MEDICATION ADMINISTRATION RECORD dated 04/01/2017 - 04/30/2017 revealed the following physician orders: [MEDICATION NAME] Tablet Give 25 mg (milligram) by mouth two times a day [MEDICAL CONDITION](hypertension) [MEDICATION NAME] Solution 3 ml (milliliter) inhale orally three times a day for Shortness of breath/Dyspnea [MEDICATION NAME] Solution 20 mg/ml Give 10 mg by mouth every 4 hours as needed for severe pain/Dyspnea [MEDICATION NAME] HCL Tablet 5 mg Give 5 mg by mouth every 4 hours as needed for Moderate/severe pain [MEDICATION NAME] Tablet 5-325 mg Give 1 tablet by mouth every 4 hours as needed for moderate pain. Further review of this MAR revealed on the front of the MAR the following medications were encircled indicating that the medication was not given: [MEDICATION NAME] Solution 3 ml was encircled 1 time on 4/15, 4/17, 4/18 and 2 times on 4/16. [MEDICATION NAME] 25 mg was encircled 1 time on 4/14 and 4/16. The facility failed to show documented evidence as to why the above listed medications were not being given to Resident #10 as ordered. Interview on 5/17/17 with Staff C (Licensed Practical Nurse) revealed that the above listed medications were encircled indicating the medications was not given and no documentation could be found to show the reason why the above listed medications were not given. Interview on 5/17/17 with Staff C and review of this MAR at approximately 2:00 p.m. revealed on the front of the MAR that 4 doses of [MEDICATION NAME] 10 mg were given to Resident #10 on 4/18/17. Review of the Narcotic Book page 214 showed 4 doses of [MEDICATION NAME] 10 mg given on 4/18/17 and reviewed the PRN PAIN MANAGEMENT FLOW SHEET showed only 3 doses of [MEDICATION NAME] on 4/18/17 and review of the PRN Sheet showed no documentation of [MEDICATION NAME] given on 4/18/17 to Resident #10. Interview on 5/17/17 with Staff C and review of this MAR at approximately 2:00 p.m. revealed on the front of the MAR that 3 doses of [MEDICATION NAME] 5-325 mg 1 tablet were given to Resident #10 on 4/13/17. Review of the Narcotic Book showed 3 doses of [MEDICATION NAME] 5-325 mg 1 tablet given on 4/13/17. Review of the PRN PAIN MANAGEMENT FLOW SHEET showed no documentation of 3 doses of [MEDICATION NAME] on 4/13/17 for Resident #10. Review and interview with Staff C revealed that the Narcotic Book showed 2 doses of [MEDICATION NAME] 5-325 mg given on 4/14/17 to Resident #10. The front of the MAR and the PRN PAIN MANAGEMENT FLOW SHEET for Resident #10 revealed no documentation for the 2 doses of [MEDICATION NAME] on 4/14/17. Review of the PRN PAIN MANAGEMENT FLOW SHEET at the time of this interview with Staff C revealed documentation once on 4/13/17 and twice on 4/14/17 for the medication [MEDICATION NAME] 5/325 being given to Resident #10. Staff C confirmed at this interview that there was no physician order for [REDACTED].#10. Resident #9 Review on 5/17/17 of the Medication Administration Record (MAR) and the PRN Pain Management Flow Sheet for the month of (MONTH) for Resident #9 revealed he/she had an order for [REDACTED]. The order was started on 1/10/17 at 1545 and was written as follows: Give 1 tablet by mouth every 4 hours as needed for pain every 4 hours as needed breakthrough pain. The (MONTH) MAR and PRN Pain Management Flow Sheets were compared and the following missing documentation was revealed: 1/15/17 the PRN Pain Management Flow Sheet reports the medication was administered to Resident #9 at 845, 1250 and 1810 and on the MAR there is only one entry for administration of this medication at 1145. 1/17/17 the PRN Pain Management Flow Sheet reveals the medication was administered to Resident #9 at 1025 and 2325 and on the MAR there are three entries for administration of this medication at 535, 1045 and 2325. 1/18/17 the PRN Pain Management Flow Sheet reveals the medication was administered to Resident #9 at 0600 and 310 and on the MAR there is only one entry for administration of this medication at 0600. The Narcotic book page 205 is missing the 310 medication administration documentation. 1/19/17 the PRN Pain Management Flow Sheet reports the medication was administered to Resident #9 at 0010 and 2315 and on the MAR there is only one entry for administration of this medication at 0010. The Narcotic book page 205 lists this medication being administered at 0620 but there is no other documentation of this medication being administered at this time. 1/20/17 the Narcotic book page 205 lists this medication being administered at 0600 but is not documented on the MAR or the PRN Pain Management Sheet. 1/23/17 the Narcotic book page 205 lists this medication as being administered at 930, the PRN Pain Management Sheet lists this medication as being administered at 830 and the MAR lists this medication as having been administered at 830. 1/23/17 the Narcotic book page 205 lists a dose of this medication being administered at 2335 however this is not documented on the PRN Pain Management Sheet and is not on the MAR. 1/24/17 the PRN Pain Management Flow Sheet reports the medication was only administered to Resident #9 at 1600 and on the MAR there is documentation that this medication was administered to Resident #9 at 0600 and again at 1600. The Narcotic book page 205 lists this medication being administered at 0640 and this dose is not on the PRN Pain Management Sheet. 1/25/17 the PRN Pain Management Sheet listed this medication as being administered at 1715 and the Narcotic book page 205 lists this medication as being administered at 1700. The MAR lists this medication as having been administered at 1715. 1/26/17 the PRN Pain Management Flow Sheet reports the medication was administered to Resident #9 at 0545, 945, 1345 and 1700 and on the MAR there are only three entries for administration of this medication at 945, 1345 and 1700. The Narcotic book page 205 lists this medication as having been administered only at 2345, the MAR is missing this administration of this medication at this time. The PRN Pain Management Sheet does not have this time documented as having been administered. 1/29/17 the Narcotic book page 205 list this medication as having been administered at 0900 and the PRN Pain Management Sheet lists this medication as having been administered at 0830. A second dose of this medication was administered at 2100 and was listed on page 205 in the Narcotic book however there was no documentation of this medication being administered on the PRN Pain Management Sheet at 2100. 1/30/17 the Narcotic book page 205 lists this medication as having been administered at 2355 however this medication is not listed as being given on the MAR or the PRN Pain Management Sheet at 2355. 1/31/17 the PRN Pain Management Flow Sheet reports the medication was administered to Resident #9 at 1630 and 2345 and on the MAR there was only one entry for administration of this medication to Resident #9 at 1630. The Narcotic book page 205 lists this medication as having been administered only at 0630 however this documentation is missing from the PRN Pain Management Sheet and the MAR. During interview on 5/17/17 at approximately 3 p.m. with Staff F (Registered Nurse/Director of Nursing), Staff F stated he/she was aware that the facility has issues with their documentation. Resident #11 Review on 5/17/17 of Resident #11's Medication Administration Record for (MONTH) (YEAR) revealed the following order: PhosLo Capsule 667 MG (Calcium Acetate), Give 667 mg by mouth with meals for take 3 tablets with meals. Several administrations in (MONTH) were initialed and circled (5/1/17, 5/8/17, 5/10/17, 5/11/17, 5/18/17, and 5/16/17). Interview on 5/17/17 at 2:45 p.m. with Staff [NAME] (Licensed Practical Nurse) confirmed the above finding and revealed that on the above days Resident #11 refused medication or was out of the building during meals. Staff [NAME] was unable to provide documentation of why the the above medications were not administered.",2020-09-01
510,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2017-05-17,441,D,0,1,UJ9B11,"Based on observation and interview, it was determined that the facility failed to maintain infection control practices to prevent cross-contamination for 3 residents in a survey sample of 17 residents and one out of sample resident. (Resident identifiers are #1, #13 and #20.) Findings include: Resident #20 Observation during a medication pass on 5/16/17 at approximately 7:35 a.m. revealed Staff H (Licensed Medication Nursing Assistant) performing a blood glucose monitoring check on Resident #20. Staff H (LMNA) cleansed Resident #20's finger with an alcohol wipe discarding this wipe on the bedside tray and proceeded to do a blood glucose check. Staff H gave Resident #20 a small 2x2 gauze to apply to the area. Then Staff H removed this 2x2 gauze and retrieved the discarded used alcohol wipe then proceeded to use this wipe to cleanse the same area. Following this procedure Staff H performed handwashing and proceeded to take the glucometer used for the blood glucose check on Resident #20 out of the room and placed this glucometer on top of the medication cart. Staff H did not clean the glucometer to prevent cross-contamination after use on Resident #20 and used the same alcohol wipe before and after the blood glucose check on Resident #20 exposing Resident #20 to possible cross contamination. Resident #1 Observation during this medication pass on 5/16/17 at approximately 8:05 a.m. revealed Staff H (LMNA) preparing multiple medication tablets for Resident #1 placing them in a small plastic medication cup on top of the medication cart. Staff H knocked this medication cup over and multiple medication tablets spilled out of this cup onto the top of this medication cart with the uncleaned glucometer. Staff H proceeded to pick these individual tablets up with bare fingers and replaced them into the medication cup. Staff H proceeded to mix all the medications in the plastic medication cup with applesauce prior to administering this medication to Resident #1. Interview on 5/16/17 at the time of this medication pass with Staff H revealed that Staff H failed to clean the glucometer after use on Resident #20 and confirmed that the spilled medications were placed back into the medication cup with bare fingers. Interview on 5/16/17 at approximately 8:45 a.m. with Staff B (Licensed Practial Nurse) revealed that the glucometer is to be cleaned after each resident use. Resident #13 Observation on 5/17/17 at 12:00 p.m. with Resident #13 revealed Staff D (Registered Nurse) administering medications to Resident #13. Staff D took an inhaler from Staff D's pocket and presented the inhaler to the resident for use. Resident #13 self administered dose through the inhaler.",2020-09-01
511,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2017-05-17,514,D,0,1,UJ9B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that the medical record was complete, accurate, and organized for 2 residents in a standard survey sample of 17 residents. (Resident identifiers are #6 and #7.) Findings include: Resident #6 Review of the medical record revealed that a Change in Condition Evaluation dated 3/25/17 was completed for Resident #6 who sustained a broken right humerus resulting from a fall at the facility on 3/25/17. There was no documentation in the medical record of the circumstances of the event or immediate action taken. Interview with Staff [NAME] (Licensed Practical Nurse) on 5/17/17 at 9:30 a.m. confirmed the above finding and revealed that the documentation of the circumstances of the event and immediate action taken, was documented in the facility's Risk Management System Report which is not part of the medical record. Resident #7 Review on 5/16/17 of Resident #7's progress notes revealed Resident #7 sustained a [MEDICAL CONDITION] resulting from a fall at the facility on 4/20/17. Review on 5/16/17 of the Nursing Home to Hospital Transfer Form dated 4/20/17 revealed the following note; Pt elevated (pronoun omitted) bed to the top and rolled out onto (pronoun omitted) left hip, daughter and I walked in the room and found (pronoun omitted) on the floor. There were no other progress notes documenting the resident's fall or the assessment of the resident immediately following the fall. Interview with Staff D (Registered Nurse) on 5/16/17 at 11:00 a.m. confirmed the above finding. Interview with Staff C (Unit Manager) revealed that an incident report/risk management system report was completed for the fall but it is not maintained as part of the resident's medical record.",2020-09-01
512,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2018-08-03,761,D,0,1,6J9S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to remove an expired medication which was found in 1 of 4 medication carts. (Resident identifier is #12.) Findings include: Observation on [DATE] at approximately 9:50 a.m. during medication pass observation revealed a bottle of Latanoprost eye drops for Resident #12. The order, written on the box for these eye drops, was to administer 1 drop in each eye every day. The plastic pharmacy container used to hold the bottle of eyes drops had a sticker on it with the date opened written in as [DATE]. The sticker also had the expiration date (not the manufacturer's expiration date) written in as [DATE]. Review on [DATE] of the Facility Policy titled Storage and Expiration Dating of Medications . last revised (MONTH) 31, (YEAR), revealed that .[MEDICATION NAME] Ophthalmic Solution (latanoprost) Refrigerate until ready to use. Date when opened and store at room temperature .Discard unused portion 6 weeks after opening . Observation on [DATE] at approximately 9:50 a.m. revealed that Staff A (Medication Nursing Assistant) started to walk towards Resident #12's room with their medications in hand, including the bottle of Latanoprost. Interview on [DATE] at approximately 9:55 a.m. with Staff A, before they reached Resident #12, confirmed that when they looked again at the eye drops, they could see that they had expired. Staff A confirmed that those eye drops should not be administered. Interview on [DATE] at approximately 9:00 a.m. with Staff B (Director of Nursing) confirmed that the Latanoprost had expired and should have been discarded.",2020-09-01
513,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2018-07-12,607,D,1,0,DWN711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to implement written policies and procedures that prevent neglect of residents for 1 resident in a sample of 1 resident. Resident identifier is #1. Findings include: Review of a Facility Reported Incident (FRI) # on 6/12/18 at approximately 8:30 a.m. which occurred on 6/6/18 revealed that on 6/6/18 at approximately 2:00 p.m., Resident #1 was found in the common bathroom [ROOM NUMBER] by Staff E, RN, and was said to be trying to clean herself/himnself up after having profuse diarrhea. Staff [NAME] then requested the assistance of Staff D (LNA) to bring Resident #1 back to their room for cleaning up. Staff D requested that Staff [NAME] bring a wheelchair. Staff [NAME] brought the wheelchair for Staff D, and Staff D proceeded to wheel Resident #1 back to the resident's room to be cleaned up. At approximately 2:15 p.m., Staff D stated to Staff [NAME] that Staff D was going to have a cigarette break. Staff [NAME] went to check on Resident #1 and found the resident to be in bed, unwashed and unchanged, with the blankets pulled up over the resident. Staff E, RN requested the assistance of Staff F, (LNA) and together they cleaned and changed Resident #1. Staff D was suspended pending investigation and later dismissed and reported to the Board of Nursing for neglect. As per interview on 7/12/18 at approximately 9:00 am with Staff B, there was no monthly QAPI (Quality Improvement Performance Improvement) meeting held and the incident was not reviewed in QAPI. Also during this interview it was revealed that Social Services was not informed about the incident and was not assigned to monitor Resident #1 for psychosocial needs. Further interview with Staff B, Director of Nursing (DON) and Staff A, (Administrator) at approximately 10:15 a.m. revealed that there had been no follow up education for the staff involved after the incident, no Social Services involvement to monitor the patient's feelings and psychosocial needs, and there was no QA plan or monitoring system in place to prevent events such as this from occurring in the future. Facility Abuse Policy and Procedures were not followed in the areas of: 7.2 Assign a representative from Social Services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation. 9. At monthly Quality Assurance and Performance Improvement (QAPI) meeings, review all allegations of abuse that were reported to the state to: 9.1 Analyze occurrences to determine what changes are needed, if any, to prevent further occurrences; 9.2 Identify situations which have a potential for risk; and 9.3 Determine what preventive measures will be implemented by staff.",2020-09-01
514,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2017-07-27,160,B,0,1,SVBJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident trust fund and interview, it was determined that the facility failed to convey resident funds within 30 days to the individual(s) or probate jurisdiction administering the resident's estate for 7 of 12 residents reviewed. (Resident identifiers are #21, #22, #23, #24, #25, #26, #27.) Findings include: Review on [DATE] at approximately 11:00 a.m. of a Facility document titled Area of Concern, dated [DATE], revealed that .several accounts of deceased residents remained open. There was no evidence of a NH Affadavit of Nursing Home Administrator on file. Residents involved were: Resident #21 died on [DATE]. Probate filed on [DATE] Resident #22 died on [DATE]. Probate filed on [DATE] Resident #23 died on [DATE]. Probate filed on [DATE] Resident #24 died on [DATE]. Probate filed on [DATE] Resident #25 died on [DATE]. Probate filed on [DATE] Resident #26 died on [DATE]. Probate filed on [DATE] Resident #27 died on [DATE]. Probate filed on [DATE] Interview on [DATE] at approximately 11:00 a.m. with Staff F (Business Office Manager) revealed that the above resident accounts were not filed within 30 days to the Probate Court and that they have all since been filed.",2020-09-01
515,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2017-07-27,281,D,1,1,SVBJ11,"> Based on interview, record review and review of the Facility's report to the Office of Long Term Care Ombudsman, it was determined that the facility failed to communicate and implement necessary care for 1 resident in a survey sample of 20 residents. (Resident identifier is #7.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 269 You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals .The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care . Review on 7/26/17 of Resident #7's General Nurse's Note dated 7/2/17 revealed that (Pronoun omitted) from Hospice in to evaluated pt. (patient) .New orders from Hospice .Pt is a total feed until further notice . Review on 7/26/17 of Resident #7's Hospice telephone order slip dated 7/2/17 revealed an order that Pt must be fed until further notice . Review on 7/26/17 of the Facility's Report to the Office of Long Term Care Ombudsman, dated 7/6/17, revealed that Resident #7's DPOA (Durable Power of Attorney) reported to the facility that on 7/4/17 Resident #7 was found slumped in a chair with Resident #7's dinner tray, which had not been touched, in front of Resident #7. Resident #7's DPOA also reported that Staff D (Licensed Nursing Assistant) stated that Staff D was not aware that Resident #7 needed to be fed. Review on 7/26/17 of the Facility's Report to the Office of Long Term Care Ombudsman, dated 7/6/17, revealed that Staff D reported that Staff D delivered the tray to Resident #7 on 7/4/17, gave Resident #7 a bite of dinner and dessert, instructed Resident #7 to continue and that Staff D would be back to check on Resident #7. When interviewed by the facility, Staff D reported that Staff D was not aware that Resident #7 needed to be fed. Review on 7/26/17 of the Facility's Report to the Office of Long Term Care Ombudsman, dated 7/6/17, revealed that Staff [NAME] (Licensed Practical Nurse, Charge Nurse) was also not aware that Resident #7 needed to be fed. Staff [NAME] reported that after giving Resident #7 a few bites of dinner, Staff D left to assist another resident with dinner. Interview on 7/26/17 with Staff C (Registered Nurse, Unit Manager) confirmed that Staff D left Resident #7 during the dinner meal and that Staff D was not aware that Resident #7 needed to be fed. Interview on 7/27/17 with Staff B (Director of Nursing) confirmed that Staff D and Staff [NAME] were not aware that Resident #7 needed to be fed.",2020-09-01
516,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2017-07-27,364,B,0,1,SVBJ11,"Based on observations and interviews the Facility failed to ensure that food temperatures were all held, as appropriate, above or below the danger zone of 41 degrees to to 135 degrees F. (Fahrenheit) before serving. Findings include: In response to multiple complaints of cold food a test tray was done. At approximately 11:45 a.m. on 7/26/17 Staff A, DFS (Director of Food Services ), was informed that a test tray would have to be done for this meal. General parameters were explained. The test tray would consist of items from the line, subject to the same process of completion as all other resident trays, nothing done differently. There should be no additional heating of the test tray. The tray was to be placed on the (Bay unit) delivery cart and delivered to the floor with the other resident trays marked as a Test Tray. While another cart was being loaded, tray by tray, this surveyor attempted to locate the serving line final cooking temperatures. The temperature log was hanging on a clipboard on the south end wall of the kitchen at the end of the serving line fixtures. Upon reviewing the temperature log it was noted that the final cooking temperatures were not written down, for this meal. This surveyor approached the head cook and inquired if the final cooking temperatures had been obtained for the serving line. He responded Yes, I took them but did not write them down, they are in my head. Staff A, DFS, obtained a new thermometer, checked the calibration, in a glass of ice water and proceeded to check the temperature of some of the food items on the serving line. The head cook filled the Test Tray from the opposite side of the tray line than the residents trays were filled. At approximately 12:15 p.m. this surveyor observed as the head cook removed a small, shallow hotel pan containing potato wedges, from the main oven and poured them directly onto the lunch plate on the test tray. The temperature of the potato wedges was not taken after they had been baked in the oven to reheat. Review of the regulations set forth by The Department of Health and Human Services DHHS), Public Health Service, Food and Drug Administration. (2013). Food Code (pp. 555) Annex 4, Table 1a. Selected Bacterial Hazards, Associated foods, and Control Measures: reveals Bacillus cereus (a preformed emetic and diarrheal toxin) can affect starchy foods (rice, potatoes) as well as other foods, and is controlled by proper cooking, cooling, cold holding, and hot holding (temperatures). The Department of Health and Human Services DHHS), Public Health Service, Food and Drug Administration. (2013). Food Code (pp. 555) Annex 5, page 608 states: Cooked hot food may be reheated to 165 degrees Fahrenheit for 15 seconds. The guidelines set forth by The Department of Health and Human Services DHHS) Centers for Medicare and Medicaid Services (CMS) at 42 CFR 483.35(i)-Sanitary Conditions, at the Prevention of Foodborne Illness section, Safe Food Preparation Safe Food Preparation, Reheating Foods, revised , remind us that: Reheated cooked foods present a risk because they have passed through the danger zone multiple times during cooking, cooling, and reheating. The Temperature Controlled Safety (TCS) food (baked potato) that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees F for at least 15 seconds before holding for hot service. The guidelines set forth by The Department of Health and Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS) at 42 CFR 483.35(i)-Sanitary Conditions, at the Prevention of Foodborne Illness section, Safe Food Preparation, Tray Line . state: The tray line may include, but is not limited to the steam table where hot prepared foods are held and served, and the chilled area where cold foods are held and served. A residents meal tray may consist of a combination of foods that require different temperatures. Food preparation or service area problems/risks to avoid include, (in part) but are not limited to: (1.)Holding foods in the danger zone temperatures which are between 41 degrees F and 135 degrees F; (2.) Monitoring of the temperature by food service workers while food is on the steam table is essential While the test tray was being assembled, it was observed that the Bay Unit cart was no longer at the serving line and had been taken from the kitchen before the Test Tray could be loaded onto it. The Test tray was completed and brought out to the Bay Unit food cart and placed to the back of the right side of the top rack. After the last resident tray had been served the Test Tray was removed from the cart and Staff A, DFS, tested the temperatures of the foods on the tray. The chicken cutlet was 142 degrees F, the potato wedges were 130 degrees F., and the fruit cup was 60 degrees F. Recalling that the potato wedges were baked in the oven to rewarm them, they still temped at 5 degrees below recommended holding temperature, This surveyor tasted them and they were not hot to the taste, but on the cool side of warm. The fruit cup was definitely too warm for this Surveyor's palate. The temperature of the melon was 19 degrees above the recommended maximum holding temperature for sliced fruit. Supporting Interview: On 7/26/17 at mid-day this surveyor interviewed the daughter of Resident #28, an out of sample resident chosen for a family interview. Resident #28's daughter stated, that her parent enjoyed breakfasts at this Facility but that s/he does not like some of the lunches and dinners because they are sometimes cold. Resident #10 Interview on 7/27/17 at approximately 2:00 p.m. with Resident #10 revealed that Resident #10 had issues with food temperatures on multiple occasions. Resident #10 reported that hot food is frequently served cold and that Resident #10 does not want to ask the LNA's and nurses, who are already very busy, to heat up food. Resident #10 reported that recently Resident #10 was served breakfast that was cold and Resident #10 could not eat it and ate only the blueberry muffin that was served. Resident #10 also reported about a recent meal that was cold and therefore not palatable, so Resident #10 only ate jello for that meal.",2020-09-01
517,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2017-07-27,371,E,0,1,SVBJ11,"Based on observations and interview, the facility failed to ensure that all food was prepared under sanitary conditions. Findings include: Observation on 7/25/17 at approximately 9:30 a.m. during the initial tour of the main kitchen, a vent pipe was observed on top of the convection oven rising up a few inches to an elbow and discharging approximately 18 inches or so, horizontally to the right, underneath the range vent hood and above a left side range top burner. At the time of this observation it was noted that there was a layer of dust and small particles on top of the horizontal section of pipe which was directly above an open pan of food cooking on top of the left side of the range. Interview on 7/25/17 at approximately 9:35 a.m. with Staff A (Director of Food Services) revealed that Staff A thought there were better ways to duct the vent of the Convection oven into the range hood. Review on 7/26/17 of the 5/2/17 Resident's Council Meeting minutes stated residents noted that the food is coming out cold. The minutes of this meeting also stated that there was a Discussion around why the food may be getting cold. Residents, according to the minutes, wondered whether the cold food resulted from the inefficiency of the kitchen or that the nursing staff is passing the food too slowly. Interview on 7/26/17 with the Resident Council with eighteen residents in attendance revealed that everyone agreed the food is being served cold when the food is supposed to be warm and/or hot.",2020-09-01
518,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,610,D,1,1,OF9N11,"> Based on observation, interview and record review, it was determined that the facility failed to thoroughly investigate an allegation of neglect, which resulted in injury, for 1 resident in a final survey sample of 23 residents. (Resident identifiers is #81.) Findings include: Resident #81 Interview on 7/24/19 at approximately 9:25 a.m. with Resident #81 revealed that Resident #81 stated that they had a problem with constipation which resulted in an incident where they were unable to move their bowels and received a suppository from a nurse. Resident #81 stated that approximately 1 and 1/2 hours later, they felt that the suppository had worked and they got themselves to the bathroom. Resident #81 stated that they sat on the toilet, but were still unable to move their bowels. They stated that they put the bathroom call light on, but nobody came for what Resident #81 described was a very llong time, and they didn't know what to do. They felt that the stool was stuck and they stated that they felt that they had to remove the feces manually. They stated that as they were removing the feces, their hand kept hitting on the toilet and they got a bruised and swollen right hand as the result of it. They stated that after they finished removing the feces with their hand they had to get up, on their own, and clean themselves. Resident #81 stated that several hours later, the nurse came into their room and asked what the results of the suppository were. Resident #81 stated that they questioned the nurse as to why they did not answer the call light and come into the room, the nurse told them that they had fallen asleep. Observation on 7/24/19 at approximately 9:25 a.m. of Resident #81's right hand revealed that just above the last four fingers of the hand there was some bruising and swelling. Review on 7/25/19 of the Facility Final Report to the Long Term Care Ombudsman, dated 7/17/19, revealed that the facility reported that the .nurse did not return for more than two hours after administration of the suppository. Resident reported that the nurse told (Resident #81) that (the nurse) was tired and that (the nurse) went to sleep . There was no mention that an investigation revealed that the resident had felt the need to disimpact themselves and that they had injured themselves in the process. Interview on 7/29/19 at approximately 11:37 a.m. with Staff G (Unit Manager) confirmed that even though it was not documented on the report to the Long Term Care Ombudsman, Resident #81 did disimpact themselves and had bruising and swelling on their right hand as a result. Staff G also confirmed that this information should have been included in the report to the Long Term Care Ombudsman.",2020-09-01
519,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,656,D,1,1,OF9N11,"> Based on record review and interview it was determined that the facility failed to implement the care plan for 3 residents in a survey sample of 23 residents. (Resident identifiers are #62, #63 and #81.) Findings include: Resident #62 Review on 7/26/19 of Resident #62's care plan revealed that Resident #62 has actual skin breakdown. Type Stage IV Location sacrum and upper medial back, actual pressure ulcer with the initiation date of 4/16/19. This skin breakdown care plan listed Weekly wound assessment to include measurements and description of wound status in the Interventions section for Resident #62. Interview and review of the medical record on 7/29/19 with Staff M (Registered Nurse) at approximately 1:00 p.m. revealed that there was no documented evidence of the weekly wound measurements and description of the Stage IV sacrum and upper medial back pressure ulcers for Resident #62 for the following weeks of 4/19/19, 4/26, 5/3, 5/10, 5/17, 5/24, 5/31, 6/7, 6/14, 6/20, 6/28, 7/5, 7/12 and 7/18 for a total of 14 weeks and confirmed that the facility failed to implement the care plan for weekly wound measurements and description of the Stage IV pressure ulcers for Resident #62. Resident #63 Review on 7/26/19 of Resident #63's current care plan revealed that Resident #63 has skin breakdown related to intermittent incontinence/limited mobility with the initiation date of 6/7/19 for the intervention of Weekly wound assessment to include measurements and description of wound status. Interview and review of the medical record on 7/29/19 with Staff M (R.N.) at approximately 1:00 p.m. revealed no documented evidence of the weekly wound measurements and description of bilateral heel pressure ulcers for Resident #63 from 6/24/19, 7/1, 7/8, 7/15 and 7/22 for a total of 5 weeks and no wound documentation & measurements for the vertebrae-lumbar wound for 6/26/19 and 7/3 for two weeks and confirmed that the facility failed to implement the care plan for weekly wound measurements and description of wound status for Resident #63. Resident #81 Interview on 7/24/19 at approximately 9:25 a.m. with Resident #81 revealed that since admission on 7/2/19 to the facility, they have been having issues with constipation due to dietary changes and decreased fluid intake. They stated that they had received a suppository and that when no staff answered their call bell for a long time they removed their own feces with their hands, resulting in bruising and swelling to their right hand. Review on 7/26/19 of Resident #81's current care plan revealed that there was no care plan in place for constipation or for Resident #81 having had disimpacted themselves. Interview on 7/29/19 at approximately 11:30 a.m. with Staff G (Unit Manager) confirmed that there was no care plan in place for Resident #81's constipation and history of disimpaction. Staff G confirmed that there should have been a care plan in place for both.",2020-09-01
520,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,658,D,0,1,OF9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow doctor's orders regarding obtaining weights for 2 residents in a final sample size of 23 residents. (Resident identifiers are #2 and #66.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients . Resident #2 Review on 7/26/19 of Resident #2's progress notes revealed a weight warning dated 7/1/19 that showed Resident #2 having a 16.8 lbs. (pounds) weight loss over 180 days. Further review of the weight warning note dated 7/1/19 revealed that dietician initiated weights three times a week. Review on 726/19 of Resident #2's current physician orders [REDACTED].#2 every Monday, Wednesday and Friday with start date of 7/1/19. Review on 7/26/19 of Resident #2's weight records for the month of (MONTH) 2019 revealed 2 documented weights after 7/1/19 which were 124 lbs. on 7/2/19 and 121.2 lbs on 7/12/19. Review on 7/26/19 of Resident #2's Electronic Treatment Administration Record (ETAR) for the month of (MONTH) 2019 revealed no documented weights for Resident #2. Interview on 7/30/19 at 1:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B was unable to provide explanation on why Resident #2's weights were not obtained per physician order [REDACTED]. Resident #66 Review on 7/26/19 of Resident #66's current physician orders [REDACTED].#66 every 3 days with a start date of 3/23/19. Review on 7/26/19 of Resident #66's Treatment Administration Record (TAR) and weight records for the month of (MONTH) 2019 to (MONTH) 2019 revealed no weight recorded on 3/23/19, 3/26/19, 3/29/19, 4/4/19, 5/16/19, and 6/9/19. Interview on 7/26/19 at 2:00 p.m. with Staff G (Unit Manager) confirmed the above findings. Staff G was unable to provide explanation why weights were not obtain per physician orders [REDACTED].",2020-09-01
521,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,676,D,1,0,OF9N11,"> Based on observation, interview, and record review, it was determined that the facility failed to ensure the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for 4 out of 10 residents observed in the Strawberry Cove dining area (Resident identifiers are #243, #64, #78 #29) and to provide restorative nursing for 1 resident out of a final sample of 23 residents. (Resident identifier is #26.) Findings include: Observation on 7/24/19 at approximately 8:50 a.m. revealed breakfast being delivered to approximately 10 residents in the Strawberry Cove dining area. Resident #243, #64, #78 and #29 all had their meals placed in front of them on the tables while the other 6 residents were eating. Resident #243 was assisted with breakfast at approximately 9:15 a.m. Resident #64 was assisted with breakfast at approximately 9:20 a.m. Resident #78 was assisted with breakfast at approximately 9:30 a.m. Resident #29 was assisted with breakfast at approximately 9:35 a.m. Interview on 7/24/19 at approximately 10:00 a.m. with Staff F (anonymous) revealed, This is always how it is. We don't have enough staff here to assist with meals. If there is a call out, this unit is always pulled from. It is not fair to the residents that there are not enough people to assist them at meals. There is always 1-2 of us to help with meals. Interview on 7/24/19 at approximately 1:30 p.m. with Staff [NAME] (Licensed Nursing Assistant) revealed that the normal staffing on the unit is 1-2 staff members on the unit to assist with meals. Observation on 7/25/19 at approximately 7:55 a.m. revealed approximately 9 residents eating breakfast in the Strawberry Cove dining area. Resident #64 and Resident #78 had their meals in front of them waiting to be assisted with breakfast. At 8:15 a.m. Resident #64 and Resident #78 were then assisted with breakfast. Interview on 7/25/19 at approximately 11:15 a.m. with Staff Q (Licensed Practical Nurse) revealed that there were 6 residents on the unit that required total assist at meals and 3 that require cueing/minimal assist. Review on 7/26/19 at approximately 2:00 p.m. of the list of residents on Strawberry Cove and the assistance needed with meals revealed: 5 residents on Strawberry Cove require minimal assistance from staff with dining. 5 residents on Strawberry Cove are dependant of staff for assistance with dining. Resident #26 Interview on 7/24/19 at 1:46 p.m. with Resident #26 revealed that Resident #26 was recently taken off therapy and requested to have more therapy. Observation on 7/25/19 at 9:10 a.m. revealed that the LNA (Licensed Nursing Assistant) staff assisted Resident #26 to the bathroom via wheelchair and once near the toilet LNA staff locked Resident #26's wheelchair and stand and pivoted Resident #26 to the toilet then Resident #26 was assisted back to wheelchair via stand and pivot once Resident #26 was done using the toilet. Observation on 7/26/19 at 1:00 p.m. revealed that LNA staff assisted Resident #26 from the toilet, which LNA staff stand and pivoted Resident #26 from toilet to wheelchair. Interview on 7/29/19 at 12:45 p.m. with Staff H (Rehab Director) revealed that Resident #26 was on physical therapy (PT) and occupational therapy (OT) and Staff H was unable to provide more information regarding when PT and OT started and ended. Staff H stated that Resident #26 was discharged from PT with a restorative nursing program (i.e. restorative toileting program) that the nursing staff has to do to maintain Resident #26's abilities of daily living. Staff H also stated that Resident #26 was to be walked to and from bathroom for toileting and nursing staff was educated on the restorative nursing program and a restorative nursing program form was filled and given to the unit manager. Staff H also stated that the process for restorative nursing programs starts with the therapist or the assistant therapist to educate most front line nursing staff, as they are not able to educate as nursing is a 24 hour and 7 days a week working hours and therapist are a day time worker with occasional weekend work times, about the restorative nursing program then the therapist or assistant therapist hands in a restorative nursing program form to the unit manager, who would be responsible for letting all nursing staff know about the restorative nursing program and updating resident plan of care. Review on 7/29/19 of Resident #26's therapy notes revealed that Resident #26 had OT from 4/22/19 to 7/10/19 and PT on 2/12/19 to 4/26/19. Review on 7/29/19 of Resident #26's Restorative Nursing Training Program form dated 5/21/19 revealed that .for Bathroom: Please park chair at 45 degree angle outside of bathroom, lock the chair and use hemiwalker to transfer to toilet with gait belt. 1-2 person transfer . Review on 7/29/19 of Resident #26's current care plan revealed a restorative toileting program that showed .Patient to be walked to and from bathroom as tolerated . Interview on 7/29/19 at 11:45 a.m. with Resident #26 revealed that nursing staff has not walked (pronoun omitted) to and from bathroom. Resident #26 stated they feel that nursing staff is in a hurry at times and short staff. Interview on 7/29/19 at 11:46 a.m. with Staff K (LNA) revealed that they were aware that Resident #26 had a restorative toileting program to walk to and from bathroom. Staff K stated that staffing is short and that it was hard to do task with short staff'. Staff K also stated that restorative program was a task that they would see in the Point of Care (P[NAME]) documentation which there was none for Resident #26. Staff K also stated that Staff K worked on the Nubble unit 7-3 shift since (MONTH) (YEAR) and had been assigned to Resident #26 as their LN[NAME] Interview on 7/29/19 at 12:55 p.m. with Staff G (Unit Manager) revealed that Restorative nursing programs given by the therapist would be given to the nurses and inputted in the P[NAME] for the LNA's to document and that is how the nursing staff would know to do the restorative nursing program. Staff G stated that Staff G was unaware of any restorative program for Resident #26. Interview on 7/29/19 at 1:00 p.m. with Staff L (LNA) revealed that Staff L was unaware of Resident #26 having a restorative toileting program to walk Resident #26 to and from bathroom. Staff L stated that the restorative toileting program was not on P[NAME] for them to do. Staff L also stated that they float to the Nubble unit, where Resident #26 resided, once a week and was assigned to Resident #26 at times. Interview on 7/29/19 at 1:07 p.m. with Staff O (Licensed Practical Nurse) revealed that Staff O was unaware of Resident #26 having a restorative toileting program which to walk Resident #26 to and from bathroom. Review on 7/29/19 of Resident #26's P[NAME] documentation, Treatment Administration Records and progress notes revealed no documentation of Resident #26's Restorative Nursing Program being done. Interview on 7/29/19 at 1:25 p.m. with Staff M (Regional) confirmed that there was no documentation for Resident #26's Restorative toileting program being done.",2020-09-01
522,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,689,E,0,1,OF9N11,"Based on observation, record review, and interview, it was determined that the facility failed to ensure that residents remain as free of accident hazards as possible by providing supervision and implementing smoking policies for 3 of 4 residents reviewed in a final sample of 23 residents. (Resident identifiers are #15, and #59.) Findings include: Resident #15 Observation on 7/24/19 at 11:45 a.m. at the facility designated smoking area located at the right front side of the facility revealed that Resident #15 was smoking their cigarette with no smoking apron on. Interview on 7/24/19 at approximately 12:05 p.m. with Resident #15 revealed that Resident #15 does not turn their lighter or cigarettes into the nurse's station when not outside smoking. Observation on 7/24/19 at approximately 2:45 p.m. revealed Resident #15 smoking outside in the designated smoking area without a smoking apron on. Review on 7/25/19 of Resident #15's nursing notes revealed that on 10/8/18 Resident #15 had a burn on right abdomen and as a result the resident was provided a smoking apron. Review of Resident #15's most recent smoking evaluation dated 5/3/19 revealed that the resident is allowed to smoke independently while wearing a smoking apron. Review on 7/25/19 of Resident #15's care plan revealed that Resident #15 was to wear a smoking apron, that Resident #15 needs reeducation secondary to noncompliance, to monitor Resident #15's compliance with smoking policy, and to maintain Resident #15's lighter at the nurse's station. Review on 7/25/19 of facility's smoking policy, revision date 7/24/18, revealed that .Patients will not be allowed to maintain their own lighter, lighter fluid, or matches . Interview on 7/25/19 8:30 a.m. with Staff K (Licensed Nursing Assistant (LNA)) revealed Staff K was unaware Resident #15 needed to use a smoking apron and confirmed that Resident #15 keeps their own lighter. Observation on 7/25/19 at 12:00 p.m. of Resident #15's room revealed an extinguished cigarette butt on the floor. Interview on 7/24/19 3:00 p.m. with Staff R (LNA) and Staff S (LNA) revealed that Resident #15 is noncompliant with facility's smoking policy. Staff S was not aware that Resident #15 needed a smoking apron to smoke. Interview on 7/25/19 at 10:59 a.m. with Staff T (Registered Nurse) confirmed Resident #15 is noncompliant with the facility's smoking policy. Interview on 7/26/19 at 8:35 a.m. with Staff U (Receptionist) revealed that Staff U does not monitor smokers. Interview on 7/26/19 9:15 a.m. with Staff V (LNA) revealed that Resident #15 kept their lighter with them when not smoking and was not aware Resident #15 needed a smoking apron. Interview on 7/26/19 at 9:30 a.m. with Staff T revealed that Staff T was not aware that resident was noncompliant recently with the smoking policy and was unable to give information how staff monitors resident needing smoking aprons. Review on 7/26/19 of the facility's smoking evaluation revealed the assessment did not include the ability of the resident to maintain and store smoking materials appropriately. Resident #59 Interview on 7/24/19 at approximately 12:14 p.m. with Resident #59 revealed that they stated that they kept their lighter with them at all times. Review on 7/29/19 of Resident #59's Smoking Evaluation dated 5/3/19, revealed that .(Resident #59); review of smoking policy and lighter at nurses station . Observation on 7/29/19 at approximately 10:28 a.m. of Resident #59 revealed that they left their room, propelling their wheelchair down the hallway, with their lighter tucked between their legs. Resident #59 did not stop at the nurses station to obtain a lighter. Interview on 7/29/19 at approximately 10:45 a.m. with Staff W (Licensed Practical Nurse) confirmed that Resident #59 had their lighter with them and that no staff had given Resident #59 their lighter that morning. Interview on 7/29/19 at approximately 11:30 a.m. with Staff G confirmed that residents' lighters were supposed to be put in the nurses station when the resident had returned inside the facility after smoking.",2020-09-01
523,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,697,D,0,1,OF9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure pain management was implemented to relieve pain for 2 residents in a final survey sample of 23 residents. (Resident identifiers are #83 and #294.) Findings include: Resident #83 Interview on 7/24/19 at approximately 10:45 a.m. with Resident #83 revealed that Resident #83 stated that they were in terrible pain and that the facility does nothing about it. Review on 7/26/19 of Resident #83's (MONTH) 2019 Medication Administration Record [REDACTED]#83 had a pain level of 7. There was no documentation on the Medication Administration Record [REDACTED]. Review on 7/26/19 of Resident #83's assessments revealed that there was no pain assessment for Resident #83 indicating what pharmacological and non pharmacological interventions were done to alleviate Resident #83's pain. There was also no documentation of what Resident #83's acceptable pain level was. Interview on 7/29/19 at approximately 11:55 a.m. with Staff G (Unit Manager) confirmed that there was no documentation regarding any interventions that had been offered to Resident #83 on the aforementioned dates. Staff G confirmed that Resident #83 should have been offered her pain medication. Staff G also confirmed that there was no documentation indicating what Resident #83's acceptable pain level was and that it should have been documented. Resident #294 Interview on 7/24/19 at approximately 11:40 a.m. with Resident #294 revealed that Resident #294 stated that they had a headache and that they had asked for medication for it during the middle of the night and never received any. They stated that their headache continued to bother them and they would like something. Interview on 7/24/19 at approximately 11:50 a.m. with Staff G revealed that Staff G stated that they would give Resident #294 something for their headache. Interview on 7/25/19 at approximately 8:45 a.m. with Resident #294 revealed, when questioned, that they still had a headache and never received any medication for it. Review on 7/25/19 at approximately 9:30 a.m. of Resident #294's current physician orders [REDACTED].#294 had no orders for pain medication. Interview on 7/25/19 at approximately 10:00 a.m. with Staff G revealed that when questioned, Staff G stated that on 7/24/19 after learning that Resident #294 had a headache, they had asked an MNA (Medication Nursing Assistant) to administer pain medication. They stated that the MNA realized that there were no pain medication orders, so they asked the APRN (Advanced Practice Registered Nurse) to see Resident #294. Staff G stated that when questioned by the nurse practitioner about pain, Resident #294 denied having pain. Staff G confirmed that they would be asking for an order for [REDACTED]. Review on 7/25/19 of Resident #294's progress notes revealed a note written by Staff X (APRN), dated 7/24/19 at 12:00 a.m. and signed 7/25/19 at 11:06 a.m., that read .4/10 (4 out of 10) Left Anterior Knee Pain . Interview on 7/25/19 at approximately 10:00 a.m. with Staff G confirmed that staff should have followed up on Resident #294's complaints of a headache and that they did not.",2020-09-01
524,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,758,D,1,1,OF9N11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to do an Abnormal Involuntary Movement Scale (AIMS) for 1 of 5 residents receiving anti-psychotic medications in a survey sample of 23 residents. (Resident identifier is #73.) Findings include: Review on 7/29/19 of Resident #73's medical record revealed that Resident #73 was receiving the anti-psychotic medication [MEDICATION NAME] three times a day for behaviors and PRN (as needed) for anxiety and agitation. No documented evidence of an AIMS could be found for Resident #73 who is receiving the anti-psychotic medication [MEDICATION NAME]. Interview on 7/29/19 with Staff M (Registered Nurse) at approximately 1:00 p.m. revealed that Resident #73 was receiving the anti-psychotic medication [MEDICATION NAME] three times a day and PRN with no documented of an AIMS being completed.,2020-09-01
525,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,867,D,0,1,OF9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to implement appropriate plans of action to correct deficiencies identified with resident's smoking. Findings include: Review on 7/24/19 of the facility's smoking policy titled OPS137 Smoking, dated revised 7/24/18, revealed the following: 2.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. 2.6.1 If the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment. 2.6.2 Patients will not be allowed to maintain their own lighter, lighter fluid, or matches. Interview on 7/24/19 at approximate 12:45 p.m. during resident council revealed that Resident #13 had started a fire while in bed filling their lighter with lighter fluid on (MONTH) 3, 2019. Resident #13 stated that they were able to put out the fire themselves but [MEDICAL CONDITION] blisters on his hands and chest and needed to go to the wound clinic. Observation on 7/24/19 at approximately 12:25 during resident council revealed that Resident #293 had their lighter in the basket on their walker. Interview on 7/24/19 at approximately 2:30 p.m. with Staff A (Administrator) revealed that after the above incident with Resident #13 the facility instituted facility audits of resident's smoking materials to ensure they are stored appropriately. Review on 7/24/19 of facility audits of resident's smoking materials revealed that the facility checked once per shift that resident's lighters are kept at the nurse's station and cigarette's are locked in their room. Review on 7/25/19 of Resident #15 nursing notes revealed that on 10/8/18 Resident #15 had a burn on right abdomen and as a result the resident was provided a smoking apron. Review of Resident #15's most recent smoking evaluation dated 5/3/19 revealed that the resident is allowed to smoke independently while wearing a smoking apron. Resident 15 was observed multiple times during the survey outside smoking without wearing a smoking apron. Cross reference F689 (Free of Accidents Hazards/Supervision/Devices) Interview on 7/29/19 at approximately 1:00 p.m. with Staff A (Administrator) confirmed the above findings. Staff A revealed smoking was not a project in Quality Assurance after the facility was cited on their 9/28/18 recertification survey for resident's not following their smoking policy. The facility's plan of action after the recertification survey to ensure smoking policies were followed by locking up resident's smoking materials. Staff A also revealed that the action taken after Resident #[MEDICAL CONDITION] to institute audits of smoking materials but the audits were not being monitored and tracked for compliance or improvement.",2020-09-01
526,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,880,E,1,1,OF9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility wound dressing policy and procedure it was determined that the facility failed to provide a safe sanitary environment on the New Castle unit and failed to adhere to professional infection control standards for 2 residents with dressing changes in a survey sample of 23 residents. (Resident identifiers are #13 and #20.) Findings include: Observation on 7/24/19 at approximately 10:00 a.m. showed that the New Castle resident hallway handrails to be sticky with chipped paint on the handrails on both sides of the resident hallway on the New Castle Unit. Observation on 7/24/19 at approximately 10:00 a.m. and on 7/29/19 at approximately 1:45 p.m. with Staff N (Registered Nurse, Infection Control) of the following resident rooms on the New Castle unit revealed that the following resident rooms had window air conditioners' with 3 inch white tape around the air conditioners: Rooms 2, 3, 4, 5, 6, 7, 8 and 9. Observations on 7/24/19 at approximately 10:00 a.m. and on 7/29/19 at approximately 1:45 a.m. with Staff N revealed dead mosquitos visible on resident room [ROOM NUMBER] window sill and in resident rooms from 2 through 14 scrapped wall paint & gouges at the head of the resident bed. Interview and observations on 7/29/19 at approximately 1:45 a.m. with Staff N confirmed that the tape on the air conditioners, the scrapped hallway hand rails and the scrapped paint & gouges at the head of the resident room beds could not be cleaned and were infection control issues. Resident #20 Observation on 7/29/19 at approximately 10:23 a.m. of Resident #20's treatment to the pressure ulcer on their sacrum revealed that Staff G (Unit Manager) did the dressing change. Staff G put on gloves prior to removing the old dressing. Staff G then removed the old dressing. Then, still with the same gloves on, Staff G picked up a container of saline and reached into a packet of gauze pads to remove several pads from the packet. Staff G then cleansed the wound with the gauze pads that they had soaked with the saline. Staff G, still with the same gloves on, took the new treatment items, packed the wound and then covered it with a new dressing. After the new dressing was in place and they still had the same gloves on, Staff G reached for a box of gloves that they had put at the top of Resident #20's bed, just above Resident #20's head. Staff G picked up the box of gloves by taking their gloved hand and putting it in the hole in the top of the box to lift the box and move it over to Resident #20's bedside table. Staff G then removed their dirty gloves and picked up the saline container and the packet of gauze pads and placed them both in a plastic bag and returned the plastic bag to the bedside table cabinet. Review on 7/29/19 of the Facility policy, titled, Wound Dressings: Aseptic, last revised on 11/28/17 revealed that when treating a wound, .16. Expose area to be treated. 16.1 Apply clean gloves. If applicable, place bed protector under or adjacent to wound site and remove the soiled dressing. 16.2 Discard dressing and gloves according to infection control policy. 17. Cleanse hands. 18. Apply gloves 19. Cleanse or irrigate wound as ordered 20. Wipe any excess fluid from the surrounding skin using a dry, gauze wipe .21.1 If gloves become contaminated, remove gloves, cleanse hands, and apply clean gloves . Interview on 7/29/19 at approximately 11:30 a.m. with Staff M (Regional Clinical Manager) confirmed that Staff G should have changed their gloves and washed their hands after removing the old dressing before cleansing the wound and applying the new treatment and dressing. Staff M also confirmed that Staff G should not have lifted the box of gloves with their dirty hands and should not have touched the saline container or the package of gauze pads with their dirty gloves on. Staff M also confirmed that the box of gloves, the saline and the gauze pads were contaminated and should not be used for further use. Resident #13 Observation on 7/29/19 at approximately 11:15 a.m. of Resident #13's treatments to the pressure ulcers on their left ankle and their right heel revealed that Staff G (Unit Manager) did the dressing change. Staff G first did the treatment to Resident #13's left ankle. Staff G put on gloves prior to removing the old dressing. Staff G then removed the old dressing. Then, still with the same gloves on, Staff G picked up a container of saline and reached into a packet of gauze pads to remove several pads from the packet. Staff G then cleansed the wound with the gauze pads that they had soaked with the saline. Staff G, still with the same gloves on, took the new dressing and applied a new dressing. After the new dressing was on, Staff G removed their gloves and applied new gloves prior to treating Resident #13's right heel. Staff G then removed the old dressing from Resident #13's right heel. The dressing was stuck with drainage, so with the same gloves on, Staff G picked up a container of saline and reached into a packet of gauze pads to remove several pads from the packet. Staff G then poured saline on the old dressing to loosen it and then cleansed the wound with the gauze pads that they had soaked with the saline. Staff G then reached back into the packet of gauze to take more gauze pads out and wiped the wound with them. Staff G, still with the same gloves on, took the new dressing and applied the new dressing. Staff G then removed their dirty gloves and picked up the saline container and the packet of gauze pads and placed them both in a plastic bag and returned the plastic bag to the bedside table cabinet. Interview on 7/29/19 at approximately 11:30 a.m. with Staff M confirmed that Staff G should have changed their gloves and washed their hands after removing the old dressings before cleansing the wounds and applying the new dressings. Staff M also confirmed that Staff G should not have touched the saline container or the package of gauze pads with their dirty gloves on. Staff M also confirmed that the saline and the gauze pads were contaminated and should not be used for further use.",2020-09-01
527,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,881,D,0,1,OF9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to establish an antibiotic stewardship program that includes a system to monitor antibiotic use for 3 of 6 months reviewed and 1 of 2 residents reviewed for urinary track infections in a final sample of 23 residents. (Resident identifier is #2.) Findings include: Review on 7/29/19 of the facility's infection control line listing for 2019 used by the facility to track and monitor infections and antibiotics revealed that they were not done in April, May, and (MONTH) of 2019. Interview on 7/29/19 at 9:34 a.m. with Staff N (Infection Preventionist) confirmed the above finding and that there were infections on April, May, and (MONTH) of 2019 but Staff N did not track them on the infection control line listing. Resident #2 Review on 7/29/19 of facility's Antibiotic Stewardship Program policy revealed that .Antibiotics are among the most frequent (sic) prescribed medications in nursing centers .communications among all clinicians is paramount as to when antibiotics are best used and best avoided .providers document clinical rationale to support the use of antibiotics .review microbiology culture date to assess and guide antibiotic selection for patient . Review on 7/29/19 of the CDC (Center of Disease Control and Prevention) website titled, Antibiotic Stewardship for Nursing Homes, revealed that .antibiotic time out is a formal process designed to prompt reassessment of the ongoing need for and choice of an antibiotic once more date (sic) is available including: .additional diagnostic information . Review on 7/29/19 of Resident #2's urinalysis culture and sensitivity final report dated 3/21/19 revealed a positive urine culture of greater than 100, 000 colonies of Escherichia Coli bacteria with antibiotic sensitivity to Pipercillin/Tazobactam, [MEDICATION NAME], Ertapenem, Imipenem, [MEDICATION NAME], and [MEDICATION NAME]; and resistant to the antibiotics [MEDICATION NAME]/Sulfamethaxole (sic), [MEDICATION NAME] and [MEDICATION NAME]. Review on 7/29/19 of Resident #2's Medication Administration Record [REDACTED].k.a. [MEDICATION NAME]/Sulfamethaxole (sic)) 800-160 mg (milligram) by mouth twice a day on 3/21/19. Further review Resident #2's MAR indicated [REDACTED]. Further review of Resident #2's (MONTH) 2019 MAR indicated [REDACTED]. Review on 7/29/19 of Resident #2's April, May, (MONTH) and (MONTH) MAR's revealed an order dated 3/28/19 for Keflex 500 mg by mouth as needed for recurrent UTI twice daily for 3 days at first sign of infection which was not used for the month of (MONTH) to (MONTH) 2019. Interview on 7/29/19 at 11:00 a.m. with Staff N (Infection Control Preventionist) confirmed above findings. Staff N was unable to provide information if the physician was notified regarding the Bactrim DS, that was prescribed on 3/21/19, was resistant to the Escherichia Coli bacteria reported on the 3/21/19 final report of the urinalysis culture and sensitivity. Staff N was unable to provide information if there was any follow up by the nursing staff or infection preventionist that Resident #2's Keflex as needed order was not used for the month of (MONTH) to (MONTH) 2019, nor Staff N was unable to provide any documented clinical rationale by the physician to support the use of antibiotics listed above.",2020-09-01
528,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2019-07-29,948,D,0,1,OF9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to use paid feeding assistants who have completed a state-approved training course for 1 of 1 paid feeding assistant (Staff Identifier is C). Findings include: Observation on 7/25/19 at 12:00 p.m. revealed Staff C (Activities/Supplies) assisting with feeding Resident #24 on the Strawberry unit. Interview on 7/26/19 at approximately 9 a.m. with Staff A (Administrator) revealed that Staff C had not completed a state-approved training course for paid feeding assistants. The facility provided a current list of residents who required assistance with eating and Resident #24 was on the list. Review on 7/29/19 of Resident #24's current care plan revealed nothing in care plan about needing assistance to eat. Review of Resident #24's nutrition assessment dated [DATE] revealed that resident was on a regular/liberalized diet.",2020-09-01
529,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2018-09-27,580,D,0,1,P0ZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facility failed to notify resident provider of assessment changes of one resident in a survey sample of 19 residents. (Resident identifier is #51.) Findings Include: Abnormal Involuntary Movement Scale (AIMS) (Retrieved from website https://dmh.mo.gov/docs/dd/forms/healthsafety/aims.doc on 9/28/2018) Definition The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in the 1970s to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications. Purpose Tardive dyskinesia is a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs, which affects 20%-30% of patients who have been treated for [REDACTED]. Results The total score on the AIMS test is not reported to the patient. A rating of 2 or higher on the AIMS scale, however, is evidence of tardive dyskinesia. If the patient has mild TD in two areas or moderate movements in one area, then he or she should be given a [DIAGNOSES REDACTED]. . If the patient's score on the AIMS test suggests the [DIAGNOSES REDACTED]. This question should be discussed with the patient and his or her family. If the patient requires ongoing treatment with antipsychotic drugs, the dose can often be lowered. . Resident #51 Review of Resident #51's medical record on 9/27/18 at approximately 9:30 AM revealed an AIMS assessment conducted on 9/2/18 at 7:00 AM that documented that Resident #51 had an increase of movement ratings of facial expression, lips and perioral area, and tongue (1,1,2 respectively). In addition the assessment of Resident #51's Global Judgements; severity of abnormal movements overall had increased to a rating of 1. The prior AIMS assessment performed on 3/2/18 revealed all indicators at zero. Review of progress notes in the medical record reveal no indication that providers were made aware of the changes with Resident #51's AIMS scores. Review of the provider (OPTUM practitioner) note dated 9/12/18 reveals no indication that the AIMS score changes between the AIMS assessment performed on 3/2/18 and 9/2/18 had been conveyed to the provider. Interview on 9/28/18 at 9:45 AM with Staff F, Licensed Practical Nurse (LPN). Staff F noted the two AIMS assessments, the lack of documentation in the progress notes that the provider was aware of the rating difference between the two AIMS assessments, the lack of documentation from the OPTUM practitioner notes dated 9/12/18 that the provider was aware of the rating differences.",2020-09-01
530,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2018-09-27,641,D,0,1,P0ZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facility failed to accurately assess one of one residents on an antipsychotic medication for side effects in a final sample of 24 Resident #37 Findings include: Review on 9/27/18 at approximately 8:15 a.m. of Resident #37's medical record in the assessment section revealed that Resident #37 has a [DIAGNOSES REDACTED]. On 4/22/18 the consultant pharmacist recommended that an AIMS (Abnormal Involuntary Movement Scale) assessment be completed as the last one documented in the medical record was on 9/17/17. Further review of Resident #37's medical record revealed that an AIMS assessment was not completed until 8/22/18. Interview on 9/27/18 at approximately 8:36 a.m. with Staff A (Center Nurse Executive) confirmed that there was not an AIMS assessment completed until 8/22/18, and that the facility policy is for AIMS assessments to be completed on admission, re-admission, every six months, and with new medication or as needed.",2020-09-01
531,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2018-09-27,761,B,0,1,P0ZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, record review and interview, it was determined that the facility failed to secure medications in a locked medication cart of 2 out of 3 observed medication carts, ensure proper storage of expired and discontinued medication and biologicals of 1 out of 3 observed medication carts and 1 out of 1 observed medication room, and ensure proper storage for oral medications and wound treatment supplies of 1 out of 3 observed medication carts. (Resident identifiers are #58, #23, #62, #42, #72, #53, #57, #69, and #84.) Findings Include: Policy: Review on 9/25/18 of facility's policy titled .8.2 Disposal/Destruction of Expired or Discontinued Medication . last revised on 6/30/16, revealed that .2. Once an order to discontinue medication is received, Facility staff should remove this medication from the resident's medication supply .4. Facility should place all discontinued or out-dated medication in a designated, secure location which is solely for discontinued medication or marked to identify the medication are discontinued and subject to destruction . Review on 9/25/18 of facility's policy titled .5.3 Storage and Expiration dates of Medications, Biologicals, Syringes, and Needles last revised on 10/31/16, revealed that .3.2 Facility should ensure that external use medications and biologicals are stored separately from internal use medication and biologicals .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart .that is inaccessible by resident and visitors .3.5 Topical (external) use medication or other medication should be stored separately from oral medication .4. Facility should ensure that medications .that: (1) have an expired date on label .are stored separately from other medication until destroyed . Observation on 9/25/18 at 10:39 a.m. of the Bay unit medication room revealed that there were 20 cartons of [MEDICATION NAME] 1.5 Cal (calorie) (tube feeding supplement) with expiration date of (MONTH) (YEAR) and were stored with other tube feeding supplements that were not expired. Interview on 9/25/18 at 10:41 a.m. with Staff B (Registered Nurse) confirmed the above findings in the Bay unit medication room. Observation on 9/25/18 at 10:45 a.m. of the Bay unit medication cart revealed that there was one flu swab (rapid diagnostic test for influenza) with an expiration date of (MONTH) (YEAR). Interview on 9/25/18 at 10:50 a.m. with Staff [NAME] (Medication Nurse Assistant) confirmed the above findings found in the Bay unit medication cart. Observation on 9/25/18 at 11:30 a.m. of the Nubble unit medication cart revealed that the medication cart was unlocked as demonstrated by easily opened drawers of the medication cart and medications were accessible. Interview on 9/25/18 at 11:31 a.m. with Staff C (Licensed Practical Nurse) confirmed that the Nubble unit medication cart was unlocked. Staff C states that they just moved away from the medication cart for a second. Resident #58 Observation on 9/25/18 at 11:32 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #58, which were 29 tablets of [MEDICATION NAME] 5 mg with an expired date of 8/31/18, 36 tablets of [MEDICATION NAME] 25 mg with an expired date of 3/31/18, 55 tablets of [MEDICATION NAME] 25 mg with an expired date of 5/31/18, 28 tablets of [MEDICATION NAME] 100 mg with an expired date of 2/28/17, 15 tablets of [MEDICATION NAME] 10 mg with an expired date of 9/14/17, that were stored with Resident #58's unexpired medications. Interview on 9/25/17 at 11:33 a.m. with Staff C confirmed the above findings. Resident #23 Observation on 9/25/18 at 11:34 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #23's, which were 12 tablets of Potassium 20 meq (milliequivalent) with an expired date of 6/20/18 and 1 tablet of Vacylcovir 1000 mg with an expired date of 9/27/17, that were stored with Resident #23's unexpired medications. Interview on 9/25/17 at 11:34 a.m. with Staff C confirmed the above findings. Resident #62 Observation on 9/25/18 at 11:35 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #62's, which were 8 tablets of [MEDICATION NAME] 4 mg with an expired date of 2/17/18 and 19 tablets of Hydorxyzine 10 mg with an expired date of 5/12/18, that were stored with Resident #62's unexpired medications. Interview on 9/25/17 at 11:35 a.m. with Staff C confirmed the above findings. Resident #42 Observation on 9/25/18 at 11:36 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #42's, which were 30 tablets of Risperdone 0.5 mg with an expired date of 8/31/18 30 and 30 tablets of Risperdone 0.5 mg with an expired date of 7/31/18, that were stored with Resident #42's unexpired medications. Interview on 9/25/17 at 11:36 a.m. with Staff C confirmed the above findings. Resident #72 Observation on 9/25/18 at 11:37 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #72's, which were 27 tablets of [MEDICATION NAME] 5 mg with an expired date of 7/31/18 and 141 tablets of [MEDICATION NAME] 325 mg with an expired date of 7/31/18, that were stored with Resident #72's unexpired medications. Interview on 9/25/17 at 11:37 a.m. with Staff C confirmed the above findings. Resident #53 Observation on 9/25/18 at 11:38 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #53's, which were 53 tablets of [MEDICATION NAME] 5 mg with an expired date of 4/30/18, that were stored with Resident #53's unexpired medications. Interview on 9/25/17 at 11:38 a.m. with Staff C confirmed the above findings. Resident #57 Observation on 9/25/18 at 11:40 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #57's, which were 8 tablets of Pantoprazole 40 mg with an expired date of 2/31/16, that were stored with Resident #57's unexpired medications. Interview on 9/25/17 at 11:40 a.m. with Staff C confirmed the above findings. Resident #69 Observation on 9/25/18 at 11:45 a.m. of the Nubble unit medication cart revealed that there were expired medications of Resident #69's, which were 60 tablets of Risperdone 0.5 mg with expired date of 7/31/18, that were stored with Resident #69's unexpired medications. Interview on 9/25/17 at 11:45 a.m. with Staff C confirmed the above findings. Review on 9/25/18 of Resident #58, Resident #23, Resident #62, Resident #42, Resident #72, Resident #53, Resident #57, and Resident #69's MAR for the month of (MONTH) (YEAR) revealed that it was difficult to determine if the expired medications were administered rather than the unexpired medications. Interview on 9/25/18 at 11:46 a.m. with Staff C revealed that they did not administer any of the expired medication for Resident #58, Resident #23, Resident #62, Resident #42, Resident #72, Resident #53, Resident #57, and Resident #69 that were listed above. Interview on 9/25/18 at 12:12 p.m. Staff A (Center Nurse Executive) confirmed that Resident #58, Resident #23, Resident #62, Resident #42, Resident #72, Resident #53, Resident #57, and Resident #69's medications that were observed were expired medications and were taken out of the Nubble unit medication cart to be sent back to the pharmacy to be destroyed. Resident #84 Observation on 9/25/18 at approximately 7:45 a.m. on the Bay Unit revealed a bottle of Resident #84's [MEDICATION NAME] Ultra 0.3% -0.4% eye drops on the medication cart without any staff present. Interview on 9/25/18 at approximately 7:50 a.m. with Staff B, Unit Manager confirmed that Resident #84's eye drops were on the medication cart without any staff member present.",2020-09-01
532,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2018-09-27,926,C,0,1,P0ZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have smoking policies and procedures that reflect practices of 5 of 5 residents reviewed who smoke. (Resident identifiers are #23, #4, #11, #15, and #29.) Findings include: Review on 9/25/18 of the facility's smoking policy titled OPS137 Smoking, dated revised 7/24/18, revealed the following: 2.1.4 Ashtrays made of non-combustible materials and safe design, and metal containers with self closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances. 2.6.2 Patients will not be allowed to maintain their own lighter, lighter fluid, or matches. Resident #23 Observation on 9/25/18 at 10:13 a.m. revealed Staff F (Unit Manager, Nubble Unit) pick up a cigarette carton from the floor of Resident #23's room and approximately 6 extinguished cigarette butts fell out. Further observation revealed an oxygen condenser in the room belonging to Resident #23. Observation on 9/25/18 at 10:55 a.m. outside in the designated smoking area revealed Resident #23 taking the top off smoking receptacle and digging through the used extinguished cigarette butts and Resident #23 removed a few cigarette butts and collected them on their lap. Interview on 9/25/18 at approximately 11:00 a.m. with Staff F revealed that Resident #23 tends to keep extinguished cigarette butts when she runs out of cigarettes. Interview on 9/25/18 12:31 p.m. with Staff G (Licensed Practical Nurse) revealed that residents were to return their lighters to the medication cart after they went outside to smoke. Observation at the time of interview revealed 5 unlabeled lighters in plastic cup in bottom of medication cart on the Nubble Unit. Staff G was unable to say who the lighters belonged to. Review on 9/26/18 at 8:33 a.m. of Resident #23's smoking assessment dated [DATE] revealed that the facility determined that Resident #23 was an independent smoker. Review of Resident #23's current care plan revealed that following intervention: Maintain (omit resident's name) smoking materials at the nurses' station. Resident #4 Interview on 9/25/18 at 12:31 p.m. with Resident #4 revealed that residents keep their cigarettes and lighters on their person and not in the medication carts or at nurses' station. Observation at the time of interview revealed Resident #4 had a plastic cup in the cupholder of their wheelchair that had greater than 12 extinguished cigarette butts in the cup. Interview with Staff B (Unit Manager, Bay Unit) on 9/26/18 at 8:34 a.m. confirmed that Resident #4 had a plastic cup in the cupholder of their wheelchair with extinguished cigarette butts. Review on 9/26/18 of Resident #4's smoking assessment dated [DATE] revealed that the facility determined that Resident #4 was an independent smoker. Review of Resident #4's current care plan revealed the following intervention: Maintain (omit resident's name) smoking materials at the nurses' station. Resident #11 Interview on 9/25/18 at 12:31 p.m. with Resident #11 revealed that residents keep their cigarettes and lighters on their person and not in the medication carts or nurses' station. Review on 9/26/18 at 8:33 a.m. of Resident #11's smoking assessment dated [DATE] revealed that the facility determined that Resident #11 was an independent smoker. Review of Resident #11's current care plan revealed that following intervention: Maintain patients smoking materials at the nurses' station. Resident #15 Interview on 9/25/18 at 9:15 a.m. with Resident #15 revealed that they kept their cigarettes and lighter with them in their room. Observation at the time of the interview revealed that they had their cigarettes and lighter in their pant's pocket. Interview on 9/25/18 at 11:14 a.m. with Staff F (Registered Nurse) revealed that residents were able to keep their own cigarettes in their rooms and the lighters were to be kept locked in the nurse's station. Resident #29 Interview on 9/25/18 at 12:41 p.m. with Resident #29 revealed that they kept their cigarettes and lighter with them in their room. Observation at the time of the interview revealed that they had their cigarettes and lighter in their coat's pocket. Interview on 9/27/18 at 12:43 p.m. with Staff A (Center Executive Nurse) confirmed that Resident #29 and Resident #15 kept their lighters with them.",2020-09-01
533,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2019-01-17,645,B,0,1,9GRI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview it was determined that the facility failed to perform a preadmission screening for mental disorder (MD) or intellectual disability (ID) prior to admission for 1 resident out of a final survey sample of 21 residents. (Resident identifier is #71.) Findings include: Interview on 1/16/19 at 12:41 p.m. with Staff A (Director of Social Services) revealed that Resident #71 was transferred from a local hospital and did not come with a Preadmission Screening and Resident Review (PASARR). On review of the current MAR (Medication Administration Record) Resident # 71 is receiving [MEDICATION NAME] Sodium ER extended release 24 hr 500 mg Give 2 tablet by mouth one time a day for [MEDICAL CONDITION], this order was written on 12/7/18 at time of admission. Interview on 01/17/19 at 10:59 AM Staff A was asked for the completed (PASARR) for Resident # 71 which was provided with a signature date of 1/16/19.",2020-09-01
534,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2019-01-17,658,D,0,1,9GRI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the Facility failed to ensure professional standards of quality were maintained while managing a patients diabetic needs. (Resident identifier is #86). Findings include: Review, on 1/15/19, of the (MONTH) 2019 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. During observation of a medication administration pass, on 1/15/19 at approximately 8:23 a.m., Staff D, LPN (Licensed Practical Nurse) was observed to approach Resident #86 as he sat at his breakfast table in the Facility's main dining room, an empty breakfast plate before him, sipping on a partially consumed glass of milk. Staff D, LPN was then observed to give Resident #86, 1 mg. of Repaglinide. This was observed to be post-prandial (occurring after a meal). Staff D was observed to relocate Resident #86 to his room and, at approximately 8:25 a.m. observed to perform a post-prandial fingerstick blood sugar with an Evencare G2 glucometer which she recorded as a blood sugar level of 151 mg/dl. Staff D then prepared and gave Resident #86, 2 units of [MEDICATION NAME] R insulin, subcutaneously, in the left upper quadrant of his abdomen. Review on 1/15/19 of the Wolfeboro Bay Center, Location of Administration report, generated 1/15/19 at 10:49:53 ET (Eastern Time) reveals that Resident #86 received Insulin Regular Human solution on 1/15/19 that was scheduled for administration at 7:00 a.m., subcutaneously in the left upper quadrant of the abdomen at 8:26 a.m. Interview on 1/15/19 at approximately 8:30 a.m. Staff D, confirmed that Resident #86 had consumed the morning meal before being tested for his blood glucose levels and before receiving the anti-diabetic medications; Repaglinide 1 mg, and Insulin regular human solution to sliding scale, (as described, above). Review, on 1/15/19, of the Facility's procedures for Fingerstick Glucose Measurement reveals a 20 item procedure list which states at item number 1, verify order, if indicated and at number 19, Follow physician/advanced practice provider order for insulin administration as ordered Review, on 1/15/19, of the Facility's procedures for Diabetic Care Protocol reveals an 11 item procedure list which states at item number 5: Perform fingerstick blood glucose monitoring as ordered. According to Essentials for Nursing Practice- Ninth Edition by Potter & Perry with Stockert & Hall, Copyright 2019, Elsevier Inc., Chapter 17, Medication Administration, pages 401, 402, 403 and 409: A medication order is required to administer any medication to a patient. The medication order needs to contain all the elements listed in Box 17.9 (page 409). These include: Patients full name, Date and time that order is written, Medication name, Dosage, Route of administration, Time and frequency of administration, and signature of health care provider. Review of the information at the Time and frequency of administration heading reveals, in part: An order will also include the time and frequency of medication administration, which is essential information for anyone . administering the medication . A health care provider often gives specific instructions for the timing of medication administration (pages 402 and 403 Chapter 17, Medication Administration), at the heading Right Time: Give priority to time-critical medications that must act at certain times. You administer time critical medications within 30 minutes before or after their scheduled time around the clock to maintain therapeutic blood levels. Examples of time-critical medications include antibiotics, anticoagulants, insulin, anticonvulsants and immunosupressive agents.",2020-09-01
535,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2019-01-17,812,D,0,1,9GRI11,"Based on observation and interview, it was determined that the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: Observation on 1/14/19 at 12:15 PM revealed during tour of kitchen with the Staff B (Director of Food Services) that Staff C (Cook) was making a sandwich bag to go. Staff C emptied the contents (Chicken salad) out of a single serving plastic holding container onto a piece of bread. Then using the bottom of the of the outside part of the plastic serving container spread the Chicken salad onto the bread. This observation was told to Staff B at the time of the event who stated they observed the same thing and will be talking to Staff C on proper handling of food products.",2020-09-01
536,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2018-02-06,740,E,0,1,BWPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy and procedure and interview it was determined that the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being on 2 out of 3 units. (Resident identifiers are #37, 40, 79 and 81.) Findings include: Resident #81 Interview on 2/1/18 at approximately 10:30 a.m. with Resident #81 revealed that Resident #81 was noted to be anxious and yelled at this surveyor, Get out of my room. Observation on 2/1/18 12:02 PM revealed Resident #81 to be making lewd comments to staff loudly in the [NAME]wood dining room. Review on 2/5/18 of Resident #81's behavior monitoring and interventions record revealed that Resident #81 had the following documented behaviors: January (YEAR) (January 12th-January 31st) V2. screaming at others 27 times V3. cursing at others 24 times 08. sitting on the floor 3 times February (YEAR) (February 1st-February 5th) V2. screaming at others 26 times V3. cursing at others 14 times Resident #79 Review on 2/6/18 of Resident #79's Medication Administration Record [REDACTED]. February's Medication Administration Record [REDACTED]. Resident #37 Review on 2/6/18 of Resident #37's behavior monitoring and interventions record revealed that Resident #37 had the following documented behaviors: January (YEAR) (January 1st-January 31st) P5. grabbing 4 times 07. screaming/disruptive sounds 26 times February (YEAR) (February 1st-February 6th) V2. screaming at others 30 times V5. complaints of anxiety 6 times Interview on 2/6/18 at approximately 9:00 a.m. with Staff A, Unit Manager revealed that Staff A is aware of Resident #37, #79 and #81's behaviors. Staff A revealed that psychiatric services had not been offered to these residents. Interview on 2/16/18 at approximately 10:30 a.m. with Staff C, Administrator revealed that Residents #37, #79 and #81 should have been offered psychiatric services. Review on 2/5/18 of the facility's policy and procedure titled, OPS415, Behavioral Health Services; Effective Date, 11/28/16 revealed: Policy Each patient must receive and the Center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a patient's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [REDACTED]. Resident #40 Review on 2/6/18 of Resident #40's Behavior Monitoring and Interventions sheet for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following episodes of behavior: December (YEAR) : Delusions 16 times Hallucinations 16 times Paranoia 4 times January (YEAR): Delusions 16 times Hallucinations 4 times Paranoia 7 times Interview on 2/6/18 at approximatley 10:30 a.m. with Staff D (Memory Care Unit Manager) revealed psychiatric services had not been offered to Resident #40. Anonymous interview with Staff RN revealed that Resident #40's physician, did not like the behavioral health company that the facility uses, and had not agreed to write an order for [REDACTED].",2020-09-01
537,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2018-02-06,809,B,0,1,BWPZ11,"Based upon staff and resident interviews the facility failed to ensure that residents are offered a nourishing snack in the evening. Findings include: On 2/1/18 at a special Resident's Council meeting most of the dozen residents in attendance stated that the facility did not routinely offer them an evening snack. Review 2/6/18 of the Facility Dining Services Meal Times schedule for all residents reveals there is greater than 14.0 hours between dinner and breakfast for all 3 dining rooms and for the times allocated for those who choose to eat in their rooms. As such, a nourishing snack must be served at bedtime. On interview, 2/6/18 at 10:45 a.m., Staff G, Dietary Services Manager stated there is a framework already in place for snack distribution. Snack one, 10:00 a.m. Nourishment pass, Hydration and snacks are passed. Snack two, 2:00 p.m. (after lunch), Hydration and Snacks are passed. Snack three, 7:00 - 8:00 p.m., similar routine. Staff G, further stated: snacks are always available, they may not always be offered. Staff G added: We could do better with leftovers for offerings. We could make extra of some items and plan on using them for sandwich materials for evening snacks. Staff G also stated: We could re-visit (the snack pass), re-vamp (the process) and increase the diligence (in distributing). Resident #79 Interview on 2/1/18 at approximately 9:50 a.m. with Resident #79 revealed that snacks had been offered a couple of times. Resident #37 Interview on 2/1/18 at approximately 11:20 a.m. with Resident #37 revealed that Resident #37 has not had any snacks offered. Interview on 2/6/18 at approximately 9:00 a.m. with Staff A, Unit Manager revealed that snacks are not offered to all residents on [NAME]wood Unit. Snacks are offered to the residents sitting in the sitting area across from the [NAME]wood Unit nursing station.",2020-09-01
538,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2018-02-06,842,B,0,1,BWPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to have medical records that accurately reflected the current status of 6 residents in a standard survey sample of 21 residents. (Resident identifiers are #4, #43, #60, #74, #75, and #86.) Findings include: Resident #4. Review on 2/6/18 of Resident #4's medical record at 9:55 a.m. revealed that Resident #4 had a change of condition in skin on 7/17/17. It was noted to the right Achilles Heel a SDTI (Suspected Deep Tissue Injury) that was 100% [MEDICATION NAME] flat with a blood blister in the center approx. 75% of the wound Ensure heel boot in proper placement done tonight. Review on 2/6/18 of Resident #4's monthly physician encounter notes dated 8/8/17, 12/12/17 and 1/9/18 revealed Continues stable with management of mutiple issues as detailed below and issues noted: with no other new changes or difficulties reported by patient, staff, or family since last rounds. Chart reviewed and changes noted: Eating well, sleeping well, no new difficulty with bowel or bladder function and no new focal neurologic changes or alterations in ambulatory status since last rounds other than as noted above. Interview on 2/6/18 at 11:15 a.m. with Staff B (RN) confirmed that Resident #4 had a change of condition in skin on 7/17/17 for a SDTI to the right Achilles Heel. Staff B also reviewed the Resident #4's monthly physician encounter note for 8/8/17 that did not discuss any change in condition for Resident #4. Resident #4's physician encounter notes for the past 3 months are the same notes except for the vital signs and dates. Resident #4 has a PEG (Percutaneous Endoscopic Gastrostomy) for feeding. Staff B indicated that the physician encounter notes are the same notes month after month and that the SDTI did not heal until 8/17/17. Resident #43 Record review on 2/6/18 of Resident #43's medical record revealed the resident developed a pressure ulcer on 12/14/17. This pressure ulcer was documented on the Skin Integrity Report (weekly wound assessment sheet) as a Stage 2 Kennedy Ulcer on the resident's coccyx and is documented as healed on 1/28/18. Staff [NAME] completed a physician visit on 12/26/17 and documented under Skin Warm and dry without rash or lesion. There is no documentation in Staff E's visit note regarding the resident's pressure ulcer. Staff [NAME] completed a physician visit note dated 1/23/18, which is the same note as was documented on 12/26/17 and again documented that the resident's skin was Warm and dry without rash or lesion. These physician notes do not accurately reflect the resident's skin condition. Interview on 2/6/18 at approximately 3:35 p.m. with Staff F (Director of Nursing - DON) revealed that the resident did have a pressure ulcer at the time of these physician visits and should have been reflected in Staff E's physician assessment note. Resident #60 Record review on 2/6/18 of Resident #60's medical record revealed the resident developed a pressure ulcer on 11/8/17. This pressure ulcer was documented on the Skin Integrity Report (weekly wound assessment sheet) as a scabbed area on the resident's left ear and is documented as healed on 1/26/18. There was a second pressure ulcer on the resident's left ischium that was discovered on 12/20/17 and was healed on 12/29/17. Staff [NAME] completed a physician visit on 12/26/17 and documented under Skin Warm and dry without rash or lesion. There is no documentation in Staff E's visit note regarding the resident's pressure ulcers. Staff [NAME] completed a physician visit note dated 1/23/18, and again documented that the resident's skin was Warm and dry without rash or lesion. These physician notes do not accurately reflect the resident's skin condition. Interview on 2/6/18 at approximately 3:40 p.m. with Staff F (Director of Nursing - DON) revealed that the resident did have a pressure ulcer at the time of these physician visits and should have been reflected in Staff E's physician assessment note. Resident #86 Record review on 2/6/18 of Resident #86's medical record revealed the resident developed a pressure ulcer on 1/16/18. This pressure ulcer was documented on the Skin Integrity Report (weekly wound assessment sheet) as a an unstageable pressure ulcer on the residents buttock and is documented as healed on 2/1/18. Staff [NAME] completed a physician visit on 1/23/17 and documented under Skin Warm and dry without rash or lesion. There is no documentation in Staff E's visit note regarding the resident's pressure ulcer. Interview on 2/6/18 at approximately 3:45 p.m. with Staff F (Director of Nursing - DON) revealed that the resident did have a pressure ulcer at the time of these physician visits and should have been reflected in Staff E's physician assessment note. Resident #75 Review of Resident #75's medical record on 2/6/18 revealed a nursing note dated 1/9/18 that stated that Resident #75 has had weight loss and a decrease in appetite and decreased ability to feed self. Nursing note dated 1/11/18 stated resident was admitted to hospice on 1/10/18 and is being fed by staff and is on a trial pureed diet. Nutrition note dated 1/16/18 states resident has inadequate oral intake. Review on 2/6/18 of Resident #75's monthly physician encounter progress note dated 1/16/18 revealed that resident had no new changes since the last physician visit on 12/19/17, and was eating well, sleeping well, no new difficulty with bowel or bladder function and no new focal neurologic changes or alterations in ambulatory status since last rounds other than noted above. Resident #74 Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 2/2/18 of Resident #74's Medication Administration Record [REDACTED] Intake and output every shift. Review on 2/2/18 of Resident #74's Total Intake - Output Record 8 Hour Shift Record revealed that from order date of 1/9/18 through 1/31/18 21 days of intake and output were not completed. Interview on 2/2/18 at approximately 1:45 p.m. with Staff A, Unit Manager revealed that the Total Intake - Output Record 8 Hour Shift log would be the only place that intake and output is recorded. Staff A confirmed that there was no documentation of intake and output for (MONTH) (YEAR). Review on 2/5/18 of the facility's policy and procedure titled, Revision date 11/30/15 revealed: 1. Use the Total Intake and Output Record .to track patient's fluid consumption and output according to Fluid Balance policy. 2. Record all intake amounts (in cubic centimeters); . 3. Record all output amounts including: 3.1 Urine in cubic centimeters or number of incontinent episodes . 4. Add shift and daily totals of both intake and output. 5. Use a Total Intake and Output Record for each 24- hour period. 6. Evaluate patient's fluid balance on daily intake and output records 7. Document: 7.1 Intake and output totals in patient's medical record",2020-09-01
539,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2018-02-06,881,D,0,1,BWPZ11,"Based on record review and interview, the facility failed to ensure that residents who required an antibiotic were prescribed the appropriate antibiotic by obtaining a culture for organism identification. Findings include: Review on 2/6/18 of the infection control line listings, which revealed 3 residents who had infections within the last 3 months and were placed on an antibiotic. The physician prescribed antibiotics based on the residents symptoms and not on a confirmed culture of the wound bed. Interview on 2/06/18 at approximately 1:48 p.m. with Staff H (RN Infection Control Program), Staff H confirmed that cultures were not done to determine the most appropriate antibiotic based on the organism.",2020-09-01
540,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2017-02-17,279,D,0,1,6FWS11,"Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 1 resident in a standard survey sample of 18 residents. (Resident identifier #13.) Findings include: Resident # 13 Review on 2/16/17 of Resident #13's comprehensive care plan revealed that the resident had a Foley Catheter. Review of Resident #13's care plan revealed no comprehensive care plan for a Foley Catheter. Interview on 2/16/17 at 1:30 p.m. with Staff A (unit manager) confirmed the above findings.",2020-09-01
541,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2017-02-17,456,E,0,1,6FWS11,"Based on record review, observation and interview, it was determined that the facility failed to maintain 2 glucometers on 1 out of 3 units and oxygen tubing in safe operating condition. Findings include: Review of the facility's policy titled (NSG217 Glucose Meter) effective date of 06/01/96 with a revision date 3/15/16 revealed that is the facility's practice that To ensure the accuracy and validity of blood glucose monitoring, blood glucose meters will be disinfected before patient use and quality control tested daily according to manufacturers guidelines. Review of daily quality control logs for the two glucose meters used on [NAME]wood Unit revealed the following missing entries: January (YEAR) meter 1 has 14 missing entries meter 2 has 10 missing entries December (YEAR) meter 1 has 15 missing entries meter 2 has 13 missing entries November (YEAR) meter 1 has 19 missing entries meter 2 has 23 missing entries October (YEAR) meter 1 has 14 missing entries meter 2 has 17 missing entries September (YEAR) meter 1 has 22 missing entries meter 2 has 20 missing entries August (YEAR) meter 1 has 19 missing entries meter 2 has 15 missing entries July (YEAR) meter 1 has 17 missing entries meter 2 has 15 missing entries Interview on 2/16/17 at 9:30 a.m. with Staff C (Registered Nurse, Unit Manager) confirmed that the logs were incomplete. Review of the Facility's Policy titled: Oxygen: Nasal Cannula Policy dated 01/01/04 with a revision date of 12/08/14 documents that Oxygen (O2) supplies are to be changed every 7 days. Review of the Facility's Policy titled: Respiratory Equipment/ Supply Cleaning/ Disinfection dated 04/01/07 with a revision date of 01/02/14 documents that nebulizer tubing is to be changed every 7 days. Resident #18 Observation on 2/15/17 at approximately 9:30 a.m., revealed that Resident #18 had O2 tubing connected to the Oxygen concentrator in the room, as well as tubing connected to a nebulizer in the resident's room; neither of these two tubes were dated when the tubing was last changed. Within a few minutes, Resident #18 returned to the room and was using O2 connected to an O2 tank. Observation of the tubing Resident #18 was using revealed that it was dated 2/4/17 and was due to be changed on 2/11/17 indicating it was 4 days over-due. Resident #19 Observation on 2/15/17 at approximately 9:30 a.m., revealed that Resident #19 had O2 tubing attached to the O2 concentrator. The date on the O2 tubing was 2/5/17 and due to be changed on 2/12/17 indicating it was 3 days overdue. There was also an O2 tube attached to an O2 tank which had no date on that tube. Interview with Staff C (Registered Nurse, Unit Manager) confirmed these findings.",2020-09-01
542,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2019-04-10,607,D,1,0,JLZZ11,"> Based on review of facility investigation records, employee personal and training records and interviews it was determined that the facility failed to follow through with facility policy and procedure guidelines for handling suspected incidents of abuse towards 2 residents (Resident identifiers are #1 and #2). Findings include: Review on 4/10/19 of facility generated report dated 3/24/19 it was revealed that at 1:00 am it was reported by Resident #1 to Staff D, (Licensed Nurse Aide), that Staff E, LNA, 'was very rough with' (Resident #1) 'up and out of bed very rapidly and seemed angry'. Review on 4/10/19 of facility generated report dated 3/24/19 at 2:45 am it was observed by Staff D, LNA, that Staff [NAME] came into Resident #2's room and 'ripped the blankets off of' Resident #2. Resident #2 informed Staff [NAME] that Staff [NAME] appeared angry. When Staff [NAME] re-approached Resident #2, Resident #2 informed Staff [NAME] that 'if your angry I don't want you touching me.' Review on 4/10/19 of the personnel files of Staff's D and E. No prior allegations of abuse were noted in regards to Staff E. Training records for Staff D and [NAME] reveal that they each participated in a training session for Abuse Prohibition on 1/2/19. On 2/11/19 both Staff D and [NAME] attended a training session for Preventing and Responding to Abuse. Review of the Genesis policy 'Abuse Prohibition', revision date 7/1/18, Section Process, paragraph 5 'Staff will identify events-such as suspicious bruising of patients, occurences, patterns, and trends that may constitute abuse-and undermine the direction of the investigation. This also includes patient-to-patient abuse.' Line 5.1 'Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately.' Review of a note, dated 3/25/19 by Staff A (Center Executive Director) in regards to the investigation of both alleged abuse incidents that occurred on 3/24/19 between 1:00 AM and 2:45 AM, reveal in paragraph two: At this point, Staff D told Staff [NAME] that two residents had complained about Staff [NAME] and that Staff [NAME] needed to go home now. Staff D encouraged Staff [NAME] to leave the building right now. I will tell the nurse, you needed to go. The nurse was on break. Staff [NAME] left the building and went home around 4 AM. Interview on 4/10/19 at 10:00 AM with Staff A, Staff B, (Center Nurse Executive), and Staff C (Nurse Practice Executive) it was revealed that: *Staff [NAME] did not exit the facility until 4 am. *The supervising nurse was not made aware of the incidents until return from break at 4:15 am. *Staff A was notified by the supervising nurse after the exit from the facility of Staff E *Staff [NAME] received education on Abuse Prohibition, We Care-Genesis Approach to Customer Service, and an interactive discussion that focused on Approaching Patient Care with with Patients, Communicating with Patients & Staff, Understand Patient Perception, Providing Care as to Patient Needs, and Reporting to Charge Nurse. Staff A and B were asked if the rest of the staff received this education and the answer was 'No'. Staff A and B were asked if the facility LNAs had the ability to send staff home when there is an allegation of abuse from residents, and the charge nurse was not made aware of the allegations prior to staff leaving. The answer was 'No'.",2020-09-01
543,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2017-11-30,609,E,1,0,FU6P11,"> Based on review of facility reported alleged violations, policy and procedures, witness statements and interview, it was determined that the facility failed to report 4 of 4 allegations immediately to the facility administrator and failed to report to the State agency in a timely manner. 1 allegation was not reported as of the date of this survey to the State agency. (Resident identifiers are #1, #2, #3 and #4.) Findings include: Resident #1 Offsite review on 11/17/17 of a facility reported allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 10/2/17. The allegation was reported to the State survey agency on 11/2/17. Review of Staff H's LNA (Licensed Nurse Assistant) witness statement dated 11/2/17 revealed that the allegation of abuse had been reported to Staff G, LPN (Licensed Practical Nurse) on 10/21/17. Review of the witness statement revealed that Staff H (LNA) did not report it to the supervisor for 2 hours and 30 minutes after the alleged abuse took place. Resident #2 Offsite review on 11/17/17 of a facilty reported allegation of verbal abuse towards Resident #2 revealed that the allegation of abuse took place on 10/21/17. The allegation was reported to the State survey agency on 11/3/17. Review of Staff H's witness statement dated 11/2/17 revealed that the allegation of abuse had been reported to Staff I, LPN on 10/21/17. Review of the witness statement revealed that Staff H did not report it to the supervisor for 2 hours and 30 minutes after the alleged abuse took place. Resident #3 Review on 11/30/17 of Staff C's, LNA witness statement dated 11/3/17 revealed an allegation of employee to resident physical abuse that allegedly occured About a month ago . with Resident #3. Staff C's witness statement revealed that this allegation of abuse was reported to Staff L, LPN. This allegation of abuse had not been reported to the state survey agency. Resident #4 Offsite review on 11/17/17 of a facility reported allegation of physical abuse towards Resident #4 revealed that the allegation of abuse took place on 10/7/17. The allegation was reported to the State survey agency on 11/3/17. Review of Staff H's witness statement revealed that the allegation of abuse had been reported to Staff G, LPN on 10/7/17. Review of the witness statement revealed that Staff H did not report it to the supervisor for 30 minutes after the alleged abuse took place. Review of the facilitys Policy and Procedure titled Abuse Prohibition, revision date 11/28/17 revealed: Policy: . Protection of patients during investigations; and reporting of incidents, investigations, and center response of their investigations. Process: . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin , or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director or designee and other officials in accordance with state law. . 6.4 Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury. Interview by telephone on 11/17/17 at approximately 8:45 a.m. with Staff A (Administrator), confirmed that the allegations were not reported to the state agency within 24 hours of the allegations.",2020-09-01
544,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2017-11-30,610,E,1,0,FU6P11,"> Based on review of 4 abuse allegations, witness statements, record reviews, facility abuse policy and procedure and interview it was determined that the facility failed to thoroughly investigate and protect residents for potential abuse for 4 residents in a survey sample of 4 residents. (Resident identifiers are #1, #2, #3 and #4.) Findings include: Review on 11/30/17 of 3 allegations of abuse against Staff B LNA (Licensed Nursing Assistant) revealed that the allegations were not investigated on an individual basis. Witness statements were not obtained for specific incidents. Review on 11/3017 of witness statements reviewed revealed the following allegations: Resident #1 Review on 11/30/17 a facility reported allegation of Staff B, LNA verbal abuse towards Resident #1, date of incident 10/2/17 (Resident identifier #1) revealed that the facility did not get individual witness statements from staff pertaining to this allegation individually. No residents who received care from Staff B, LNA on the unit were interviewed. Resident #2 Review on 11/30/17 of a facility reported allegation verbal abuse towards Resident #2, date of incident 10/21/17 revealed that the facility did not get individual witness statements from staff pertaining to this allegation individually. No residents on the unit whom recieved care from Staff B were interviewed. Resident #3 Review on 11/30/17 of Staff C's (LNA) witness statement dated 11/3/17 revealed the following allegation of abuse: About a month ago from 11/3/17 Staff C witnessed Resident #3 running down the hallway screaming and crying with face reddened, with tooth paste on her face and was shaky and nervous. Resident #3 stated, pinching, pushing, she was sweet at first about Staff B (LNA). Interview on 11/30/17 at approximately 10:00 a.m. with Staff A (Administrator) confirmed that there was no investigation done with Staff C's allegation obtained through the witness statement. Interview on 11/30/17 at approximately 1:30 p.m. with Staff A confirmed that the witness statements obtained were not for individual allegations of abuse. Staff A also confirmed that no other residents were interviewed regarding Staff B (LNA). Resident #4 Review on 11/30/17 of a facility reported allegation verbal abuse towards Resident #4, date of incident 10/7/17 revealed that the facility did not get individual witness statements from staff pertaining to this allegation individually. No residents whom received care from Staff B on the unit were interviewed. Review on Policy and procedure titled Abuse Prohibition, revision date 11/28/17 Policy: . Protection of patients during investigations; and reporting of incidents, investigations, and center response of their investigations. Process: . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin , or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director or designee and other officials in accordance with state law. . 6.4 Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury.",2020-09-01
545,WOLFEBORO BAY CENTER,305083,39 CLIPPER DRIVE,WOLFEBORO,NH,3894,2019-12-13,689,D,1,0,4Q1I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to provide an environment that is free from accident hazards and to eliminate the risk for elopement from occurring for 1 resident out a complaint survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on 12/13/19 at 1:00 p.m. of Resident #1's care plan under the focus area revealed Resident/Patient is at risk for elopement related to: confusion, [MEDICAL CONDITION], self propels in wc (wheelchair), behaviors with a created date of 3/1/19. Review on 12/13/19 revealed a nurses note dated 11/3/19 at 8:14 a.m. A change in condition has been noted. The symptoms include: Other change in condition elopement 11/3/19 in the morning . Review on 12/13/19 at 10:10 a.m. of the Logbook Documentation revealed under Instructions Doors, Locks & Alarms: Test operation of door and locks. Further review of the logs show the following door locations: Front Lobby, Solana Main Entry, Solana Dining Room, Solana West Entry, Kit Dish Wash Room, Kit Delivery , Employee Entry, [NAME]wood East Entry, [NAME]wood Patio, [NAME]wood Ramp. Review on 12/13/19 of the Instructions on how to perform testing under Check delayed egress operation .#6. Confirm that security panels at Nurse Station activate when door is opened and that it properly indicates the location of the door released Interview on 12/13/19 at 10:20 a.m. with Staff G revealed Resident #1 eloped from Employee Entry door. Staff G was asked how could Resident #1 have exited through the employee entry door. Staff G stated the door does not always fully shut due to the pressure between the outside door and inside door. Staff G explained it's like a wind tunnel. Staff G was then asked what testing was done when checking the doors. Staff G stated they make sure the door latches correctly and that the magnet releases within the 15 seconds when testing. Staff G was then asked if they check the alarm/security panel at the nurse station. Staff G stated No that is not on the Logbook Documentation check off. Review on 12/13/19 of a vendors report dated 11/5/19 reveals Problem: 500DE not announcing at Nurse Station .Solution: Relays dead. Replaced with refurbished 500DE . Interview on 12/13/19 at 11 a.m. revealed Staff G added to the Logbook Documentation testing security panels at Nurse Station and that it properly indicates the location of the door released. Staff G confirmed that the vendor was called in response to Resident #1's elopement.",2020-09-01
546,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-10-12,279,D,1,1,PXTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop a comprehensive [MEDICAL TREATMENT] care plan for 1 of 2 [MEDICAL TREATMENT] residents in a survey sample of 16 residents. (Resident identifier is #11.) Findings include: Review on 10/12/17 of Resident #11's medical record revealed a [DIAGNOSES REDACTED]. Resident #11 had initially been admitted to the facility on [DATE] and had a re-admitted to the facility of 9/26/17. Interview on 10/12/17 at approximately 10:45 a.m. with Staff [NAME] (Registered Nurse) review Resident #11's medical record and revealed that Resident #11 was going to [MEDICAL TREATMENT] treatment center three times a week and that there was no [MEDICAL TREATMENT] care plan for Resident #11.",2020-09-01
547,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-10-12,280,D,0,1,PXTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update care plans for 3 residents in a survey sample of 16 residents. (Resident identifiers are #11 and #14.) Findings include: Resident #11 Review on [DATE] of Resident #11's telephone order dated [DATE] revealed the following physician order [REDACTED]. Another verbal order dated [DATE] for Resident #11 revealed the following physician orders: DO NOT RESUSCITATE (DNR) DISCONTINUE and change to FULL CODE. Interview on [DATE] at approximately 10:45 a.m. with Staff [NAME] (Registered Nurse) reviewed Resident #11's care plan and revealed that the care plan for Resident #11 showed advanced directive and/or DNR order in place. Staff [NAME] confirmed that the care plan had not been updated from DNR to Full Code status for Resident #11. Resident #14 Review on [DATE] of Resident #14's care plan at time of death on [DATE] revealed the resident had a code status full code. Review of the advance directives in the resident's chart and in the electronic medical record revealed a code status of DNR (Do Not Resuscitate). Review of the resident's Medical Administration Record for (MONTH) (YEAR) revealed a code status of full code. Review of physician orders [REDACTED]. The staff did not attempt to resuscitate the resident at the time of death on [DATE]. Interview on [DATE] at approximately 10:00 a.m. with Staff D (Unit Manager) confirmed the above finding.",2020-09-01
548,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-10-12,281,D,0,1,PXTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop an interim care plan at the time of admission for 2 of 4 newly admitted residents reviewed. (Resident identifiers are #1 and #16.) Findings include: Reference for the professional standard of practice for medication documentation is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines. Box 35-1 Guidelines for Safe Narcotic Administration and Control . . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication, dose, and signature of nurse dispensing the medication. . If a nurse gives only part of a pre-measured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers Page 709 Right Documentation. Nurses and other health care providers use accurate documentation to communicate with each other. Many medication errors result from inaccurate documentation. Therefore ensure that accurate and appropriate documentation exists before and after giving medications. Verify inaccurate documentation before giving medications . After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care . Page 269 relates under Planning Nursing Care, You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals .The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care .A correctly formulated nursing care plan makes it easy to continue care from one nurse to another. Resident #1 Interview on 10/10/17 at 10:30 a.m. with Staff B (Licensed Practical Nurse) revealed Resident #1 had a history of [REDACTED]. Staff B further revealed that Resident #1 developed an ulcer at the facility while wearing a boot for contractures that the resident brought from home. Staff B was unsure when the resident's boot came from home but it was not with the resident on admission. Review on 10/11/17 of Resident #1's medical record revealed Resident #1 was admitted on [DATE]. Resident #1's care plan revealed interventions for activities, no other interventions. Interview on 10/12/17 at approximately 9:10 a.m. with Staff D (Unit Manager) confirmed the above findings for Resident #1 and that there were no interventions care planned for pressure ulcers. Staff D revealed that physical therapy had not evaluated the fitting of the boot. Review on 10/12/17 of the facility's policy titled Person-Centered Care Plan dated 11/28/16 revealed the following: The Center must develop and implement a baseline person-centered care plan within 48 hours of each patient and that includes the instructions needed to provide effective and person-centered care that meet professional standard of quality care. Resident #16 Review on 10/12/17 of Resident #16's medical record revealed an admission [DIAGNOSES REDACTED]. Review on 10/12/17 of Resident #16 medical record revealed Resident #16 was receiving [MEDICAL TREATMENT] treatment 3 times a week. The only documented evidence in the facility any care plan that could be found regarding the [MEDICAL TREATMENT] treatments was in the nutrition care plan, that was initiated on 9/27/17, that stated Weigh per facility protocol, dry weight post [MEDICAL TREATMENT] and alert dietitian and physician to any significant loss or gain. Interview on 10/12/17 at approximately 2:45 p.m. with Staff D (Unit Manger), reviewed Resident#16's the facility admission care plan and Staff D verified that there was not any documentation on this admission care plan for [MEDICAL TREATMENT] treatments for Resident #16.",2020-09-01
549,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-10-12,431,E,0,1,PXTJ11,"Based on observation, record review, and interview, the facility failed to store all drugs and biologicals under proper temperature controls in 1 of 3 of residential units. Findings include: Observation on 10/10/17 at 11:00 a.m. revealed the temperature in the medication storage room on the Bretton [NAME] unit was 90 degrees Fahrenheit (F). Interview with Staff B (Licensed Practical Nurse) on 10/10/17 at 11:00 a.m. confirmed the temperature in the medication room. Observation on 10/11/17 at approximately 8:00 a.m. revealed that the temperature in the medication storage room on the Bretton [NAME] unit was 90 degrees F. The inside of the medication refrigerator in the medication room was wet and the cardboard boxes for 2 of 2 of the flu vaccine vials were completely soggy and did not hold their integrity when touched. Interview with Staff B on 10/11/17 at approximately 8:00 a.m. confirmed the above findings and revealed staff on the unit were aware that temperature in the medication room is consistently elevated and that the inside of the refrigerator needed to be wiped down daily because of condensation build up. Observation on 10/11/17 at 8:30 a.m. revealed the following medications in the room: Lumigan Opthamalic Solution, Nitroglycerin Tablets, Naproxen, Docusate Sodium, Acetaminophen, and Ipratropium/Albuterol. Review of manufacturer's and pharmacy instructions for the above medication revealed the above medication are to be stored at room temperature from 59-77 degrees F. Some of the above medications allow for excursion up to 86 degrees F. Interview on 10/11/17 at approximately 1:45 p.m. with Staff C (Facilities Director) revealed that Facilities had been unaware of the the elevated temperature in the medication room and the condensation in the medication refrigerator. Observation on 10/12/17 at 1:50 p.m. revealed the temperature in the medication storage room on the Bretton [NAME] unit was 85 degrees F. Interview with Staff D (Unit Manager) on 10/12/17 at 1:50 p.m. confirmed the temperature in the medication room.",2020-09-01
550,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-10-12,456,B,0,1,PXTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the manufacturers instructions the facility failed to maintain the facility [MEDICATION NAME] in a safe manner. Findings include: The facility's [MEDICATION NAME] manufacturers user manual dated 2009 revealed the following: SAFETY PRECAUTIONS . The recommended operating temperature is 160 (degrees) F to 165 (degrees) F (71 degrees C to 74 degrees C). The temperature of the water should be checked with a thermometer after every adjustment, before using the HotPac. Always allow sufficient time for the water temperature to stabilize . . Check water level daily as it has a natural loss due to evaporation . . If the unit is to be left unattended for a period of time, unplug the unit, remove the packs, empty the water, and clean the tank. MAINTENANCE Care and Cleaning It is critical to maintain the water level over the top of the HotPac to avoid damage to the heating element, the stainless steel, or the HotPac. Water is constantly lost during operation due to evaporation. Therefore, it is essential that water be added daily. The tank should also be drained, cleaned, and inspected at minimum intervals of every two weeks. Review and interview of the facility Physical Agent Modality Temperature/Cleaning Log on 10/12/17 at approximately 10:00 a.m. with Staff F (Occupational Therapist) revealed that the facility [MEDICATION NAME] temperature and cleaning log failed to show that the [MEDICATION NAME] was cleaned every two weeks. Staff F confirmed that this log showed no documentation for cleaning in January, March, April, May. July, (MONTH) (YEAR) and a blank page with no documentation for (MONTH) (YEAR). Staff F also confirmed during this interview that temperatures were not consistently documented and that there were no temperatures listed on the blank page for (MONTH) (YEAR).",2020-09-01
551,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-10-12,514,C,0,1,PXTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, it was determined that the facility failed to maintain accurately documented and readily accessible medical records for 4 residents out of a survey sample of 16 residents. (Resident identifiers are #7, 9, #10, #11 and #12.) Findings include: Resident #7 Review on 10/11/17 of Resident #7's medical record revealed that the resident had a fall on 9/1/17. Review of the neurological assessment flow sheet revealed that on 9/2/17 from 8:45 a.m. to 8:45 p.m. there were no neurological assessments completed and on 9/3/17 on the 7-3 shift neurological assessments were not completed. Interview on 10/11/17 at approximately 9:30 a.m. with Staff D (Licensed Practical Nurse) revealed that it is the facility's practice to complete the post fall neurological assessments and it was not completed. Resident #10 Review on 10/10/17 of Resident #10's medical record revealed that Resident #10 had an active physicians order dated 3/2/17 for 2Liter/24 hour fluid restriction. Call physician if exceeds limit. Further review of the medical record revealed that there was no documentation of Resident #10's intake for the months of (MONTH) and (MONTH) (YEAR). Review of the facility policy and procedure revealed: Fluid Restriction, dated 1/2/14 . 4. Monitor fluid intake. Monitor output as ordered. . 8. Document: 8.1 Intake; Interview on 10/10/17 at approximately 3:30 p.m. with Staff D confirmed that there was no record of Resident #10's intake for (MONTH) and (MONTH) (YEAR). Interview on 10/12/17 at approximately 11:30 a.m. with Staff [NAME] (Director of Nurses) confirmed that there was no record of Resident #12's intake for (MONTH) and (MONTH) (YEAR). Resident #12 Interview on 10/11/17 at approximately 10:00 a.m. during resident council, Resident #12 voiced concerns about missing cochlear implant appointments. Review on 10/1217 of Resident #12's physician progress notes [REDACTED].>Hearing Examination: 11/2016. Appointment with audiology pending for new cochlear implant. Review on 10/12/17 of Resident #12's medical record revealed that there was no information available in the medical record of any previous appointments to (hospital name omitted) for Resident #12's cochlear implant. Interview on 10/12/17 at approximately 11:00 a.m. with Staff D confirmed that Resident #12's medical record did not have any information on Resident #12's cochlear implant yearly appointment. Interview on 10/12/17 at approximately 12:30 p.m. with Staff [NAME] confirmed that the facility had no documentation of Resident #12's last follow up at (hospital name omitted). Resident #9 Review on 10/12/17 of Resident #9's progress notes revealed on 10/7/17 Resident #9 had a fall that the resident sustained [REDACTED]. Review of Resident #9's Neurological Assessment Flow Sheet for 10/7/17 to 10/10/17 revealed 14 of 20 neurochecks were incomplete for the sections of level of consciousness, pupil response, motor function, pain response, and/or vitals. Interview on 10/12/17 at approximately 9:00 a.m. with Staff B (Licensed Practical Nurse) confirmed the Neurological Assessment Flow Sheet was incomplete for Resident #9 and revealed it is the facility's practice to complete the above sheet when a resident has a fall and hit their head. Resident #11 Review on 10/12/17 of Resident #11's Medication Administration Record [REDACTED]. Documentation on this MAR indicated [REDACTED]. The three doses of [MEDICATION NAME] 2 mg are documented on this MAR indicated [REDACTED]. Interview on 10/12/17 at approximately 10:45 a.m. with Staff [NAME] (Registered Nurse) reviewed the MAR indicated [REDACTED].",2020-09-01
552,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2019-10-18,641,B,0,1,MQ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to include hospice and urinary tract infection information on an MDS (Minimum Data Set) assessment for 1 resident in a final survey sample of 20 residents. (Resident identifier is #30.) Findings include: Interview on 10/15/19 at approximately 1:15 p.m. with Staff D (Licensed Practical Nurse) revealed that Resident #30 was receiving hospice services. Review on 10/16/19 of Resident #30's current care plan revealed that Resident #30 had been admitted to hospice on 10/14/19. Review on 10/16/19 of Resident #30's significant change in status MDS assessment with ARD (Assessment Reference Date) of 10/15/19 revealed that the question on Section O100 K of Hospice services was marked as No. Review on 10/16/19 of Resident #30's active physician orders [REDACTED].#30 was receiving [MEDICATION NAME] intramuscularly for 5 days, with a start date of 10/14/19, for a UTI (Urinary Tract Infection.) Interview on 10/18/19 at approximately 9:30 a.m. with Staff [NAME] (Licensed Practical Nurse) confirmed that Resident #30 had been receiving an antibiotic for a UTI since 10/14/19. Review on 10/16/19 of Resident #30's significant change in status MDS assessment with ARD of 10/15/19 revealed that the question on Section I2300 of UTI last 30 days was marked as No. Interview on 10/18/19 at approximately 10:00 a.m. with Staff C (Clinical Reimbursement Coordinator) confirmed that Resident #30's significant change of status MDS assessment, with ARD of 10/15/19, did not indicate that Resident #30 was receiving hospice services or that Resident #30 had a UTI. Staff C also confirmed that those items should have been on the MDS.",2020-09-01
553,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2019-10-18,656,B,0,1,MQ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to develope a care plan that reflected the current interventions for IV (Intravenous) care and transmission based precaution care for 1 resident in a final survey sample of 20 residents. (Resident identifier is #262.) Findings include: Interview on 10/14/19 at approximately 7:00 p.m. with Staff F (Registered Nurse) revealed that Resident #262 was receiving [MEDICATION NAME] through a PICC line (Peripherally Inserted Central Catheter.) Observation on 10/14/19 at approximately 7:15 p.m. during medication pass observation revealed that Resident #262 received cephazoline through a PICC line. Review on 10/17/19 of Resident #262's current care plan revealed that the care plan read Peripheral IV/Midline IV. Interview on 10/18/19 at approximately 9:20 a.m. with Staff B (Director of Nursing) confirmed that Resident #262's IV was a PICC line and that it was incorrectly documented in Resident #262's care plan. Interview on 10/14/19 at approximately 7:00 p.m. with Staff F (Registered Nurse) revealed that Resident #262 was not on transmission based precautions. Observation on 10/14/19 at approximately 7:15 p.m. during medication pass observation revealed that Resident #262 had no PPE (Personal Protective Equipment) used for transmission based precautions either outside or inside of their room. Review on 10/17/19 of Resident #262's current care plan revealed that the care plan read Contact Precautions. Interview on 10/18/19 at approximately 9:20 a.m. with Staff B (Director of Nursing) confirmed that Resident #262 was not on contact precautions and that it was incorrectly documented in Resident #262's care plan.",2020-09-01
554,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2019-10-18,658,D,0,1,MQ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #262.) Findings include: Professional reference: Potter, [NAME] [NAME], and Perry, Anne Griffin. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Interview on 10/14/19 at approximately 7:00 p.m. with Staff F (Registered Nurse) revealed that Resident #262 had a PICC line. Review on 10/17/19 of Resident #262's (MONTH) 2019 Medication Administration Record [REDACTED]. Indicate external catheter length and upper arm circumference (10 cm (centimeters) above antecubital.) Notify practitioner if the external length has changed since last measurement. One time only for 1 day Post PICC insertion or upon admission . Review on 10/17/19 of Resident #262's (MONTH) 2019 Medication Administration revealed that Resident #262's PICC line dressing was changed on 10/12/19, the day after their admission from the hospital with the PICC line in place, but there was no documentation of what the external catheter length and upper arm circumference measurements were. Interview on 10/18/19 at approximately 9:20 a.m. with Staff B (Director of Nursing) confirmed that the measurements that were ordered for Resident #262 had not been done. Staff B also confirmed that the measurements should have been taken.",2020-09-01
555,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2019-10-18,692,D,0,1,MQ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, it was determined that the facility failed to ensure that weights were obtained and monitored as per the registered dietitian's recommendations for 3 residents in a final survey sample of 20 residents. (Resident identifiers are #26, #36, and #55.) Findings include: Resident #55 Review on 10/16/19 of Resident #55's Weights and Vitals Summary revealed that Resident #55 had a weight documented on 9/27/19 of 175 lbs (pounds). The next weight documented for Resident #55 was on 10/3/19 for 160 lbs. This represented a 8.57% weight loss. There were no other documented weights for Resident #55. Review on 10/17/19 of Resident #55's nutritional assessment, dated 10/3/19, revealed that Staff J (Registered Dietitian) documented that Resident #55 had a 8.6% weight loss .(Resident #55) is at nutritional risk due to significant weight loss, increased nutrition needs for wound healing . Staff J recommended .weekly weights . for Resident #55. Review on 10/17/19 of the facility policy titled, Weights and Heights, last revised on 3/5/19, revealed that .If a patient's weight is less than or greater than five pounds from the previous weight, the patient will be re-weighed and the weight verified by a licensed nurse to determine accuracy . Interview on 10/17/19 at approximately 11:35 a.m. with Staff B (Director of Nursing) confirmed that no further weights were obtained after 10/3/19 for Resident #55 and that a reweigh should have been done after the 10/3/19 weight and that Resident #55 should have had weekly weights obtained. Resident #26 Review on 10/17/19 at approximately 11:18 a.m. of Resident #26's nutrition assessment dated [DATE] in section N Nutrition Interventions revealed that the facility's registered dietician documented weekly weights as a recommended intervention begining on 9/25/19. Review on 10/17/19 at approximately 11:18 a.m. of Resident #26's weights and vitals summary revealed Resident #26 has had one documented weight taken on 10/5/19 since the 9/25/19 nutrition assessment recommending weekly weights. Interview on 10/17/19 with Staff B (Center Nurse Executive) confirmed that Resident #26 had weights taken monthly and not weekly as recommended by the facilities registered dietician in the nutrition assessment dated [DATE]. Resident #36 Review on 10/17/19 at approximately 1:25 p.m. of Resident #36's nutrition assessment dated [DATE] in section N Nutrition Interventions revealed the facility's' registered dietician recommended weekly weights begining 9/18/19. Review on 10/17/19 at approximately 1:25 p.m. of Resident #36's weights and vitals summary revealed Resident #36's last documented weight was on 9/10/19. Interview on 10/17/19 with Staff B (Center Nurse Executive) confirmed that the registered dietician recommended on 9/18/19 that Resident #36 have weekly weights taken. Staff B also confirmed upon interview that Resident #36 has not had their weight taken since 9/10/19.",2020-09-01
556,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2019-10-18,761,E,0,1,MQ5H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to follow expiration dates for medications on 2 out of 3 observed medication carts. (Resident identifiers are #22, #44 and #48.) Findings include: Review on 10/16/19 of the facility policy, titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles,last revised on 10/31/16 revealed that .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened Resident #48 Observation on 10/16/19 at approximately 8:30 a.m. of the front side of Champney medication cart revealed a [MEDICATION NAME] pen for Resident #48. There was a sticker attached to the plastic bag holding the pen that read Refrigerate until open. Discard unused medication after 28 days. Date opened . The date opened part of the sticker had a line to write in the date opened, but it was blank with no date entered. There was also a sticker on the pen that read Date opened . After opening do not use after 28 days. The date opened part of that sticker also had a line to write in the date opened, but it was blank with no date entered. There was no 28 discard date written on the pen. Review on 10/16/19 of the facility policy, titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, last revised on 10/31/16 revealed that .[MEDICATION NAME] pen .Refrigerate until expiration date .Room temperature 28 days . Interview on 10/16/19 at approximately 8:30 a.m. with Staff G (Registered Nurse) confirmed that there was no date written in when the insulin pen was opened, and that it should have been dated. Staff G also confirmed, by looking at the EMAR (electronic medication administration record) that Resident #48 had received [MEDICATION NAME] at bedtime, as ordered, on 10/15/19. Resident #44 Observation on 10/16/19 at approximately 9:00 a.m. of the back side of the Washington unit medication cart revealed a [MEDICATION NAME]pen for Resident #44. There was a sticker on the plastic bag holding the pen that read Refrigerate until open then room temperature. Date opened . The date opened part of the sticker had a line to write in the date opened, but it was blank with no date entered. Interview on 10/16/19 at approximately 9:10 a.m. with Staff H (Medication Nursing Assistant) confirmed that the pen should have been dated when opened. Observation on 10/16/19 at approximately 9:00 a.m. of the back side of the Washington unit medication cart revealed a [MEDICATION NAME]pen for Resident #44. There was a sticker on the plastic bag holding the pen that read Refrigerate until open then room temperature. Discard unused medication after 28 days. There was no date opened written on either the plastic bag holding the pen or on the pen itself. There was no 28 discard date written on the pen. Interview on 10/16/19 at approximately 9:10 a.m. with Staff I (Registered Nurse) confirmed that the pen should have been dated when opened. Staff I also confirmed that Staff I had used that [MEDICATION NAME] pen to administer insulin to Resident #44 earlier that morning. Review on 10/16/19 of the facility policy, titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, last revised on 10/31/16 revealed that [MEDICATION NAME] pen .Refrigerate until expiration date .Room temperature 42 days .[MEDICATION NAME] pen .Refrigerate until expiration date .Room temperature 28 days . Resident #22 Observation on 10/16/19 at approximately 9:00 a.m. of the back side of the Washington unit medication cart revealed 2 opened Lantanoprost eye drop vials for Resident #22. There was a sticker on both of the plastic containers holding the vials that read Refrigerate until opened. Date opened .After opening do not use after 42 days. The date opened part of the stickers had lines to write in the date opened, but they were blank with no date entered. There was no 28 discard date written on the vial. Review on 10/16/19 of the facility policy, titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, last revised on 10/31/16 revealed that .Latanoprost .Store in the refrigerator .until ready to use. Date when opened and discard after 6 weeks. Store at room temperature .after opening . Interview on 10/16/19 at approximately 9:10 a.m. with Staff H (Medication Nursing Assistant) confirmed that the eye drop vials should have been dated when opened. Staff H also confirmed, after looking at the EMAR, that Resident #22 had received the Latanoprost eye drops during the evening of 10/15/19.",2020-09-01
557,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2018-11-08,696,D,0,1,6XYY11,"Based on interview and medical record review it was determined that the facility failed to provide assistance to ensure a resident was able to use a prosthetic device for 1 resident with a prosthetic device out of a standard survey sample of 18 residents. (Resident identifier is #51.) Findings include: Interview on 11/5/18 at approximately 10:45 a.m. with Resident #51 revealed that Resident #51 has not been able to utilize their prosthetic leg for approximately 5-6 months. Resident #51 stated, I have been telling them (the staff) for months that my prosthetic leg does not fit right. I have not been able to use it at all, nobody tells me anything. Review on 11/7/18 of Resident #51's nurse practitioner note dated 2/9/18 revealed that Resident #51stated, (pronoun omitted) has been feeling pretty good but thinks (pronoun omitted) has gained some weight because .prosthetic leg has not been fitting. Review on 11/7/18 of Resident #51's nursing notes revealed the following: 7/17/18 15:32 . (pronoun omitted) requested an appointment to have fake leg fitted. 7/21/18 13:38 . Daughter notified of (Resident #51''s) wish to resize prosthetic leg and plan to set up appointment to do so. 7/25/18 14:37 .therapy notified of (pronoun omitted) wishes to have prosthetic leg resized/readjusted. Interview on 11/7/18 at approximately 12:15 p.m. with Staff A (Registered Nurse) revealed that Staff A was aware of Resident #51 not being able to use the prosthesis and Staff A had informed therapy verbally as well for Resident #51's prosthesis not fitting correctly. Interview on 11/7/18 at approximately 1:45 p.m. with Staff B (Director of Therapy) revealed that Resident #51 had not been seen in regards to the prosthesis in approximately a year or greater. Staff B did reveal that nursing had put in a request a while ago and there was not a therapist in the facility comfortable to work with prosthetics. The facility's therapist left (MONTH) 6, (YEAR). Staff B stated that a therapist from another facility had come into the facility about a month ago and Resident #51 was on the list, but there were more acute residents that needed to be seen. Staff B also stated that Resident #51 was Medicare part B and unfortunately not a priority. Resident #51's prosthetic leg had not been assessed by any discipline as of the survey exit date of 11/8/18.",2020-09-01
558,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2018-11-08,825,B,0,1,6XYY11,"Based on observation, interview and medical record review it was determined that the facility failed to ensure that specialized rehabilitative services was provided to 1 resident with a prosthetic device out of a standard survey sample of 18 residents. (Resident identifier is #51.) Findings include: Interview on 11/5/18 at approximately 10:45 a.m. with Resident #51 revealed that Resident #51 has not been able to utilize their prosthetic leg for approximately 5-6 months. Resident #51 stated, I have been telling them (the staff) for months that my prosthetic leg does not fit right. I have not been able to use it at all, nobody tells me anything. Observation on 11/5/18 at approximately 10:45 a.m. revealed a prostetic leg near the dresser in Resident #51's room. Review on 11/7/18 of Resident #51's nurse practitioner note dated 2/9/18 revealed that Resident #51stated, (pronoun omitted) has been feeling pretty good but thinks (pronoun omitted) has gained some weight because .prosthetic leg has not been fitting. Review on 11/7/18 of Resident #51's nursing notes revealed the following: 7/17/18 15:32 . (pronoun omitted) requested an appointment to have fake leg fitted. 7/21/18 13:38 . Daughter notified of (Resident 51's) wish to resize prosthetic leg and plan to set up appointment to do so. 7/25/18 14:37 .therapy notified of (pronoun omitted) wishes to have prosthetic leg resized/readjusted. Interview on 11/7/18 at approximately 12:15 p.m. with Staff A (Registered Nurse) revealed that Staff A was aware of Resident #51 not being able to use the prosthesis and had informed therapy verbally as well for Resident #51's prosthesis not fitting correctly. Interview on 11/7/18 at approximately 1:45 p.m. with Staff B (Director of Therapy) revealed that Resident #51 had not been seen in regards to the prosthesis in approximately a year or greater. Staff B did reveal that nursing had put in a request a while ago for the prosthesis to be assessed for proper fitting and there was not a therapist in the facility that was comfortable to work with prosthetics. The facility's therapist with prosthetic experience had left the faciity on (MONTH) 6, (YEAR) . Staff B revealed that the therapy department had been with out anyone who specializes in prosthetics since 7/6/18. Staff B stated that a therapist from another facility had come into the facility about a month ago and Resident #51 was on the list but there were more acute residents that needed to be seen. Staff B also stated that Resident #51 was Medicare part B and unfortunately not a priority. Resident #51's prosthetic leg had not been assessed by any discipline as of the survey exit date of 11/8/18.",2020-09-01
559,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2018-11-08,842,B,0,1,6XYY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review it was determined that the facility failed to maintain complete and accurate medical records for 1 resident out of a standard survey sample of 18 records reviewed. (Resident identifier is #36.) Findings include: Review on 11/7/18 of Resident #36's Medication Administration Record [REDACTED] Physicians order- [MEDICATION NAME] Lock Flush Solution 10 unit/ml (milliliter) Use 5 ml intravenously every 6 hours for SASH (Saline, Antibiotic, Saline, [MEDICATION NAME]) technique after administration of saline. BOTH LUMENS. The following dates and times had no documentation of the medication being administered: November 1st at 0200, 3rd at 1400, 4th at 2000, 6th at 1400 and the 7th at 0200. Physicians order- Administration Set Reconciliation: Reconcile upon admission, shift change, new infusion or device, any intravenous related procedure or when order changes every shift. The following dates and times had no documentation of reconciliation being done: November 3rd 7-3shift and the 4th 3-11 shift. Physicians order- [MEDICATION NAME] Solution Reconstituted 3.375 (3-0.375) Gram ([MEDICATION NAME] Sod-TazobactamSo) Use 3.375 gram intravenously every 6 hours for wound infection (mix with 100 ml normal saline from omnicell and run over one hour. when 50 ml [MEDICATION NAME] solution arrives from pharmacy, run over 30 minutes). The following dates and times had no documentation of the medication being administered: November 1st 0200, 3rd at 1400, 4th at 2000, 6th at 1400 and the 7th at 0200. Physicians order- Normal Saline Flush Solution Use 10 ml intravenously every 6 hours for SASH/SAS (Saline, Antibiotic,Saline) technique after medication administration. BOTH LUMENS. The following dates had no documentation of it being done: November 1st at 0200, 3rd at 1400, 4th at 2000, 6th at 1400 and the 7th at 0200. Physicians order- Normal Saline Flush Solution Use 10 ml intravenously every 6 hours for SASH/SAS technique prior to medication administration. BOTH LUMENS. The following dates had no documentation of it being done: November 1st at 0200, 3rd at 1400, 4th at 2000, 6th at 1400 and the 7th at 0200 had no documentation of it being done. Interview on 11/7/18 at approximately 2:00 p.m. with Staff C, Director of Nurses revealed that there was no documentation of the above being completed.",2020-09-01
560,LANGDON PLACE OF KEENE,305085,136 A ARCH STREET,KEENE,NH,3431,2018-01-02,812,D,0,1,3AM411,"Based on observation, interview and policy and procedure review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 2 dining areas and the main kitchen. Findings include: Observation on 12/27/17 at approximately 10:09 a.m. of the kitchen revealed a rolling salad bar that is offered daily with individual containers for meats, vegetables and cheese without any dates. Some of the containers were partially full and other containers were empty. Interview on 12/27/17 at approximately 10:10 a.m. with Staff A (Dietary Manager) revealed that it is not the facility's practice to date the containers individually. Review on 12/27/17 of the policy and procedure, Food and Nutrition Services Policies and Procedures, Revision date 11/28/17 revealed: Use By Dating Guidelines 25. Foods that are marked with the manufacturer's use by date that are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in any way including portioning. Once a product has been prepared or portioned, a new use by date is established. 25.1 Ready to eat, Time/Temperature Control for Safety Food prepared and held to 41 degrees or below must be used or discarded at a maximum of seven days. Observation on 12/27/17 at approximately 10:20 a.m. of the the walk in refrigerator revealed a tray of hamburg that was partially covered with plastic wrap. Interview on 12/27/17 at approximately 10:20 a.m. with Staff A confirmed that the hamburg was partially covered with plastic wrap. Observation on 12/27/17 at approximately 10:30 a.m. in the kitchen of the microwave revealed a food subtstance adhered to the inside top, back and sides of the microwave. Interview on 12/27/17 at approximately 10:30 a.m. with Staff A confirmed that the microwave had a food substance adhered to the inside top, back and sides of the microwave. Observation on 12/27/17 at approximately 12:00 p.m. of the microwave in the dining area revealed a food substance adhered to the inside top, back and sides of the microwave. Interview on 12/27/17 at approximately 12:00 p.m. Staff B (Recreation Assistant) confirmed the food substance adhered to the inside top, back and sides of the microwave. Review on 12/27/17 of the cleaning procedure for Microwave Oven (that was not dated), revealed that it should be cleaned after each use/weekly.",2020-09-01
561,LANGDON PLACE OF KEENE,305085,136 A ARCH STREET,KEENE,NH,3431,2018-01-02,842,B,0,1,3AM411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to maintain medical records for one resident out of a survey sample of 16 residents for complete, accurately documented, readily accessible and systemically organized. (Resident identifier is #21.) Findings include: Review on 12/29/17 of Resident #21's physician progress notes [REDACTED]. Review on 12/29/17 of Resident #21's treatment sheet for December 2017 revealed that there was no record of the order for barrier cream and mepiplex to lower sacral area. Interview on 12/29/17 at approximately 10:00 a.m. with Staff C (Director of Nurses) confirmed that there was no documentation of the order being transcribed or administered.",2020-09-01
562,LANGDON PLACE OF KEENE,305085,136 A ARCH STREET,KEENE,NH,3431,2016-10-04,278,B,0,1,12JU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that the MDS (Minimum Data Set) assessment was accurate for 1 resident in a survey sample of 12 residents. (Resident identifier is #4.) Findings include: Review on 10/3/16 of Resident #4's MDS with an ARD (Assessment Reference Date) of 8/4/16 section I , titled Active [DIAGNOSES REDACTED]. A review of an admission assessment with an ARD date of 4/8/16 revealed multiple [DIAGNOSES REDACTED]. Review on 10/3/16 of Resident #4's MDS with an ARD of 9/13/16 section N0410 A titled Medications revealed 0 to indicate that the resident has not been administered Antipsychotic medications during the 7 day look back period. Review of the MAR (Medication Administration Record) for the month of (MONTH) (YEAR), revealed licensed staff signatures to indicate that the resident was given the medication [MEDICATION NAME] daily. Interview on 10/3/16 with Staff A (MDS Coordinator) confirmed the above findings.",2020-09-01
563,LANGDON PLACE OF KEENE,305085,136 A ARCH STREET,KEENE,NH,3431,2016-10-04,371,E,0,1,12JU11,"Based on observation and interview it was determined the facility failed to properly clean equipment that was identified as ready to use, and failed to properly maintain the condensing units in the walk in freezer. Findings include: Observation on the initial tour of the main kitchen on 10/3/16 at approximately 9:45a.m with Staff B (Director of Food Services) and Staff C (Administrator) revealed that the can opener blade had a large pieces of food like material adhered to it. Interview on 10/3/16 at approximately 9:45a.m. with Staff B confirmed this finding. Observation of the main kitchen on 10/3/16 at approximately 9:50a.m. with Staff B also revealed that the two condenser units in the walk in freezer had large amounts of ice built up on them. Interview on 10/3/16 at approximately 9:50a.m. with Staff B confirmed this finding.",2020-09-01
564,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2017-07-17,281,D,1,0,LGNR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy and procedure for the Management of Controlled Drugs and General Medication Administration it was determined that the facility failed to follow the professional standards of practice for the administration, disposal and documenting of narcotic medications for 2 of 9 residents. (Resident identifiers are #1 and #2.) Findings include: Review of the facility policy and procedure on 7/17/17, titled Controlled Medication Storage dated 12/12 revealed the following: POLICY Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations . 6. At each shift change or when keys are surrendered, a physical inventory of all Scheduled II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification if controlled substance count report. The nursing care center may elect to count all controlled medications at shift change. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director of nursing or designee investigates and makes every reasonable effort to reconcile all reported discrepancies while nurses remain on duty, The director of nursing, in a report to the administrator, documents irreconcilable. Review of the facility policy and procedure on 7/17/17, titled Monitoring of Medication Administration dated 05/16 revealed the following: POLICY The consultant pharmacist evaluates medication administration to verify that the resident has received medications in accordance with the prescriber's orders and nursing care center policy. Procedures, personnel, and techniques are monitored, and intervention is provided when necessary. Medication administration monitoring includes, but is not limited to, medication pass observations, which are conducted by the consultant pharmacist or other designated nursing care center or pharmacy personnel. PR[NAME]EDURES 1. The consultant pharmacist, designated nursing staff or pharmacy designee, performs quality assurance evaluations to determine that: . c. Refusal or inability of the resident to take medications is evaluated, documented and responded to appropriately . e. Administration of medications is documented, including frequency and reason for administration of as needed (PRN) medications. Reference for the professional standard of practice for medication documentation is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. page 688 Guidelines for Safe Narcotic Administration and Control . Store all narcotics in a locked, secure cabinet or container. (Computerized, locked cabinets are preferred.) . Narcotics are frequently counted. Usually counts are made on a continuous basis with the opening of narcotic drawers and/or at shift change. . Report discrepancies in narcotic counts immediately. . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. . If a nurse gives only part of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers. Instead, flush wasted portions of the tablets down the toilet and wash liquids down the sink. Resident #2. Review on 7/17/17 of Resident #2's medical record revealed a physician order for [REDACTED].>[MEDICATION NAME] 10/325 mg (milligrams) Give 1 tablet by mouth every 6 hours for pain. Start date 10/22/2016 Also an order for [REDACTED]. Review on 7/17/17 of Resident #2's (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MAR (Medication Administration Record) and Narcotic Count Book (Resident #2's page for [MEDICATION NAME]'s administration) revealed the following discrepancies; Record review of the Narcotic Book page #105 for Resident #2 revealed the following documentation: 3/1/17 0747 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #117 for Resident #2 revealed the following documentation: 3/2/17 3:15 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/2/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/8/17 3 :00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/8/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/10/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/10/17 9:07 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #119 for Resident #2 revealed the following documentation: 3/14/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/14/17 9:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/16/17 3:15 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/16/17 9:32 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/17/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/23/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #124 for Resident #2 revealed the following documentation: 3/24/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/24/17 9:30 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 3:15 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 9:42 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/30/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/30/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/31/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] April (YEAR) 4/3/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/3/17 9:50 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #130 for Resident #2 revealed the following documentation: 4/5/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/6/17 7:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/9/17 3:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/11/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/14/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #136 for Resident #2 revealed the following documentation: 4/21/17 2:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/21/17 7:20 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/23/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/23/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/24/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/25/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/25/17 9:30 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/26/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/26/17 3:20 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/27/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/27/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #143 for Resident #2 revealed the following documentation: 4/28/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/28/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] May (YEAR) 5/1/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/1/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/3/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/4/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/4/17 9:30 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/8/17 9:20 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/10/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Record review of the Narcotic Book page #154 for Resident #2 revealed the following documentation: 5/12/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED] 5/13/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/13/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/15/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/15/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/18/17 7:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/19/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/19/17 3:05 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Record review of the Narcotic Book page #165 for Resident #2 revealed the following documentation: 5/21/17 11:30 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED] 5/21/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/25/17 2:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Record review of the Narcotic Book page #6 for Resident #2 revealed the following documentation: 5/29/17 8:40 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/29/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/30/17 9:30 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/30/17 11:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Review of the facility Narcotic Book and the MAR's for Resident #2 showed that the documentation for the scheduled [MEDICATION NAME] 5/325 mg tabs and for the PRN [MEDICATION NAME] 5/325 mg tabs administered and not administered to Resident #2 were not documented in the MAR indicated [REDACTED] Interview on 7/17/17 at approximately 10:30 a.m. with Staff A, (Director Of Nurses) revealed that an audit of the narcotic count books with the MAR indicated [REDACTED]. Interview at approximately 10:30 a.m. on 7/17/17 with Staff C (Administrator) and Staff A both Staff C and Staff A agreeded that there were multiple discrepancies with the adminstration of PRN narcotic medications to include but not limited to the above listed findings. That the Staff A Resident #1 and Resident #2 with suspected drug diversion. Staff A did not expand the audit because it would take too long. Resident #1 Review on 7/17/17 of Resident #1's (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MAR (Medication Administration Record) and Narcotic Count Book revealed the following noted discrepancies: Resident #1 had an order for [REDACTED]. March (YEAR) 3/5/17 6:00 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/9/17 6:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/15/17 4:50 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/20/17 7:14 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/26/17 1:02 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 10:45 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 7:22 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/31/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] April (YEAR) 4/17/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/21/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/23/17 8:00 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/24/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/25/17 8:30 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/27/17 8:00 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/28/17 4:05 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] May (YEAR) 5/01/17 4:05 p.m. [MEDICATION NAME] 50 mg was documented in the MAR indicated [REDACTED]. 5/25/17 7:30 p.m. [MEDICATION NAME] 50 mg was documented in the MAR indicated [REDACTED]. Interview on 7/17/17 at approximately 10:30 a.m. with Staff A, Director Of Nurses revealed that an audit of the narcotic count books with the MAR indicated [REDACTED]. Staff A did not expand the audit because it would take too long.",2020-09-01
565,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2017-07-17,431,B,1,0,LGNR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to coordinate with the pharmacy the process for controlling, reconciling and administering narcotic medications for 2 of 9 residents. (Resident identifiers are #1 and #2.) Findings include: Resident #2 Record review on 7/17/17 of Resident #2's Medication Administration Record [REDACTED]. Start date 10/22/2016 Also on the MAR indicated [REDACTED]. Give 1 tab for mod pain (6-7). The front section of the MAR for the month of (MONTH) (YEAR) revealed that Resident #2 were signed out as given prn (as needed) Norco 10/325 mg 1 tab on the following dates: 3/1, 3/2, 3/3, 3/6, 3/7, 3/8, 3/12, 3/13, 3/17, 3/23, 3/28, 3/30, and 3/31. Review of the Narcotic Book pages 105,117, 119 and 124 revealed that Norco 10/325 mg 1 Tab was given to Resident #2 prn on the following dates: 3/1, 3/2 (twice), 3/3, 3/6, 3/7, 3/8, 3/9 (twice), 3/10 (twice), 3/12, 3/13, 3/14 (twice), 3/16 (twice), 3/17 (twice), 3/23 (twice), 3/24 (twice), 3/27 (twice),3/28, 3/30 (twice) and 3/31(twice). The front section of the MAR for the month of (MONTH) (YEAR) revealed that Resident #2 were signed out as given prn Norco 10/325 mg 1 tab was given on the following dates: 4/6, 4/7, 4/9, 4/10, 4/11, 4/13, 4/14, 4/17, 4/20, 4/21, and 4/23. Review of the Narcotic Book pages 124, 130, 136 and 143 revealed that Norco 10/325 mg 1 Tab was given to Resident #2 prn on the following dates: 4/3, 4/5, 4/6, 4/7, 4/9./10, 4/11, 4/13, 4/14,(twice), 4/17, 4/20 (twice), 4/21 (three), 4/23 (three), 4/24, 4/25 (twice), 4/26 (twice), 4/27 (twice), and 4/28 (three). The front section of the MAR for the month of (MONTH) (YEAR) revealed that Resident #2 were signed out as given prn Norco 10/325 mg 1 tab was given on the following dates: 5/9 (twice), 5/10, 5/12 (twice), 5/18 (twice), 5/19 (three), 5/21 (twice), 5/22 (twice), 5/25, 5/26 (twice), 5/29, 5/30 (twice) and 5/31 (twice). Review of the Narcotic Book pages 143, 154, 165 and 6 revealed that Norco 10/325 mg 1 Tab was given to Resident #2 prn on the following dates:5/1 (twice), 5/3, 5/4 (twice), 5/8, 5/9 (twice), 5/10 (twice), 5/12 (three), 5/13 (three), 5/15 (twice), 5/18 (three), 5/19 (five), 5/21 (four), 5/22 (twice), 5/25 (twice), 5/26 (twice), 5/29 (three), 5/30 (four), 5/31 (twice). During interview with Staff A, Director of Nurses and Staff C, Administrator on 7/17/17 at approximately 2:30 p.m. they indicated that they had only reviewed Resident #1's and Resident #2's medical records from (MONTH) (YEAR) though (MONTH) (YEAR) because Staff B (Registered Nurse) mostly worked on one floor and Staff A did not audit any other floor or nurses. Resident #1 Review on 7/17/17 of Resident #1's (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MAR (Medication Administration Record) and Narcotic Count Book revealed the following noted discrepancies: Resident #1 had an order for [REDACTED]. March (YEAR) 3/5/17 6:00 a.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/9/17 6:00 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/15/17 4:50 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/20/17 7:14 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/26/17 1:02 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 10:45 a.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 7:22 a.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/31/17 4:00 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] April (YEAR) 4/17/17 4:00 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/21/17 4:00 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/23/17 8:00 a.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/24/17 4:00 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/25/17 8:30 a.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/27/17 8:00 a.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/28/17 4:05 p.m. Ultram 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] May (YEAR) 5/01/17 4:05 p.m. Ultram 50 mg was documented in the MAR indicated [REDACTED]. 5/25/17 7:30 p.m. Ultram 50 mg was documented in the MAR indicated [REDACTED]. Interview on 7/17/17 at approximately 10:30 a.m. with Staff A, Director Of Nurses revealed that an audit of the narcotic count books with the MAR indicated [REDACTED].",2020-09-01
566,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2017-07-17,514,B,1,0,LGNR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview it was determined that the facility failed to maintain a complete and accurate medical record for 2 residents in a survey sample of 9. (Resident identifiers are #1 and # 2.) Findings include: Resident #2. Review on 7/17/17 of Resident #2's medical record revealed a physician order [REDACTED].>[MEDICATION NAME] 10/325 mg (milligrams) Give 1 tablet by mouth every 6 hours for pain. Start date 10/22/2016 also an order [REDACTED]. Review on 7/17/17 of Resident #2's (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MAR (Medication Administration Record) and Narcotic Count Book (Resident #2's page for [MEDICATION NAME]'s administration) revealed the following discrepancies; Record review of the Narcotic Book page #105 for Resident #2 revealed the following documentation: 3/1/17 0747 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #117 for Resident #2 revealed the following documentation: 3/2/17 3:15 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/2/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/8/17 3 :00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/8/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/10/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/10/17 9:07 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #119 for Resident #2 revealed the following documentation: 3/14/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/14/17 9:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/16/17 3:15 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/16/17 9:32 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/17/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/23/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #124 for Resident #2 revealed the following documentation: 3/24/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/24/17 9:30 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 3:15 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 9:42 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/30/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/30/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/31/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] April (YEAR) 4/3/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/3/17 9:50 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #130 for Resident #2 revealed the following documentation: 4/5/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/6/17 7:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/9/17 3:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/11/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/14/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #136 for Resident #2 revealed the following documentation: 4/21/17 2:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/21/17 7:20 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/23/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/23/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/24/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/25/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/25/17 9:30 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/26/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/26/17 3:20 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/27/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/27/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] Record review of the Narcotic Book page #143 for Resident #2 revealed the following documentation: 4/28/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/28/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] May (YEAR) 5/1/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/1/17 10:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/3/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/4/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/4/17 9:30 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/8/17 9:20 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/10/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Record review of the Narcotic Book page #154 for Resident #2 revealed the following documentation: 5/12/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED] 5/13/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/13/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/15/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/15/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/18/17 7:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/19/17 3:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/19/17 3:05 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Record review of the Narcotic Book page #165 for Resident #2 revealed the following documentation: 5/21/17 11:30 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED] 5/21/17 2:45 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/25/17 2:00 p.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Record review of the Narcotic Book page #6 for Resident #2 revealed the following documentation: 5/29/17 8:40 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/29/17 9:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/30/17 9:30 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. 5/30/17 11:00 a.m. [MEDICATION NAME] 10/325 mg was documented in the MAR indicated [REDACTED]. Review of the facility Narcotic Book and the MAR's for Resident #2 showed that the documentation for the scheduled [MEDICATION NAME] 5/325 mg tabs and for the PRN [MEDICATION NAME] 5/325 mg tabs administered and not administered to Resident #2 were not documented in the MAR indicated [REDACTED] Interview on 7/17/17 at approximately 10:30 a.m. with Staff A, (Director Of Nurses) revealed that an audit of the narcotic count books with the MAR indicated [REDACTED]. Staff A has not expanded the audit. Interview at approximately 10:30 a.m. on 7/17/17 with Staff C (Administrator) and Staff A both Staff C and Staff A agreeded that there were multiple discrepancies with the adminstration of PRN narcotic medications to include but not limited to the above listed findings. That the Staff A Resident #1 and Resident #2 with suspected drug diversion. Staff A did not expand the audit because it would take too long. Resident #1 Review on 7/17/17 of Resident #1s (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MAR (Medication Administration Record) and Narcotic Count Book revealed the following noted discrepancies: Resident #1 had an order for [REDACTED]. March (YEAR) 3/5/17 6:00 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/9/17 6:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/15/17 4:50 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/20/17 7:14 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/26/17 1:02 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 10:45 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/27/17 7:22 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 3/31/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] April (YEAR) 4/17/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/21/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/23/17 8:00 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/24/17 4:00 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/25/17 8:30 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/27/17 8:00 a.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] 4/28/17 4:05 p.m. [MEDICATION NAME] 50 mg was removed from the narcotic count, not documented in the MAR indicated [REDACTED] May (YEAR) 5/01/17 4:05 p.m. [MEDICATION NAME] 50 mg was documented in the MAR indicated [REDACTED]. 5/25/17 7:30 p.m. [MEDICATION NAME] 50 mg was documented in the MAR indicated [REDACTED]. Interview on 7/17/17 at approximately 10:30 a.m. with Staff A, Director Of Nurses revealed that an audit of the narcotic count books with the MAR indicated [REDACTED]. Staff A did not expand the audit because it would take too long.",2020-09-01
567,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2018-04-18,689,D,1,0,XWTH11,"> Based on record review and interview, it was determined that the facility failed to prevent an accident, resulting in a burn injury for 1 resident in a survey sample of 3 residents. (Resident identifiers are #1 and #2 .) Findings include: Review on 4/18/18 of the facility's Unusual Incident-Resident Injury, dated 3/27/18, revealed that on 3/19/18, Resident #1 spilled hot tea on their lap (left hip and thigh area.) .The hot water for tea was found to be taken directly from the 'Hot Water' spout from the coffee maker. It was determined that the water from the spout was at a temperature that was hotter than desired at serving. A plan was put in place to brew hot water thru (sic) the coffee system and placed (sic) in carafe for serving. This would allow for time to cool prior to serving at breakfast. Carafes have been purchased for all units in the facility and a procedure was developed. All employees were notified of the new procedure. Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 4/11/18, revealed that on 4/10/18, Resident #2 spilled a cup of hot tea their stomach, which resulted in redness and then blisters. Review also revealed that .Due to a previous incident, the hot water has been shut off to the spouts from the coffee pots due to the lack of ability to regulate the temperature. At meal time hot water is now served from a carafe on each unit allowing the water temperature to cool . Interview on 4/18/18 at approximately 10:00 a.m. with Staff A (Director of Nursing) revealed that the investigation into the incident with Resident #2 revealed that the LNA who had served tea to Resident #2 used a microwave to heat the water. Review on 4/18/18 of the statement written by Staff B (Licensed Nursing Assistant,) who had served the tea to Resident #2 on 4/10/18, confirmed that Staff B had prepared the tea in the microwave, instead of brewing the water in the coffee maker and putting it in a carafe. Interview on 4/18/18 at approximately 1:00 p.m. with Staff A confirmed that Staff B should not have prepared the tea in the microwave, as they do not use thermometers and would not be able to tell how hot the water was. All staff were educated on the new procedure and Staff B should have followed the procedure that had been developed after the incident with Resident #1, which was brewing hot water through the coffee system.",2020-09-01
568,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2018-04-18,867,E,1,0,XWTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to develop and implement a timely plan of action to correct the recent issues they have had with residents spilling hot tea on 2 out of 4 nursing units. (Resident identifiers are #1 and #2.) Findings include: Review on 4/18/18 of the facility's Unusual Incident-Resident Injury, dated 3/29/18, revealed that on 3/19/18, Resident #1 spilled hot tea on their lap (left hip and thigh area.) .The hot water for tea was found to be taken directly from the 'Hot Water' spout from the coffee maker. It was determined that the water from the spout was at a temperature that was hotter than desired at serving . Review on 4/18/18 of emails written between Staff C (Food Service Supervisor) and the representative from the company that managed the facility's coffee makers revealed an email, dated 3/26/18, which was 7 days after the incident, that read .I have a question about the coffee machines. The nurses are stating that the water is too hot for residents to drink, we had an injury report from over the weekend and they asked if it can be turned down. I thought it might have to be set at a specific temp to brew the coffee properly. It is currently set for 200 degrees on all machines . The response email, dated 3/26/18 read Proper temp is 195. Please call (phone number) to have service come out to lower all [MEDICATION NAME] . Review on 4/18/18 of the Work Order from the equipment company, revealed that the hot water spouts were taken out of service and no longer active on 3/30/18. Interview on 4/18/18 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed that from 3/19/18 until 3/30/18, the hot water spouts were still available to residents and staff. Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 3/19/18, also had an action plan that stated A plan was put in place to brew hot water thru (sic) the coffee system and placed in carafe for serving. This would allow for time to cool prior to serving Resident #2 Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 4/11/18, revealed that on 4/10/18, Resident #2 spilled a cup of hot tea on their stomach, which resulted in redness and then blisters. Interview on 4/18/18 at approximately 10:00 a.m. with Staff A revealed that the investigation into the incident that occurred to Resident #2 revealed that the LNA who had served tea to Resident #2 on 4/10/18 failed to use the carafe, as written in the action plan dated 3/19/18, and instead used a microwave to completely prepare the tea. Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 4/11/18, revealed that on 4/10/18 when Resident #2 spilt a cup of hot tea on their stomach, which resulted in redness and then blisters, they reported that they had used a paper cup with no handle and that they didn't have a good grip on the cup. Interview on 4/18/18 at approximately 1:30 with Staff [NAME] (Administrator) revealed that Staff [NAME] was still in the process of deciding on new cups to be used for hot beverages for the residents. Staff [NAME] also confirmed that Resident #2 had not been evaluated by Therapy to determine the appropriate cup for Resident #2 to use. Interview on 4/18/18 at approximately 1:00 p.m. with Staff A confirmed that nothing had been put in place, such as education regarding microwaving, since the incident with Resident #2 occurred on 4/10/18. Staff A also confirmed that there is not a definite plan in place to prevent hot water spills and burn injuries to residents. It will be discussed at the next QAPI meeting, but that will not be held until 4/24/18.",2020-09-01
569,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2017-09-07,281,D,0,1,ES8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #7.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary Review on 9/5/17 of Resident #7's Physician's Telephone Orders dated 8/3/17 revealed a telephone order that read Try reinsert foley cath (catheter) 16# (size) 10 ml (milliliters) coude tip (tip designed for easier insertion) . Review on 9/5/17 of Resident #7's physician progress notes [REDACTED].they had a difficult time re-inserting and ended up with a #16 Coude placed .Otherwise, with the [MEDICAL CONDITION] ([MEDICAL CONDITION],) will continue with Coude in the future . Review on 9/5/17 of Resident #7's Physician order [REDACTED].#14-10 ML Balloon per protocol PRN (as needed) (Silicone Foley) Review on 9/5/17 of Resident #7's Problem Oriented - Progress Notes revealed a note written on 8/27/17 that read .Changed cath to a 100% Silicone 14 FR (French) - 10 cc(cubic centimeter) . There was no documentation of a coude tip. Review on 9/5/17 of Resident #7's Problem Oriented - Progress Notes revealed a note written on 8/26/17 that read .Foley cath removed - as unable to flush - #14 FR - 10 cc inserted . There was no documentation of a coude tip. Review on 9/5/17 of Resident #7's Problem Oriented - Progress Notes revealed a note written on 8/20/17 that read .Foley cath (symbol, meaning change, omitted) #14 - 10 ml . There was no documentation of a coude tip. Interview on 9/5/17 at approximately 2:00 a.m. with Staff A (Registered Nurse) confirmed that Resident #7 had a #14 FR catheter in place. Staff A also confirmed that there was a discrepancy in Resident #7's urinary catheter orders.",2020-09-01
570,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2017-09-07,309,D,0,1,ES8Y11,"Based on record review and interview, it was determined that the facility failed to develop a coordinated/integrated Plan of Care for 2 of 2 residents reviewed receiving hospice services in a standard survey sample of 21 residents. (Resident identifiers are #19 and #6.) Findings include: Resident #19 Review on 9/6/17 of Resident #19's medical record revealed that on 8/9/17 Resident #19 was admitted to hospice and was receiving hospice services. Further review of the record revealed that only the hospice nurse documented in the facility's medical record in the section for nurse progress notes. Not in the hospice binder. Review of the hospice binder revealed that there was no documentation from the hospice nurse, social worker, home health aide, chaplain, or hospice volunteer regarding the care provided or the communication between the facility and the hospice agency for Resident #19. Interview on 9/6/17 at approximately 2:00 p.m. with Staff F (Unit Manager), and with Staff [NAME] ( LPN) confirmed that Resident #19 was receiving hospice services and that the scheduling of visits, the care provided, and the communication between the facility and the hospice agency were not present in Resident #19's hospice binder and that is where staff would look for information regarding coordination of care and communication between the hospice agency and the facility. Resident #6 Review on 9/6/17 of Resident #6's Plan of Care - Current dated 1/26/16, revised 7/8/17, revealed that Resident #6 was receiving Hospice services. The care plan included an intervention Hospice to provide Nurse, LNA, Social Worker, Chaplin and Volunteers as needed (See Hospice binder for frequency - Frequency of visits determined by Hospice Provider.) Review on 9/6/17 of the Hospice Binder for Resident #6 revealed that the Hospice Plan of Care was for the benefit period ending on 7/7/17. There was no current certification or Plan of Care for Resident #6. Interview on 9/6/17 with Staff D (Registered Nurse) confirmed that the current certification and plan of care for Resident #6 was not in the Hospice binder.",2020-09-01
571,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2017-09-07,441,D,0,1,ES8Y11,"Based on observation, medical record review and interview, it was determined that the facility failed to ensure that the professional standard of practice for hand hygiene was implemented to reduce the spread of infection and prevent cross contamination for 2 of 3 residents observed during medication pass observation. (Resident identifiers are #22 and #23.) Findings include: Resident #22 Observation on 9/6/17 at approximately 8:15 a.m. of the medication pass on the Mount Chicoura Unit revealed Staff B MNA (Medication Nursing Assistant) finishing administration of medications to a resident in the central dining area. When Staff B completed that resident's administration, Staff B walked over to the medication cart and started pouring Resident #22's medications. Staff B did not wash hands or use hand sanitizer before beginning to pour the medications for Resident #22. After pouring and gathering Resident #22's medications, Staff B brought the medications to Resident #22, who was sitting at a table in the central dining area. Staff B placed the cup of pills and water on the table, donned gloves and then administered eye drops to Resident #22. Staff B removed the gloves and told Resident #22 that Staff B would be back to check to see how Resident #22 did with taking the medications. Resident #23 Observation on 9/6/17 at approximately 8:20 a.m. of the medication pass on the Mount Chicoura Unit revealed Staff B who had just finished administering medications to Resident #22 and then went over to the medication cart and started pouring medications for Resident #23. Staff B did not wash hands or apply hand sanitizer before pouring the medications for Resident #23. Staff B brought the medications to Resident #23 and administered the medications to Resident #23. After the administration of medications to Resident #23, Staff B returned to the medication cart and this time Staff B used hand sanitizer to clean Staff B's hands. Review on 9/6/17 of the Facility Policy, Titled Hand Hygiene. Date Initiated: 2/2003. Reviewed/Revised: 7/2017 revealed that .Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water) or hand rub (using alcohol based hand rub) .It is the policy of Mountain View Community that staff will use proper hand hygiene to help prevent the spread of infection .When to wash hands (at a minimum) .Before and after each resident contact . Interview on 9/6/17 at approximately 2:00 p.m. with Staff C (Director of Nursing) confirmed that hand hygiene was supposed to be done between residents during medication administration.",2020-09-01
572,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2018-11-08,656,B,0,1,BU1011,"Based on record review and interview it was determined that the facility failed to develop a coordinated Plan of Care for 4 of 4 resident's receiving Hospice services in a survey sample of 24 residents. (Resident identifiers are #12, #22, #40 and #59.) Findings include: Record review on 11/7/18 for Resident's #12, #22, #40 and #59 revealed that the facility failed to show a coordinated Plan of Care as evidenced by not including or documenting the Hospice goals and interventions in order to ensure that facility staff is providing consistent care when Hospice staff are not scheduled in the facility. The Hospice care plans did not establish which services will be provided to each individual resident. Interview on 11/7/18 at 1:30 p.m. with Staff A (DON) and Staff B (LPN) including review of Resident #12's, Resident #22's, and Resident #40's care plans revealed and confirmed that the Hospice Care Plans are not individualized with established services for each resident and are from the library, facility's computerized base care plan. Interview on 11/7/18 at 11:30 p.m. with Staff C, (ADON) icluding review of Resident #59's care plan revealed and confirmed that the goals and interventions were not listed for specific Hospice disciplines and frequencies rendering care to Resident #59.",2020-09-01
573,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2018-11-08,842,D,0,1,BU1011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy and procedure it was determined that the facility failed to ensure that the medical record was accurate for 1 resident in a survey sample of 24 residents. (Resident identifier is #32.) Findings include: Resident #32. Review on 11/8/18 of the facility policy and procedure titled Cardiopulmonary Resuscitation dated 12/07/2016 revealed the following; Policy: Cardiopulmonary resuscitation will be initiated on all residents who have a respiratory or [MEDICAL CONDITION] unless contraindicated with a DNR (Do Not Resuscitate) order written by a physician. Procedure: . d. DNR will be noted on the MAR (Medication Administration Record). Review on 11/8/18 of the facility policy and procedure titled Physician Transcription dated 4/15/15 revealed the following: Procedure: . Monthly Physician Order Sheets 1) Pharmacy provides new 4 part Physician Order Sheets every month . 2) Two 11-7 staff licensed nurses check these entries and make necessary corrections . 4) The MAR indicated [REDACTED]. Review on 11/7/18 of the medical record for Resident #32 revealed a PORTABLE DO NOT ATTEMPT RESUSCITATION .ORDER signed and dated by the physician on 8/8/18. Further review of Resident #32's Medication Administration Record [REDACTED]. Review on 11/7/18 of the MAR for Resident #32 dated 11/1/18 showed the code status as FULL CODE with a line through it and hand written in the letters DNR (Do Not Resuscitate). Review on 11/7/18 of the signed Physician Orders for Resident #32 dated 9/1/18 revealed Resident #32's code status as FULL CODE. Interview on 11/7/`18 at approximately 10:30 a.m. with Staff D (Licensed Practical Nurse) confirmed that Resident #32 is a DNR as of 8/8/18 and that the 8/1, 9/1, 10/1 MAR's and the signed physician orders for 9/1/18 were not correct and accurate for Resident #32. That the 8/1/18 MAR indicated [REDACTED]. Interview on 11/7/18 at approximately 1:30 p.m. with Staff A (Director of Nursing) after review of the above listed MAR's, DNR order and Physician Orders for Resident #32 revealed Staff A confirmed that Resident #32 was a DNR as of 8/8/18 and that these documents listed were incorrect and not accurate. Staff A confirmed at this time that the 11/1/18 MAR for Resident #32 with the crossed out Full Code should have been initialed and dated by the person changing the code status from Full Code to DNR.",2020-09-01
574,ST JOSEPH RESIDENCE,305088,495 MAMMOTH RD,MANCHESTER,NH,3104,2018-05-02,756,D,0,1,YGT111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility's pharmacist failed to report medication irregularities for 1 resident in a standard survey sample of 12 residents. (Resident identifier is #13.) Findings include: Review on 5/2/18 of Resident #13's Active Medication Profile revealed that Resident #13 had an order, dated 6/28/17, for [MEDICATION NAME] 60 mg tablet orally one time a day. The review also revealed that Resident #13 had been receiving the [MEDICATION NAME] every day. Review on 5/2/18 of Resident #13's current list of allergies [REDACTED].#13 was allergic to [MEDICATION NAME] ([MEDICATION NAME].) Review on 5/2/18 of Resident #13's Consultant Pharmacist Medication Review form, revealed that Resident #13's medications had been reviewed by the pharmacist every month from (MONTH) (YEAR) to (MONTH) (YEAR), with no recommendations listed. The review also revealed that Resident #13's allergies [REDACTED]. There were no pharmacist notes indicating that Resident #13 was allergic to [MEDICATION NAME], but was receiving [MEDICATION NAME]. Interview on 5/2/18 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A also confirmed that the pharmacist should have notified the facility of this irregularity.",2020-09-01
575,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,580,E,1,1,4J1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, policy and procedure review, it was determined that the facility failed to notify the physician about clinical changes in 3 residents out of a final sample of 18 residents. (Resident identifiers are #10, #120, and #121.) Resident #10 Review on 3/28/19 of Resident #10's medical record in the nurses notes revealed that Resident #10 had a fall on 3/20/19 at 8:45 p.m. Review on 3/28/19 of the RMS (risk management summary) dated 3/21/19 revealed that Resident #10 had complaints of some pain in left buttocks/hip during assessment prior to Resident #10 being moved. Review on 3/28/19 of Staff E, (Nurse Practitioner) progress noted dated, 3/21/19 13:12 revealed, (pronoun omitted) landed on (pronoun omitted) left hip/buttock region and had acute pain. (pronoun omitted) was hoyered to (pronoun omitted) recliner last night and been unable to stand since. (pronoun omitted) reports pain is 10/10. Review on 3/29/19 of the SBAR (situation, background, assessment, recommendation) dated, 3/21/19, 8:30 a.m. revealed: . Resident Evaluation . 9. Pain Evaluation Does the resident have pain? yes. Is the pain new? yes. Review on 3/28/19 of the Radiology report, date of service 3/21/19 11:52 a.m. revealed: . Conclusion: suspect left pubic fractures, Consider CT (Cat Scan) if indicated. Review on 3/28/19 of nurses notes revealed the following note dated 3/21/19, 5:55: . Dr. (pronoun omitted) updated about orthopedic suggestions (pronoun omitted) and ordered to send to ED (emergency department) for CT now. Patient sent 911 per (pronoun omitted). Interview on 3/29/19 at approximately 9:30 a.m. with Staff [NAME] revealed that there had been no notification of Resident #10's fall or pain until 3/21/19 at 9:00 a.m. Staff hoyered (pronoun omitted) into a recliner after the fall, stayed (pronoun omitted) stay in the recliner all night, and was not moved until I was notified of the fall around 9:00 a.m.) Review on 3/29/19 of the facility policy and procedure titled, NSG115 Physician/Advanced Practitioner Provider (APP) Notification, revision date 12/1/18 revealed: Policy Upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform clinical observations, and collect pertinent patient information such as age, diagnoses, prior vital signs, labs, recent changes in medications, previous incidents of a similar nature, code status, etc. and report to physician/advanced practice provider (APP). If unable to contact attending physician/APP, the Medical Director will be contacted. . Purpose To communicate a change in patient's condition to physician/APP and initiate interventions as needed/ordered. Resident #120 Review on 3/29/19 of Resident #120's medical record revealed the following nursing note dated, 1/20/19 8:25: @ (at) change of shift this RN (Registered Nurse) was made aware of patients change in condition and assessed patient. Findings were: Patient alert, respirations 28-32, pulse ox (oximeter) 79% on 5 LPM (liters per minute) via NC (nasal cannula), HR (heart rate) irregular @144 BPM (beats per minute) apically, BP (blood pressure) stable 117/55. No c/o (complaints of) CP (chest pain), denies any discomfort anywhere. Foley patent draining CYU (clear yellow urine). Patients skin was cold and clammy. Patient is very difficult to understand any verbal communication. EMS (emergency medical services) notified of need for transfer to (pronoun omitted) and report called to (pronoun omitted) in the ED (emergency department). DPOA (durable power of attorney) notified, Portable DNR (do not resuscitate) sent with patient along with all pertinent care records. Per previous nurse attempts to notify MD (Medical Doctor) / on call of change in condition were unsuccessful. DON (Director of Nursing) made aware of transfer. Review on 3/29/19 of nursing notes for previous shift dated 1/20/19 revealed that there was no documentation of Resident #120's decline. Interview on 3/29/19 at approximately 11:45 a.m. with Staff A (Senior Center Nurse Executive) confirmed that there was no documentation of Resident #120's change in condition from the previous shift. Staff A was unable to locate/determine a time on when the previous shift nurse noted in the 1/20/19 nursing note attempted to notify the MD. Review on 3/29/19 of the (pronoun omitted) hospital discharge summary dated 1/27/18 revealed: . (pronoun omitted) transitioned to comfort care on 1/24/19. passed away a few hours after (pronoun omitted) was transitioned to comfort care. Cause of death is acute hypoxemic [MEDICAL CONDITION] in the settling of aspiration pneumonia and [MEDICAL CONDITION]. Contributing factors are rapid ventricular [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Interview on 3/29/19 at approximately 1:45 p.m. by telephone with Staff D (Licensed Practical Nurse) revealed that Resident #120's change in condition was verbally given during report by the previous nurse on 1/20/19. Staff D immediately assessed resident and sent Resident #120 to the hospital by EMS. (pronoun omitted) was hypoxic during my assessment. Staff D stated that during report the previous shift nurse stated that the on call MD was called about 1 1/2 to 2 hours prior to Staff D arriving with no call back to the facility. Resident #121 Review on 3/29/19 on Resident #121's progress notes dated 1/20/19 revealed the resident had a fall on 1/20/19 and the resident's right side was sore. The progress note indicated the Staff [NAME] (Nurse Practitioner) was notified. Interview on 3/29/19 at 9:35 a.m. with Staff [NAME] revealed that Staff [NAME] was not notified of a fall on 1/20/19. Staff [NAME] examined Resident #121's side on 1/25/19 where there was bruising from a fall. Staff [NAME] did not send Resident #121 to the hospital on [DATE] as Staff [NAME] did not think the ribs were broken and would not treat them any different if they were. Staff [NAME] revealed Resident #121 denied pain. Review on 4/1/19 of Resident #121's Nursing Home to Hospital Transfer Form dated 1/26/19 revealed that Resident #121 was transferred to the hospital because the daughter insisted. Review on 4/1/19 of Resident #121's hospital discharge summary dated 1/31/19 revealed that Resident #121 was admitted to the hospital on [DATE] for a fall, dyspnea and change in mental status. The resident was found to have right sided rib fractures and other unrelated diagnoses.",2020-09-01
576,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,656,B,0,1,4J1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, it was determined that the facility failed to have person-centered comprehensive care plans for 3 residents out of a final survey sample of 18 residents. (Resident identifiers are #2, #10, and #22.) Findings include: Resident #22 Review on 3/29/19 at 11:04 a.m. of Resident #22's medical record revealed that on 12/27/18 an order was written by the physician placing Resident #22 on care and comfort. On review of Resident #22's care plan there fails to be one written to address how care and comfort will be provided to Resident #22. Interview on 3/29/19 at 11:57 a.m. with Staff A (Senior Center Nurse Executive) reviewed the above findings and Staff A confirmed that a care and comfort care plan was not created for Resident #22. Resident #2 Review on 3/29/19 of Resident #2's medical record revealed that Resident #2 was admitted to the facility on [DATE] and has been receiving insulin since admission. Review on 3/29/19 of Resident #2's care plans revealed the following care plan: The resident has a [DIAGNOSES REDACTED]. Interview on 3/29/29 at approximately 10:30 a.m. with Staff A (Senior Center Nurse Executive) confirmed that the care plan was not correct. Resident #10 Review on 3/29/19 of Resident #10's physicians orders revealed that Resident #10 was on a fluid restriction from 2/22/19 thru 3/29/19. Review on 3/29/19 of Resident #10's care plans revealed that there was no care plan put in place for the Resident #10's fluid restriction. Interview on 3/29/19 at approximately 10:30 a.m. with Staff A confirmed that there was no care plan for Resident #10's fluid restriction.",2020-09-01
577,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,658,D,1,1,4J1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #121 and #120.) Findings include: Review of Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009 reveals: Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #121 Review on 3/19/19 of Resident #121's physician orders [REDACTED]. Review on 3/29/49 of Resident #121's Medication Administration Record [REDACTED]. Interview on 4/1/19 at approximately 10:30 a.m. with Staff A (Senior Center Nurse Executive) confirmed the above finding. Resident #120 Review on 3/28/19 of Resident #120's Januarys MAR (Medication Administration Record) revealed the following physicians order, dated 12/17/18: [MEDICATION NAME] Tablet. Give 12.5 mg (milligrams) by mouth every 6 hours for heart HOLD for SBP (systolic blood pressure) Review on 3/28/19 of Resident #120's medical record revealed that there were no blood pressures or heart rates recorded prior to Resident #120 receiving the medication. Interview on 3/28/19 at approximately 12:45 p.m. with Staff A, Senior Center Nurse Executive revealed that there was no documented blood pressures for Resident #120 prior to receiving the medication with parameters. Review on 3/29/19 of the facility policy and procedure titled, OPS402 Clinical Record: Charting and Documentation . 2. Chart pertinent changes in the patient's condition, reaction to treatment, medication, etc., as well as routine observations.",2020-09-01
578,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,755,D,0,1,4J1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined that the facility failed to assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of 2 residents in a survey sample of 18 residents. (Resident identifier is #7) Resident #7 Review on 3/28/19 at 1:16 p.m. Resident #7's record showed that on 3/7/19 an order was written for [MEDICATION NAME] HCI tablet 50 MG (mailgram) Give 1 tablet by mouth one time a day for B-6 SUPP (supplement) From 3/7/19 - 3/25/19 this medication was not given due to it not being available as written on the MAR (Medication Administration Record). Interview on 3/29/10 with Staff A (Senior Center Nurse Executive) confirmed that this medication was not given until 3/26/19 when the facility got the medication.",2020-09-01
579,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,760,D,0,1,4J1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to ensure that residents are free of significant medication errors for 1 of 2 residents reviewed on anticoagulation therapy in a final sample of 18 residents. (Resident identifier is #11.) Findings include: Review on 3/29/19 of Resident #11's physician orders [REDACTED]. There was no order for [MEDICATION NAME] after 3/24/19. Review on 3/29/19 of Resident #11's laboratory requisitions revealed a specimen was drawn on 3/25/19 with PT/INR ordered. Review on 3/29/19 of Resident #11's laboratory reports revealed no PT/INR testing reports dated 3/25/19. Review on 3/29/19 of Resident #11's Medication Administration Record [REDACTED]. Resident #11 did not received [MEDICATION NAME] after 3/24/19. Interview on 3/29/19 at approximately 11:00 a.m. with Staff A (Senior Center Nursing Executive) confirmed the above findings. Interview with Staff A further revealed that when the facility receives PT/INR results, they are called to the physician and new [MEDICATION NAME] orders are obtained. Staff A also revealed that Resident #11's PT/INR results were not received by the facility, and the facility did not follow up on the why they had not received results. Staff confirmed Resident #11 did not received [MEDICATION NAME] between 3/25/19 and 3/29/19.",2020-09-01
580,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,842,B,1,1,4J1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined that the facility failed to maintain complete and accurate medical records on 2 residents in a final sample of 18 residents. (Resident identifiers are #22 and #120.) Findings include: Resident #120 Review on 3/28/19 of Resident #120's medical record revealed the following nursing note dated, 1/20/19 8:25: @ (at) change of shift this RN (Registered Nurse)was made aware of patients change in condition and assessed patient. Findings were: Patient alert, respirations 28-32, pulse ox (oximeter) 79% on 5 LPM (liters per minute) via NC (nasal cannula), HR (heart rate) irregular @144 BPM (beats per minute) apically, BP (blood pressure) stable 117/55. No c/o (complaints of) CP (chest pain), denies any discomfort anywhere. Foley patent draining CYU (clear yellow urine). Patients skin was cold and clammy. Patient is very difficult to understand any verbal communication. EMS (emergeny medical services) notified of need for transfer to (pronoun omitted) and report called to (pronoun omitted) in the ED (emergeny department). DPOA (durable power of attorney) notified, Portable DNR (do not resucitate) sent with patient along with all pertinent care records. Per previous nurse attempts to notify MD (medical doctor) / on call of change in condition were unsuccessful. DON (director of nursing) made aware of transfer. Review on 3/28/19 of Resident #120's medical record revealed that there was no documentation for the decline in condition for Resident #120 that was mentioned in the nursing note dated, 1/20/19 8:25. Interview on 3/29/19 at approximately 11:00 a.m. with Staff A confirmed that there was no documentation on Resident #120's clinical decline. Resident #22 Review on 3/29/19 at 12:00 p.m. of Resident # 22's nurses notes reveal a note written on 1/3/19 which states .Now unresponsive with cheyne-stoke respirations. No PO (by mouth) intake in a few days. Death is imminent. Cont (continue) [MEDICATION NAME] and [MEDICATION NAME] at current doses. Family at bedside. Further review of Resident #22's nurses' notes did not reveal any further documentation regarding Resident #22 having passed and that their body has been released. Interview on 3/29/19 at 1:00 p.m. with Staff A (Senior Center Nurse Executive) reviewed above findings and Staff A confirmed. Staff A also was able to find a New Hampshire Certificate of Death but the nursing notes fail to show that Resident #22 had passed on 1/3/19.",2020-09-01
581,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,880,D,0,1,4J1Q11,"Based on observation and interview, it was determined that the facility failed to educate house keeping on the proper use of PPE (Personal Protecive Equipment) when entering and exiting a resident's room. Findings include: Observation on 3/27/19 at 10:41 a.m. revealed that Staff F (House keeper) after cleaning a room that was on contact precautions come out into the hallway with their PPE on walked to their cleaning cart and removed their PPE placing their yellow gown into the trash container located on the back of their cleaning cart. Interview at 10:50 a.m. with Staff F confirmed that they should have changed and left there PPE in the room. Interview on 3/27/19 at 2:30 p.m. Staff B (Infection Control) revealed that he had not trained the house keeping staff on the proper way to put on and take off PPE equipment. Staff B also did a education training on all house keeping staff to educate on the proper donning of PPE. Staff B showed the sign in sheet that was created for training.",2020-09-01
582,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2019-04-01,881,D,1,1,4J1Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of hospital history, and review of physical examination, and review of the facility's antibiotic line listing it was determined that the facility failed to determine a stop date for an antibiotic for 1 resident out of a final sample of 18 residents. (Resident identifier is #120.) Finding include: Review on 3/28/19 of Resident #120's (MAR) Medication Administration Record [REDACTED] [MEDICATION NAME] 750 mg (milligrams), give 1 tablet by mouth one time a day for infection, start date: 12/29/19. Review on 3/28/19 of Resident #120's medication regimen reviews dated, 1/4/19 and 1/18/19 revealed the following: Need a stop date on levoquin. Interview on 3/29/19 at approximately 11:00 a.m. with Staff A (Senior Center Nurse Executive) revealed that there was no evidence that the 2 pharmacy medication regimen reviews were addressed by the facility or physician. Review on 3/29/19 of the (pronoun omitted) hospital history and physical examination [REDACTED] . [MEDICATION NAME] 750 mg table directions: 1 tablet oral daily every morning. . Patient has been on for the whole month of January. (pronoun omitted) MAR indicated [REDACTED]. OVERTREATMENT?",2020-09-01
583,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2016-12-21,271,D,0,1,QXXQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to develop a comprehensive care plan for 1 resident out of survey sample of 10 residents. (Resident identifier #9.) Findings include: Review on 12/21/16 of Resident #9's nursing notes from 12/19/16 revealed Resident #9 utilized the Continous Passive Motion (CPM) at 5:00 a.m. and Continous Positive Air Pressure ([MEDICAL CONDITION]) at 11:07p.m. Review of Resident #9's interdisciplinary care plan revealed that the care plan did not address CPM, and [MEDICAL CONDITION] use with resident. No direction's were available for duration, frequency or settings for either machine. On 12/21/16 at 2:00pm interview with Staff A (Unit Manager) confirmed the above findings. On 12/21/16 at 2:30p.m. interview with Staff C (Director of Physical Therapy) revealed both Physical Therapy and Admissions were aware the CPM was coming for Resident #9.",2020-09-01
584,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2016-12-21,371,D,0,1,QXXQ11,"Based on observation and interview, it was determined that the facility failed to ensure that food stored was properly labeled and dated to ensure it was not outdated. Findings include: Observation on 12/20/16 of the Main Kitchen storage freezer during tour with Staff G (Head Chef) in the morning revealed an uncovered, unlabeled tray of meat patties. Observation on 12/20/16 during morning tour with Staff G of the Main Kitchen preparation refrigerator revealed a storage bin of thawed nutrition supplement shakes, Sysco brand, that had been thawed from their frozen storage state. On the carton of each shake there is a printed area for the facility to label when the shake was thawed. These areas were blank. In addition there is no 'use by date' on any of the cartons of shakes. The policy, Use By Dating Guideline it states that in regards to frozen shakes 'Date carton when removed from freezer' and 'Use by date of 14 days once thawed'. Observation on 12/20/16 during morning tour of the facility kitchenette refrigerator revealed a red colored substance, (presumed to be ketchup), stored in two cylindrical containers with spouts, located in the appliance door. Neither of these containers were labeled and the spouts were uncapped. In addition, there was a small storage bin filled with thawed nutrition supplement shakes, Sysco brand, that had resident labels and no thawed date nor use by dates on the cartons. Interview on 12/21/16 and observation with Staff F (Food Service), Staff F reviewed the above findings and revealed the containers of ketchup (verified) and the tray of frozen meat were discarded and the thawed nutrition supplement shakes, Sysco brand, were being labeled with the thawed and use by dates.",2020-09-01
585,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2016-12-21,441,B,0,1,QXXQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to ensure proper infection control practices were adhered to for cleaning of the 4 of 4 glucometers on the Unit, and failed to ensure that the means for proper sanitation were readily available in the physicial therapy room. Findings include: Observation on 12/20/16 and 12/21/16 on the Unit of all 4 glucometers revealed a piece of clear tape on the back of the glucometers. One meter had a piece of tape that stated This meter sings on the back of the meter that was starting to lift up on the corner of the tape. Interview with Staff B, (Licensed Practical Nurse) and Staff A (Unit Manager) at the time of discovery confirmed the above findings. During interview on 12/21/16, midday, with Staff C (Director of Rehab), in a small office adjacent to the physical therapy room, Staff C related that in the therapy rooms they sanitize with wipes between each patient, and handwash between patients. Staff C related they can accommodate a Clostridium difficile (C. diff) patient in the physical therapy room and in the occupational therapy room, and they would use soap and water to handwash after a C.diff patient. Observation on 12/21/16 revealed that the physical therapy room and adjacent office are separated from the occupational therapy room by a common corridor. Observation in the physical therapy room just prior to the above interview revealed a patient in the physical therapy room with a staff person to receive services. After the above interview was completed, observation with Staff C in the occupational therapy room revealed two containers of sanitizing wipes stored in the cupboard(s): a red top container and a white top container. The labels on the containers were reviewed by Staff C who related that both sanitize for hepatitis, and the white top also covers [DIAGNOSES REDACTED]; neither was listed as covering C.difficile. The room contained a sink with soap dispenser for handwashing. Subsequent observation on 12/21/16 in the physical therapy room, which was now unoccupied, revealed, as Staff C opened the cupboard to identify the sanitizer wipes available for use in that room, that there were no sanitizer wipe containers available in the physical therapy room. Also, there was no sink for soap and water handwashing, although there was hand sanitizer. Interview on 12/21/16 with Staff C revealed that both the occupational therapy room and the physical therapy room are busy/in use with patients every day on Mondays through Fridays. Interview on 12/21/16 about an hour later, with Staff D (Nursing) and Staff [NAME] (Educator), revealed that the facility has bleach wipes available, which would be utilized by physical therapy and occupational therapy to sanitize for C.diff.",2020-09-01
586,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2016-12-21,514,D,0,1,QXXQ11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to maintain complete medical records on each resident for 2 residents out of a survey sample of 10 residents (Resident identifiers #1 and #9.) Findings include: Review of Resident #1's medical record on 12/20/16 revealed Resident #1 had 6 treatment orders for multiple skin tears and barrier creams. The facility was unable to provide Treatment Administration Records (TARs) for skin impairments during (MONTH) (YEAR). Interview on 12/20/16 at 3:15 p.m. with Staff A (Unit Manager) confirmed the above finding. Review on 12/20/16 of Resident #9's medical record revealed nursing notes from 12/19/16 and 12/20/16 stating that a Continuous Passive Motion (CPM) machine and a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine were being utilized. A self administration test had not been done to use these machines. Further review of record revealed Resident #9 did not have orders for use of a CPM and [MEDICAL CONDITION] machine. Interview on 12/20/16 at 3:15 p.m. with Staff A confirmed the above finding. Review of Resident #9's Discharge Summary dated 12/18/16 from Hospital (name omitted) contained the following orders that were not addressed in admission orders [REDACTED]. There was not a stop date of two weeks on the order in medical record. There was no evidence that these orders were addressed.,2020-09-01
587,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2017-10-05,279,D,0,1,XE0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for a resident with a pacemaker for 1 resident out of a survey sample of 10 residents. (Resident identifier is #8.) Findings include: Review on 10/4/17 of Resident #8's [DIAGNOSES REDACTED].#8 had a Cardiac Pacemaker. Review on 10/4/17 of Resident #8's Plan of Care, initiated on 9/28/17, revealed that there was no care plan in place for Resident #8's pacemaker. Interview on 10/4/17 at approximately 1:15 p.m. with Staff A (Assistant Director of Nursing) confirmed that Resident #8 had a pacemaker and that there was no documented care plan in place for the pacemaker.",2020-09-01
588,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2017-10-05,281,D,0,1,XE0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow the professional standard of practice for the administration of narcotics for 1 resident in a standard sample of 10 residents. (Resident identifier is #9.) Findings include: Reference for the professional standard of practice for medication documentation is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines. Box 35-1 Guidelines for Safe Narcotic Administration and Control . . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication, dose, and signature of nurse dispensing the medication. . If a nurse gives only part of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers Page 709 Right Documentation. Nurses and other health care providers use accurate documentation to communicate with each other. Many medication errors result from inaccurate documentation. Therefore ensure that accurate and appropriate documentation exists before and after giving medications. Verify inaccurate documentation before giving medications . After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care Reference for pain scale is the Northeast Healthcare Quality Foundation (NHCQF), Pain tool indicates 0 - No Pain, 1-4 Mild Pain, 5-6 Moderate Pain and 7-10 Severe Pain. Resident #9 Review on 10/5/17 of the Medication Administration Record (MAR) for Resident #9 dated 9/1/17 - 9/30/17 revealed the following physician orders: [MEDICATION NAME] Solution give 0.25 ml (milliliter) by mouth every 1 hour as needed for mild-moderate pain and [MEDICATION NAME] Solution give 0.5 ml by mouth every 1 hour as needed for severe pain. Further review of this 9/1/17 MAR showed that [MEDICATION NAME] 0.25 ml for mild-moderate pain was administered to Resident #9 with a pain rating of 7,8 and 10. These documented pain ratings indicate severe pain and not mild-moderate pain. Review of the 9/1/17 MAR also showed [MEDICATION NAME] 0.5 ml for severe pain was administered to Resident #9 with pain ratings of 4 and 6. These documented pain ratings indicate mild-moderate pain and not severe pain. Interview and review on 10/5/17 at approximately 1:00 p.m. with Staff B (Registered Nurse) revealed that Resident #9's MAR for [MEDICATION NAME] and the facility Narcotic log for the doses of [MEDICATION NAME] administered to Resident #9 did not match. Resident #9 was given [MEDICATION NAME] on the following dates with the following inaccurate documentation: DATE MAR (9/1/17) Narcotic Log Page #107 9/20/17 5 doses 4 doses 9/21/17 3 doses 5 doses 9/23/17 5 doses 3 doses 9/24/17 3 doses 4 doses 9/26/17 3 doses 6 doses 9/27/17 1 dose 4 doses 9/28/17 0 doses 3 doses 9/29/17 2 doses 5 doses 9/30/17 0 doses 2 doses Interview on 10/5/17 at approximately 1 p.m. with Staff B revealed that the MAR and Narcotic documentation were inaccurate for the [MEDICATION NAME] given to Resident #9 on the dates listed above and that the pain ratings listed above for the [MEDICATION NAME] were also inaccurate for the pain scale used for Resident #9. Review on 10/5/17 of the facility Narcotic log revealed a page with Resident #9's name, the physician name and in the section for the physician medication order a note written as . (one) po (by mouth) BID (twice a day). There was no documentation on this page to indicate the name of the medication or dose. This page showed multiple individual dates, times, amount of medication on hand, amount of medication used, route, amount of medication left and nurses' signatures for dates from 9/5 through 10/5 for a total of 54 doses given to Resident #9 Interview and review of a second Narcotic log page with no page number on 10/5/17 at approximately 1 p.m. with Staff B confirmed that there was no name of the medication and no dose documented on the second Narcotic log page for narcotic medication listed as given to Resident #9.",2020-09-01
589,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2017-10-05,328,D,0,1,XE0211,"Based on observation and interview, the facility failed to provide foot care for 1 resident in a survey sample of 10 residents. (Resident identifier is #4.) Findings include: Interview on 10/4/17 at approximately 9:45 a.m. with Resident #4 revealed that Resident #4 had asked to be seen by the podiatrist on 7 different occasions. Resident #4 stated that Resident #4's toenails were very long and needed to be trimmed. Resident #4 also stated that it was uncomfortable to walk. Observation on 10/4/17 at approximately 9:55 a.m. revealed that Resident #4 had contracted toes on both feet with toes rolled down underneath the bottom of the foot. Resident #4's toenails on both feet were very long and on the right foot the toenails were touching the ball of the foot. Interview on 10/4/17 at approximately 10:15 a.m. with Staff B (Director of Nursing) confirmed that Resident #4's toenails needed to be cut and after Staff B observed Resident #4's toenails, Staff B immediately called the podiatrist to come in and cut Resident #4's toenails.",2020-09-01
590,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2017-10-05,371,E,0,1,XE0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of manufacturers instructions, the facility failed to properly cover and date food items, as well as to separate non-food items, ice packs, from food items in the one facility kitchenette. Findings include: Observation on 10/3/17 at approximately 9:45 a.m. of the kitchenette located on the East Wing revealed the following: 1. Five Mighty shakes in the refrigerator with no date written on them. 2. Two banana yogurts in the refrigerator, both opened with the foil cover not completely down to cover the opening. Neither of the yogurts were dated. 3. A container of Good [NAME]y [MEDICATION NAME] in the refrigerator, opened but not dated. 4. Four ice packs in the freezer next to food items. Interview on 10/3/17 at approximately 9:45 a.m. with Staff C (Licensed Nursing Assistant) revealed that one of the four ice packs was for Staff C's mouth as Staff C had just had teeth extracted. Review on 10/5/17 of the Manufacturer's Instructions for Mighty Shakes, Revision Date: 9/18/14, revealed that the .Shelf Life: Unopened: 15 months (450 days) frozen .Refrigerated: 14 days thawed. Observation on 10/4/17 at approximately 10:00 a.m. of the kitchenette located on East Wing revealed the following: 1. One banana yogurt in the refrigerator, opened with the foil cover not completely down to cover the opening. The yogurt was dated with the date that was put on it on 10/3/17 during the previous observation of the kitchenette. 2. A container of thickened prune juice, open with no date on it. Observation on 10/5/17 at approximately 1:00 p.m. of the kitchenette located on East Wing revealed the following: 1. One banana yogurt in the refrigerator, opened with the foil cover not completely down to cover the opening. The yogurt was dated with the date that was put on it on 10/3/17 during the observation of the kitchenette. 2. A container of thickened prune juice, open with no date on it. 3. An ice pack in the freezer next to food items. Interview on 10/3/17 at approximately 9:45 a.m. with Staff D (Licensed Practical Nurse) revealed that the banana yogurts were for a resident who used them for medication administration. Staff D removed one of the yogurts and dated the other as Staff D stated that Staff D observed that yogurt being opened that morning. Staff D confirmed that the Mighty Shakes and the Good [NAME]y [MEDICATION NAME], which Staff D removed, should have been dated. Staff D also confirmed that the ice packs should not have been in the freezer with food items, and Staff D removed the ice packs. Interview on 10/5/17 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that the yogurts should have been covered, that the prune juice should have been dated when opened and that the ice pack should not have been in that freezer.",2020-09-01
591,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2017-10-05,456,B,0,1,XE0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to maintain oxygen concentrators in safe operating condition for 2 out of 2 oxygen concentrators observed during tour of the North Unit, and the facility failed to follow manufacturers guidelines for cleaning of the hydroculator. (Resident identifiers are #11 and #12) Findings include: Observation on 10/3/17 at approximately 9:00 a.m. on North Unit tour with Staff A (Licensed Practical Nurse) revealed that Resident #11 and Resident #12's oxygen concentrator filters had a visible amount of dust and debris adhered to them. Interview with Staff A confirmed that the filters had a visible amount of dust and debris adhered to them. Review on 10/4/17 of the facility policy named Oxygen Administration (undated) revealed in the section titled Documentation: 12. Oxygen concentrator filters will be assessed and cleaned weekly. Interview on 10/4/17 at approximately 10:00 a.m. with Staff A stated that the Oxygen concentrator filters are cleaned weekly. Staff A revealed that the facility had no documentation of any cleaning of the oxygen concentrator filters. Observation and review on 10/3/17 of the facility [MEDICATION NAME] revealed that the facility [MEDICATION NAME] log showed no documentation that the [MEDICATION NAME] was cleaned for (YEAR) for the months of January, March, April, (MONTH) and July. This (YEAR) log also showed that the [MEDICATION NAME] temperatures were not done on a daily basis for 18 days in April, 14 days in May, 10 days in (MONTH) and 11 days in July. The facility's [MEDICATION NAME] manufacturers user manual dated 2009 revealed the following: SAFETY PRECAUTIONS . The recommended operating temperature is 160 (degrees) F to 165 (degrees) F (71 degrees C to 74 degrees C). The temperature of the water should be checked with a thermometer after every adjustment, before using the HotPac. Always allow sufficient time for the water temperature to stabilize . . Check water level daily as it has a natural loss due to evaporation . . If the unit is to be left unattended for a period of time, unplug the unit, remove the packs, empty the water, and clean the tank. MAINTENANCE Care and Cleaning It is critical to maintain the water level over the top of the HotPac to avoid damage to the heating element, the stainless steel, or the HotPac. Water is constantly lost during operation due to evaporation. Therefore, it is essential that water be added daily. The tank should also be drained, cleaned, and inspected at minimum intervals of every two weeks. Interview on 10/3/17 at approximately 9:00 a.m. with Staff [NAME] (Occupational Therapy) confirmed the above listed findings that the facility [MEDICATION NAME] is not cleaned every two weeks at a minimum and that temperatures are not consistently taken before using the HotPacs.",2020-09-01
592,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2018-10-31,658,D,0,1,FCJX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #27 and #39.) Findings include: Professional reference: Potter, [NAME] [NAME], and Perry, Anne Griffin. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #27 Interview on 10/29/18 at approximately 9:50 a.m. with Resident #27 revealed that Resident #27 had difficulty hearing and needed to have questions repeated. Resident #27 stated that they were supposed to get ear drops and then an ear flush, but that it did not happen and that they did not know why. Review on 10/30/18 of Resident #27's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records revealed that Resident #27 had an order for [REDACTED].#27 received [MEDICATION NAME] ear drops on 9/30/18 at 6:02 p.m., but never received any ear drops or flushing after that initial dose. Interview on 10/30/18 at approximately 2:30 p.m. with Staff A (Director of Nursing) confirmed that the physician orders [REDACTED].#27's ear drops and flushing. Resident #39 Observation on 10/29/18 at approximately 9:00 a.m. revealed that Resident #39 had a PICC (peripherally inserted central catheter) line in the right upper arm. Review on 10/30/18 at approximately 10:30 a.m. of Resident #39's physicians order revealed the following order dated 10/3/18: Change PICC dressing to right upper extremity once a week day shift every Wednesday. Document site condition, measure length of catheter and arm circumference. Interview on 10/30/18 at approximately 10:45 a.m. with Staff A Director of Nurses revealed that there was no documentation of the catheter length and arm circumferences being measured weekly. Review on 10/31/18 at approximately 9:30 a.m. of the facility policy and procedure titled, 4-5 Central and Midline catheter care and maintenance, revision date (MONTH) (YEAR), effective date (MONTH) 20,2017 revealed: .General Information . Assess for any signs and symptoms of complication or malfunction. If exists, LIP (Licensed Independant Practitioner) shall be notified . Procedure . Assess insertion site including resident site and skin condition as well measurement of external catheter . Documentation . catheter length and external measurement .",2020-09-01
593,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2018-10-31,761,B,0,1,FCJX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure proper storage of expired medications for 1 out of 1 observed medication room. Findings include: Policy: Review on 10/30/18 of facility's policy titled, 7-3 Disposal of Medication Syringes and Needles, revealed that .1. All discontinued medication must be removed from active medications in the medication cart/cabinets immediately .Ointments, creams, and similar substances are placed in trash receptacles in the medication room. Tablets, capsules, and liquids are disposed of in acceptable manner .Expired medications should be destroyed as per above procedures . Observation on 10/29/18 at 9:20 a.m. of the medication room revealed that there were expired Over The Counter (OTC) medications which were 1 opened box of Salonpas (pain relief patch) with an expired date of 7/2018, 1 unopened bottle of [MEDICATION NAME] ([MEDICATION NAME]) oral drops with an expired date of 9/18, 1 unopened box of Dairy Aide (enzyme supplement) with an expired date of 9/2018, and 2 unopened boxes of Altalube ointment (eye lubricant) with an expired date of 9/18 that were stored in the cabinets with the unexpired medications. Interview on 10/29/18 at 9:21 a.m. with Staff B (Registered Nurse) confirmed the above findings. Interview on 10/29/18 at 9:22 a.m. with Staff A (Director of Nursing) revealed that the facility would remove expired medications from the unexpired medications in the cabinet and place the expired medications on the left side countertop to be destroyed per facility policy.",2020-09-01
594,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2020-01-17,609,D,0,1,Z66811,"Based on interview and medical record review, it was determined that the facility failed to report alleged violation related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property for 1 of 1 residents identified with an allegation of abuse during initial pool of 28 residents (Resident identifier is #7). Finding include: Interview on 1/15/20 at 9:45 a.m. revealed Resident #7 stated last night the nurse who was caring for me yelled at me telling me to go to bed, I got so upset. While Resident #7 was talking about the event they started to cry stating I'm so scared of them I do not want to see them again. Review on 1/16/20 at 9:35 a.m. of the nurse's notes dated 1/15/19 states .Voiced concern to this writer regarding another staff member in which she felt that the staff member could have worded differently her noise level, appeared upset, but emotional support and reassurance provided. Resident satisfied and in agreement that this writer can speak with staff member regarding her feelings . Interview on 1/16/20 at 9:54 am with Resident #7 revealed that Resident #7 said that the aide that got her upset came into her room and apologized for upsetting her .She said she was telling me to go to sleep, so that I would not try to get up without assistance. I have forgiven her and I'm all set. Interview on 1/16/20 with Staff [NAME] (Director of Nurses) revealed when asked if the above event was or would be reported. Staff [NAME] stated no we have addressed the issue and resident is okay with the outcome. Staff [NAME] was then asked why there have not been any FRI (Facility Reported Incidents) in the past year by evidence of the ACTS (Aspen Complaint Tracking System). Staff [NAME] stated when they have allegations, they are taken care of right away and never become an issue.",2020-09-01
595,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2020-01-17,689,D,0,1,Z66811,"Based on interview, observation, medical record review, and policy review, it was determined that the facility failed to ensure smoking evaluations or assessments were completed to determine that each residents received adequate supervision and assistance devices to prevent accidents related to smoking for 2 out of 2 residents that smoked. (Resident identifiers are #2 and #4.) Findings include: Review on 1/16/20 of the facility's smoking policy, no revision/origin date, revealed that .Residents who smoke will be monitored for their ability to smoke safely and independently .These residents will be reevaluated as dictated by any significant change in condition, to ensure that they continue to be capable of smoking and using smoking materials without presenting a danger to themselves or other .Should burn holes be found in a resident's clothing or bedding or any incidents of unsafe smoking occur, nursing staff will be notified immediately and a new smoking evaluation completed. If deemed necessary, a smoking apron may be offered .Residents deemed unsafe to smoke independently will be allowed to smoke only when under the direct supervision of family members, friends (that are not residents), significant others or facility staff . Resident #2 Interview on 1/15/20 at 11:00 a.m. with Staff [NAME] (Director of Nursing) revealed that there are only 2 smokers in the facility and one of them was Resident #2. Staff [NAME] stated that both smokers were supervised and smoking materials (e.g. lighters and cigarettes) were kept in the medication cart. Review on 1/16/20 of Resident #2's smoking care plan dated 10/15/19 revealed .care plan problem : smoking .upset when asked to use apron, has been found taking it off past attempts to smoke in (his/her) room .care plan interventions .assess resident's ability to smoke safely-lighter/matches to be kept at nurses desk . Review on 1/16/20 of Resident #2's non-compliance care plan dated 10/15/19 revealed .resident refused to use smoking apron .past attempts to smoke in (his/her) room when (he/she) doesn't wish to use the smoking room .interventions .distant supervision for use of smokers room, check in frequently to prevent resident from falling asleep in smoker room-lighters to be kept in nurses cart for safety, remind resident (he/she) is able to continue to smoke as often as (he/she) wishes, staff will promptly supply lighter when requested Review on 1/16/20 of Resident #2's nurse note dated 10/16/19 revealed .upset (he/she) cannot have lighter on .person .Get me some cigarettes. Don't let the nurse or my spouse know .I want some in my room .Has cigars in room, would not give them up . Review on 1/16/20 of Resident #2's nurses note dated 10/17/19 revealed .noncompliance with cigarette routine .Bringing self to smoking room, on assess, noted patient going down hallway into smoking room. (Resident) was sitting in reclining chair when nurse got there, resident was looking through ashtray. Resident stated (he/she) was looking for butts. Nurse reminded (him/her), that (he/she) could have one of (their) cigarettes anytime and to just ring for nurse. (Resident) stated I would rather do this than ask (Nurse) asked (Resident) do you mean look for used butts and resident said yes .2 more times found in smoking room, on check, attempting to light cigars once with matches, once with lighter .when asked where (they) obtained the lighter (he/she) said I have them all over the place. Resident declined to give the lighter and the matches .half an hour later resident gave them to staff .1 on 1 encouragement given to work with staff to get privileges back. Reminded (Resident) regarding safety issues recently with (Resident) lighting up in room Review on 1/16/20 of Resident #2's nurses note dated 10/21/19 revealed .self transferring to smoke room, does have cigarettes (partially full box) and refused to give the cigarettes to nurse .Resident does not seem confused at this time .education provided to resident regarding fall risk and fire safety . Review on 1/16/20 of Resident #2's nurses note dated 11/13/19 revealed .resident rang for lighter, very upset (they) can't have lighter in room stated If I can't get my lighter back, I will burn the building down .emotional support provided . Review on 1/16/20 of Resident #2's nurses note dated 11/29/19 revealed .Resident request for lighter escalating/increasing with staff and APRN (Advanced Practice Registered Nurse). Tonight resident was seen with a lighter refused to return lighter when asked .later returned lighter to LNA (Licensed Nursing Assistant) Review on 1/16/20 of Resident #2's nurses note dated 12/17/19 revealed .(Resident) .called me in again and said it wasn't fair that other resident could have lighter, and that other resident was asking (him/her) to light (his/her) cigars for (them) . Review on 1/16/20 of Resident #2's nurses note dated 12/26/19 revealed Resident refuses to give up .lighter-(resident) was found lighting a cigarette (without) asking for the lighter located in the med-cart draw. The resident absolutely denies having a lighter on .person then later admitted to having matches/lighter in (their) room. Refused to give up lighter .3 lighters hidden in [NAME]et . Interview on 1/17/20 at 10:19 a.m. with Staff C (Unit Manager) revealed that Resident #2 smokes in the evenings. Staff C confirmed above findings related to the nurses notes pertaining to smoking. Staff C stated that Resident #2 had multiple unsafe behaviors since (MONTH) 2019 which were smoking in their room while Resident #2 was using oxygen in their room, multiple occasions resident lighting up cigarette in room, and multiple occasions that Resident #2 had lighters and matches on their person despite multiple reminders and education from nursing staff that Resident #2 cannot have them related to Resident #2 past attempts to smoke in their room. Staff C also stated that Resident #2 does need supervision during smoking. Staff C was unable to provide smoking evaluations for Resident #2's unsafe smoking behaviors. Staff C stated that they chart by exception and that they only document if there were smoking concerns. Interview on 1/17/20 at 10:47 a.m. with Staff F (Licensed Practical Nurse) revealed that Staff F does not know if the residents that smoke needed supervision or any assistive devices (e.g. smoking apron). Interview on 1/17/20 at 10:50 a.m. with Staff [NAME] revealed that the facility does not have a smoking evaluation and that Resident #2 was assessed for smoking daily as Resident #2 was assisted and supervised for smoking. Staff [NAME] also revealed that they only chart by exception, so if there are no issues with smoking then assessment would not be documented. Staff [NAME] stated that distant supervision meant that Resident #2 can smoke independently in the smoking room and that nursing staff would do a random visual check while resident was smoking. Staff [NAME] also stated that Resident #2 was independent for smoking and was capable of lighting their cigarette. Staff [NAME] was unable to provide documentation of assessments (e.g. what type of supervision, ability to light cigarettes safely, ability to smoke and dispose of ashes appropriately, what type of assistive device is needed to safely smoke, cognitive ability to safely smoke and understand facility smoking policy) in regards to the above documented unsafe smoking behaviors on 10/16/19, 10/17/19, 10/21/19, 11/13/19, 11/29/19 and 12/26/19. Resident #4 Interview on 1/15/20 at approximately 10:30 a.m. with Resident #4 revealed that Resident #4 stated that they smoke. Resident #4 stated that they kept their cigarettes in their room, but that their lighter is kept with the staff, who light their cigarette for them. Review on 1/16/20 of Resident #4's assessments revealed that there was no smoking assessment for Resident #4. Review on 1/16/20 of Resident #4's current smoking care plan revealed an intervention .Assess resident's ability to smoke safely . Observation on 1/17/20 at approximately 10:25 a.m. revealed that Resident #4 was sitting alone in the smoking room, smoking a cigarette. Interview on 1/17/20 at approximately 10:25 a.m. with Resident #4 revealed that Resident #4 stated that they smoke independently, after staff light their cigarette, most of the time. Interview on 1/17/20 at approximately 10:30 a.m. with Staff [NAME] (Director of Nursing) confirmed that there was no documented evidence that a smoking assessment had been done on Resident #4, indicating whether or not they were safe to smoke independently.",2020-09-01
596,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2020-01-17,812,D,0,1,Z66811,"Based on interview and observation, it was determined that the facility failed to prepare unpasteurized eggs until they are completely firm or use pasteurized eggs. Findings include: Observation on 1/15/20 at 8:47 a.m. during the initial tour of the facility's kitchen Staff A (Morning cook) was asked about the menu and how eggs are served. Staff A (Cook) stated eggs are served anyway the resident wants, sunny side up, easy over, etc. When inspecting the eggs, which were no longer in the box they were delivered in, none of the eggs had a (P) on them indicating they were pasteurized. Staff A said they questioned the eggs being pasteurized or not, but was told they are the correct eggs but were taken out of the carton and placed in trays. Staff A stated there will be a delivery today of eggs and they will show the box prior to taking the eggs out. Observation on 1/15/20 at 1:30 p.m. after the delivery of the eggs to the facility from the vendor the box says Wholesome farms, Fresh shell eggs-loose large white but did not say pasteurized on the box. Interview on 1/16/20 at 11:00 a.m. with Staff B (Food Director) said that a couple of months ago they had changed vendors and the new vendor must not have carried over the pasteurized egg. Interview on 1/17/20 at 2 p.m. with Staff B revealed that the facility received another shipment of eggs from the vendor and these eggs had a (P) on the eggs, and written on the box was the word pasteurized.",2020-09-01
597,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2020-01-17,919,E,0,1,Z66811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility has failed to make sure that all portions of the call bell system were functioning as designed with both audible and lights outside resident rooms and nursing station 1 of 3 units. Findings include: Observation on 1/17/20 at 11:46 a.m. revealed that the call light to room [ROOM NUMBER] was lit up outside the room but there was no audible sound heard at the nurse's station nor anywhere else in the building. room [ROOM NUMBER] could not be seen from the nursing station. Interview on 1/17/20 at 11:55 a.m. with Staff C (Unit Manager) revealed Staff C was not aware room [ROOM NUMBER]'s call light was on. Staff C then went down to the end of the hall and helped the resident in room [ROOM NUMBER]. When Staff C returned back down the hall after caring for the resident they were asked to test all the other rooms (20, 21, 22, 23, 24, and 25) on the unit to see if their rooms were also effected by not having the audible part of the system as designed. Interview and observation on 1/17/20 at 12:00 p.m. with Staff C revealed none of the resident rooms on the whole unit rooms (20, 21, 22, 23, 24, and 25) audible part worked. Staff C had been aware that the bells were not working. While testing the audible portion of the call system was that the light above room [ROOM NUMBER] did not work nor did the light at the nurse's station",2020-09-01
598,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2019-02-15,580,D,0,1,JCM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy and procedure and record review it was determined that the facility failed to notify the physician of 1 resident that developed a pressure ulcer out of a final survey sample of 12 residents. (Resident Identifier is #26.) Findings include: Observation on 2/13/19 at approximately 11:00 a.m. of Resident #26's coccyx with Staff D LNA (Licensed Nursing Assistant) revealed that Resident #26 had a duoderm (dressing) applied to area on coccyx. Duoderm had an application date written on it of 2/11/19. Interview on 2/13/19 at approximately 11:15 a.m. with Staff C RN Registered Nurse) revealed that the duoderm dressing was due to be changed on 2/15/19. Review on 2/15/19 of Resident #26's (MONTH) treatment record revealed that there was no physicians order for a duoderm to Resident #26's coccyx. February's treatment record revealed that from 2/1/19 through 2/13/19 there had not been any treatment orders for the coccyx area. Interview on 2/15/19 at approximately 9:00 a.m. with Staff A (Director of Nurses) revealed that Resident #26 has had a chronic split to coccyx since admission 2/12/15 and that the split was not pressure. Staff A also revealed that a physician had not seen the area on Resident #26's coccyx since 11/17/15 and that there had been no facility monitoring of the slit area to coccyx since 8/14/18. Observation on 2/15/19 at approximately 10:00 a.m. of Resident #26's coccyx revealed an unstageable pressure ulcer measuring 3.0 cm (centimeter) x 0.5 cm and a depth of 0.5 cm with slough surrounding a black eschar center approximately 0.2 cm x 0.2 cm. Interview on 2/15/19 at approximately 10:00 a.m. with Staff B LPN (Licensed Practical Nurse) revealed the following statement, This is the worst I have ever seen it. I think that the duoderm caused more harm than good, it seems to have removed a layer of skin when it was removed. Interview on 2/15/19 at approximately 10:30 a.m. with Staff A revealed, We should have been coding this as unstageable. I think this would be a Stage 4 pressure ulcer. Staff A confirmed the area had black eschar in the center of the wound. When asked if the area to Resident #26's coccyx was being treated, Staff A stated, (pronoun omitted) was care and comfort. Staff A confirmed that the physician had not been notified of the split on Resident #6's coccyx changing to a pressure ulcer. Review on 2/15/19 of Resident #26's skin condition tracking report sheets revealed that the last time it was measured and assessed was on 8/14/18 by nursing staff. On 8/14/18 the wound measured at 1.0 cm x 0.4 cm (no depth measured.) Description of wound was no change, open slit. The facility had no documentation of when the area on Resident #26's coccyx went from a baseline slit to a pressure ulcer. Review on 2/15/19 of the facility policy and procedure for pressure ulcers, (not titled and not dated) revealed the following: . Pressure ulcer injuries are described as: . Unstageable: Full-thickness loss. The base of the ulcer is covered by slough which can be yellow, tan, gray, green or brown in color and/or eschar which can be tan, brown or black in color in the wound bed Policy: [NAME]sboro House shall have a system in place that assures assessments are timely and appropriate; interventions are implemented, monitored and revised as appropriate; and changes in condition are recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals (i.e , wound nurse) as appropriate. Procedure: . Nursing Staff Shall: Observe for infection . Follow practitioner's orders for treatment (if any) of the pressure ulcer (injury), including cleansing and dressing. Monitor the healing process Observe and change dressings as ordered and needed. Monitoring of Pressure Ulcer (Injury) Shall Include: . The pressure ulcer (injury) wound shall be assessed and documented (this is usually performed by a physician, advanced practice nurse, physician assistant, certified wound care specialist.) The assessment will mandate what further treatment, in the judgement of the physician, is necessary and appropriate Documentation: When a physician has ordered treatment for [REDACTED]. Documentation shall include a combination of . Size of the pressure ulcer (length and width) The depth: base of wound to skin in centimeters Exudate: type, amount, color and odor Stage 1-4, Unstageable, Deep Tissue Injury . Tissue type: necrotic, granulation, slough, epithelization Condition of skin around the pressure ulcer (injury) Note any change in the condition or size of the ulcer (injury). Changes shall be documented in the medical record",2020-09-01
599,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2019-02-15,656,D,0,1,JCM911,"Based on record review and interview, it was determined that the facility failed to develop and implement a comprehensive pain care plan for 1 resident out of a final survey sample of 12 residents. (Resident identifier is #26.) Findings include: Review on 2/14/19 of Resident #26's (MONTH) 2019 Medication Administration Record [REDACTED]. The review of the MAR indicated [REDACTED]. Review on 2/14/19 of a form titled, Record of Interdisciplinary Care Plan Meeting which was dated 2/6/19, revealed the following note: Continue comfort care, continue support of repositioning + turning, no new skin issues - pain well controlled. Review on 2/14/19 of Resident #26's current care plans revealed that Resident #26 did not have a care plan in place for pain. Interview on 2/14/19 at approximately 12:40 p.m. with Staff A (Director of Nursing) confirmed that there was no pain care plan for Resident #26. Observation on 2/13/19 at approximately 10:30 a.m. in Resident #26's room revealed that Resident #26 was moaning out loud. Interview on 2/13/19 at approximately 10:30 a.m. with Resident #26 revealed that Resident #26 was in pain stating, My butt is burning.",2020-09-01
600,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2019-02-15,686,G,0,1,JCM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility policy and procedure review and record review it was determined that the facility failed to provide necessary treatment to prevent development/progression of a non-pressure ulcer lesion to an unstagable pressure ulcer and failed to assess a pressure ulcer for 1 resident out of a final survey sample of 12 residents. (Resident identifier is #26.) Findings include: Observation on 2/13/19 at approximately 10:30 a.m. in Resident #26's room revealed that Resident #26 was moaning out loud. Interview on 2/13/19 at approximately 10:30 a.m. with Resident #26 revealed that Resident #26 was in pain stating, My butt is burning. Observation on 2/13/19 at approximately 11:00 a.m. of Resident #26's coccyx with Staff D LNA (Licensed Nursing Assistant) revealed that Resident #26 had a duoderm (dressing) applied to area on coccyx. Duoderm had an application date written on it of 2/11/19. Interview on 2/13/19 at approximately 11:15 a.m. with Staff C, RN (Registered Nurse) revealed that the duoderm dressing was due to be changed on 2/15/19. Review on 2/15/19 of Resident #26's (MONTH) treatment record revealed that there was no physicians order for a duoderm to Resident #26's coccyx. February's treatment record revealed that from 2/1/19 through 2/13/19 there had not been any treatment applied to the coccyx area. Interview on 2/15/19 at approximately 9:00 a.m. with Staff A (Director of Nurses) revealed that Resident #26 has had a chronic split to coccyx since admission 2/12/15 and that the split was not pressure. Staff A also revealed that a physician had not seen the area on Resident #26's coccyx since 11/17/15 and that there had been no facility monitoring of the slit area to coccyx since 8/14/18. Observation on 2/15/19 at approximately 10:00 a.m. of Resident #26's coccyx revealed an unstageable pressure ulcer measuring 3.0 cm (centimeter) x 0.5 cm and a depth of 0.5 cm with slough surrounding a black eschar center approximately 0.2 cm x 0.2 cm. Interview on 2/15/19 at approximately 10:00 a.m. with Staff B revealed the following statement, This is the worst I have ever seen it. I think that the duoderm caused more harm than good, it seems to have removed a layer of skin when it was removed. Interview on 2/15/19 at approximately 10:30 a.m. with Staff A revealed, We should have been coding this as unstageable. I think this would be a Stage 4 pressure ulcer. Staff A confirmed the area had black eschar in the center of the wound. When asked if the area to Resident #26's coccyx was being treated, Staff A stated, (pronoun omitted) was care and comfort. Review on 2/15/19 of Resident #26's skin condition tracking report sheets revealed that the last time it was measured and assessed was on 8/14/18. On 8/14/18 the wound measured at 1.0 cm x 0.4 cm (no depth measured.) Description of wound was no change, open slit. The facility had no documentation of when the area on Resident #26's coccyx went from a baseline slit to a pressure ulcer. Review on 2/15/19 of the facility policy and procedure for pressure ulcers, (not titled and not dated) revealed the following: . Pressure ulcer injuries are described as: .Unstageable: Full-thickness loss. The base of the ulcer is covered by slough which can be yellow, tan, gray, green or brown in color and/or eschar which can be tan, brown or black in color in the wound bed Policy: [NAME]sboro House shall have a system in place that assures assessments are timely and appropriate; interventions are implemented, monitored and revised as appropriate; and changes in condition are recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals (i.e , wound nurse) as appropriate. Procedure: . Nursing Staff Shall: Observe for infection . Follow practitioner's orders for treatment (if any) of the pressure ulcer (injury), including cleansing and dressing. Monitor the healing process Observe and change dressings as ordered and needed. Monitoring of Pressure Ulcer (Injury) Shall Include: . The pressure ulcer (injury) wound shall be assessed and documented (this is usually performed by a physician, advanced practice nurse, physician assistant, certified wound care specialist.) The assessment will mandate what further treatment, in the judgement of the physician, is necessary and appropriate Documentation: When a physician has ordered treatment for [REDACTED]. Documentation shall include a combination of . Size of the pressure ulcer (length and width) The depth: base of wound to skin in centimeters Exudate: type, amount, color and odor Stage 1-4, Unstageable, Deep Tissue Injury . Tissue type: necrotic, granulation, slough, epithelization Condition of skin around the pressure ulcer (injury) Note any change in the condition or size of the ulcer (injury). Changes shall be documented in the medical record Review on 2/15/19 of the facility policy and procedure for physician orders, (not titled and not dated) revealed the following: Policy: Orders for residential treatment and medications, including the administration of medications, shall be carried out only when given by a qualified physician, surgeon, dentist, podiatrist or other person duly licensed or authorized to prescribe by the state of New Hampshire and who has been approved as a member of the medical staff of this facility. All orders of medication and treatment shall be written into the medical record of the resident and signed by the ordering licensed independent practitioner.",2020-09-01
601,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2019-02-15,761,D,0,1,JCM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to remove expired medications from 1 of 1 medication cart. (Resident identifier is #27.) Findings include: Observation on 2/13/19 at approximately 12:10 p.m. during review of medication storage and medication labeling of pharmaceuticals within the medication cart revealed the following expired medications: [REDACTED] [MEDICATION NAME] - dispensed on 5/16/16 and an expiration date of 1/19 (month/year), [MEDICATION NAME] Syrup 5 mg (milligrams) per 5 ml (milliliters) 270 ml left in the bottle and an expiration date of 1/19, Calcium Antacid - dispensed on 10/12/18 a hand written lot # and expiration date of 10-18, Milk Of Magnesia - Dispensed on 5/31/17 and an expiration date of 10/18, Milk Of Magnesia - Dispensed on 7/5/17 and an expiration date of 10/18, Mucous + Chest liquid 100 mg per 5 ml - an expiration date of 11/18, [MEDICATION NAME] topical cream 100,000 u (units) per gm (gram) and an expiration date of 12/18, [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 3 mg - twenty five 3 ml tubes with an expiration date of 12/18, [MEDICATION NAME] cream 100,000 u per gm - Dispensed on 5/1/17 and expiration date that was no longer legible, [MEDICATION NAME] Ointment with an expiration date of 11/18. Interview on 2/13/19 at approximately 15:15 p.m. with Staff C (Registered Nurse) confirmed the expiration of the above listed medications. Resident #27 Observation on 2/13/19 at approximately 11:45 a.m. during medication pass with Staff C (Registered Nurse) revealed that Resident #27 had a medication card of [MEDICATION NAME] 10MG (Milligrams) with an expiration date of 2/8/19 in the medication cart. Interview on 2/13/19 at approximately 11:45 a.m. with Staff C revealed that Staff has been administering the Oxcodone as ordered from the medication card with the expiration date of 2/8/19. Review on 2/13/19 at approximately 12:30 p.m. of the narcotic book revealed that from 2/8/19 through 2/13/19 Resident #27 was administered 42 doses of [MEDICATION NAME] from that medication card with an expiration date of 2/8/19.",2020-09-01
602,SULLIVAN COUNTY HEALTH CARE,305093,5 NURSING HOME DRIVE,UNITY,NH,3743,2017-11-16,282,G,1,0,GN8E11,"> Based on interview and record review, it was determined that the facility failed to provide the necessary transfer services outlined in a resident's care plan which resulted in harm for 1 resident who sustained fractures to their face for 1 resident reviewed. (Resident identifier is #1.) Findings include: Review on 11/16/17 of Resident #1's care plan revealed an intervention dated 8/28/17 Two assist for transfers . Review on 11/16/17 of Resident #1's care plan revealed an intervention dated 8/31/17 2 assist with bed mobility. Use Hoyer (mechanical lift) . Review on 11/16/17 of the facility's Incident/Accident Investigation report, dated 9/15/17 revealed that Resident #1's care plan had been updated on 8/31/17 with Resident #1's transfer status of 2 assist and a mechanical lift for all transfers but that the Kiosk used by LNA's (Licensed Nursing Assistants) and the LNA tickets had not been updated with this new information. Review on 11/16/17 of the facility's Incident/Accident Investigation report, dated 9/15/17 revealed that on 9/8/17, Staff A (Licensed Nursing Assistant) transferred Resident #1 without the use of a mechanical lift and without the assistance of another staff member. During this transfer, Staff A lost balance and Resident #1's head hit a Broda chair resulting in fractures to Resident #1's right maxillary sinuses, orbital wall and an oblique fracture to the anterior inferior C2 (Cervical 2) vertebral body. Interview on 11/16/17 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that Staff A did transfer Resident #1 on 9/8 /17 without the use of a mechanical lift and without having a second staff member for assistance.",2020-09-01
603,SULLIVAN COUNTY HEALTH CARE,305093,5 NURSING HOME DRIVE,UNITY,NH,3743,2017-11-16,514,D,1,0,GN8E11,"> Based on interview and record review, it was determined that the facility failed to ensure accurate documentation of the transfer assistance given to a resident for 1 resident reviewed. (Resident identifier is #1.) Findings include: Review on 11/16/17 of Resident #1's Departmental Notes, dated 8/31/17 revealed that Resident #1 .is transferred with two assist .(Resident #1) requires extensive to total assist of two for bed mobility . Review on 11/16/17 of the facility's Incident/Accident Investigation report, dated 9/15/17 revealed that Staff A (Licensed Nursing Assistant) transferred Resident #1 without the use of a mechanical lift and without the assistance of another staff member. During this transfer, Staff A lost balance and Resident #1's head hit a Broda chair resulting in injuries. Review on 11/16/17 of the facility's Incident/Accident Investigation report, dated 9/15/17 revealed that Staff A .admitted that (Staff A) had been transferring (Resident #1) as a stand pivot with a gait belt for quite some time .(Staff A) has been signing off in the kiosks a two person stand pivot with gait belt, (Staff A) admits (Staff A) was not reading what (Staff A) was signing off . Interview on 11/16/17 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that Staff A did admit to incorrect documentation of the transfers of Resident #1.",2020-09-01
604,MORRISON NURSING HOME,305094,6 TERRACE STREET,WHITEFIELD,NH,3598,2018-10-23,550,B,0,1,U0XQ11,Based on Resident Council interview and a staff interview it was determined that the facility failed to find out whether there were residents who wanted to exercise their right to vote during New Hampshire's 9/11/18 primary or to offer any assistance to residents towards enabling them to participate in this election. Finding include: Four of five residents present during a 10/19/18 Resident Council interview stated that they would have voted in the New Hampshire Primary on 9/11/18 but said that the facility failed to assist them in exercising their right to for this election. Interview on 10/19/18 with Staff A (Activity Director) reviewed the above findings and Staff A confirmed that no resident was asked if they wanted to vote in the New Hampshire primary on 9/11/18.,2020-09-01
605,MORRISON NURSING HOME,305094,6 TERRACE STREET,WHITEFIELD,NH,3598,2017-12-07,812,C,0,1,GRSG11,"Based on observation and interview, it was determined that the facility failed to maintain the facility's walk-in refrigerator in good repair so as to ensure a sanitary environment. Findings include: Observation on 12/4/17 at 10:15 a.m. during the initial tour of the kitchen revealed that the floor in the walk-in refrigerator was rusted and pitted causing the surface to be unable to be cleaned completely. Interview on 12/4/17 at approximately 10:15 a.m. with Staff A (Food Director) reviewed the above findings and Staff confirmed that the floor of the walk-in refrigerator could not be completely cleaned due to the condition of the surface.",2020-09-01
606,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2020-02-14,623,B,0,1,IF3311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to provide written notice of transfer or discharge for 2 of 2 residents reviewed for discharge in a survey sample of 18 residents. (Resident identifiers are #56 and #59.) Findings include: Resident #59 Review on 2/14/20 at approximately 11:27 a.m. of Resident #59's progress notes revealed that Resident #59 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Further review of the medical record revealed no notice of transfer or discharge. Interview on 2/14/20 at approximately 12:43 p.m. with Staff A (Social Worker) confirmed that the facility did not provide a notice of transfer or discharge to Resident #59 upon discharge from the facility. Resident #56 Review on 2/13/20 of Resident #56's electronic demographic information and [DIAGNOSES REDACTED].#56 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review on 2/13/20 of Resident #56's Progress Notes dated 1/6/20 at 12:41 p.m. revealed Resident #56 was sent to a wound clinic appointment at 10:30 a.m. Further review of this note read, in part, .Wound Clinic did call this facility, at approximately at 12:30, and stated that they were transferring this resident to (hospital), for further eval. (evaluation) Resident's (family member) is with resident, and is aware of the transfer . Review on 2/13/20 of Resident #56's progress notes dated 1/7/20 at 3:13 p.m. revealed the resident was admitted to a local hospital. Review on 2/13/20 of Resident #56's medical record revealed there was no documentation that the facility notified the resident's representative of the transfer in writing or that the Office of the State Long-Term Care Ombudsman's office had been sent a copy of the notice of transfer. Interview on 2/13/20 at 2:30 p.m. with Staff B (Unit Manager) confirmed that there was no documentation in Resident #56's medical record that the Transfer/Discharge forms had been completed or that the Ombudsman's office had been notified of the transfer. Review of the facility's undated Hospital Transfer Checkoff List revealed the following instructions . 8. Complete and send the original notice of transfer with the resident, faxing a copy to the LTC Ombudsman. At the bottom of this check off list were instructions in red font to fax the notice of transfer to the Ombudsman's office immediately at time of transfer and to make sure to document this in the nursing note.",2020-09-01
607,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2020-02-14,658,D,0,1,IF3311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that there was a physicians order for [MEDICAL TREATMENT] for 1 out of 1 residents reviewed on [MEDICAL TREATMENT] and that physician's orders were clarified for 1 out of 3 residents reviewed for unnecessary medications out of a survey sample of 18 residents reviewed. (Resident identifiers are #15 and #57.) [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Resident #57 Review on 2/13/20 of Resident #57's (MONTH) Medication Administration Record [REDACTED] Trazadone HCL ([MEDICATION NAME] acid) 50 mg (milligram) 0.5 tablet via PEG (Percutaneous Endoscopic Gastrostromy) tube every 8 hours as needed for agitation, restlessness for 46 days. [MEDICATION NAME] tablet 0.5 mg ([MEDICATION NAME]) Give 1 tablet via [DEVICE] (Gastrostomy) every 4 hours as needed for anxiety/restlessness for 90 days. [MEDICATION NAME] tablet give 1 mg via [DEVICE] every 4 hours as needed for agitation/hallucinations. Interview on 2/14/20 at approximately 2:45 p.m. with Staff [NAME] (Licensed Practical Nurse) and Staff B (Unit Manager) both revealed that it would be at the nurse's discretion as to what medication to utilize. Resident #15 Interview on 2/12/20 at approximately 9:00 a.m. with Staff B UM (Unit Manager) revealed Resident #15 went to [MEDICAL TREATMENT] three times a week. Review on 2/12/20 of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Interview on 2/12/20 at 1:35 p.m. with Resident #15 revealed he/she went to [MEDICAL TREATMENT] three times a week. Review on 2/12/20 of Resident #15's medical record revealed a Quarterly Minimum Data Set (an assessment completed by nursing homes to assess and plan care for patients) dated 12/1/19 had [MEDICAL TREATMENT] coded in section O0100J2 ([MEDICAL TREATMENT] While a Resident) in the affirmative. Further review of Resident #15's medical record revealed a care plan to go to [MEDICAL TREATMENT] three times a week. Review on 2/12/20 of Resident #15's physician's orders revealed there was no physician's order to go to [MEDICAL TREATMENT]. Interview on 2/13/20 at 3:30 p.m. with Staff B, UM (Unit Manager) confirmed that Resident #15 went to [MEDICAL TREATMENT] three times a week. Staff B reviewed Resident #15's medical record and could not locate a physician's order for transport to [MEDICAL TREATMENT]. Staff B indicated that Resident #15 had been going to [MEDICAL TREATMENT] for years and was not sure what happened to the physician's order.",2020-09-01
608,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2020-02-14,726,F,0,1,IF3311,"Based on interview, record review, and observation, it was determined that the facility failed to ensure that licensed nurses have demonstrated competencies in skills necessary to care for resident's needs. Findings include: Review on 2/14/20 of the Facility Assessment revealed under section II titled Staffing, Training, Services, & Personnel to refer to section C.1. for information on staff competencies. Section C.1. referred to a document titled Staff training and competency program for the necessary competencies. Interview on 2/14/20 with Staff C (Director of Nursing) confirmed that the facility did not have documentation to show that licensed nurses have demonstrated competencies, and were not following the document outlined in the facility assessment titled Staff training and competency program. Staff C stated that the facility has developed a competency program; however, it has not yet been implemented. Observation on 2/14/20 at 10:40 a.m. of Staff [NAME] (Charge Nurse) performing wound care to Resident #28's right lower leg revealed concerns with professional standards of practice by not following the facility's policies and procedures for wound care. (Refer F880) Interview on 2/14/20 at 12:45 p.m. with Staff [NAME] revealed Staff [NAME] could not recall when he/she had last had a skills check for wound care.",2020-09-01
609,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2020-02-14,727,F,0,1,IF3311,"Based on interview and review of the facility daily nursing schedules, it was determined that the facility failed to ensure that a registered nurse was on duty for 8 consecutive hours a day 7 days a week. Findings include: Review on 2/13/20 of the facility daily staffing on weekends from 1/4/20 through 2/9/20 revealed that there was no registered nurse scheduled to be on duty for Saturdays and Sundays. Interview on 2/13/20 at approximately 4:00 p.m. with Staff D (Administrator), and Staff C (Director of Nursing) confirmed that there is no registered nurse on duty on the weekends.",2020-09-01
610,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2020-02-14,758,D,0,1,IF3311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of interview and record review, it was determined that the facility failed to adequately monitor the use of antipsychotic medications for 1 resident in a survey sample of 18 residents. (Resident identifier is #49.) Findings include: Review on 2/12/20 of Resident #49's medical record revealed a physician's orders [REDACTED]. Review of Resident #49's Medication Administration Record [REDACTED]. Further review of Resident #49's medical record revealed that there was no Abnormal Involuntary Movement Scale (AIMS) assessment done to monitor for side effects from the use of antipsychotic medication. Interview on 2/14/20 at approximately 12:17 p.m. with Staff C (Director of Nursing) confirmed that the facility uses the AIMS to monitor for side effects from the use of antipsychotic medication, and that there was no AIMS assessment completed for Resident #49.",2020-09-01
611,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2020-02-14,880,D,0,1,IF3311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain infection control practices in regards to hand hygiene during wound care in 1 out of 2 observations of wound care; and failed to use proper PPE (Personal Protective Equipment) to prevent the potential transmission of communicable diseases in 1 of 1 resident on contact precautions for a draining wound. (Resident identifier is #28.) Findings include: Resident #28 Interview on 2/12/20 at approximately 9:00 a.m. with Staff B UM (Unit Manager) revealed that Resident #28 was on contact precautions due to [MEDICAL CONDITION] (MRSA) to a right lower leg [MEDICAL CONDITION] wound. Staff B reported that only gloves were needed for precautions when touching the resident. Observation on 2/12/20 at 9:45 a.m. revealed a sign outside Resident #28's room alerting to see nurse before entering. There were isolation supplies of gowns and gloves noted outside of room in a plastic drawered container. Review on 2/13/20 of Resident #28's medical record revealed a laboratory result (with a collection date of 1/28/20) from a superficial wound to the right ankle. The results revealed heavy [MEDICAL CONDITION]. Continued review revealed a physician's orders [REDACTED]. Observation on 2/13/20 at 11:30 a.m. and at 3:15 p.m. revealed there was no longer isolation set up outside the room. Interview on 2/13/20 at 3:15 p.m. with Staff F (Charge Nurse) revealed that Staff F was the nurse responsible for Resident #28's care that day and Resident #28 was no longer on contact isolation precautions. Interview on 2/13/20 at 3:15 p.m., Staff B revealed Resident #28 was taken off contact precautions per the Nurse Practitioner on 2/12/20 in the morning; however, Staff B further stated the evening of 2/12/20 there was a new order to re-culture the wound due to drainage. Staff B stated Resident #28 was placed back on contact precautions the morning of 2/13/20, but the supply cart had not yet been placed outside the patient room. Staff B stated the facility does not obtain physician's orders [REDACTED].>Review on 2/13/20 of Resident #28's Nurses Note dated 2/12/20 at 9:54 read Call returned by Nurse Practitioner this a.m. new order to [MEDICAL CONDITION] precautions, [MEDICATION NAME] completed. No s/x (symptoms) of infection noted to wound lower right extremity. Review of the Nurses Note dated 2/12/20 at 13:30 read RLE (right lower extremity) draining large amounts of serous fluid MD notified of increased drainage . new treatment order in place. Review on 2/13/20 of Resident #28's Certified Physician Assistant (PA-C) 2/12/20 progress note revealed a [DIAGNOSES REDACTED]. Further review revealed a note to start on [MEDICATION NAME] (an antibiotic) for seven days, repeat bacterial culture and continue wound care. Review on 2/13/20 of Resident #28's physician's orders [REDACTED]. Review on 2/13/20 of Resident #28's physician's orders [REDACTED]. Review on 2/14/20 of Resident #28's Nurses Note dated 2/13/20 at 15:43 read late entry for 2/12/20. NP (nurse practitioner) in to assess resident wound on RLE. Noted to have redness and large amount of serous drainage on old dressing. Wound culture obtained per . order Observation on 2/14/20 at 10:40 a.m. of Staff [NAME] (Charge Nurse) performing wound care to Resident #28's right lower leg revealed Staff [NAME] brought in a plastic zippered bag with supplies into the room to use for the wound care. Staff [NAME] removed the soiled and yellow saturated dressing with gloved hands and scissors. Staff [NAME] stated that the dressing was heavy due to a lot of drainage. Without changing gloves or cleaning the scissors, Staff [NAME] reached into the plastic bag to remove supplies including gauze, tape and wound cleanser bottle. Staff [NAME] then sprayed the wound cleanser on the leg, cleaned the area with gauze, cut the xeroform dressing and applied it to the leg. Staff [NAME] then used the same scissors to cut the tape to secure the xeroform dressing with a gauze roll dressing. With the same gloved hands, Staff [NAME] removed a pen from his/her pants pocket, dated the dressing, and placed the pen back into the pocket. Staff [NAME] opened the plastic bag and placed the supplies back into the bag, including the bottle of wound cleanser and tape, and then placed the bag on the bed. Staff [NAME] then removed his/her gloves, washed their hands, picked up the dirty scissors and plastic bag without cleaning them and returned them to the bottom drawer of the medication cart in the hallway. Interview on 2/14/20 at 12:45 p.m., Staff [NAME] confirmed that he/she did not change gloves and wash hands after removing the soiled dressing. Staff [NAME] acknowledge that he/she then proceeded to touch the plastic bag, scissors, pen, and applied the new dressing with the soiled gloved hands. Staff [NAME] was not sure of what the facility's policy was for dressing changes and could not recall when he/she had been observed for a skills check for wound care. When asked what could happen to items that the plastic bag, scissors or pen had touch, Staff [NAME] responded that it could spread infection to others. Review on 2/14/20 of Resident #28's laboratory report for superficial wound culture collected on 2/12/20 at 17:30 from RLE skin revealed moderate [MEDICATION NAME] cells seen, gram positive cocci in pairs and in clusters. The culture and sensitivities were pending. Review on 2/14/20 of the facility's undated Transmission-Based Precautions reads, in part, Contact Precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharge from the body suggest an increased potential for extensive environmental contamination and risk of transmission Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment Review on 2/14/20 of the facility's policy and procedure titled Dressing, Clean dated (MONTH) 2012 revealed Procedure: . 6. Put on gloves. 7. Remove tape and soiled dressing gently . 9. Dispose of soiled dressing and gloves in plastic bag . 11. Wash hands. 12. Put on clean gloves. 13. Cleanse wound with prescribed solution . 17. Apply clean dressing and tape using the least amount of tape as possible",2020-09-01
612,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2019-02-22,635,B,0,1,5BCL11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure that there were complete admission physician orders for 1 Resident in a final sample of 18 Residents. (Resident identifier is #47.) Findings include: Review on 2/20/19 at approximately 9:18 a.m. of Resident #47's medical record revealed that Resident #47 was admitted to the facility on [DATE] on hospice care for a [DIAGNOSES REDACTED]. Review of the physician's orders for admission to the facility on [DATE] revealed no physician order for [REDACTED].>Interview on 2/22/19 at approximately 1:52 p.m. with Staff A (Director of Nursing) confirmed that the facility did not obtain a physcian's order for hospice.,2020-09-01
613,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2019-02-22,645,B,0,1,5BCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that PASRR (Preadmission Screening and Resident Review) screening was accurately done for 2 residents in a final sample of 18 residents. (Resident identifiers are #23 and #53.) Findings include: Resident #23 Review on 2/22/19 at approximately 1:27 p.m. of Resident #23's medical record [DIAGNOSES REDACTED].#23 has a primary [DIAGNOSES REDACTED].#23's PASRR (Pre-admission Screening and Resident Review) dated 7/24/13 revealed that question #1 in Section II titled PASRR Level I Screening for Mental Illness (MI) was answered NO to indicate that Resident #23 does not have a [DIAGNOSES REDACTED]. Interview on 2/22/19 at approximately 2:00 p.m. with Staff C (Social Worker) confirmed that this question was answered incorrectly and that Resident #23 does have a [DIAGNOSES REDACTED]. Resident #53 Review on 2/22/19 at approximately 10:00 a.m. of Resident #53's medical record [DIAGNOSES REDACTED].#53 has a primary [DIAGNOSES REDACTED].#53's PASRR dated 7/7/17 revealed that Section 2 Screening for Mental Ilness (MI) sub-section 2A Has the individual been diagnosed with [REDACTED].? the box that indicates No was checked. Interview on 2/22/19 at approximately 10:47 a.m. with Staff C (Social Worker) confirmed that Staff C is the person responsible for completing the PASRR and that Staff C marked the NO box indicating that Resident #53 did not have a [DIAGNOSES REDACTED].",2020-09-01
614,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2019-12-19,609,E,1,0,JNOY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review and interview it was determined that the facility failed to report to the State Survey Agency and thoroughly investigate an alleged drug diversions in a timely manner. Findings include: Review on 12/18/19 of the facility policy title Abuse Prevention Program-Reporting and Response with a revision date of 1/1/19 reveals the following: that all personnel must promptly report any incident or suspected incident of resident abuse, including injuries of an unknown source and misappropriate(sic) of resident property. The Center will conduct a thorough investigation of all reports . 3. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source or abuse is reported, the facility administrator, or his/her designee, will notify Long Term Care Ombudsman and DHHS (not later then 2 hours). The center will also notify the resident's representative and physician. Review on 12/18/19 of the Board of Nursing (BON) Complaint Form dated 4/15/19 written by Staff F (Director of Nurses (DON)) revealed that Staff H (Licensed Practical Nurse (LPN)), had the following alleged complaint registered against Staff H. The complaint form revealed that Staff H had signed for a medication delivery slip from the pharmacy for five [MEDICATION NAME]es, however the [MEDICATION NAME]es were not signed into the narcotic book and were unable to be found after multiple searches. The BON report revealed the local police department and the Ombudsman received the same complaint. A response letter to the Administrative Prosecutions Unit written by Staff F was written on 4/25/19 revealed that local police has not been in touch with anyone since the original report. The original patch was due to be changed on 4/11/19 at 6 p.m. and the nurse was unable to do so. A call to the pharmacy determined a delivery had been made on 4/8/19 and the [MEDICATION NAME]es should have been available. Further review on 12/18/19 of the incident report revealed that Staff H received re-education on policy and procedure regarding narcotic documentation and was later terminated. Review on 12/18/19 a typed written statement dated 4/14/19 from Staff H to Staff F indicated that Staff H does not recall signing for medication because sometimes the medication can be in a gray bag within the clear bag. From Staff H understanding the medication was delivered around 9 p.m. and a lot is going on at that time. Review on 12/18/19 a shipping manifest dated 4/8/19 at 7:14 p.m. that Staff H signed for a delivery that had 5 [MEDICATION NAME]es within it. Phone interview on 12/24/19 at approximately 10:45 a.m. to the Ombudsman revealed that the Ombudsman did not received any notification of missing [MEDICATION NAME]es from the facility in (MONTH) 2019. Interview on 12/19/19 at approximately 11:45 a.m. with Staff D (Confidential employee) revealed that Staff D had brought concerns of drug diversion taking place at the facility in (MONTH) 2019 to Staff C (Unit Manager). This has been going on for a while and no one has done anything about it. Counts are off, [MEDICATION NAME] bottles smell different and appear to be tampered with. Interview on 12/18/19 at approximately 10:45 a.m. with Staff B (Assistant Director of Nurses) revealed that different staff members began coming to Staff B over the last week or two with concerns of drug diversion. Interview on 12/19/19 at approximately 11:00 a.m. with Staff [NAME] (Administrator) revealed that there was no investigation done on the concerns of drug diversion. Staff [NAME] confirmed that the concerns of drug diversion had not been reported to the State Survey Agency.",2020-09-01
615,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2019-12-19,726,D,1,0,JNOY11,"> Based on interview and record review it was determined that the facility failed to provide education on a continuous glucose monitoring device for 1 out of 1 resident's reviewed with this device. (Resident identifier is #1.) Findings include Review on 12/19/19 of Resident #1's medical record revealed that Resident #1 returned to the facility from an Endocrinologist appointment on 6/28/19 with a continuous glucose monitoring system. Resident #1 utilized this device in the facility from 6/28/19 until 8/15/19 in the MAR (Medication Administration Record). Interview on 12/19/19 at approximately 11:00 a.m. with Staff A (Licensed Practical Nurse) revealed that Staff A did not receive any training or education regarding the new continuous glucose monitoring device. Interview on 12/19/19 at 11:30 a.m. with Staff B (Assisted Director of Nurses) revealed that there had not been any education provided to any staff with the continuous glucose monitoring device. Staff B also stated that there were no manufacturer's instructions available at the facility, no policy and procedure for the continuous glucose monitoring device. Review on 12/19/19 of Resident #1's care plans during the time period of 6/28/19 thru 8/15/9 revealed that there was no care plan for the continuous glucose monitoring device.",2020-09-01
616,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2019-12-19,755,E,1,0,JNOY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility has failed to promptly identify the loss of controlled medications and maintain accurate physical account of narcotics in the facility for 5 out of 5 narcotic books,1 out of 1 narcotic destruction log book. Findings include: Interview on 12/19/19 with Staff D (Confidential employee) and Staff G (Confidential employee) revealed that when they are passing medication Staff F (Director of Nurses) would tell them to take a break or go do your mandatory training etc . and that Staff F would manage their medication carts but would not sign in to the Shift count form. Then by the end of the day when count would occur the liquid [MEDICATION NAME] would be off. Interview with several Staff members including Staff [NAME] (Administrator) revealed that Staff F would come in all the time at night between 11 p.m. and 7 a.m. relieve staff by working on a medication cart for about an hour and never sign in or out of the medication cart. Interview on 12/19/19 at 12:30 p.m. with Staff D revealed I was passing medication on one medication cart when (Staff F) came up and took over another medication cart next to me, (Staff F) would always have a lab coat on when they took over a mediation cart, this time I saw (Staff F) enter the narcotic box remove a bottle of [MEDICATION NAME] and remove a syringe from the cart, left the cart and went to the bathroom and returned to the cart. Review on 12/18/19 and 12/19/19 of Narcotic book #17 revealed the following: Resident #2 On 1/27/19 at 6:00 a.m. the [MEDICATION NAME] 20 mg/ml (milligram/milliliters) count was 2.5 ml. On 1/27/19 at 7:00 a.m. the count was corrected to the actual amount of 0.5 ml of [MEDICATION NAME]. On 1/27/19 at 7:00 p.m. 0.5 ml of [MEDICATION NAME] was wasted, count 0 ml. Resident #4 On 2/2/19 Resident #4 showed 64.75 ml of [MEDICATION NAME] (100 mg/5 ml). Staff F transferred the medications from page 34 to page 35 with only one signature (Staff F signature). Staff F wrote on 2/2/19 at 9:45 a.m. transferred from page 34 book #17 amount left 4.75 ml. On 2/4/19 at 8:50 a.m. the amount left was 1.50 ml and on 2/4/19 at 12:50 p.m. the count was adjusted R/T (Related to) evaporation unable to pull dose, count 0 ml, signed by Staff F. During interview on 12/19/19 with Staff F, Staff F was asked what happened to the above 60 ml of [MEDICATION NAME] not accounted for after transferring it from page 34 - page 35. Staff F stated I do not know what happened. What do you think? I do know that I have not diverted any medications. On 3/28/19 at 10:50 p.m., 2.0 mls of [MEDICATION NAME] 100 mg/5 ml was recorded, then wasted 2 ml with no date or time with [MEDICATION NAME] 0 ml recorded. On 4/26/19 at 8:40 p.m. 1 ml of [MEDICATION NAME] 100 mg/5 ml was recorded. On 4/27/19 at 12:15 a.m., 1 ml [MEDICATION NAME] (no reason indicated) was wasted to 0 ml. On 5/31/19 at 12:01 a.m. the count was 0 ml. On 5/31/19 at 12:01 a.m. there was a note stating bottle removed from med cart and given to (Staff [NAME] Administrator) at 8:53 a.m. Interview with Staff [NAME] on 12/18/19 at approximately 12:30 p.m. revealed staff thought the bottle smelled like cough syrup or had been tampered with. Staff [NAME] said the pharmacy had seen the [MEDICATION NAME] bottle and the pharmacy thought there were not issues with the bottle. Review on 12/19/19 of Narcotic book #21 revealed the following: Resident #2 On page 26, Resident #2 had an order ([MEDICATION NAME] 100 mg/5 ml Directions 1 ml SL (Sublingual) every four hours as needed for pain). On 8/21/19 at 12:00 p.m. showed 5 ml left and at 3:15 p.m. that same day showed 1 ml with a note stating count corrected. On 8/22/19, medication discontinued and signed by Staff F. Resident #6 On page 28, showed on 8/2/19 [MEDICATION NAME] 20 mg/ml transferred from page #15 amount left was 50.5 ml. On 8/2/19 at 1:14 p.m. revealed an amount used .25 ml and the amount left was 50.25 ml and it was discontinued. When the medication was logged into the narcotic destruction log book on 8/2/19 it showed 56.25 ml. On 9/20/19 at 3:05 a.m. 1.50 ml of [MEDICATION NAME] 20 mg/ml was recorded. On 9/20/19 at 7:16 a.m. 1.50 ml of [MEDICATION NAME] was wasted (no reason). On 10/4/19 at 2:00 p.m. 4.0 mls of [MEDICATION NAME] 20 mg/ml was recorded. On 10/4/19 at 11:15 p.m. the count was adjusted down to 0 ml. Review on 12/19/19 of Narcotic book #24 revealed the following: On page #16 shows on 11/19/19 at 9:58 a.m. the amount of [MEDICATION NAME] 100 mg/5 ml recorded was 4.0 ml. When the medication was logged into the narcotic destruction log book on 11/20/19 it showed 5 ml. Review on 12/19/19 of Narcotic book #18 revealed the following: Resident #7 On 5/1/19 at 1:45 p.m. 1.0 ml of [MEDICATION NAME] 100 mg/5 ml was recorded. On 5/1/19 at 1:45 p.m. the count was adjusted with the reason end of bottle evaporation/spill. The count changed to 0 ml. Review on 12/18/19 of Narcotic Book #20 revealed the following: Resident #2 On 2/8/19 at 12:45 p.m. 3.75 ml's of [MEDICATION NAME] 20 mg/ml was recorded. On 2/8/19 at 1:30 p.m. the count was adjusted wasted related to evaporation and dosing syringe (count changed to 0 ml's). On 3/22/19 at 6:00 a.m. 52.75 ml's of [MEDICATION NAME] 100 mg/5 ml was recorded. On 3/22/19 at 7:30 a.m. recorded 40.00 ml's of [MEDICATION NAME] (dose adjusted related to spill due to no plunger med in bag/cap). Staff F did not have a co-signature for this count. On 3/27/19 at 5:40 a.m. 3.0 ml's of [MEDICATION NAME] 100 mg/5 ml was recorded. On 3/27/19 at (no time entered) the count was adjusted to 0 ml with plunger in bottle; end of bottle (count changed to 0 ml). On 4/5/19 at 4:35 a.m. 3.5 ml's of [MEDICATION NAME] 100 mg/5 ml was recorded. On 4/5/19 at 11:00 a.m. the dose was adjusted to 0 mls related to end of bottle. On 4/25/19 at 8:00 p.m. 6.5 ml's of [MEDICATION NAME] 100 mg/5 ml was recorded. On 4/25/19 at (no time entered) 6.5 ml's were wasted and count changed to 0 ml. On 4/30/19 2:00 a.m. 2 ml's of [MEDICATION NAME] 2 mg/ml was recorded. On 4/30/19 at 8:45 a.m. the count adjusted to 0 ml related to evaporation/leakage. Resident #3 On 2/12/19 at 7:10 p.m. 3.25 ml's of [MEDICATION NAME] was recorded (no dosage recorded). On 2/12/19 at (no time recorded). the off count was adjusted, related to end of bottle to 0 ml. On 3/27/19 at 10:00 a.m. 3.75 ml's of [MEDICATION NAME] 100 mg/5 ml was recorded. On 3/27/19 at 11:20 a.m. the dose was adjusted; count is zero/leaking/no [MEDICATION NAME]/end of bottle, count changed to 0 ml. Interview on 12/18/19 at approximately 1:45 p.m. with Staff [NAME] (Administrator) regarding the altered counts in the narcotic book revealed that Staff [NAME] had spoken to the pharmacy prior to this interview and that the [MEDICATION NAME] bottles that are sent to the facility do not have a long enough shelf life to have evaporation concerns. Interview on 12/18/19 at approximately 2:15 p.m. with Staff [NAME] revealed that there were no facility/pharmacy policy and procedures for Narcotic count adjusting. Review on 12/19/19 of the facility's policy and procedure titled, Disposal of Medications, Syringes and Needles, dated 12/12 revealed: Policy . 2. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center with federal and state laws and regulations. . Procedures . 2.b For the State of New Hampshire, these controlled substances shall be disposed of by the nursing care center in the presence of appropriately title professionals; Licensed nurse employed by the nursing care center and a pharmacist or one licensed nurse employed by the nursing center and one medication dispensing personal employed by the facility. Review on 12/18/19 at approximately 8:15 a.m. with Staff F in the medication room of the locked narcotic box of narcotics to be destroyed and to reconcile with the narcotic log book of narcotics to be destroyed revealed that the the following entry in the narcotic log book of narcotics to be destroyed was not in the narcotic box. Narcotic log book of narcotics to be destroyed read: 12/10/19 (pronoun omitted) drug MSO4 ([MEDICATION NAME] sulfate) 100 mg /2 ml. Interview on 12/18/19 at approximately 2:30 p.m. with Staff F revealed that the [MEDICATION NAME] sulfate was not there. Staff F stated, I am the only person with a key to this narcotic box in the medication room. Interview on 12/18/19 at approximately 2:30 p.m. with Staff [NAME] confirmed that Staff F was the only one with a key to the narcotic box of narcotics to be destroyed. Review of the bound narcotic log book of narcotics to be destroyed revealed that there was a page ripped out between the dates of 10/26/18 and 11/21/18. Interview on 12/18/19 at approximately 2:30 p.m. with Staff F revealed, I have no idea why that page is ripped out.",2020-09-01
617,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2017-05-23,241,B,0,1,4H4111,"Based on observation and interview, it was determined that the facility failed to ensure the resident's dignity and respect while rendering care to four out of sample residents during a medications pass and one resident in a survey sample of 10 residents. (Resident identifier's are #1, #12, #13, #16 and #17.) Findings include: Observation on 5/23/17 at approximately 8:05 a.m. during a medication pass with Staff H (Licensed Practical Nurse) revealed Staff H performed vital signs on Resident #16 in the resident restorative dining room with 5 other residents present. Staff H proceeded to administer nasal spray medication and multiple oral medications to Resident #16 at this time. Observation on 5/23/17 at approximately 8:35 a.m. with Staff H revealed Staff H returning to the resident restorative dining room with multiple residents seated at individual tables eating breakfast and administered multiple medications to Resident #17. Interview with Staff H at the time of the above listed findings revealed that vital signs and administration of multiple medications to two residents were done in the resident restorative dining room with other residents eating breakfast were present. Observation on 5/23/17 at approximately 8:30 a.m. of a dressing change with Staff A (Registered Nurse) on Resident #1 revealed that the dressing change was done in the resident's room without closing the privacy curtain or door. Resident #1's roommate and a housekeeper were present at the time of the dressing change. Observation on 5/23/17 at approximately 10:15 a.m. in the restorative dining room with Staff C (Licensed Nursing Assistant) was observed taking Resident #12's vital signs with 5 other residents present in the dining room. Observation on 5/23/17 at approximately 11:15 a.m. with Staff A (Registered Nurse) of Resident #13 of a CBG (Capillary Blood Glucose) test and an insulin injection being administered. The 2 observations were done without closing the resident's door or privacy curtain being pulled. The door to the hallway was open and resident was in view from the hallway.",2020-09-01
618,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2017-05-23,281,B,0,1,4H4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to follow the professional standards of practice for the administration of medications and failed to follow physician orders [REDACTED]. (Resident identifiers are #8 and #16.) Findings include: Reference for the professional standard of practice for medication documentation is: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009, which revealed the following: Chapter 23 Legal Implications in Nursing Practice page 336 and Chapter 35 Medication Administration on page 721. On page 336 - Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary. Page 721 O. Do not leave medications unattended. Reference for the standard of practice for medication disposal is the FDA Safe Disposal of Medicines, (YEAR)-06-08 Medicines play an important role in treating many conditions and diseases and when they are no longer needed it is important to dispose of them properly to help reduce harm from accidental exposure or intentional misuse . 1. Mix medicines (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds; . Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. Resident #16 Observation on 5/23/17 at approximately 8:00 a.m. during a medication pass with Staff H (Licensed Practical Nurse) revealed Staff H prepared the following medications, [MEDICATION NAME] 17 grams mixed in 8 ounces of fluid and [MEDICATION NAME] 40 mg (milligram) one tablet for Resident #16. Staff H proceeded to administer the [MEDICATION NAME] medication to Resident#16 who was seated for breakfast in the restorative dining room. Resident #16 did not completely drink the [MEDICATION NAME] medication. Staff H placed this cup on a side table in the restorative dining room where multiple residents were present eating breakfast. Staff H exited the restorative dining room leaving this [MEDICATION NAME] medication unattended and proceeded down the hallway to the medication cart to continue with the morning medication pass. Interview with Staff H at the time of this medication pass observation revealed that Staff H left the cup of [MEDICATION NAME] not finished and unattended in the restorative resident dining room. Resident #8 Review on 5/23/17 at approximately 11:00 a.m. of Medication Administration Record [REDACTED]. Review of PRN doses administered revealed that on 5/14/17 Resident #8 received 3 PRN doses in a 24 hour period of time. The doses were given at 1:00 a.m., 2:30 p.m., and at 8:00 p.m. Interview on 5/23/17 at approximately 3:30 p.m. with Staff B, RN (Registered Nurse) confirmed that the physician's orders [REDACTED].",2020-09-01
619,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2017-05-23,356,C,0,1,4H4111,"Based on observation and interview, it was determined that the facility failed to post the required data on daily basis. Findings include: Observation on 5/23/17 at approximately 10:00 a.m. of the nurse staffing data posted at the rear entrance to the facility revealed that the facility failed to include, the facility name, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift, Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, and the resident census. Interview on 5/23/17 at approximately 1:00 p.m. with Staff B (Registered Nurse) confirmed that the daily staffing that is posted had not included the required information.",2020-09-01
620,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2017-05-23,371,E,0,1,4H4111,"Based on observation, review of temperature logs, interview, and policy & procedure review it was determined that the facility failed to do the following: identify foodstuffs stored in the main storage refrigerator; properly date stored items in the main facility refrigerator; properly date stored items in the refrigerator in the kitchenette; provide documentation for the temperatures of the main storage refrigerator, main storage freezer, and the holding refrigerator located in the facility kitchen; and to provide documentation that the food stored in the steam tables at meal times was maintained at optimal temperatures prior to being served to residents. Findings include: Review on 5/23/17 of the facility policy for Health Shakes Handling and Storage (no date noted), under the heading . Imperial Nutritional Orange Drink .Imperial Health Shakes instructions are: Arrives Frozen to be stored Frozen Thaw and store under refrigeration at 40 degrees or below Use within 14 days after Thawing Review on 5/23/17 of the facility policy for Food Safety requirements-Use and storage of food and beverage brought in for residents, Food Procurement (no date noted) instructions are: Pg 1, paragraph 3 The food service workers, cooks, dietary aides, dishwashers, food prep aides, or any person(s) who are in the kitchen working with any type of food, are responsible for to adhere to the food safety requirements. Pg 1, paragraph 4, section B Danger Zone refers to temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause food borne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a food borne illness outbreak if consumed. Observation on 5/22/17 at 9:00 a.m., during the tour of the main kitchen refrigerator; revealed there was a cardboard box located on a mid-level shelf that had containers of health shakes and nutritional orange drink. There were no labels indicating when they had been removed from freezer storage or when they were to be consumed. On the top shelf of the refrigerator there was a tray of small, clear, covered containers filled with a dark substance. The containers lacked a date or any identification of the substance inside each container. Outside the kitchen refrigerator/freezer and the holding refrigerator a clipboard had temperature logs in which the temperatures of all three food storage areas was recorded in the [NAME]M. and the P.M. For the month of (MONTH) (YEAR) the log for the main refrigerator had temperatures recorded 35 entries of 60 possible entries; the log for the main freezer had temperatures recorded 35 entries of 60 possible entries; the log for the holding refrigerator had temperatures recorded 30 entries of 60 possible entries. The refrigerator located in the resident living area revealed containers health shakes and nutritional orange drink located in the bottom drawers that had no thaw by or use by date labels. Interview on 5/22/17 at 10:00 a. m. with Staff D (Dietary Services Director) revealed that the substance in the clear covered containers that was noted on the top shelf in the main refrigerator was fruitie; a substance made in the kitchen that was composed of prunes, raisins, dates, and a splash of orange juice. The substance was provided on all the meal trays to help residents with their bowel regularity. When questioned about the inconsistent recording of temperatures during the month of (MONTH) for the main refrigerator, freezer, and the holding refrigerator, Staff D replied that there were staff that did not carry out the requirements of the job and they either left or were terminated. When questioned about the logs for the food stored in the steam tables prior to being served to residents, Staff D replied that while the temperatures were being monitored, none were documented.",2020-09-01
621,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2017-05-23,441,D,0,1,4H4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, it was determined that the facility had failed to adhere to hand hygiene practices that are consistent with accepted standards of practice to be followed by staff involved in direct resident contact. (Resident identifiers are #1, #12 and #18.) Findings include: Observation on 5/23/17 at approximately 7:50 a.m. of medication pass revealed that Staff A, RN administered medications to Resident #12 and Resident #18 without any handwashing in between residents. Staff A was then observed at approximately 8:20 a.m. during an ordered dressing change with Resident #1. Staff A, did not perform any handwashing in between the prior medication administration and the dressing change. Staff A, entered room, knelt down on floor, removed gloves, took scissors out of right pocket of scrub top where Staff A had medication cart keys and gloves. Staff A applied gloves that were in right scrub top pocket. Staff A removed the old dressing and placed it on the floor. Staff then reached in right pocket of scrub top and applied another pair of gloves. Staff A finished the dressing change and put scissors in right scrub pocket without cleaning the scissors and discarded the old dressing in the trash along with the used gloves. Staff A proceeded out of the residents room without any handwashing. There was no red bag for discard of used dressing utilized during dressing change. Staff A was then approached by an LNA (Licensed Nursing Assistant) with a resident request for a pain medication. Staff A proceeded to the medication cart and obtained the medication without any handwashing. Review of the undated policy and procedure titled Dressing - Clean Technique on 5/23/17 at 10:00 a.m. revealed that under the procedure section Step 3. action is as follows: Wash hands before and after procedure and wear gloves. Step 4. Remove soiled dressing and discard into a red plastic bag. Interview on 5/23/17 at approximately 11:30 a.m. with Staff A confirmed that there was no handwashing in between residents and that the scissors and gloves were placed in the same pocket as the medication cart keys. Resident #16 Observation on 5/23/17 at approximately 8:05 a.m. in the resident restorative dining room with Staff H (Licensed Practical Nurse) revealed Staff H donned gloves and proceeded to administer [MEDICATION NAME] nasal spray medication one spray to each nostril to Resident #16. Staff H removed and discarded the gloves after administering the nasal spray. Staff H placed the nasal spray in her uniform pocket. No hand washing was done after removal of the gloves used for the nasal spray. Staff H proceeded to perform vital signs on Resident #16 in the resident restorative dining room. No handwashing was performed after taking these vital signs. Staff H proceeded to kneel down at the side of Resident #16's wheelchair to administer multiple medications with a spoon to Resident #16. During this medication administration, the nasal spray fell out of the uniform pocket onto the restorative dining room floor. Staff H picked the nasal spray up from the floor with one hand, replaced it into the uniform pocket and continued to administer the rest of the medications to Resident #16. Interview with Staff H at the time of the above listed findings revealed that handwashing was not done after discarding gloves used with the nasal spray administration, following the taking of vital signs, after picking up the nasal spray container from the floor and continuing to administration of medications to Resident #16. Observation on 5/22/17 at approximately 9:30 am; the refrigerator in the kitchenette located in the residents activity/dining room revealed a cold pack in the freezer section with no label. The two lower drawers in the refrigerator contained: in the left drawer, cartons of nutritional orange drink that had no use by date and in the right drawer cartons of health shakes with no use by dates. The bottom of the right drawer was highly soiled and the substance was gooey in nature. Interview on 5/22/17 after 10:00 am the same day Staff D (Director of Dietary Services),when asked if cleaning the refrigerator was a task of the Housekeeping Department, Staff D replied that it was the responsibility of dietary services to clean the kitchenette refrigerator.",2020-09-01
622,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2017-05-23,456,D,0,1,4H4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of manufacturer's recommendations, it was determined that the facility failed to maintain maintain essential equipment in safe operating condition. The facility failed to maintain a cleaning schedule of the hydroculator and temperatures per manufacturers instructions. Observation of 2 out of 2 oxygen concentrators during tour determined that the oxygen concentrators filters had not been cleaned . (Resident identifiers are #12, and #14.) Findings include: Observation on 5/22/17 at approximately 9:15 a.m. on North Unit tour with Staff A (Registered Nurse) revealed that Resident #12 and Resident #14's oxygen concentrator filters had a visible amount of white and grey dust and debris adhered to them. Interview on 5/22/17 at approximately 9:20 a.m. with Staff A stated that the oxygen filters were disgusting. Interview on 5/22/17 at approximately 10:30 a.m. with Staff B (Director of Nurses) revealed that housekeeping was responsible for vacuuming the concentrator filters weekly and had been educated. Observation on 5/22/17 at approximately 9:45 am, the [MEDICATION NAME] in the Physical Therapy(PT) area was warm, with a temperature reading of 160 degrees Fahrenheit (F), and contained items identified by unknown Physical Therapy (PT) staff as Hot Pacs. A review of the temperature logs revealed that in (MONTH) (YEAR), there were only 12 days out of 30 days that the water temperature was at the manufacturer's recommendation of 160 degrees F. Reviewing the log for (MONTH) of (YEAR), temperature was only documented on 11 days of 22 days. Further review of the logs for both months, it was documented that the unit was cleaned on 4/7/17. There was no other documentation either month that the unit was cleaned. The Hydroculator unit is identified as a SS-2 Model according to the operating instructions. On page 2, in the section labeled CAUTION, 2nd bullet-the thermostat is extremely sensitive and the slightest adjustment will alter the temperature several degrees. The recommended operating temperature is 160 degrees F. The temperature of the water should be checked with a thermometer after every adjustment, before using the Hot Pacs. Always allow sufficient time for the water to stabilize. Page marked as 18, in the section marked MAINTENANCE, under section CLEANING TIPS .the interior of the unit should be cleaned, usually every two weeks, using a low abrasive bathroom cleaner. Review of the facility policy and procedure titled MOIST HEAT, revised 5/4/17 under the section PR[NAME]EDURE, subsection UNIT, paragraph A-the moist heat unit ([MEDICATION NAME]) shall be checked each day of clinic operation: a-The unit should be maintained per manufacturer's recommendation between 160-165 degrees F. b-The temperature shall be logged in the Temperature Log Book. Under subsection labeled CLEANING, A-the unit shall be cleaned per manufacturer's recommendations.",2020-09-01
623,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2018-06-06,655,B,0,1,QYCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to develop and implement a baseline care plan for pressure ulcer prevention for one resident and for diuretic use for another resident, in a standard survey sample of 16 residents. (Resident identifiers are #2 and #280.) Findings include: Resident #2 Interview on 6/5/18 at approximately 11:00 a.m. with Resident #2 revealed that Resident #2 stated that they had a sore on their bottom. When asked how this occurred Resident #2 stated that it was because they sat in a chair for long periods of time and did not have a cushion. Resident #2 stated that they had a history of [REDACTED]. That area had healed, but it was for that reason that they sat on a cushion in their chair at home. They said that they wanted to bring the cushion in from home, but then some time after admission, the facility provided them with one. They said that they are not sure of the exact date. Review on 6/6/18 of Resident #2's Baseline Care Plan revealed that Resident #2 was admitted to the facility on [DATE]. Review of this care plan revealed that Resident #2's skin concerns were checked off as Skin intact and the areas for interventions, which were turn and reposition, specialty mattress, and cushions or wedges, were left unchecked. Review on 6/6/18 of Resident #2's nurse's note, dated 5/18/18, revealed a note which read .noted coccyx to be a little red . Review on 6/6/18 of Resident #2's Wound Assessment Report, dated 5/21/18, revealed that Resident #2 had a pressure ulcer on their sacrum, which was identified on 5/21/18. Review on 6/6/18 of Resident #2's Wound Assessment Report, dated 5/24/18, revealed that Resident #2 had a second Stage 2 pressure ulcer on their sacrum, above the original area, to the right of the sacrum on buttock, that was identified on 5/24/18. Review on 6/6/18 of Resident #2's Wound Assessment Report, dated 5/29/18, revealed that Resident #2 also had a Stage 2 pressure ulcer on their left buttock, that was identified on 5/29/18. Review on 6/6/18 of Resident #2's Altered Skin Integrity care plan, initiated on 5/21/18, revealed that on 5/21/18, Resident #2 had an open area on their sacrum to the right side, on 5/24/18 Resident #2 had a second open area on their right buttock, above the previous area, and on 5/29/18 Resident #2 had an open area on their left buttock. The review also revealed that there was no intervention for a pressure relieving cushion until 5/29/18, when it was hand written in. Review on 6/6/18 of the Facility's policy, titled Prevention of Pressure Ulcers, dated 11/17, revealed that the .General Preventive Measures .For a person in a chair: Use foam, gel or air cushion as indicated to relieve pressure . Interview on 6/6/18 at approximately 11:00 a.m. with Staff A (Licensed Practical Nurse) revealed that upon admission a chair cushion was not used for Resident #2. Staff A reported that nursing staff started using the cushion at the time when Resident #2's bottom started getting red. At that time, a chair cushion was initiated and a referral was made to Therapy for positioning. Interview on 6/6/18 at approximately 9:15 a.m. with Staff B (Registered Nurse) confirmed that Resident #2's care plan did not have an intervention for a pressure relieving cushion until 5/29/18 and that this intervention should have been on the care plan since Resident #2 was admitted . Resident #280 Observation on 6/5/18 at approximately 9:35 a.m. of Resident #280 revealed that Resident #280's lips appeared dry and cracked. There were no fluids observed on Resident #280's bedside table. Interview on 6/5/18 at approximately 9:35 a.m. with Resident #280, revealed that Resident #280 said that they are not offered snacks or extra fluids to drink, except at bedtime. Resident #280 stated that they think they should be drinking more. Observation on 6/6/18 at approximately 10:30 a.m. of Resident #280 revealed that Resident #280's lips again appeared dry and cracked. Review on 6/6/18 of Resident #280's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review on 6/6/18 of Resident #280's care plan revealed that there was not a care plan for Resident #280's use of a diuretic and no interventions for ensuring that fluids are provided for Resident #280 and that Resident #280 was monitored for signs and symptoms of dehydration. Interview on 6/6/18 at approximately 9:31 a.m. with Staff B confirmed that there should have been a care plan and interventions in place for Resident #280's risk for signs and symptoms of dehydration with the use of a diuretic medication.",2020-09-01
624,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2018-06-06,695,B,0,1,QYCW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to provide ordered respiratory care to 1 resident in a standard survey sample of 16 residents. (Resident identifier is #13.) Findings include: Observation on 6/5/18 at approximately 9:50 a.m. of Resident #13 revealed that Resident #13 was receiving oxygen through a nasal cannula that was attached to an oxygen concentrator. The oxygen tubing was connected directly to the oxygen concentrator and there was no humidifier bottle attached. Review on 6/5/18 of Resident #13's care plan for oxygen therapy, initiated on 4/13/18, revealed an intervention that read Provide humidification. Review on 6/5/18 of Resident #13's Physician telephone orders revealed an order written [REDACTED].Change O2 (oxygen) tubing and humidifier weekly 11-7 (11-7 shift) Wed. (Wednesday) Date and initial tubing and humidifier . Interview on 6/5/18 at approximately 12:14 p.m. with Resident #13's family member revealed that they noticed when they visit Resident #13 that the humidifier bottle is not always on the oxygen concentrator. They said that sometimes it was there and other times it was not. Interview on 6/5/18 at approximately 11:00 a.m. with Staff A (Licensed Practical Nurse) confirmed that a humidifier bottle should have been on the oxygen concentrator for Resident #13.",2020-09-01
625,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2018-02-20,656,D,1,0,5HTU11,"> Based on observation, interview and record review it was found that the facility failed to provided services , in accordance with the care plan, that are to be furnished to attain resident's medical well-being for one resident. (Resident identifier is #1) Findings include: Observation on 2/20/18 at 12:00 p.m. revealed that Resident #1 was observed alone in bed eating a peanut butter and jelly sandwich. While observing Resident #1 eating their sandwich by themself Resident #1 started to choke, bringing up pieces of the peanut butter and jelly sandwich. At that time this surveyor entered the room to make sure Resident #1 was O K. Resident #1 stated yes. As surveyor was leaving the room after the occurrence Staff B LPN (Licensed Practical Nurse) entered the room, when entering this surveyor told the Staff B what had happend On review of the facility's NUTRITION ASSESSMENT AND PROGRESS NOTES for Resident #1, dated 12/11/17 it states under eating abilities's Fed by staff at all meals does minimal self feeding using adaptive equipment . On review of the care plan dated 12/11/17 under approach #10 it states Assist/feed for all intake. On review of the facility's LNA care card under Resident #1 there fails to be any care instructions stating to assist or feed Resident #1. Also, on the meal card there fails to be any instructions in regards to assist or feed Resident #1. These findings were shown to Staff A (Director of Nurses) on 2/20/18 who confirmed that the facility failed to follow the care plans as written and failed to supervise Resident #1 during their meal.",2020-09-01
626,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2018-06-01,584,B,0,1,561D11,"Based on observation, interview and facility policy and procedure review, it was determined that the facility failed to provide a homelike dining environment for 1 out of 1 restorative dining room. (Resident identifiers is #4.) Findings include: Observation on 5/30/18 at approximately 12:00 p.m. of the facility restorative dining room revealed that Resident #4 was at a table with two other residents. The two residents that were at Resident #4's table had eaten their lunch and Resident #4 had not been served lunch. Interview on 5/30/18 at approximately 12:15 p.m. with Staff A (Licensed Nursing Assistant) revealed that the other LNA's were in the hallway passing trays and it was normal practice for residents to wait for assistance with meals until the trays are done being passed. Staff A revealed that Resident #4 requires total assistance with meals. Observation on 5/31/18 at approximately 11:45 a.m. to 12:00 p.m. revealed that Resident #4 was at a table with two residents. The two residents sitting with Resident #4 were eating their lunch, Resident #4 did not have a meal. Interview on 5/31/18 at approximately 12:00 p.m. with Staff B (Nurse Manager) confirmed that Resident #4 had not been provided lunch while the two others residents had been eating lunch for approximately 15 minutes. Review on 6/1/18 of the facility policy and procedure titled, Dining Room Audits, revision date (MONTH) 2009 revealed: Policy Statement Our facility audits the Food Services Department regularly to ensure that resident needs are met and that dining is a safe and pleasant experience for residents. Policy Interpretation and Implementation: . 2. The auditor will assess: . d. If residents at each table are served together; . f. If adequate staff are available to assist with passing trays, meal set-up feeding;",2020-09-01
627,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2018-06-01,697,D,0,1,561D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure adequate relief of pain for 1 resident in a standard survey sample of 14 residents. (Resident identifier is #39.) Findings include: Interview on 5/30/18 at approximately 10:50 a.m. with Resident #39 revealed that when asked how they were doing, Resident #39 stated that they were Lousy. When asked why they were lousy, Resident #39 stated that they have sores on their butt and that they have a lot of pain because of them. When asked if the pain medications given to them by the nurses helped the pain, they said no. Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/20/18, that read, .family in to visit, req (requesting) something stronger than Tylenol. (Spouse) asked nurse on other side to call Dr. (Staff J) Nurse left msg (message) regarding family rec. (request.) Waiting for return call from Dr. (Staff J) If unable to address today resident and (spouse) agreeable to wait until tomorrow to obtain order . Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/20/18, that read, .LNA (Licensed Nursing Assistant) ambulates resident back to bed almost at bedside legs gave out and resident went down to the floor .MD (Medical Doctor) updated. There was no indication in the note that the resident's pain management was discussed with the physician. Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/21/18, that read, .C/O (complained) of pain in buttocks and legs . Review on 5/31/18 of Resident #39's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/21/18, that read, .Stated (he/she) wish (he/she) was dead .Call placed to Dr. (Staff J) Await call back. There was no indication in the note that the physician returned the call until 5/24/18. Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/22/18, that read, .C/O back pain . Review on 5/31/18 of Resident #39's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/23/18, that read, .Tylenol 650 mg (milligrams) for C/O back discomfort . Review on 5/31/18 of Resident #39's (MONTH) (YEAR) Medication Administration Record [REDACTED].) There were no results documented after this dose of Tylenol was given. Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/24/18, that read, Refused supper tonight. Seems down in the dumps. Buttocks hurting a lot. Tylenol does nothing for the pain (he/she) says .Dr. (Staff J) called to say he hadn't gotten my message, doesn't check them. Let him know that buttocks is causing Resident #39 a lot of pain. There was no indication in the note of what the physician's response was to the report of Resident #39 having a lot of pain. Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/26/18, that read, .Tylenol given X 1 (one time) for C/O bottom pain 'It hurts like hell.' Minimal effect if any . Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/27/18, that read, .PRN (as needed) Tylenol given with minimal to 0 effect . Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/28/18, that read, Medicated with Tylenol 650 mg at 900 (9:00 a.m.) and 1330 (1:30 p.m.) for lower back complaint with fair effect . Review on 5/31/18 of Resident #39's Nurse's Notes revealed a note, dated 5/29/18, that read, .Medicated with Tylenol 650 mg X 2 (two times) with fair effect for back .Spoke with (Staff K) APRN N.O. (New order) [MEDICATION NAME] 1 tab (tablet) po (by mouth) q6h (every 6 hours) PRN 1-5/10 pain (1 to 5 out of 10 pain level,) [MEDICATION NAME] 2 tabs po q6h PRN 6-10/10 pain (6 to 10 out of 10 pain level) . Review on 6/1/18 of Resident #39's Physician's Progress Note, dated 5/28/18, revealed a note written by Staff K which read, Nursing has noted a marked decrease in appetite over the last month, documentation of 'bites' at meals and meal refusals. (Resident #39) is not snacking in between meals as (pronoun) had been. (Resident #39) is in bed more due to macerated area on (pronoun) coccyx. (Mental Health) has seen (Resident #39) for depressed thoughts. (Resident #39) has lost 25 lbs (pounds) over the last month . Interview on 6/1/18 at approximately 1:00 p.m. with Staff [NAME] (Assistant Director of Nursing) confirmed that Resident #39's waiting from 5/20/18, after their family requested something stronger than Tylenol for pain, until 5/29/18 for a change of orders should not have occurred. Staff [NAME] also confirmed that there was documented evidence of Resident #39 several times not getting good relief from the Tylenol given. Interview on 6/1/18 at approximately 3:30 p.m. with Staff F (Director of Nursing) confirmed that the staff were aware that Resident #39 was having pain, but because it was a long weekend, Staff F directed the nursing staff to administer Tylenol to Resident #39 every 4 hours around the clock through the weekend. Review on 6/1/18 at approximately 3:30 p.m. of Resident #39's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review also revealed that Resident #39 received Tylenol on the following dates, 1 time on 5/26/18 with a result of helps little, 2 times on 5/27/18 with results written both times as little help, and 2 times on 5/28/18 with results written as fair for 1 dose and no results written for the second dose. Staff F confirmed that the staff did not follow the directive to administer Tylenol every 4 hours around the clock to Resident #39.",2020-09-01
628,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2018-06-01,842,E,0,1,561D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure that medical records were readily accessible and included all current information for 6 residents in a standard survey sample of 14 residents. (Resident identifiers are #8, #21, #23, #39, #40 and #46.) Findings include: Resident #40 Review on 5/31/18 of Resident #40's Resuscitation Designation form revealed that Resident #40 had checked off the desire to have cardiopulmonary resuscitation performed at the facility if they suffered cardiac or respiratory arrest. The form was signed by Resident #40 on 4/4/18 and had 2 witness signatures on it. There was no physician signature or order on this form. Review on 5/31/18 of the Facility's policy, titled Advance Directives, revised on (MONTH) (YEAR), revealed that .The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care . Review on 5/31/18 of Resident #40's medical record revealed that there were no (MONTH) (YEAR) physician orders [REDACTED]. Observation on 5/31/18 at approximately 9:30 a.m. of the medical records room, which was located on the lower floor from the nursing units, revealed that there was a stack of residents' (MONTH) (YEAR) physician orders. Interview on 5/31/18 at approximately 9:30 a.m. with Staff H (Medical Records) revealed that Staff H had removed all of the (MONTH) (YEAR) physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:30 a.m. with Staff G (Registered Nurse) revealed that if Resident #40 went into [MEDICAL CONDITION], Staff G stated that they would look in the medical record for the (MONTH) (YEAR) physician orders [REDACTED]. Staff G stated that if the physician orders [REDACTED]. would be. Staff G confirmed that the (MONTH) (YEAR) physician orders [REDACTED]. Resident #8 Review on 5/31/18 of Resident #8's medical record revealed that there were no (MONTH) (YEAR) physician orders [REDACTED]. Observation on 5/31/18 at approximately 9:30 a.m. of the medical records room revealed that Resident #8's (MONTH) (YEAR) physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:00 a.m. with Staff I (Registered Nurse) stated that the (MONTH) (YEAR) orders should be in the record, and not in the medical record room, in the event that a nurse needed to call a physician about a resident or needed to emergently send a resident to the hospital, where copies of the physician orders [REDACTED]. Review on 5/31/18 of Resident #8's Nutrition Assessment and Progress Notes revealed that Resident #8 was not having weights monitored and there was a physician's orders [REDACTED]. Review on 5/31/18 of Resident #8's (MONTH) (YEAR) Physician orders, after it was retrieved from the medical record room, revealed that the physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:30 a.m. with Staff I confirmed that it was generally the facility's practice to include the order to discontinue weights on the physician order [REDACTED]. Resident #21 Review on 5/31/18 of Resident #21's medical record revealed that there were no (MONTH) (YEAR) physician orders [REDACTED]. Observation on 5/31/18 at approximately 9:30 a.m. of the medical records room revealed that Resident #21's (MONTH) (YEAR) physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:30 a.m. with Staff G confirmed that the (MONTH) (YEAR) orders should be in the record, and not in the medical record room. Review on 5/31/18 of Resident #21's Nutrition Assessment and Progress Notes revealed that Resident #21 was no longer having weights monitored and there was a physician's orders [REDACTED]. Review on 5/31/18 of Resident #21's (MONTH) (YEAR) Physician orders, after it was retrieved from the medical record room, revealed that there was no order on the current physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:30 a.m. with Staff G confirmed that it was generally the facility's practice to include the order to discontinue weights on the physician order [REDACTED]. Resident #23 Review on 5/31/18 of Resident #23's medical record revealed that there were no (MONTH) (YEAR) physician orders [REDACTED]. Observation on 5/31/18 at approximately 9:30 a.m. of the medical records room revealed that Resident #23's (MONTH) (YEAR) physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:30 a.m. with Staff G confirmed that Resident #23's (MONTH) (YEAR) physician orders [REDACTED]. Review on 5/31/18 of Resident #23's Nutrition Assessment and Progress Notes revealed that Resident #23 was no longer having weights monitored and there was a physician's orders [REDACTED]. Review on 5/31/18 of Resident #23's (MONTH) (YEAR) Physician orders, after it was retrieved from the medical record room, revealed that there was no order on the current physician orders [REDACTED]. Interview on 6/1/18 at approximately 1:00 p.m. with Staff [NAME] (Assistant Director of Nursing) confirmed that it was generally the facility's practice to include the order to discontinue weights on the physician order [REDACTED]. Resident #39 Review on 5/31/18 of Resident #39's Resuscitation Designation form revealed that Resident #39 had checked off the desire to have cardiopulmonary resuscitation performed at the facility if they suffered cardiac or respiratory arrest. The form was signed by Resident #39's wife and had 2 witness signatures on it. Review on 5/31/18 of Resident #39's medical record revealed that there were no (MONTH) (YEAR) physician orders [REDACTED]. Observation on 5/31/18 at approximately 9:30 a.m. of the medical records room revealed that Resident #39's current physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:35 a.m. with Staff G revealed that if Resident #39 went into [MEDICAL CONDITION], Staff G stated that they would look in the medical record for the (MONTH) (YEAR) physician orders [REDACTED]. Staff G stated that if the physician orders [REDACTED].#39's Resuscitation Designation form, that had been signed by Resident #39's wife, although it did not contain a physician order, to determine what the resident's wishes would be. Resident #46 Review on 5/31/18 of Resident #46's medical record revealed that there were no (MONTH) (YEAR) physician orders [REDACTED]. Observation on 5/31/18 at approximately 9:30 a.m. of the medical records room revealed that Resident #46's (MONTH) (YEAR) current physician orders [REDACTED]. Interview on 5/31/18 at approximately 9:30 a.m. with Staff G revealed that Staff G said that the (MONTH) (YEAR) physician orders [REDACTED].",2020-09-01
629,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2020-01-24,658,D,0,1,9OIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, it was determined that that facility failed to ensure that a physician order [REDACTED]. (Resident identifier is #76.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009, states Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Observation on 1/22/20 at 10:00 a.m. revealed that Resident #76 was in bed sleeping with a nasal cannula on their nares and oxygen concentrator in use and on 2 lpm (liters per minute) of oxygen. Observation on 1/22/20 at 1:10 p.m. with Staff J (Licensed Nursing Assistant) revealed that Staff J found Resident #76's nasal cannula on Resident #76's lap and had placed the nasal cannula on Resident #76's nares. Further observation with Staff J revealed that oxygen concentrator was on 2 lpm. Interview on 1/22/20 at 1:15 p.m. with Staff M (Licensed Practical Nurse) revealed that Resident #76 uses the oxygen for comfort. Staff M stated that Resident #76 uses the oxygen as needed. Review on 1/23/20 of Resident #76's (MONTH) 2019 and (MONTH) 2020 physician orders [REDACTED]. Review on 1/23/20 of Resident #76's respiratory care plan dated 12/24/19 revealed .provide oxygen therapy as ordered . Review on 1/23/20 of Resident #76's (MONTH) 2019's nurses notes revealed that on 12/24/19 Resident #76 had oxygen in use. Review on 1/23/19 of Resident #76's (MONTH) 2020 nurses notes revealed that Resident #76's oxygen was in use on 1/13/20 and 1/15/20 to 1/22/20. Interview on 1/23/20 at 1:14 p.m. with Staff K (Charge Nurse) confirmed that Resident #76 had no orders for oxygen therapy. Interview on 1/23/20 at 1:15 p.m. with Staff L (Unit Manager) revealed that Resident #76 used oxygen as needed and had been on oxygen intermittently for the month of (MONTH) 2020. Staff L stated that Resident #76 should have an order for [REDACTED].",2020-09-01
630,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2020-01-24,676,E,0,1,9OIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) did not diminish for 1 of 1 resident reviewed for ADLs in a survey sample of 23 residents. (Resident identifier is #23) and for 1 out of 5 dining areas observed (West day room). (Resident identifiers are #29, #47 #49, #63, #84, #86, #87 and #88) Findings include: The following observations and interviews took place on 1/22/20 in the West area day room from approximately 12:00 p.m. to 12:50 p.m.: Observation on 1/22/20 at approximately 12:10 p.m. revealed that there were 2 LNA's (Licensed Nursing Assistant) in the dining room (Staff B and Staff C) with 12 Residents. Observation of the West Day Room assisted dining room on 1/22/20 at approximately 12:07 p.m. revealed Resident #87 seated at a table with a tray of food in front of them. Review of Resident #87's medical record revealed [DIAGNOSES REDACTED]. Resident #87 stated I want some food. Staff B and Staff C (Licensed Nursing Assistants) were present in the dining room. Resident #87 was handed a cup of chocolate milk but not assisted with taking any bites of food. Resident #87 was observed sitting with a plate of food that appeared to not have been touched. At 12:37 Resident #87 stated to Staff B I'm hungry. Staff B gave Resident #87 one bite of food while standing and then walked away. Interview on 1/22/20 at approximately 12:24 p.m. with staff B who states that Resident #87 drinks more than she eats, and at times does require assistance with meals. Review on 1/22/20 at approximately 1:30 P.M. of Resident #87's Resident Care Guide in the section marked Eating revealed that Resident #87 is marked as requiring Limited Assistance. Review of Resident #87's ADL (Activities of Daily Living) Tracking Form revealed that Resident #87 is documented as being totally dependant and requiring full staff assistance with one person physical assist for the month of (MONTH) 2020 on the 7:00 a.m. to 3:00 p.m. shift. Staff C was observed feeding 4 residents on 2 different tables. Staff C would assist them with bites and go to the other table and do the same with the other 2 residents and then return to the table and assist the other 2 residents. Resident #49 was observed at approximately 12:00 p.m. sitting at a table with meal untouched and uncovered. Assistance was provided by Staff C at approximately 12:15 p.m. The meal was not offered to be reheated. Resident #87 was observed at approximately 12:00 p.m. sitting at a table with meal untouched and uncovered. Resident #87 yelled out approximately 3 times, I want some food! Staff B walked over to Resident #87 and filled Resident #87's cup of milk and did not provide any assistance with the meal. At 12:50 p.m. Staff B revealed that, (pronoun omitted) drinks more than eats. At that time Staff B began to assist Resident #87. Staff B confirmed that Resident #87 does require assistance with meals. Resident #63 was seated at a table alone without a meal. At 12:15 p.m. Resident #84 was seated (with a meal) with Resident #63. Resident #63 immediately stated, Where is my food! Resident #63 stated to Resident #84, Go ahead and eat hopefully I will get mine soon. Resident #63 asked for (pronoun omitted) food and stated I'm starving! Staff B and Staff C repeatedly told Resident #63 that the meal was coming. Resident #63's peanut butter and jelly sandwich and a gingerale arrived at the table at approximately 12:40 p.m. No dessert was offered to Resident #63. Resident #86 was observed to have fingers in food. No assistance was offered by staff with meal. Resident #86 was then removed from the dining room. Staff B stated, Are you ready to go lay down. Resident #29 at 12:30 p.m. stated, I am having a hard time eating. Resident #29 was observed attempting to eat and dropping food in lap. Staff B stated, I will be right back. Staff B did not return to assist Resident #29. Resident #29 left the dining room with approximately 50% of meal on table at approximately 12:40 p.m. Resident #47 at 12:40 p.m. was eating meal, Staff B removed meal from table without asking Resident #47 if (pronoun omitted) was finished. Resident #47 was eating prior to Staff B removing the tray. Staff B was observed at 12:45 p.m. sweeping the dining room and spraying down some tables that were now empty while other residents were still eating. Observation on 1/23/20 at approximately 8:30 a.m. revealed Staff H (Hospice LNA) was standing and feeding Resident #88. The following observations and interviews took place on 1/24/20 in the West area day room from approximately 12:00 p.m. to 12:50 p.m. : Interview at approximately 12:25 p.m. with Staff I, LNA revealed that there were 7 residents at that time requiring assistance with meals and 2 LNA's present to assist. Observation of the dining area revealed that the 7 residents that required staff assistance with meals were sitting at 4 different tables. The meals were left uncovered for greater than 15 minutes and not offered to be reheated prior to assistance being provided. Resident #29 stated while attempting to feed self stated out loud, I'm frustrated! Resident #29's yogurt and spoon were noted to fall over on the table for approximately 10 minutes and Resident #29 was unable to reach them. No staff member came over to assist Resident #29. Review on 1/24/20 of the facility policy and procedure titled, Assistance with Meals; revision date (MONTH) (YEAR) revealed: Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Dining Room Residents: . 2. Facility Staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals; . Review on 1/22/20 at approximately 2:00 p.m. of the facility policy titled Assistance with Meals (undated) revealed under the section titled Dining Room Residents #2. Facility staff will serve resident trays and will help residents who require assistance with eating. #3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals. Review of the facility policy titled Activities of Daily Living (ADL), Supporting (undated) revealed a Policy Statement that reads Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs.) Resident #23 Interview on 1/23/20 at approximately 10:30 a.m. during resident council, Resident #23 stated, I am suppose to be walking everyday with 2 staff and they never do it. I am losing my ability to walk everyday and no one does anything. Review on 1/23/20 of Resident #23's care plan for ADL (activities of daily living) revealed the following interventions: Ambulation X1 assist via RW (rolling walker) and w/c (wheelchair) follow as tolerated; date initiated 11/20/19. Assess and report to my MD (Medical Doctor)/PA (physicians assistant)/NP (nurse practitioner) of any changes, any potential for improvement, any discovered reasons for self-care deficit, declines in function as needed; date initiated 11/20/19. Review on 1/24/20 of Resident #23's LNA (Licensed Nursing Assistant) flow sheets revealed the following: November 2019 7-3 LNA flow sheet -11/20 thru 11/27 Resident #23 ambulated with 1 staff member and limited assist. November 2019 3-11 no ambulatation documented November 2019 11-7 no ambulation documented. December 2019 7-3 no ambulatation documented. December 2019 3-11 no ambulatation documented. December 2019 11-7 no ambulation documented. January 2020 7-3 no ambulatation documented. January 2020 3-11 no ambulation documented. January 2020 11-7 no ambulatation documented. Review on 10/24/20 of the LNA's care guide (no date) revealed: Locomotion on the unit - does not occur is checked off Locomotion off the unit - does not occur is checked off Walk in room - limited assistance is checked off and 2 person assist Walk in corridor - does not occur The back of the care guide has the following Rehabilitation notes:Dated, 11/26/19 Patient 1 assist tolieting, Use w/c up to bathroom door and use r/w to walk from bathroom door to toilet. Reverse to go back to recliner. If fatigued, use w/c-Do not use stand lift. Interview on 1/24/20 at approximately 10:45 a.m. with Staff D, (Unit Manager) revealed that there LNA's do not have consistent LNA's. The LNA's float to different assignments. Staff D did confirm that the care guide is where LNA's find information on what each resident requires for assistance. Interview on 1/24/20 at approximately 10:50 a.m. with Staff E, LNA revealed that the LNA care guide is the only place to go to find out how to take care of the residents. Staff [NAME] stated, I report changes to the nurse including difficulty with ADL's. Review on 1/24/20 of Resident #23's medical record revealed there was documentation of MD being notified of ambulation decline from 11/27/19 - 1/20/20. There was a new order for PT (physical Therapy) eval (evaluation) and treat as indicated dated 1/21/20. PT 3x/week x4 weeks to include . gait in the treatment of [REDACTED]. Review on 1/24/20 of the facility policy and procedure titled, Activities of Daily Living, Supporting; Revision date (MONTH) (YEAR) revealed: Policy Statement Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). . 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADL's) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADL's are unavoidable. . 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate.",2020-09-01
631,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2020-01-24,761,D,0,1,9OIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility policy and procedure and review of manufacturer's instructions, it was determined that the facility failed to remove an open expired vial of [MEDICATION NAME] from the medication cart, 1 out of 3 medication carts reviewed. (East low medication cart) Findings include: Observation on [DATE] at approximately 7:45 a.m. of the East (low) medication cart revealed Resident #12 had a vial of [MEDICATION NAME] with a do not use after [DATE] date on it. There was no date of opening labeled on the vial. Interview on [DATE] at approximately 7:45 a.m. with Staff A (Medication Nursing Assistant) confirmed that the vial of insulin was expired. Review on [DATE] of the manufacturer's instructions for [MEDICATION NAME], revision date (MONTH) 2019 revealed: . 16.2 Storage . In use (opened) vial of insulin expires 28 days after opening . Review on [DATE] of the facility's policy and procedure titled, 5.3 Storage and Expiration of Medications, Biological's, Syringes and Needles, revision date [DATE] revealed: . Procedure . 4. Facility should ensure that medications and biological's that: (1) have an expired date on them; (2) have been retained longer than recommended by manufacturer or supplier guidelines; . 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with the respect to expiration dates for opened medications. Facility staff should record the date opened medication container when the medication has a shortened expiration date once opened. . 16. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biological's in accordance with Pharmacy return/destruction guidelines .",2020-09-01
632,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2020-01-24,809,B,0,1,9OIS11,"Based on interview it was determined that the facility failed to provide a nourishing snack at bedtime while having 15 hours between the evening meal and the breakfast meal. Findings include: Review on 1/23/20 at approximately 9:30 a.m. of the facility document titled Meal Service Times and Truck Order revealed that breakfast is served at 7:30 a.m. and dinner is served at 4:30 p.m. which leaves a space of 15 hours between meals. Interview on 1/23/20 at approximately 10:30 a.m. with resident council revealed that there are no snacks offered at bedtime, and resident council did not approve the span of time between meals. Of the 8 residents who attended resident council 7 were in agreement that there is no snack offered at bedtime, and that they would like to have a snack at bedtime. The 1 resident who stated there was a snack provided stated that he/she received a snack due to being diabetic. Interview on 1/23/20 at approximately 1:20 p.m. with Staff F (Dietary Manager) confirmed that there is 15 hours between the evening meal and breakfast and that no nourishing snack is offered to all residents at bedtime. Interview on 1/23/20 at approximately 1:26 p.m. with Staff G (Director of Nursing) confirmed that the facility does not offer a nourishing snack to all residents at bedtime and that there is 15 hours between the evening meal and breakfast.",2020-09-01
633,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2020-01-24,811,D,0,1,9OIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents were not fed by paid feeding assistants after the facility had discontinued the paid feeding assistant program for 3 of 3 residents observed being fed by non-licensed staff. (Resident identifiers are #28, #66, and #90.) Findings include: Review on 1/23/2020 of the facility's policy titled, Paid Feeding Assistants, revised (MONTH) (YEAR), revealed that .Paid Feeding assistants provide dining assistance only for residents with no complicated feeding problems. Complicated feeding problems include difficulty swallowing, recurrent lung aspiration and tube or [MEDICATION NAME] I.V. (intravenous) feedings .Residents are assessed for appropriateness for feeding assistant program by the IDT (interdisciplinary team), taking into consideration the most recent assessment and plan of care .only residents who have been selected by the IDT are eligible for feeding assistance by a paid feeding assistant . Review on 1/23/2020 of the facility's policy titled, Updated Addendum to the FVHC (Fairview Healthcare Center) Paid Feeding Assistant Program, Updated (MONTH) 1, 2019, revealed, Paid feeding assistants will assist with feeding residents who do not have a complicated feeding problem of difficulty swallowing, recurrent lung aspirations or are receiving services provided by the Speech Therapist. An approved list of residence (sic) whom PFA's may feed will be provided by the Registered Dietitian weekly. Resident #66 Observation on 1/22/2020 at 12:10 p.m. revealed that Staff N (Paid Feeding Assistant/Activities Assistant) was feeding Resident #66 during the noon time meal in the library. Observation on 1/23/2020 at 8:00 a.m. revealed that Staff N was in the library passing trays and assisting residents with feeding or placing trays in front of residents. Observation on 1/23/2020 12:16 p.m. revealed that Staff N started to assist other residents and then feed Resident #60. Resident #90 Observation on 1/22/2020 at 12:20 p.m. revealed that Staff N was feeding Resident #90 during the noon time meal in the library. Observation on 1/23/2020 at 12:16 p.m. revealed that Staff N started to feed Resident #90 during the meal time meal. Interview on 1/22/2020 at 8:30 a.m. indicated Staff O (Administrator) revealed that the facility stopped the PFA program last year after the survey. Interviewed on 1/22/2020 at 12:25 p.m. Staff N stated Staff N had been trained the paid feeding program but does not remember when the last time it was. Staff N has been at the facility for about 5 years. The PFA's have a list of resident's diet to go by and which ones that the PFA's can feed. The sheets are hanging up in the library. Staff N had a state approved training about 5 years ago but has had no other training since. Staff N goes by the list. Interview on 1/24/2020 at 11:30 a.m. with Staff D, (Unit Manager) confirmed Staff N can feed certain residents though the PFA program. Staff N has taken the program and the list of residents is in the library. Resident #28, #66 and #90 are included in this list of residents to feed. Interview on 1/24/2020 at 2:00 p.m. Staff I with (Director of Nurses) revealed the facility does not have a PFA program. On 1/22/2020 observation in the library at 11:00 a.m. confirmed a list of residents that the PFA's can feed. Also, confirmed the Policy for the PFA's.",2020-09-01
634,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2020-01-24,868,B,0,1,9OIS11,"Based on interview and record review it was determined that the facility failed maintain quarterly meetings within the Quality Assurance and Performance Improvement (QAPI) program. Findings include: Interview on 1/24/2020 at approximately 2:30 p.m. with Staff G (Director of Nurses) confirmed that the facility is working on developing a new QAPI program which will be more data driven and proactive. Staff G has set goals for the upcoming year. Staff G could not find that all QAPI quarterly meetings were attended since the last recertification survey of 3/5/2019. Staff O, Administrator indicated that the quarterly (MONTH) meeting was conducted but no sign in sheet was available for documentation of the meeting or all appropriate members were present. Review of the QAPI attendance sheets on 1/24/2020 at approximately 2:30 p.m. with Staff G revealed the following dates: 1/23/19 all appropriate members present; (MONTH) 31,2019 all appropriate members present; (MONTH) 26, 2019 ; Staff G indicated that the Administrator called in via phone due to being on vacation. Neither Staff G or Staff O could find the missing sign in sheet for the quarterly (MONTH) meeting.",2020-09-01
635,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2019-03-05,658,D,0,1,U4I111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, it was determined that the facility failed to discard medications in accordance to professional standards for 5 out of 27 medication administrations observed. (Resident identifier is #44.) Findings include: Review on 3/1/19 of FDA (Food and Drug Administration) website titled, Disposal of Unused Medicines: What You Should Know, last updated date: 2/27/19, revealed that .1. Remove the drugs from their original containers and mix them with something undesirable, such as used coffee grounds, dirt, or cat litter. This makes the medicine less appealing to children and pets and unrecognizable to someone who might intentionally go through the trash looking for drugs .2. Put the mixture in something you can close (a re-sealable zipper storage bag, empty can, or other container) to prevent the drug from leaking or spilling out .3. Throw the container in the garbage . Observation on 3/1/19 at 8:45 a.m. of the medication administration for Resident #44 with Staff A (Registered Nurse) revealed that Staff A had 1 capsule of [MEDICATION NAME] 50 mg (milligram) (antibiotic), 2 tablets of Senna-S 8.6 mg-50 mg (stool softener), 1 tablet of [MEDICATION NAME] 100 mg (antidepressant), 4 capsules of [MEDICATION NAME] sodium 125 mg (anti-epileptic), and 1 tablet of [MEDICATION NAME] 50 mg (antidepressant) in a medicine cup which Staff A had dropped on the medication cart. Staff A then gathered the medications listed above and disposed of them in the medication cart trash bin with no lid. Staff A then obtained another 1 capsule of [MEDICATION NAME] 50 mg, 2 tablets of Senna-S 8.6 mg-50 mg, 1 tablet of [MEDICATION NAME] 100 mg, 4 capsules of [MEDICATION NAME] sodium 125 mg and 1 tablet of [MEDICATION NAME] 50 mg. Staff A crushed the tablets of [MEDICATION NAME], Senna-S and [MEDICATION NAME], and opened capsules of [MEDICATION NAME] and [MEDICATION NAME] sodium and mixed it with pudding. Staff A then went to Resident #44's room to give the medications and Resident #44 refused twice. Staff A then threw the medications mixed in pudding in the medication cart trash bin with no lid. Interview on 3/1/19 at 8:50 a.m. with Staff A confirmed the above findings. Staff A states that they had always thrown medications in the medication trash bin. Interview on 3/1/19 at 8:51 a.m. with Staff G (Charge Nurse) revealed that medications would be discarded by flushing down the toilet. Interview 3/1/19 at 1:49 p.m. with Staff C (Director of Nursing) revealed that they utilized the facility policy titled, Discarding and Destroying Medication, revised (MONTH) 2014, as guidelines in discarding controlled and non-controlled medications. Review on 3/1/19 of the facility's policy titled, Discarding and Destroying Medication, revised (MONTH) 2014, revealed that .6. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substances with other solid waste following steps below .a. take medication out of original containers .b. mix medications, either liquid or solid, with an undesirable substance .include sand, coffee grounds, kitty liter or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage .",2020-09-01
636,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2019-03-05,684,D,0,1,U4I111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the hospice contract it was determined that the hospice and the facility failed to collaborate care for 1 resident out of 2 residents reviewed receiving hospice services. (Resident identifier is #290.) Findings include: Review on 3/4/19 of Resident #290's medical record revealed the following speech evaluation dated 2/26/19, titled, Speech Therapy SLP (Speech Language Pathologist) Evaluation and Plan of Treatment: . History/Complexities Current/PMH (Past Medical History): Patient is a Long Term Resident who has a history of dysphagia and had previously been on ST (Speech Therapy) to address pocketing 9/2/16-11/27/16. Patient was d/c'd (discharged ) with moderate-severe pocketing on a regular diet. Patient was downgraded by nursing pending ST evaluation to moist ground with puree, no breads/thin. Patient is currently a max assistance for all meals. PMHX (Past Medical History): dysphagia, dementia, [MEDICAL CONDITION], altered mental status. .Dysphagia Medical Workup: Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase History of =Aspiration Problems . Recommendations Intake Diet Recommendations-Solids=Puree Consistencies . Assessment Summary Skilled Justification Reason for skilled services: at this time, patient has been transferred to hospice care. Clinician has provided hospice nurse with results of evaluation including all diet recommendations and safe swallow strategies. P[NAME] (plan of care) and diet recommendations are per discretion of hospice care. Review on 3/4/19 of Resident #290's diet orders revealed, moist ground diet (texture) with pureed vegetables. Review on 3/5/19 of Resident #290's Hospice chart/visit log revealed the following nursing note dated 2/26/19: .new texture diet puree due to pocketing. Interview on 3/5/19 at approximately 11:00 a.m. with Staff D (Unit Manager) revealed that there were no diet recommendations given to the physician by hospice or SLP which resulted in the diet texture not being changed. Interview on 3/5/19 at approximately 11:30 a.m. with Staff [NAME] (Speech Therapist) revealed that the diet recommendations were given verbally to the hospice nurse. Staff [NAME] stated, When a patient goes on hospice, we are no longer able to document in the patient's chart. Interview on 3/5/19 at approximately 11:45 a.m. with Staff C (Director of Nurses) revealed that the facility did not have a policy and procedure for speech recommendations for residents on hospice services. Review on 3/5/19 of the the hospice contract with the facility dated 1/9/09 revealed: . 3. Standard: Written Agreement (a) Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of the Hospice Patients are met 24 hours per day (c) Hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided to a Hospice Patient",2020-09-01
637,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2019-03-05,756,D,0,1,U4I111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it and if there is to be no change in the medication that the attending physician documented his or her rationale in the resident's medical record for 1 resident out of a final sample size of 25 residents. (Resident identifier is #39.) Findings include: Review on 3/4/19 of Resident #39's medication regimen review on 1/23/19 revealed that there were recommendations from the pharmacist. Review on 3/4/19 of Resident #39's pharmacy consultation report dated 1/23/19 revealed that the pharmacist had recommendations to attempt gradual dose reduction (GDR) for quetiapine (antipsychotic) to 12.5 mg (milligram) in AM (morning), and 25 mg at HS (bedtime). Further review of the pharmacist recommendations revealed that there was no documentation of acceptance or rationale for decline on the pharmacy consultation report by the PCP (primary care physician) or the house psychiatrist. Review on 3/4/19 of Resident #39's current physician orders [REDACTED]. Review on 3/4/19 of Resident #39's physician notes revealed that Resident #44's PCP had visit notes on 2/11/19 and 2/18/19 which had no documentation in regards to the pharmacy recommendation for Resident #39's quetiapine. Review on 3/4/19 of Resident #39's consult notes revealed that the house psychiatrist had a visit note 2/23/19 which had no documentation in regards to the pharmacist recommendations for Resident #39's quetiapine. Review on 3/4/19 of Resident #39's medication regimen review on 2/11/19 revealed that there were no irregularities documented by the pharmacist. Interview on 3/4/19 at 11:20 a.m. with Staff B (Unit Manager) confirmed the above findings. Interview on 3/4/19 at 12:20 p.m. with Staff B revealed that Staff B had contacted the house psychiatrist on 3/4/19 at 12:00 p.m. and that the house psychiatrist had not seen the pharmacist recommendation dated 1/23/19 on their last visit on 2/23/19. Staff B revealed that the pharmacist recommendation dated 1/23/19 was put in the binder with the doctors notes to be filed in the charts rather than the psychiatrist communication binder where [MEDICAL CONDITION] pharmacy recommendations would have been placed to be reviewed by house psychiatrist which was the reason why it was missed. Staff B states that they get the pharmacist recommendation from the DON (Director of Nursing) then place the pharmacist recommendations in the physician communication book or the house psychiatrist communication book. Staff B was unable to provide any explanation if they follow up on the pharmacist recommendations if the PCP or house psychiatrist had followed up on the recommendations or any time frames for follow up. Interview on 3/5/19 at 2:00 p.m. with Staff C (DON) revealed that they do not have a policy or procedure for time frame and monitoring for the pharmacist recommendations. Staff C revealed that they get the recommendations from the pharmacist the same day that the pharmacist visited on a monthly basis. Staff C distributes the pharmacist recommendations to the unit managers and expects the recommendations to be followed up and that they do not follow up after, with the unit managers, if the pharmacist recommendations were reviewed by the physician or not.",2020-09-01
638,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2019-03-05,761,D,0,1,U4I111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to follow expiration dates for multidose bottles of insulin found on 2 of 5 medication carts. Findings include: Observation on [DATE] at approximately 8:00 a.m. during medication cart review of the Lower Wing West Cart revealed an opened vial of [MEDICATION NAME]. Observation of the opened bottle revealed following sticker on the vial as: Refrigerate Until Opened. The other sticker read Date opened [DATE]. After opening do not use after 28 days. Discard after [DATE]. Interview on [DATE] at approximately 8:15 a.m. with Staff A (Registered Nurse) confirmed that Staff A had given the [MEDICATION NAME] that a.m. and that Staff A had not looked at the date this a.m. and that it had expired the day before. Observation on [DATE] at approximately 10:15 a.m. during medication cart review of the Lower Wing East cart revealed a opened vial of Humalog, which had two different dates on the outside of the vial. One date was [DATE] with a discard date of [DATE] and the other opened date was [DATE]. Review of the facility's blood sugar log on [DATE] at approximately 10:15 a.m. it was noted this Humalog is only used for a sliding scale and it was not used between [DATE]-[DATE]. Interview on [DATE] at approximately 10:30 a.m. with Staff D (East Unit Manager) confirmed that Humalog had expired. Staff D confirmed the opened date was [DATE] and the not the [DATE] date. The wrong date was [DATE]. Staff D, looking at the Medication Administration Record, [REDACTED].",2020-09-01
639,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2019-03-05,811,E,0,1,U4I111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that the paid feeding assistants (PFA) provided dining assistance only for residents who have no complicated feeding problems for 4 residents out of a final sample size of 25 residents. (Resident identifiers are #3, #57, #69, #290.) Findings include: Review on 3/5/19 of the facility's paid feeding assistance program pamphlet, chapter 1 page 6, revealed that Important! Feeding assistants are not permitted to feed residents with dysphagia (difficulty swallowing) . Review on 3/5/19 of the facility's policy titled, Paid Feeding Assistants, revised (MONTH) (YEAR), revealed that .Paid Feeding assistants provide dining assistance only for residents with no complicated feeding problems. Complicated feeding problems include difficulty swallowing, recurrent lung aspiration and tube or [MEDICATION NAME] I.V. (intravenous) feedings .Residents are assessed for appropriateness for feeding assistant program by the IDT (interdisciplinary team), taking into consideration the most recent assessment and plan of care .only residents who have been selected by the IDT are eligible for feeding assistance by a paid feeding assistant . Resident #3 Interview on 3/5/19 at 9:13 a.m. with Staff I (Paid Feeding Assistant/Activities Assistant) revealed that Staff I had been a PFA for 7 years. Staff I revealed that they were not given a list of residents that they would feed. Staff I states that they would feed anybody that would need help as long as they do not have any complicated swallowing difficulties such as choking hazards. Staff I also revealed that they physically assisted Resident #3 for eating. Review on 3/5/19 of Resident #3's current diet order revealed a diet of ground texture with nectar thick liquids. Review on 3/5/19 of Resident #3's medical [DIAGNOSES REDACTED]. Review on 3/5/19 of Resident #3's nursing assistant flowsheets from 2/28/19 to 3/4/19 revealed that Resident #3 was totally dependent on one staff for eating. Review on 3/5/19 of Resident #3's current care plan revealed a care plan for Resident #3 that they required a mechanically altered diet related to dysphagia and edentulousness with no interventions documented that Resident #3 can be fed by a paid feeding assistant. Review on 3/5/19 of Resident #3's speech therapy notes dated 2/28/18 revealed a medical [DIAGNOSES REDACTED]. Interview on 3/5/19 at 12:00 p.m. with Staff B (Unit Manager) confirmed the above findings. Staff B was unable provide explanation on how residents are chosen to be fed by paid feeding assistants. Resident #57 Observation on 2/28/19 at 11:42 a.m. of Resident #57 revealed that Staff I was assisting Resident #57 with dining. Staff I physically assisted in feeding Resident #57 their lunch meal alternating with Resident #57's drink. Interview on 2/28/19 at 11:42 a.m. with Staff G (Charge Nurse) revealed that Resident #57 required one on one physical assistance for eating. Review on 3/5/19 of Resident #57's current diet order revealed a diet of Puree and thin liquids. Review on 3/5/19 of Resident #57's medical [DIAGNOSES REDACTED]. Review on 3/5/19 of Resident #57's nursing assistant flowsheets from 2/28/19 to 3/4/19 revealed that Resident #57 was totally dependent on one staff for eating. Review on 3/5/19 of Resident #57's current care plan revealed a care plan for Resident #57 that they required a therapeutic and mechanically altered diet related to ARF (Acute [MEDICAL CONDITION]), [MEDICAL CONDITION] (high potassium level) and dysphagia with no interventions documented that Resident #57 can be fed by a paid feeding assistant. Review on 3/5/19 of Resident #57's speech therapy notes dated 11/21/18 revealed a medical [DIAGNOSES REDACTED]. Interview on 3/5/19 at 1:00 p.m. with Staff G confirmed the above findings. Staff G was unable to provide explanation on how residents are chosen to be fed by paid feeding assistants. Resident #290 Observation on 2/28/19 at approximately 12:00 p.m. in the East Dining Room revealed Staff H (Activities Director) (who is a paid feeding assistant) was feeding Resident #290 lunch. Review on 2/28/19 of the facility's paid feeding assistant list of residents that they can assist dated, 2019 revealed that Resident #290 was not approved to be assisted by a paid feeding assistant. Interview on 3/4/19 at approximately 2:00 p.m. with Staff H revealed that Staff H assists any resident that needs assistance. Staff H was unaware that there was a list of residents who could be assisted by paid feeding assistants. Review on 3/5/19 of Resident #290's Speech Therapy SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 2/26/19 revealed: . Hx (history)/Complexities Current/PMHx (past medical history): Patient is Long Term Resident who has history of dysphagia and had previously been on st (Speech Therapy) to address pocketing 9/2/16-11/27/16. Patient was d/c'd (discharged ) with moderate-severe pocketing on a regular diet. Patient was downgraded by nursing pending ST evaluation to moist ground with puree, no breads/thin. Patient is currently a max assistance for all meals. Dysphagia Medical Workup: Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase Supervision: Supervision for Oral Intake=close supervision Strategies: . Alternate bites of food with bites of ice cream to help clear stasis in lateral sulci Discrete bites and sips Alternate liquids and solids . Interview on 3/5/19 at approximately 2:00 p.m. with Staff H revealed that Staff H had no knowledge of the interventions that were recommended in the Speech Therapy SLP Evaluation and Plan of treatment for [REDACTED]. Resident #69 Observation on 3/4/19 at approximately 12:15 p.m. in the East Dining Room revealed Staff H was feeding Resident #69. Review on 3/4/19 of the facility's paid feeding assistant list of residents that they can assist dated, 2019 revealed that Resident #69 was not approved to be assisted by a paid feeding assistant. Review on 3/5/19 of Resident #69's Speech Therapy SLP (Speech Language Pathologist) Evaluation and Plan of Treatment (certification period 2/4/19-3/319) revealed the following: . HX (History)/Complexities . Patient is currently on aspiration precautions and supervised max (maximum) assistance for dining. PMHX (Past Medical History): hx of PNA (Pneumonia), aspiration PNA, dysphagia . Review on 3/5/19 of Resident #69's Speech Therapy Discharge Summary, dated 2/18/19 revealed: . Skill . Patient is currently a max assistance to feed and has 1:1 supervision for all meals. Interview on 3/5/19 at approximately 2:00 p.m. with Staff H revealed that Staff H had no knowledge of the interventions that were recommended in the Speech Therapy SLP Evaluation and Plan of treatment for [REDACTED].",2020-09-01
640,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2019-03-05,880,F,0,1,U4I111,"Based on observation, record review and interview it was determined that the facility failed to ensure that the infection prevention and control program is maintained in a safe and sanitary environment to prevent the development and transmission of infections. Findings include: Observation on 2/28/19 at approximately 9:30 AM on the East/West unit revealed a white dust like substance covering the resident hallway flooring, handrails and walls. Further observation revealed a unattached lifted blue matt on the resident hallway floor with a white dust like substance on this matt. Interview and observation on 2/28/19 at approximately 10:45 a.m. with Staff J (Infection Control, Registered Nurse) confirmed that there was a white dust like substance covering the East and West resident hallway flooring, handrails and walls and that there was a unsecured lifted blue floor matt on the resident hallway floor with a white dust like substance covering this matt. Staff J confirmed that this area was undergoing construction. Staff J and a unidentified construction electrician confirmed that this area was under construction and that the blue lifted floor matt in the above findings should be placed inside the doorway entrance to the construction area and that white dust like substance observed was due to the construction and that there was no barrier in place to prevent dust and debris from entering areas in the facility outside of the construction area. Observation on 3/1/19 at approximately 7:20 a.m. on the East and West unit construction area revealed an unlocked room with unattended construction tools and equipment which were accessible to unauthorized individuals and to residents on the East and West units. Interview and observation on 3/1/19 at 7:20 a.m. with Staff L (Licensed Nursing Assistant) at the time of the above listed observation confirmed the findings listed above. Interview and observation on 3/1/19 at approximately 8:30 a.m. with Staff J and an unidentified construction project manager confirmed that there were no containment measures or barriers in place for the facility ventilation, plumbing and electrical construction. The construction project manager confirmed that an ICRA (Infection Control Risk Assessment) was not done for this facility construction project. Staff J confirmed at this interview and observation that the facility had no ICRA completed for the facility construction. Review on 3/5/19 of the facility ICRA (Infection Control Risk Assessment) revealed the following: Step 6. Identify issues related to: ventilation, plumbing,electrical in terms of occurrence of probable outages. Dust generated from demo/construction. Step 6. Identify containment measures, using prior assessment. What types of barriers? (E.g., solids wall barriers); Will HEPA filtration be required/ Plastic Barrier, Hepa filtered vacuum, neg pressure. (Note: Renovation/construction area shall be isolated from the occupied area during construction and shall be negative with respect to surrounding area) . Interview on 3/5/19 at approximately 9:45 a.m. with Staff K (Administrator) and Staff M (Director of Maintenance) confirmed that the facility construction project had been ongoing for a few/couple weeks and ICRA was not completed before the construction in order to ensure that barriers and containment measures were in place to prevent exposure to materials/substances that may lead to infection control issues. Interview on 3/4/19 at approximately 2:00 p.m. with Staff J revealed that Staff J does not do surveillance in the kitchen, laundry and rehabilitation therapy departments. Infection/safety surveillance is completed by the directors of each individual department and the Director of Maintenance. Staff J confirmed that there was no systematic analysis and interpretation of the data collected by these individuals related to the infection control surveillance done in the facility. Staff J reported that the tracking and monitoring of the pneumococcal immunizations for residents is done by each of the individual unit managers and that Staff J is not responsible for the administration, monitoring or tracking of the pneumococcal immunizations. The facility infection control program only handles the Flu immunization program. Review on 3/5/19 at approximately 10:00 a,m, of the facility pneumococcal monitoring and tracking documentation with Staff C revealed that the East unit documents a Y in the section indicating that the resident has received the pneumococcal vaccine and does not document the date the pneumococcal vaccine was given, the West unit utilizes the same form and indicates Y with the date the resident was given the pneumococcal vaccine and the Rehabilitation unit utilizes the facility INFORMED CONSENT FOR PNEUM[NAME][NAME]CAL VACCINE and documents year this vaccine was given and/or documents rec'd states yes. Interview on 3/5/19 at approximately 10:00 a.m. with Staff C (Director of Nursing) revealed that each of the three individual unit managers are responsible for ensuring that eligible residents are offered and when needed are administered the pneumococcal vaccine. Staff C reported that there was no documented evidence to show that residents are offered the second pneumococcal vaccine when eligible and that there is no facility system review and analysis of the pneumococcal immunization program. Interview on 3/5/19 at approximately 10:00 a.m. with Staff C confirmed that there was no documented evidence to show that an annual review of the Infection Control Program policies and procedures had been conducted. Observation on 02/28/19 at 9:20 a.m. with Staff F (Director of food serves) while touring the kitchen area revealed that several items are in need of repair or placement. These areas are as follows: 1) Both the walk in refrigerator and freezer floors were dirty due to the condition of the floor being unable to be cleaned due to pitting of the flooring and the lifting of the floors due to wear and tear of both units. 2) A large amount of dust was observed on the condenser fan in the walk-in refrigerator and build up of rust, this observed was shown to Staff (F) who stated the unit can not be cleaned due to the condition of the unit. 3) Storage racks in the walk-in refrigerator are rusted pitted and unable to be properly cleaned due to there conditions. 4) On top of the stove is a Griddle covered in build up and unable to be properly cleaned. Staff (F) stated that the grill is still used everyday for eggs and grilled cheese.",2020-09-01
641,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2019-03-05,883,B,0,1,U4I111,"Based on review of the individual facility unit pneumococcal resident Report Sheets and interview the facility failed to ensure and implement a facility system for the monitoring and recording of pneumococcal immunizations. Findings include: Review on 3/5/19 at approximately 10:00 a.m. of the facility pneumococcal monitoring and tracking documentation with Staff C (Director of Nursing) revealed that the West unit documents a Y in the section indicating that the resident has received the pneumococcal vaccine and does not document the date the pneumococcal vaccine was given, the East unit utilizes the same form and indicates Y with the date the resident was given the pneumococcal vaccine and the Rehabilitation unit utilizes the facility INFORMED CONSENT FOR PNEUM[NAME][NAME]CAL VACCINE and documents the year this vaccine was given and/or documents rec'd states yes. Interview on 3/5/19 at approximately 10:00 a.m. with Staff C (Director of Nursing) revealed that each of the three individual unit managers are responsible for ensuring that eligible residents are offered and when needed are administered the pneumococcal vaccine. Staff C reported that there was no documented evidence to show that residents are offered the second pneumococcal vaccine when eligible and that there is no facility systematic review and analysis of the pneumococcal immunization program data from each of the individual facility units.",2020-09-01
642,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2018-04-27,607,E,1,0,13LE11,"> Based on record review and interview, it was determined that the facility failed to follow their written polices and procedures for allegations of abuse for 2 of 2 sampled allegations of abuse. (Resident identifiers are #1, #2, #3, #4 and #5.) Findings include: Review on 4/27/18 at approximately 8:30 a.m. of the facility's investigation for an allegation of verbal abuse against Staff [NAME] (Licensed Nursing Assistant(LNA)) during care of Resident #1 revealed the approximate time of the alleged verbal abuse was approximately 6:45 p.m. on 1/27/18. An investigation statement from Staff F (LNA) revealed the incident was reported to the nurse in charge following the incident. An investigation statement from Staff G (LNA) revealed a separate incident of an alleged verbal abuse against Staff [NAME] with Resident #2 and Resident #3 on 1/27/18 between 9:30 p.m. and 10:30 p.m An investigation statement from Staff H (LNA) revealed a separate incident of alleged verbal abuse against Staff [NAME] of Resident #4 on 1/27/18 at approximately 10:30 p.m. which was reported to the nurse. Review on 4/27/18 at approximately 11:00 a.m. of Staff E's time sheet for 1/27/18 revealed that Staff [NAME] left the facility 11 p.m. at the end of shift. Review on 4/27/18 at approximately 8:30 a.m. of the facility's investigation for an allegation of verbal abuse by Staff I (LNA) on 4/8/18 at approximately 6:00 p.m. revealed an allegation of verbal abuse of a group of residents sitting in the hallway. This alleged verbal abuse was immediately reported by Staff J (LNA) to Staff K (Floor Nurse) and Staff L (Weekend Supervisor) but no investigation was initiated until 4/13/18. Further review of the investigation revealed that on 4/13/18 a separate incident of abuse was alleged for Staff I from Resident #5. Review on 4/27/18 at approximately 11:00 a.m. of Staff I's time sheet for the week of (MONTH) 8, (YEAR) revealed that Staff I worked Sunday 4/8/18, Monday 4/9/18, Tuesday 4/10/18, and Thursday 4/12/18. Review on 4/27/18 at approximately 10:00 a.m. of the facility's policy titled Abuse Prevention, Reporting, and Prevention Program revised 1/24/18, page 5, under Protection, revealed the following .The supervisor must ensure that the appropriate action is taken to treat the resident and to protect the resident while the investigation is being conducted. This will include the following actions: 1) Instructing the alleged individual to punch out and leave the facility (suspension) pending further notification from the director of nursing or his/her designee . Interview on 4/27/18 at 12:55 p.m. with Staff B (Director of Nursing) confirmed the above findings for Staff [NAME] and that Staff [NAME] was allowed to continue to work after the first allegation of abuse on 1/27/18 at approximately 6:45 p.m. until the end of shift at 11:00 p.m. The above interview also confirmed the above findings for Staff I and that Staff I was allowed to work 3 days after the first allegation of abuse and no investigation had be initiated.",2020-09-01
643,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2018-04-27,947,B,1,0,13LE11,"> Based on record review and interview, it was determined that the facility failed to ensure that in-service training for nurse aides included resident abuse prevention training for 2 of 5 nurse aides reviewed. Findings include: Review on 4/27/18 at approximately 10:15 a.m. of Staff E's LNA (Licensed Nurse Aide) and Staff I's (LNA) employee records revealed no documentation of abuse training. Interview on 4/27/18 at 12:55 p.m. with Staff B (Director of Nursing) confirmed the above finding. The above interview revealed that Staff [NAME] and Staff I were agency staff and the agency did not mandate abuse training. The above interview also revealed that abuse training for Staff [NAME] and Staff I had not been done at the facility.",2020-09-01
644,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2018-10-05,552,B,0,1,7FX411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to fully inform residents of the risk of treatment from [MEDICAL CONDITION] medications for 4 of 4 residents reviewed in a standard survey sample of 19. (Resident identifiers are #26,#53, #35, #39) Findings include: Resident #53 Review on 10/5/18 at approximately 10:30 a.m. of Resident #53's medical record revealed that Resident #53 had a physician's orders [REDACTED].#53 has a [DIAGNOSES REDACTED]. Review on 10/5/18 at approximately 10:45 a.m. of Resident #53's informed consent for Psychopharmacologic medication revealed the boxes indicating that the resident or representative was given information pertaining to the black box warning associated with [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME] were not checked off. Interview on 10/5/18 at approximately 10:45 a.m. with Staff B (Unit Manager) revealed that the staff would check off the boxes to indicate the resident or representative was given information pertaining to black box warnings. Staff B confirmed that the boxes were not checked off on Resident #53's informed consent for [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME]. Resident #35 Review on 10/5/18 at 2:37 p.m. of Resident #35's physician orders [REDACTED].#35's Medication Administration Record [REDACTED]. Review on 10/5/18 at 2:40 p.m. of Resident #35's Informed Consent for Psychopharmacologic Medication, dated 2/2/18, signed by the Power of Attorney, revealed the boxes indicating that the resident or representative was given information pertaining to the black box warning associated with [MEDICATION NAME] were not checked off. Interview on 10/5/18 at approximately 2:45 p.m. with Staff C (Unit Manager) revealed that staff would check off the boxes to indicate the resident or representative was given information pertaining to black box warnings. Staff confirmed that the boxes were not checked off on Resident #35's informed consent for [MEDICATION NAME]. Resident #39: Record review on 10/5/18 at approximately 1:00 pm for Resident #39 revealed a consent form dated 6/15/17 signed by the resident for the Antipsychotic medication [MEDICATION NAME] 25 mg (milligrams), 1 tab PO (by mouth) BID (twice per day), and [MEDICATION NAME] 50 mg PO at HS (Bedtime). Further record review at the same time revealed that there were lines with check boxes on the consent form that were meant to indicate that the responsible party/parties had received the required information in order to make an informed consent to the use of this drug, and, that the Black Box Warning had been clearly explained in order to provide an informed concent for the resident to receive the drug. The check boxes that indicate that a copy of the FDA Patient Information Sheet, and FDA warning letter (Black Box Warning) for the drug were left blank, and, as a result, the consent form did not indicate that the responsible party/parties had the information necessary to make an informed decision regarding consent for the resident to receive this medication. Interview with Staff D (Director of Nursing) revealed that this form was not utilized as it was designed to be, and therefore, does not indicate that the responsible parties had the information necessary to make an informed decision regarding consent for the resident to receive this medication. Resident #26 Review on 10/5/18 at approximately 2:05 PM of Resident #26's medical record revealed a Psychopharmacological Medication-Informed Consent for the use of [MEDICATION NAME] for the condition of Alzheimer/Dementia with Behaviors. The consent had a telephone consent dated 11/1/16 and a signature from Resident #26's Responsible Party dated for 11/4/16. There is no documentation in the medical record that the Responsible Party was provided information that users of Antipsychotic medication experienced increased rates of mortality (Food & Drug Administration Mortality Warning). Interview on 10/5/18 at 2:45 PM with Staff C (Unit Manager) regarding the lack of documentation that residents and their responsible parties are informed about the FDA mortality warning when notified of the addition or change of psychopharmacologic medication to a resident's pharmacy orders. Staff C confirmed that the unit staff did not document that the FDA Mortality Warning was provided when obtaining consent from responsible parties.",2020-09-01
645,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2018-10-05,582,B,0,1,7FX411,"Based on record review and interview, it was determined that the facility failed to provide form NOMNC (CMS Notice of Medicare Non-Coverage), for 2 out of 3 residents reviewed for Beneficiary Protection Notification. (Resident identifiers are #26 and #46). Findings include: On 10/4/18 at approximately 11:00 am, a Beneficiary Protection Notification Review was conducted on 3 resident records requested. As per record review on 10/4/18 at approximately12:30 pm and interview with Staff A (Administrator) on 10/4/18 at approximately 1:00 pm, it was revealed that Resident #26 and Resident #46 remained in the facility but were reaching their last covered day of Medicare Part A services. Resident #26 and Resident #46 were only issued a SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice form CMS- ), which informs the beneficiary of any liability for payment of any services that the beneficiary wants to continue that will no longer be covered by Medicare. Resident #26 and Resident #46 were not issued a NOMNC (Notice of Medicare Non-Coverage) which informs the beneficiary of their rights to an expedited review of a service termination, but does not fullfill the obligation of the facility to inform the beneficiary of any liability for payment for continued services. Facilities are required to provide both forms SNFABN and NOMNC in this instance. Interview with Staff A, Administrator revealed that the facility misunderstood the requirements for which forms were to be provided for their residents when Medicare Part A services were ending. After Staff A reviewed the requirements, Staff A agreed with the above statements regarding issuing of the NOMNC.",2020-09-01
646,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2018-10-05,610,D,0,1,7FX411,"Based on record review and interview, it was determined that the facility failed to have evidence that alleged violations were thoroughly investigated for 1 of 19 residents in the final sample. (Resident identifier is #35.) Findings include: Review on 10/05/18 at 10:13 a.m. of Resident #35's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed 5 of 30 days (9/4/18, 9/6/18, 9/9/18, 9/14/18, and 9/20/18) in which Resident #35 kissed 1 or 2 female residents and 1 of 30 days (9/19/18) in which Resident #35 got into bed with another resident. Review on 10/5/18 at 11:50 a.m. of Resident #35's nursing notes from 9/4/18 revealed the following: Resident kissed 2 residents in dayroom. (Initials removed) (who was very upset at (pronoun removed) . There were no other nursing notes for the above incidents when Resident #35 kissed residents or when Resident #35 got into bed with another resident. There was no indication who the above residents were and no evidence that an assessment was done to determine if the behaviors were unwanted or if the residents were impacted negatively. Interview on 10/5/18 at 12:30 p.m. with Staff D (Director of Nursing) confirmed the above findings and revealed that the above behaviors were not reported to the State Agency. Interview also revealed that Staff D would report and investigate the above behaviors if the resident that was kissed or crawled into bed with were psychologically impacted. Interview on 10/5/18 at 1:30 p.m. with Staff C (Unit Manager) revealed that when Staff C intervenes with Resident #35's above behaviors, Staff C made sure the residents that are being kissed were okay.",2020-09-01
647,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2018-10-05,641,B,0,1,7FX411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview it was determined that the facility failed to accurately code the Minimum Data Set (MDS) of two residents in a survey sample of 19 residents. (Resident identifiers are #11 and #84.) Findings include: Resident #11 Observation on 10/3/18 at 11:45 AM of Resident #11 revealed no presence of a [MEDICAL CONDITION] or the aftermath of tissue disruption indicative of the resident having had a recent [MEDICAL CONDITION]. Interview with Resident #11 at the same time as the observation reveal Resident #11 denial that they ever had a [MEDICAL CONDITION]. Review on 10/4/18 review of Resident #11's medical record of revealed no documentation that Resident #11 had a tracheosteomy. Review of Resident #11's Admission MDS dated [DATE] revealed that in Section O; question 0100; line E; under the column 'While a Resident', Resident #11 was coded 'Yes' as to receiving trachostomy care at the time the entry was made. Resident #84 Observation on 10/3/18 at 12:17 AM of Resident #84 revealed no presence of restraints. Review of Resident #84's living accommodations revealed no use of restraints. Short siderails were noted in use on Resident #84's bed, and the bed was not located against the wall on either of the sides of the bed. Review on 10/4/18 at approximately 10:00 AM of Resident #84's medical record and the care plan revealed that Resident #84 was not subjected to restraints. Review of Resident #84's 5-Day MDS assessment dated [DATE] revealed that in Section P; question 0100; line H (Other), Resident #84 was coded 'Used Daily' as to receiving restraint care. Interview on 10/5/18 at 2:30 PM with Staff E, RN (Registered Nurse), revealed that the two entries were coded incorrectly for Residents #11 & #84. When asked if there was a process in place to ensure the accuracy of entries in to the MDS template, Staff [NAME] replied that there was no such process.",2020-09-01
648,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2018-10-05,926,B,0,1,7FX411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to have smoking policies and procedures that address that individual's risk of smoking for 1 of 1 resident reviewed who smoked. (Resident identifier is #23.) Findings include: Interview on 10/4/18 at 9:55 a.m. with Resident #23 revealed Resident #23 goes outside to the designated smoking area to smoke. Resident #23 revealed they can not keep their cigarettes or lighter on their person and can only smoke if a friend or family member is outside with them. Review on 10/5/18 at 9:49 a.m. of Resident #23's assessments revealed no smoking assessment. Review of Resident #23's current care plan revealed no goals/interventions for smoking. Review of Resident #23's demographics revealed that Resident #23 was admitted to the facility on [DATE]. Observation on 10/5/18 at 11:30 a.m. revealed Resident #23 was outside smoking with a man in the designated smoking area (in front of the facility at a bench and an ash tray). Review on 10/5/18 at 12:00 p.m. of the policy titled Resident Smoking Policy, last revised 3/1/16, revealed the following: Our facility has been designated a resident smoke-free facility as of 6/1/08., 2. Smoking materials, matches, lighters or any other incendiaries devices may not be kept in the resident's room or nursing home common area., and Residents may smoke outside the facility, at least twenty-five (25) feet away front he building, with the supervision of a family member. The facility's smoking policy did not address assessing the resident's ability to independently smoke. Interview on 10/5/18 at 12:45 p.m. with Staff D (Director of Nursing) confirmed that there was no smoking assessment or care plan interventions for smoking for Resident #23. Interview revealed that the facility does not do a smoking assessment on residents who smoke because they require a resident to smoke with a friend or family member and do not allow residents to have smoking materials. Observation on 10/5/18 at 3:36 p.m. revealed Resident #23 sitting outside at the above designated smoking area. Resident #23 took a cigarette out of their pocketbook and put it in (pronoun removed) mouth until a woman arrived to smoke with resident.",2020-09-01
649,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2019-12-06,689,D,0,1,W0Z511,"Based on interview, record review, policy and procedure review and review of manufacturers instructions it was determined that the facility failed to ensure that 1 resident out of 4 residents reviewed for falls were free from falls and accidents in a final survey sample of 19 residents. (Resident identifier is #91). Findings include: Interview on 12/4/19 at approximately 9:15 a.m. with Resident #91 revealed, I slid right out off of my pad out of my chair yesterday. Review on 12/5/19 of the post fall report dated 12/3/19 revealed: .Describe incident (FACTS ONLY) include injuries sustained): Scooting forward in wheelchair from middle of room to get to (pronoun omitted) lunch, lift pad in wheelchair, fell on floor Interview on 12/6/19 at approximately 9:00 a.m. with Staff A (Unit Manager) revealed that lift pads are not left under residents in wheelchairs unless they have been assessed and it is care planned. Staff A confirmed that Resident #91 had not been assessed and was not care planned to leave the lift pad on after transfer to wheelchair. Review on 12/6/19 of the manufacturers instructions for the Vancare Lift, dated (MONTH) (YEAR) revealed: .Leaving slings positioned under patients in wheelchairs, etc. There are times when leaving the sling under a patient while he or she is seated in a wheelchair or chair would promote patient comfort and would enable staff to provide care. Before this can be done, however, the patient's posture must be evaluated by a nurse or professional rehabilitation department staff member to see if leaving the sling under the patient might contribute to the patient sliding out of, or falling off of, a wheelchair or chair. Secondly, the patient's clothing, the sling fabric, and the surface of the chair or wheelchair must be assessed for slipperiness. WARNING If leaving the sling under the patient places the patient at risk for sliding out of, or falling off of, the chair or wheelchair, the sling may not be left under the patient Interview on 12/6/19 at approximately 10:30 a.m.with Staff B (Director of Nurses) confirmed that the lift pad should not have been left under Resident #91 after the transfer to the wheelchair. Staff B revealed that there was no assessment done by therapy or nursing to evaluate Resident #91's safety to leave the lift pad on after transfer. Review on 12/6/19 of the facility's policy and procedure titled, Transfer, Transport, and Repositioning of Residents-Minimal Lifting, Revision date 8/5/19 revealed: .Procedure 1. Transfer of a Resident .c.ii. Use mechanical lifting devices and other approved resident handling aids in accordance with instructions and training",2020-09-01
650,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2019-12-06,695,D,0,1,W0Z511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and policy and procedure review, it was determined that the facility failed to ensure respiratory care is provided for 1 out of 2 residents reviewed for respiratory care in a final sample of 19 residents. (Resident identifier is #7.) Findings include: Review on 12/6/19 of Resident #7's current physician orders [REDACTED]. Fill portable 02 (oxygen) tanks prior to end of shift every day shift, dated 9/6/19. 02 @ 3L/min (Liters per minute) via (by means of) n/c (nasal cannula) continuously while at rest, 4 L/min when ambulating, dated 3/29/19. Review on 12/5/19 of Resident #7's nursing notes revealed the following: Nursing note dated 9/5/19 at 15:55, Resident upset and complained to staff that 02 tanks are empty and not being filled consistently. Task entered for LNA's (Licensed Nursing Assistant) to fill prior to end of shifts. Nursing note dated 11/1/19 at 13:57. Call from social services stating that (pronoun omitted) was having SOB (shortness of breath) and c/o (complaints of) chest pain. VS (vital signs) 98.2 65 20 140/44 92% room air. Noted oxygen tank empty. Oxygen tanks filled by LNA (Licensed Nursing Assistant). After sitting for a while was feeling better. Able to walk to room (short distance) and was put on the wall 02 (oxygen). Review on 12/6/19 of Resident #7's oxygen care plan revealed the following: Focus Oxygen: I require oxygen therapy related to my [DIAGNOSES REDACTED]. Interventions, . Observe oxygen precautions. Keep portable 02 tanks filled at all times and anticipate the need to refill prior to shift change. Review on 12/6/19 of the liquid oxygen tank duration chart which was provided by the facility revealed the following: Portable oxygen tanks at 3 lpm (liters per minute) have a run time of 5.3 hours. Portable oxygen tanks at 4 lpm have a run time of 4.1 hours. Review on 12/6/19 of the facility's policy and procedure titled, Liquid Oxygen [MEDICATION NAME], revision date 7/7/19 revealed: .Monitoring . 3. The LNA assigned to the resident who is using liquid oxygen portable canister is responsible for checking the oxygen level in the canister during care. If the oxygen level is found to be one-quarter or less, the canister shall be refilled Interview on 12/6/19 at approximately 9:15 a.m. with Staff A (Unit Manager) revealed that there would be a 1-2 hour window that Resident #7's portable oxygen tank would be empty on a regular basis due to lpm's that the resident is on. Interview on 12/6/19 10:45 AM interview with Staff B (Director of Nursing) revealed that the LNA's are filling the 02 tanks at the end of each shift.",2020-09-01
651,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2019-12-06,727,C,0,1,W0Z511,"Based on interview and review of the facility daily nursing department schedules, it was determined that the facility failed to ensure that a Registered Nurse was on duty 8 consecutive hours a day 7 days a week. Findings include: Review on 12/6/19 of the facility daily nursing department schedules revealed that there was no Registered Nurse (R.N.) scheduled on duty for three shifts, 7A-3P . 3P-11P . 11P-7A, on both the East and West units on the following days: - Sunday, (MONTH) 19, 2019 - Sunday, (MONTH) 25, 2019 - Sunday, (MONTH) 3, 2019 Review on 12/6/19 of the facility daily nursing department schedules revealed that there was no Registered Nurse scheduled on duty for two shifts, 3P-11P . 11P-7A and the R.N. scheduled 7A-3P scheduled 7 hours, 7a-2p and not 8 consecutive hours on Saturday, (MONTH) 19, 2019. Interview on 12/6/19 at 1:00 p.m. with Staff B (Director of Nursing) confirmed that there was no R.N. on duty for 8 consecutive hours on the three days listed in the above findings. Staff B also confirmed that the R.N. on duty for Saturday, (MONTH) 19, 2019 was scheduled for 7 hours and there was no R.N. on duty for 8 consecutive hours on Saturday, (MONTH) 19, 2019.",2020-09-01
652,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2019-12-06,732,C,0,1,W0Z511,Based on interview it was determined that the facility failed to retain the posted daily nursing staff data for a minimum of 18 months. Findings include: Interview on 12/6/19 at approximately 1:00 p.m. with Staff B (Director of Nursing) revealed that the facility was unable to produce any daily posting of nursing staff to review except for today. Staff B stated the the facility does not retain the posted daily nursing staff data and these postings are thrown out.,2020-09-01
653,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2017-12-14,550,B,0,1,PFEE11,"Based on observation, review of facility policy and procedure and interview, it was determined that the facility failed to provide meals to all residents at a table at the same time and to talk with a resident for whom they are providing assistance, rather than conducting social conversations with other staff. (Resident identifiers are #2, #8, #14, and #59.) Findings include: Observation on 12/12/17 at approximately 11:30 a.m. to 12:20 p.m. revealed 13 residents in the dining area on East Unit sitting at tables. At approximately 12:30 p.m. meals were starting to be served. There were no staff interaction with these 13 residents during that time. Staff noted to be around the nursing station. Observation on 12/12/17 at approximately 12:30 p.m. in the East Unit dining room revealed that meals were not being served table by table rather 1 resident at one table, then 1 resident at another table. Observation on 12/13/17 at approximately 8:45 a.m. in the East Unit dining room revealed that meals were not being served table by table. Observation on 12/13/17 at approximately 8:58 a.m. revealed the following residents were seated at different tables in East Unit dining , Resident #2, Resident #8, Resident #14, and Resident #59. These 4 residents, were eating their meals and the other residents at the tables did not have any meals served. Interview on 12/13/17 at approximately 9:20 a.m. with Staff A (Unit Manager) revealed that there was no system in place on how meal trays are distributed to residents in the East Unit dining area. Review on 12/14/17 of the facility policy and procedure, Serving of Food revision date 5/30/17 revealed that there was no system in place for meal delivery for table to table service. Observation on 12/12/17 at approximately 11:58 a.m. of Staff F, LNA (Licensed Nursing Assistant) in the dining room on the East unit revealed Staff F feeding a resident while having an extended personal conversation with another employee. Observation on 12/12/17 at approximately 12:30 p.m. in the dining room on the East unit revealed that meals were not being served by table, but were being distributed randomly to 1 resident at 1 table then 1 resident at another table, so that at no time during the dining observation was there a table where all residents had their meals at the same time. Observation on 12/13/17 at approximately 12:00 p.m. to 12:30 p.m. of the main dining room revealed approximately 25 residents who were being served at different times. There was only one staff member serving residents for approximately the first fifteen minutes. Residents, who were sitting at the same table, were not served at the same time. Some residents were served their meal and had finished eating and were getting ready to leave when other residents, at the same table, had not been served yet.",2020-09-01
654,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2017-12-14,656,D,0,1,PFEE11,"Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan for 2 residents in a standard survey sample of 25 residents. (Resident identifiers are #40 and #56.) Findings include: Resident #40 Observation on 12/12/17 at approximately 10:00 a.m. of Resident #40 revealed that Resident #40 used a seat belt in the wheelchair. Review on 12/13/17 of Resident #40's medical record revealed that there was no documentation in the care plan that Resident #40 used a seatbelt when in the wheelchair. Interview on 12/14/17 at approximately 11:00 a.m. with Staff B (Unit Manager) confirmed that there was no documentation in the care plan of Resident #40's use of a seatbelt in the wheelchair and that it should have been documented in the care plan. Resident #56 Review on 12/14/17 of Resident #56's progress note, dated 12/10/17, revealed that Resident #56 had a Boil noted to right inner buttock draining yellow drainage . Review on 12/14/17 of Resident #56's care plan revealed that there was no documentation in the care plan that Resident #56 had a boil. Interview on 12/14/17 at approximately 12:44 p.m. with Staff B confirmed that there was no documentation in the care plan of Resident #56's boil and that it should have been documented in the care plan.",2020-09-01
655,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2017-12-14,657,D,0,1,PFEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interview, it was determined that the facility failed to follow the care plan and based on documentation of one on one visits failed to revise the care plan for 1 resident in a standard survey sample of 25 residents. (Resident Identifier is #74.) Findings include: Review on 12/14/17 of Resident #74's comprehensive care plan for activities states that this resident, who's record revealed is severely cognitively impaired because of a [DIAGNOSES REDACTED]. A review of activity documentation indicated that Resident #74 received 2 1 to 1 visits in (MONTH) (YEAR), 2 1 to 1 visits in (MONTH) (YEAR), 1 1 to 1 visits in (MONTH) (YEAR) and 1 1 to 1 visits in (MONTH) (YEAR). There was no evidence that the facility revised Resident #74's care plan goal of 8-12 1 to 1 visits every month with activity staff which from (MONTH) (YEAR) through (MONTH) 14,2017 wasn't met. Resident #74 was not observed participating either actively or passively in any activities from 12/13-14/17 during survey. Interview on 12/14/17 with Staff I (Activities director) revealed that the activities department was short staffed. Interview on 12/14/17 with Staff H (Administrator) confirmed that the facility for three to four months recently had operated with a shortage of activity staff with only 2 of 5 activity positions being filled.",2020-09-01
656,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2017-12-14,679,D,0,1,PFEE11,"Based on record review and interview, it was determined that the facility failed to provide activities that meet the interest and needs of each resident for 1 resident out of a standard survey sample of 25 residents. (Resident identifier is #74.) Findings include: Review on 12/14/17 of Resident #74's activities care plan revealed a goal of participating in 2-3 weekly 1 to 1 visits with activity staff or 8-12 times a month. Review of Resident #74's activity participation documentation revealed that this goal from (MONTH) through (MONTH) 14, (YEAR) was not met when Resident #74 participated in 6 total 1 to 1 visits with activity staff. Resident #74 was not observed participating either actively or passively in any activities from 12/13-14/17 during survey. Interview on 12/14/17 with Staff I (Activity Director) revealed that the facility has in the activity department been short staffed. Interview on 12/14/17 with Staff H (Administrator) confirmed that for three to four months recently that the facility has been short staffed with only 2 of 5 activity staff positions being filled.",2020-09-01
657,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2017-12-14,880,D,0,1,PFEE11,"Based on record review, interview, and observation, it was determined that the facility failed to follow infection control practices of cleaning and disinfecting 1 glucometer out of 8 glucometers, and failed to offer a pneumococcal vaccination for 1 resident in a standard survey sample of 25 residents. (Resident identifier is #76.) Findings include: Resident #76 Review on 12/14/17 of Resident #76's Pneumococcal Immunization Informed Consent revealed that it was blank except for the resident identifier information. Review on 12/14/17 of Resident #76's MDS's (Minimum Data Set) dated 8/29/17 and 11/21/17 revealed that Section O0300 Pneumococcal Vaccine is checked as no, not offered. Interview on 12/14/17 at approximately 12:05 p.m. with Staff B (Unit Manager) confirmed that there was no documentation that Resident #76 was offered the pneumococcal vaccination. Observation on 12/13/17 at approximately 8:15 a.m. revealed that Staff C (Medication Nursing Assistant) wiped a glucometer with an alcohol prep pad after checking a resident's blood sugar. After wiping the glucometer with the alcohol for approximately 3 seconds, Staff C placed the glucometer back in it's case and then placed it into the medication cart. Interview on 12/13/17 at approximately 8:15 a.m. with Staff C revealed that Staff C said that either alcohol prep pads or disinfecting wipes (which were located in the bottom of the medication cart) could be used to clean and disinfect the glucometer between resident use. Interview on 12/13/17 at approximately 8:55 a.m. with Staff B confirmed that the glucometer should be cleaned and disinfected between resident use with disinfecting wipes, not alcohol prep pads. Review on 12/14/17 of the facility's policy, Infection Control - Disinfection of Resident Care Items, DATE REV(Revised) 12/13/16 revealed that .PDI - disinfectant wipes, may be used on hard surfaces and items that should not be heavily wetted. It is appropriate for .glucometers . Interview on 12/13/17 at approximately 10:09 a.m. with Staff [NAME] (Director of Nursing) confirmed that the glucometer should have been cleaned and disinfected with disinfecting wipes.",2020-09-01
658,COOS COUNTY NURSING HOME,305102,364 CATES HILL RD  PO BOX 416,BERLIN,NH,3570,2018-06-29,656,D,0,1,Q7LO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to develop a comprehensive care plan that included a resident's Urinary Tract Infection [MEDICAL CONDITION] with blood in the urine for 1 resident in a standard survey sample of 20 residents. (Resident identifier is #83.) Findings include: Observation on 6/27/18 at approximately 8:15 a.m. of Resident #83 revealed that Resident #83 ambulated out of the assisted dining room and ambulated into room [ROOM NUMBER], which was not Resident #83's room, to use the bathroom. Review on 6/27/18 of Resident #83's Progress Notes revealed the following notes dated; 6/17/18, at 17:15 (5:15 p.m.) that read .displays urgency, difficulty to start voiding, urine foul smelling . 6/18/18, at 14:51 (2:51 p.m.) that read .LNA (licensed nursing assistant) states urine foul . 6/19/18, at 14:15 (2:15 p.m.) that read .urine foul, no s/s (signs and symptoms) urinary discomfort, increased fluids encouraged . 6/20/18, at 14:11 (2:11 p.m.) that read .housekeeping notified nursing staff that resident voided in bathroom (Room #, not Resident #83's bathroom) and there was blood in the toilet. Toilet bowl noted to have multiple large clots and dark red stained water, blood noted to be driping (sic) .down (Resident #83's) leg. Noted foul urine odor. Noted lower abdomen to be rigid and notable discomfort. Resident walking around holding onto .(body part,) weeping. PCP (Primary Care Physician) faxed at this time. N/O (New order) start Bactrim DS (Double Strength) 800/160 BID (twice daily) x (for) 7 days and acidophilus TID (three times daily) x7 days . 6/20/18, at 18:19 (6:19 p.m.) that read .Resident is rushing to the toilet approx. (approximately) q 30 min. (every 30 minutes) Hematuria (blood in urine) with clots noted . 6/20/18, at 19:14 (7:14 p.m.) that read .Resident noted to be going from bathroom to bathroom, using garbage cans, incontinent of bloody urine deep red in color, at this time resident has been voiding bloody/cloty (sic) urine q (every) 15 minutes, unable to hold (pronoun omitted) urine, removed a pull up staff attempted, (sic) been changed x5. (5 times) Due to roaming to use bathrooms, and infection control resident placed 1 on 1 with staff assist as the need arises . 6/20/18, at 19:48 (7:48 p.m.) that read Resident voided 60cc (cubic centimeters) of dark thick syrup consistency urine with small amount of clots, foul odor to urine. Noted blood dripping from (genital area) . 6/20/18, at 20:09 (8:09 p.m.) that read Call placed to POA (Power of Attorney) regarding gross hematuria, (pronoun omitted) requests on call (physician on call) be notified . 6/20/18, at 20:10 (8:10 p.m.) that read Call placed to On call MD (Medical Doctor) regarding hematuria/clots and frequent voiding. T/O (Telephone Order (Physician name omitted) , obtain CBC w/diff (Complete blood count with differential) stat (immediately) and again tomorrow AM (morning) -- dx (diagnosis) gross hematuria, hold ASA (Aspirin) have PCP (Primary Care Physician) arrange bladder ultrasound . Review on 6/28/18 of Resident #83's current care plan revealed that there was no care plan for Resident #83's UTI, hematuria, or associated symptoms. Interview on 6/29/18 at approximately 10:00 a.m. with Staff A (Director of Nursing) confirmed that there was not a care plan for Resident #83's UTI, hematuria, and associated symptoms, and that these should have been addressed in their care plan.",2020-09-01
659,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2019-08-07,776,D,1,0,PF5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility failed to obtain radiology services in a timely manner for 3 residents in a final survey sample of 13 residents. (Resident identifiers are #1, #7 and #8.) Findings include: Resident #8 Review on 8/7/19 of Resident #8's progress note, dated/timed 4/2/19 9:05 p.m., revealed that Resident #8 had a witnessed fall with an assessment that showed Resident #8 had .+ROM x (positive Range of Motion for) all four extremities, no c/o (complaints of) pain, abrasions to bilateral knees noted . Review on 8/7/19 of Resident #8's progress note, dated/timed 4/3/19 12:39 p.m., revealed that Resident #8 .reports NOT being able to stand and walk on (Resident #8's) right ankle assessed right ankle appears with mild swelling no redness, palpated site and resident reports that 'it feels like its (sic) broken' 'I cant (sic) walk' . Review on 8/7/19 of Resident #8's progress note, written by Staff C (Advanced Practice Registered Nurse) dated/timed 4/3/19 12:49 p.m., revealed that Resident #8 was examined by Staff C with the documented findings of .the right ankle does appear to be slightly swollen. (Resident #8) reports pain with passive range of motion of that ankle including flexion and extension .We will send (Resident #8) for a right ankle x-ray to rule out a fracture . Review on 8/7/19 of Resident #8's physician orders [REDACTED]. Review on 8/7/19 of Resident #8's right ankle x-ray results, dated 4/4/19, revealed an oblique nondisplaced [MEDICAL CONDITION] fibula. Interview on 8/7/19 at approximately 1:45 p.m. with Staff A (Director of Nursing) and Staff B (Unit Manager) confirmed that Resident #8 had a fall on 4/2/19, complained of pain on 4/3/19 but did not have the ordered X-ray until 4/4/19. Staff A and Staff B confirmed that there was no documented evidence that Staff C was made aware that the x-ray would not be done until 4/4/19 or that 911 was called so that Resident #8 could be transported to the hospital and have the x-ray done in a timely manner. Resident #1 Review on 8/7/19 of Resident #1's progress note dated/timed 6/16/19 8:45 a.m. revealed that Resident #1 had an unwitnessed fall with an assessment that revealed Resident #1 complained of pain in right leg and that Resident #1 has full range of motion at baseline. Review on 8/7/19 of Resident #1's progress note dated/timed 6/16/19 4:21 p.m. revealed that Resident #1 continues to complain of severe pain to RLE (right lower extremity) while bearing weight. And Resident has been limping all day. Review on 8/7/19 of Resident #1's progress note dated/timed 6/16/19 5:36 p.m. revealed that Resident #1 was transported to the emergency room by ambulance at 5:05 p.m. Review on 8/7/19 of Resident #1's progress note dated/timed 6/16/19 10:20 p.m. revealed that Resident #1 returned to the facility with a [DIAGNOSES REDACTED]. Interview on 8/7/19 at approximately 1:00 p.m. with Staff A (Director of nursing) confirmed that Resident #1 had an unwitnessed fall on 6/16 at 8:45 a.m. and complained of pain and was not sent to the emergency room for evaluation until 5:05 p.m. Resident #7 Review on 8/7/19 of Resident #7's progress note dated 2/13/19 revealed that Resident #7 had an unwitnessed fall on 2/13/19 at 3:50 a.m. Nursing Assessment revealed a 1 centimeter laceration to the head after hitting it on the knob of the dresser. Resident #7 complained of severe pain to left hip and tenderness to the neck area while moving it. Progress note further states that the physician was notified by phone and gave instructions to give Resident #7 Tylenol or [MEDICATION NAME] for pain and to wait until after 0700 (7:00 a.m.) to send Resident #7 to the emergency room for evaluation. Review on 8/7/19 of Resident #7's progress note dated/timed 2/13/19 8:43 a.m. revealed that Resident #7 did not leave the facility at 8:40 a.m. to be evaluated at the emergency room . Review of Resident #7's [DIAGNOSES REDACTED].#7 had a [DIAGNOSES REDACTED]. Review of Resident #7's MAR (Medication Administration Record) revealed that Resident #7 received [MEDICATION NAME] sodium 75 mg (milligrams) twice a day, [MEDICATION NAME] 300 mg 3 caps (caplets) three times a day, [MEDICATION NAME] adhesive patch 5% 1 patch once a day and [MEDICATION NAME] 5 mg 1 tab (tablet) twice a day for pain management. Review of Resident #7's MAR for 2/13/19 revealed that Resident #7 did receive the above listed medications as scheduled. Further review of MAR for 2/13/19 revealed that following call to the physician, Resident #7 did receive Tylenol 325 mg 2 tabs at 3:48 a.m. Interview on 8/7/19 at approximately 1:15 p.m. with Staff A (Director of nursing) confirmed that physician's instructions were followed to wait until 0700 (7:00 a.m.) to transport Resident #7 to the emergency room for evaluation. Review of Resident #7's progress note dated 2/13/19 at 1:24 p.m. revealed that Resident #7 returned to facility with no further injury identified and no new orders.",2020-09-01
660,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2019-12-16,583,D,0,1,Y8EL11,"Based on observation and interview, it was determined that the facility failed to protect resident dignity by ensuring that insulin administration and blood glucose testing were done in private for 2 residents in a final survey sample of 28 residents. (Resident identifiers are #29 and #52.) Findings include: Resident #29 Observation on 12/11/19 at approximately 12:20 p.m. of the 1st floor dining room revealed that Resident #29 was seated at a table with 2 others residents. Resident #29 was eating their lunch. Staff A (Licensed Practical Nurse) approached Resident #29 and told Resident #29 that Staff A needed to administer their insulin. Staff A then lifted Resident #29's clothing up their leg exposing their upper right thigh and injected the needle into Resident #29's thigh. Resident #52 Observation on 12/11/19 at approximately 12:27 p.m. of the 1st floor dining room revealed that Resident #52 was seated at a table with 2 others residents. Resident #52 was eating their lunch. Staff A approached Resident #52 and told Resident #52 that Staff A needed to check their blood sugar. Resident #52 extended their hand and Staff A pricked their finger, drew blood and tested the blood using a glucometer. Staff A then walked over to the medication cart and returned, after a few minutes, with a syringe of insulin. Staff A told Resident #52 that Staff A needed to administer their insulin. Staff A then lifted Resident #52's shirt and administered the insulin into Resident #52's abdomen. Observation on 12/12/19 at approximately 12:27 p.m. of the 1st floor dining room revealed that Resident #52 was seated at a table with 2 others residents. Resident #52 was eating their lunch. Staff A approached Resident #52 and told Resident #52 that Staff A needed to check their blood sugar. Resident #52 extended their hand and Staff A pricked their finger, drew blood and tested the blood using a glucometer. Staff A then walked over to the medication cart and returned, after a few minutes, with a syringe of insulin. Staff A told Resident #52 that Staff A needed to administer their insulin. Staff A then lifted Resident #52's shirt and administered the insulin into Resident #52's abdomen. Interview on 12/13/19 at approximately 7:30 a.m. with Staff B (Director of Nursing) confirmed that blood glucose monitoring and insulin administration should not be done while a resident is seated in the dining room, eating a meal with other residents, but should be done with privacy.",2020-09-01
661,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2019-12-16,758,D,0,1,Y8EL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to ensure documentation of the rationale for continued use and the duration for use of PRN (as necessary) [MEDICAL CONDITION] medications for 2 residents in a final survey sample of 28 residents. (Resident identifiers are #29 and #37.) Findings include: Resident #29 Review on 12/13/19 of Resident #29's (MONTH) 2019 Medication Administration Record [REDACTED]. The review revealed that the start date for the medication order was 4/7/17 and that it was written as open ended with no stop date written. Interview on 12/16/19 at approximately 12:00 p.m. with Staff B (Director of Nursing) confirmed that Resident #29 did not have scheduled reviews of their [MEDICATION NAME] order and did not have the documented rational for continued use of this medication. Staff A also confirmed that there was no documented duration for the use of the [MEDICATION NAME] and that there should have been. Resident #37 Review on 12/16/19 of Resident #37's (MONTH) 2019 Medication Administration Record [REDACTED]. The review revealed that the start date for the medication order was 2/1/19 and that it was written as open ended with no stop date written. Interview on 12/16/19 at approximately 12:00 p.m. with Staff B confirmed that Resident #37 did not have scheduled reviews of their Trazadone order and did not have the documented rational for continued use of this medication. Staff A also confirmed that there was no documented duration for the use of the Trazadone and that there should have been.",2020-09-01
662,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2019-12-16,761,D,0,1,Y8EL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy & procedure review, and interview, it was determined that the facility failed to label a resident's insulin pens with the date of removal from cold storage in the refrigerator for 1 resident in a final survey sample of 28 residents. (Resident identifier is #83.) Findings include: Observation on 12/12/19 at approximately 11:00 a.m. of the Rose Unit medication cart revealed that there were 2 Insulin pens, one Flexitouch Tresiba and one [MEDICATION NAME] Flexipen, stored within a bag labeled for Resident #83. Neither pen was dated with the date they were removed from the medication storage refrigerator. Review on 12/13/19 of the facility policy, titled (Noun Omitted) Pharmacy Services effective date (MONTH) (YEAR), revealed that .All insulins should be stored in the refrigerator until opening. Once opened or removed from the refrigerator for storage in the medication cart, the insulin should be dated as it will expire in a given time frame per manufacturer: .Tresiba Pen 56 day expiration date .[MEDICATION NAME] Flexipen 28 day expiration date . Interview on 12/12/19 at approximately 11:00 a.m. with Staff C (Licensed Practical Nurse) confirmed that there were two Insulin pens that were not dated or labeled when removed from refrigeration. Staff C confirmed that there was no way to tell how long these two Insulin pens for Resident #83 had been stored on this medication cart and not refrigerated. Interview on 12/16/19 at approximately 7:30 a.m. with Staff B (Director of Nursing) confirmed that the Insulin pens should have dated when they were removed from the refrigerator.",2020-09-01
663,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2019-12-16,842,D,0,1,Y8EL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to ensure that a resident's record had accurate information for 1 resident in a final survey sample of 28 residents. (Resident identifier is #52.) Findings include: Review on 12/12/19 of Resident #52's face sheet revealed that Resident #52 wanted to be a full code and that Resident #52's allergies [REDACTED]. Review on 12/12/19 of Resident #52's physician orders [REDACTED]. These pages were preprinted with the resident's advanced directive and allergy information. Four out of the five pages had the following information: Under the section of for Advance Directives, it read DNR (Do Not recessitate) and the words [MEDICATION NAME] and silk tape were typed into the section of the page titled allergies [REDACTED]. The third page contained telephone orders written on 10/23/19, 10/30/19, 11/3/19 and 11/6/19. The fourth page contained telephone orders written on 10/9/19, and 10/22/19. The fifth page contained telephone orders written on 8/29/19, 9/5/19, 9/11/19, 9/23/19, 9/24/19 and 9/25/19. Interview on 12/12/19 with Staff C (Licensed Practical Nurse) revealed that during a code situation, staff would look at the Resident's face sheet, Interview on 12/16/19 at approximately 7:30 a.m. with Staff B (Director of Nursing) confirmed that Resident #52 wanted to be a Full Code. Staff B (Director of Nursing) confirmed that Resident #52's allergies [REDACTED]. Staff B also confirmed that the pre-populated Written Order pages above did not contain the information for Resident #52 and were used for Resident #52's in error.",2020-09-01
664,MERRIMAN HOUSE,3e+63,3073 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2019-05-31,740,D,0,1,G9NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility assessment review, it was determined that the facility failed to provide behavioral health/psychiatry consults for 3 residents in a final survey sample of 15 residents. (Resident identifiers are #24, #34, and #38.) Findings include: Resident #24 Observation on 5/31/19 at 9:00 a.m. of Resident #24 revealed that Resident #24 was sleeping in the activity room. Review on 5/31/19 of Resident #24's MDS (Minimum Data Set) dated 4/11/19 revealed that Resident #24 has a BIMS (Brief Interview of Mental Status) score of 00 which indicate severe cognitive impairment. Review on 5/31/19 of Resident #24's medical [DIAGNOSES REDACTED].#24 had psychiatric and neurological [DIAGNOSES REDACTED]. Review on 5/31/19 of Resident #24's current care plan revealed that Resident #24 has severely impaired cognition, depression, anxiety, dementia with behavioral disturbances, and impaired ability to engage in diversional activity for socialization and diversion. Further review revealed interventions for psych consult prn (as needed) per providers orders. Further review of Resident #24's current care plan also revealed that Resident #24 has BPSD (Behavioral and Psychological Symptoms of Dementia), distressed anxious expression, calling out, screaming, yelling, resistance with care, refusal of medications. Review on 5/31/19 of Resident #24's current [MEDICAL CONDITION] medication use care plan revealed that Resident #24 had multiple adjustments of their [MEDICAL CONDITION] medications which were as follows: .8/31/18 decreased [MEDICATION NAME] (anticonvulsant/anti-epileptic) and [MEDICATION NAME] (anti-anxiety) and increase [MEDICATION NAME] (antidepressant) . .10/24/18 start [MEDICATION NAME] (antipsychotic) 0.25 mg (milligram) q (every) 1500 (3:00 p.m.), [MEDICATION NAME] 1 mg qd (every day) and 1 mg BID (twice a day) prn . .10/28/18 [MEDICATION NAME] increase to 0.5 mg at 2:00 p.m. x 1 dose then start [MEDICATION NAME] 0.5 mg q 24 hours. d/c'd (discontinued) on 2/21/19 .12/13/18 [MEDICATION NAME] increase to 0.25 mg q 0800 (8:00 a.m.) and continue [MEDICATION NAME] 0.5 mg q 1400 (2:00 p.m.) . .12/14/18 [MEDICATION NAME] 0.25 mg q 0600. d/c'd on 2/21/19 . .12/21/18 multiple medication time changes d/t frequent refusal and to improve efficacy. [MEDICATION NAME] 0.25 mg BID x 2 days . .2/1/19 decrease [MEDICATION NAME] (antidepressant) to 25 mg qd x (for) 1 week then d/c (discontinue). Start [MEDICATION NAME] (antidepressant) 5 mg qd and reassess in 1 week . .2/8/19 [MEDICATION NAME] 1 mg qd and BID prn d/c'd . .2/9/19 [MEDICATION NAME] 5 mg qd . .2/12/19 [MEDICATION NAME] 1 mg BID prn until 2/21/19 . .2/22/19 [MEDICATION NAME] 5 mg qd- BPSD .[MEDICATION NAME] 1 mg BID prn until 3/14/19 . .3/14/19 [MEDICATION NAME] 1 mg BID prn until 4/18/19 . .4/2/19 [MEDICATION NAME] 5 mg increase to BID . .4/16/19 [MEDICATION NAME] decreased to 0.5 mg q AM (morning) . .4/20/19 [MEDICATION NAME] 1 mg q AM; [MEDICATION NAME] 1 mg BID prn . .5/10/19 [MEDICATION NAME] 1 mg BID prn d/c'd. [MEDICATION NAME] 5 mg BID d/c'd . .5/11/19 [MEDICATION NAME] increase to 10 mg qd. [MEDICATION NAME] 2.5 mg BID. [MEDICATION NAME] 0.5 mg BID x 1 day. [MEDICATION NAME] 1 mg IM (intramuscular) prn TID (3 time a day) if unable to take PO (by mouth) . .5/12/19 [MEDICATION NAME] 0.5 mg qd continued. [MEDICATION NAME] changed to liquid concentrate 2 mg/ml 0.5 mg BID . .5/14/19 [MEDICATION NAME] 50 mg 1 time only . .5/15/19 [MEDICATION NAME] increased to 75 mg BID . Review on 5/31/19 of Resident #24's progress notes for the month of (MONTH) 2019 revealed that Resident #24 had daily documentation of anxiousness, crying, yelling out, refusing care at times, refusing medication at times, hallucinations at times, redirectable at times, unable to console at times. [MEDICATION NAME] prn that was given on 5/12, 13, 14, 16, 21, 23, 24, 25 were ineffective in managing Resident #24 behavioral changes listed above. Review on 5/31/19 of Resident #24's consult notes from (MONTH) to (MONTH) 2019 revealed no psychiatry visit notes. Interview on 5/31/19 at 9:15 a.m. with Staff B (Registered Nurse Case Manager) revealed that Resident #24 had ongoing and daily BPSD, delusions, hallucinations, yelling out, screaming, unable to redirect and multiple [MEDICAL CONDITION] medication changes. Staff B stated that Resident #24's behaviors were attributed by Resident #24's [MEDICAL CONDITION] history. Staff B confirmed that the facility does not provide in-house behavioral health services/psychiatry consults. Staff B stated that the in-house nurse practitioner followed up with Resident #24's psychiatric needs. Staff. Staff B stated that the in-house nurse practitioner would consult with with a hospital psychiatrist verbally for any recommendations about Resident #24 but no psychiatrist has seen Resident #24 in the facility. Review on 5/31/19 of facility's current facility assessment, revision dated 5/28/19, revealed that the following is a list of services, contracts, and memorandums of understanding provided to the (facility name omitted) .Mental health- Maine Medical Partners- Geriatric medicine (Telehealth) . Interview on 5/31/19 at 9:20 a.m. with Staff C (Administrator) confirmed findings on the facility assessment and that the facility had no in-house behavioral health services or psychiatrist. Staff C stated that they have been working for approximately 3 years to get an in-house behavioral health/psychiatrist. Resident #38 Review on 5/30/19 of Resident #38's primary [DIAGNOSES REDACTED]. When reviewing Resident #38's Behaviors-Monitor log it revealed over the last two months that Resident #38's behaviors have increased in agitation, aggression, negative comments, kitting kicking, and throwing items. Review on 5/30/19 of Resident #38's care plan revealed under the focus area [MEDICAL CONDITION] Medication Use: (Resident #38) uses [MEDICAL CONDITION] medication r/t (related to) mood imbalance, depression, negativity, angry outburst, verbal and/or physical threats Under interventions the care plan reveals .3/20/18 [MEDICATION NAME] dosing changed to weekly due to noted spitting out of medication with inability to convince to take. 3-25-19 [MEDICATION NAME] 0.5 mg TID started 4-25-19 [MEDICATION NAME] 50 mg QAM and 100 mg QHS started 4-25-19 [MEDICATION NAME] 100 DC's and start 50 mg Bid 4-26-19 [MEDICATION NAME] 50 mg BID DC'd and 25 mg BID started 5-6-19 [MEDICATION NAME] increased to 1 mg TID. [MEDICATION NAME] changed to 10 mg Daily x 5 days 5-13-19 [MEDICATION NAME] 90 mg Weekly restarted 5-16-19 [MEDICATION NAME] 50 mg BID started. Review on 5/30/19 of Resident #38's nurses note dated 5/5/19 revealed that Resident had episode of agitation and confusion during mealtime, stating (he/she) wanted to leave while ambulating in hallway with unsteady gait. (He/she) was verbally abusive to staff and clenched fists, but once redirected to (his/her) room, (he/she) was much calmer and reoriented. (He/she) did say that (he/she) knew (he/she) was not the same anymore and could 'just kill myself'. Frequent room checks on resident, calmly sitting at bedside with no further agitated episodes . (physician) notified. Review on 5/30/19 of the nurses notes dated 5/6/19 revealed Emailed (physician) to inform them of residents escalation of aggressive behavior. Per (physician) increase [MEDICATION NAME] to 1 mg TID . Review on 5/30/19 of the nurses notes dated 5/13/19 revealed The system has identified this order as being outside of the recommended dose for this drug On further review of the of the medical record there fails to be any nurses notes or physician notes stating they have addressed the above concern. Review on 5/30/19 of the nurses notes dated 5/16/19 reveled (physician) updated on resident's continued behaviors on increase of [MEDICATION NAME], ordered increased of [MEDICATION NAME] as listed above ([MEDICATION NAME] 50 mg BID) Prior to the above medication changes the last physicians visit was on 4/9/19 stating .[MEDICATION NAME] 90/week, .new [MEDICATION NAME] 0.5 mg TID helping with routine issues such as bathing etc . Since this note Resident #38 has not had a face to face meeting by a physician and only phone orders have been made around medication changes. Interview on 05/30/19 at 03:01 p.m. revealed that Staff A (Registered Nurse) stated that they do not have any behavioral specialist nor do they use these types of specialist. Resident #34 Review of the [DIAGNOSES REDACTED].#34 revealed that Resident #34 has diagnosis' of [MEDICAL CONDITION], Major [MEDICAL CONDITION], Anxiety Disorder, Restlessness and Agitation, and Unspecified Dementia with Behavioral Disturbance. Review on 5/31/19 of Resident #34's current psychosocial well being care plan revealed Resident #34 has impaired ability to engage in diversional activity for socialization and diversion related to impaired cognition. Review on 5/31/19 of Resident #34's mood/behavior care plan revealed that Resident #34 has the potential for poor sleep pattern, poor oral intake, increased exit seeking, resistance to care, yelling at other residents, occasional episodes of anger, refusal of medications, restlessness and aggressive behaviors of hitting. The care plan further documents comments made by Resident #34 on 2/1/19 of I just want to die, I'll just kill myself. Further review of the care plan revealed interventions for behavioral health consults as needed (psycho-geriatric team, psychiatrist.) Review on 5/31/19 if Resident #34's current [MEDICAL CONDITION] medication use care plan revealed that Resident #34 had multiple adjustments made of psychotripic medication as follows: 5/2/19 [MEDICATION NAME] decreased to 0.25 ml (milliliter) BID (two times a day) due to increased lethargy. 5/6/19 [MEDICATION NAME] changed to 0.25 ml every HS (hour of sleep), and 0.5 ml every AM (morning). 5/9/19 [MEDICATION NAME] changed to 0.25 ml every AM, and 0.5 ml every HS. 5/11/19 [MEDICATION NAME] changed to 0.5 ml every AM and every HS. 5/13/19 [MEDICATION NAME] 1 ml (now) one time only, and then give 1 ml BID (start tonight). 5/14/19 [MEDICATION NAME] 0.5 mg (milligrams) every HS x 3 days; d/c'd 5/14/19. Changed to [MEDICATION NAME] 1 mg every AM and 0.5 mg every HS starting on 5/15/19. Review of Resident #34's progress notes for (MONTH) revealed documentation on 5/8/19 Resident #34 was awake all night, frequently wandering. 5/10/19 Resident refused am meds. Slept until 11am. Anxious and restless this pm. 5/11/19 Resident up and wandering throughout the night, very difficult to console or redirect. Frequently stating What can I do? and I can't do it. 5/13/19 With the exception of a half-hour nap, resident awake all night, wandering into rooms, repeatedly saying, help me, and what should I do? Sad, anxious affect. 5/14/19 Please help me. 5/19/19 Resident has been wandering all night, climbing out of bed and recliners, repeatedly. Continually asks, Help me, or What can I do. 5/21/19 Please help me, and I can't do this. 5/25/19 Very difficult to redirect and reassure. Resident frequently states I can't do it! and appears very anxious and sad. 5/26/19 Resident appeared restless ambulating with walker this AM stating help me repeatedly. Interview on 5/31/19 at approximatley 10:32 a.m. with Staff B (Case Manager) who stated that Resident #34 did require 1:1 support at times and did verbalize I just want to die, I'll just kill myself and that this behavior/statement was care planned for and that there are no further behavioral health services that have been offered.",2020-09-01
665,MERRIMAN HOUSE,3e+63,3073 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2019-05-31,880,D,0,1,G9NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, it was determined that the facility failed to maintain infection control during medication administration for 2 residents out of 29 residents observed for medication administrations. (Resident identifiers are #32 and #41.) Findings include: Review on 5/31/19 of facility's policy titled, Hand Hygiene, revised date (MONTH) 27, (YEAR), revealed that .employees perform hand hygiene before and after contact with any patient, their supplies, the patient's room .personnel are expected to perform hand hygiene with alcohol-based hand sanitizer (ABHR) .before and after direct patient/resident contact . Review on 5/31/19 of facility's policy titled, Standard Precautions and Care of All Residents, revision date (MONTH) 30, (YEAR), revealed that hand hygiene .wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites .hand hygiene can be performed using soap and water or ABHR . Resident #41 Observation on 5/30/19 at 9:17 a.m. with Staff A (Registered Nurse) of the medication administration at the rose hall unit for Resident #41 revealed that Staff A popped 1 tablet of [MEDICATION NAME] (antidepressant) 10 mg (milligram) from the medication pack into a pill cutter then Staff A used their right bare hand and touched the [MEDICATION NAME] 10 mg tablet to align the tablet in the pill cutter. After cutting the [MEDICATION NAME] 10 mg tablet in half Staff A grabbed, with their right bare hand, 2 one-half [MEDICATION NAME] tablets and placed them into 2 separate medicine cups, 1 one-half tablet of [MEDICATION NAME] was discarded via toilet and 1 one-half [MEDICATION NAME] tablet was placed with the other morning medications for Resident #41. Further observation with Staff A's medication administration for Resident #41 revealed that Staff A went to Resident #41's room and handed Resident #41 the medicine cup with Resident #41's morning medications and a cup of water which Resident #41 took with water then Resident #41 handed back the empty medicine cup and a cup of water back to Staff A which Staff A discarded in Resident #41's trash bin. Staff A then went out of Resident #41's room without hand washing or utilizing an ABHR. Resident #32 Observation on 5/30/19 at 9:24 a.m. with Staff A revealed that after the medication administration for Resident #41 Staff A went back to the rose hall unit medication cart and proceeded to obtain medication for Resident #31 without hand washing or using ABHR. Staff A poured 1 tablet of Aspirin 81 mg and 1 tablet of [MEDICATION NAME] ER 25 mg in a medicine cup and poured a glass of water from a pitcher of water in the rose hall unit medication cart. Staff A then went to the Activity room and handed Resident #31 the medicine cup with Resident #31's morning medication and a cup of water which Resident #31 took with water then handed back to Staff [NAME] Staff A then went back to the rose hall unit medication cart discarded the empty medicine cup and cup of water in the trash bin. Staff A then proceeded to start another resident's medication administration without hand washing or using ABHR. Interview on 5/30/19 at 9:26 a.m. with Staff A confirmed the above observations. Staff A stated that they should not have touched the [MEDICATION NAME] tablet with their bare hands and that they forgot to do hand washing or used ABHR before and after Resident #32 and #41's medication administrations.",2020-09-01
666,MERRIMAN HOUSE,3e+63,3073 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-07-07,282,D,0,1,8Y8Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that dietary and psychiatric interventions indicated in the comprehensive care plans were implemented for 2 residents in a survey sample of 12 residents. (Resident identifiers are #7 and #9.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 269 You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals .The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care . Resident #7 Review on 7/6/17 of Resident #7's Weights and Vitals Summary revealed that Resident #7 had a 13.4% weight loss from 141.5 lbs (pounds) on 1/9/17 to 122.5 lbs on 7/3/17. Review also revealed that the last Nutrition Assessment was on 4/11/17, at which time the Dietitian wrote that Resident #7 has experienced experienced 9% weight loss in the past 6 months . Review on 7/6/17 of Resident #7's Nutrition Care Plan, last updated on 6/21/17, revealed interventions that stated RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (As needed) .Monitor .report to provider .significant weight loss. No documented evidence could be found for a Nutrition Assessment for Resident #7 after 4/11/17, even with a further weight loss of 6 lbs from that date. Review on 7/6/17 of Resident #7's Health Status Update note dated 6/12/17 revealed that Resident #7 had a choking episode which required the [MEDICATION NAME] maneuver. Resident #7's Health Status Update note dated 6/16/17 revealed that Resident #7 had another choking episode, APRN (Advanced Practice Registered Nurse) was notified on 6/16/17 and a new order for a Swallowing Evaluation was ordered. Review of Resident #7's chest x-ray report, dated 6/21/17, which was done for Cough and fatigue. A recent choking episode revealed that Resident #7 had a left lower lobe infiltrate and was treated with antibiotic therapy. Review of APRN note dated 6/21/17 revealed .We have asked for a swallow evaluation and we are awaiting a consultation . Review of Resident #7's Nutrition Care Plan, last updated on 6/21/17 revealed an intervention Obtain and monitor lab/ diagnostic work as ordered. Report results to provider and follow up as indicated. Interview on 7/7/17 at approximately 10:00 a.m. with Staff B (Registered Nurse) revealed no documented evidence that the dietitian was made aware of the 13.4% weight loss and no documented evidence that a swallowing evaluation had been done since 6/21/17. Review on 7/6/17 of Resident #7's APRN note dated 3/1/17 revealed a note which stated Severe dementia with progressively worsening symptoms. At this point in time we will await (psychiatrist) visit .upon (psychiatrist) reevaluation we may want to consider .outpatient evaluation in a Geri psych unit. We will await his determination. Review on 7/6/17 of Resident #7's Psychiatric Consultation note dated 3/3/17 revealed that Some staff members have questioned a possible role for an inpatient geropsychiatric admission .due diligence suggests that we evaluate this option more deliberately. Resident #7 has not received Psychiatric Consultation since 3/3/17 as the facility no longer has psychiatric services since this psychiatrist has left. Resident #7's Mood/Behavior Care Plan, last revised on 4/20/17, revealed an intervention for psychiatric consult PRN. Interview on 7/7/17 at approximately 10:00 a.m. with Staff B confirmed that there is no documented evidence of a geropsychiatric admission and/or evaluation since 3/3/17. Resident #9 Review on 7/7/17 of Resident #9's Weight and Vitals Summary revealed the following weights: 6/1/17 - 120 lbs 6/2/17 - 107.5 lbs 6/10/17 - 103.5 lbs 6/17/17 - 112 lbs Review of Resident #9's medical record revealed no documented evidence that reweights were obtained to verify the accuracy of the above listed weights. Review on 7/7/17 of Resident #9's Nutrition Care Plan, dated 6/13/17, revealed an intervention Monitor and assess for changes and .report PRN. Interview on 7/7/17 at approximately 10:00 a.m. with Staff C (Registered Nurse) confirmed that there was no documented evidence of reweights being obtained. Staff C also confirmed that the Nutrition Care Plan for assessing for changes and reporting those changes was not implemented.",2020-09-01
667,MERRIMAN HOUSE,3e+63,3073 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2017-07-07,516,D,0,1,8Y8Q11,"Based on observation and interview, it was determined that the facility failed to safeguard resident information on 2 of 2 medication carts. Findings include: Observation on 7/7/17 at approximately 10:30 a.m. revealed an unattended medication cart on the Green Unit. The medication cart had a computer on top of it. The screen on the computer was open with an unidentified list showing on it. There were two Tabs at the top of the screen. These Tabs could be accessed by the surveyor by clicking the mouse located on top of the medication cart. Clicking on one of the individual screen Tabs showed access to a resident's EMAR (Electronic Medication Administration Record) and clicking on the second screen Tab allowed access to any resident's name and medical record. After approximately 5 minutes, Staff F (Licensed Practical Nurse) came over to the medication cart. Interview on 7/7/17 at approximately 10:35 a.m. with Staff F revealed that Staff F was not aware that the other Tabs could be opened up by just clicking on them. Staff F stated that Staff F would lock the computer screen when no longer using it. Observation on 7/7/17 at approximately 10:40 a.m. revealed the same medication cart, again unattended. This time, the unidentified list was on the open computer screen and the first Tab showed a locked screen when it was clicked on by the surveyor. When the second Tab was clicked on by the surveyor, it opened up the list of residents and by clicking on the resident's name, it opened up the medical record for that resident. After approximately 5 minutes, Staff F returned to the medication cart. Interview on 7/7/17 at approximately 10:45 a.m. with Staff F revealed that Staff F thought that all the screens were locked when leaving the cart. Observation on 7/7/17 at approximately 10:50 a.m. revealed an unattended medication cart on the Rose Unit. The medication cart had a computer on top of it. The screen on the computer indicated a locked screen. There was a TAB at the top of the screen, which when clicked on by the surveyor, opened up a list of residents and by clicking on the resident's name, the medical record for that resident could be accessed. Interview on 7/7/17 at approximately 10:50 a.m. with Staff A (Registered Nurse) confirmed that all screens should be locked when the cart is left unattended.",2020-09-01
668,MERRIMAN HOUSE,3e+63,3073 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2018-08-16,656,B,0,1,M9BJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan that included care, maintenance and assessment of an Arteriovenous Fistula (AVF) for [MEDICAL TREATMENT] for 1 of 1 residents in a standard survey sample of 13 residents. (Resident identifier is #21.) Findings include: Resident #21 Review on 8/16/18 of Resident #21's medical record revealed Resident #21 has a [DIAGNOSES REDACTED]. There was no record that the the AVF was currently being used and there was no documentation in the medical record that revealed Resident #21 had ever received [MEDICAL TREATMENT] treatment. There was no documentation of the AVF being assessed for Bruit and Thrill. Review on 8/16/18 of Resident #21's current care plans revealed that there was no care plan in place for Resident #21's AVF. Interview on 8/16/18 at approximately 11:30 a.m. with Staff A (Administrator) confirmed that a care plan should be in place for Resident #21 for his/her AVF as the AVF was placed earlier in (YEAR) for anticipated need for [MEDICAL TREATMENT] treatment based on his/her current [DIAGNOSES REDACTED]. Staff A stated that based on a recent doppler study that was performed on Resident #21's AVF that it is patent and mature (ready for use).",2020-09-01
669,MERRIMAN HOUSE,3e+63,3073 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2018-08-16,761,B,0,1,M9BJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review, it was determined that the facility failed to appropriately dispose of unusable medications during 1 of 2 medication pass observations. Findings include: Observation on [DATE] at approximately 7:10 a.m. during the medication pass observation with Staff B (Licensed Practical Nurse) revealed that when Staff B realized that the Tylenol that they had put in a medicine cup had expired on [DATE], they removed the Tylenol from the medicine cup with a spoon and threw it in the uncovered, unlocked trash receptacle located on the side of the medication cart. Staff B also accidentally dropped a Senna S capsule on the floor and picked it up and threw it in the same trash receptacle. Interview on [DATE] at approximately 7:10 a.m. with Staff B confirmed that it was their usual practice to discard non controlled medications in the trash receptacle on the side of the medication cart. Review on [DATE] of the Facility Policy, titled Medication Policy, dated [DATE], revised [DATE] revealed that .Wasting the remaining medication will render the medication un-usable and irretrievable. The medication should be flushed down a toilet. Do not place .into a sharps container . Interview on [DATE] at approximately 7:59 a.m. with Staff A (Administrator) confirmed that the medications should not have been discarded in the trash receptacle. Staff A stated that the facility policy was to flush all unusable medications down the toilet.",2020-09-01
670,COOS COUNTY NURSING HOSPITAL,3e+77,136 COUNTY FARM ROAD,WEST STEWARTSTOWN,NH,3597,2018-11-15,761,D,0,1,99PD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, it was determined that the facility failed to appropriately store Insulin on 1 out of 5 observed medication carts. (Resident identifier is #37.) Findings include: Observation on 11/14/18 at approximately 10:00 a.m. of the 3rd Floor North medication cart, which contained medications that were available and being used for residents, revealed a multidose vial of [MEDICATION NAME] Insulin for Resident #37. The vial had a sticker attached to it that read date open (the date of 10/1 was hand written in) and it also read discard (42 was hand written in) days after open. The vial was located in a box and the box also had a sticker on it that read Date open (10/1 was hand written in) Refrigerate until opened. If room temp. (temperature) expires (11/11 was hand written in.) Review on 11/14/18 of Resident #37's (MONTH) Medication Administration Record [REDACTED]. Interview on 11/14/18 at approximately 10:05 a.m. with Staff A (Registered Nurse) confirmed that the expiration date of the medication was 11/11/18, because it had been out of the refrigerator for 42 days. Staff A confirmed that medications stored in the medication cart are available for resident use. Staff A also confirmed that there were no other opened vials of [MEDICATION NAME] Insulin in the medication cart and that after looking at Resident #37's Medication Administration Record [REDACTED]. Review on 11/15/18 of the Facility policy titled, Medications With Special Expiration Date Requirements dated 12/12, revealed that .The beyond use date after initially entering or opening multiple dose vials is 28 days unless otherwise specified by the manufacturer . It also read .[MEDICATION NAME] vial .in use, not refrigerated 42 days .The end of use expiration date begins after opening/puncturing the product or after removing from refrigerator.",2020-09-01
671,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2017-04-28,157,E,1,0,7X5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to consult with the resident's physician when a resident's medications were not administered as prescribed or to notify the resident's representative when there was a decision to transfer a resident for 2 residents in a standard sample size of 20 residents. (Resident Identifier's are #18 and #20). Findings include: Resident #18 Review of Resident #18's admission documents revealed that the resident's son had been named the Representative on the Representative Designation form and the Consent of Treatment and Release of Information form upon admission on 12/14/15. Review of the (YEAR) Welcome Packet, under Resident Rights under Federal Law 11(n), page 21, revealed A center must immediately inform you, consult with your physician, and notify, consistent with your authority, your representative(s) when there is: .4. A decision to transfer or discharge you from the center. Review of Resident #18's progress notes from 4/7/17 revealed the resident was transferred to the hospital. There was no documentation in progress notes that the resident's representative had been notified. Interview on 4/28/17 at approximately 11:30 a.m. with Staff A (Administrator) and Staff B (Director of Nursing) confirmed that the resident's representative had not been notified. Review on 4/28/17 of Resident #20's (MONTH) and (MONTH) MAR's (Medication Administration Record) revealed the following order: [MEDICATION NAME] Acetate 1 drop each eye four times daily. In the month of (MONTH) from the 23rd thru the 31st the medication had not been administered 16 times. In the month of (MONTH) from the 1st thru the 14th the medication had not been administered 47 times. Review on 4/28/17 of the facility's policy and procedure NSG (Nursing) Physician/Advanced Practice Nurse (APN)/Physician Assistant (PA) Revision, Dated 3/15/16, revealed To communicate a change in patient's condition to physician/mid-level provider and initiate interventions as needed/ordered. Interview on 4/28/17 at 11:10 a.m. with Staff A, confirmed that there was no documentation of Physician notification of the prescribed medication not being administered.",2020-08-01
672,HANOVER HILL HEALTH CARE CENTER,305009,700 HANOVER STREET,MANCHESTER,NH,3104,2016-08-11,154,B,0,1,YCTM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, it was determined that the facility failed to ensure that consents for antipsychotic medication use were complete and correctly executed for 5 of 5 residents using antipsychotic medications in the standard survey sample of 24 residents. (Resident identifiers are #9, #12, #13, #23, and #24.) Findings include: An FDA Alert (2005) addressed Increased Mortality in Patients with Dementia-Related [MEDICAL CONDITION] (see http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm 1.htm accessed [DATE].) A website page last updated [DATE] related, in part, Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. (see http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ucm 6.htm accessed [DATE]). Resident #13 Review of this resident's current Medication Administration Record [REDACTED]. Review of the Informed Consent For Psychoactive Medications signed by the Guardian on [DATE] for use of [MEDICATION NAME] CR, [MEDICATION NAME], and [MEDICATION NAME] reveals that Possible Side Effects/Risks include death: and Nsg 2010 Drug Handbook Lippincott. This signed consent does not clearly address the increased risk of death associated with [MEDICATION NAME]. This was the most recent consent for this resident's Risperidal use in the resident's record on day one of survey ([DATE]). Resident #24 Review of this resident's current MAR indicated [REDACTED]. Review of the Psychoactive Medication Informed Consent for [MEDICATION NAME] reveals it was signed by the daughter on [DATE] and the Possible Side Effects/Risks include death increased with Dementia. The ink color for increased with Dementia did not match the rest of the document and interview with Staff B, LPN, on [DATE] revealed that Staff B added these words to the document on [DATE]. Review of the above Psychoactive Medication Informed Consent on [DATE] revealed the revision of the document was not initialed or dated, and after surveyor pointed this out to Staff B on [DATE], Staff B was observed to initial the change. The revision to the consent was not initialed or signed by the Resident/Resident Representative. Further record review revealed an Interdisciplinary Progress Notes entry dated/timed [DATE] 15:37 (the day after the [MEDICATION NAME] consent was revised) that relates DPOA contacted this shift; informed consent from DPOA obtained regarding use of antipsychotic meds and black box warning for increased mortality/death on elderly with dementia Resident #9. Record review on [DATE] of the facility form titled PSYCHOACTIVE MEDICATION INFORMED CONSENT for Resident #9 dated [DATE] revealed that Resident #9 had a medical [DIAGNOSES REDACTED].@ HS (hour of sleep). Record review and review of this consent form revealed that the facility failed to inform Resident #9 of the black box warnings associated with the use of antipsychotic medications. Resident #12. Record review on [DATE] of the facility form titled PSYCHOACTIVE MEDICATION INFORMED CONSENT for Resident #12 dated [DATE] revealed that Resident #12 had a medical [DIAGNOSES REDACTED]. Record review and review of this consent form revealed that the facility failed to inform Resident #12 of the black box warnings associated with the use of antipsychotic medications. Resident # 23 Review of Resident # 23's record revealed that the document titled Psychoactive Medication Informed Consent dated [DATE] displayed a Black Box warning that reflects the possibility of medical risks including death. On [DATE] the document was added to in the possible side effects/risks section of the form to include increased with dementia but did not have the signature of the change from the durable power of attorney or Staff B who made the change. Interview on [DATE] at approximately 3:00 p.m. with Staff B LPN (Unit Manager) confirmed that this change was made to the document on [DATE] without prior consent.",2020-04-01
673,HANOVER HILL HEALTH CARE CENTER,305009,700 HANOVER STREET,MANCHESTER,NH,3104,2016-08-11,514,B,0,1,YCTM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that medical records were complete and accurate for 2 residents in a survey sample of 24 residents. (Resident identifiers are #21 and #24.) Findings include: Resident #24 Review of this resident's Significant Change MDS with an ARD of 6/15/16 revealed that Section L was coded to indicate the resident has: No natural teeth or tooth fragment(s). However review of the Significant change MDS with an ARD of 7/28/16 revealed in Section L that L0200.B. was not checked off, indicating that the resident does have natural teeth or tooth fragments. Interview with Staff C, Administrator, on 8/11/16 revealed that Resident #24 does have teeth and that a modification is being done to correct the MDS error. Resident #21 Review 8/11/16 of the (MONTH) (YEAR) MAR for Resident #21 revealed physician orders [REDACTED].(hours) PRN (as needed for) pain (level) 1-5 and [MEDICATION NAME] IR 5 mg 2 tabs po (by mouth)Q (every) 4 .(hours) PRN (as needed for) pain (level) 6 - 10. Review of the (MONTH) (YEAR) MAR for Resident #21 revealed physician orders [REDACTED]. tab (let) by mouth every 4 hours as needed for severe pain. and [MEDICATION NAME] HCL 'IR' 5 mg tablet .2 tabs by mouth every 4 hours as needed for severe pain. On interview Staff A, RN, DON, confirmed that the orders did not appear to be correctly transcribed by pharmacy concerning the [MEDICATION NAME] orders for both 1 tab and 2 tabs administration, on the (MONTH) (YEAR) Physicians Order Sheet for Resident #21. Additional record review on 8/11/16 reveals there are no medication administration pain level parameters stated in the MAR's in an order for [REDACTED].",2020-04-01
674,HANOVER TERRACE HEALTH AND REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-12-15,281,D,0,1,GX1911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the facility adhered to professional standards of quality for not following the physician's orders [REDACTED]. (Resident identifiers are #1, #15) Review of Fundamentals of Nursing, [NAME] [NAME] Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's order [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Findings include: Review of Resident #1's medical record revealed that weekly skin assessments ordered by the physician on 10/19/16 for preventive measures were not completed on a weekly basis. The skin assessment for 12/14/16 was not signed off as completed. Review of Resident #15's medical record revealed that weekly skin assessments were not signed off as completed on 10/25/16, 11/14/16, 11/29/16, 12/14/16. At approximately 10:15 AM interview with Staff A, LPN (Licensed Practical Nurse), Unit Manager confirmed that the facility did not complete the above mentioned skin assessments.",2020-04-01
675,HANOVER TERRACE HEALTH AND REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-12-15,334,D,0,1,GX1911,"Based on record review and staff interview, the facility failed to ensure that the resident was immunized per doctor's order for 1 resident in a survey sample of 18. (Resident identifier #15) Findings include: Review of Resident #15's medical record revealed the Pneumococcal Vaccine consent form dated 9/27/16 was by the durable power of attorney requesting the vaccination. The vaccination was indicated for administration in the Medication Administration Record [REDACTED]. There is no documented evidence that the vaccination was administered. There was no documented evidence on October, November, and the (MONTH) MAR for the vaccination to be administered. On 12/15/16 at approximately 10:00AM interview with Staff A, LPN (Licensed Practical Nurse, Unit Manager) confirmed that the above findings that the Pneumococcal Vaccine had not been administered to Resident #15.",2020-04-01
676,HANOVER TERRACE HEALTH AND REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-12-15,371,E,0,1,GX1911,"Based on observations, review of Facility's food storage policilies and procedures, and interview the Facility failed to ensure that outdated foods and improperly stored foods were removed from the 2 kitchenettes that each serve 1 of the 2 nursing units in the Facility. Findings include: Observations made on 12/14/16 in the kitchenette that serves the New Horizons Nursing Unit at this facility revealed several items that were either out of date or undated: 2 loaves of bread were observed to be in the cupboard across from the refrigerator. One was a partial loaf of white bread with a date of 12/6/16. The surface of the bread appeared to be dry. It was in its original plastic wrapper, unsealed with the plasic wrapped around the remainder of the loaf. There was also a partial loaf of wheat bread with a date of 11/27/16 that was in its original plastic wrapper, unsealed with the plasic wrapped around the remainder of the loaf. It too, appeared to be dry. There were 2 medium sized coffee cups each partially full with a residents name on them one dated 12/11/16 and the other with no date. There was an undated plastic storage container of a substance that appeared to be soup. It had a residents name written on the container. There was an undated fruit plate in the bottom left front corner of the refrigerator. there was a small black covered bowl of red jello with illegible markings. Also observed, was an undated, covered breaded haddock plate with a residents name in place. Observations made on 12/15/16 in the kitchenette that serves the Reflections Unit at this facility revealed several items that were either out of date or undated: There was a partially full 48 oz. container of Thickened Lemon Flavored Water with a 9/26/16 delivery date on top, no open date or use by date was observed. The facility threw this out on 12/15/16. There was a half full bottle of bottled water with no open date observed toward the back of the refrigerator shelf. A factory package containing cheese bearing a resident's name was observed in a left hand drawer of the refrigerator. The package was open to air and the cheese was drying out and getting darker where it stuck out through the open package. A partially full box of cranberry cocktail located on the door had a use by date of 12/11/16. It was thrown out by Facility staff on 12/15/16. A partially full prune juice container was on the door with a use by date of 12/11/16. It was also discarded 12/15/16. An 8 oz. Ginger Ale was open, undated, approximately half full and sitting on top of the refrigerator, in the center at the edge of the door seal for the freezer. Review, 12/15/16, of a printed food storage policy Revised (MONTH) 7, (YEAR) and provided by Facility management, reads in part: Procedure- Foods will be labeled and dated and monitored, including but not limited to leftovers, so it is used by its use-by dae, or frozen (where applicable) or discarded. Normally this date would be 3 days from its label date. Always follow the most basic rule, when in doubt, throw it out. On interview 12/15/16 Staff D, Food Service Director stated: Generally food items are kept in the refrigerator 3 days after opening.",2020-04-01
677,HANOVER TERRACE HEALTH AND REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-12-15,441,D,0,1,GX1911,"Based on observation and interview the facility failed to ensure proper infection control practices were adhered to cleaning of the 4 of 4 glucometers on the New Horizons Unit. Findings include: Observation on 12/15/16 on the New Horizon Unit of all 4 glucometers revealed a piece of adhesive tape with the edges of the tapes frayed. Each meter was number respectively numbered in ordered to monitor. Interview with Staff B, LPN (Licensed Practical Nurse) and Staff C, LPN at the time of discovery confirmed the above findings.",2020-04-01
678,HANOVER TERRACE HEALTH AND REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-12-15,456,E,0,1,GX1911,"Based on record review and interview the facility failed to ensure 16 of 424 blood glucose monitoring results for the high control range on the Reflections unit , from (MONTH) 1, (YEAR) to (MONTH) 15, (YEAR) were within the specified high range parameters, failed to ensure 1 of 424 high control range parameters was transcribed properly and failed to ensure, on the New Horizons unit, that glucose test strips were dated when opened. Findings include: Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/4/16 the indicated high control range for glucometer #1 was 212-264, the high control range test result was 355, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #1 was 196 - 245, the high control range test result was 330, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #1 was 196 - 245, the high control range test result was 330, above the stated parameters with no corrective action documented. On 9/2/16 the indicated high control range for glucometer #1 was 199 - 249, the high control range test result was either 271 or 291, either of which is above the stated parameters with no corrective action documented. On 9/30/16 the indicated high control range for glucometer #1 was 208 - 259, the high control range test result was 271, above the stated parameters with no corrective action documented. Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/4/16 the indicated high control range for glucometer #2 was 212-264, the high control range test result was 356, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #2 was 196 - 245, the high control range test result was 340, above the stated parameters with no corrective action documented. Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/4/16 the indicated high control range for glucometer #3 was 214-267, the high control range test result was 368, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #3 was 212 - 265 the high control range test result was 330, above the stated parameters with no corrective action documented. On 10/5/16 the indicated high control range for glucometer #3 was 208 - 259, it appears on the log sheet, incorrectly, as 208 - 359. Review of the (manufacturers name redacted) Blood Glucose Monitoring System, Quality Control Record sheets, 12/15/16, on the Reflections Unit, revealed the following: on 12/1/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 250, above the stated parameters with no corrective action documented. On 12/2/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 252, above the stated parameters with no corrective action documented. On 12/3/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 256, above the stated parameters with no corrective action documented. On 12/4/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 373, above the stated parameters with no corrective action documented. On 12/5/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 260, above the stated parameters with no corrective action documented. On 12/6/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 254, above the stated parameters with no corrective action documented. On 12/7/16 the indicated high control range for glucometer #4 was 214-247, the high control range test result was 255, above the stated parameters with no corrective action documented. On 11/20/16 the indicated high control range for glucometer #4 was 212-265, the high control range test result was 350, above the stated parameters with no corrective action documented. On interview 12/15/16 with Staff A, LPN (Licensed Practical Nurse) Reflections Unit Coordinator confirmed there were some high control test results outside of the stated high control test ranges.",2020-04-01
679,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-10-19,155,B,0,1,Z00B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility's policy, state law and interview it was determined that the facility failed to adhere to the State of New Hampshire's Chapter 137-J, WRITTEN DIRECTIVES FOR MEDICAL DECISION MAKING FOR ADULTS WITHOUT CAPACITY TO MAKE HEALTH CARE DECISIONS, Section 137-J:5 for 3 residents in a standard survey sample of 24 residents. (Resident identifier's are #3, #6 and #18.) Findings include: Review on 10/18/17 of the facility's policy titled Advance Directives with a revision date of (MONTH) (YEAR) revealed the following: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with State and Federal law .5. If a resident has not executed an advance directive and does not have capacity to do so at the time of admission, then the facility must follow state law to determine who has authority to make health care decisions on behalf of the resident. Review of New Hampshire state law for Advance Directives, Section 137-J:5, effective Jan. 1, (YEAR) reveals the following: II. An agent's or surrogate's authority under an advance directive shall be in effect only when the principal lacks capacity to make health care decisions, as certified in writing by the principal's attending physician or APRN, and filed with the name of the agent or surrogate in the principal's medical record. When and if the principal regains capacity to make health care decisions, such event shall be certified in writing by the principal's attending physician or APRN, noted in the principal's medical record, the agent's or surrogate's authority shall terminate, and the authority to make health care decisions shall revert to the principal. Resident #6 Review on 10/18/17 of resident #6's medical record revealed a physician order [REDACTED].#6. Interview on 10/18/19 at 2:30 p.m. with Staff A (Social Worker) and review of the medical record for Resident #6 showed no documentation of an assessment to determine that Resident's #6's capacity for decision-making and no written statement by the physician to certify that Resident #6 lack the capacity to make health care decisions prior to activating the Durable Power of Attorney for Health Care (DPOA-HC). Resident #3 Review on 10/18/17 of Resident #3's physician orders [REDACTED]. Review of Resident #3's physician written/telephone orders revealed the following on 8/15/17: Recommend activation of POA (Power of Attorney) by PCP (Primary Care Physician). There was no statement by the physician to certify that Resident #3 lacked the capacity to make health care decisions prior. Interview with Staff A (Social Worker) on 10/18/17 at approximately 2:30 p.m. confirmed there was no reason documented for the activation of DPOA for Resident #3 and Resident #6 Resident # 18 Record review on 10/19/17 of the physician's orders [REDACTED]. There was no documentation to indicate the reason why Resident # 18 lacks the capacity to make health care decisions. Interview on 10/18/17 at approximately 2:20 p.m. with Staff G (Registered Nurse) confirmed that there was no written documentation by the physician, to certify that Resident # 18 lacked the capacity to make health care decisions prior to activating the Durable Power of Attorney for Health Care.",2020-04-01
680,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-10-19,274,B,0,1,Z00B11,"Based on record review and interview the facility failed to ensure that a comprehensive assessment is conducted within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 1 of 2 hospice residents in a standard survey sample of 24 residents. (Resident identifier is #17.) Findings include: Review on 10/19/17 of Resident #17's medical record reveals that Resident #17 received an order from the nurse practitioner on 7/31/17 to place Resident #17 on hospice. A hospice care plan was created starting on 7/31/17. Resident #17's medical record contains no documented evidence of a significant change of status assessment being completed. During an interview with Staff F, RN, on 10/19/17 Staff F confirmed that Resident #17 does not have a significant change of status assessment completed.",2020-04-01
681,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-10-19,280,D,0,1,Z00B11,"Based on medical record review, observation and interview it was determined that the facility failed to evaluate and revise care plans as the resident's status changes for 2 out of 18 sample survey. (Resident identifiers #4 and #8.) Findings include: Resident #4 Review on 10/17/17 of Resident #4's medical record in the (MONTH) (YEAR)'s Medication Administration section revealed that the Resident #4's advanced directives was full code. Review of Resident #4's advance directives care plan dated 10/6/17, revision date:10/17/17 revealed that the resident was do not resuscitate. Interview on 10/18/17 at approximately 10:00 a.m. with Staff B (Unit Coordinator) revealed that Resident #4's advance directives were full code. Resident #8 Review on 10/17/17 of Resident #8's care plan dated 10/6/14, revision date: 8/16/17 reveals (name omitted) desires bed to be placed against the wall (less than 3 feet from wall) (name omitted) requests bed against the wall to increase movement and increased independence when in room. Interview on 10/18/17 at approximately 9:30 a.m. with Staff C Licensed Practical Nurse revealed that Resident #8's bed is not against the wall. Observation on 10/18/17 at approximately 9:35 a.m. of Resident #8's room confirmed that the bed was not against the wall. Review on 10/17/17 of Resident #8's care plan dated 10/7/14, revision date 8/16/17 revealed (name omitted) is at risk for falls related to gait/balance problems. Intervention: (name omitted) will use safety belt when in motorized wheelchair. Interview on 10/18/17 at approximately 9:40 a.m. with Staff C revealed that Resident #8 does not and has not utilized a seat belt in the motorized wheel chair in a long time. Observation on 10/18/17 at approximately 9:50 a.m. of Resident #8 in motorized chair revealed that there was no seat belt on the Resident.",2020-04-01
682,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-10-19,281,D,0,1,Z00B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to follow physician's orders on 3 out 22 residents reviewed. (Resident identifier's are ##2, #17 and #21.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Pages 479 - 480 Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care .Documentation of death provides a legal record of the event. Follow agency policies and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death .Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting .Documentation of End-of-Life Care . .Time and date of death and all actions taken to respond to the impending death .Name of health care provider certifying the death .Persons notified of the death (e.g., health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death . Resident #21 Observation on 10/18/17 at approximately 7:30 a.m. during medication administration task revealed that Resident #21 was administered [MEDICATION NAME] ER (extended release) 24 hour 100 mg (milligrams). Review of the MAR (medication administration record) revealed the following physicians order: [MEDICATION NAME] ER 100 mg 24 hour 100 mg, Give 1 tablet by mouth every 12 hours [MEDICAL CONDITION](hypertension). Hold for systolic blood pressure less than 100 and pulse less than 60. Order dated 5/1/15. There was no observation of Staff D Licensed Practical Nurse monitoring the blood pressure or pulse prior to the administration of this medication. Review on 10/18/17 of Resident #21's (MONTH) (YEAR)'s Medication Administration Record [REDACTED]. Interview on 10/18/17 at approximately 8:30 a.m. with Staff D, revealed that the blood pressure and pulse had not been checked prior to the administration of this medication. Staff D revealed that because the parameters do not pop up on the computer, I never check them. Resident #17 Review on 10/19/17 of the progress notes for Resident #17 revealed the following note for 8/21/17 at 3:44 p.m Patient this shift passed away at 1429 family and hospice notified chaplain from (local hospice) in with patient at time (physician) notified patient to be transported to . There was no documentation in the medical record of the actions taken to respond to the impending death. Interview on 10/19/17 with Staff F (RN) at approximately 1:00 p.m. confirmed the above finding. Staff F indicated that the staff should have taken vitals to see if the Resident #17 had ceased breathing and the heart had stopped beating. Resident #2 Review on 10/18/17 at approximately 11:10 a.m. of Resident # 2's Medication Administration Record [REDACTED]. On 10/10/17 the medication was administered for a documented pain level of 7 and on 10/17/17 the medication was administered for a documented pain level of 6. Interview on 10/18/17 at approximately 11:10 a.m. with Staff C (Licensed Practical Nurse) confirmed that the medication was administered outside of the physician ordered parameters.",2020-04-01
683,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-10-19,332,D,0,1,Z00B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview it was determined that the facility failed to ensure medication error rates are not 5 percent or greater on 1 out of 3 units observed. (Resident identifier is #22.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 707 To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation Resident #22 Observation on 10/18/17 at approximately 7:45 a.m. during medication observation task with Staff [NAME] Licensed Practical Nurse on the Complex Care Unit revealed that Resident #22 was administered one [MEDICATION NAME] 325 mg tablet, and one Acidophillus capsule. Review on 10/18/17 of the MAR indicated [REDACTED] Aspirin Tablet, give 325 mg by mouth one time a day related to Essential Hypertension. Acidophilus Capsule (Lactobacillus) Give 2 capsules by mouth three times a day for [MEDICATION NAME] until 10/19/17. Interview on 10/18/17 at approximately 8:15 a.m. with Staff [NAME] confirmed that wrong medication was administered for the Aspirin Tablet. Staff [NAME] also confirmed that 1 capsule of Acidophilus was administered.",2020-04-01
684,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-10-19,431,D,0,1,Z00B11,"Based on observation, review and interview it was determined that the facility failed to date 2 opened multidose vials on 1 of 3 units observed. Findings include: Observation on 10/18/17 at approximately 7:40 a.m. of the Medication Room refrigerator on East Unit, revealed 2 opened vials of Aplisol, Tuberculin Purified Protein Derivative, which were not dated. Review on 10/18/17 of the Manufacturer's instructions for the Tuberculin Purified Protein Derivative revealed that A vial of Tubersol (Aplisol) which has been entered and in use for 30 days should be discarded. Interview on 10/18/17 at approximately 7:40 a.m. with Staff G (Licensed Practical Nurse) confirmed that all multidose vials were to be dated when opened and that these multidose vials were not dated.",2020-04-01
685,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2016-08-25,281,D,0,1,W09I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to transcribe a medical order correctly for 1 resident and failed to follow a physician's orders [REDACTED]. (Resident identifier is #17.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary And on page 699 it relates, Prescribers must document the diagnosis, condition, or need for use for each medication ordered and on page 708 The prescriber often gives specific instructions about when to administer a medication The text also relates on page 707 The six rights of medication administration include . The right medication . The right dose .The right route .The right time and on page 691 Excess amounts of a medication within the body sometimes have lethal effects, depending on the medication's action Resident #17 Review of Resident #17's medical record on 8/25/16 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 8/25/16 with Staff A (DON) reviewed the above findings and confirmed that the order was transcribed incorrectly and that the medication was administered once daily starting from 4/8 until Resident's #17 discharge on 6/10/16.",2020-04-01
686,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2016-08-25,499,D,0,1,W09I11,"Based on review of personnel records and interview, it was determined that the facility failed to ensure that 1 employee, out of three examined, was licensed to practice Nursing in the State of New Hampshire (NH) in accordance with applicable State laws. Findings include: Review on 8/24/16 of a sample of three personnel revealed one of the newly hired staff did not have the required licensure from the Board of Nursing (BON) in the State of New Hampshire (NH). Staff B, RN (Registered Nurse) had been hired on 7/6/16. Staff B as of 7/19/16 held an RN license with the state of Vermont. As of 8/26/16, a query on the website for the BON of the State of NH revealed no issue of any nursing license to Staff B. An examination of time card records reveal that Staff B has worked approximatly 180 hours since Staff B's hire date. A call to the NH BON on 8/29 revealed that Staff B had not applied for an NH License to practice nursing at the time of the survey. Interview on 8/25/16 at approximatly 12:30 was done with Staff D, (Director of Human Resources). The absence of a valid license for Staff B was reviewed. Staff D also stated Staff B had an issue with the fingerprints. Staff D then indicated that the facility misunderstood the NH BON website information and knew Staff B did not hold NH License to practice nursing at the time of the survey but had currently held a license from the state (he/she) had prior employment.",2020-04-01
687,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2017-04-28,281,D,0,1,7X5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to provide pain scale parameters for the use of pain medication according to accepted standards of clinical practice for 3 of 20 sampled residents. (Resident identifiers are #1, #4 and #9) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 669 Prescriber must document the diagnosis, condition, or need for use for each medication ordered . Page 708 The prescriber often gives specific instructions about when to administer a medication . Page 1063 One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. Page1234 descriptive scale are useful not only in assessed the severity of pain, but also in evaluate changes in a client's condition. The nurse can use the scales after an intervention or when symptoms become aggravated to evaluate whether the pain has decreased or increased. Resident #4 Review on 4/26/17 of Resident #4's Medication Administration Record [REDACTED]. Orders read as follows: [MEDICATION NAME] 100 mg (milligram) Capsule 1 Cap by mouth daily as needed for headache. Isomethept - Dichloralp - Acetamin 65-100-325 Capsule 2 Caps by mouth daily as needed for headache - (MONTH) repeat every hour PRN (as needed) persistent headache - Max 5 Caps/24 hrs [MEDICATION NAME] HCL F/C 50 mg 1/2 tab (25 mg) by mouth every 4 hours as needed Interview on 4/26/17 with Staff A (Registered Nurse) and Staff B (Nurse Practitioner) confirmed that there are no pain scale parameters as to which medication to use. Resident #9 Review on 4/26/17 of Resident #9's Medication Adminstration Record (MAR) for (MONTH) (YEAR) revealed the following orders: [MEDICATION NAME] 650 milligrams Suppository For TYLENOL (One) SUPP. RECTALLY EVERY 4 HOURS AS NEEDED FOR PAIN / ELEVATED Temperature (Initial start date of 12/28/14) PRN (as needed) [MEDICATION NAME] (MPAP) 325 MG TABLET FOR TYLENOL TAB 325 MG, 2 Tablets (650 MG) BY MOUTH EVERY 4 HOURS AS NEEDED FOR PAIN/ Elevated TEMP. (Initial start date 12/28/16) [MEDICATION NAME] A/F, S/F, CHERRY 160 MG/5Milliliters LIQUID FOR Tylenol 20.3 MLS (650 MG) BY MOUTH EVERY 4 HOURS AS NEEDED FOR PAIN / ELEV. TEMP. (Initial start date 12/28/16) Review of Resident #9's Medication Administration Record [REDACTED]. (Initial start date 3/20/17) There also weren't instructions or parameters regarding which of the three above medications as to when to administer based on level or type of pain. Further review of Resident #9's MAR indicated [REDACTED]. (Initial start date of 3/15/17) This physician order [REDACTED]. Review of Resident #9's (MONTH) (YEAR) nurses' medication notes revealed the following: On 4/1/17 at 2:00 a.m. Resident #9 reported pain; however, there was no documentation recording the level or location of pain reported on the back of the MAR indicated [REDACTED]. [MEDICATION NAME] 50 mg was administered and there was positive effect noted at 3:00 a.m. Review of Resident #9's (MONTH) (YEAR) PRN pain management flow sheet, the back of the MAR (Nurses' Medication Notes) and nurses' notes revealed the following: On 4/1/17 at 1400 (2:00 p.m.), Resident #9 reported pain in hands at level 8 of 10. Resident #9 was administered [MEDICATION NAME] 2 tabs; however, under the section for documenting the effectiveness of treatment it was blank. On 4/2/17 at 2:00 a.m. Resident #9 had an initial pain level 7 of 10 for back pain with [MEDICATION NAME] 50 mg administered. Effectiveness of treatment was not documented. On 4/3/2017 at 2:00 a.m. Resident #9 had a pain level rating 6 out of 10 with [MEDICATION NAME] 50 mg administered. Effectiveness of treatment was not documented. On 4/4/17 at 1:00 a.m. Resident #9 reported back pain at level 8 of 10 with [MEDICATION NAME] administered. Effectiveness of treatment was not documented. On 4/6/2017 Resident #9 reported complaints of pain at 1:30 a.m.; however, there was no pain level documented, but [MEDICATION NAME] 50 mg was administered according to the MAR. The PRN pain management flow sheet it did not indicate that Resident #9 had received the [MEDICATION NAME]. On 4/7/2017 at 2:00 a.m. Resident #9 reported back pain of level 8 out of 10 and [MEDICATION NAME] 50 mg was administered; however, effectiveness of treatment was not documented. On 4/9/17 at 1:50 a.m. Resident #9 received [MEDICATION NAME] 50 mg for pain as indicated on the MAR; however, no level of pain was noted. This administration of [MEDICATION NAME] was not recorded on the PRN pain management flow sheet. Interview on 4/27/17 in the afternoon with Staff F (Register Nurse), Staff F indicated the [MEDICATION NAME] would be given PRN if the resident's pain level was at level 6 or higher.",2020-04-01
688,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2017-04-28,282,D,0,1,7X5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to follow plan of care for 1 resident out of sample survey of 20 residents. (Resident #1) Findings include: Review on 4/26/17 of Resident #1's MAR (Medication Administration Record), care plan, PRN (as needed) Pain Management Flow sheet and Interview with staff revealed that the facility failed to evaluate pain characteristics and utilize pain scale per interventions in Resident #1's care plan. Review on 4/26/17 of Resident #1's care plan titled, Resident exhibits or is at risk for alterations in comfort related to acute pain dated, 4/18/17 revealed the following interventions: Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors. Utilize pain scale. Review on 4/26/17 of Resident #1's (MONTH) 1st thru (MONTH) 9th and (MONTH) 17th thru (MONTH) 30th (YEAR) MAR (Medication Administration Record) and the PRN Pain Management Flow Sheet revealed PRN [MEDICATION NAME] medication was administered for pain without utilizing a pain scale and also did not characterize pain per care plan. On (MONTH) 2nd (2 doses), (MONTH) 3rd (1 dose), (MONTH) 4th (1 dose), (MONTH) 5th (1 dose), (MONTH) 6th (1 dose), (MONTH) 8th (1 dose), (MONTH) 19th (1 dose), (MONTH) 20th (2 doses), (MONTH) 22nd (2 doses), (MONTH) 23rd (3 doses), (MONTH) 24th (2 doses), and (MONTH) 26th (1 dose). Review on 4/26/17 of Resident #1's MAR indicated [REDACTED] Order 1. [MEDICATION NAME] 650 MG or [MEDICATION NAME] PO (by mouth) or SUPP (suppository) PR (by rectum) every 4 hours PRN for temp >100.4 or mild pain NTE (Not to exceed) 3GMS in 24 hours. Order 2. [MEDICATION NAME] 5 MG by mouth every 6 hours as needed for pain. Order 3. [MEDICATION NAME] 10 MG by mouth every 4 hours as needed for pain. On 4/22/17 at 13:30 Resident #12 was administered PRN [MEDICATION NAME] 5 MG for 7/10 pain. On 4/24/17 at 03:00 Resident #12 was administered PRN [MEDICATION NAME] 10 MG for 7/10 pain. Interview on 4/27/17 at 2:10 p.m. with Staff [NAME] (Licensed Practical Nurse) revealed that it was staff/resident discretion on which PRN pain medication to be administered.",2020-04-01
689,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2017-04-28,371,D,0,1,7X5D11,"Based on observation, interview and review of manufacturer's instructions, it was determined that the facility failed to properly maintain thickener products in 2 of 3 refrigerators located in dining rooms/units. Findings include: Observation on 4/27/17 at 9:30 a.m. of Country Kitchen assisted dining room refrigerator revealed 2 opened, outdated thickened dairy drinks with a manufacturer use by date of 4/20/17. Observation on 4/27/17 at at 9:35 a.m. of the Francoeur Unit refrigerator revealed 1 thickened apple juice labeled opened 4/18/17 and 1 thickened lemon juice labeled opened 4/1/17. Observation in the same refrigerator further revealed 4 opened thickener beverages that were not labeled with an open date (2 lemon, 1 orange, 1 apple flavored). Review on 4/27/17 of the manufacturer's instructions on the above thickener cartons, revealed See top of carton for use-by date. Shake well before using. Once opened, store at ambient temperatures for up to 8 hours or refrigerate for up to 7 days. Interview on 4/27/17 at approximately 1:30 p.m. with Staff B (Director of Nursing) confirmed that once opened, thickeners can be refrigerated for up to 7 days.",2020-04-01
690,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2017-04-28,431,D,0,1,7X5D11,"Based on observation, interview, and policy and procedure review, it was determined that the facility failed to ensure that facility residents were safe from a discarded medication, disposed in the medication cart waste receptacle. Findings include: Observation on 4/27/17 at 8:15 am, during medication pass, Staff C (Licensed Practical Nurse) handed Resident #21 his/her scheduled medication in a medicine cup. Resident #21 took medication, one pill at a time. When Resident #21 reached in for a pill, a pill flew out of the cup and onto the floor. Staff C reached down and picked up the pill. On arrival back to the medication cart, Staff C was able to identify the dropped pill as Lexapro 10 mg and then discarded the pill into the medication cart trash bin. Interview on 4/27/17 at approximately 8:30 a.m. with Staff C it was asked if discarding into the trash was the proper procedure with all dropped pills, Staff C replied that it was. Later on 4/27/17, a current copy of policy and procedure for Medication Administration was requested from Staff B (Director of Nursing). Review of the current facility policy for Medication Administration: General (NSG305) Section: Practice Standards, #6. If medication is refused by patient, discard medication and attempt to administer again at a later time.",2020-04-01
691,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2017-04-28,514,D,0,1,7X5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to maintain complete medical records for 2 residents in a survey sample of 20 residents. (Resident identifiers are #12 and #11) Findings include: Review on 4/27/17 of Resident #12's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident #12's [MEDICATION NAME] was to be held for a Systolic Blood Pressure (SBP) less than 100/ Heart Rate (HR) less than 60. Resident #12's [MEDICATION NAME] was to be held for a SBP less than 100. Resident #12's [MEDICATION NAME] was to be held for SBP less than 100 or HR less than 60. Resident #12's Losartan Potassium was to be held for SBP less than 110. There was no documentation on the MAR indicated [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. Interview on 4/27/17 at approximately 3:00 p.m. with Staff D (Licensed Practical Nurse) confirmed the above findings. Resident #11 Review of Resident #11's progress notes from 2/4/17 revealed 3 notes: at 12:22 p.m. Resident sent to (name omitted) hospital @ 0930 orders from (physician name omitted) for L (left) hip fx (fracture) and severe pain ., at 9:30 a.m. (Resident #11) had an unplanned transfer. Contact person was notified of the transfer . and at 6:45 a.m. New order, may onstain 2 views left hip/femur r/o (rule out) fracture. There were no Progress notes documenting when the resident fell or the assessment of the resident immediately following the fall. Interview on 4/27/17 at approximately 2:30 p.m. with Staff B (Director of Nursing), Staff B confirmed that no fall assessment had been documented on Resident #11's fall on 2/4/17 and revealed it is the facility's policy to access and document the assessment when a resident has had a fall.",2020-04-01
692,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2016-10-19,152,D,0,1,UEHD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to adhere to the State of New Hampshire's Chapter 137-J, WRITTEN DIRECTIVES FOR MEDICAL DECISION MAKING FOR ADULTS WITHOUT CAPACITY TO MAKE HEALTH CARE DECISIONS, Section 137-J:5 for 1 resident in a standard survey sample of 20 residents. (Resident identifier is #15.) Findings include: Review of New Hampshire state law for Advance Directives, Section 137-J:5, effective (MONTH) 21, 2009 reveals the following: - II. An agent's authority under an advance directive shall be in effect only when the principal lacks capacity to make health care decisions, as certified in writing by the principal's attending physician or APRN, and filed with the name of the agent in the principal's medical record. When and if the principal regains capacity to make health care decisions, such event shall be certified in writing by the principal's attending physician or APRN, noted in the principal's medical record, the agent's authority shall terminate, and the authority to make health care decisions shall revert to the principal. Review on 10/19/16 of Resident #15's document titled physician progress notes [REDACTED]. This section was not completed by the physician to indicate the reason why Resident #15 lacks the capacity to make health care decisions. Further record review revealed that Resident #15 had a physician order [REDACTED]. Interview on 10/19/16 at approximately 10:30 a.m. with Staff B (Registered Nurse), Staff B reviewed the above listed document as well as the clinical record and verified that there was no documentation of an assessment to determine that Resident #15's capacity for decision-making and no written statement by the physician to certify that Resident #15 lacked the capacity to make health care decisions prior to activating the Durable Power of Attorney for Health Care (DPOA-HC).",2020-04-01
693,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2016-10-19,279,D,0,1,UEHD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 1 resident in a survey sample of 20 residents. (Resident identifier is #5.) Findings include: Review on 10/19/16 of Resident #5's nursing and social service notes from 9/1/16 to present revealed that the resident had [MEDICAL CONDITION] and spoke of suicide on 9/1/16, 9/8/16, 9/10/16, 9/14/16. Review of Resident #5's current care plan revealed no comprehensive plan of care for [MEDICAL CONDITION]. Interview on 10/18/16 at 11:15 a.m. with Staff B (Unit Manager) confirmed the above findings and revealed that staff perform 15 minute checks on days for Resident #5's [MEDICAL CONDITION] on days (pronoun removed) says something. Review of 15 Minute Check logs for (MONTH) (YEAR) revealed that facility had no 15 Minutes Check logs for 9/1/16, 9/10/16, and 9/14/16.",2020-04-01
694,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2016-10-19,281,E,0,1,UEHD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to follow physician orders, failed to properly dispose of medications and failed to follow the professional standards of practice for the administration of pain medications for 4 residents in a survey sample of 20 residents.(Resident identifiers are #5, #6, #17 and #18.) Findings include: Reference for the professional standard of practice is, Fundamentals of Nursing, 7th Edition, Potter-Perry, Mosby, Elsevier, Evolve, 2009. On page 336 - Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Reference for the standard of practice for medication disposal is the FDA (Food and Drug Administration) Safe Disposal of Medicines: Medicines play an important role in treating many conditions and diseases and when they are no longer needed it is important to dispose of them properly to help reduce harm from accidental exposure or intentional misuse . steps to dispose of most medicines in the household trash: 1. Mix medicines (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds; 2. place the mixture in a container such as a sealed bag; 3. Throw the container in your household trash; 4. Scratch out all personal information on the prescription label of your empty pill bottle or empty medicine package to make it unreadable, then dispose of the container . Resident #5 Review of the Medication Administration Record (MAR) for 10/1/16 to 10/18/16 revealed the following orders: [MEDICATION NAME] Tablet 15 MG, Give 1 tablet by mouth every 4 hours as needed for moderate pain (4-7). [MEDICATION NAME] Tablet 30 MG, Give 1 tablet by mouth every 4 hours as needed for severe pain (8-10). Further review of the MAR revealed that 15 MG of [MEDICATION NAME] was administered to the Resident on 10/6/16 with a pain rating of 0, on 10/13/16 with a pain rating of 9, and on 10/14/16 with a pain rating of 3. Pain ratings of 0,3, and 9 are outside of the ordered pain parameters for moderate pain with a rating of 4-7. 30 MG of [MEDICATION NAME] was administered to the Resident on 10/2/16 with a pain rating of 6, on 10/8/16 with a pain rating of 7, and on 10/16/16 with a pain rating of 6. Pain ratings of 6-7 are below the ordered pain parameters for severe pain with a pain rating of 8-10. Interview on 10/19/16 with Staff D (Unit Manager) confirmed the above finding and revealed that the pain rating is the pain level prior to administration. Resident #18 Review of the MAR for 6/10/16 to 6/30/16 revealed the following order: Flush PICC (Peripherally Inserted Central Catheter) line with 10 cc (cubic centimeter) of normal saline every shift three times a day [MEDICAL CONDITION]. Further review of the MAR and the Infusion Therapy Medication Administration Record revealed that there was no documentation that the picc line was flushed with 10 cc of normal saline on 10 of 63 shifts. Interview on 10/19/16 with Staff D reviewed and confirmed the above finding. Resident #6 Review of the Medication Administration Record for 09/1/16 to 09/30/16 revealed the following orders: [MEDICATION NAME] ([MEDICATION NAME]) 325 MG (Milligrams) Tablet 15 MG, Give 2 tablet orally every 4 hours as needed for mild pain. NTE (Not to Exceed) 2 g (grams)/24 hrs (hours) Start date 05/27/2016. The MAR revealed that on 9/26/16 Resident #6 received [MEDICATION NAME] at 0242 for a pain level of 8. Interview on 10/19/16 with Staff B reviewed and confirmed the above finding. Resident #17 Review of the Medication Administration Record for 10/1/16 to 10/18/16 revealed the following orders: [MEDICATION NAME] HCL Tablet 5 MG, Give 1 tablet by mouth every 6 hours as needed for pain. Start date of 07/25/2016. The MAR revealed that on 10/5/16 Resident#17 received [MEDICATION NAME] HCL 5 mg at 1935 for a pain level of 0. Interview on 10/19/16 with Staff D reviewed and confirmed the above finding. Observation on 10/18/16 at approximately 7:30 a.m. with Staff [NAME] (Registered Nurse) revealed that Staff [NAME] was preparing to dispense one tablet of [MEDICATION NAME] from the bingo card dispenser and the tablet fell into the open top drawer of the medication cart. Staff [NAME] retrieved this tablet and proceeded to wrap the tablet in a white tissue and discarded this wrapped tablet into the open trash receptacle attached to the medication cart. This medication cart is stored in the resident hallway where it is unattended and the open trash receptacle can be easily accessed by residents. Interview during this observation with Staff [NAME] reviewed how medications are discarded and Staff [NAME] confirmed the [MEDICATION NAME] tablet was discarded in the open receptacle attached to the medication cart and that it was covered and wrapped in a tissue.",2020-04-01
695,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2016-10-19,323,D,0,1,UEHD11,"Based on record review and interview, it was determined that the facility failed to transfer the resident with a two person assist resulting in a fall and the facility failed to maintain the resident on in place until transported to the emergency department for 1 resident in a survey sample of 20 residents. (Resident identifier is #11.) Findings include: Review on 10/18/16 and 10/19/16 of Resident #11's nursing progress notes dated 5/17/16 revealed the following: notified by staff that resident was on floor in room. Resident observed sitting on floor leaning against bed. No apparent distress: ROM (range of motion) WNL (within normal limits) .LNA stated 'I was transferring (resident) from w/c (wheelchair) to bed .(resident) stood up and .foot slipped out from under (resident), .butt landed on my knee and I lowered (resident) to the floor' . Review of Resident #11's fall incident report revealed that the resident has a lift code of 2 person assist. Review on 10/18/16 of Resident #11's fall incident report dated 9/30/16 and nurses progress notes revealed that a LNA, in close proximity to room 201, heard .(Resident #11) cry out and heard (resident) hit the floor. Another resident was standing in the door frame. Denied pushing resident . Documentation continued VS (vital signs) WNL (within normal limits). Poor ROM (range of motion) on right and left hip, right greater than left. Resident transported to ED (Emergency Department) .No contact with .hospital ED regarding resident's disposition. Review of Resident #11's documentation for Immediate Action Taken revealed VS WNL. Poor ROM to right and left hip; greater on the right. Resident assisted to wheelchair . Further review showed that Resident #11's pain was rated at a 7 and displayed facial grimacing, repeated troubled calling out, loud moaning or groaning, crying with rigid fists clenched, knees pulled up, pulling or pushing away and striking out. Interview on 10/18/16 with Staff F (Medical Records) reviewed the above findings and revealed that there was no documentation that could be found following Resident #11's return from the hospital emergency department to ascertain if there was an injury with treatment and did not include discharge diagnosis. Review of Resident #11's emergency room visit dated 9/30/16 revealed that Resident #11 had bilateral hip x-rays done. At the time of this interview, 18 days after the fall, there was also no documented evidence of the results of the bilateral hip x-rays. Interview on 10/19/16 at approximately 1:20 p.m. with Staff F (Director of Nursing), Staff F reviewed the above findings and Staff F confirmed that Resident #11 was a two person lift assist at the time of the incident. Staff F confirmed that Resident #11 should of been left on the floor following the 9/30/16 fall incident before being transported to the emergency room .",2020-04-01
696,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2016-10-19,356,C,0,1,UEHD11,"Based on observation and interview, it was determined that the facility failed to post the nursing staffing data and resident census on a daily basis and post in a prominent place readily accessible to residents and visitors. Findings include: Observation on 10/19/16 at 2:45 p.m. of the facility entrance way revealed the nursing staffing data and resident census was not posted. Interview on 10/19/16 at 2:45 p.m. with Staff A (Quality Assurance) confirmed the above finding and revealed that the nursing staffing data and resident census was not posted for that day anywhere in the facility. Staff A also stated that in the past it has been posted in the locked employee area near the timeclock. The employee area is not readily accessible to residents and visitors.",2020-04-01
697,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2016-08-18,281,D,0,1,M46Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and review of the facility policy and procedure it was determined that the facility failed to follow the professional standard of practice for the administration of medications and following physician orders for 3 residents in a survey sample of 20 residents. (Resident identifier's are #5, #8 and #13.) Findings include: Reference for the professional standard of practice for the administration of medications are: The Fundamentals of Nursing, 7th Edition, POTTER-PERRY, MOSBY Elsevier, Evolve, 2009 Page 336 reveals the following; Physician' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary. Page 713 reveals the following; Recording Medication administration. After administering a medication, record it immediately on the appropriate record form . Never chart a medication before administering it. Recording immediately after administration prevents errors. The recording of a medication includes the name of the medication, dose, route and exact time of administration . If a client refuses a medication or is undergoing tests or procedure that result in a missed dose, explain the reason the medication was not given in the nurse's notes. Some agencies require the nurse to circle the prescribed administration on the medication record or to notify the physician when a client misses a dose. Be aware of the effects missing doses have on a client such as in hypertension or diabetes. Coordinating care with other services when testing or procedures are being completed helps ensure therapeutic control of the disease. Review of the facility policy and procedure titled Pain Assessment and Management dated 3/19/07 revealed the following: Policy: To maintain a acceptable of comfort for all residents . Process . 3. The RN/LPN will initiate prescribed pharmalogical interventions and record them on the PRN (as needed) pain management flow sheet. 4. The RN/LPN shall document patient response to pharmalogical pain management on the PRN pain management flow sheet . Documentation . 2. Document prescribed PRN pharmalogical intervention on the PRN pain management flow sheet each time initiated. Resident #8. Review on 8/17/16 of Resident #8's Medication Administration Record [REDACTED] [MEDICATION NAME] 1 tablet by mouth every 6 hours as needed for pain PRN [MEDICATION NAME] Solution 5 mg (milligram) sublingually every 30 minutes as needed for chest pain and pain Tylenol 2 tablets 650 mg by mouth every 4 hours as needed for pain or fever not to exceed 3 GM (grams) of APAP in 24 hours PRN Review of the facility PRN Pain Management Flow Sheet revealed that Resident #8 was given the following: 17 individual doses of PRN [MEDICATION NAME] 1 tablet with a pain rating of 6/10 through 10/10, 3 individual doses of PRN [MEDICATION NAME] with a pain rating of 6/10 through 7/10 and 5 individual doses of Tylenol 650 mg with pain rating of 4/10 during the following time of 8/10 from 8/1/16 through 8/17/16. The facility failed to ensure that these three physician orders were clarified to indicate a pain rating/parameter/indication for each individual PRN medications for Resident #8. Further review of this PRN Pain Management Flow Sheet revealed that the [MEDICATION NAME] and Tylenol were given to Resident #8 when complaining of stomach, mouth, throat and all over pain with any pain rating of 10/10 to 4/10. No documented evidence was found to show that Resident #8 had requested a particular PRN pain medication for a specific pain complaint. Interview on 8/18/16 at approximately 2:00 p.m. with Staff A (Registered Nurse) and Staff B (Registered Nurse), after Staff A and B reviewed the above listed findings both Staff A and B verified that the 3 individual PRN pain medications did not have a pain rating scale/parameter for usage. Staff B verbalized that Resident #8 was able to inform the nurse what specific pain medication she needed but there is no documented evidence to show the requested PRN pain medication that was administered. Resident #5 Review of Resident #5's Medication Administration Record [REDACTED] [MEDICATION NAME] ([MEDICATION NAME]) 325 mg tablet 2 tabs (650) by mouth every 6 hours as needed for pain. [MEDICATION NAME] HCL F/C 50 mg tablet 1 tab by mouth every 6 hours as needed for pain. Further review of the physicians orders on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 8/3/16 the documented systolic blood pressure was greater than 120 and the medication was omitted. Resident #13 Review of Resident's MAR for 8/1/16 to 8/16/16 revealed that the following orders did not contain indications for use: [MEDICATION NAME] 650 mg suppository rectally every 6 hours as needed for pain or elevated temperature. Do not exceed 3 gm. [MEDICATION NAME] 325 mg 2 tabs by mouth every 4 hours as needed for pain. Do not exceed 3 gm. [MEDICATION NAME] 15 mg 1 tab by mouth every 4 hours as needed for pain.",2020-04-01
698,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2016-08-18,371,E,0,1,M46Q11,"Based on observation, record review and interview, the facility failed to properly maintain supplementary products in the kitchen Findings include: Observation in the kitchen on 8/16/16 at approximately 10:30 a.m. revealed approximately 50 undated thawed supplemental shakes (MightyShakes(R)) in the refrigerator. Manufacturer's instructions for the supplementary shakes stated that the shakes were good up to 14 days at 34 -40 Fahrenheit. Interview on 8/16/16 at approximately 10:30 a.m. with Staff C (Director of Food Services) confirmed the above findings.",2020-04-01
699,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2016-11-09,156,B,0,1,8D8C11,"Based on observation, interview and review of the facility admission information packet it was determined that the facility failed to prominently display names, addresses and telephone numbers of all pertinent State client advocacy groups and a statement that residents may file complaints with the State survey and certification agency. The facility failed to display written information about how to apply for and use Medicare and Medicaid benefits. Findings include: Observation on 11/8/16 revealed a posting of advocacy groups in the Activity/Dining room to the left of the entrance not visible to review. An information packet that is given to residents upon admission was reviewed and noted to have an incorrect address and contact number for the State survey and certification agency. Staff B (Administrator) pointed out resident rights information posted to a bulletin board not prominently displayed to view located through a door to an activity room located at the end of a hall. There was no evidence of written information about how to apply for Medicare and Medicaid benefits in the admission packet or posted in the facility. Interview on 11/08/16 with Staff B (Administrator) confirmed that the facility failed to prominently display pertinent updated information as listed in the above findings.",2020-04-01
700,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2016-11-09,167,C,0,1,8D8C11,"Based on observation and interview, it was determined that the facility failed to make the most recent survey results available for examination in a place readily accessible to residents. Findings include: Observation on 11/8/16 of the entrance to the facility revealed no recent survey results available for examination. Further observation revealed a black binder connected to a chain, located on the top of a shelf approximately 8 feet high in the living room. This binder contained only the 2012 through 2014 survey results. Interview on 11/8/16 with Staff B (Administrator) confirmed that survey results are not the most recent and are not easily accessible to residents and visitors.",2020-04-01
701,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2016-11-09,280,D,0,1,8D8C11,Based on medical record review and interview it was determined that the facility failed to update resident care plans for 1 resident in a standard survey sample of 10 residents. (Resident identifier is #8.) Findings include: Review on 11/9/16 of Resident #8's care plan revealed resident has wishes to FULL CODE dated 11/2/16. Review on 11/9/16 of Resident #8's medical record revealed a telephone order dated 9/13/16 to change the resident's code status to DNR/DNI (do not resuscitate/do not intubate). Interview on 11/9/16 at approximately 10:30 a.m. with Staff A (Registered Nurse) confirmed the above care plan has not been updated.,2020-04-01
702,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2016-11-09,356,C,0,1,8D8C11,"Based on observation and interview, it was determined that the facility failed to post nurse staffing information in a prominent place readily accessible to residents and visitors. Findings include: Observation on 11/08/16 of the entrance to the facility revealed there was no nurse staffing information in a prominent place readily accessible to residents and visitors to view. Interview at this time with Staff A (Registered Nurse) revealed a nurse staffing posting in the Activity/Dining room to the left of the entrance. It did not include the current date, the total number of actual hours worked for each category of licensed and unlicensed nursing staff. Staff A indicated that this posting had been here for awhile. Interview on 11/8/16 with Staff B (Administrator) confirmed that there have not been any daily staffing postings.",2020-04-01
703,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2016-11-09,425,D,0,1,8D8C11,Based on observation and interview it was determined that the facility failed to provide pharmaceutical services that assure accurate dispensing of medication for 1 out of sample resident in a survey sample of 10 residents. (Resident identifier is #13.) Findings include: Observation on 11/9/16 with Staff A (Registered Nurse) revealed an Oxycodone 10 mg tablet blister pack for Resident #13. Review of the CONTROLLED MEDICATION UTILIZATION RECORD for Resident #13's Oxycodone 10 mg documentation revealed on 11/7/16 1 missing from pharmacy. Interview and observation at this time with Staff A revealed that the above listed blister pack had an intact individual Oxycodone medication section with no medication within this intact section. The individual medication sections above and below this section were empty with documentation showing that the medication had been administered. Staff A confirmed at this time that one Oxycodone tablet was not in the unopened section and that this section of the Oxycodone 10 mg blister pack was intact and contained no Oxycodone tablet.,2020-04-01
704,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2016-11-09,456,E,0,1,8D8C11,"Based on interview and review of the manufacturer's instructions for the facility glucometer testing solutions it was determined that the facility failed to maintain and utilize the glucometer testing solutions according to the manufacturer's instructions. Findings include: Review of the manufacturer's instructions for the facility Blood Glucose Monitoring System, Control Solution revealed the following: STORAGE AND HANDLING . When opening a new vial of . Control Solution, write the discard date on the label. Control Solution is good for three months after opening the vial, or until the expiration date printed on the label . Interview on 11/9/16 with Staff A (Registered Nurse) during observation and review of the Blood Glucose Control Solution high and low vials with Staff A confirmed that the high and low solutions vials were not labeled with the discard date when the vials were opened.",2020-04-01
705,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2017-03-23,281,D,0,1,0Q0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that physician's orders were followed in accordance with professional standards for 2 residents out of a survey sample of 14 residents. (Resident identifier are # 6 and #14.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 3/22/17 of Resident #6's Medication Administration Record [REDACTED]. The Physician's order states [MEDICATION NAME] 2 MG/ML ([MEDICATION NAME]) give 0.5 ml by mouth three times a day related to anxiety disorder unspecified ;other [MEDICAL CONDITION] give 0.5 ml = 1 mg. There was no documentation of the physician being notified that the scheduled dose was not given. Interview on 3/22/17 at 2:00 p.m. with Staff C (Nurse Supervisor) confirmed that this medication was not given and that the physician had not been notified. Observation on 3/22/17 at 7:50 a.m. of medication pass was done with Staff B (Licensed Practical Nurse) with Resident #6. Observation of the medications being administered with Staff B were 1 spray of [MEDICATION NAME] Proprianate Suspension 50 MCG (Microgram)/ACT2 in both nostrils and 150 MG (Milligram) [MEDICATION NAME] HCL ER tablet. Reconciliation of the medication in the MAR indicated [REDACTED] [MEDICATION NAME] Proprionate Suspension 50 MCG/ACT 2 sprays in both nostrils one time a day. [MEDICATION NAME] HCL ER tablet extended release 150 MG 24 hour give 1 tablet by mouth one time a day, total dose to be given 250 M[NAME] [MEDICATION NAME] HCL ER tablet extended release 100 MG 24 hour give 1 tablet by mouth one time a day, total dose to be given 250 M[NAME] Observation on 3/22/17 of medication pass task at 8:10 a.m. with Resident #14. Reconciliation of the medication in the MAR indicated [REDACTED] The physician's order was Calcium-Vitamin D3 tablet 600-400 MG-UNIT (Calcium Carb-[MEDICATION NAME]) give 1 tablet by mouth one time a day. Observation of medication administration revealed that Staff B administered Calcium -Vitamin D 600- 200 MG-UNIT. Interview on 3/22/17 at 8:50 a.m. with Staff B, confirmed the above medication errors were observed.",2020-04-01
706,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2017-03-23,332,E,0,1,0Q0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure that medication error rates were not 5 percent or greater for 2 of 2 residents observed on medication pass. (Resident identifiers #6 and #14). The facility error rate was 12%. Findings include: Observation on 3/22/17 at 7:50 a.m. of medication pass was done with Staff B (Licensed Practical Nurse) with Resident #6. Observation of the medications being administered with Staff B were 1 spray of [MEDICATION NAME] Proprianate Suspension 50 MCG (Microgram)/ACT2 in both nostrils and 150 MG (Milligram) [MEDICATION NAME] HCL ER tablet. Reconciliation of the medication in the MAR (Medication Administration Record) revealed that the following 2 medications were not given as ordered by the physician: [MEDICATION NAME] Proprionate Suspension 50 MCG/ACT 2 sprays in both nostrils one time a day. [MEDICATION NAME] HCL ER tablet extended release 150 MG 24 hour give 1 tablet by mouth one time a day, total dose to be given 250 M[NAME] [MEDICATION NAME] HCL ER tablet extended release 100 MG 24 hour give 1 tablet by mouth one time a day, total dose to be given 250 M[NAME] Observation on 3/22/17 of medication pass task at 8:10 a.m. with Resident #14. Reconciliation of the medication in the MAR indicated [REDACTED] The physician's orders [REDACTED]. Observation of medication administration revealed that Staff B, (LPN) administered Calcium -Vitamin D 600- 200 MG-UNIT. Interview on 3/22/17 at 8:50 a.m. with Staff B, confirmed the above medication errors were observed.",2020-04-01
707,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2017-03-23,456,D,0,1,0Q0111,"Based on observation, interview and facility policy review, it was determined that the facility failed to ensure oxygen concentrators were maintained in safe operating condition. Findings include: Observation on 3/21/17 at approximately 9:15 a.m. on West Unit tour with Staff C (Registered Nurse) revealed that Resident #9 and Resident #22's oxygen concentrator filters had a visible amount of dust and debris adhired to them. Interview with Staff C confirmed that the filters had not been clean. At that time Staff C took the filters in the resident's bathroom and rinsed them out with water in the sink. Review on 3/23/17 of facility policy named Respiratory Therapy: Oxygen Concentrator, Care Of dated (MONTH) 2021 (sic) revealed that a dated label on the concentrator after cleaning is placed on the concentrator. Interview on 3/2317 at approximately 10:00 a.m. with Staff A (Director of Nurses) stated that oxygen concentrator filters were cleaned weekly by an outside company and in accordance to the facility policy named Respiratory Therapy: Oxygen Concentrator, Care Of dated (MONTH) 2021 (sic). Interview on 3/23/17 at approximately 10:15 a.m. with Staff C confirmed the oxygen concentrators in Resident #9 and resident #22's rooms did not have a dated label on either concentrator in accordance with the facilities policy for care of oxygen concentrator.",2020-04-01
708,DERRY CENTER FOR REHABILITATION AND HEALTHCARE,305095,20 CHESTER ROAD,DERRY,NH,3038,2017-03-23,520,E,0,1,0Q0111,"Based on interview, it was determined that the facility failed to identify quality assessment and assurance activities and failed to develop and implement plans of action to correct these quality deficiencies within the Quality Assessment and Assurance Committee. Findings include: Interview on 3/23/2017 at approximately 1:00 p.m. during Quality Assurance review with Staff A (Director of Nurses) confirmed that the facility had not identified any quality deficiencies, and Staff A confirmed that there have been no Quality Assessment projects since the last survey on 6/16/16.",2020-04-01
709,FAIRVIEW NURSING HOME,305100,203 LOWELL ROAD,HUDSON,NH,3051,2017-01-27,157,D,0,1,A3IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined that the facility failed to notify the physician of significant change for 2 out of 19 sampled residents. (Resident identifiers are #5 and #14.) Findings include: On 1/25/17, review of Resident #5's (MONTH) (YEAR)'s Medication Administration Record [REDACTED]. Review of nurse medication notes during that time period indicated that the prn doses were given for sternal and right hand pain. Interview on 1/26/17 at 9:00 a.m. with Staff A, LPN (Licensed Practical Nurse) confirmed that the doses were given for pain and the consistent need for prn medication was not addressed with the physician. On 1/27/17 MAR indicated [REDACTED]. There was no evidence that the physician had been notified of the multiple medications being refused. The following is a breakdown of the months and medications that were refused: November (YEAR) the resident refused the following scheduled medications 18 out of 30 days- Cranberry tabs 450 mg (9 doses), Tylenol 650 mg (27 doses), [MEDICATION NAME] 2.5 mg (1 dose), aspirin EC 81 mg (10 doses), [MEDICATION NAME] 20 mg (11 doses), Potassium Chloride 40 meq (12 doses), [MEDICATION NAME] S 8.6 mg/50 mg (3 doses). December (YEAR) the resident refused the following scheduled medications 10 out of 31 days- Cranberry tabs 450 mg (10 doses), Tylenol 650 mg (12 doses), [MEDICATION NAME] 2.5 mg (3 doses), aspirin EC 81 mg (2 doses), [MEDICATION NAME] 20 mg (2 doses), Potassium Chloride 40 meq (3 doses), [MEDICATION NAME] S 8.6 mg/50 mg (2 doses). January (YEAR) the resident refused the following scheduled medications 10 out of 27 days- Cranberry tabs 450 mg (7 doses), Tylenol 650 mg (16 doses), [MEDICATION NAME] 2.5 mg (5 doses), aspirin EC 81 mg (6 doses), [MEDICATION NAME] 20 mg (6 doses), Potassium Chloride 40 meq (5 doses), [MEDICATION NAME] S 8.6 mg/50 mg (1 dose), [MEDICATION NAME] 150 mg (2 doses), Acidophilus (2 doses). Medical record was reviewed. There was no evidence that the physician had been notified of the medication refusal. Interview on 1/27/17 at 10:15 a.m. with Staff B, (Clinical Leader) confirmed that there was no evidence that the medication refusal was reported to the physician.",2020-04-01
710,COOS COUNTY NURSING HOSPITAL,3e+77,136 COUNTY FARM ROAD,WEST STEWARTSTOWN,NH,3597,2016-10-20,458,B,0,1,J67911,"Based on interview and observation the facility failed to have 6 resident bedrooms with the minimum required 80 square feet per resident. Findings include: Observations during survey on 10/18/16-10/20/16, revealed that residents' rooms #230, #304, #305, #312, #314, and #321 had limited space available and did not meet the regulatory requirement for square footage in a bedroom. Interview with Staff A (Administrator) and Staff B (Director of Nursing) on 10/18/16 at 11:45 a.m., confirmed that the aforementioned rooms do not meet the minimum requirement of 80 square feet per resident in a multiple resident room. The State Survey Agency has granted a waiver for the aforementioned rooms.",2020-04-01
711,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-03-09,281,E,1,0,MEHK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of facility policy and procedure for the administration of controlled substances it was determined that the facility failed to ensure the professional standards of practice for the administration and documentation of narcotic medications were followed for 3 of 4 residents with prn (as needed) narcotic medications. (Resident identifiers are #1, #2 and #3) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. Page 709 After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Review of Section 7.4 of the facility's policy entitled: Medication Administration, Controlled Substances, as outlined in the Nursing Care Center Pharmacy & Procedure Manual-copyright 2007 PharmMerica Corp. revealed that line 5. Administer the controlled medication and document dose administration on the MAR (Medication Administration Record). Resident #1. Review of a narcotic log book from the Glenwood Unit for Resident #1 with No. 69 imprinted at the top of the page, revealed the following: [MEDICATION NAME] hcl (sic), 5 mg, every 6 hours, prn pain. Between 1/30/17 and 3/8/17 there are 15 entries on this page in the narcotic log book. Three of the fifteen date-lines in the narcotic log book do not have an entry for the corresponding dates on the corresponding MAR (2/23/17, 2/24/17 and 3/8/17). Resident #2. Review of a narcotic log book from the Glenwood Unit for Resident #2 with an unreadable number imprinted at the top of the page, revealed the following: [MEDICATION NAME] Hcl (sic), 5 mg, every 4 hours, prn pain. Between 1/24/17 and 3/7/17 there are 32 entries on this page in the narcotic log book. Two of the 32 date-lines do not have an entry for the corresponding dates on the corresponding MAR (2/21/17 and 3/2/17). Resident #3. Review of a narcotic log book from the Transitional Care Unit for Resident #3 with No. 78 imprinted at the top of the page, revealed the following: [MEDICATION NAME] Hcl (sic), 5 mg, (1/2 tablet). Between 2/15/17 and 3/3/17 there are 12 entries on this page in the narcotic log book. Two of the 12 date-lines do not have an entry for the corresponding dates on the corresponding MAR (2/20/17 and 2/24/17). Interview on 3/9/17 at 2:20 p.m. with Staff C (Registered Nurse) confirmed it is the practice of the facility to document medicine administration of both in the narcotic nook and on the MAR. During interview on 3/9/17 at approximately mid-day, Staff A (Administrator), when asked if they had reviewed narcotic log books periodically, stated: No, we do not have that kind of time.",2020-03-01
712,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-03-09,514,E,1,0,MEHK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of facility policy and procedure for the administration of controlled substances the facility failed to maintain clinical records that are complete and accurately documented in accordance with accepted professional standards and practices for 3 of 4 residents with prn (as needed) narcotic medications (Resident identifiers are #1, #2, and #3). Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. Page 709 After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Resident #1. Review of a narcotic log book from the Glenwood Unit for Resident #1 with No. 69 imprinted at the top of the page, revealed the following: [MEDICATION NAME] hcl (sic), 5 mg, every 6 hours, prn pain. Between 1/30/17 and 3/8/17 there are 15 entries on this page in the narcotic log book. Three of the fifteen date-lines in the narcotic log book do not have an entry for the corresponding dates on the corresponding MAR (2/23/17, 2/24/17 and 3/8/17). Resident #2. Review of a narcotic log book from the Glenwood Unit for Resident #2 with the number imprinted at the top of the page, unreadable, revealed the following: [MEDICATION NAME] Hcl (sic), 5 mg, every 4 hours, prn pain. Between 1/24/17 and 3/7/17 there are 32 entries on this page in the narcotic log book. Two of the 32 date-lines do not have an entry for the corresponding dates on the corresponding MAR (2/21/17 and 3/2/17). Resident #3. Review of a narcotic log book from the Transitional Care Unit for Resident #3 with No. 78 imprinted at the top of the page, revealed the following: [MEDICATION NAME] Hcl (sic), 5 mg, (1/2 tablet). Between 2/15/17 and 3/3/17 there are 12 entries on this page in the narcotic log book. Two of the 12 date-lines do not have an entry for the corresponding dates on the corresponding MAR (2/20/17 and 2/24/17). Interview on 3/9/17 at 2:20 p.m. with Staff C (Registered Nurse) confirmed it is the practice of the facility to document medicine administration of both in the narcotic nook and on the MAR.",2020-03-01
713,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,278,D,1,0,4ZUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to accurately identify the medical status as reflected on the MDS (Minimum Data Set) Assessments for 3 residents in a survey sample of 20 residents. (Resident identifiers are #7, #13 and #20.) Findings include: Resident #7 Review on 3/6/17 of Resident #7's MDS with an ARD (Assessment Reference Date) of 7/1/16 revealed that the resident was not assessed for Cognitive Patterns in all of section C0100-C1310 and was not assessed for Mood in all of section D0100-D0650. Interview on 3/13/17 with Staff M (Registered Nurse), reviewed the above findings and Staff M confirmed the above omitted data on the MDS. Resident #13 Review on 3/6/17 of Resident #13's MDS with an ARD (Assessment Reference Date) of 12/19/16 revealed that under section O, for Special Treatments the resident was not listed as being a [MEDICAL TREATMENT] patient. Interview on 3/8/17 with Staff M, reviewed the above findings and Staff M confirmed that Resident #13 does in fact go to [MEDICAL TREATMENT] three times per week and confirmed the above omitted data on the MDS. Resident #20 Review on 3/6/17 of Resident #20's MDS with an ARD of 1/4/17 revealed that under section E1100 for Change in Behavior or Other Symptoms the facility documented N/A because no prior MDS assessment. Resident #20 was admitted to this facility on 1/9/15 and did receive all the required MDS assessments with the previous ARD date of 10/4/16. Interview on 3/8/17 with Staff M, reviewed the above findings and Staff M confirmed the above error on the most recent MDS.",2020-03-01
714,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2017-03-13,388,E,1,0,DUQJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that all skilled visits required by the physician were made by the physician personally for 6 residents out of a sample selection of 14 records. (Resident identifiers are: #3, #6, #7, #9,#11, and #12.) Findings include: Resident #3 Review on 3/13/17 of Resident #3's medical record revealed that Staff A (Nurse Practitioner)is listed as the primary care provider. On 1/15/17 an admission visit was performed by Staff [NAME] This same admission visit was later co-signed by Staff D (Medical Doctor), but Staff D did not perform an admission visit for this resident at that time. This is not in compliance with facility policy and procedure or Federal Regulations for admitting and recertifying a resident. Resident #6 Review on 3/13/17 of Resident #6's medical record revealed that Staff A performed the admission visit for this resident on 1/23/17. Admission visit, admission orders [REDACTED]. Resident #7 Review on 3/13/17 of Resident #7's medical record revealed that admission visit on 1/12/17, all admission orders [REDACTED]. Interview on 3/13/17 with Staff B (Admitting Director) confirmed the above findings for resident #'s 3,6 and 7 and stated that, at the time, the facility believed that Staff A could perform and sign for admission and recertification visits in the place of a medical doctor. Staff B indicated that the facility understands that, as per their facility admission policy and federal regulations, Staff A is not qualified to perform admission visits for the purpose of initial certification. The facility's Admission Policy and Procedure states under #7: admissions must be made only upon the order of the resident's physician who must be licensed as a Doctor of Medicine in the State. Resident #9 Review on 3/13/17 of Resident # 9's medical record of the admission paperwork revealed resident #9 was readmitted back to the facility as a SNF(Skilled Level Of Care) resident on 2/28/17. The initial visit note dated 3/8/17 revealed that this initial visit was completed by Staff [NAME] The progress note revealed that Resident #9 was had a hospital stay for complicated UTI (urinary tract infection) (MRSA), [MEDICAL CONDITION], toxic metabolic [MEDICAL CONDITION], and acute [MEDICAL CONDITION]. Resident #9 remains on IV (intravenous) [MEDICATION NAME] 1500 mg daily . Also remains on IV [MEDICATION NAME] .Nursing staff called regarding ? blockage of PICC line Additional review of the Progress notes for Resident #3 on 3/13/17 revealed no other visits were completed by any physician. Further record review revealed that Resident #9 was seen by Occupational Therapy on 3/1/17. Interviews on 3/13/17 with Staff B confirmed that there were no physician visits for Resident #9 between 2/28/17 and 3/13/17,that the only visits during this time period were by the Nurse Practitioner. Resident #11 Review on 3/13/17 of Resident #11's admission paperwork revealed Resident #11 was readmitted back to the facility as a SNF resident on 3/2/17. Review of the physician standing orders and physician orders [REDACTED]. Additional review of the orders for Resident #11 an order was written by Staff A on 3/3/17 for skilled PT eval (evaluation) and Treat and 3/4/17 for ST(speech) eval(evaluation) and tx(treatment) as indicated. Further review of Resident #11's medical record revealed a Physical Therapy Certification that was signed on 3/8/17 by Staff [NAME] Interviews on 3/13/17 with Staff B confirmed that there were no physician visits for Resident #11 between 2/28/17 and 3/13/17, that the only visits during this time period were by the Nurse Practitioner. Resident #12 Review on 3/13/17 of Resident #12's medical record of the admission paperwork revealed resident #12 was readmitted back to the facility as a SNF resident on 2/24/17. The initial progress visit note dated 3/8/17 revealed that this initial visit was completed by Staff [NAME] Interviews on 3/13/17 with Staff B confirmed that there were no physician visits for Resident #12 between 2/24/17 and 3/13/17, that the only visits during this time period were by the Nurse Practitioner.",2020-03-01
715,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,225,B,0,1,WZTO11,"Based on record review and interview, it was determined that the facility failed to immediately report allegations of misappropriation of resident property and report results of these investigations to the State Survey Agency for 3 alleged violations between 2/11/16 and 1/31/17. (Resident identifiers #24, #25 and #26.) Findings include: Review of the facility's list of investigations since the last recertification survey (2/11/16) revealed 3 investigations (dated 2/27/16, 4/6/16, and 5/11/16) listed for missing items. Review of these incidents revealed no incidents of misappropriation of resident property had been reported to the State Survey Agency. Interview on 2/2/17 at 2:30 p.m. with Staff B (Administrator) confirmed the above finding.",2020-02-01
716,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,226,D,0,1,WZTO11,"Based on record review and interview, it was determined that the facility failed to implement written policies and procedures for allegations of abuse for 2 of 2 investigations reviewed. Findings include: Review of the facility's policy titled Patient Abuse Prohibition Policy and Procedure dated 7/12/13, page 6, revealed After investigation, the appropriate disciplinary action is taken. Counseling occurs at the time of discipline. If termination is not warranted, the following may be implemented. In-service determined by incident. Weekly monitoring report by the Administrative Designee with be given to the Administrator and Director of Nursing. Interview of the resident regularly who are being cared for by the employee and document all findings. Review of the facility's Investigation Summary from (MONTH) 4, (YEAR) revealed that there was an allegation of abuse by Staff F (Licensed Nursing Assistant) against a resident. The facility's conclusion was that Staff F would be counseled and educated regarding resident right's, dignity, reporting, and standards of conduct. (pronoun omitted) will also be monitored for any similar violations going forward and appropriate actions taken. Review of the facility's Investigation Summary from (MONTH) 25, (YEAR) revealed that there was an second allegation of abuse by Staff F against a resident. The facility's conclusion was that Staff F would .attend in-services for LNA staff . Review of the Staff F's employee record revealed no documentation of the counseling, education or in-services following the investigations completed (MONTH) 4, (YEAR) or (MONTH) 25, (YEAR) Interview on 2/2/17 at approximately 2:30 p.m. with Staff B confirmed that there was no record of counseling or education of Staff F after the above investigations.",2020-02-01
717,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,278,B,0,1,WZTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to accurately code the MDS (Minimum Data Set) for 2 residents in a standard survey sample of 20 residents. (Resident identifiers are #13 and #20.) Findings include: Resident #20 Review of Resident #20's medical record revealed that Resident #20 was admitted to Hospice services on 11/22/16. A MDS for Resident #20 Significant Change assessment was completed by the facility on 11/28/16 due to the resident's admission to Hospice. Section J1400, Prognosis with a life expectancy of less than six months was coded as no. Interview on 2/1/17 at approximately 2:00 p.m. with Staff A (RN/Unit Manager) confirmed that above finding. Resident #13 Review of the MDS for Resident #13's Significant Change assessment dated [DATE], revealed that Section O, Special Treatments, Procedures, and Programs did not indicate that the resident was receiving [MEDICAL TREATMENT] treatment. Interview on 2/2/17 at 8:00 a.m. with Staff G (Unit Manager) revealed that Resident #13 had been on [MEDICAL TREATMENT] since the resident was admitted on [DATE].",2020-02-01
718,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,281,D,0,1,WZTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility Pain Management policy and procedure it was determined that the facility failed to follow the professional standard of practice for monitoring the effectiveness of pain medications for 3 residents in a survey sample of 20 residents. (Resident identifier's are #4, #5 and #18.) Findings include: Review of the facility policy and procedure titled PAIN ASSESSMENT MONITORING AND D[NAME]UMENTATION revealed the following: Procedures: . 6. The effectiveness of PRN (as needed) pain meds will be documented either on the MAR (medication administration record) or in the nursing notes . PAIN MANAGEMENT FLOWSHEET . . Document pain site(s) for the resident and the name of the [MEDICATION NAME](s) ordered. If multiple [MEDICATION NAME] are ordered, there should be a Pain Management Flowsheet for each [MEDICATION NAME] received . . Place the Pain Management Flowsheet in the Medication Administration Record [REDACTED]. . Use the 0 or 10 Numeric Pain Intensity Scale to rate the resident's pain level. Ask the resident to rate his/her pain intensity with '0' representing 'No pain' and '10' representing the 'worst possible pain imaginable.' Write the number stated by the resident on the pain evaluation under pain intensity. . If the resident is unable to rate pain due to confusion, level of consciousness or other reason, rate the resident's pain through observation of the resident's behavior, demeanor, facial expression or other objective means. . If the resident is unable to speak or use the Numeric scale but is able to point, have the resident use the analog 'Faces' scale by pointing to the appropriate 'Face' and record the corresponding number in the column labeled 'pain intensity' . Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009 Pages 1063 and 1082-1083 reveal the following: .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity. Although different clients prefer different pain scales, it is important for you to select and consistently use the same scale with a specific client. You do not use a pain scale to compare the pain of one client to that of another client. Evaluation of pain is one of many nursing responsibilities the require effective critical thinking .The client's behavioral responses to pain-relief interventions are not always obvious. Evaluating the effectiveness of a pain intervention requires you to evaluate the client after an appropriate period of time. You need to continually assess whether the character of the client's pain changes and whether individual interventions are effective. .You are successful in treating pain when the client's expectations of pain relief are met. Use evaluative criteria in determining the outcome of pain-relief interventions. Effective communication of a client's assessment of pain and his or her response to intervention is facilitated by accurate and thorough documentation. This communication needs to happen from nurse to nurse, shift to shift and nurse to other .It is the professional responsibility of the nurse caring for the client to report what has been effective for managing the client's pain. A variety of tools such as pain flow sheet or diary will help centralize information about pain management. The client expects you to be sensitive to his or her pain and to be attentive in attempts to manage that pain. Effectively communicating with primary .will assist you in achieving optimal pain relief for clients. Resident #4. Record review on 2/1/17 of the Medication Administration Record [REDACTED]. Review of the facility PAIN MANAGEMENT FLOWSHEET for Resident #4 showed in the section labeled SCALE USED (A, B, C or D) for pain intensity was scale C. Further review of the facility PAIN MANAGEMENT FLOWSHEET revealed that 8 PRN doses of [MEDICATION NAME] 650 mg. were administered to Resident #4 for a pain rating of three or four out of 10 on a C pain scale from 1/28/17 through 1/30/17. Review of the pain management flowsheet and nurses notes showed no documented evidence of a numeric pain rating utilizing the C pain scale following the administration of these 8 doses to monitor the effectiveness of this PRN medication for Resident #4. Further review of the Medication Administration Record [REDACTED]. Review of the facility PAIN MANAGEMENT FLOWSHEET revealed that 2 doses of [MEDICATION NAME] 650 mg. were administered to Resident #4 for a pain rating of 3 out of 10 on a C pain scale on 2/1 and 2/2/2017. Review of the pain management flowsheets and nurses notes showed no document evidence of a numeric pain rating utilizing the C pain scale following the administration of these 2 doses to monitor the effectiveness of this PRN medication for Resident #4. Resident #5. Record review on 2/1/17 of the Medication Administration Record [REDACTED]. Review of the facility PAIN MANAGEMENT FLOWSHEET for Resident #5 showed in the section labeled SCALE USED (A, B, C or D) for pain intensity was scale C. Further review of the facility PAIN MANAGEMENT FLOWSHEET revealed 14 doses of [MEDICATION NAME] 100 mg were administered to Resident #5 for a numeric pain rating of six or seven out of ten from 12/23/2016 through 12/30/16. Review of the pain management flowsheets and nurses notes showed no documented evidence of a numeric pain rating utilizing the C pain intensity scale following the administration of these 14 doses to monitor the effectiveness of this PRN medication for Resident #5. Review of the Medication Administration Record [REDACTED]. Review of the facility PAIN MANAGEMENT FLOWSHEET revealed 47 doses of [MEDICATION NAME] 100 mg were administered to Resident #5 for a numeric pain rating of a six or seven out of ten from 1/1/2017 through 1/31/2017. Review of the pain management flowsheets and nurses notes showed no documented evidence of a numeric pain rating utilizing the C pain scale following the administration of these 47 doses to monitor the effectiveness of this PRN medication for Resident #5. Interview on 2/1/17 with Staff I (Licensed Practical Nurse), after Staff I reviewed the above listed findings, Staff I confirmed that there was no numeric pain intensity documentation for the monitoring of the effectiveness for the PRN pain medications listed above when administered to Resident #4 and #5. Review on 2/2/17 of Resident #18's medical record revealed that on 1/31/17 per the Medication Administration Record, [REDACTED]. There was no documented pain assessment prior to or post administration. Interview on 2/2/17 at 10:30 am with Staff A (RN) confirmed that pain assessments were not documented for Resident #18.",2020-02-01
719,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,323,E,0,1,WZTO11,"Based on observations and interview, it was determined that the facility failed to ensure that one emergency exit path and the exterior exit stairs (in the rear of the building) were clear of snow and ice creating an accident hazard. The emergency exit stairs to a public way were covered with snow and ice and at the bottom of the exit stairs were also blocked by multiple parked vehicles. Also, the facility failed to provide an environment free from accident hazards by ensuring that doors are kept locked to the laundry room. Findings include: Observation by the Health and the Life Safety surveyor on 1/31/17 at approximately 10:00 a.m. revealed that the 2nd floor Rehabilitation Unit's rear emergency exit leads to a sidewalk and exterior egress stair to the parking lot. The sidewalk was clear of snow and ice for approximately 15 feet from the exit door. The rest of the path to the exterior stairs were covered in 2-3 inches of snow and ice. At the bottom of the stairs multiple cars were parked. Interview on 1/31/17 with Staff B (Administrator) confirmed that the some of the egress path was not maintained and that exterior stairs are not maintained during the winter. Observation on 1/31/17 during the initial tour at approximately 9:40 a.m. of the second floor Rehabilitation Unit revealed an emergency exit door leading to a partially cleared sidewalk which had ice and snow not cleared. This sidewalk leads to a set of exterior egress stairs that were not cleared of snow and ice. The bottom of these exit stairs ended at a public way which was blocked by multiple parked vehicles. Cross reference K271 . During tour on 1/31/17 at approximately 10:30 a.m. with Staff A (RN, Unit Manager) of the unlocked laundry room on the dementia unit of the second floor an unlocked cabinet was noted to have a small plastic tub of a white grainy powder substance with a small clear scoop inside, also in the unlocked cabinet was an aerosol can that was labeled disinfectant. Interview on 1/31/17 at approximately 10:35 a.m. with Staff A who confirmed the above findings and Staff A confirmed that this laundry room and the cupboard is never locked.",2020-02-01
720,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,364,C,0,1,WZTO11,"Based on observation, interview, and resident council review, it was determined that the facility failed to assure that food is palatable, attractive and at the proper temperature to ensure resident's satisfaction. Findings include: Resident council review on 2/1/17 at 10:30 a.m. with 9 residents in attendance revealed that all residents present had concerns related to the food. These concerns included: vegetables were overcooked and mushy, meats were tough to chew, toast was often soggy or dry, the powdered eggs and potatoes did not taste good, fish is usually dry and without flavor, food is often not hot when served, staff do not always reheat food due to being too busy and the alternative choices are not palatable. Observation of on 2/1/17 at 11:40 a.m. of a third floor dining room revealed two food carts and three staff members delivering meals on trays; first to the dining room then to individual resident rooms. Four residents in the dining room requested peanut butter and jelly sandwiches instead of the chop suey and green vegetables. The vegetables appeared overcooked and soggy. One resident received a grilled cheese sandwich that appeared dry with overcooked darkened bread. Interview on 2/2/17 at 12:45 p.m. with Resident #13 revealed that the food served is not very good and the scrambled eggs are always cold. Staff will heat them up but it takes ten minutes before they get to it. Interview on 2/2/17 at 1:30 p.m. with Resident #23 revealed that the food was often served cold when it should be hot. Interview on 2/2/17 at 1:30 p.m. with Resident #11 revealed that the food was mostly always cold. Observations on 2/2/17 at 11:30 a.m. of food service performed identified that the holding temperature on the steam table of the Shepard's pie prior to being served was 202 degrees Fahrenheit. The holding temperature of the cauliflower on the steam table prior to being served was 186 degrees Fahrenheit. A test tray was prepared at 11:48 a.m. and left the kitchen at 11:57 a.m. for the second floor. The last tray was served to a resident at 12:20 p.m. and the test tray was pulled from the tray cart. At that time the Shepard's pie had a temperature of 108.1 degrees Fahrenheit and the cauliflower had a temperature of 94.1 degrees Fahrenheit. Shepard's pie and cauliflower was tested for palatability and found to be an unappetizing low temperature.",2020-02-01
721,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,371,E,0,1,WZTO11,"Based on observation and interview, it was determined that the facility failed to properly label and date supplemental shakes in 3 of 3 kitchenettes and to properly serve food from the kitchen. Findings include: Observation on 1/31/17 at approximately 9:45 a.m. of the 2nd floor kitchenette revealed 5 undated thawed supplemental shakes in the refrigerator. Observation on 1/31/17 at approximately 9:50 a.m. of the Rehabilitation kitchenette revealed 5 undated thawed supplemental shakes in the refrigerator. Observation on 1/31/17 at approximately 9:55 a.m. of the 3rd floor kitchenette revealed 13 undated thawed supplemental shakes in the refrigerator. Review of the manufacturer's instructions for the supplemental shakes revealed that the shakes were good up to 14 days once thawed, if refrigerated. Interview on 1/31/17 at approximately 9:55 a.m. with Staff C (Director of Food Services) confirmed the above findings and Staff C was unable to say for certain when the supplemental shakes had been thawed. Observation on 2/2/17 at approximately 11:45 a.m. of food service to residents from the kitchen revealed Staff [NAME] (Dietary Aide) used the serving spoon from the Shepard's pie to lift an empty serving tray from the steam table, set the spoon down on the steam table, and after placing a new serving tray with Shepard's pie on the steam table, used the same spoon to proceed with serving Shepard's pie to residents.",2020-02-01
722,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,425,E,0,1,WZTO11,"Based on observation during the medication pass and interview, it was determined that the facility failed to identify and remove medications that were past the manufacturer's expiration date for 2 of 5 medication carts, in the Pyxis machine on the 2nd floor and the labeling of the emergency kit which had three dates on it, one that was expired. Findings include: Observation on 2/1/17 during medication pass on the 3rd floor at approximately 8:30 a.m. revealed that the bulk supply areas on each of the 2 medication carts had medications that had expired. The following medications were found in the medication carts: 1. Vitamin B-12 (100 mcg) (microgram)- both medication carts (Vitamins) expiration date of 1/17 2. Major Ear Drop (ear wax removal) one expired 7/16 (one cart only) In the Pyxis Machine the following medication were found: 1. 4 Gericare Vitamin [NAME] 100 softgel 2000 IU (international units) all expired 7/16 2. 1 Ibuprofen 200 mg (pain relief, anti-inflammation) expired 12/16 3. 4 Normal Saline 120 ml (milliliters) expired 1/17 Interview on 2/1/17 at 9:30 a.m. with Staff G (Unit Manager of 3rd floor) reviewed the above findings and Staff G confirmed the above-listed drugs were expired. Staff G stated that the supply clerk checks and fills the Pyxis machine. Review of the facility policy and procedure titled STORAGE OF MEDICATIONS dated 09/10 revealed the following: POLICY Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall only be assessible only to nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. PR[NAME]EDURES . 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . and reordered from the pharmacy if a current order exists. Observation on 2/1/17 with Staff A (Registered Nurse) at approximately 9:40 a.m. in the second floor locked medication room containing the residents backup supply of medications showed 5 vials of expired Ativan dated 1/2017 for Resident #24 and 2 vials of expired Ativan dated 2/1/17 for Resident #25. Observation on 2/1/17 with Staff I (Licensed Practical Nurse) at approximately 10:00 a.m. on the Skilled Care Unit (SCU), also located on the second floor, in the locked medication room revealed all the emergency medications for the second floor residents. Further observation showed a locked E-Kit (emergency) with an outside neon yellow expiration sticker dated (MONTH) (YEAR). The top of this E-Kit had a attached outside clear plastic sleeve with the notation to order after 1/29/17. In addition there was a white sticker attached to the clear plastic sleeve on this E-Kit box with an expiration date of 9/2016. At the time of this observation Staff I confirmed the different multiple expiration dates on this E-Kit and was not able to determine the correct expiration date from these multiple expiration labels.",2020-02-01
723,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,431,D,0,1,WZTO11,"Based on observation, interview and review of the facility medication storage policy and procedure it was determined that the facility failed to ensure medications are locked and secure from access by unauthorized personnel for 2 medications carts on one floor. Findings include: Review of the facility policy and procedure titled STORAGE OF MEDICATIONS dated 09/10 revealed the following: POLICY Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall only be assessible only to nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. PR[NAME]EDURES . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access . Observation on 1/31/17 upon exiting the facility elevator to the second floor at approximately 9:30 a.m. showed an unlocked, unattended medication cart directly across from this elevator in the resident hallway. The top drawer of this unlocked, unattended medication cart was freely opened by this surveyor. Interview on 1/31/17 with Staff H (Licensed Medication Nursing Aide) at approximately 9:35 a.m., after Staff H observed the opened drawer, Staff H verbally agreed that this medication cart was left unlocked and unattended and could be accessed by unauthorized individuals. Observation on 2/2/17 at 10:10 a.m. revealed the medication cart on the second floor East Wing was unlocked and unsupervised leaving medications accessible. Interview on 2/2/17 at approximately 10:10 a.m. with Staff D (Registered Nurse) confirmed that Staff D had left the above medication cart unlocked.",2020-02-01
724,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,441,D,0,1,WZTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain infection control practices in regards to the following: hand washing after handling catheter bags, appropriately attaching catheter bags to wheelchairs so they don't lay on the floor, linen cart coverage, boxes and medical equipment stored on the floor under a storage rack in the tub room and following manufacturer's instructions for cleaning of the blood coagulation meter. Findings include: Observation on 1/31/17 at approximately 10:00 a.m. of the tub room on the second floor with Staff A (RN/Unit Manager) revealed that a linen cart containing towels was uncovered in the tub room. Also in the tub room it was revealed that a cardboard box with seat cushion covers was sitting on the floor next to a metal rack and under this metal rack on the floor were extra wheelchair leg rests. Interview on 1/31/17 at approximately 10:00 a.m. with Staff A (Registered Nurse) confirmed the above findings. Observation on tour of the East and West units on the second floor with Staff A revealed that a blood coagulation meter was stored in the medication room and Staff A stated that this meter is used for residents on a regular basis. Staff A stated that this coagulation meter is cleaned with alcohol between resident use. Staff A also stated that the machine is taken to the residents' bedside/chair side. Staff A confirmed the coagulation meter is cleaned between resident use with alcohol. Staff A also confirmed that the meter is not cleaned with bleach. Upon leaving the medication room where this meter is stored Staff A pointed to the plastic jug of wipes that are used on this meter. Review of the plastic jug of wipes revealed the cleaning wipes as being 50% alcohol. Review of the Manufacturer's instruction on page 34 of the coagulation meter instruction manual under the heading, Cleaning/Disinfecting the Exterior it says, Use only the following items for cleaning/disinfection the (manufacturer name omitted) .- 70% [MEDICATION NAME] alcohol - 10% Sodium hypochlorite solution (1 part bleach to 9 parts deionized water, made fresh every 24 hours) . Observation on 2/1/17 at 1:00 p.m. of Staff A (Registered Nurse, Unit Manager) revealed Staff A picked up a catheter bag from the floor without wearing gloves, untangled the catheter tubing, and hung the catheter bag underneath Resident #16's wheelchair. Staff A returned to the nurse's station, reviewed a medical record and used the photocopier. Staff A did not wash their hands between manipulating the catheter bag and returning to the nurse's station and proceeding to work. Observation on 2/1/17 at approximately 1:15 p.m. revealed Resident #16 was sitting in the resident's wheelchair in the resident's room. The catheter bag was noted to be underneath the resident's wheelchair uncovered and resting on the floor. Staff A untangled the catheter bag and hooked it underneath the wheelchair. Interview at the time of observation with Staff A, revealed Staff A was unsure if the facility had catheter bag covers. Staff A stated that Resident #16 did not like the catheter bag covered but sometimes would cover the catheter bag with a grocery bag. Review on 2/1/17 of the Resident #16's care plan for Foley catheter care revealed no documentation that the catheter bag needs to be covered with a privacy cover nor a grocery bag per Resident #16 choice.",2020-02-01
725,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,456,D,0,1,WZTO11,"Based on observation and interview, it was determined that the facility failed to date the glucometer testing solutions that were opened for 2 of 5 medication carts. Findings include: Observation of glucometer quality control testing logs on the second floor for the east and west units revealed that the high and low quality control testing solutions were not dated when they were opened and as a result of the these solutions not be dated when opened Staff A (RN, Unit Manager) stated there was no way to know when the solutions were no longer usable. Interview on 1/31/17 at approximately 10:15 a.m. with Staff A, Staff A confirmed the above findings and stated that the facility's policy is to date the high and low solutions when they are opened to ensure the appropriate discard date per manufacturer's instructions.",2020-02-01
726,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2017-02-02,514,B,0,1,WZTO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to maintain a complete medical record for 1 of 1 residents receiving [MEDICAL TREATMENT] in a standard survey sample of 20 residents. (Resident identifier is #13.) Findings include: Review of the nursing notes, social work notes and dietary notes for Resident #19 from admission 9/24/17 to 2/2/17 revealed there was no evidence of any communication between the [MEDICAL TREATMENT] center and the facility. Interview on 2/2/17 at approximately 8:00 a.m. with Staff G on 2/2/17 confirmed the above finding and revealed there was no communication binder for residents on [MEDICAL TREATMENT] and any communication would be documented in the nursing notes.",2020-02-01
727,WEBSTER AT RYE,305099,795 WASHINGTON ROAD,RYE,NH,3870,2016-12-30,281,D,0,1,5O8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to follow physician's orders for wound assessment for 1 resident out of a survey sample of 12 residents. (Resident identifier is #2.) Findings include: Review on 12/28/16 of Resident #2's medical record revealed an order for [REDACTED]. Physician's order dated 12/5/16 stated that nursing was to assess the wound twice per day (BID). There were daily assessments in the nurses notes that reflected that an assessment of the wound was done once daily. There were no notes in the resident record to demonstrate that an order change was requested or made to reduce the assessments by the nursing staff to once per day. Interview on 12/30/16 with Staff A (Director of Nurses) confirmed the above findings.",2020-02-01
728,WEBSTER AT RYE,305099,795 WASHINGTON ROAD,RYE,NH,3870,2016-12-30,441,E,0,1,5O8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to establish an infection control program that identifies the communicable disease [DIAGNOSES REDACTED] (TB) for all residents and staff. The facility failed to have in practice a working program that provides an adequate system of surveillance designed to identify possible cases of [DIAGNOSES REDACTED] in 2 residents out of a survey sample of 12 residents, and 1 staff out of 5 staff. (Resident identifiers: #2 and #4.) Findings include: Resident #2 Review on 12/28/16 on Resident #2's medical record revealed that the 2-step TB test had not been performed as per Center for Disease Control (CDC) guidelines/recommendations. The TB step #1 was performed on 12/23/15 and had a notation of historical written next to it in the record. There was no evidence in the resident's record that the TB Step #2 had been performed. Interview on 12/29/16 with Staff A (Director of Nursing-DON) revealed that it is allowable at this facility for a resident to decline the second step TB test and not receive a chest x-ray as is recommended by the CDC. Instead, the facility reviews a symptoms check list with the resident that identifies an active disease process of Tubercilosis. The DON further explained that it is not the practice of this facility to perform a chest x-ray if the 2 step TB test is not performed. The CDC recommends that a two step TB test be performed on every resident on admission, and reviewed annually. If the 2 step TB test cannot, or is not performed, a chest x-ray is then recommended. There was no evidence that a chest x-ray had been performed in the absence of the two step TB test for this resident. Resident #4 Review on 12/29/16 of Resident #4's medical record revealed Resident #4 had a negative 1st step TB read on 12/10/15 and refused the second step TB. Interview with Staff A on 12/29/16 at 10:22 a.m. confirmed the above findings and revealed when a resident refuses a TB test they would be asked a series of TB related questions. If the resident's answers to those questions would indicate they were at risk for TB they would then have a chest X-ray. Interview also revealed that Resident #4 was not asked a series of TB related questions nor did Resident# 4 have a chest X-ray. New Hampshire Code of Administrative Rules, Chapter He-P 800, Part He-P 813, New Hampshire Nursing Home Rules, effective 1/26/11, page 33, section 811.13 (i)(1)-(2) states (1) Prior to having contact with clients, all personnel shall: Submit to the licensee the results of a physical examination or a health screening and submit results of a 2-step [DIAGNOSES REDACTED] (TB) test, Mantoux method, or other method approved by the Centers for Disease Control, conducted not more than 12 months prior to employment. (2) Be allowed to work while waiting for the results of the second step of the TB test when the results of the first step are negative for TB; Review of employee records on 12/30/16 revealed Staff C (License Nursing Assistant) did not have a 2 step TB test upon hire (date of hire 10/31/16). Interview on 12/30/16 at approximately 10:15 a.m. with Staff D (Director of Human Resources) confirmed the above finding and revealed that Staff C told the facility that Staff C had a history of [REDACTED]. Interview also revealed that Staff C did not have a chest X-ray.",2020-02-01
729,WEBSTER AT RYE,305099,795 WASHINGTON ROAD,RYE,NH,3870,2016-12-30,514,D,0,1,5O8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a complete medical record with informed consents for each resident for 1 resident in a sample of 2 resident on anti-psychotic medications. (Resident identifier #8.) Findings include: Review on 12/30/16 of Resident #8's Medication Administration Record [REDACTED]. Give 400 mg (milligrams) by mouth at bedtime for [MEDICAL CONDITION]. (Order Date 11/16/16). Review of Resident #8's medical record revealed the medical record did not contain an informed consent form for [MEDICATION NAME]. Interview on 12/30/16 at approximately 11:55 a.m. with Staff A (Director of Nursing) confirmed the above findings and revealed there was no documentation of consent for [MEDICATION NAME] for Resident #8.",2020-02-01
730,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-12-02,282,D,0,1,EU2J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide services outlined by the comprehensive care plan for falls for 1 resident in a sample of 19 residents. (Resident identifier is #2.) Findings include: Review on 12/1/16 of Resident #2's current comprehensive care plan revealed the following intervention for falls: non-skid socks or foot wear while in and out of bed. This intervention was initiated on 6/29/16. Review on 12/1/16 of the Resident #2's change in condition note from 10/31/16 revealed that the resident fell on [DATE]. Review of the change in condition note revealed that Resident #2 stated I just slipped out of bed. and the nurse noted Resident #2 had Regular socks on. Interview with Staff A (Unit Manager) on 12/1/16 at approximately 11:30 a.m. confirmed the above findings.",2020-01-01
731,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-12-02,371,E,0,1,EU2J11,"Based on observation and interview, the facility failed to ensure sanitary conditions for food storage and preparation in the kitchen. Findings include: Observation on 11/29/16 at approximately 9:10 a.m. revealed a large clear plastic container with tea bags in liquid brewing in the kitchen's walk in refrigerator. The container was covered with plastic wrap and dated 11/16/16. Interview with Staff C (Director of Food Services) on 11/29/16 at approximately 9:10 a.m. confirmed the above finding and revealed the kitchen staff date food/drink the date it was made and keep it for 10 days. Observation on 11/29/16 at approximately 9:15 a.m. revealed a block of sliced cheese in the kitchen's food prep refrigerator not completely covered in plastic wrap. The uncovered areas of the cheese had darkened and hardened. Interview with Staff C on 11/29/16 at approximately 9:15 a.m. confirmed the above finding. Observation on 11/29/16 at approximately 9:20 a.m. revealed dried food on the back splash of the kitchen's floor mixer. Interview with Staff C on 11/29/16 at approximately 9:20 a.m. confirmed the above finding and revealed the kitchen had not used the mixer that day and it is the kitchen's policy to clean the mixer after each use. Observation on 11/29/16 at approximately 9:25 a.m. revealed a large amount of dust on sections of the hood above the kitchen's stove. The stove also had an oven above it on the left side that had a handle that was covered in dust. The dials and handles on the front on the stove had grease and food build up. Interview with Staff C on 11/29/16 at approximately 9:25 a.m. confirmed the above finding and revealed that the hood had not been cleaned in a couple weeks and the oven above the stove was not used.",2020-01-01
732,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-12-02,387,D,0,1,EU2J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure physician visits occurred at the required frequency for 4 of 19 residents in a standard survey sample. (Resident identifiers are #1, #2, #14, and #22). Findings include: Resident #22 Review of Resident #22's medical record it was revealed that the resident had not been seen by a physician since 1/16/16. Physician visits are required once every 60 days for this resident. Interview on 12/1/16 at approximately 2:15 p.m., Staff A (Unit Manager) confirmed that Resident #22 has not seen a physician since 1/16/16. Resident #1 Review of Resident #1's medical record revealed the resident was admitted on [DATE]. Review of the Resident #1's progress notes revealed that Resident #1 had physician visits on 8/5/16 and 11/4/16 and a nurse practitioner visit on 8/24/16. There were no visits between 8/24/16 and 11/4/16. Interview with Staff B (Unit Manager) on 12/1/16 at approximately 11:45 a.m. confirmed the above finding. Resident #2 Review of the Resident #2's medical record revealed Resident #2 was admitted on [DATE]. Review of the Resident #2's progress notes revealed that Resident #2 did not have any physician or nurse practitioner visits between visits on 4/1/16 and 7/8/16. Interview with Staff A (Unit Manager) on 12/1/16 at approximately 11:30 a.m. confirmed the above finding Resident #14 Review of Resident #14's medical record revealed Resident #14 was admitted on [DATE]. Review of the Resident 14's progress notes revealed that Resident #14 did not have any physician or nurse practitioner visits between 4/4/16 and 7/13/16. Interview with Staff B on 12/1/16 at approximately 11:45 a.m. confirmed the above finding.",2020-01-01
733,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-12-02,431,D,0,1,EU2J11,"Based on observation and interview the facility failed to ensure medications were stored per manufacturer's instructions and glucometer testing solutions were not properly dated in 1 of 3 medication rooms. Findings include: Observation on 12/2/16 at approximately 11:00 a.m. upon entering the 3rd floor medication room the temperature felt very warm. Observation of the thermometer within the medication room revealed a temperature of 82 degrees Fahrenheit. There were numerous medications (Pro-Air 59 F - 77 F, Ipratropium Bromide Inhaler, 9 boxes, store below 77 degree's Fahrenheit, Albuterol Sulfate inhalerstore below 77 degree's Fahrenheit, Budesonide inhaled medication, 2 boxes store below 77 degrees Fahrenheit) stored in cupboards that according to manufacturer's instructions located on the medication containers that read to store at no more than 77 degrees Fahrenheit. Interview with Staff A (Unit Manager/RN) on 12/2/16 at approximately 11:05 a.m. who was present at the time of entry to the medication who confirmed the above findings and stated the medication room is always very warm.",2020-01-01
734,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-12-02,456,D,0,1,EU2J11,Based on observation and interview the facility failed to ensure glucometer control solutions were properly dated after opening for 1 of 3 units. Findings include: Observation on 12/2/16 at approximately 11:20 a.m. it was revealed that the high and low glucometer testing solutions that were kept with the testing log in a drawer in the medication room were not dated as to when they were opened or dated for when they should be discarded. Interview with Staff D (RN) on 12/2/16 at approximately 11:25 a.m. confirmed the above findings.,2020-01-01
735,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-12-02,514,E,0,1,EU2J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review, interview, and facility policy and procedure, it was determined that the facility failed to fully document fall reporting on 4 Residents (#1, #2, #9, #10) and wound documentation for five weeks on Resident #2 out of a sample of 19. Attempts were made on 12/8/16 and 12/16/16 to obtain the correct falls reporting policy and procedure from the facility via Staff A (Clinical Nurse Executive). Messages were left regarding the request. No return call or aknowledgement of the message has been recieved. Resident #10 Resident had a reported fall on 5/11/16 at approximatly 7:30 pm. There was no documentation in the progress notes how the resident was moved from the location of the fall to either a chair or the resident's bed. This resident had a reported fall on 6/03/16 at approximatly 2:00 pm. There was no documentation in the progress notes how the resident was moved from the location of the fall to either a chair or the resient's bed. Resident #1 Review of Resident #1's medical record revealed that Resident #1 had a fall on 9/23/16. Further review revealed the Change in Condition report and the Nursing note from 9/23/16 did not reveal information detailing if the assessment of Resident #1 was performed before the patient was moved from the floor after the fall. Resident #2 Review of Resident #2's medical record revealed that the resident had falls on 11/21/16 and 11/25/16. The Change in Condition report and the Nursing note from the above dates did not have information detailing if the assessment of Resident #2 was performed before the patient was moved from the floor after the fall. Review of Resident #2's skin integrity reports from 8/9/16 to 12/1/16 revealed Resident #2 had a stage IV pressure ulcer on the sacrum. Further review of Resident #2's skin integrity reports revealed a gap of 12 days between the 8/19/16 and 8/31/16 weekly assessments, a gap of 22 days between the 9/14/16 and 10/6/16 weekly assessments, and a gap of 20 days between the 10/14/16 and 11/3/16 weekly assessments. Interview with Staff A (Unit Manager) on 11/30/16 at approximately 2:00 p.m. confirmed the missing skin assessments and revealed that there was no other documentation of skin assessments. Review of a facility incident report for 8/21/16 revealed that at approximately 6p.m. Resident #9 fell on the third floor resulting in a [MEDICAL CONDITION]. Other than Resident #9's vital signs being recorded minutes after the fall there's no documentation in Resident #9's clinical record detailing how facility responded after finding Resident #9 on the floor.",2020-01-01
736,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2016-10-13,252,E,0,1,DHDH11,"Based on observation and interview it was determined that the facility failed to provide a clean and homelike environment for 2 of 3 units in the facility. Findings include: During the initial tour on 10/11/16 between 9:15-9:30 a.m. of both the 200 and 300 floor, it was observed: On the 200 floor the Exit door was blocked by a large broda chair. The walls had a brown splatter pattern on multiple areas throughout the hallway. At the other end of the hallway was a green chair that had a brown smear stain in the seat part that also had a strong odor. In the kitchenette/dining area, the vents had black substances on the sides of the vents and what appears to be orange drips going down the walls by the vents. Near the elevator's handrails was a red substance on the handrails. On the 300 floor was observed to have the same brown splattered pattern on the hallway walls. The walls had dust build up on the wainscots in the hallway. In the kitchenette/dining area, the vents had black substances on the sides of the vent and what appears to be orange drips going down the walls by the vents. A wheelchair with rips in the both arms was observed at the end of the hallway. Interview on 10/12/16 during tour with Staff B (Administrator) and Staff [NAME] (District Manager HCSG) the above areas were toured and discussed. Staff B and Staff [NAME] confirmed the environment concern areas that needed to be cleaned. The broda chair was not blocking the exit and the wheelchair was not observed. Cross reference F441.",2020-01-01
737,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2016-10-13,281,D,0,1,DHDH11,"Based on record review, review of the Facility's investigation report, and staff interviews it was determined the facility failed to ensure that 1 medication was given at the proper time to 1 of 44 residents and failed to ensure that a medication error was reported by the nurse involved in a timely fashion. (Identifier is Resident #9) Findings include: Review on 10/13/16, of Potter & Perry, Fundamentals of Nursing, 7th Edition, on page 706 and 707 reveals, in part, at the heading entitled Standards: Standards are those actions that ensure safe nursing practice. Standards for medication administration are set by individual health care agencies and by the nursing profession .Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004) . apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration Further review, on 10/13/16, of Potter & Perry, Fundamentals of Nursing, 7th Edition, on page 708, (part of the 6 rights of medication administration) reveals, in part, under the heading Right Time: Nurse need to know why a medication is ordered for certain times of the day and whether they are able to alter the time schedule. and The presciber often gives specific instructions about when to administer a medication . and Give all routinely ordered medications within 60 minutes of the times ordered Review, on 10/13/16, of Potter & Perry, Fundamentals of Nursing, 7th Edition, on pages 704 and 705 reveals, in part, at the heading entitled Medication Errors: A medication error can cause or lead to inappropriate medication use or client harm. Medication errors include .using the wrong .time interval . .nurses need to be vigilant in prevention of medication errors. When a medication error occurs , the nurse is responsible for preparing a written occurrence or incident report that usually needs to be filed within 24 hours of the error. Review of the Facility's self-reported investigation report dated 9/7/16 revealed, in part, that When 3-11 nurse (Staff A, LPN) was interviewed, she stated, after she gave resident .meds she proceeded with the eye drops. After the eye drops were given, resident questioned if (he/she) receives eye drops at night. Nurse realized (resident) was only supposed to be given in the morning (sic) Review of Resident #9's Medication Administration Record [REDACTED]. Review of the Facility's self-reported investigation report revealed, in part, that The LPN, (Staff A) was interviewed on 9/6/16 about administering the eye drops at the incorrrect time. She indicated that it was after the eye drops were administered did the resident question the timing of the eye drops. She then realized that the drops were only supposed to be given in the morning. She had not reported the medication error. Interview 10/13/16 at 10:45 a.m. with Staff B (Administrator) and Staff C (DON) both confirmed the incident had occurred and shared the contents of the counseling report identifying the points of re-education that were covered with Staff A, to prevent a re-occurrence.",2020-01-01
738,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2016-10-13,323,E,0,1,DHDH11,"Based on observation, record review and interview, the facility failed to ensure that the fireplace in a resident common area was properly shielded and the controls secured to protect residents from the potential hazard of burns. Findings include: Observation of the Piano/Fireplace room on 10/11/16 at 8:40 a.m. revealed a functioning gas fireplace in use by a resident. There was no facility staff in with the resident or who had view of the Piano/Fireplace room at that time. The fireplace was a direct-vent fireplace heater insert with a sealed glass front. The fireplace did not have a protective panel or screen to prevent residents from contacting the glass front. The burner on/off switch and blower speed control located just to the left of the unit on the wall were not locked or secured. Interview with Staff [NAME] (Receptionist) on 10/11/16 at 11:00 a.m. revealed that many residents use the Piano/Fireplace room and facility staff do not always supervise residents in that room. Staff [NAME] had sight of the entrance to the Piano/Fireplace room from Staff E's desk but not directly into the room. Review of the Lennox Hearth Products Direct-Vent Gas Fireplace Heater Inserts Care and Operation Instructions, Rev J, dated 12/2007, provided by the facility revealed the following warnings: Hot! Do not touch! The glass and surfaces of this appliance will be hot during operations and will retain heat for a while after shutting off the appliance. Severe burns may result. (Page 1) Children and adults should be alerted to the hazards of high surface temperatures. Use caution around the application to avoid burns or clothing ignition. (page 2) Do not attempt to touch the front enclosure glass with your hands while the fireplace is in use. (Page 5) Interview with Resident #25 on 10/11/16 at 9:30 a.m. revealed the resident sits in the Piano/Fireplace room daily because he/she likes to use the fireplace to warm his/her hands. The resident stated he/she did not remember there ever being a screen in front of the fireplace and anyone can turn the fireplace on and off. The resident stated that many residents enjoy the common room and fireplace. The resident stated he/she was legally blind and he/she used a walker.",2020-01-01
739,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2016-10-13,371,F,0,1,DHDH11,"Based on observation and interview, the facility failed to maintain sanitary conditions in the main kitchen and kitchenettes located on each unit. Findings include: Observation in the kitchen on 10/11/16 at approximately 7:20 a.m. revealed the meat slicer had a small white hard substance adhered to the back of the blade. Interview with Staff D (Director of Food Services) at that time confirmed the above findings and revealed the meat slicer had been cleaned and was covered and ready for use. Observation in the kitchen on 10/11/16 at approximately 7:30 a.m. revealed that hood had a build of grease on the inside of the hood and a build up of grease and dust on the horizontal lighting under the hood. Interview with Staff D at that time confirmed the above finding. Observation in the kitchen of the ceiling tiles on 10/11/16 at approximately 7:35 am revealed a missing ceiling tile in the dry food storage area exposing pipes and the area above the ceiling. Observation also revealed a ceiling tile near the walk-in freezer had a black substance on it. Interview with Staff D at that time revealed that staff had notified maintenance and they removed the tile in dry storage because it had a been moldy and maintenance had not replaced the ceiling tile. Staff D had not been aware of the tile with a black substance near the freezer. Observation in the kitchenette on the first floor on 10/11/16 at approximately 7:45 a.m. revealed a dried brown substance consistent with coffee covering the counters and cupboards. The substance was also found inside the cupboards which contained pots and pans. Interview with Staff D at that time confirmed the above finding and revealed that the first floor kitchenette was mainly used for activities. Cross reference F441.",2020-01-01
740,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2016-10-13,441,E,0,1,DHDH11,"Based on observations, interview and review of the facility infection control program it was determined that the facility failed to ensure an environment that is safe and sanitary by not implementing a facility wide surveillance of infection control practices and investigations throughout the facility that provides a safe, sanitary and comfortable environment. Findings include: Review of the facility Infection Control Program revealed the following: The Infection Control Program is a comprehensive process that addresses detection, prevention and control of infections . The major activities of the program are: 1. Surveillance of Infections which includes ongoing monitoring for occurrence of infections among patients and staff. 2. Process Surveillance to review practices directly related to patient care. 3. Implementation of Control Measures and Precautions which include basics such as cleaning and hand hygiene, as well as Standard and Transmission Based Precautions . GOALS The Infection Control Program has been developed to provide staff with a coordinated organizational structure, technical procedures, comprehensive work practices and guidelines to reduce the risk of transmission of infection. The Infection Control Program encompasses both employee health . and patient care practices. The goals of the program are to: 1. Provide a safe and sanitary environment; 2. Decrease the risk of infection to patients and staff; 3. Monitor for occurrence of infection and implement appropriate control measures; 4. Identify and correct problems relating to infection control practices; 5. Facilitate compliance with state and federal regulations relating to infection control . In order to carry out the major activities of the Program, the Infection Control Coordinator has the following responsibilities . - Monitor selected procedures for proper technique, as indicated and appropriate . - Perform surveillance to monitor the rate of healthcare acquired infection and as needed conduct studies that relate to infection prevention and control activities . - Review information obtained from the infection prevention, surveillance and control activities to improve patient care, employee work practices and the environment of care and report findings to the Quality Improvement Committee . Interview on 10/13/16 with Staff C (Director of Nursing) and Staff F (Infection Control Registered Nurse), Staff F revealed that no infection control environmental rounds are done in the facility laundry area, kitchen and rehabilitation area and that there was no documented evidence of infection control surveillance in these listed areas. Staff F also verbalized that there is no documentation of infection control surveillance rounds for the resident care areas or infection control practices related to medication pass observation techniques. Review of a facility documentation to include but not limited to the following; Food & Nutrition Services audit forms dated 9/26/16, 8/17/16, Health Department Inspection 7/25/16 and facility tour sheets 5/31/16 through 9/30/16 revealed that there was dust on vents, ice machines on the units have mold in reservoir, Kitchen one visibly dirty on outside, poor quality cleaning in resident bathrooms, laundry area in need of organization, floors, walls, microwaves, ice machines need cleaning. Staff F verified that Infection Control does not participate in the above mentioned audits and that there are facility designated staff conducting the self inspection audits in assigned facility areas. The facility failed to follow the facility infection control policy and procedure to provide a safe sanitary comfortable environment and failed to document infection control surveillance rounds throughout the facility. Cross reference F371 and F252.",2020-01-01
741,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2016-06-16,514,B,0,1,4WG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, it was determined that the facility failed to ensure clinical records were complete and accurate for 3 residents in a standard survey sample of 17 residents. (Resident identifiers are #9, #10, & #16.) Findings include: Resident #9 Review of this resident's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/10/16 revealed in Section J that the fields for pain assessment were completed with dashes with no assessment of pain evident. Interview with Staff B, MDS Coordinator on 6/16/16 revealed that the nurse assessment for pain was completed late so it was unavailable to Staff B when this MDS was done. Review of Section F revealed that the fields for Customary Routine and Activities were completed with dashes, with no assessment of these preferences evident. Interview with Staff B on 6/16/16 revealed that Staff B saw no recreation assessment for this Section, so Staff B is unsure if the dashes are due to no assessment being done or due to Staff B thinking it was a Quarterly MDS (which would not require Section F to be completed). Review of Resident #9's Medication Administration Record [REDACTED].(Calcitonin (Salmon)) 1 spray Alternating nostrils in the evening for allergies [REDACTED]. Resident #10 Review of this resident's Quarterly MDS with an ARD of 5/7/16 revealed in Section J that the fields for pain assessment were completed with dashes with no assessment of pain evident. Interview with Staff B on 6/16/16 revealed that the nurse assessment for pain was completed late so was unavailable to Staff B when this MDS was done. Review of this resident's current care plan revealed the resident is to have checks every hour when in their room, and not in bed. The facility was unable to produce documentation that these hourly checks were being tracked on an ongoing basis to ensure completion. The facility subsequently revised this care plan intervention, on 6/15/16 to frequent checks when in room [ROOM NUMBER]/15/16. Resident #16 Review of this resident's care plan revealed an intervention to Assist resident in repositioning q-2-hrs that was initiated in (MONTH) of (YEAR). The facility was unable to produce documentation of this assist in repositioning. Interview with Staff B on 6/16/16 revealed that the assist in repositioning every two hours was never done as the resident didn't need it, but this intervention was still in the care plan.",2020-01-01
742,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-11-23,279,D,0,1,3G5211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to provide comprehensive care plans for 3 residents in a survey sample of 11. (Resident identifiers are: #2, #4, and #11. ) Findings include: Resident #2: Review on 11/22/16 of the resident's medical record, it was discovered that there was a copy of a card/certificate that stated that the resident had an internal pacemaker planted. Further record review of the paper and electronic chart it was revealed that there was no entry in the resident's plan of care to indicate that caring for the pacemaker was part of the comprehensive care of the patient, and there was no further mention of the pacemaker anywhere else in the resident's record. There was also no internal pacemaker noted on the list of [DIAGNOSES REDACTED]. Interview on 11/22/16 with Staff A (Director of Nursing-DON) revealed that Staff A was in agreement that there was no careplan for the pacemaker, and stated that there should have been one written for it. Staff A stated that the son verbalized that while his parent was at this facility, he did not want (his parent) going out for cardiology appointments, and did not want the staff to care for the pacemaker device. On further interview, Staff A did state that there should be a [DIAGNOSES REDACTED]. Resident #4 Review on 11/22/16 of the resident's [DIAGNOSES REDACTED]. Review of the resident's current care plan revealed that the resident was not care planned for the cardiac pacemaker. Interview with Staff A (DON)on 11/22/16 at 8:45 a.m. confirmed the above finding and revealed that it would be the facility's policy to care plan for a pacemaker. Resident #11 Review on 11/22/16 of the resident's [DIAGNOSES REDACTED]. Review of the resident's current care plan revealed that the resident was not care planned for the cardiac pacemaker.",2020-01-01
743,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-11-23,281,D,0,1,3G5211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders [REDACTED]. (Resident identifier is #5). Findings include: Reference for the professional standard of practice is, Fundamentals of Nursing, 7th Edition, Potter-Perry, Mosby, Elsevier, Evolve, 2009. On page 336 - Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 11/23/16 of Resident #5's Medication Administration Record [REDACTED] [MEDICATION NAME] 325 MG (milligrams) Tabs: 2 Tabs (650 MG) by mouth twice daily *Hold if 2 GM (grams)/24 HRS (hours)will be exceeded. [MEDICATION NAME] 325 MG Tabs: 1 Tab by mouth every 4 hours PRN (as needed) mild to mod pain/ NTE (not to exceed) 2 GM/24 HRS. [MEDICATION NAME] 325 MG Tabs: 2 tabs (650 MG) by mouth three times daily PRN severe pain/fever. Further review of the MAR indicated [REDACTED]. Interview with Staff A (Director of Nursing) on 11/23/16 at approximately 12:00 p.m. confirmed the above finding.",2020-01-01
744,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-11-23,282,D,0,1,3G5211,"Based on review of records and interview the facility failed to perform skin assessments in accordance with the resident's written plan of care for 1 resident in a sample size of 11 residents. (Resident identifier is #4.) Findings include: Review on 11/23/16 of Resident #4's current care plan revealed the resident would have weekly skin assessments. Review of Resident #4's weekly skin assessments for (MONTH) (YEAR) revealed skin assessments performed on 11/2/16 and 11/9/16. On 11/2/16 the nurse noted a red blanchable area on the right buttock. On 11/9/16, the nurse noted a red area on buttocks, mostly right side. On 11/16/16 the nurse notes the resident refused their shower. There was no other skin assessment between 11/9/16 and end of survey on 11/23/16. Interview with Staff B (Assistant Director of Nursing), on 11/23/16 at 11:10 a.m. confirmed the above finding.",2020-01-01
745,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2016-10-26,159,E,0,1,2TS011,"Based on a resident trust fund review and staff interview, it was determined that the facility failed to ensure that the funds managed by the facility for 62 residents in excess of $50 were in an interest bearing account. Findings include: Review on 10/26/16 of the resident trust fund task revealed that the funds of 62 residents in excess of $50 managed by the facility were not in an interest bearing account. The resident trust fund was transferred to a new bank account starting in (MONTH) (YEAR) that was not an interest bearing account. Interview on 10/26/16 with Staff C (Business Office Manager) confirmed the above findings.",2020-01-01
746,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2016-10-26,431,E,0,1,2TS011,"Based on observation and interview, it was determined that the facility failed to label glucose testing solutions in two out of two bottles examined on the East Wing and in two out of two bottles examined on the West Wing. Findings include: Observation on 10/26/16 at approximately 11:45 am of the medication room on the East Wing with Staff A LPN (Licensed Practical Nurse) revealed that the High and Low glucose control solution bottles were not labeled with the Opened on date. Interview at the time of this observation with Staff A revealed that Staff A was unable to explain why the glucose control solutions were not labeled. Observation on 10/26/16 at approximately 12:15 am, of the medication room on the West Wing with Staff B RN (Registered Nurse) revealed that the High and Low glucose control solution bottles were not labeled with the Opened on date on each bottle. Interview at the time of this observation with Staff B revealed that Staff B was unable to explain why this was not done. The facility Policy and Procedure on Diabetes Management was requested and under the section 'Monitoring', paragraph five, number four it states Individual glucose control solutions bottles and glucometer strips will be labeled with the date (M-D-Y) opened.",2020-01-01
747,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2017-04-21,157,D,0,1,UJTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that the facility failed to notify the physician when implementation of a physician order [REDACTED].#16.) Findings include: Review on 4/21/17 of Resident #16's Physician order [REDACTED]. This was ordered by Staff A (Physician Assistant). Review on 4/21/17 of Resident #16's progress notes from 3/31/17 revealed Shift Nurse Called (names of laboratory/portable X-ray supplier omitted) and requested a STAT Ultrasound at 14:00, but was told at 19:00 that the Lab is not coming tonight or weekend. Interview with Staff B (Registered Nurse, Unit Manager) on 4/21/17 at approximately 3:00 p.m. revealed that it was actually the contracted portable x-ray supplier, not the lab, that did not come that night and over the weekend. Staff B also revealed that neither Staff A (ordering Physician Assistant) nor the on-call physician were notified that the ultrasound would not be done until Monday. Staff B also revealed that radiology studies ordered in the afternoon would often be performed the next day depending on the portable x-ray supplier's schedule. Review on 4/21/17 of Resident #16's Radiology reports revealed that Resident #16 had a Venous Doppler for right leg pain on 4/3/17 at 6:30 p.m. performed by a portable X-ray supplier at the facility. Results from this study were Positive [MEDICAL CONDITION] in the right lower extremity. Interview on 4/21/17 at approximately 4:45 p.m. with Staff C (Chief Clinical Officer) revealed that it was Staff C's belief that staff and providers knew that radiology studies ordered in the afternoon might not be done that day or over the weekend. Interview on 4/21/17 at approximately 5:00 p.m. with Staff A, Staff A confirmed Staff A ordered an ultrasound of the right leg early Friday (3/31/17) afternoon to rule out [MEDICAL CONDITION]. Staff A stated they were not aware that X-rays were not performed on the weekends at the facility. Staff A revealed they had not been notified that the ultrasound would not be performed until Monday evening (4/3/17). Staff A stated that if they had been notified of the delay in the ultrasound until Monday, Staff A would have sent Resident #16 out to the hospital for an ultrasound or started the resident on medications for treating [MEDICAL CONDITION] instead of waiting until Monday. Review on 4/21/17 on Resident #16's Medication Administration Record [REDACTED]",2019-11-01
748,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2017-04-21,280,D,0,1,UJTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to update a comprehensive care plan for 1 resident in a standard survey sample of 30 residents. Findings include: Review on 4/20/17 of Resident #5's medical record revealed that Resident #5 had a foley catheter discontinued per physician order [REDACTED].#5 had been incontinent of urine. Review of Resident #5's current comprehensive care plan revealed that there was no care plan which addressed the urinary incontinence. Interview on 4/20/17 with Staff D (Registered Nurse, Unit Manager) confirmed that there was no care plan for urinary incontinence.",2019-11-01
749,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2017-04-21,281,E,0,1,UJTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to clarify which pain medication would be given for pain reported by resident for 3 residents, and failed to follow doctor's orders for 1 resident, in a standard sample size of 30 residents. (Resident identifiers are #3, #12, #16 and #29.) Findings include: Professional reference: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 .The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary .A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the client suffers Page 699 Prescribers must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Resident #3 Review on 4/19/17 of Resident #3's Medication Administration Record [REDACTED]. Orders read as follows: [MEDICATION NAME] suppository 650 mg (milligrams) Insert 1 suppository rectally every 6 hours as needed for pain. Not to exceed 3 grams in 24 hours. [MEDICATION NAME] HCL Concentrate 100 mg/ml (milligrams/milliliter) Give 0.25 ml by mouth every 2 hours as needed for pain. Interview on 4/19/17 with Staff I (Licensed Practical Nurse) and Staff J (Registered Nurse) confirmed that there are no pain parameters for use. Resident #16 Review on 4/20/17 of Resident #16's physician's orders [REDACTED]. [MEDICATION NAME] HCl Tablet 5 MG, Give 1 tablet by mouth every 6 hours for Pain (PRN). Further review of the MAR indicated [REDACTED]. Interview on 4/20/17 at 4:00 p.m. with Staff B (Unit Manager) confirmed there were not clear parameters for when or when not to administering [MEDICATION NAME] and revealed that a pain rating of 1-3 would be considered mild pain and a pain rating of 4-6 would be considered moderate pain. Resident #12 Review on 4/19/17 of Resident #12's MAR (Medication Administration Record) revealed that Resident #12 had a Humalog insulin order that read, If 0-200 = 0 Insulin, Call MD if BS (Blood Sugar) Review on 4/20/17 of Resident #12's nursing notes revealed there was no documented notification to the physician of the abnormal CBG's. Interview on 4/20/17 at 9:00 a.m. with Staff B (Registered Nurse - Unit Manager) confirmed that there was no notification of the abnormal CBG results in the medical record. Resident #29 Review on 4/21/17 of Resident #29s medical record revealed that Resident #29 had an order for [REDACTED].#29 received [MEDICATION NAME] on 4/10/17 for a pain level of 6. Resident #29 also had orders for [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 2 MG Give 1 tablet by mouth every 4 hours as needed for moderate pain. Resident #29 received [MEDICATION NAME] HCl 2 MG on 4/20/17 and 4/21/17 for a pain level of 6. Resident #29 also had an order for [REDACTED].#29 received [MEDICATION NAME] HCl 4 MG on 4/21/17 for a pain level of 6. Interview on 4/21/17 at approximately 1:00 p.m. with Staff D (Registered Nurse, Unit Manager) confirmed the above findings.",2019-11-01
750,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2017-04-21,441,D,0,1,UJTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to implement sanitary practices for glucose testing used for 1 of 6 units and failed to ensure that the appropriate isolation precautions were followed by staff to help prevent the development and transmission of disease and infection for 1 of 6 units. Findings include: Observation on 4/21/17 at approximately 10:00 a.m. during tour of unit 5-2 (building 5, floor 2) revealed a brown substance on the back of the point of care instrument used for glucose testing that was sitting in the docking station at the nurses station. Interview on 4/21/17 at approximately 2:00 p.m. with Staff D (Registered Nurse, Unit Manager) confirmed the above findings and revealed that the above instrument was used for multiple residents and the brown substance on the back of the glucose instrument was consistent with blood. Staff D explained that it is the practice of staff to disinfect the meter after using it and that the meter in docking station was ready for use. Review on 4/21/17 on infection control revealed a precaution sign checklist form on the doorway of a resident's room on unit 5-2. Interview on 4/21/17 at approximately 3 p.m. with Staff G (RN/Registered Nurse) at the unit 5-2 nurses station, Staff G stated that a resident in this room has a [DIAGNOSES REDACTED]. Interview on 4/21/17 at approximately 3:02 p.m. with Staff H (LNA/Licensed Nurses Aide) at the unit 5-2 nurses station, Staff H confirmed verbally that one of the residents in this room is on Clostridium difficile precautions and MRSA (Methicillin Resistant Staph Aureus). Staff G corrected Staff H by saying, No, this resident does not have MRSA only[DIAGNOSES REDACTED] (sic). Staff F (RN/Unit Manager and previous Infection Control Nurse) walked to the room where Staff G and Staff H stated earlier that one of the resident's in this room were on Clostridium difficile precautions. Upon arrival to this room a precaution sign checklist form was noted to be hung on the outside of the door casing. The precaution sign read as follows: CAUTION EVERYONE SEE BELOW FOR REQUIRED PPE (personal protective equipment)! ALL PPE MUST BE REMOVED & DISPOSED OF BEFORE LEAVING THE ROOM! HANDWASHING MUST BE DONE THE SAME WAY YOU DID IT BEFORE ENTERING THE ROOM! BEFORE ENTERING THE ROOM HANDWASHING WITH SOAP & WATER YES NO X HANDWASHING WITH ANTIMICROBIAL GEL&/OR ALCOHOL HANDRUB YES X NO . Interview on 4/21/17 at approximately 3:15 p.m. with Staff F who stated that handwashing with soap and water is required and that the use of alcohol based rubs/hand sanitizer is not effective against the spread of Clostridium difficile. Staff F completed a new precaution form where she/he corrected the form by indicating that hand washing with soap and water must be done when entering the room and that handwashing with antimicrobial gel &/or alcohol handrub is not to be used. While Staff F returned to the resident room to post this new precaution sign checklist form, it was reviewed with Staff G and Staff H what the concerns were regarding the directions that were provided to staff and visitors of a resident or residents room with a known or suspected case of[DIAGNOSES REDACTED]icile. Staff H stated in the presence of Staff F that she/he was directed to complete the precaution sign checklist form originally by another LNA which Staff F documented that the use of antimicrobial gel and/or alcohol handrub was an acceptable means of hand hygiene for care of residents/rooms that contained Clostridium difficile. Interview on 4/21/17 at approximately 3:35 p.m. with Staff F who stated that LNA's are not allowed to direct other LNA's specific to the completion of the precaution sign checklist form. Staff F stated that a nurse should be directing the completion of these forms and she/he was not sure why the sign for this room was not managed correctly. Staff F has been out of the role as the Infection Control Preventionist for several weeks and was just filling in for the purpose of the infection control portion of the survey.",2019-11-01
751,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2017-04-21,508,J,0,1,UJTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that the facility failed to obtain diagnostic services in a timely manner to meet the needs for diagnosis, treatment, and prevention for 1 resident in a standard survey sample of 30 residents. This resulted in an Immediate Jeopardy as the facility failed to communicate with the physician when implementation of a physician order [REDACTED].#16.) Findings include: Clinical Guideline Review: [DIAGNOSES REDACTED].D., on (MONTH) 1, 2013, relates in part . the consequences of missing the [DIAGNOSES REDACTED]. Per http://www.acepnow.com/article/clinical-guideline-review-diagnosis-[MEDICAL CONDITION]/ - accessed 5/17/17. Review on 4/21/17 of Resident #16's Physician order [REDACTED]. This was ordered by Staff A (Physician Assistant). Review on 4/21/17 of Resident #16's progress notes from 3/31/17 revealed MD/PA wrote an order for [REDACTED]. Shift Nurse Called (names of laboratory/portable X-ray supplier omitted) and requested a STAT Ultrasound at 14:00, but was told at 19:00 that the Lab is not coming tonight or weekend. Interview on 4/21/17 at approximately 3:00 p.m. with Staff B (Registered Nurse, Unit Manager) revealed that it was actually the contracted portable x-ray supplier, not the lab, that did not come that night and over the weekend. Staff B also revealed that neither Staff A (ordering Physician Assistant) nor the on-call physician were notified that the ultrasound would not be done until Monday. Staff B also revealed that radiology studies ordered in the afternoon would often be performed the next day depending on the portable x-ray supplier's schedule. Review on 4/21/17 of Resident #16's Radiology reports revealed that Resident #16 had a Venous Doppler ultrasound for right leg pain on 4/3/17 at 6:30 p.m. performed by a portable X-ray supplier at the facility, more than 72 hours after it was ordered. Results from this study were Positive [MEDICAL CONDITION] in the right lower extremity. Interview on 4/21/17 at approximately 4:45 p.m. with Staff C (Chief Clinical Officer) revealed that it was Staff C's belief that staff and providers knew that radiology studies ordered in the afternoon might not be done that day or over the weekend. Interview on 4/21/17 at approximately 5:00 p.m. with Staff A (Physician Assistant), confirmed that Staff A ordered an ultrasound of the right leg early Friday (3/31/17) afternoon to rule out [MEDICAL CONDITION]. Staff A stated they were not aware that ultrasounds were not performed on the weekends at the facility. Staff A revealed they had not been notified that the ultrasound would not be performed until Monday evening (4/3/17). Staff A stated that if they had been notified of the delay in the ultrasound until Monday, Staff A would have sent Resident #16 out to the hospital for an ultrasound or started the resident on medications for treating [MEDICAL CONDITION] instead of waiting until Monday. Interview on 4/21/17 at approximately 5:10 p.m. with Staff A, Staff A stated that Resident #16 had presented with a red, swollen, warm to touch right leg and Resident #16 had complained of pain so at that time Staff A ordered an ultrasound of the right leg early Friday (3/31/17) afternoon to rule out [MEDICAL CONDITION]. Review on 4/21/17 on Resident #16's Medication Administration Record [REDACTED] From the review of this incident, thru interview and record review it was revealed that there was no documented evidence that once the facility became aware of Resident #16's [MEDICAL CONDITION] that the staff and providers were educated or re-educated after this event that studies ordered from this company had the potential to be delayed due to operating only during contractual hours.",2019-11-01
752,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2016-12-21,279,D,1,0,0CSE11,"> Based on medical record review and interview, it was determined that the facility failed to develop a comprehensive care plan for safety for 1 resident in a survey sample of 6 residents. (Resident identifier is #1.) Findings include: Review on 12/21/16 of Resident #1's interim care plan titled Nursing Initial Plan of Care with an effective date of 11/4/16 revealed under section D. Safety/Falls the following items checked: 1a. Potential Safety risk, and 1b. Safety related to Wandering. Review of Interventions revealed the following items checked: 3a. Observe frequently during increased wandering to ensure safety, 3b. Observe for exit seeking behaviors and provide diversion activities, 3c. Wanderguard or other electronic safety devices as deemed necessary by observation, 3d. Observe for placement and function of devices per facility protocols, and 3e. Initiate safety checks as indicated. Review of Resident #1's physician monthly orders for November; signed 11/5/16 by the physician and December; signed 12/8/16 by the physician revealed that Resident #1 had the following order: Device: Wanderguard; Check for proper placement, functionality every shift. During interview on 12/21/16 at 12:20 p.m. with Staff D (Director of Nurses) the above findings were reviewed. Staff D confirmed that a comprehensive care plan for safety should have been developed for Resident #1 once the Wanderguard was placed on the resident.",2019-11-01
753,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2016-12-21,323,D,1,0,0CSE11,"> Based on review of the Incident/Accident report, medical record review and interview, it was determined that the facility failed to provide the appropriate level of supervision on an appointment for 1 resident in a survey sample of 6 residents. (Resident identifier is #1.) Findings include: Review on 12/21/16 of the facility's initial Incident/Accident report dated 12/13/16 revealed the following: Resident was transported by (name omitted) ambulance w/c (wheelchair) van to a.m. appointment at (name omitted) medical ctr. (center) for 1:30 p.m. The facility telephoned (name omitted) medical center at approx. (approximately) 5:30 p.m. to inquire upon resident status, as he had not yet returned. The nursing supervisor at (medical center name omitted) advised staff that the resident was signed in but was observed leaving at 1:18 p.m. the staff was informed that the resident did not keep his/her appointment. Review on 12/21/16 of the Resident #1's Brief Interview for Mental Status (BIMS) dated 11/9/16 revealed a score of 13 indicating cognitively intact. Review of Resident #1's Elopement Risk dated 11/4/16 revealed a score of 11 indicating not at risk. Review on 12/21/16 of Resident #1's interim care plan titled Nursing Initial Plan of Care with an effective date of 11/4/16 revealed under section D. Safety/Falls the following items checked: 1a. Potential Safety risk, and 1b. Safety related to Wandering. Review of Interventions revealed the following items checked: 3a. Observe frequently during increased wandering to ensure safety, 3b. Observe for exit seeking behaviors and provide diversion activities, 3c. Wanderguard or other electronic safety devices as deemed necessary by observation, 3d. Observe for placement and function of devices per facility protocols, and 3e. Initiate safety checks as indicated. Review of Resident #1's physician monthly orders for November; signed 11/5/16 by the physician and December; signed 12/8/16 by the physician revealed that Resident #1 had the following order: Device: Wanderguard; Check for proper placement, functionality every shift. Interview on 12/21/16 at 10:10 a.m. with Staff A (Administrator) revealed that on 12/13/16 Resident #1 went out to lunch with Resident #1's sisters. Staff A explained that when Resident #1 returned from lunch, it was time for Resident #1 to go to an appointment at the hospital. Staff A stated that the nurse assumed that Resident #1's sisters were going with Resident #1 to the appointment since Resident #1's sisters exited the building with Resident #1. Staff A stated that when the facility realized the resident had not returned from Resident #1's appointment, the facility contacted Resident #1's sister to see when Resident #1 would be back. Staff A explained that although Resident #1's BIMS was 13 and Resident #1 was not at risk for elopement, Resident #1 had a Wanderguard, had a guardian and the facility staff were still getting to know Resident #1. Staff A expressed that the facility would have normally sent a staff person with Resident #1 to an appointment due to these factors. Interview on 12/ 21/16 at 10:35 a.m. with Staff B (Licensed Practical Nurse) revealed that on 12/13/16 Staff B was covering for another nurse on a unit that Staff B did not normally work on. Staff B explained that on 12/13/16 Staff B received report that Resident #1 had appointment that Resident #1 was leaving for at 1:00 p.m. Staff B explained that on 12/21/16 at 12:55 p.m., Resident #1 returned from lunch with Resident #1's sisters. Staff B stated that Staff B assumed that Resident #1's sisters were going to the appointment with Resident #1 since they went outside at the same time as Resident #1 to the van. Interview on 12/21/16 at 11:30 a.m. with Staff D (Director of Nurses) revealed that it is the nurse's responsibility to ask who is going with a resident to appointments. Staff D explained that prior to this incident there was a form that is written out for appointments that indicates if a resident needs to have someone accompany them to an appointment. Staff D stated that the nurse should have checked this form. Staff D explained that this form is not the same on each unit. Staff D also explained that Resident #1 had not had any exit seeking behaviors or elopement attempts prior to this incident while at the facility. Staff D confirmed that if Resident #1 was not going to be going to the appointment with Resident #1's sisters, Staff D would expect Resident #1 to have been accompanied by a staff member. Staff D explained that since Resident #1 had a Wanderguard and the facility staff were still getting to know that resident, supervision on appointments was needed until Resident #1's next assessment to determine if it was still appropriate.",2019-11-01
754,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2016-11-10,154,D,0,1,HDFM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to obtain permission for the use of an Anti-Psychotic medication with an FDA (Food & Drug Administration) mortality warning for 2 residents in a standard survey sample of 18. (Resident identifiers are #7 and #8.) Findings include: Resident #8 Review of the pharmacy orders in the electronic medical record for Resident #8 reveal that [MEDICATION NAME] was ordered on [DATE] and started on 3/29/16 as PRN(as needed) medication for anxiety. The consent section of the medical record revealed a form titled Psychotherapeutic Medication Informed Consent. [MEDICATION NAME] was circled to identify the name of the drug being referenced. The FDA mortality warning was in place on the form. The signature of an LPN (Licensed Practical Nurse) is in place. There are no other signatures nor notations that the resident/responsible party was informed of the FDA mortality warning nor indication that permission was given, either orally or written. A review of the progress note for 3/28/16, time stamped 12:22, the order for [MEDICATION NAME] is noted, a drug to drug interaction indication is noted, and a notation of MD and family aware. No indication is made if the family member understood the FDA warning or identifies the family member as the Durable Power Of Attorney-Health Care. An FDA Alert (2005) addressed Increased Mortality in Patients with Dementia-Related [MEDICAL CONDITION], noting, in part, that patients with dementia-related [MEDICAL CONDITION] treated with atypical (second generation) antipsychotic medications are at an increased risk of death compared to placebo. (See http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm 1.htm accessed 11/15/16.) Also, a website page last updated 6/19/09 related, in part, Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. (See http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ucm 6.htm accessed 11/15/16.) Resident #7 Review of this resident's Order Summary Report, dated 10/3/16 and signed by the physician on 10/13/16, revealed that Resident #7's medications include the antipsychotics [MEDICATION NAME] ([MEDICATION NAME]) 1 mg by mouth daily, and [MEDICATION NAME] 20 mg by mouth daily. Additional record review revealed an Anti-Psychotic Medications Consent, signed by the Legal Representative on 7/23/05, consenting to the use of [MEDICATION NAME] and [MEDICATION NAME]. A subsequent verbal Anti-Psychotic Medications Consent, for [MEDICATION NAME], related 1/9/10 - Daughter refused to consent to med decrease. Neither consent addressed the Black Box warning or increased risk of death in the elderly. This finding was pointed out to nursing, Staff A and/or Staff B, during survey, and the facility obtained a verbal Psychotherapeutic Medication Informed Consent from the Co-Guardian on 11/2/16 that included information that The Food and Drug Administration (FDA) has .Found that older patients taking atypical antipsychotics for dementia have a higher risk for death than those that do not take the medication.",2019-11-01
755,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2016-11-10,279,D,0,1,HDFM11,"Based on record review, the facility failed to develop a complete care plan for 1 resident, in a survey sample of 18 residents. (Resident identifier is #14.) Findings include: Review of this resident's Minimum Data Set assessment for Assessment Reference Date 6/25/16 reveals in Section G, Functional Status, that the resident requires Extensive assistance for Self-Performance in multiple ADL (Activities of Daily Living) areas, including Bed mobility, Transfer, Walk in room, Locomotion on unit, Dressing, Toilet use, and Personal hygiene. The Care Area for ADL Functional/Rehabilitation Potential triggered, and in their Care Area Assessment the facility determined that they would address this area in the Care Plan. Closed record review of Resident #14's care plans revealed that the facility failed to fully address the extensive assistance this resident needs for ADL self-performance. The lack of a comprehensive ADL care plan was pointed out to nursing, Staff A or Staff B, during survey, and a copy of the resident's cancelled and resolved care plans was provided by fax, and review of same corroborated the above findings, albeit some interventions such as Monitor for and assist toileting needs and Bed against wall as an enabler .",2019-11-01
756,PHEASANT WOOD CENTER,305059,50 PHEASANT ROAD,PETERBOROUGH,NH,3458,2016-11-10,514,B,0,1,HDFM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure medical records were complete and accurate for 2 residents, in a survey sample of 18 residents. (Resident identifiers are #7 and #14.) Findings include: Resident #7 Review of this resident's Order Summary Report, dated 10/3/16 and signed by the physician on 10/13/16, reveals that Resident #7's medications include four PRN (as needed) medications for pain: [MEDICATION NAME] 650 mg by mouth every four hours prn pain, [MEDICATION NAME]-[MEDICATION NAME] 2.5-325 mg one tablet by mouth every 6 hours prn pain, [MEDICATION NAME] Gel 2 gram [MEDICATION NAME] prn pain apply to lower back four times a day prn, and [MEDICATION NAME] Gel 4 gram [MEDICATION NAME] prn for pain related to PAIN, UNSPECIFIED (R52) 4 times a day prn to left knee. The parameters do not always identify which [MEDICATION NAME] is to be administered; for example, for low back pain one could administer [MEDICATION NAME]-[MEDICATION NAME], or [MEDICATION NAME]. The Order Summary Report also includes an order for [REDACTED]. Review of Resident #7's Minimum Data Set (MDS) assessment for Assessment Reference Date (ARD) 7/18/16 revealed in Section H Bladder and Bowel, that the resident coded for occasionally incontinent of urine. The Care Area for Urinary Incontinence and Indwelling Catheter triggered, and in their Care Area Assessment (CAA) the facility determined that they would address this area in the Care Plan. However, review of the resident's care plans revealed urinary incontinence was not addressed, resulting in an inconsistency between the CAA and the Care Plan. Interview with Staff A (nursing) during survey, revealed that the resident fell on on 4/20/16 and was treated with a knee brace, with decreased mobility, need for more ADL (Activities of Daily Living) help and occasional incontinent of urine, but now the resident is independent and no longer incontinent of urine. Review of the MDS assessment with an ARD of 8/3/16 revealed the resident coded as Always continent. Resident #14 Review of this resident's Order Summary Report, dated 9/7/16 and signed by the physician on 9/9/16, reveals an order for [REDACTED].",2019-11-01
757,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2016-11-16,155,D,0,1,Q1DI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to adhere to the State of New Hampshire's Chapter 137-J, WRITTEN DIRECTIVES FOR MEDICAL DECISION MAKING FOR ADULTS WITHOUT CAPACITY TO MAKE HEALTH CARE DECISIONS, Section 137-J:5 for 3 residents in a standard survey sample of 24 residents. (Resident identifier's are #10, #12 and #17.) Findings include: Review of New Hampshire state law for Advance Directives, Section 137-J:5, effective (MONTH) 21, 2009 reveals the following: II. An agent's authority under an advance directive shall be in effect only when the principal lacks capacity to make health care decisions, as certified in writing by the principal's attending physician or APRN, and filed with the name of the agent in the principal's medical record. When and if the principal regains capacity to make health care decisions, such event shall be certified in writing by the principal's attending physician or APRN, noted in the principal's medical record, the agent's authority shall terminate, and the authority to make health care decisions shall revert to the principal . Resident #10. Record review on 11/15/16 revealed a physician order [REDACTED].#10. Resident #17. Record review on 11/16/16 revealed a physician order [REDACTED].#17. Interview on 11/16/16 with Staff D (Registered Nurse) and review of the medical record for Resident #10 and #17 showed no documentation of an assessment to determine that Resident's #10 and #17's capacity for decision-making and no written statement by the physician to certify that Resident #10 and Resident #17 lack the capacity to make health care decisions prior to activating the Durable Power of Attorney for Health Care (DPOA-HC). Resident #12 Record review on 11/16/16 revealed a physician order [REDACTED].#12. There was no documentation of an assessment to determine Resident's #12's capacity for decision-making and no written statement by the physician to certify that Resident #12 lacks the capacity to make health care decisions prior to activating the DPOA-HC. Interview with Staff B (Director of Nursing) on 11/16/16 at approximately 11:00 a.m. confirmed the above finding.",2019-11-01
758,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2016-11-16,280,D,0,1,Q1DI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interview, the facility failed to review and revise comprehensive care plans for 1 of 24 residents in a survey sample (Resident identifier #19) Findings include: Review of Resident #19's care plan revealed interventions for both a [MEDICAL TREATMENT] catheter and a fistula. Review of Resident #19's [MEDICAL TREATMENT] Communication book revealed that the resident had a fistula used for [MEDICAL TREATMENT]. Interview with Staff [NAME] (Registered Nurse, Unit Manager) on 11/16/16 at 3:10 p.m. confirmed the above finding and revealed that Resident #19 has not had a catheter since (YEAR).",2019-11-01
759,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2016-11-16,281,D,1,1,Q1DI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview it was determined that the facility failed to follow the professional standard of practice for pronouncing at the end of life for 1 closed record resident, failed to follow professional standard of practice for discarding medications for 1 out of sample resident, failed to follow the professional standard of practice for the administration of medications for 1 out of sample resident and documentation of narcotic medications for 2 out of sample residents. (Resident identifier's are #6, #20, #25, #29, #30 and #31.) Findings include: Reference is Fundamentals of Nursing, 7th Edition, MOSBY/ELSEVIER, 2009, Evolve, pages 479 - 480, reveal the following: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care .Documentation of death provides a legal record of the event. Follow agency policy and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death .Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting Documentation of End-of-Life Care .Time and date of death and all actions taken to respond to the impending death Name of health care provider certifying the death Persons notified of the death (e.g. health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death Request for organ or tissue donations made and by whom Special preparations of the body (e.g., desired or required religious/cultural rituals) Medical tubes, devices, or lines left in or on the body Personal articles left on and secured to the body Personal items given to the family with description, date, time, to whom given Location of body identification tags Time of body transfer and destination Any other relevant information or family requests that help clarify special circumstances. Reference for the standard of practice for medication disposal is the FDA (Food and Drug Administration) Safe Disposal of Medicines: Medicines play an important role in treating many conditions and diseases and when they are no longer needed it is important to dispose of them properly to help reduce harm from accidental exposure or intentional misuse . 1. Mix medicines (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds; 2. place the mixture in a container such as a sealed bag; 3. Throw the container in your household trash; 4. Scratch out all personal information on the prescription label of your empty pill bottle or empty medicine package to make it unreadable, then dispose of the container . Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009, revealed the following: Chapter 35 Medication Administration, Right Documentation on pages 709, page 688 for Guidelines for Safe Narcotic Administration and Control and page 720 for Administering Oral Medications reveals the following: page 709 After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care . page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed . Use the record to document the client's name, date, time of medication, name of medication, dose and signature of nurse dispensing the medication . page 720 To prepare tablets or capsules from a floor stock bottle, pour required number into bottle cap and transfer medication to medication cap. Do not touch medications with fingers. page 688 Guidelines for Safe Narcotic Administration and Control . Store all narcotics in a locked, secure cabinet or container . . Narcotics are frequently counted. Usually counts are made on a continuous basis with the opening of narcotic drawers and/or at shift change. . Report discrepancies in narcotic counts immediately . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication,dose and signature of nurse dispensing the medication. . If a nurse gives only part of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers. Instead, flush wasted portions of the tablets down the toilet and wash liquids down the sink. Resident #25. Observation during medication pass on 11/15/16 at approximately 7:55 a.m. showed that Staff A (Licensed Practical Nurse) had prepared multiple tablets of medication in a plastic medication cup for Resident #25. Upon entering the resident room and identifying the resident the multiple medications in this medication cup spilled out of the cup onto the bed linens at the foot of Resident #25's bed. Staff A proceeded to pick each individual medication tablet up from the resident's bed linen with bare hands and return them to the plastic medication cup. Staff A then administered these tablets to Resident #25 followed by a cup of water to swallow the medications. Resident #29. Review of a Narcotic Book on 11/15/16 revealed inaccurate documentation for the narcotic medication [MEDICATION NAME] 10 mg administered to Resident #29 on page #70. This document showed on 10/17/16 that 16 tabs of [MEDICATION NAME] 10 mg were on hand two tabs was the amount used with 14 tabs remaining. The next entry dated 10/17/16 showed 14 tabs on hand with the notation 1 pill wasted and 14 tabs remaining. An entry made on 10/20 showed 1 tab of [MEDICATION NAME] 10 mg left with 30 tabs received on 10/21 for total of 31 tabs. The next entry made on this document showed 10/24 0500 wasted 1 with 0 remaining. Resident #30. Further review of this Narcotic Book revealed that the narcotic medication for Resident #30 on page #100 was listed as 2 wasted and only signed off by one nurse. Interview on 11/15/16 with Staff D (Registered Nurse) and after review of the the two findings listed above Staff D confirmed that the documentation was inaccurate for Resident #29 and that two nurses should sign when a narcotic medication was wasted for Resident #30. Review on 11/14/16 of the facility's Medication Administration: General policy with a revision date of 03/15/16 reveals the following: 4. If discrepancies, including medication not available, notify physician/mid-level provider and/or pharmacy as indicated . Resident #6 Review on 11/14/16 of Resident #6's MAR (Medication Administration Record) for 11/01/16- 11/30/16 revealed that on 11/1/16 an order for [REDACTED]. Review of Resident #6 medical record revealed a physican note dated 11/7/16 indicated that the physican and family were not notified of the missed Phemobarnital suppository on 10/31/16 and 11/1/16 until after Resident #6 had [MEDICAL CONDITION] activity on 11/4/16. Interview on 11/14/16 with Staff B, DON (Director of Nursing) indicated that a medication omission was discovered for 10/31/16 and 11/1/16 due to medication not given/not available on 11/4/16 when Resident #6 had [MEDICAL CONDITION]. Even though the MAR indicated [REDACTED]. Resident #20 Review of progress notes for Resident #20 revealed the following note from 10/8/16 at 6:20 a.m. patient pronounced at 0545. There was no documentation of the actions taken to respond to the impending death. Interview with Staff B (Director of Nursing) on 11/16/16 at approximately 1:00 p.m. confirmed the above finding. Resident #31 Observation during medication pass for Resident #31, Staff F (LPN) presented Resident #31 with poured medications in a medicine cup. Resident #31 indicated they would not take scheduled [MEDICATION NAME] due to it caused frequent urination. Staff F shook out the medication on to the overbed table top, picked up the refused medication from the table top, then gave Resident #31 the remainder of the poured medication in the medicine cup. Resident #31 took the medication given in the medicine cup and followed with water. Staff F then took the Flowmax medication and disposed it in the sharps waste container located on the medicine cart. Review of the facility Policy 8.2 Disposal/Destruction of Refused, Discontinued, and Expired Medications; Section Process; Subsection 1.0; Paragraph 1.1 When a patient refuses a dose that has already been prepared for administration by Center staff or if a dose is deemed unusable (e.g., dropped on floor), document the refusal on the MAR (Medication Administration Record); Paragraph 1.2 Immediatly dispose of the dose in water or alcohol to make unsusable and dispose in trash, sink drain, or toilet.",2019-11-01
760,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2016-11-16,329,D,0,1,Q1DI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to monitor two residents by not conducting the ABNORMAL INVOLUNTARY MOVEMENT SCALE and failed to refer one resident for a complete neurological exam following the results of this monitor for 3 of 9 resident's receiving antipsychotic medications in a survey sample of 24 residents. (Resident identifier's are #1, #4 and #10.) Findings include: Resident #4. Record review on 11/15/16 of the Abnormal Involuntary Movement Scale (AIMS) for Resident #4 dated 10/22/16 revealed that Resident #4 scored 2 in two areas of Section B. Extremity Movements and scored 2 in one area of Section C. Trunk Movements. Review of the interpretation of AIMS score reveal that when a resident scores 2 in two or more of the seven body areas REFERRAL FOR COMPLETE NEUROLOGICAL EXAM. Interview on 11/15/16 with Staff A (Registered Nurse) at approximately 10:00 a.m. after Staff A reviewed the above listed AIMS findings, Staff A verbally confirmed that that no referral for a neurological exam was done for Resident #4. Resident #10 Record review on 11/15/16 of the physician orders [REDACTED].#10 was receiving the antipsychotic medication [MEDICATION NAME]. Further record review revealed no documented evidence of an AIMS completed for Resident #10. Interview on 11/15/16 and review of the medical record with Staff A revealed no evidence of a AIMS completed for Resident #10. Resident #1 Record review on 11/15/16 of the physician orders [REDACTED].#1 was receiving the antipsychotic medication [MEDICATION NAME]. Further record review revealed no documented evidence of an AIMS completed for Resident #1 Interview with Staff [NAME] (Register Nurse, Unit Manager) on 11/15/16 at 2:05 p.m. confirmed the above finding and revealed that Resident #1 should have had an AIMS completed at admission. The resident was admitted on [DATE].",2019-11-01
761,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2016-11-16,514,D,0,1,Q1DI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain clinical records for 2 of 24 resident in a survey sample (Resident identifiers #1 and #12). Findings include: Resident #1 Review of the resident's allergies [REDACTED]. Interview with Staff [NAME] on 11/15/16 at 2:15 p.m. confirmed the above finding and revealed that the practice would be to refer to the MAR for allergies [REDACTED].>Resident #12 Review of the resident's Treatment Administration Record (TAR) for 11/1/16 to 11/15/16 revealed Empty Foley Catherter Drainage Bag every shift and as needed every shift was missing doucmentation of completion on 11/7/16, 11/10/16, 11/11/16, and 11/14/16 from 7 a.m. to 3 p.m. and on 11/8/16 from 3 p.m. to 11p.m. Further review of the TAR revealed the following tasks not documented on 11/11/16 and 11/14/16 during the 7 a.m. to 3 p.m. shift: Air mattress 5 LED (Light Emitting Diode) from the floor every shift, antifungal powder to groin BID (twice a day) unresolved every day and evening shift for redness, check air mattress Q (every) shift for bottoming out, encourage patient to turn and reposition in bed every 2 hours as patient allows every shift, float heals in bed as patient allows every shift, perform catheter care every shift, and side rails 2 1/2 (two half side rails) as an enabler for turning and repositioning in bed every shift.",2019-11-01
762,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2016-12-01,514,D,1,0,O6Q011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to provide complete documentation and sufficient information to support the needs of 1 resident out of a sample size of 1. (Resident identifier is #1.) Findings include: Review of Resident #1's record from a local hospital on [DATE], revealed a psychiatric consultation report dated [DATE] that the patient admitted to suicidal ideation but no formed plan. A History and Physical report dated [DATE] indicates an admission to the hospital from [DATE] through [DATE] for severe anxiety and suicidal ideation. The hospital record dated [DATE] includes a [DIAGNOSES REDACTED]. Review of Resident #1's medical record revealed a physicians order dated [DATE] for a psychiatric consult through (name omitted) Mental Health Services. Resident #1 was not seen for an initial evaluation until [DATE]. There was no documentation to explain the approximately 6 week gap between the order and start of services. Review of a nurses note dated [DATE] indicates a negative statement by Resident #1 about life and harming herself/himself during a therapy session. Resident #1 denied a plan to harm self. This was reported by Staff A (Physical Therapist) per the nurse note as well as the documentation titled: Event Investigation Interview dated [DATE]. This interview revealed that Staff A overheard the residents (spouse) say something like 'Stop that or I'll put a bag over your head'. Resident #1's spouse's statement was reported to the social worker. There are no social service notes to support this conversation. There is no documentation by Staff A to support this conversation in Resident #1's medical record. Review of Social Service notes revealed no documentation of any kind after [DATE]. Resident #1 expired on [DATE]. Interview on [DATE] with Staff B (Social Services) confirmed that there was no social service documentation to support the reported conversation regarding the residents statement of wanting to harm self and that of his spouse's threat overheard by Staff [NAME] Interview with Staff C (Social Service Director) on [DATE] confirmed that there was no Social Service note in relation to the circumstances around the residents death that occurred on [DATE].",2019-11-01
763,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2017-03-17,281,D,0,1,PA8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to follow the physician orders [REDACTED]. (Resident identifier is #10.) Findings include: Professional Standard Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 3/16/17 of Resident #10's physician's orders [REDACTED].*Check Patch Placement every Shift* 11 p.m. to 7 a.m., 7 a.m. to 3 p.m., 3 p.m. to 11 p.m Review of Resident #10's MAR (Medication Administration Record) revealed for the month of (MONTH) (YEAR) on the 11 p.m. - 7 a.m. shift for the dates of 3/9/17 and 3/13/17 sign-offs for checking the [MEDICATION NAME] placement were blank. On the 7 a.m.-3 p.m. shift, documentation review revealed on 3/4/17, 3/5/17, 3/9/17, 3/10/17 and 3/13/17 sign-offs for checking the [MEDICATION NAME] placement were blank. On the 3 p.m.-11 p.m. shift documentation review revealed on 3/4/17 and 3/7/17 sign-offs for checking the [MEDICATION NAME] placement were blank. Interview on 3/17/17 at approximately 1:00 p.m. with Staff B (Registered Nurse) reviewed the above findings and confirmed the [MEDICATION NAME] placement had not been checked and/or signed off as present by staff.",2019-11-01
764,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2017-03-17,456,D,0,1,PA8511,"Based on medical record review, observation and interview, it was determined that the facility failed to maintain 3 glucometers on 2 out of 3 units. Findings include: Review on 3/15/17 of the facility policy titled NSG217 Glucose Meter (revision date 3/15/16) revealed that it is the facility's practice to To ensure the accuracy and validity of blood glucose monitoring, blood glucose meters will be disinfected before patient use and quality control tested daily according to manufacturers guidelines. Review of daily quality control logs for three out of four glucose meters revealed the following missing entries: Meter #EG 2 January (YEAR) was missing 1/1, 1/2, 1/7, 1/12, 1/21 and 1/30 calibrations. Meter #EG 8 January (YEAR) was missing 1/1, 1/2, 1/7, 1/16 and 1/21 calibrations. February (YEAR) was missing 2/6 calibrations. Meter #EG 6 January (YEAR) was missing 1/1, 1/2, 1/7, 1/18 and 1/21 calibrations. February (YEAR) was missing 2/6 calibrations. March (YEAR) was missing 3/9, 3/10, 3/13 calibrations. Interview on 3/16/17 at approximately 9:10 a.m. with Staff A (Unit Manager) reviewed the above findings and Staff A confirmed on these dates for the calibration of the glucometers were missing.",2019-11-01
765,"MOUNTAIN RIDGE CENTER, GENESIS HEALTHCARE",305075,7 BALDWIN STREET,FRANKLIN,NH,3235,2017-03-17,514,D,0,1,PA8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to maintain accurate clinical information on 2 residents in a survey sample of 17 residents. (Resident identifiers are #8 and #16.) Findings include: Review on 3/16/17 of Resident #8's nursing note dated 3/10/17 revealed Resident #8 had returned from a transfer to the hospital on [DATE]. There was no nursing note, doctor's order, or clinical assessment documentation done in regards to resident clinical condition or transfer to the hospital. Interview on 3/16/17 at 12:00 p.m. Staff B (Director of Nursing) review the above finding and Staff B confirmed that there was no documentation on the event that led to a hospital transfer. Review on 3/16/17 of Resident #8's MAR (Medication Administration Record) revealed that the facility failed to adhere to the facility's policy, NSG227 Pain Management, with a revision date of 11/28/16, which states Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status, and as required there after .Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Review of Resident #8's PRN (as needed) pain medications revealed they were administered on the following dates and did not have any documentation for effectiveness: December (YEAR) -12/13/16, 12/16/16, 12/17/16 (3 different PRN's) and 12/18/16. January (YEAR)- 1/1/17, 1/4/17, 1/14/17 (2 different PRN's), 1/15/17 (2 different PRN's), 1/20/17, 1/24/17 (2 different PRN's) and 1/30/17. February (YEAR)- 2/4/17, 2/12/17, 2/14/17, 2/17/17, 2/22/17, 2/25/17 (2 different PRN's) and 2/27/17. March (YEAR)- 3/2/17, 3/3/17, 3/7/17, 3/10/17 and 3/13/17. Review on 3/16/17 review of Resident #16's MAR indicated [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. Interview on 3/17/17 at approximately 8:00 a.m. with Staff B reviewed the above findings and Staff B confirmed that there should have been a documented reason on the MAR indicated [REDACTED].",2019-11-01
766,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2016-10-26,156,C,0,1,Z77H11,"Based on observation and interview, it was determined that the facility failed to have a current posting of names, addresses, and telephone numbers of all pertinent state client advocacy groups such as the state survey and certification agency and the state licensure office. Findings include: Observation on 10/25-10/26/16 revealed that facility had not posted all pertinent state client advocacy groups such as the phone numbers for the state survey and certification agency and the state licensure office in the main lobby or throughout the nursing home units. Interview on 10/26/16 with Staff D (Administrator) verified that the phone numbers were not on the wall in the lobby. Staff D obtained the one from the assisted living entrance and placed on the lobby wall.",2019-11-01
767,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2016-10-26,221,D,0,1,Z77H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to properly implement a restraint for 1 resident in a survey sample of 24 residents. (Resident identifier is #12.) Findings include: Resident # 12 During tour on 10/24/16 in the a.m., Resident #12 was observed in a wheel chair with a seat belt. Review of Resident #12's record on 10/26/16, revealed that Resident #12 was admitted to the facility on [DATE]. Review of the physician's note on 2/24/16 revealed an order that was written, to a lap buddy or seat belt while sitting in w/c(wheelchair). Will obtain one ASAP (as soon as possible) for resident safety. Resident very restless tonight & trying to stand up constantly. Will also check U/A (urinalysis) & tx(treat) if indicated. On 8/13/16 a physician order [REDACTED]. Use only while up in wheelchair. Further review of the medical record failed to show an initial and ongoing assessments, for the use of seatbelt. The medical record also failed to have a physician order [REDACTED]. Interview on 10/26/16 at 2:00 p.m. with Staff E, (Director of Nurses) revealed that no initial assessment was done because the facility didn't feel it was a restraint due to Resident #12 being able to release it when ever she/he wants depending on her/his cognitive ability at that moment. Staff [NAME] confirmed that no assessment had been done to determine if Resident #12 could release belt.",2019-11-01
768,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2016-10-26,329,D,0,1,Z77H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to have informed consent for anti-psychotic medication for 1 of 5 residents receiving anti-psychotic medications in a survey sample of 17 residents. (Resident identifier is #5.) Findings include: Resident #5 Record review on 10/24/16 and 10/15/16 revealed a physician order [REDACTED].#5. Review of the facility Psychotherapeutic Medication Informed Consent form revealed the following: Instructions: Circle or write in drug name for each drug ordered. The section on this form titled Disclosure of Risks and Benefits Regarding the Use of Psychotherapeutic Medications revealed The following list contains information regarding different classes of psychotherapeutic medications, the brand names by which they are known, the conditions they seek to alleviate, and possible adverse reactions to their use. It is important to note the following: It is important that you are fully informed about psychotherapeutic medications. If you have any questions regarding the information contained herein, please direct them to your attending physician or psychiatrist. *Denotes Black Box Warning (a type of warning that appears on the package insert for prescription drugs that may cause serious, adverse effects). The section of this form titled Drug Information has a listing of Anti-Psychotic Drugs: to include *[MEDICATION NAME] and includes a listing of Benefits, Adverse Reactions and Of Special Concerns . Review of this facility document for Resident #5 revealed that the anti-psychotic [MEDICATION NAME] medication was not completed. The section titled Informed Consent revealed the following; The information above regarding the risks and benefits of psychotherapeutic medication have been verbally explained to me and/or provided in writing. I understand that I have the right to refuse the administration of these medications and the right to withdraw consent of medications administration at any time by informing the Center staff . The signature section was dated and signed by the health care decision maker and clinician on 8/20/16. Interview on 10/25/16 at 3:15 p.m. with Staff C (Registered Nurse) confirmed that the consent was not completed for the administration of the anti-psychotic medication [MEDICATION NAME] to Resident #5.",2019-11-01
769,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2016-10-26,356,C,0,1,Z77H11,"Based on observation and interview, it was determined that the facility failed to post nurse staffing data specific to the Skilled Nursing Facility (SNF). Findings include: Observation on 10/26/16 at 8:00 a.m. of the document titled, GenSTAR Daily Nurse Staffing Form on the wall by the entrance to the(NAME)Wing revealed the Day Shift census was documented as 93. The facility is licensed for a maximum of 87 beds. Interview on 10/26/16 at 3:00 p.m. with Staff D (Administrator) reviewed the above findings and Staff D confirmed the census was 87 residents at the Skilled Nursing Facility and the GenSTAR Daily Nurse Staffing Form included the staffing for the SNF as well as the Assisted Living Facility (ALF).",2019-11-01
770,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2016-10-26,387,E,0,1,Z77H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure physician visits occurred at least once every 30 days for the first 90 days after admission for 2 residents in a survey of 17 residents. (Resident identifiers are #1 and #3.) Findings include: Resident #1 Review on 10/24/16 of Resident #1's medical record revealed that Resident #1 was re-admitted on [DATE] and was not seen by his/her physician until 7/24/16 which is beyond the required 30 days. Interview on 10/26/16 with Staff B (Licensed Practical Nurse/Unit Manager) reviewed the above findings and Staff B confirmed that the physician had not seen the resident within 30 days of re-admission to the facility. Resident #3 Review of Resident #3's medical record revealed that the resident was admitted on [DATE] were receiving skilled nursing services. Further review revealed that between 6/20/16 to 10/24/16, the resident was seen by the physician only once on 8/24/16, which was not within the first 30 days of admission. Interview on 10/24/16 at 3:00 p.m. with Staff A (Licensed Practical Nurse) reviewed the above findings and confirmed that the physician had not seen the resident within 30 days of admission.",2019-11-01
771,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2016-10-26,441,E,0,1,Z77H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to implement sanitary practices for International Normalized Ratio (INR) testing used for monitoring [MEDICATION NAME] therapy on 2 of 3 units. Findings include: Observation on 10/24/16 at approximately 10:00 a.m. during tour on the Bretton Woods unit in the medication room revealed a brown substance on the back of the point of care instrument used for INR testing. Interview on 10/24/16 at approximately 10:00 a.m. with Staff A (Licensed Practical Nurse) reviewed the above findings which revealed that the above instrument was used for multiple residents and the brown substance on the back of the Coaguchek instrument was consistent with blood. Staff A explained that it is the practice of staff to disinfect the meter after using it and that the meter in the medication room was ready for use. Tour of the Champney Unit on 10/24/16 at approximately 11:45 [NAME]M. with Staff B (Licensed Practical Nurse/Unit Manager) revealed a PT/INR (Pro-Time/In Ratio) machine which was stored at the nurses station on this unit, presented with a dried brown substance on the front and back of the unit. Review of the facility's policy and procedure titled, PT/INR Testing with (tradename omitted) Monitoring System, effective date of policy is listed as 12/1/04 and the last revision date is listed as 7/1/15, revealed in section 8.2.7 under #13 Disinfect meter after patient use and before storing the meter at the end of the day. Review of the manufacturer's instructions titled, (tradename omitted) System User Manual on page 17 under the heading Infection Control reads as follows: .Follow all other hygiene and safety procedures applicable. On page 34 under the heading titled, Cleaning/Disinfecting the Exterior under the first bullet it reads as follows Use only the following items for cleaning/disinfecting the (tradename omitted) housing for a contact time of >1 minute: .10% Sodium hypochlorite solution (1 part bleach to 9 parts water deionized water, made fresh every 24 hours). Interview on 10/24/16 with Staff B confirmed that the dried brown substance on the front and back of the PT/INR machine is blood. Staff B explained that the PT/INR machine is used at least weekly, depending on physician orders [REDACTED]. The PT/INR machine is taken to the bedside to collect the blood sample from the resident.",2019-11-01
772,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2016-09-22,281,C,0,1,C97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to ensure that Glucometer testing solution bottles (both high and low ranges) utilized on all three nursing units to test the accuracy of each of the glucometers in the building were labeled with the date of opening. Findings include: On [DATE], during a review of the facility's blood-glucose testing equipment, it was noted that none of the bottles of Evencare G2 control solutions (both high control and low control) were dated with the date of opening. The dates of opening were found on the boxes containing the bottles but not on the bottles themselves. Review of the manufacturer's insert, packaged with every box of high and low range control solutions, revealed, under the heading TO PERFORM A TEST WITH CONTROL SOLUTIONS FOLLOW THESE STEPS: 1. Newly opened bottles of control solutions must be marked on the space provided on the control solutions label with the date it was opened. Check the expiration date of the control solutions to make sure they have not expired. Discard any unused control solutions 90 days after opening or after (manufacturer's) expiration date. On interview, 9 ,[DATE] at approximately 10:40 a.m., Staff A, RN (Registered Nurse), confirmed that the bottles of high and low control solution were not labeled as specified in the manufacturer's guidance insert.",2019-10-01
773,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2016-10-06,224,D,1,0,BICI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review it was determined that the facility failed to ensure that a resident on the locked behavioral unit was prevented from abusing another resident (Resident identifiers are #1, #2 and #3). Findings include: Review of Resident #1's mental health progress note dated 5/17/16 revealed Resident #1 had engaged in sexual behavior with another resident on Unit 5 and was thought to be possibly exhibiting [MEDICAL CONDITION]. For these reasons Resident #1 was transferred from Unit 5 to Unit IA the locked behavioral unit on 3/14/16. Review of Resident #1's nurses notes of 5/15/16 revealed on that date at approximately 1420 Resident #1 was observed by an LNA (Licensed Nursing Assistant) naked and on top of (Resident #2). Nursing notes stated that there was no penetration or distress noted regarding Resident #2. Nurses notes of 5/16/16 at 0545 indicated that an LNA reported that when Resident #2 heard Resident #1 talking Resident #2 appeared to be frightened and had a startled expression which was atypical. Interview on 10/6/16 with Staff A (Administrator) revealed that the 5/15/16 incident involving Resident #1 and Resident #2 hadn't been reported or investigated by the facility. A review of Resident #1's comprehensive care plan revealed that there were no revisions made to it following the 5/15/16 incident with Resident #2. Review of Resident #1's nurses notes on 6/8/16 revealed Resident #1 was observed to be naked in Resident #3's room. Resident #1's hand was also observed to be touching Resident #3's genital area and Resident #3's pants were pulled down to their hips. Interview on 10/6/16 with Staff A (Administrator) revealed that the 6/8/16 incident involving Resident #1 and Resident #3 hadn't been reported or investigated by the facility.",2019-10-01
774,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2016-10-06,226,D,1,0,BICI11,"> Based on interview and medical record review the facility failed to report and investigate two incidents of suspected sexual abuse (Resident identifiers are #1, #2 and #3). Findings include: Review of Resident #1's nurses notes dated 5/15/16 at approximately 1420 Resident #1 was observed by an LNA(Licensed Nursing Assistant) naked and on top of (Resident #2). Nursing notes stated that there was no penetration or distress noted regarding Resident #2. Nurses notes dated 5/16/16 at 0545 indicated that an LNA reported that when Resident #2 heard Resident #1 talking Resident #2 appeared to be frightened and had a startled expression which was atypical. Review of the facility Abuse, Neglect, Involuntary Seclusion, Misappropriation of Property policy with a revised date of 11/2011 states that employees must immediately report in writing to Nursing Supervisors all suspected incidents of Abuse and any reasonable suspicion of a crime against a Resident. Interview of 10/6/16 with Staff A (Administrator) revealed that the 5/15/16 incident involving Resident #1 and Resident #2 hadn't been reported or investigated by the facility. A review of Resident #1's comprehensive care plan revealed that there were no revisions made to it following the 5/15/16 incident with Resident #2. Review of Resident #1's nurses notes dated 6/8/16 revealed that Resident #1 was observed to be naked in Resident #3's room. Resident #1's hand was also observed to be touching Resident #3's genital area and Resident #3's pants were pulled down to their hips. Interview on 10/6/16 with Staff A (Administrator) revealed that the 6/8/16 incident involving Resident #1 and Resident #3 hadn't been reported or investigated by the facility.",2019-10-01
775,JAFFREY REHABILITATION AND NURSING CENTER,305072,20 PLANTATION DRIVE,JAFFREY,NH,3452,2016-08-19,164,C,0,1,C6KS11,"Based on observation and interviews, it was determined that the facility failed to ensure the confidentiality of residents medical information from public view on all three units of the facility. Findings include: Observation on 08/18/16 at 7:50 am of Staff A, (Registered Nurse) distributing morning medications to residents that live on the East Wing, revealed the report list of resident names and medical information was left exposed on the medication cart and left unattended. Interview on 08/18/16 at 8:15 am with Staff A confirmed that resident information was not safeguarded from public view. Observation on 08/18/16 at 8:30 am of Staff B, (Licensed Practical Nurse) distributing morning medications to residents that live on the Chapel Unit, revealed the report list of resident names and medical information was left exposed on the medication cart and left unattended. Interview on 08/18/16 at 8:50 am with Staff B confirmed that resident information was not safeguarded from public view. Observation on 08/18/16 at 9:05 am of Staff C, (Licensed Medication Nurse Assistant) distributing morning medications to residents that live on the South Wing, revealed the report list of resident names and medical information was left exposed on the medication cart and left unattended. Interview on 08/18/16 at 9:30 am with Staff C confirmed that resident information was not safeguarded from public view.",2019-10-01
776,JAFFREY REHABILITATION AND NURSING CENTER,305072,20 PLANTATION DRIVE,JAFFREY,NH,3452,2016-08-19,371,E,0,1,C6KS11,"Based on observation and interview, it was determined that the facility failed to ensure foods which had been opened were dated, labeled and discarded within the appropriate time frames. Findings Include: Observation of the kitchen on 8/17/16 between 9:15 a.m. and approximately 10:30 a.m. with Staff D (Food Services Supervisor) revealed that when foods are opened, the food is labeled with the date opened and are labeled with discard dates to be within or no later than 3 days after opening. Observation revealed in the kitchen refrigerator the following food items with the date prepared/cooked and the discard dates as follows: Fried clams labeled as cooked on 8/13/16 were confirmed by Staff D as needing to have been discarded on 8/16/2016 which was 1 day beyond the discard date at the time of the observation. Lemon picatta was labeled as cooked on 8/10/16 with a discard date of 8/15/16. Staff D confirmed the discard date documented was 5 days after cooking and 2 days beyond this discard date. [NAME]ato soup was dated opened on 6/5/16 with a discard date of 6/8/16 which at the time of this observation was two months beyond the discard date. Purple cabbage had a prepared on date of 8/11/16 with a discard date of 8/15/16 which at the time of this observation was 2 days beyond the discard date. A bowl of french fries had a prepared on date of 8/13/16 with a discard date of 8/16/16 which at the time of this observation was 1 day beyond the discard date. Beer battered cod had a prepared of date of 8/9/16 with a discard date 8/14/16 which at the time of this observation was 3 days beyond the discard date. Interview on 8/17/16 at 10:30 a.m. with Staff D reviewed the above findings and confirmed that these foods items should have been discarded.",2019-10-01
777,VILLA CREST,305079,1276 HANOVER STREET,MANCHESTER,NH,3104,2016-07-29,281,D,0,1,G6CY11,"Based on observation and interview, it was determined that the facility failed to follow the professional standards of practice along with the facility policy and procedure for the disposal of medications for 1 out of sample resident. (Resident identifier is #25.) Findings include: The facility policy tilted Discarding and Destroying Medications with a revision date of (MONTH) 2014 .6. revealed, For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA (Environmental Protection Agency) recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medications, either liquids or solid, with an undesirable substance. Undesirable substance include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. c. Dispose with the solid waste (i.e., regular trash) d. Document the disposal on the medication disposition record . 9. Ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room. Observation on 7/27/16 at approximately 7:50 a.m. during a medication pass with Staff C (Licensed Practical Nurse) revealed Staff C preparing multiple medication tablets for Resident #25. Staff C dropped these medication tablets on the medication cart. Staff C picked the medication tablets up and placed the tablets into a medication cup and discarded this medication cup into the trash container attached to the medication cart which can be accessed by unauthorized individuals.",2019-10-01
778,VILLA CREST,305079,1276 HANOVER STREET,MANCHESTER,NH,3104,2016-07-29,371,E,0,1,G6CY11,"Based on observation and interview, it was determined that the facility failed to properly maintain supplementary products in 2 of 3 nourishment kitchens, and failed to ensure proper sanitizing solution used in the kitchen's three compartment sink. Findings include: Observation on 7/27/16 at approximately 9:15 a.m. of the nourishment kitchen on the south unit revealed approximately 25 undated thawed supplemental shakes in the refrigerator. Observation on 7/27/16 at approximately 9:20 a.m. of the nourishment kitchen on the special care unit revealed approximately 12 undated thawed supplemental shakes in the refrigerator. Interview on 7/27/16 at approximately 9:20 a.m. with Staff A (Director of Food Services) confirmed the above findings. Review of the supplemental shake carton revealed the following instructions: After thawing, keep refrigerated. Use within 14 days after thawing. Observation on 7/27/16 at approximately 9:00 a.m. of pHydrion testing of the Oasis 146 Multi-Quat Sanitizer in the kitchen's three compartment sink performed by Staff B (Kitchen Manager), revealed a result of 500 parts per million (ppm). The water in the sanitizing sink was approximately 6 inches above the designated fill line at the time of testing. Observation on 7/28/16 at approximately 9:15 a.m. of the pHydrion testing of the Oasis 146 Multi-Quat Sanitizer in the kitchen's three compartment sink performed by Staff B (Kitchen Manager), revealed a result of 500 ppm. The water in the sanitizing sink was approximately 6 inches below the fill line at the time of testing. Review of the manufacturer's directions for use for the Oasis 146 Multi-Quat Sanitizer revealed that the sanitizing solution should be between 150-400 ppm. Interview on 7/28/16 at 9:15 a.m. with Staff A and Staff B confirmed the facility used the manufacturer's range of 150-400 ppm for the sanitizing solution in the three compartment sink and that the water in the sanitizing sink should be at the designated fill line in order to mix an effective solution.",2019-10-01
779,"LEBANON CENTER, GENESIS HEALTHCARE",305050,"RR #1 BOX 13K,  24 OLD ETNA ROAD",LEBANON,NH,3766,2016-09-29,514,B,0,1,EKBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and interview, it was determined that the facility failed to ensure that clinical records were complete, timely and accurately documented for 3 residents in a standard survey sample of 21 residents. (Resident identifiers are #1, #8, and #17.) Findings include: Resident #1 Review of this resident's Physician's Orders sheets for the month of (MONTH) (YEAR), signed by the physician on 9/2/16, revealed an order for [REDACTED].e. not liquid), and review of that entry onto the Physician's Orders sheet reveals it was added to the sheet by hand after the orders were printed, and the date it was added and initials of the person adding it were not documented. These sheets also reveal a printed order for [MEDICATION NAME] (for [MEDICATION NAME]) 4 milligram twice a day as needed (this order lacks an indication for use); and a second [MEDICATION NAME] order was added to the sheet, for 2 milligram twice a day as needed for diarrhea, again with no date or initials for the addition. These two [MEDICATION NAME] orders have conflicting doses. Review of this resident's Medication Regimen Review for the months of (MONTH) through September, (YEAR), revealed that on 8/16/16 the pharmacist checked off See report for any noted irregularities and/or recommendations. Review of that Consultation Report revealed that it comments on missing lab values. Interview on the morning of 9/28/16 with Staff A (Director of Nurses) revealed that while this pharmacist report is dated 8/16/16, the facility did not receive it until more than a month later, on 9/28/16. Review of this resident's record revealed a Report of Consultation filed in the resident's chart that relates a plan to meet with physical therapy, and the entry is signed but the document lacks any date of service or date of signature to indicate when the service occurred. Resident #8 Review of this resident's Physician's Orders sheets for the month of (MONTH) (YEAR), signed by the physician on 9/2/16, revealed orders for two different doses of Cal-Gest 200(500) milligram tab chew, one order is for one tab three times a day as needed for heartburn, and the other order is for 2 tabs three times a day as needed heartburn, with no instruction provided for when one dose is to be selected over the other. These Orders sheets also include a hand-written as needed order for [MEDICATION NAME] 30 minutes before PT/Rehab that lacks a dose and a route of administration; this order also lacks both the date it was added and the initials of the person adding it to the Physician's Orders sheet. Observation on 9/27/16 during interview with Resident #8 revealed that their bed was positioned against the wall. Earlier that day during tour of this unit, a number of residents were observed to have their bed against the wall, and when initially called to the attention of Staff E (Nurse Manager) for one of these other residents, Staff E related the bed against the wall is care planned and assessed. Review of Resident #8's clinical record revealed no assessment or care plan for positioning the bed against the wall, and a consideration of its possible potential to interfere with the resident's mobility. Interview on 9/28/16 with Staff D (Registered Nurse) confirmed that there was no bed against the wall assessment done this admission for Resident #8. Interview on 9/27/16 with Resident #8 related they had no trouble getting in and out of bed. Resident #17 Review of this resident's 9/19/16 nursing assessment revealed that the resident had a fall with fracture prior to admission and was admitted to the facility post operatively. Review of the hospital Discharge Summary for 9/19/16 reveals screw fixation for a left fracture, and instruction for touchdown weight bearing at time of discharge. This resident's physician orders in the facility were reviewed with Staff D on 9/28/16 and there was no physician's order that addressed the weight bearing status of this patient. Review of this resident's current care plans also revealed no intervention for touchdown weight bearing.",2019-09-01
780,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2016-08-05,272,B,0,1,4T3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to enter data into section I Active [DIAGNOSES REDACTED]. (Resident identifier #9.) Findings include: Review on 8/4/16 of Resident #9's Quarterly Assessment with an ARD (Assessment Reference Date) of 7/20/16 revealed it was not coded for a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The note indicated that Resident #9 has a [DIAGNOSES REDACTED]. Interview on 8/4/16 at 1:30 PM with Staff B (Licensed Practical Nurse) confirmed that section I was not coded for the [DIAGNOSES REDACTED].",2019-09-01
781,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2016-08-05,281,D,0,1,4T3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and review of the facility Pain Management policy and procedure, it was determined that the facility failed to follow the professional standard of practice for the administration and documentation of narcotic medications for 1 resident and failed to follow the professional standard of practice for monitoring the effectiveness of pain medications for 1 resident in a survey sample of 21 residents. (Resident identifier's are #1 and #15.) Findings include: Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009, revealed the following: Chapter 35 Medication Administration, Right Documentation on pages 709 - 713 and page 688 for Guidelines for Safe Narcotic Administration and Control reveals the following: After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care . The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed .Use the record to document the client's name, date, time of medication, name of medication, dose and signature of nurse dispensing the medication . Pages 1082-1083 of this reference shows: Evaluation of pain is one of the many nursing responsibilities that require effective critical thinking .The client's behavioral responses to pain relief interventions are not always obvious. Evaluating the effectiveness of a pain intervention requires you to evaluate the client after an appropriate period of time. For instance, oral medications usually peak in about 1 hour; whereas IVP medications peak in 15 to 30 minutes. Ask the client if the medication alleviated the pain when it is peaking. Do not expect the client to volunteer the information .The client, if able, is the best resource for evaluating the effectiveness of pain-relief measures. You need to continually assess whether the character of the client's pain changes and whether individual interventions are effective . You are successful in treating pain when the client's expectation of pain relief are met. Use evaluative criteria in determining the outcome of pain-relief interventions. Effective communication of a client's assessment of pain and his or her response to intervention is facilitated by accurate and thorough documentation. This documentation needs to happen from nurse to nurse, shift to shift and nurse to other HCPs. It is the professional responsibility of the nurse caring for the client to report what has been effective for managing the client's pain . Reference for pain scale is the Northeast Healthcare Quality Foundation (NHCQF), Pain tool indicates 0 - No Pain, 1-4 Mild Pain, 5-6 Moderate Pain and 7-10 Severe Pain. Review of the facility policy and procedure titled Pain Management with a review date of 03/01/16 revealed the following: 5. If PRN medications are given, document on the back of the MAR . 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document: 8.1 Effectiveness of PRN medications. Resident #1 Review on 8/3/16 of Resident #1's Medication Administration Record (MAR) dated 7/01/16 THROUGH 7/31/16 revealed the following physician order: [MEDICATION NAME] HCL IR 10 MG (milligrams) TABLET 1 TAB BY MOUTH AS NEEDED FOR CHRONIC PAIN PRN. Further review of the front and back of this MAR and the facility Narcotic Book pages 190 and 207 revealed that Resident #1 was administered the following doses of [MEDICATION NAME] 10 mg. The facility failed to consistently document the doses of the PRN narcotic [MEDICATION NAME] in the required places and failed to consistently document the effectiveness of the PRN pain narcotic administered to Resident #1: DATE FRONT MAR BACK MAR NARCOTIC BOOK 7/1/16 2 doses blank (no documentation) 2 doses 7/3/16 2 doses 3 doses 4 doses 7/4/16 3 doses 1 dose 3 doses 7/6/16 1 dose Blank 3 doses 7/7/16 3 doses Blank 3 doses 7/8/16 3 doses 1 dose 3 doses 7/11/16 3 doses 1 dose 3 doses 7/12/16 3 doses 1 dose 3 doses 7/13/16 2 doses Blank 2 doses 7/14/16 2 doses Blank 2 doses 7/15/16 2 doses Blank 2 doses 7/16/15 2 doses Blank 2 doses 7/17/16 2 doses 1 dose 2 doses 7/18/16 2 doses Blank 2 doses 7/19/16 2 doses 1 dose 3 doses 7/20/16 3 doses 1 dose 3 doses 7/21/16 2 doses Blank 3 doses 7/22/16 2 doses 2 doses 3 doses 7/23/16 3 doses 3 doses 4 doses 7/24/16 1 dose 1 dose 3 doses 7/25/16 2 doses Blank 3 doses 7/26/16 2 doses Blank 3 doses 7/27/16 2 doses Blank 3 doses 7/28/16 3 doses 1 dose 3 doses 7/29/16 1 dose Blank 2 doses Interview on 8/3/16 with Staff C (Licensed Practical Nurse) reviewed the above findings and Staff C confirmed that the MAR and Narcotic Book did not match for the individual doses of the narcotic [MEDICATION NAME] administered to Resident #1. Staff C reviewed the nurses notes and the MAR for the monitoring of the effectiveness of [MEDICATION NAME] and verbally confirmed that there was lack of and inconsistent documentation for the monitoring of the effectiveness of the PRN [MEDICATION NAME] in the nurses notes and on the MAR for the individual doses of [MEDICATION NAME] administered to Resident #1.",2019-09-01
782,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2016-08-05,322,D,0,1,4T3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interview, it was determined that the facility failed to meet professional standards of quality for checking placement of a gastric tube prior to administering medications for 1 out of sample resident. (Resident identifier is # 22.) Findings include: Nursing Interventions and Clinical Skills, 2000, second Edition, [NAME] A. Potter, Anne Griffen Perry and Martha Keene Elkin, on page 789, states Aspirate stomach contents for residual volume, determine volume with graduate container if necessary and reinstall to client (see illustration). Observation on 8/4/16 at 11:20 am, during the medication pass, Staff A (Licensed Practical Nurse) did not check for residual by aspirating stomach contents via gastric tube prior to administering medications and a bolus feed of [MEDICATION NAME] which is a nutrient, ordered by the physician. Review of the facility policy and procedure titled Enteral Feeding and Medication: Administration by Syringe Bolus dated 1/2/14 indicates check for residual using syringe to: Aspirate stomach contents, measure amount of residual and follow physician orders. The treatment administration record states Check residual if 150 ml or over hold feeding for 1 hour and recheck, if over 150 ml, notify the physician and document the amount of residual. Interview on 8/4/16 at 11:45 am with Staff A confirmed that the residual of stomach contents was not aspirated prior to administering medication or a bolus feed via gastric tube per professional standards.",2019-09-01
783,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2016-08-05,456,D,0,1,4T3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of the manufacturer's instructions and review of the facility policy and procedure for Application of Superficial Moist Heat it was determined that the facility failed to maintain the [MEDICATION NAME] in a safe operating condition. Findings include: Review of the facility policy and procedure titled Application of Superficial Moist Heat with a revision date of 7/1/15 revealed the following: [MEDICATION NAME]/Hot Packs 3. [MEDICATION NAME] unit should be maintained according to manufacturer guidelines. This includes, but is not limited to, grounding, calibrating and cleaning of the [MEDICATION NAME] unit . 4. The temperature of the [MEDICATION NAME] unit should be routinely monitored according to manufacturer guidelines, but less than monthly, when there are no manufacturer guidelines, the suggested temperature range is between 155 (degrees) and 170 (degrees) F. 4.1 The [MEDICATION NAME] temperature must be checked for appropriate temperature range prior to application of moist heat to patients. Treatment should be withheld if temperature is above guidelines . Review of the manufacturer's instructions for the facility [MEDICATION NAME] revealed in the section starting on page 13 through 15 the following: CLEANING . 2-Routine Cleaning (every 2 weeks or as needed) . MAINTENANCE 2. Monthly Maintenance . . Keep the pH (a measure of acidity of the water) between 7.4 and 7.8 to reduce the scaling and residue build up . Interview and record review on 8/5/16 at approximately 3:00 p.m. with Staff D (Director of Rehabilitation) revealed that the facility Physical Agent Modality Temperature/Cleaning Log dated from (MONTH) (YEAR) through (MONTH) (YEAR) showed that the [MEDICATION NAME] had been cleaned monthly and not according to the manufacturer's cleaning instruction's of every two weeks. Staff D confirmed that the [MEDICATION NAME] log did not show that cleaning was done every two weeks and the there was no documentation of monthly maintenance to show that the pH of 7.4 and 7.8 to reduce scaling and residue build up was done for the facility [MEDICATION NAME].",2019-09-01
784,"KEENE  CENTER, GENESIS HEALTHCARE",305051,677 COURT STREET,KEENE,NH,3431,2016-08-05,514,E,0,1,4T3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure medication indications for use were provided on all PRN (as needed) medications for 3 residents in a survey sample of 21 residents. (Resident identifiers are #5, #7, and #21.) Findings include: Resident #5 Review of medical record, Medication Administration Record [REDACTED] [MEDICATION NAME] 10 milligrams suppository rectally - Insert 1 supp. rectally as needed if no results from Milk of Magnesia. [MEDICATION NAME] HFA 90 micrograms aerosol with adapter 2 puffs by mouth every 4 hours as needed - use with spacer PRN. Interview on 7/29/16 with Staff E (Administrator) confirmed that the above referenced PRN medication does not have an indication for use listed on the order. Resident #7 Review of medical record, Medication Administration Record [REDACTED] [MEDICATION NAME] concentrate (pink) 20 mg/1 ml solution - 0.5 ml (10 mg) by mouth every 15 minutes PRN pain. [MEDICATION NAME] concentrate (pink) 20 mg/1 ml solution - 0.25 ml (5 mg) by mouth every 15 minutes PRN pain/dyspnea. [MEDICATION NAME] concentrate (pink) 20 mg/1 ml solution - 1 ml (20 mg) by mouth every 15 minutes PRN severe pain/dyspnea. Interview on 7/29/16 at approximately 2 p.m. with Staff E (Administrator) confirmed that this order was missing the parameters for use. Resident #21 Review of medical record, Medication Administration Record [REDACTED] [MEDICATION NAME] 50 mg hour of sleep PRN [MEDICATION NAME] 0.5 mg by mouth PRN BID Interview on 7/29/16 at approximately 2 p.m. with Staff E (Administrator) confirmed that this order was missing the indication for use.",2019-09-01
785,CHESHIRE COUNTY HOME,305054,201 RIVER ROAD,WESTMORELAND,NH,3467,2016-04-08,431,C,0,1,Z0VS11,"Based on observation and interview, the facility failed to discard over the counter expired medications from 3 of 4 patient care unit medication carts. Findings include: On 4/7/16 at 8:35am during inspection of the medication cart on The Locked Unit, a bottle of magnesium oxide 400 mg (milligrams) had an expiration date of 3/16. A bottle of Ocular Vitamin had an expiration date of 3/16. An interview with Staff A (MNA) and Staff B (LPN) on 4/7/16 at 8:35 a.m. confirmed the above. On 4/7/16 at 8:50 a.m. during inspection of the medication cart on the 4th floor, a bottle of Vitamin C 250 mg (milligrams) had an expiration date of 2/16. A bottle of Ocean Nasal Spray had an expiration date of 10/11. An interview with Staff C (LPN) on 4/7/16 at 8:50 a.m. confirmed the above. On 4/7/16 at 9:10 a.m. during inspection of the medication cart on the second floor, a bottle of Oscal 500 mg (milligrams) had an expiration date of 12/15. A bottle of Vitamin B Complex had an expiration date of 3/15. A bottle of Allergy Relief nasal spray had an expiration date of 1/16. A bottle of Zinc Sulfate 200 mg (milligrams) had an expiration date of 2/16. An interview with Staff D (LPN) and Staff E (RN) unit manager on 4/7/16 at 9:10 a.m. confirmed the above. When interviewed on 4/7/16, all nurses listed above indicated that it is all nurses and MNA's responsibilities to check the expiration of all medications. An interview on 4/7/16 at 9:10 a.m. with Staff E (RN) indicated that there was not a specific system in place to check medications for expiration dates.",2019-09-01
786,CHESHIRE COUNTY HOME,305054,201 RIVER ROAD,WESTMORELAND,NH,3467,2016-04-08,502,D,0,1,Z0VS11,"Based on observation, documentation review and interview, the facility failed to provide quality laboratory services for residents that are required to receive physician ordered blood glucose monitoring on 1 of 4 care units. Findings include: On 4/7/16 at 8:40 a.m. during observation on The Locked Unit, the glucometer control solutions were labeled with a use by date of 3/10/16. Review of Facility Glucometer Testing Log documentation indicated that the night shift nurses conducted daily calibrations on dates 3/1/16 through 4/7/16. Twenty-eight of these dates were beyond the use by date. An interview on 4/7/16 at 8:40 a.m. with Staff A (MNA) and Staff B (LPN) confirmed that the glucometer solution had been used after the use by date.",2019-09-01
787,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2016-07-01,274,D,0,1,QZTP11,"Based on record review and interview, it was determined that the facility failed to do a comprehensive assessment of a resident after there was a significant change in the resident's condition, for one resident in a survey sample of 17 residents. (Resident identifier is #17.) Findings include: Interview with Staff A, unit manager, on 7/1/16 revealed this resident was admitted to hospice on 5/24/16. Review of the clinical record revealed the hospice certification was signed by the Hospice Medical Director on 5/20/16 and by the attending physician on 6/10/16, for an effective date of certification of 5/24/16 and a benefit period of 5/24-8/21/16. Review, during survey, of the list of completed Minimum Data Set (MDS) assessments for Resident #17 revealed the most recent comprehensive assessment was the Annual MDS with an Assessment Reference Date (ARD) of 12/9/15. A Quarterly MDS was also completed with an ARD of 4/20/16. There was no Significant Change MDS completed for the resident's (MONTH) (YEAR) admission to Hospice. Interview with Staff A on 7/1/16 confirmed that there was no Significant Change MDS done with the move to hospice.",2019-09-01
788,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2016-07-01,514,B,0,1,QZTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, it was determined that the facility failed to maintain clinical records that were current and complete for three residents in a survey sample of 17 residents. (Resident identifiers are #2, #16, and #17.) Findings include: Resident #2 Review of this resident's Significant Change Minimum Data Set assessment with an Assessment Reference Date of 5/16/16 revealed in Section Q at Q0500 that the resident is coded as wanting to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community. Review of the resident's care plan did not reveal any plan to address the possibility of this resident's return to the community. Interview on 7/1/16 with Staff B, Social Services revealed that this MDS coding at Q0500 is an error. Observation of Resident #2's room revealed this resident's bed was positioned against the wall. Review of this resident's care plan revealed an Intervention for Bed against wall to allow to allow (sic) for care and transfer .(Resident #2) and .family preference. The care plan does not address whether the bed against the wall restrains the resident's mobility. Interview with Staff C, nursing on 7/1/16 revealed that it is not documented anywhere (in the record) if the bed against the wall interferes with the resident's ability to get out of bed, and Staff C related the resident couldn't get out of bed by themselves anyway. Review of Resident #2's electronic MAR for the month of (MONTH) (YEAR) reveals that a [MEDICATION NAME] trough lab is to be done 30 minutes before every fifth dose, with a discontinue date of 6/6/16. The order is checked off as completed on 6/1 and 6/11, but the block for 6/6 is left blank. Interview with Staff C on 7/1/16 revealed that the trough lab was done on 6/6/16 but just not charted. Review of this resident's record revealed inconsistent documentation of a left ankle pressure ulcer. Review of the (MONTH) (YEAR) charting for Diabetic Foot Care/Check Daily Observation of feet, toes, ankles, soles . reveals that daily checks from (MONTH) 1 through (MONTH) 24 were all coded as 1 (no alternation noted). However, by 1/25/16 the clinical progress notes document that eschar had already developed: Review of the Progress Notes entry for 1/25/16 21:40 reveals the resident .has an area on his L (left) lateral malleolus, an area that is eschar measuring 1.0 x 0.5cm no depth Eschar is described at 42 CFR 483.25(c) as .thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physicial properties and biological acitvity Review of the 4/25/16 visit note by the DPM (podiatrist) reveals assessments listed as 1. DM (diabetes mellitus) .2. [MEDICAL CONDITION] of arteries .3. Onchyodystrophy . The Integrumentary exam for that visit addresses skin temperature, skin color, digital hair growth, and nails. There is no mention of any pressure sore. However, the Skilled Nursing progress note of 4/25/16 10:09 relates .Wound is noted to malleolus, 3.3x2.8x0.2 entire wound base is yellow/grey spongy slough, edges are rolled . Note, the subsequent podiatrist visit of 6/27/16 added two additional entries to the Assessment list: .4. Heel ulcer .5. Ankle ulcer Resident #16 Review of this resident's electronic MAR for the period 5/1/16 - 5/31/16 revealed an order for [REDACTED]. Also, this MAR indicated [REDACTED]. This order lacks a frequency of administration for the [MEDICATION NAME]. Resident #17 Observation of this resident's room on 7/1/16 revealed that the resident's bed is positioned against the wall. Review of this resident's current care plan revealed an intervention for I have my bed against the wall this provides me with more privacy and I feel safer. The care plan does not address whether the bed against the wall restrains the resident's mobility. When documentation was requested that addresses the possibility of the bed restricting the resident's mobility, Staff A, RN made available a Care Plan Evaluation dated 1/13/14 which relates Resident #17 .is able to get in and out of bed without assistance mobility is not limited by placement . Interview with Staff A at this time revealed this document (from over two years ago) is the most recent bed against the wall assessment note.",2019-09-01
789,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2016-08-02,279,E,0,1,020I11,"Based on medical record review and interview, it was determined that the facility failed to develop comprehensive care plans for 5 residents in a survey sample of 17. (Resident identifiers are #3, #5, #13, #15 and #16.) Findings include: Review on 8/1/16 and 8/2/16 of Resident #3, #13, #15 and #16's current facility and collaborative care plans revealed that the care plans did not include the frequency of services provided by the hospice agency for the skilled nurse, licensed nursing aide, social worker, spiritual and volunteer staff. Interview on 8/2/16 at 11:00 a.m. with Staff A (DON) revealed that above findings and Staff confirmed that the frequency of services were not present on the care plans for these hospice residents. Review of Resident #5's nursing notes dated 6/22/16 revealed that Resident #5 developed a small open area on the buttocks. Resident #5's comprehensive plan of care says that their skin integrity is at risk of being compromised and did not address the development of this open area on Resident #5's buttocks.",2019-09-01
790,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2016-08-02,281,D,0,1,020I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to provide PRN (as needed) medication parameters for 1 of 2 residents, failed to follow a physician's orders [REDACTED]. (Resident identifiers are #1, and #7.) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates The physician is responsible for directing medical treatment. Nurses follow physicians ' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary And on page 699 it relates, Prescribers must document the diagnosis, condition, or need for use for each medication ordered and on page 708 The prescriber often gives specific instructions about when to administer a medication The text also relates on page 707 The six rights of medication administration include . The right medication . The right dose .The right route .The right time and on page 691 Excess amounts of a medication within the body sometimes have lethal effects, depending on the medication's action Resident #7 Review of the Medication Administration Record [REDACTED]. The original physician order [REDACTED]. The order was not transcribed correctly onto the MAR indicated [REDACTED]. Review on 8/1/16 of the MAR indicated [REDACTED]. The medication was not given as prescribed. Resident #1 Review of Resident #1's medical record revealed orders for Tylenol ([MEDICATION NAME]) and [MEDICATION NAME]/[MEDICATION NAME] as follows: Tylenol 325 mg 2 tabs (tablets) by mouth every 4 hours as needed for pain or elevated temp (temperature) (if no allergy). [MEDICATION NAME] HCL F/C 50 mg tablet IC [MEDICATION NAME] 50 mg 1 tab by mouth every day as needed for pain. There are no parameters or indications for when to give each of these medications, or any record of attempt to clarify the orders. Interview with Staff D (LPN) reviewed the above findings and confirmed that the order was transcribed incorrectly.",2019-09-01
791,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2016-08-02,441,D,0,1,020I11,"Based on observation and interview, it was determined that the facility failed to ensure that the appropriate isolation precautions were followed by staff to help prevent the development and transmission of disease and infection. Findings include: Observation on 8/1/16 at approximately 11:15 a.m. of Resident #9's room noted that the Resident #9 was on precautions. Staff B (Physical Therapy Assistant) was observed at that time in Resident #9's room wearing a mask that Staff B pulled away from their face to speak to the resident. Staff B was not wearing gloves or a gown. There was personal protective equipment (gloves, masks, and gowns) available outside of the Resident #9's room. Interview on 8/1/16 at approximately 11:20 a.m. with Staff A (Director of Nursing) confirmed that Resident #9 was on precautions and revealed that it was the facility's policy to properly wear a mask, gown, and gloves in rooms designated with precautions.",2019-09-01
792,EPSOM HEALTHCARE CENTER,305080,901 SUNCOOK VALLEY HIGHWAY,EPSOM,NH,3234,2016-08-02,465,D,0,1,020I11,"Based on interview and review of manufacturer's instructions, it was determined that the facility failed to maintain the moist heat therapy unit in safe operating condition. Findings include: Review of the Whitehall Manufacturing Instructions for Operation and Care of The Perambulator Moist Heat Therapy Unit provided by the facility , revealed that routine bimonthly maintenance includes cleaning and disinfecting and that The water temperature for normal operating conditions is 165 degrees Fahrenheit. Instructions also stated to Keep the pH (a measure of acidity of the water) between 7.4 and 7.8 to reduce scaling and residue build-up. Interview on 8/1/16 at approximately 1:30 p.m. with Staff C (Direction of Rehabilitation) revealed that the facility did not take temperatures of their moist heat therapy unit and they did not test for pH. Staff C indicated that the facility did clean and disinfect the unit but did not document it.",2019-09-01
793,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,156,C,0,1,4JNZ11,"Based on observation, record review and interview, the facility failed to provide information on Medicare, Medicaid, advocacy and State agency information to all residents and failed to provide accurate contact information to the Office of Long Term Care Ombudsman's to their residents. Findings include: Observation on 9/1/16, revealed that contact information for Medicare, Medicaid, Advocacy groups and State agencies were located in the foyer/lobby area of the facility only. The lobby area is not accessible to any resident who is considered a flight risk and is wearing a bracelet that activates the door alarms or anyone on the locked units. Interview on 9/1/16 with Staff E (Administrator), and Staff D (Director of Nursing) confirmed that the above information was only available to those residents who could access the foyer/lobby area and did preclude those with bracelets that activate the door alarms from accessing the above information or those residing on the locked units. Review of the facility's admission packet revealed that the two phone numbers provided to residents for the Office of Long Term Care Ombudsman's office were not correct. One of the two numbers listed was not a working number and the second number belonged to a hospital in northern New Hampshire. A tour of the facility on 9/1/16 revealed that the only correct phone numbers to the Office of Long Term Care Ombudsman (OLTCO) were located in the lobby area of the facility. The lobby area was not accessible to any resident who is considered a flight risk and wearing a bracelet that activates the door alarms or anyone who resides on the locked units. Interviews on 9/1/16 with Staff E, Staff D and Staff F (Corporate Director) revealed all stated they were not aware these phone numbers were incorrect and that the required posting for OLTCO contact information was not accessible to all residents.",2019-09-01
794,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,167,C,0,1,4JNZ11,"Based on observation and interview, the facility failed to assure the previous survey results were available to all residents of the facility. Findings include: Observtion on 8/31/16 and 9/1/16 revealed that the previous year's survey results were only available within the lobby area. There was no other place within the facility where the survey results were posted for all residents to review. The lobby area is not accessible to any resident who is considered a flight risk and is wearing a bracelet that would activate the door alarms or those residents on the locked units. Interview on 9/1/16 with Staff E (Administrator) and Staff D (Director of Nursing) at approximately 11:15 a.m. confirmed the survey results were only posted in the foyer/lobby area.",2019-09-01
795,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,279,E,0,1,4JNZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for 4 residents in a survey sample of 19 residents. (Resident identifiers: #1, #5, #10 and #14) Resident #1: Review of Nurse Practitioner's progress notes from 8/4/16 revealed Patient and sister agree that staying here for end of life care would be best for (pronoun omitted). Patient agreeable to comfort care and is not looking for further treatment for [REDACTED]. Review of Nursing Progress Notes from 8/30/16 revealed that Resident on comfort care. Record review of the resident's current care plan revealed that there were no care plan interventions written for comfort care. Interview with Staff D (Director of Nursing) on 9/1/16 at 3:45 p.m. confirmed the above findings. Resident #5: Review of resident #5's Comprehensive Assessments dated 4/22/16 and 7/20/16, and electronic medical records (EMR) for weights and vital signs revealed that between 4/22/16 and 7/20/16 this resident had a 16 pound weight loss (149 pounds down to 133 pounds). Record review of the care plan for this resident revealed that there was no care plan intervention written for nutritional status in any of this resident's current or prior care plans to address the weight loss. Resident #14: Record review of the Annual and Comprehensive assessments for Resident #14 on 9/1/16 revealed that this resident was independent with all Activities of Daily Living (ADL's) and was alert and oriented with a Brief Intellectual Mental Status score (BIMS) of 15, which is the highest score that can be attained on this test for mental status. The resident was also assessed as being fully continent of bowel and bladder. The care plan for this resident revealed interventions that portrayed this resident as needing assistance with bathing, grooming, dressing, bed mobility, transfers, locomotion, toileting, impaired mobility, and urinary incontinence. During interview on 9/1/16, the resident verbalized independence with toileting, ambulating, bed mobility, transfers, bathing, grooming and dressing, and continence of bladder and bowel. The care plan for this resident does not reflect the information gathered about this resident during the comprehensive assessments. Resident #10 Review of this resident's Significant Change MDS (Minimum Data Set) with an Assessment Reference Date of 7/1/16 revealed that resident triggered for a Care Area Assessment (CAA) of Communication. Review of this CAA revealed that the facility decided they would care plan for this area. Review of the resident's care plans revealed there was no dedicated care plan for communication. While the existing care plan included an intervention to Be alert to non-verbal clues of problems, a dedicated focus for impaired communication was not initiated until after the above finding was pointed out to the facility. This latter focus, initiated on 9/1/16, included interventions to Speak in normal tone voice clearly and slowly .Reduce external noise when communicating with patient .Repeat answers to verify that what you understood is correct",2019-09-01
796,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,281,B,0,1,4JNZ11,"Based on record review and interview, the facility failed to follow professional standards of practice with regards to end of life pronouncement of death and reliable documentation of all assessments and activities surrounding the death for 2 of 2 residents discharged due to death in a survey sample of 19 residents. (Resident identifier's: #1 and #18) Findings include: Reference is Fundamentals of Nursing, 7th Edition, MOSBY/ELSEVIER, 2009, Evolve, pages 479 - 480, reveal the following: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care . Documentation of a death provides a legal record of the event. Follow agency policy and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death . Resident #1 Record review on 9/1/16 revealed a Nurse Progress note written on 8/31/16 at 6:16 a.m. by Staff L (Registered Nurse), that stated Resident time of death 0350. Time of death called by this RN at 0350 . Resident #18 Record review on 9/1/16 revealed a Nurse Progress Note written on 8/18/16 at 6:17 am by Staff L that stated Death called at 0300 on 8/18/16. Interview with Staff D (Director of Nursing) on 9/1/16 at approximately 3:45 p.m., confirmed that there was no documentation of assessments and activities surrounding the deaths of residents #1 and #18.",2019-09-01
797,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,356,C,0,1,4JNZ11,"Based on record review and interview, the facility failed to post accurate nurse staffing data to the public for review. Findings include: Review of the facility posted nurse staffing data on 8/30/16 at approximately 1 p.m. revealed that the facility had posted their daily nurse staffing data in the facility's lobby area for the public to view. The resident census was documented on this form as 123 and the number of nursing staff listed were more than what the facilities current nursing schedule listed. Interview with Staff E (Administrator) on 8/30/16 at 3 p.m revealed that the actual census was 94 residents and that the listed census of 123 and the number of nursing staff listed is inclusive of the Long Term Care Facility and the Assisted Living Facility next door.",2019-09-01
798,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,371,E,0,1,4JNZ11,"Based on observation, record review and interview, it was determined that the facility failed to provide a clean and sanitary environment while storing and preparing foods, and during the 3 part sink sanitization process. In addition, the facility failed to label and date perishable items found in periferal refrigeration sources in the facility. Findings include: On 8/30/16 at approximately 9:45 a tour of the kitchen was conducted. During the tour, it was observed that the manual can opener had a small amount of dried food on the blade. Likewise, the meat slicer, which was stored in the dry goods storage area, was uncovered, had crumbs on the bottom plate area, and had food particulates on the blade. Further observation of the dry goods storage area revealed that there were two opened bags of bread crumbs and graham cracker crumbs that were sealed with plastic wrap, but not dated. Observation of 2 large storage bins, one containing Panko Crumbs and another containing white granulated sugar, revealed that the original bags from the Panko and sugar were crumpled up and resting directly on top of the Panko and sugar, contaminating both food sources. Interview with Staff A, (Food Service Director) revealed that this individual had been on the job less than one year at this facility, and was unsure of facility policy concerning the above issues. Further interview with Staff B, (Regional Food Service Director) on 8/31/16 yielded policies on the above issues and Staff B stated the above practices did not reflect current facility policy. During observation of the three part sink sanitization process, it was observed that there was a laminated placard with printed directions from the manufacturer on the wall directly over the 3 part sink. These directions stated that items need to be submerged in the sanitizer for no less than one minute. Observation of the process revealed that the items were left in the sanitizer for 15 seconds. Manufacturers instructions for safe sanitization were not followed by staff during this observation. On 8/30/16 at approximatley 10:00 a.m observation in the kitchenette on Nubble Unit revealed that approximatley 10 undated, thawed supplemental shakes were in the refrigerator. Interview on 8/30/16 at approximatley 10:00 a.m. with Staff C (Unit Manger) confirmed that no dates were written on any of the shakes. Manufacturer's instructions state that shakes have a shelf life of 1 year from production date if frozen and once thawed, the refrigerated shelf life is 14 days. Facility policy states that the shakes be individually labeled with name, product, date, and time once thawed. Due to the fact that these shakes were not dated, it is not possible to determine how long the shakes had been in the refrigerator, or if they were safe for consumption. Observation on 8/30/16, during morning tour of the Strawberry Cove unit with Staff M, Program Director, revealed a dish of uncovered and undated sliced pears in the unit's refrigerator. This finding was pointed out to Staff M, who removed the food item from the refrigerator and discarded it.",2019-09-01
799,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,431,D,0,1,4JNZ11,"Based on documentation review and interview the facility failed to store narcotics appropriately and failed to permit only authorized personnel access to medication rooms for 1 of 2 medication rooms. Findings include: Review on 8/31/16 of an incident report revealed that on 3/4/16 Staff G (Licensed Practical Nurse/LPN) accepted delivery of 6 Oxycodone 5 mg (milligram) tablets from the facility's pharmacy. These tablets were to be placed in the locked medication system upon receipt. Staff G stated in his/her written statement that he/she presumed immediately to the locked med room to place the narcotics that were still in the plastic bag, on top of the red/orange extra E-kit, so it could be restocked as soon as a second nurse was available (sic). These tablets which are a controlled substance were locked in the medication room and are required by Federal law to be stored within a double locking system. On 3/7/16 the pharmacy contacted Staff H (previous Director of Nursing Services - DNS) requesting validation that the medications had been placed in the locked medication system. Upon doing a cycle count of the medications in the locked medication system it was discovered that the 6 Oxycodone 5 mg tablets were not accounted for. An investigation was completed and included interviews with staff who had access to the medication room between 3/4/16, when the medications were delivered and accepted and 3/7/16 when the medications were discovered missing. The facility compiled a list of staff who had access to the medication room during the dates specified above - none of the listed staff remember seeing these medications and were unaware of the whereabouts of the medication. Further review of the investigation documents revealed a statement by Staff I (Registered Nurse/RN) who refers to 3/4/16 when he/she worked that, That night I remember letting (Staff J, LNA) and (Staff K Medication Nursing Assistant) in the med room because they needed ABD (abdominal) pads, I opened the door for them but I did not go inside with them. They came at different times of the night. It is not within Staff J's scope of practice as a Licensed Nurses Aid (LNA) to have access to medications. Review of the compiled list of staff who had access to the medication room from 3/4/16 to 3/7/16, Staff J and Staff K were not listed. There were no revealed statements from either Staff J or Staff K as to whether they had seen the missing controlled medications during their unsupervised time in the medication room on 3/4/16. Interview with Staff H (previous DNS) on 9/1/16 Staff H stated he/she had in fact interviewed Staff J and Staff K via telephone but that Staff H could not find his/her notes regarding these interviews. Interview with Staff D (Certified Nurse Educator/Registered Nurse - CNE/RN) on 9/1/16 at noon Staff D stated he/she was not working at this facility at the time of this incident but did state that LNA's are not authorized to be in the medication rooms.",2019-09-01
800,CLIPPER HARBOR,305082,188 JONES AVENUE,PORTSMOUTH,NH,3801,2016-09-02,514,B,0,1,4JNZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure proper documentation of a resident's transfer, medication consents, dental assessment, and/or restraint assessments, for 4 residents in a survey sample of 19 residents. (Resident identifiers are #2, #6, #9, and #10.) Findings include: Resident #6 Review of this resident's active physician orders [REDACTED]. There is also an order [REDACTED]. And while there are prn orders for [MEDICATION NAME] with doses clearly designating 5 mg prn pain, 10 mg prn moderate pain, and 20 mg prn sever pain, there is also an order [REDACTED]. Review of this resident's current care plan revealed an intervention for Bed against the wall to decrease fall risk that was resolved on 6/8/16, and Fall mat @ bedside while in bed was resolved on 8/27/16. Review of the Restraint Evaluation/Reduction assessments for 7/2/16 and 8/2/16 revealed type of restraint is listed as bed rails, and restraint specifics identify bed against the wall and blue mat. The 7/2/16 document relates Care plan updated. These Restraint Evaluation/Reduction assessments both indicate bed against the wall, although this is listed as resolved on 6/8/16 on the current care plan, and neither the care plan nor the listed Restraint Evaluation/Reduction assessments address whether the bed against the wall compromises the resident's freedom of movement. Review of a Psychotherapeutic Medication Administration Disclosure form for [MEDICATION NAME] and [MEDICATION NAME] reveals the name from whom Verbal Consent was obtained on 11/14/13 but the line for the name of the person who obtained the consent is blank, and the signature of Physician/Mid-level Provider acknowledging that review was completed is dated 6/8/15 (i.e., more than a year later). An updated Verbal Consent was obtained by the facility on the third day of survey, 9/1/16. Resident #9 Review of this resident's active physician orders [REDACTED]. Also, the resident's orders include two different medications available for use as needed for pain: [MEDICATION NAME] HCl 5 mg by mouth every 4 hours prn pain, and Tylenol 650 mg by mouth every 6 hours prn pain, fever. Review of the facility's Pain Management policy, revision date 3/15/16, reveals no instruction that Tylenol is to be selected as the first med of choice for prn pain management when Tylenol and other [MEDICATION NAME](s) are prescribed for prn use. Resident #10 Review of this resident's Significant Change MDS (Minimum Data Set) with an Assessment Reference Date of 7/1/16 revealed that the Section L Oral/Dental Status that L0200.B. No natural teeth or tooth fragment(s) (edentulous) was not checked. However, review of the 6/21/16 nursing note revealed that the resident went to the hospital with both top and bottom dentures Coding Instructions from the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, (MONTH) (YEAR), Page L-2, relate: Check L0200B . if the resident is edentulous or lacks all natural teeth or parts of teeth. Interview on 9/2/16 with Staff N, one of the MDS coordinators, confirmed the resident has no teeth/fragments. Review of this resident's active physician orders [REDACTED]. There is no instruction provided in these prn orders to differentiate when one medication is to be selected over another when the resident is having pain. Review of Psychotherapeutic Medication Administration Disclosure disclosures for Resident #10 dated 6/24/16 and 8/5/16 revealed that the updated consent of 8/5/16 identifies the person from whom Verbal Consent was obtained only by their first name. The facility also provided a copy of a Psychotherapeutic Medication Administration Disclosure form that relates DPOA (durable power of attorney) gave Verbal Consent for [MEDICATION NAME] 50 mg BID (twice a day), and is dated 6/19/16, and signed by the Clinician Performing Review with Patient Signature, but this consent form lacks any patient identification such as name, room number, record number, or date of birth, and also lacks the name of the DPOA from whom verbal consent was obtained. Resident #2 Review of the Nursing Progress notes from 8/19/16 at 4:24 p.m. revealed Resident admitted /readmitted to (room number omitted). Arrived by ambulance and stretcher. The Nursing Progress Note prior to that was a post falls assessment done 8/11/16 at 10:37 p.m. indicating the resident was confused and experiencing pain. There were no Nursing Progress notes between the above mentioned notes from 8/11/16 and 8/19/16. Interview with Staff D (Director of Nursing) on 9/2/16 at approximately 12:15 p.m. confirmed the above finding and revealed the resident had been transferred and admitted to the hospital on [DATE] via ambulance.",2019-09-01
801,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2016-04-14,431,B,0,1,SYNK11,"Based on observation and interview, it was determined that the facility failed to discard over the counter expired medication from 1 care unit medication cart of two carts on one unit. Findings include: During medication pass observation on 4/13/16 at 08:10 with Staff B (Licensed Practical Nurse) emptied one tablet from a bottle of multivitamins into a paper medicine cup. The expiration date on the bottle was 2/16. When Staff B became aware of the expiration date, Staff B set aside the bottle, obtained a new medicine cup, and retrieved from the drawer of medication bottles another bottle of the same multivitamin. This bottle's expiration date was 2/16. Both bottles were removed from the medication cart by Staff B. Interview at the time of this observation with Staff B revealed that the night shift checks for expired medications. Review of other medication in this cart by Staff B revealed no other expired medications. An exam of the other 3 medication carts by Staff C (Unit Manager) also revealed no other expired medications.",2019-08-01
802,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2016-07-08,281,E,0,1,FF0M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow physician orders for residents and failed to follow the professional standard of practice for the administration and documentation of pain medications for 6 residents in a survey sample of 30 residents and failed to follow the professional standard of practice for the the administration and documentation of narcotic medications for 1 resident in a survey sample of 30 residents. (Resident identifiers are #10, #11, #14, #15, #25 and #30.) Findings include: Reference for the professional standard of practice is, Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009. On page 336 - Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009, revealed the following: Chapter 35 Medication Administration, Right Documentation on pages 709 - 713 and page 688 for Guidelines for Safe Narcotic Administration and Control reveals the following: After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care . The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed .Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication . Reference for pain scale is the Northeast Healthcare Quality Foundation (NHCQF), Pain tool indicates 0 - No Pain, 1-4 Mild Pain, 5-6 Moderate Pain and 7-10 Severe Pain. Review of the facility policy and procedure titled PAIN MANAGEMENT dated 7/15 revealed the following: .9. In addition to the usual components of a medication order, PRN medication orders must include the following: - Indication for use - Severity of pain it is ordered for . 11. Documentation on the EMAR will include: - Pain rating - Location of pain - Exact time pain medication given - Effectiveness of pain medication . Resident #30. Record review on 7/8/16 of the MEDICATION ADMINISTRATION RECORD (MAR) dated 06/01/2016 - 06/30/2016 for Resident #30 revealed the following physician orders: [MEDICATION NAME] 5 mg Give 1 tablet by mouth every 4 hours as needed for moderate pain (5-7) and [MEDICATION NAME] 5 mg Give 1.5 tablet by mouth every 4 hours as needed for severe pain (8-10). Further record review of this MAR revealed that Resident #30 was given three individual doses of [MEDICATION NAME] 1 tablet outside the prescribed parameters of the pain rating of (5-7) with a documented pain rating of 4 and two individual doses of [MEDICATION NAME] 1 tablet with a documented pain rating of 8 . This MAR continued to show that Resident #30 was given four individual doses of [MEDICATION NAME] 1.5 tablet outside the prescribed parameters of the pain rating of (8-10) with a documented pain rating of 7 and one individual dose of [MEDICATION NAME] 1.5 tablet with a documented pain rating of 6. Review of the facility Narcotic Book page #167 for Resident #30 revealed the following documentation: - 6/12/16 four doses of [MEDICATION NAME] 1.5 tablet were signed out as given PRN (as needed) and the MAR showed two doses given on 6/12/16 - 6/13/16 three doses of [MEDICATION NAME] 1.5 tablet were signed out as given PRN and the MAR showed two doses given on 6/13/16 - 6/14/16 four doses of [MEDICATION NAME] 1.5 tablet were signed out as given PRN and the MAR showed three doses given on 6/13/16. Record review of the MAR dated 07/01/2016 - 07/31/2106 for Resident #30 revealed no documentation of [MEDICATION NAME] 1.5 tablet or 1 tablet administered to Resident #30 on 7/4/16. Review of the facility Narcotic Book page #189 for Resident #30 revealed the following documentation; - 7/4/16 one dose of [MEDICATION NAME] 1 tablet was signed out as given PRN . Interview with Staff C (Licensed Practical Nurse) on 7/8/16 at approximately 1:30 p.m. after Staff C reviewed the above listed findings to include the physician orders, MAR and Narcotic Book, Staff C confirmed that narcotic medications were given outside of the prescribed parameters and that the MAR and the Narcotic Book were not accurate to show all documented narcotics administered to Resident #30. During this interview Staff C and surveyor reviewed nursing progress notes for narcotic pain medication administered and Staff C agreed that the narcotic documentation in the nurse notes was not consistent with the documented narcotic medications listed as administered for Resident #30. Resident # 11 Review of the physician's orders on the Medication Administration Record (MAR) dated (MONTH) (YEAR) for Resident #11 revealed the following orders: [MEDICATION NAME] 325 MG, Give 2 tablet by mouth every 4 hours as needed for mild pain (1-3) and [MEDICATION NAME] HCl Tablet 5 MG, Give 1 tablet by mouth every 4 hours as needed for moderate pain (4-7). The MAR also showed that [MEDICATION NAME] (650 MG) was administered to the resident with a pain rating of 8 on 6/9/16 and a pain rating of 5 on 6/21/16 which is outside of the ordered parameters for mild pain (1-3). Further review of the MAR showed that [MEDICATION NAME] (5 MG) was administered to the resident with a pain rating of 1 on 6/3/16 and 6/23/16, a pain rating of 2 twice on 6/13/16 and once on 6/14/16, and a pain rating of 0 on 6/6/16. Pain ratings of 0-2 are below the ordered parameters for moderate pain (4-7). Resident #10: Review of Medication Administration Record for resident #10 revealed that several PRN (as needed) pain medications were ordered for this resident without clear parameters and/or indications for use. Record revealed the following: Tylenol ([MEDICATION NAME]) extra strength tablet 500 mg: Give 1000 mg by mouth every 6 hours as needed for pain, elevated temperature. Not to exceed 3,000 mg daily. [MEDICATION NAME] Tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]): Give two tablets by mouth every 6 hours as needed for Severe Pain (8-10). [MEDICATION NAME] Tablet 5-325mg: Give 1 tablet by mouth every 6 hours as needed for Moderate Pain (no numeric scale). These pain medications were transcribed in such a way that they may be unclear to the clinician passing them to the resident, increasing the possibility for a medication error. Resident #14 Review of Resident #14's EMAR (Electronic Medication Administration Record) reveals on (MONTH) 15, (YEAR) Staff Nurse F, LPN, assessed this resident as having a level 4 pain, and administered per written order [MEDICATION NAME] Tablet 325 mg. Give 2 tablet (sic) by mouth every 4 hours as needed for mild pain 1-4 at 0327 hours (3:27 a.m.). Further review of the EMAR for this resident reveals that Staff F, LPN wrote 4 as the pain level for this resident and at 0328 (3:28 a.m.) also administered [MEDICATION NAME] Tablet 50 mg ([MEDICATION NAME] (sic) Hcl) Give 2 tablet (sic) by mouth every 6 hours as needed for Severe Pain (8-10). Thus giving this medication outside the stated parameters for usage in the physicians order. Resident #15 Review of Resident #15's EMAR reveals many instances of pain medications being given outside of the ordered parameters or given with no ordered parameters in place. Further review of the (MONTH) (YEAR) EMAR reveals an order for [REDACTED]. Review of the (MONTH) (YEAR) EMAR also reveals that [MEDICATION NAME] 325 mg tablets were given 17 times in June, 14 times, simultaneously with [MEDICATION NAME]: 6/1/16, 6/2, 6/3, 6/15, 6/17, 6/18, 6/19, 6/20, 6/22, 6/25, 6/26, 6/27, 6/29, and 6/30/16. Additional review of the (MONTH) (YEAR) EMAR reveals an order for [REDACTED]. During the month of (MONTH) (YEAR), the [MEDICATION NAME] 50 mg was given outside the parameters, as follows: 6/4/16 the stated pain level was 0, the [MEDICATION NAME] 50 mg was administered at 9:19 a.m.; 2 times the [MEDICATION NAME] was given when the stated pain level of the resident was a 3, on 6/15/16 at 2:07 a.m. and 6/19/16 at 6:13 p.m.; 4 times the residents stated pain level was a 5, 6/2 at 7:25 p.m., 6/17 at 8:57 a.m., 6/20 at 1:24 p.m. and 6/22 at 8:00 a.m.; 9 times when the residents stated pain level was a 6, 6/1 at 8:06 a.m., 6/3 at 10:13 a.m., 6/19 at 8:09 a.m., 6/20 at 8:08 a.m., 6/26 at 9:14 a.m., 6/27 at 8:21 a.m.,6/28 at 8:49 p.m., 6/29 at 9:17 a.m., and 6/30/16 at 8:29 a.m. and 11 times that the resident's stated pain level was a 7, 6/7 at 7:55 a.m., 6/9 at 8:31 a.m., 6/10 at 8:36 a.m., 6/11 at 8:06 a.m., 6/12 at 1:30 p.m., 6 /14 at 8:30 a.m., 6/14 at 8:43 p.m., 6/15 at 8:21 p.m., 6/16 at 7:45 a.m., 6/24 at 4:22 a.m., and 6/25/16 at 9:00 a.m In all there were 8 different nurses involved in the passing of these medications throughout the month of June, (YEAR). Resident #25 Review of Resident #25's (MONTH) (YEAR) EMAR revealed an order for [REDACTED].! Review of the (MONTH) (YEAR) EMAR for Resident #25 reveals on 7/4/16 Staff E, RN, assessed this resident as having pain at a level 8 on a scale of 10. Staff E initialed and checkmarked the EMAR at 6:17 a.m. indicating they had given this resident 2 [MEDICATION NAME] 500 mg tablets. This medication was given outside of the parameters indicated in the Physicians order.",2019-08-01
803,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2016-07-08,425,B,0,1,FF0M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that the pharmaceutical services within the facility ensure safe and effective use of medications and failed to ensure the accurate acquiring, receiving, dispensing and administering of a medication for 1 resident in a survey sample of 30 residents. (Resident identifier is #19.) Findings include: Observation on 7/7/16 at approximately 8:25 a.m. during a medication pass with Staff D (Licensed Practical Nurse ) revealed the physician ordered medication Cholestoff Tablet 450 mg .Give 2 tablets by mouth two times a day related to [DIAGNOSES REDACTED] .(0800 and 2000) was not available for Resident #19. Review of the Medication Administration Record [REDACTED]. Further review of this MAR indicated [REDACTED]. Staff D verbally confirmed that Cholestoff had not been delivered from the pharmacy and a physician order [REDACTED].",2019-08-01
804,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,155,B,0,1,SFO511,"Based on record review and interview, it was determined that the facility failed to accurately document the resident's choice of an advance directive for 1 resident in a survey sample of 17 residents. (Resident identifier is #6.) Findings include: Review on 6/14/17 of Resident #6's medical record revealed a pink Portable Do Not Attempt Resuscitation (P-DNR) Order with the box checked that says Do Not Attempt Resuscitation (DNR). The form was signed on 12/26/16 by the physician. Review on 6/14/17 of Resident #6's current Medication Administration Record [REDACTED]. Interview on 6/14/17 at approximately 10:20 a.m. with Staff H (Licensed Practical Nurse) confirmed the above findings. During the interview, Staff H was asked how Staff H would find what the advanced directive was in the case of discovering a resident had stopped breathing with cessation of heart beat. Staff H indicated that Staff H would go to the electronic MAR indicated [REDACTED]. Staff H also revealed that the licensed nursing assistants (LNAs) have the same information in their computer program.",2019-07-01
805,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,157,D,0,1,SFO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to notify the physician of resident's daily complaint of pain and daily PRN (as needed) [MEDICATION NAME] usage for 1 resident in a standard survey sample of 17 residents. (Resident identifier is #1.) Findings include: Review on 6/14/17 of Resident #1's nursing notes revealed a nurses note on 2/9/17 at 7:53 a.m. that medication was found on patients floor. ? what ones. Nurses note on 3/2/17 at 6:42 a.m. stated, Lately when the med is brought into the patient, she appears to already be medicated. Slurred speaking, slow movement and difficulty moving upper extremities. Question if patient is receiving med's from somewhere else. Pills have been found at the bed side. Interviews on 6/14/17 at approximately 11:00 a.m. with Staff D (Director of Nurses) and Staff A (Registered Nurse) revealed that neither of them had knowledge of the 2 incidents prior to today. Interviews on 6/14/17 at approximately 11:30 a.m. with Staff D and Staff A confirmed that there was no evidence of physician notification of the 2 incidents of the suspicion of Resident #1 self medicating. Review on 6/14/17 of Resident #1's MAR (Medication Administration Record) revealed the following: January 3rd- (MONTH) 27th (YEAR) - daily complaints of pain; 64 PRN (as needed) doses of [MEDICATION NAME] HCL 10 MG (milligrams) administered. February 3rd-February 28th (YEAR)- daily complaints of pain; 75 PRN doses of [MEDICATION NAME] HCL 10 MG were administered. March 1st -March 22nd (YEAR)- daily complaints of pain; 56 PRN doses of [MEDICATION NAME] HCL 10 MG were administered. March 26th-March 31st (YEAR) daily complaints of pain; 18 PRN doses of [MEDICATION NAME] HCL 10 MG were administered. April 1st- (MONTH) 30th (YEAR)- daily complaints of pain; 93 doses of [MEDICATION NAME] HCL 10 MG were administered. May 1st-May 12th (YEAR)- daily complaints of pain; 36 doses of [MEDICATION NAME] HCL 10 MG were administered. May 18th-May 31st (YEAR)-daily complaints of pain; 29 doses of [MEDICATION NAME] HCL 5 MG were administered. June 1st-June 14th (YEAR) -daily complaints of pain; 29 doses of [MEDICATION NAME] HCL 5 MG were administered. The following PRN [MEDICATION NAME] were administered from (MONTH) 3, (YEAR) thru (MONTH) 14, (YEAR) without positive effect and the physician was not notified: January (YEAR)- 1 PRN dose administered. February (YEAR)- 4 PRN doses administered. March (YEAR)- 1 PRN dose administered. April (YEAR)- 10 PRN doses administered. May (YEAR)-5 PRN doses administered. Review of the facility policy and procedure Clinical Services, Subject: Pain Management, dated 09/05 revealed: The overall goals of care of the resident with pain are: #6. Residents experiencing pain will be evaluated and placed on a schedule of pain medication administration. It is not advisable for the resident to experience pain, notify the nurse and then have the medication provided. This results in poor control of the symptoms. Practice guidelines: #6. Consult physician for the additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. Interview on 6/14/17 at approximately 10:30 a.m. with Resident #1 revealed that the resident stated that daily pain level was about a 7. Resident #1 stated that when PRN's are given, the pain level usually is a 4. Interview on 6/15/17 at approximately 10:30 a.m. with Staff D and Staff A revealed that there was no documentation of the physician being notified of the Resident #1's daily complaints of pain or daily PRN [MEDICATION NAME] usage.",2019-07-01
806,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,226,D,0,1,SFO511,"Based on interview and a review of facility reported cases of abuse, it was determined that the facility failed to report or investigate an allegation of verbal abuse for 1 out of sample resident. (Resident identifier is #20.) Findings include: Interview of 6/15/17 with Resident #20's family revealed that a friend of Resident #20 had made a complaint in (MONTH) of (YEAR) against a member of the staff yelling at Resident #20. Interview on 6/15/17 with Staff D (Director of Nurses) and with Staff M (Social Worker) confirmed that there had been an allegation of staff yelling at Resident #20 in (MONTH) of (YEAR) made by a friend of Resident #20 . Staff D and Staff M stated that this alleged allegation of verbal abuse had not been either reported to the State Survey Agency or documented by the facility. A review of facility reported allegations of abuse revealed that the facility had not obtained a complaint statement by Resident #20's friend or statements from other potential witnesses. Also there was no documentation at the facility of any facility investigation of this complaint of alleged verbal abuse. The facility Abuse Policy says that the facility will follow the per individual state reporting requirements and that the findings of the facility investigation will be done in writing and reviewed by the QPI Committee procedures which Staff D and Staff M did not state had been followed regarding the allegation of verbal abuse made by Resident #20's friend.",2019-07-01
807,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,280,D,0,1,SFO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to update a care plan for 1 resident out of a standard survey sample of 17 residents. (Resident identifier is #4.) Findings include: Resident #4 Review on 6/13/17 of Resident #4's medical record revealed the following diagnosis, [MEDICAL CONDITION], Stage #3, [MEDICAL CONDITIONS] Fibrillation. Essential Hypertension, Type 2 Diabetes Mellitus without Complications, Presence of Cardiac Pacemaker, [MEDICAL CONDITIONS], Difficulty Walking, Muscle Weakness, Unsteadiness on Feet, Right Tibial Fracture, Dysphagia History of Falling . Review of a signed physician order [REDACTED].>Discontinue leg brace Weight bearing as tolerated with therapy only May progress to full ROM (range of motion) with therapy. Review of a signed physician diet change order for Resident #4 dated 5/31/2017 revealed the following: REASON FOR DIET CHANGE: Pt. (Resident #4) tolerating thin liq (liquids) with no oral deficits or s/s (signs/symptoms) of aspiration/penetration. SWALLOWING PRECAUTIONS: . Pt (Resident #4) should be upright at 90 . (degrees) during and at least 30 min (minutes) after meal . Review on 6/13/17 of Resident #4's current care plan revealed that the above listed findings including identifying the pacemaker and listing care plan interventions to reach goals were not documented on this current care plan for Resident #4. Interview on 6/14/17 at approximately 1:30 p.m. with Staff A (Registered Nurse) revealed that the care plan for Resident #4 had not been updated to show the discontinuation of the leg brace, weight bearing as tolerated with therapy only and that Resident #4 should be in an upright sitting position during meals and at least 30 minutes after meals.",2019-07-01
808,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,281,E,0,1,SFO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure that physician orders [REDACTED].#6, #7, #10, #12, and #14.), failed to ensure that medication administration for narcotics were properly documented on for 2 residents in a standard survey sample of 17 residents (Resident identifiers are #7 and #14.), and failed to appropriately administer medications for 1 residents in a standard sample of 17 residents. (Resident identifier is #23.) Findings include: Potter, [NAME] A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009, revealed the following: Chapter 35 Medication Administration, Right Documentation on pages 709, 720 and 721, Chapter 23 Legal Implications in Nursing Practice page 336 and Chapter 35 Medication Administration page 688 for Guidelines for Safe Narcotic Administration and Control reveals the following Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 688 The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed . Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication. Guidelines for Safe Narcotic Administration and Control . Store all narcotics in a locked, secure cabinet or container . . Narcotics are frequently counted. Usually counts are made on a continuous basis with the opening of narcotic drawers and/or at shift change. . Report discrepancies in narcotic counts immediately . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. . Use the record to document the client's name, date, time of medication administration, name of medication,dose and signature of nurse dispensing the medication. . If a nurse gives only part of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. If paper records are kept, both nurses sign their names on the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers. Instead, flush wasted portions of the tablets down the toilet and wash liquids down the sink. Page 708 The prescriber often gives specific instructions about when to administer a medication Page 709 After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care . Page 713 .A registered nurse compares the list of medications on the MAR (Medication Administration Record)against the original orders for accuracy and thoroughness .After administering a medication, record it immediately on the appropriate record form .After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurse's notes. page 720 To prepare tablets or capsules from a floor stock bottle, pour required number into bottle cap and transfer medication to medication cap. Do not touch medications with fingers. Page 721 O. Do not leave medications unattended. Page 1063 .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity .Although different clients prefer different pain scales, it is important for you to select and consistently use the same scale with a specific client. You do not use a pain scale to compare the pain of one client to that of another client. Reference for the standard of practice for medication disposal is the FDA Safe Disposal of Medicines, (YEAR)-06-08. Medicines play an important role in treating many conditions and diseases and when they are no longer needed it is important to dispose of them properly to help reduce harm from accidental exposure or intentional misuse . 1. Mix medicines (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds. Resident #12 Review on 6/15/17 of the Medication Administration Record [REDACTED] Interview on 6/15/17 at approximately 2:45 p.m. with the Staff L (Registered Nurse, Unit Manager) confirmed the above findings. Resident #23 Observation on 6/14/17 during medication pass on the Passport Unit at approximately 7:40 a.m. with Staff K (Registered Nurse) revealed that Staff K dropped one medication tablet on top of the medication cart. Staff K proceeded to pick this medication up with bare hands and discarded the medication tablet into the open trash receptacle attached to the side of this medication cart. This medication cart was located in the resident hallway and the open trash receptacle is accessible to unauthorized individuals. Observation at this time showed that Staff K dropped two individual medications for Resident #23 on top of the medication cart and picked each of these individual medications up with bare hands and placed them in the plastic medication cup with other prepared medications for Resident #23. Further observation at this time showed Staff K administered oral medications to Resident #23 and then Staff K prepared the liquid medication [MEDICATION NAME]-[MEDICATION NAME] 3 ml (milliliters) in the hand held inhalation chamber mechanism. Staff K placed this mechanism upright on top of the inhalation machine located at Resident #23's bedside stand . Staff K donned gloves and subcutaneously injected [MEDICATION NAME] 2.5 mg into Resident #23's lower abdomen. Staff K discarded gloves and informed Resident #23 she would return to administer the inhalation medication when the resident was done with breakfast. Staff K exited the room leaving this prepared medication at the bedside. Resident #6 Review on 6/14/17 of the Medication Review Report to include all MEDICATION ORDERS FOR [REDACTED] NPO (nothing by mouth)- tube feeding only diet. [MEDICATION NAME] Tablet 1 MG Give 1 tablet by mouth as needed for anxiety related to ANXIETY DISORDER, UNSPECIFIED .twice a day. KlonoPIN Tablet 0.5 MG ([MEDICATION NAME] ) Give 1 tablet by mouth two times a day for anxiety. [MEDICATION NAME] HCL Tablet 150 MG Give 1 tablet orally at bedtime for [MEDICAL CONDITION]. Interview on 6/14/17 at approximately 11:30 a.m. with Staff E (Licensed Practical Nurse) confirmed the above orders were written to be administered by mouth instead of via gastrostomy tube. Resident #25 Observation on 6/14/17 at 7:45 a.m. of medication pass was done with Staff H (Licensed Practical Nurse) with Resident #25. Observation of the medications being administered with Staff H were [MEDICATION NAME] 220 mg 2 tablets just prior to breakfast. Reconciliation of the medication with the MAR indicated [REDACTED] [MEDICATION NAME] Tablet 500 MG, Give 1 tablet orally two times a day for right shoulder pain, Give with food. Interview on 6/14/17 at approximately 8:15 a.m. with Staff H (Licensed Practical Nurse) confirmed the above findings. Staff H revealed that Resident #25 has a bingo card of the [MEDICATION NAME] 500 mg in the medication draw. Resident #7 Review on 6/14/17 of Resident #7's (MONTH) (YEAR) Medication Administration Record [REDACTED].) Resident #7 also had an order for [REDACTED]. Resident #7 also had an order for [REDACTED]. Review of this MAR indicated [REDACTED]. Resident #7 received 11 doses of [MEDICATION NAME] for documented pain levels of 3, 5, 6, 7, and 8. Resident #7 received 3 doses of Tylenol for documented pain levels of 3, 5 and 7. Review revealed that Resident #7 received both [MEDICATION NAME] and [MEDICATION NAME] for pain at the same time on 6/7/17 at 5:27 p.m. and on 6/13/17 at 9:19 p.m. Resident #7 also received [MEDICATION NAME] and Tylenol, all for pain, at 10:37 p.m. on 6/10/17. Review on 6/15/16 of Resident #7's Controlled Medication Log for [MEDICATION NAME] revealed doses of [MEDICATION NAME] that were documented as being supplied on the Control log but not documented in Resident #7's MAR indicated [REDACTED] Resident #10 Review on 6/14/17 of Resident #10's (MONTH) (YEAR) MAR indicated [REDACTED]. Resident #10 also had an order for [REDACTED]. Review of this MAR indicated [REDACTED]. Resident #14 Review on 6/15/17 of Resident #14's (MONTH) (YEAR) MAR indicated [REDACTED].) Resident #14 had an order for [REDACTED].#14 also had an order for [REDACTED]. Review revealed that Resident #14 received 10 doses of [MEDICATION NAME] for documented pain levels of 5, 6, 7, and 8. Resident #14 did not receive any doses of [MEDICATION NAME]. Review on 6/15/17 of Resident #14's Controlled Medication Log for [MEDICATION NAME]-[MEDICATION NAME] revealed doses of [MEDICATION NAME]-[MEDICATION NAME] that were documented as being taken but not documented in Resident #14's MAR indicated [REDACTED] Review on 6/15/17 of Resident #14's (MONTH) MAR indicated [REDACTED] Interview on 6/15/17 at approximately 9:40 a.m. with Staff A (Registered Nurse) confirmed that there was no clear indication of which [MEDICATION NAME] to administer to Resident #7, Resident #10 or Resident #14. Staff A also confirmed that the documented BP's indicate that the [MEDICATION NAME] should have been held. Interview on 6/15/17 at approximately 9:40 a.m. with Staff C (Licensed Practical Nurse) confirmed that there was no documentation of the BP or HR for some the [MEDICATION NAME] administration. Interview on 6/15/17 at approximately 4:30 p.m. with Staff A and Staff D (Director of Nursing) confirmed that there were discrepancies in the documentation of medications on the Narcotic Control Log and on the MAR for Resident #7 and Resident #14.",2019-07-01
809,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,328,D,0,1,SFO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility's policy, it was determined that the facility failed to verify the placement of the Gastrostomy Tube ([DEVICE]) for 1 out of sample resident in a standard survey sample of 17 residents. (Resident identifier is #6.) Findings include: Resident#6 Review of Resident #6's MAR from (MONTH) (YEAR) revealed the following physician order [REDACTED]. Review of the facility's policy titled Medication Administration, Enteral Tubes, dated (MONTH) (YEAR), page 4, revealed the following directions 8. Verify tube placement. a. unclamp tube and use the following procedures: Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds. Observation during medication pass on 6/14/17 at approximately 11:30 a.m. with Staff I (Licensed Practical Nurse) revealed that Staff I placed the stethoscope upon the abdomen area near the [DEVICE] area and appeared to be listening for a few seconds. Then Staff I stated, It's in place. She then proceed to feed and give Resident #6's medication. Staff I did not insert a small amount of air into the tube prior to listening to the stomach. Interview on 6/14/17 at approximately 12:00 p.m. with Staff I, revealed that Staff I didn't know what they were listening for when listening to the stomach prior to medication administration.",2019-07-01
810,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,371,E,0,1,SFO511,"Based on observation, interview and review of manufacturer's instructions, it was determined that the facility failed to ensure that thickened juice is dated when opened, scoops are removed from storage containers, kitchen items are appropriately stored when no longer in use, ceiling tiles are in place and base boards are present in food storage areas in the main kitchen and in 1 of 2 kitchenettes. Findings include: Observation on 6/13/17 at approximately 9:30 a.m in the main kitchen revealed 2 open thickened juice containers in the refrigerator, with no date on them. Observation on 6/13/17 at approximately 10:00 a.m. in the kitchenette on the Glenwood Unit revealed 1 opened thickened juice container in the refrigerator with no date on it. Review on 6/13/17 at approximately 9:30 a.m. of the thickened juice container revealed the following instructions Once opened store at ambient temperatures for up to 8 hours or refrigerate for up to 7 days. Interview on 6/13/17 at approximately 9:30 a.m. with Staff J confirmed that the opened juice containers should have been dated. Observation on 6/13/17 at approximately 9:30 a.m. in the main kitchen revealed a ceiling tile that had been pushed to the side leaving an opening in the ceiling. This open area was located over the oven. Interview on 6/13/17 at approximately 9:30 a.m. with Staff J confirmed that the tile should have been replaced. Staff J revealed that the tile had been pushed aside for approximately one week when the facility staff came to fix an area in the ceiling damaged by water. Observation on 6/13/17 at approximately 9:30 a.m. in the main kitchen revealed cleaned pots and pans laying upright on the top of the oven under where the ceiling tile was open. Interview on 6/13/17 at approximately 9:30 a.m. with Staff J confirmed that the pots and pans should have been placed in their storage area and not left on top of the oven. Observation on 6/13/17 at approximately 9:30 a.m. in the main kitchen revealed a scoop almost completely submerged inside the large plastic container with flour stored in it. Interview on 6/13/17 at approximately 9:30 a.m. with Staff J confirmed that the scoop should have been removed and not left inside the flour container. Observation on 6/13/17 at approximately 9:30 a.m. in the main kitchen revealed a missing baseboard on the wall in the dry goods storage area, causing an open gap where the drywall and the floor meet. Interview on 6/13/17 at approximately 9:30 a.m. with Staff J (Food Service Supervisor) confirmed that the base board should have been replaced.",2019-07-01
811,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,386,B,0,1,SFO511,"Based on record review and interview, it was determined that the facility failed to have physician orders dated and signed for 3 residents in a survey sample of 17 residents. (Resident identifiers are #1, #3 and #13.) Findings include: Resident #3 Review on 6/13/17 of the physician telephone/verbal orders for Resident #3 revealed that orders written on 1/30/17 and 3/29/17 were not dated and signed by the physician for Resident #3. Interview on 6/13/17 at approximately 3:45 p.m. with Staff L (Registered Nurse) revealed that the above listed telephone/verbal orders for Resident #3 were not dated and signed by the physician. Resident #1 Review on 6/15/17 of Resident #1's medical record revealed physician telephone orders that were not signed by the physician. Orders dated: 3/26/17, 3/27/17, 4/3/17, 4/4/17 and 4/17/17. Resident #13 Review on 6/15/17 of Resident #13's medical record revealed physician telephone orders that were not signed by the physician. Orders dated 1/3/17 and 1/5/17 did not have physician signatures. Interview on 6/15/17 at approximately 10:00 a.m. with Staff E (Licensed Practical Nurse) confirmed the telephone orders for Residents #1 and #13 and that the physician signatures were not completed.",2019-07-01
812,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,431,E,0,1,SFO511,"Based on observation, record review and interview, it was determined that the facility failed to keep medications safe and in a secure storage on 2 out of 3 units (Glenwood and Passport). The facility failed to maintain a system of medication records that enables periodic accurate reconciliation and accounting of all controlled medications on 1 out of 3 units (Glenwood). Findings include: Observation on 6/14/17 at approximately 2:45 p.m. on the Passport Unit revealed that 1 out of 2 medication carts was unlocked without any nursing staff in the immediate area of the medication cart. Interview on 6/14/17 at approximately 2:50 p.m. with Staff F (Registered Nurse) confirmed that the medication cart had been left unlocked. Observation on 6/15/17 at approximately 7:55 a.m. revealed that the Glenwood Unit medication room door was open. There were no staff present in the immediate area. At 8:00 a.m. Staff G was witnessed , Licensed Medication Assistant closed and locked the door to the medication room. Interview on 6/15/17 at approximately 8:00 a.m. with Staff G confirmed that the medication room door was open without any staff in the immediate area. Review on 6/15/17 of 1 out of 2 narcotic count books on Glenwood Unit revealed that the the narcotic count for Resident #13's Oxycodone 5 milligram entries were as follows: 6/14/17 at 2:00 p.m. the narcotic count was 52. 6/15/17 at 1:30 a.m. the narcotic count was 56. 6/15/17 at 8:20 a.m. the narcotic count was 55. Observation on 6/15/17 at 10:40 a.m. with Staff A and Staff H revealed that the medication actual count on hand was 50. Review on 6/15/17 of the facility policy Medication Storage controlled medication storage policy and procedure dated 12/12 revealed that the policy reads: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. Interview on 6/15/17 at 10:40 a.m. with Staff A (Registered Nurse) and Staff H (Licensed Practical Nurse) confirmed that the actual physical count was not the count recorded in narcotic count book. Glenwood Unit Observation on 6/14/17 during a medication pass at approximately 8:00 a.m. revealed that Staff H (Licensed Practical Nurse) left the medication cart in the resident hallway while Staff F went into a resident's room out of sight of the medication cart. Interview on 6/14/17 at the time of this observation with Staff H, Staff H confirmed that the medication cart was left unlocked and unattended in the resident hallway. Observation on 6/14/17 at approximately 7:40 a.m. during medication pass on the Passport Unit with Staff K (Registered Nurse) revealed that Staff K dropped one medication tablet on top of the medication cart. Staff K proceeded to pick this medication up with bare hands and discarded the medication tablet into the open trash receptacle attached to the side of this medication cart. This medication cart was located in the resident hallway and the open trash receptacle is accessible to unauthorized individuals.",2019-07-01
813,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,441,E,0,1,SFO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to implement procedures and document [MEDICATION NAME] skin tests for 3 residents in a survey sample of 17 residents, failed to ensure that the professional standards of practice for hand hygiene and for equipment used between residents is implemented to reduce the spread of infections and prevent cross-contamination for 2 out of sample residents. (Resident identifiers are #3,, #7, #10, #22 and #23.) Findings include: Resident #22 Observation on 6/14/17 at approximately 7:40 a.m. during medication pass on the Passport Unit with Staff K (Registered Nurse) revealed that Staff K was administering medications to Resident #22 when this resident requested Staff K to place a sock on the right foot of Resident #22. Staff K placed sock on Resident #22's right foot and exited the room proceeding to the medication cart in the resident hallway. Staff K poured a cup, located on the medication cart, of water from the water pitcher on the medication cart and returned to room. Staff K gave this cup of water to Resident#22 so resident could consume all the oral medications. No handwashing was performed by Staff K after rendering care to Resident #22. Resident #23 Observation on 6/14/17 at approximately 7:40 a.m. during medication pass on the Passport Unit with Staff K (Registered Nurse) revealed that Staff K dropped one medication tablet on top of the medication cart. Staff K proceeded to pick this medication up with bare hands. Observation at this time showed that Staff K dropped two individual medications for Resident #23 on top of the medication cart and picked each of these individual medications up with bare hands and placed them in the plastic medication cup with other prepared medications for Resident #23. Further observation at this time showed Staff K administered the above prepared oral medications to Resident #23. Staff K prepared the liquid medication [MEDICATION NAME]-[MEDICATION NAME] 3 ml (milliliters) in the hand held inhalation chamber mechanism. Staff K placed this mechanism upright on top of the inhalation machine located at Resident #23's bedside stand . Staff K donned gloves and subcutaneously injected [MEDICATION NAME] 2.5 mg (milligram) into Resident 23's lower abdomen. Staff K discarded gloves and informed Resident #23 she would return to administer the inhalation medication when the resident was done with breakfast. Staff K exited the room leaving this prepared medication at the bedside. Staff K performed no handwashing after discarding gloves and exiting the resident room. Resident#6 Observation during a medication pass on 6/14/17 at approximately 11:30 a.m. with Staff I (Licensed Practical Nurse) revealed the following physician order [REDACTED]. Resident #6 is in a precaution room. It is noted that Resident #6 has contact precautions for MRSA. Observation at this time revealed that Staff I, placed the stethoscope upon the abdomen area near the GT area and appeared to be listening for a few seconds. Staff I stated, It's in place. Then placed the stethoscope upon the edge of the bed. Staff H, wash his/her hands upon leaving the room but proceeded to pick up the stethoscope off the bed and clean the stethoscope off with an alcohol wipe and place on the medication cart. Interview on 6/14/17 at approximately 12:00 p.m. when this surveyor questioned what Staff H was listening too, Staff H indicated, I don't know what I would have been was listening for. Professional reference: Potter, [NAME] A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 923 Diagnostic Tests One screening mechanism is [DIAGNOSES REDACTED] (TB) skin testing . This is a simple test and is required for .residents of long-term care facilities (Centers for Disease Control and Prevention (CDC), 2005, 2006a and b). Page 924 [DIAGNOSES REDACTED] Skin Testing [MEDICATION NAME] skin tests are read between 48 to 72 hours. If the site is not read within 72 hours, the client must have another skin test. Resident #7 Review on 6/14/17 of Resident #7's Immunization Record revealed that there was no documented evidence of Resident #7's TB screening test, which was administered on 6/26/15, being read for results. Interview on 6/15/17 with Staff A (Registered Nurse) confirmed that the TB screening test reading documentation for Resident #7 could not be found. Resident #10 Review on 6/14/17 of Resident #10's Immunization Record revealed that there was no documented evidence of Resident #10 receiving a TB screening test. Interview on 6/15/17 with Staff A confirmed that the TB screening test documentation for Resident #10, which should have been done, could not be found.",2019-07-01
814,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2017-06-15,520,E,0,1,SFO511,"Based on record review and interview, it was determined that the facility failed to have oversight to determine that the implemented plan of action was successful for all residents receiving narcotics. Findings include: Review on 6/15/17 of the Medication Administration Record (MAR) and the narcotic log books from 6/1/17 to 6/13/17 for Residents #7 and #14 revealed that MAR and the narcotic log books did not match on multiple occasions (Cross Reference F281). Interview on 6/15/17 at approximately 3 p.m. with Staff D (Director of Nursing) confirmed the above finding. Interview revealed that Staff D was a member of the Quality Assurance (QA) committee that meets monthly. Staff D had done monthly audits of the MAR and narcotic log books since (MONTH) (YEAR) and results were reported to the QA committee. Interview with Staff D revealed that the facility had not changed or added new measures to identify and correct the root cause resulting in the discrepancies. The deficiency resulting from the MAR and narcotic log book (F281) was cited both the 6/24/16 recertification survey and the 3/9/17 investigation survey.",2019-07-01
815,RIVERWOODS AT EXETER,305049,7 RIVERWOODS DRIVE,EXETER,NH,3833,2016-07-29,280,D,0,1,00YE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure a plan of care was updated for 1 resident in a survey sample of 16 residents. (Resident identifier is #1.) Findings Include: Review of Resident #1's MDS (Minimum Data Set) Admission assessment dated [DATE] indicated that Resident #1 was independent in bed mobility and was independent with transfers moving between surfaces and standing. Review of Resident #1's Quarterly MDS dated [DATE] indicated Resident #1's bed mobility has declined and Resident #1 is not independent in bed mobility. The MDS codes Resident #1 as 2-2 which indicates limited assistance is required. Interview on 7/28/16 with Staff D (Assistant Director of Nursing) confirmed Resident #1's LNA (Licensed Nursing Assistant) had reported that Resident #1's abilities had declined and was requiring increased physical assistance. Staff D also confirmed that Resident #1 is not on a scheduled turning or repositioning program. Review of Resident #1's care plan was not updated to identify that Resident #1's ability to reposition in bed had declined nor that Resident #1 needed or required physical assistance with bed mobility for turning or repositioning for prevention of skin breakdown.",2019-07-01
816,RIVERWOODS AT EXETER,305049,7 RIVERWOODS DRIVE,EXETER,NH,3833,2016-07-29,281,D,0,1,00YE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to follow the professional standard of practice for pronouncing at the time of death for 1 resident and failed to follow the professional standard of practice for the administration of medications for 5 resident in a survey sample of 16 residents. (Resident identifiers are #5, #6, #12, #15 and #16.) Findings include: Reference is Fundamentals of Nursing, 7th Edition, MOSBY/ELSEVIER, 2009, Evolve, pages 479 - 480, reveal the following: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care .Documentation of death provides a legal record of the event. Follow agency policy and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death . Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting . Documentation of End-of-Life Care .Time and date of death and all actions taken to respond to the impending death Name of health care provider certifying the death Persons notified of the death (e.g. health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death Request for organ or tissue donations made and by whom Special preparations of the body (e.g., desired or required religious/cultural rituals) Medical tubes, devices, or lines left in or on the body Personal articles left on and secured to the body Personal items given to the family with description, date, time, to whom given Location of body identification tags Time of body transfer and destination Any other relevant information or family requests that help clarify special circumstances. Pages 1063 and ,[DATE] reveal the following: .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity. Although different clients prefer different pain scales, it is important for you to select and consistently use the same scale with a specific client. You do not use a pain scale to compare the pain of one client to that of another client. Evaluation of pain is one of many nursing responsibilities the require effective critical thinking .The client's behavioral responses to pain-relief interventions are not always obvious. Evaluating the effectiveness of a pain intervention requires you to evaluate the client after an appropriate period of time. You need to continually assess whether the character of the client's pain changes and whether individual interventions are effective .You are successful in treating pain when the client's expectations of pain relief are met. Use evaluative criteria in determining the outcome of pain-relief interventions. Effective communication of a client's assessment of pain and his or her response to intervention is facilitated by accurate and thorough documentation. This communication needs to happen from nurse to nurse, shift to shift and nurse to other HCPs. It is the professional responsibility of the nurse caring for the client to report what has been effective for managing the client's pain. A variety of tools such as pain flow sheet or diary will help centralize information about pain management. The client expects you to be sensitive to his or her pain and to be attentive in attempts to manage that pain. Effectively communicating with primary HCPs will assist you in achieving optimal pain relief for clients. Review on [DATE] of Resident #12's nurses notes dated [DATE] revealed the following: [DATE] (,[DATE]) Resident died @ 5:20 p.m. peacefully, .was present ., PCP notified. Released to funeral home @ . Interview on [DATE] at 3:40 p.m. with Staff A (Vice President of Health Services) reviewed the above findings and Staff A confirmed that there was no documented evidence of an assessment at the end of life for the pronouncement of Resident #12. Review on [DATE] of Resident #12's Medication Administration Record [REDACTED] [MEDICATION NAME] 30 mg/ml liquid 0.25 ml po (by mouth)/sl (sublingual) q (every)1 (hour) prn (as needed), pain, SOB (shortness of breath) or dyspnea and [MEDICATION NAME] 20 mg/ml liquid 0.5 ml po/sl q (every) 1 (hour) prn, SOB (shortness of breath) or dyspnea. Further review of this MAR indicated [REDACTED]. No documented evidence for the monitoring of the effectiveness of the individual doses of PRN (as needed) [MEDICATION NAME] was found during record review. Interview on [DATE] at approx. 3:40 p.m. with Staff A reviewed the above findings and Staff A confirmed that the documentation showed care and comfort listed for the reason that [MEDICATION NAME] 0.25 ml was administered and that there was no documentation for the 13 individual doses of [MEDICATION NAME] to show the effectiveness. There was no documentation to show that a higher dosage of [MEDICATION NAME] 0.5 ml was offered to Resident #12 to relieve pain, shortness of breath or dyspnea due to the lack of documentation for the effectiveness for the lower dose of [MEDICATION NAME] 0.25 ml. Resident #5 Review of Resident #5's Medication Administration Record [REDACTED] [MEDICATION NAME] Sodium 220 mg - 1 Tab by mouth every 12 hours as needed Resident #6 Review of Resident #6's Medication Administration Record [REDACTED] Tylenol 325 mg -650 mg by mouth every 4 hours as needed max 5 doses/3250/day [MEDICATION NAME] 10 milliters by mouth every 6 hours as needed [MEDICATION NAME] Migraine ,[DATE] mg tab by mouth every 6 hours as needed [MEDICATION NAME] 10 mg suppository rectally every day as needed [MEDICATION NAME] ,[DATE] 1 tab by mouth every 6 hours as needed [MEDICATION NAME] 25 mg tab 12.5 mg every day as needed [MEDICATION NAME] 220 mg by mouth every pm as needed do not exceed 3 tabs every 24 hours [MEDICATION NAME] 440 mg every day at bedtime as needed do not exceed 3 tabs every 24 hours Trazadone 50 mg tab 25 mg by mouth every day as needed Resident #15 Review of Resident #15's Medication Administration Record [REDACTED] Cal-Gest Assorted Flavors 200(500) mg tab chew, ,[DATE] tabs by mouth as needed - not within 4 hours of Levothyroxin Resident #16 Review of Resident #16's Medication Administration Record [REDACTED] [MEDICATION NAME] 5 mg by mouth every 8 hours as needed [MEDICATION NAME] ,[DATE] mg 1 by mouth every 6 hours as needed [MEDICATION NAME] 17 grams by mouth every day as needed Interview on [DATE] at approx. 1:45 pm with Staff C (RN) agreed that the indications for use were missing from the above orders.",2019-07-01
817,CRESTWOOD CENTER,305061,40 CROSBY STREET,MILFORD,NH,3055,2016-03-02,281,D,0,1,765611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow the professional standard of practice for the administration of medications and following physician orders [REDACTED]. (Resident identifier is #15.) Findings include: Reference for the professional standard of practice for the administration of medications are: The Fundamentals of Nursing, 7th Edition, POTTER-PERRY, MOSBY Elsevier, Evolve, 2009 Page 336 reveals the following; Physician ' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary. Page 713 reveals the following; Recording Medication administration. After administering a medication, record it immediately on the appropriate record form . Never chart a medication before administering it. Recording immediately after administration prevents errors. The recording of a medication includes the name of the medication, dose, route and exact time of administration . If a client refuses a medication or is undergoing tests or procedure that result in a missed dose, explain the reason the medication was not given in the nurse's notes. Some agencies require the nurse to circle the prescribed administration on the medication record or to notify the physician when a client misses a dose. Be aware of the effects missing doses have on a client such as in hypertension or diabetes. Coordinating care with other services when testing or procedures are being completed helps ensure therapeutic control of the disease. Record review on 3/2/16 revealed Resident #15 had the following diagnosis, End Stage [MEDICAL CONDITION], Dependence on [MEDICAL TREATMENT], Essential Hypertension, [MEDICAL CONDITIONS], Obesity, [MEDICAL CONDITION], Muscle Weakness and [MEDICAL CONDITION] in [MEDICAL CONDITION]. Further record review showed that Resident #15 was transported out to a [MEDICAL TREATMENT] Treatment Center three days a week Monday, Wednesday and Fridays for [MEDICAL TREATMENT] at approximately 5:30 a.m. Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet Give 800 mg by mouth with meals related to End Stage [MEDICAL CONDITION] at 0730, 1130 and 1630. Documentation further showed a Leave of Absence (LOA) at the 0730 time on 2/10 (Wed), 2/12 (Fri), 2/15 (Mon) and 2/19 (Fri) indicating this medication was not administered for a total of 4 doses during this time frame. [MEDICATION NAME] Tablet Give 12.5 mg by mouth one time a day [MEDICAL CONDITION](hypertension) 0900 was crossed out and 1200 written as a time. Initials were encircled on 2/5 (Fri) indicating that this medication was not administered. Magnesium Oxide Tablet Give 400 mg by mouth two times a day for supplement 0900 was crossed out and 1200 was written as a time. Initials were encircled on 2/5 (Fri) indicating that this medication was not administered. Sevelamer Tablet 800 mg Give 1 tablet by mouth three times a day for CKD. Administration times are listed as 0800, 1200 and 1700. Initials were encircled at 0800 on 2/1 (Mon), 2/3 (Wed), 2/5 (Fri) for both 0800 and 1200 indicating that this medication was not administered for a total of 4 doses during these 3 days. Triphrocaps 1 mg Give 1 capsule by mouth one time a day related to End Stage [MEDICAL CONDITION] 0900 was crossed out with 1200 was written as a time. Initials were encircled on 2/5 (Fri) and LOA written on 2/10 (Wed) indicating that this medication was not administered. During interview with Staff A (Registered Nurse, Director of Nursing) and Staff B (Registered Nurse, Unit Manager) on 3/2/16 after review of the above listed findings and further record review Staff A and B verbally confirmed that Resident #15 was not administered the above listed medications on the schedule [MEDICAL TREATMENT] days and that the physician was not notified that these medications were not administered to Resident #15 as ordered.",2019-07-01
818,MAPLE LEAF HEALTH CARE CENTER,305030,198 PEARL STREET,MANCHESTER,NH,3104,2015-12-04,281,D,0,1,O4LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and Policy/Procedure review, it was determined the facility failed to follow the Professional standards of practice for documenting the effectiveness of PRN (as needed) [MEDICATION NAME] for 1 resident in a survey sample size of 15. Review on 12/4/15 of the facility Medication Administration Policy in #4 Medications and Treatments, section b PRN medications: [REDACTED]. Record notes on the PRN record or in the Nurses Notes if prn records are not used c Psychoactive medications: [REDACTED]. Reference for the professional standard of practice is: Potter-Perry, 2009, Review of the Fundamentals of Nursing, Patricia Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 26, pg.387, Nurses need to indicate all assessments, interventions, client responses, instructions, and referrals in the medical record. Record review on 12/4/15 of the (MONTH) and (MONTH) Medication Administration Record [REDACTED]. On twenty occcasionsns there was no documentation as to how the medication affected the resident. During interview with Staff B, RN on the afternoon of 12/2/15 about the absent documentation. Staff B had no answer for the missing documenttion.",2019-06-01
819,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2016-06-02,282,E,1,0,KLTO11,"> Based on medical record review and interview, it was determined that the facility failed to implement the care plan for 2 residents in a survey sample of 22. (Resident identifier's are #20 and #22.) Findings include: Review on 6/2/16 of the care plan's for Resident #20 and #22 revealed in the sections under nutritional problems the following interventions; Provide, serve diet as ordered. Observe intake and record q (every) meal. Interview on 6/2/16 with Staff E (Registered Nurse) verbalized that the diet intake is documented daily for a resident by the Licensed Nursing Aide (LNA) after each meal on the individual three nursing shifts. This LNA documentation is found on the nutrition meal percentage consumption report by date and meal time for each individual resident. The facility failed to implement the nutrition care plan for Residents' #20 and #22 by not consistently documenting the diet intake for every meal. Cross reference F368.",2019-06-01
820,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2016-06-02,368,D,1,0,KLTO11,"> Based on medical record review and interview, it was determined that the facility failed to provide at least three meals a day to 4 residents in a survey sample of 22 residents. (Resident identifiers are #3, #19, #20 and #22.) Findings include: Resident #19. Review on 6/2/16 of the daily nutrition meal percentage consumption reports for Resident # 19 revealed only two meal percentage consumed on 2/9/16. Further documentation on this report showed Response Not Required on 2/1, 2/2, 2/5, 2/8 2/19, 2/22 and 2/24 for one meal on these dates with no percentage listed. Resident #20. Review on 6/2/16 of the daily nutrition meal percentage consumption for Resident #20 revealed only one meal percentage consumed on 3/2/16 and 3/4/16. Further documentation on this report showed Response Not Required for two meals on 3/17 and 3/20 and for one meal on 3/18/16 with no percentage listed. Resident #22. Review on 6/2/16 of the daily nutrition meal percentage consumption for Resident #22 revealed only one meal consumed on 3/4/16 and only two meals consumed on 3/6/16, 3/13/16 and 3/27/16. Interview on 6/2/16 with Staff E (Register Nurse) and Staff F (Registered Nurse) both Staff E and Staff F reviewed the above listed daily nutrition meal percentage consumption reports for Residents' #19, #20 and #22 and reviewed nursing documentation for the dates indicated above for these three residents. Staff E and Staff F verbally confirmed no documented evidence could be found to show that Resident #19, #20 and #22 had been provided with and consumed three meals a day for the days listed in the above findings. Resident #3 Review of Resident #3's medical record revealed several pages entitled Follow Up Question Report: Nutrition- Amount Eaten. This report lists date and time of entry percentage of meals eaten, expressed as a range, and the person documenting this information. The documents printed included a range of dates from 5/10/16 to 6/1/16, a period of 23 days. Additional review revealed that there were 2 of the 23 days where there was no documented evidence of Resident #3 receiving an evening meal.",2019-06-01
821,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2016-06-02,514,D,1,0,KLTO11,"> Based on medical record review and interview, it was determined that the facility failed to accurately document meal consumption for 4 residents in a survey sample of 22 residents. (Resident identifiers are #19, #20, #22 and #3 .) Findings include: Resident #19. Review on 6/2/16 of Resident #19's medical record of the daily nutrition meal percentage consumption reports revealed only two meal percentage consumed on 2/9/16. Further documentation on this report showed Response Not Required on 2/1, 2/2, 2/5, 2/8 2/19, 2/22 and 2/24 for one meal on these dates with no percentage listed. Resident #20. Review on 6/2/16 of Resident #20's medical record of the daily nutrition meal percentage consumption revealed only one meal percentage consumed on 3/2/16 and 3/4/16. Further documentation on this report showed Response Not Required for two meals on 3/17 and 3/20 and for one meal on 3/18/16 with no percentage listed. Resident #22. Review on 6/2/16 of Resident #22's medical record of the daily nutrition meal percentage consumption revealed only one meal consumed on 3/4/16 and only two meals consumed on 3/6/16, 3/13/16 and 3/27/16. Interview on 6/2/16 with Staff E (Register Nurse) and Staff F (Registered Nurse) both Staff E and Staff F reviewed the above listed daily nutrition meal percentage consumption reports for Residents' #19, #20 and #22 and reviewed nursing documentation for the dates indicated above for these three residents. Staff E and Staff F verbally confirmed no documented evidence could be found to show that Resident #19, #20 and #22 had been provided with and consumed three meals a day for the days listed in the above findings. Resident #3 Review of Resident #3's Electronic Medical Record revealed several pages entitled Follow Up Question Report: Nutrition- Amount Eaten. This report lists date and time of entry percentage of meals eaten, expressed as a range, and the person documenting this information. The documents printed included a range of dates from 5/10/16 to 6/1/16, a period of 23 days. Additional review revealed that there were 2 of the 23 days where there was no documented evidence of Resident #3 receiving an evening meal. Cross reference F368.",2019-06-01
822,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-02-26,224,D,0,1,L9RS11,"Based upon a facility investigation report dated 1/13/16, a statement by a Licensed Nurses Assistant, interviews on 2/26/16 with the facility Administrator and Director of Nurses and a complaint made by a resident it was determined the facility failed to provide care following a resident becoming incontinent of urine for 1 out of sample resident in a survey sample of 24 (Resident identifier is #25.) Findings include: Resident #25 on 1/12/16 stated during an interview with Staff F (Social Worker) that during the 11-7 shift sometimes the aides will only change the pad, not the sheet which remains wet after Resident #25 has become incontinent of urine. A written statement dated 1/15/16 by Staff G (LNA) confirmed that at approximately 2:30 a.m. on 1/9/16 Staff G found Resident #25 was soaking wet in urine from head to toe. Staff G wrote that Resident #25 said that the girls didn't change her at all. Interview on 2/26/16 with Staff H (Facility Administrator) and Staff A (DON) confirmed the facility investigation of 1/25/16 finding that Staff I (LNA) and Staff J (LNA) hadn't provided incontinent care to Resident #25 by failing to change wet sheets after Resident #25 became incontinent of urine.",2019-06-01
823,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-02-26,309,D,0,1,L9RS11,"Based on record review and interview it was determined that the facility failed to develop a coordinated plan of care for 1 of 4 resident's receiving Hospice services in a survey sample of 24 residents. (Resident identifiers are #8.) Findings include: Record review of Resident #8 medical record on 2/24/16 revealed two individual plans of care for Resident #8 who was receiving hospice services. Record review on 2/24/16 of the facility plan of care for Resident #8 date initiated 2/23/16 revealed in the section titled Focus Resident is Incontinent of urine with potential for improved control or management of urinary elimination In another section of this plan of care dated 2/23/16 under the heading of Inventions was listed; Assist the resident to the toilet at scheduled times i.e. upon rising, before meals, at HS (before bedtime) , and as needed. Further review of Resident #8's care plan revealed a care plan for falls and impaired mobility . under the section Interventions revealed transfer resident with gait belt transfer one assist. Further record review on 2/24/16 of the Hospice documentation titled Hospice Aide Care Plan as of 11/13/15 for Resident #8 with a start of care date of 10/13/15 revealed a check off list with catheter care checked off. Further review under the Mobility section Ambulation or stair climbing, wheelchair . Transfer using Hoyer Lift. Interview with Staff E (Unit Manager) on 2/25/16 at approximately 1:00 p.m. Staff A reviewed the above listed documentation and verbalized that Resident #8 did not have a catheter and that he/she was a one person assist with a gait belt. That the hospice sends a schedule in every week or every 2 weeks when everyone comes in.",2019-06-01
824,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-02-26,441,E,0,1,L9RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure proper infection control practices were adhered to for one out of sample resident in a survey sample of 24 residents during the medication pass and to maintain patient care equipment in a safe operating condition. (Resident identifier is #26.) Findings include: Review of this Resident #26's current orders during survey on 2/24-26/16 revealed that the resident was actively receiving [MEDICATION NAME] 1 gram via I.V. (intravenous) every 6 day. Observation of the resident's room during the 1:00 p.m. medication pass revealed on 2/25/16 a sign by the entrance to Resident #26's room that identified Contact Precautions, which in part includes, per the facility's CONTACT PRECAUTIONS form, wear gown and gloves and change gloves and gowns during care if come in direct contact with infectious material. Observation on 2/25/16 revealed that Staff B (Occupational Therapy Aide) was with Resident #26 when Resident #26 requested to be put back to bed prior to the start of of receiving the [MEDICATION NAME]. Staff B reached under Staff B's gown and removed his/her gait belt and placed gait belt around Resident #26 and assisted Resident #26 to bed. Staff B placed gait belt onto wheelchair and made Resident #26 comfortable in bed. Returned gait belt back under the gown and proceed to leave the room after taking the protective covering off. Interview on 2/25/16 with Staff B at the time of this time of observation revealed that he/she does this all the time and would take the gait belt to the laundry after leaving the room. Observation on 2/25/16 at 12:30 p.m. of the exercise table in the Physical Therapy room revealed that the edges on the bottom and left sides were worn so that the vinyl covering was removed and the underneath was exposed. There was also an L shaped tear on the top of the exercise table approximately an inch in size. Breaches in the integrity of the exercise table can prevent proper disinfection. Interview on 2/26/16 at 10:00 a.m. with Staff C (Director of Rehabilitation) revealed that Staff C was not aware of the breach in the integrity of the exercise table and confirmed the above finding.",2019-06-01
825,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-02-26,456,D,0,1,L9RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the manufacturer's instructions, the facility failed to maintain the Chattanooga [MEDICATION NAME] to ensure safe operating condition. Findings include: Review on 2/26/16 of the manufacturer's instructions for the facility's Chattanooga Hydocollator revealed the instructions under Maintenance - Care and Cleaning are .The tank should also be drained and cleaned systematically at minimum intervals of every two weeks. Interview on 2/26/16 at 12:00 p.m. with Staff C (Director of Rehabilitation) revealed that the Chattanooga [MEDICATION NAME] was cleaned quarterly.",2019-06-01
826,"PLEASANT VIEW CENTER, GENESIS HEALTHCARE",305045,239 PLEASANT STREET,CONCORD,NH,3301,2016-02-26,514,D,0,1,L9RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed toensure that the medical records were complete for [MEDICAL TREATMENT] treatments for 2 resident in a survey sample of 25. (Resident identifiers are #15 and #24.) Findings include: Resident #15 Interview on [DATE] at 8:40 a.m. with Staff D (Registered Nurse) revealed staff were unable to locate the [MEDICAL TREATMENT] book for Resident #15 that contained communications to and from the [MEDICAL TREATMENT] center and [MEDICAL TREATMENT] treatment sheets. Staff D confirmed with Resident #15 that the resident had not brought the book with her to and from [MEDICAL TREATMENT] treatments for approximately two weeks. Resident #15 received [MEDICAL TREATMENT] treatments 3 times a week. Interview with Staff E (Unit Manager) on [DATE] at 8:45 a.m. confirmed the above finding. Resident#24. Record review on [DATE] of the Progress Notes for Resident #24 dated [DATE] revealed the following; Wife was up to desk to talk with staff and then went back to client's room, at about 1350 sheasked for staff to come in and client cease to breathe RN in to pronounce at that time. Client's daughter has been notified . During interview with Staff A (Director of Nursing) on [DATE] at approximately 1:15 p.m., after Staff A verbally confirmed that there was no physical assessment to establish that Resident #24 had died on [DATE]. The facility failed to follow the professional standards of practice for the pronouncing with end of life care for Resident # 24.",2019-06-01
827,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2016-05-26,278,D,0,1,WMMY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to complete an accurate MDS (Minimum Data Set) for 2 residents in a survey sample of 30 residents. (Resident identifiers are #9, and #14.) Findings include: Resident #9. Review of Resident #9's medical record revealed that he/she was admitted to hospice on 11/2/15. Review of this resident's MDS dated [DATE] for a Significant Change and the quarterly MDS dated [DATE] under section J1400 which asks .life expectancy of less than 6 months the facility answered no instead of yes. Interview on 5/26/16 at approximately 2:45 p.m.with Staff A (RN/MDS Coordinator) revealed that this was an error and will be corrected. Resident #14. Review of Resident #14's medical record revealed that the resident has used a traychair as a restraint since 9/24/15 and a wheelchair seatbelt as a restraint since 4/18/16. Review of Resident #14's Significant Change MDS dated [DATE] and Quarterly MDS dated [DATE] revealed that the codes in Section P0100 for Physical Restraints indicated no restraints were used. Interview on 5/26/16 at approximately 3:00 p.m. with Staff A confirmed the above finding. Interview on 5/26/16 at 3:15 (.m. with Staff E (Licensed Practical Nurse) revealed that Resident #14 used a traychair or seatbelt daily as a restraint since ordered.",2019-06-01
828,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2016-05-26,279,D,0,1,WMMY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to develop a comprehensive care plan that describes the services to be furnished in order to meet the resident's [MEDICAL TREATMENT] needs for 1 of 1 residents receiving [MEDICAL TREATMENT] services in a survey sample of 30 residents. (Resident identifier #19.) Findings include: Review of the facility's Roster Matrix revealed that Resident #19 receives [MEDICAL TREATMENT] treatments. Review of Resident #19's interim care plan revealed that the resident was care planned for a renal diet, but not for the care of the resident's [MEDICAL TREATMENT] or for the frequency of the resident's [MEDICAL TREATMENT] treatments. Interview on 5/26/16 at approximately 1:00 p.m. with Staff B (Unit Manager, Registered Nurse) confirmed the above findings and revealed that Resident #19 receives [MEDICAL TREATMENT] treatments three times per week.",2019-06-01
829,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2016-05-26,280,D,0,1,WMMY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #7.) Findings include: The 7th edition of Potter, P. A., and A. G. Perry. 2009. Fundamentals of Nursing. St. Louis, MO: Mosby Elsevier on page 336 relates Nurses follow physicians' orders unless they believe the orders are in error or harm clients . Record review on 5/24/16 of the Medication Administration Record [REDACTED]. Further review revealed that Resident #7 was administered Tylenol 650 mg as needed for pain for a total of 10 times from 4/11/16 through 4/24/16. This documentation showed that Resident #7's pain rating was above the physician ordered parameter of 1-5. The pain ratings during these 10 Tylenol administrations were documented as a 6 or 8 pain rating prior to the administration of the Tylenol. Interview on 5/25/16 at approximately 3:30 p.m. with Staff C (Director of Nursing) after Staff C reviewed the above listed MAR, Staff C verbally confirmed that the documentation revealed that Tylenol 650 mg PRN for pain was administered 10 times for a pain rating above 5 and that the physician orders [REDACTED].#7. Record review on 5/25/16 and 5/26/16 revealed a physician note dated 4/21/16 showing that a hospital x-ray for Resident #7 showed a suspected non-displaced left ankle fracture to the tip of the fibula. Review of the current comprehensive care plan for Resident #7 revealed that this care plan had not been updated with focus (identified problem), goal or interventions/tasks related to the provided care following this injury. Review of a physical therapy note dated 4/20/16 revealed the following instructions for Resident #7's left ankle care, be sure to elevate leg & ice leg utilize ankle support brace and bed cradle to avoid blankets touching her ankle which she reports hurts at night. Interview on 5/26/16 at approximately 4:00 p.m. with Staff C, reviewed the above listed comprehensive care plan and verbally confirmed that the care plan had not been updated with focus, goals and interventions for Resident #7's left ankle.",2019-06-01
830,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2016-05-26,309,E,0,1,WMMY11,"Based on medical record review and interview, it was determined that the facility failed to develop a coordinated/integrated Plan of Care for 6 of 6 residents receiving Hospice services in a survey sample of 30 residents. (Resident identifiers are #12, #14, #20, #27, and #30.) Findings include: Review of medical records revealed that Residents #12, #14, #20, #27, and #30 were receiving hospice services. Further review of the records revealed that the facility failed to show a coordinated plan of care as evidenced by no documentation of the scheduling of visits, the care provided, or the communication between the facility and the hospice agency. Interview on 5/26/16 at approximately 1:00 p.m. with Staff B (Unit Manager, Registered Nurse) confirmed that Residents #14 and #20 were receiving hospice care and revealed that all of the coordination of care with the hospice agency is done solely through verbal communication. Resident #27 Resident # 27 was admitted to the nursing facility on 5/16/12 with a start of care date of 3/18/16 for hospice services. Review on 5/26/16 of Resident #27's medical record and hospice chart revealed no documented evidence of coordination of care between the hospice agency and nursing facility. Interview Staff D (RN) stated: Hospice staff check in with the RN's on the floor, before and after working with residents. Hospice staff come and go on a fairly regular schedule. There is no formal log in or log out (for these Hospice staff members). Nothing is written down, it is verbal communication only . Resident #12 Review on 5/26/16 of Resident #12's medical record and the facility hospice binder revealed that Resident #12 had a start of care date for hospice on 4/14/16. Further review revealed of these records revealed that the facility failed to show a coordinated plan of care as evidenced by no documentation of the Hospice nursing, social worker, home health aide, chaplain and volunteer scheduling visits, the care provided or the communication between the facility and the hospice agency. Interview on 5/26/16 at approximately 11:45 a.m. with Staff F (Licensed Practical Nurse) and Staff G (Hospice Registered Nurse) confirmed that Resident #12 was receiving hospice care and that the communication section of the hospice binder had no documentation for the communication of the plan of care and services being provided to Resident #12 currently receiving full hospice services Resident #30. Review on 5/26/16 of Resident #30's medical record revealed that Resident #30 was a General In Patient (GIP) with a start of care date for hospice services on 4/20/16. Further review of the record revealed that the facility failed to show a coordinated plan of care as evidenced by no documentation of the scheduling of visits, the care provided by the individual hospice agency staff, or the communication between the facility and the hospice agency. Interview on 5/26/16 with Staff H (Registered Nurse) after review of the medical record Staff H verbalized that most of the coordinated care with the individual Hospice agencies is done through verbal communication.",2019-06-01
831,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2016-08-25,156,B,0,1,7RRP11,"Based on record review and interview, it was determined that the facility failed to notify residents of their right to appeal the decision to end Medicare coverage with the Notice of Medicare Non-Coverage form prior to coverage ending for 5 out of sample residents. (Resident identifiers #16, #17, #18, #19, and #20). Findings include: Review of Notice of Medicare Non-Coverage forms given between (MONTH) (YEAR) and (MONTH) (YEAR), revealed that the following residents were not notified prior to their coverage ending: Resident #16, services ending 5/9/16, notified 5/10/16 Resident #17, services ending 7/31/16, notified 8/1/16 Resident #18, services ending 5/12/16, notified 5/12/16 Resident #19, services ending 7/27/16, notified 7/27/16 Resident #20, services ending 4/20/16, notified 4/21/16 Interview on 8/25/16 at 11 a.m. with Staff A (Business Manager) confirmed the above findings.",2019-06-01
832,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2016-08-25,371,D,0,1,7RRP11,"Based on observation, interview, and record review, it was determined that the facility failed to ensure that pots and pans were properly sanitized in the three compartment sink and that dietary products were not used past the expiration date. Findings Include: Observation on 8/23/16 at approximately 10:15 a.m. of the kitchenettes revealed that 8 thickened juice drinks and 2 thickened dairy drinks located in the Birch unit refrigerator had expired (2 expired 7/1/16, 1 expired 7/4/16, 2 expired 7/14/16, 5 expired 7/19/16). In the kitchenette on the Spruce unit there was 1 expired thickened juice (expired 7/19/16). Interview on 8/25/16 at approximately 10:15 a.m. with Staff D (Director of Dining Services) confirmed the above finding. Observation on 8/25/16 at approximately 8:30 a.m. in the kitchen revealed pots and pans were not being sanitized with Oasis 146 Multi-Quat Sanitizer for the appropriate amount of time in the three compartment sink. Staff E (Cook) was observed dipping cookware into the sanitizing sink for less than 5 seconds before placing on the rack to dry. Record review of manufacturers instructions for ECOLAB Oasis 146 Multi-Quat Sanitizer revealed directions for use stating Expose all surfaces of equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry. Interview on 8/25/16 at approximately 8:30 a.m. with Staff E revealed Staff E was unaware of any time requirements for sanitizing equipment, ware, or utensils.",2019-06-01
833,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2016-08-25,441,D,0,1,7RRP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that a resident had a 2-step [DIAGNOSES REDACTED] (TB) test upon entry for 1 resident in a survey sample of 15 residents. (Resident identifier #13.) Findings include: Review on 5/13/16 of Resident #13's medical record revealed that resident was admitted on [DATE] from an assisted living facility. There was no record of a 2-step TB test in the electronic medical record, on the Medical Administration Record (MAR), or physician orders. Interview on 5/25/16 at 10:30 a.m. with Staff F (Licensed Practical Nurse) confirmed the above finding. Interview on 5/25/16 at 10:45 a.m. with Staff B (Director of Nursing) revealed that the resident came from a nearby assisted living facility and since the resident would have had a TB test there, it would not be the facility's policy to perform TB testing upon admit. Staff B also confirmed that there was no record of TB testing in the medical record from either facility.",2019-06-01
834,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2016-08-25,456,D,0,1,7RRP11,"Based on record review and interview with Staff B (DON/CNE) and Staff C (Nurse Practice Educator), the facility failed to provide documentation that demonstrated the safe use and testing of blood glucose monitoring from 7/28/16 to 8/24/16. Documents reviewed were the Blood Glucose Quality Control Logs for the Birch,(NAME)and Spruce Units. Findings include: On 8/24/16 the blood glucose control monitoring logs were reviewed. The log review revealed that during the timeframe of 7/28/16 to 8/24/16, the blood glucose control logs were not appropriately filled out in the spaces provided for the month, control lot#, date opened, or manufacturer's title/name. The logs did not record the High and Low Control value range for the purpose of comparing the daily controls performed with the safety ranges supplied on the control strip container. There were 2 boxes of test control liquids in the pocket of the binder where the testing results are recorded. One box contained test bottles that were dated 6/2016, another box had test bottles dated 3/2016. The manufacturer's instructions for the EvenCare G2 Blood Glucose System specify to Write down the date when the control solution is first opened; Discard three months after the date of the first opening. The second set of control solution bottles mentioned were well beyond the discard date of 3/2016, but were not discarded as per manufacturer's directions. There was no documentation to indicate which box of control solutions was in use at the time. Facility Policy and Procedure for testing the accuracy and validity of blood glucose monitoring states that blood glucose meters will be disinfected before patient use and quality control tested daily according to manufacturer's guidelines. There was no documentation to indicate that the controls were being performed and compared to the safe ranges specified by the manufacturer's listed ranges and guidelines. As a result of the lack of documentation, the clinician using the equipment would not know if the equipment being used to test resident/patient blood glucose levels was in safe working condition, and would be unable to ascertain whether or not the blood glucose meter was providing accurate blood glucose levels, which could possibly place the resident/patient in danger of receiving too much or too little insulin. Interview on 8/25/2016 with Staff B (DON/CNE) and Staff C (Nurse Practice Educator) confirmed the above findings.",2019-06-01
835,COLONIAL HILL CENTER,305081,62 ROCHESTER HILL ROAD,ROCHESTER,NH,3867,2016-03-04,514,B,0,1,WGHX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that clinical records were complete and accurately documented, for 2 residents in a standard survey sample of 15 residents. (Resident identifiers are #5 and #10.) Findings include: Resident #5 Review of this resident's current care plan reveals that no known allergies [REDACTED]. Review of the 1/28/16 Medication Review Report, signed by the practitioner/physician on 2/5/16 reveals No Known allergies [REDACTED]. Review of the Medication Regimen Review in Resident #5's clinical record reveals the pharmacist has documented allergies [REDACTED]. 2. [MEDICATION NAME]. Resident #10 Review of this resident's clinical record reveals a practitioner's assessment for Date of Service 2/5/16 that includes in the A&P (assessment and plan) Toilet schedule every 2 hours while awake. Interview with Staff A, nursing on 3/3/16 revealed that this is incorrect and the resident was not, on 2/5/16, and is not currently, on this toileting program.",2019-06-01
836,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2015-11-13,281,D,0,1,0M1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow doctors orders for one resident and failed to ensure proper medication parameters for another resident, in a survey sample of 10 residents. (Resident identifiers are #5 and #10.) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the client suffers On page 708 this reference relates The prescriber often gives specific instructions about when to administer a medication The text also relates on page 707 The six rights of medication administration include . The right medication . The right dose . The right route . The right time . The right documentation and on page 691 Excess amounts of a medication within the body sometimes have lethal effects, depending on the medication's action Resident #5 Review of this resident's record revealed a prescribed order dated 9/21/15 for [MEDICATION NAME] 650 mg by mouth every 4 hours as need for Mild Pain .Do not exceed 3g/day Review of the (MONTH) (YEAR) Medication Administration Record (MAR) with Staff E, Registered Nurse on 11/12/15 revealed that the PRN (as needed) [MEDICATION NAME] was administered for a total of 1 to 5 doses daily. 5 doses, for a total of 3.25 grams, was administered on (MONTH) 5 and on (MONTH) 6. These two daily totals exceed the 3g/day maximum ordered by the Prescriber. Review of the (MONTH) (YEAR) MAR reveals that the 0800 Hours daily dose of [MEDICATION NAME] is to be held for systolic blood pressure Resident #10 Review of this resident's record revealed a physician order [REDACTED]. This order is incomplete as it lacks a frequency for administration.",2019-05-01
837,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2015-11-13,356,C,0,1,0M1C11,"Based on observation and interview the facility failed to post nurse staffing data specific to the Skilled Nursing Facility (SNF). Findings include: On 11/12/15 at 5:55 p.m. a document titled, GenSTAR Daily Nurse Staffing Form was noticed at the nurses station in plain view of anyone visiting the facility. The Day Shift census was documented as 111. The facility is licensed for a maximum of 30 beds. During an interview with Staff A (Director of Nurses/Nursing) on 11/12/15 at 6 p.m., Staff A verbally confirmed the census was 28 residents at the Skilled Nursing Facility and the GenSTAR Daily Nurse Staffing Form included the staffing for the SNF as well as the Assisted Living Facility (ALF). Interview with Staff B (Administrator) on 11/13/15 at approximately 5:45 p.m. with Staff C (Corporate) present also confirmed that the GenSTAR Daily Nurse Staffing Form included the staffing for the SNF as well as the ALF.",2019-05-01
838,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2015-11-13,364,B,0,1,0M1C11,"Based on observation and interview, it was determined that the facility on occasion failed to serve food at the proper temperature to be palatable. Findings include: Interview with Resident #1 on 11/12/15 revealed that their food tastes okay, except when it's cold. Some foods are served cold, especially the scrambled eggs and pancakes, usually the other food is warm. A test tray of food was evaluated by Staff D, Food Service, and surveyor on 11/12/15 at about 12:17 p.m. The warm food's temperatures were measured as green beans 101.5 degrees, mashed potato 114 degrees, and beef 104 to 109.5 degrees (Fahrenheit). The jello tested at 58.4 degrees. The surveyor tasted the food and assessed appearance and aroma as excellent, flavor as good; and temperature palatability as potatoes and green beans warm, not hot; meat borderline cool to room temperature, milk cold, and jello (with whip cream) cool. During an 11/12/15 resident's council meeting six of six residents present said that the food is regularly served cold especially at breakfast. They felt that the scrambled eggs were always served cold but that other breakfast foods had been served cold as well like pancakes and oatmeal.",2019-05-01
839,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2015-11-13,371,D,0,1,0M1C11,"Based on observation and interview, it was determined that the facility failed to ensure that food stored was properly labeled and dated to ensure it was not outdated. Findings include: Observation of the Main Kitchen prep refrigerator during tour on the morning of 11/12/15 revealed an opened container of thickened orange juice and an opened container of thickened milk that were not dated when opened. Observation during morning tour of the facility kitchenette on 11/12/15 revealed that food stored in the cupboards included three different dry cereals, each out of its original container, stored in plastic containers with no labels or dates. In addition breads stored but undated included two full sliced loaves, a less than full bread, and a bag of English muffins. In a lower cupboard there was a partially filled container of pancake syrup that had no open date or expiration date. In the residents' refrigerator there was also a small bread loaf, uncut, labeled with a person's name, but with no date. These findings were brought to the facility's attention; and subsequent interview and observation with Staff D, Food Service, on 11/13/15 revealed the cereals were now dated, Staff D indicated the undated breads were removed, and the breads now in the cupboards were dated. Staff D explained the syrup is open and is good until the manufacturer's use by date, but Staff D was unable to determine the use by date for the container of syrup. A later observation in the kitchenette on 11/13/15 in the p.m. revealed that the undated container of pancake syrup was still present in the kitchenette cupboard.",2019-05-01
840,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2016-04-01,333,E,1,0,XLTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined that the facility failed to ensure that all residents were protected from having a significant medication error during their stay at the facility for 1 resident in a survey sample of 4 residents. (Resident identifier is #1.) Findings Include: Resident #1 During a complaint investigation on 3/24/16 Resident #1's medication records were reviewed and it was determined that on 3/11/16 this Resident did not receive their scheduled daily [MEDICATION NAME] 20 mg (Milligrams). The record also indicated that the [MEDICATION NAME] was also omitted each following day until 3/20/16 when documentation indicated that they received the medication again. Interview on 3/24/16 with Staff A (Administrator) confirmed the accuracy of the medical record. Interview on 3/31/16 with Staff B (Registered Nurse) and on 4/1/16 with Staff C (Registered Nurse) revealed that on 3/19/16 Staff B noticed that Resident #1 was no longer receiving their [MEDICATION NAME] as it appeared to have been discontinued in the electronic medical record by Staff C. Staff B and Staff C met to discuss this a couple of hours later during shift change on 3/19/16. Staff C agreed that the electronic medical record indicated that they had discontinued the medication even though there was no discontinue order from the physician. During interview on 4/1/16 Staff C stated that they had no recollection of discontinuing the medication and that it must have been done in error. As soon as the error was identified, the physician was notified and documentation indicated that Resident #1 was made aware of the error. During interview, Staff C indicated that as soon as they had confirmed the error that the physician was made aware and an order to restart the medication was taken. Staff C asked the physician if they should start the medication that evening on 3/19/16, but the physician replied to start the medication in the morning 3/20/16.",2019-04-01
841,COURVILLE AT MANCHESTER,305057,44 WEST WEBSTER STREET,MANCHESTER,NH,3104,2016-01-15,281,D,0,1,Z54S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and the professional standard of practice for following physician orders [REDACTED]. (Resident identifier is #18.) Findings include: Resident#18 Review of the professional standard of practice found in the 'Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following: On page 336 - Physicians' Orders states, The physician is responsible for directing medical treatment. Nurse's follow physicians' orders unless they believe the orders are in error or harm clients . Observation during a medication pass on 1/14/16 at approximately 9:15 a.m. with Staff A (Licensed Practical Nurse) revealed the following physician order [REDACTED]. Observation at this time revealed that Staff A had crushed the Vitamin D3 and [MEDICATION NAME] 100 mg together and placed into [DEVICE] dry. At the bottom of the [DEVICE] a small amount of liquid from the previous medication was present. Staff A had to milk the tubing to get all the medication down and finish with the Jevitiy 1.2 cal and coke. Interview at this time with Staff A, indicated that sometimes Staff A dilutes the mixtures and sometimes she puts the medications into the [DEVICE] dry. Interview with the Staff B, (DON) indicated that it should be diluted before it is placed into the [DEVICE].",2019-04-01
842,COURVILLE AT MANCHESTER,305057,44 WEST WEBSTER STREET,MANCHESTER,NH,3104,2016-01-15,431,D,0,1,Z54S11,"Based on observation and interview it was determined that the facility failed to ensure that 1 out of 4 medication carts was locked and secure from access by unauthorized personnel. Findings include: Observation on 1/11/16 of a medication cart at approximately 6:10 p.m. revealed an unattended, unlocked medication cart in the resident hallway on the 200 wing. During interview with Staff C (LPN) on 1/11/16 at the time of this observation, Staff C confirmed that the medication cart was left unattended and unlocked in the resident hallway. Staff C stated that she left the med cart to go administer medications to a resident in a room down this hallway. Staff are trained to leave medication carts locked when unattended. Interview with Staff B (DON) on 1/11/16 indication that it is the policy of this facility that the medication cart is to be kept locked if it to be left unattended in the resident's hallway.",2019-04-01
843,COURVILLE AT MANCHESTER,305057,44 WEST WEBSTER STREET,MANCHESTER,NH,3104,2016-01-15,465,B,0,1,Z54S11,"Based on observation and interview the facility failed to provide an environment that is safe for residents. Findings include: During tour of the 200 unit on 1/11/16 at approximately 9:00 p.m., the closet door to the electrical panels was unlocked as well as the electrical panel itself. Staff B, (DON) confirmed the observation. Interview at this time with Staff B did not know how long the door and the electrical panel had been opened.",2019-04-01
844,THE ELMS CENTER,305068,71 ELM STREET,MILFORD,NH,3055,2015-12-09,225,D,0,1,10MS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon a review of a facility investigation for the abuse protocol the facility failed to protect a resident who alleged abuse by a staff member (Resident identifier is #15). Findings include: Reveiw of a facility investigation report dated 10/6/15 revealed that on 10/5/15, during the 3-11 shift Resident #15 stated to Staff B (Registered Nurse) that Staff C (Licensed Nurse Assistant) was rough with and swore at Resident #15. Resident #15, according to the written statement of Staff B pointed out Staff C and said that's her identifying Staff C as the alleged perpetrator. The facility Abuse Prohibition policy of 6/1/96 revised 12/1/11 specifically states that an employee alleged to have committed the act of abuse will be immediately removed from duty pending the results of an investigation. According to the written statement by Staff B, Staff C remained on duty the night of 10/5/15 and was told not to either care for Resident #15 or to enter Resident #15's room. Staff B's written statement stated that Resident #15 was visibly upset and worried upon seeing Staff C. Resident #15's concern regarding Staff C was confirmed by the written statement of Staff D (LNA). Staff D's written statement noted that Staff C, after having reportedly having been told not to care for Resident #15 or to enter Resident #15's room stood outside the door of Resident #15's room and said this[***] said I was rough with him. Staff D wrote that right after Staff C made that comment, Resident #15 put his hand on my arm and said that's her isn't it. Resident #15, according to Staff D's statement, needed and received reassurance from Staff D that it was okay. However, Staff D wrote that everytime Staff C would walk by Resident #15's room, Resident #15 would get upset and ask me to stay longer. Staff D wrote that Staff E (LNA) was also in Resident #15's room at the time. Staff E noted in a written statement that Staff C was right next to Resident #15's room and stated he is saying I was rough with (sic), I didn't even do care on him I sat outside his room the whole time. Staff E wrote that as Staff C spoke Resident #15 said I want to see if that is the lady the one who ripped my stuff off. Staff E immediately reported the conversation to the nurse as my shift was over. Staff C, according to both Staff D and Staff E, came to Resident #15's room doorway and denied Resident #15's allegation of rough treatment, a denial Resident #15 apparently witnessed. Resident #15 should not have been subjected to this conversation which Staff D said was abusive. The facility failed to ensure that Resident #15 was protected after making an allegation of abuse.",2019-04-01
845,THE ELMS CENTER,305068,71 ELM STREET,MILFORD,NH,3055,2015-12-09,226,D,0,1,10MS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon a review of a facility investigation for the abuse protocol the facility failed to implement it's Abuse Prohibition policy to immediately remove a staff member who was alleged to have abused a resident(Resident identifier is #15). Findings include: Reveiw of a facility investigation report dated 10/6/15 revealed that on 10/5/15, during the 3-11 shift Resident #15 stated to Staff B (Registered Nurse) that Staff C (Licensed Nurse Assistant) was rough with and swore at Resident #15. Resident #15, according to the written statement of Staff B pointed out Staff C and said that's her identifying Staff C as the alleged perpetrator. The facility Abuse Prohibition policy of 6/1/96 revised 12/1/11 specifically states that an employee alleged to have committed the act of abuse will be immediately removed from duty pending the results of an investigation. According to the written statement by Staff B, Staff C remained on duty the night of 10/5/15 and was told not to either care for Resident #15 or to enter Resident #15's room. Staff B's written statement stated that Resident #15 was visibly upset and worried upon seeing Staff C. Resident #15's concern regarding Staff C was confirmed by the written statement of Staff D (LNA). Staff D's written statement noted that Staff C, after having reportedly having been told not to care for Resident #15 or to enter Resident #15's room stood outside the door of Resident #15's room and said this[***] said I was rough with him. Staff D wrote that right after Staff C made that comment, Resident #15 put his hand on my arm and said that's her isn't it. Resident #15, according to Staff D's statement, needed and received reassurance from Staff D that it was okay. However, Staff D wrote that everytime Staff C would walk by Resident #15's room, Resident #15 would get upset and ask me to stay longer. Staff D wrote that Staff E (LNA) was also in Resident #15's room at the time. Staff E noted in a written statement that Staff C was right next to Resident #15's room and stated he is saying I was rough with (sic), I didn't even do care on him I sat outside his room the whole time. Staff E wrote that as Staff C spoke Resident #15 said I want to see if that is the lady the one who ripped my stuff off. Staff E immediately reported the conversation to the nurse as my shift was over. Staff C, according to both Staff D and Staff E, came to Resident #15's room doorway and denied Resident #15's allegation of rough treatment, a denial Resident #15 apparently witnessed. Staff E immediately reported the conversation to the nurse as my shift was over.",2019-04-01
846,THE ELMS CENTER,305068,71 ELM STREET,MILFORD,NH,3055,2015-12-09,280,D,0,1,10MS11,"Based on record review and interview, the facility failed to timely update and ensure care plans were current, for 2 of 12 residents in the survey sample. (Resident identifiers are #2, and #3.) Findings include: Resident #2 Review of Resident #2's physician Order dated 1/12/15 revealed that a Foley change was ordered to change sizes from a 16Fr(french) with 10 cc(cubic centimeter) balloon to a 18Fr with 30 cc balloon. due to leakage. Review of Resident #2's current care plans revealed a care plan addressing goals and interventions for the 16Fr with 10cc balloon. Review of Resident #2's care plan under the focus area reveals, resident to be out of bed for 2 hours 3x week and under the interventions area it states nursing to help resident be out of bed for 2 hours 3x week. another Focus area for actual skin breakdown in the intervention area it states . is to be out of bed no more than 2 hours per day unless he is out for an appointment or activity out of the building. Interview with Staff A (RN), on 12/7/15 revealed that this is not the resident's current care plan, it was confirmed by record review and interview that the resident's care plan was not updated timely. Resident #3 has a current comprehensive care plan of 11/6/15 which states that this resident has an actual skin breakdown related to moisture/excessive prespiration that's located under the left breast. Staff interview of 12/8/15 with Staff A( RN) revealed that this area was resolved months before the survey. The facility failed to update the comprehensive care plan for this resident.",2019-04-01
847,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2016-03-24,279,D,0,1,72ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan that included all pertinent care areas, for 2 resident in a survey sample of 13 residents. (Resident identifiers are #4 and #11.) Findings include: Resident #4 Review of this resident's Annual MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 11/12/15 revealed that the Care Area of [MEDICAL CONDITION] Drug Use triggered, and the facility did a Care Area Assessment (CAA) and determined that they would care plan. Review of the CAA dated 11/19/15 revealed that Resident #4 takes an antidepressant daily . is monitored . for changes in mood and behavior, and any potential side effects Will proceed to care plan as resident is a risk for potential side effects of his medications Review of this resident current care plan reveals, for [MEDICAL CONDITION] Drug Use, the Crosswalk points to the Care Area of Emotional Well Being. Review of the Emotional Well Being section of the care plan reveals that family/staff support is addressed, but there is no mention of any depression, medication use, or monitoring for side effects. Interview with Staff C, RN on 3/24/16 revealed this resident's [MEDICAL CONDITION] medication is used for sleep, not depression. Resident #11 Review of this resident's Significant Change MDS with an ARD of 5/20/15 revealed that the Care Area of [MEDICAL CONDITION] Drug Use triggered, and the facility did a Care Area Assessment and determined that they would care plan for this area. Review of the 5/30/15 CAA for [MEDICAL CONDITION] Drug Use reveals Nursing administers the medications and monitors for changes in mood and behavior is at risk for possible side effects of . medications Review of the hospice document Physician Verbal Order dated 3/22/16 reveals this resident's medications include daily [MEDICATION NAME] ([MEDICATION NAME]) for depression. Review of this resident's current CHAT Biography care plan under Emotional Well Being reveals no mention of the [DIAGNOSES REDACTED].",2019-04-01
848,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2016-03-24,441,D,0,1,72ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to use proper cleaning procedure after the use of a unit glucometer observed during medication pass. (Resident identifier #15 out of sample) Findings include: References: Obtained on-line 11/20/15 at http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#unsafe, under Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration - Blood Glucose. Also, in the above document under Additional Information on pages 7 and 8 refers to the following resource: FDA Communication: Leter for Manufacturers of Blood Glucose Monitoring Systems Listed with the FDA most current update (MONTH) 2, 2012 and is found on-line at http://www.fda.gov/MedicalDevices/Productsand MedicalProcedures/InVitroDiagnostics/ucm 5.htm. Page 2 under section 2 Validated cleaning and disinfection procedures states: .Please note that 70% [MEDICATION NAME] solutions are not effective against viral bloodbourne pathogens . During the medication pass for the 100 unit on 3/22/16 at 8:15a.m. with Staff G(RN), performed a repeat blood glucose test on Resident #15. After test was completed, Staff G returned to the medication cart where Staff G wiped glucometer clean with an alcohol wipe. When asked if the glucometer was a common use glucometer for the unit Staff G worked on, Staff G replied that it was. When asked 'What is the accepted protocol for cleaning the glucometer between residents.' Staff G replied 'Alcohol?'.",2019-04-01
849,HILLSBORO HOUSE NURSING HOME,305092,PO BOX 400 67 SCHOOL STREET,HILLSBORO,NH,3244,2015-10-20,514,D,0,1,4RYJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to maintain clinical records that were complete and accurately documented, for 3 residents in a survey sample of 10 residents. (Resident identifiers are #2, #3, and #10.) Findings include: Resident #2 Record review of Resident #2's current care plan revealed, Resident has wishes to be DNR/DNI (do not resuscitate/do not intubate) dated 7/31/15 with a review date of 8/14/15. Interview with Staff A, RN on 10/20/15 revealed that Resident #2 has never been a DNR and is a full code, and that the entry on the care plan is an error. Staff A explained that in the event of a code, staff would look at the list of residents who are a Full Code posted on the wall (in the room with the medical records), and observation by surveyor during interview revealed that such a posting exists and that Resident #2 is on it. Record review also revealed that the outside binder and inside front cover of the resident's chart identified the resident as a full code, and the physician's orders [REDACTED]. Review of physician's orders [REDACTED]. This finding was pointed out to Staff A, who related that changes to the physician's orders [REDACTED]. Review of these physician's orders [REDACTED]. Resident #3 Review of Resident #3's physician's orders [REDACTED]. Interview with Staff A revealed that this date is an error and should read 10/9/15. Review of the Orders sheets also revealed an order for [REDACTED]. Interview with Staff A on 10/20/15 revealed that the physician gave a verbal order on 10/9/15 not to do anything, including the PT/INR, and that verbal order to not do the PT/INR never got written in the patient's medical record. Resident #10 Review of Resident #10's physician's orders [REDACTED]. instill 1 drop in each eye every 1-2 hours as needed for irritation. By listing a range for frequency of administration, this order failed to clearly define a specific time interval for use.",2019-04-01
850,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2016-05-20,279,D,0,1,8O7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan with interventions for 2 out of 17 sampled residents. (Resident identifier are #14 and #17.) Findings include: Resident #14. Record review on 5/20/16 revealed that Resident #14 did not have a comprehensive care plan with interventions related to pain. The record indicated the excision of a left upper arm squamous cell [MEDICAL CONDITION] that was performed on 4/26/16. The resident also had the coded [DIAGNOSES REDACTED]. This resident was prescribed [MEDICATION NAME] 300 mg (milligrams) by mouth three times a day for pain, [MEDICATION NAME] 5/325 mg (milligrams) 1 tab by mouth every 4 hours as needed for left arm pain, and an order for [REDACTED]. An interview on 5/20/16 at 9:45 AM with Staff B RN (Registered Nurse) confirmed that Resident #14 did not have a care plan related to pain. Resident #17. Record review on 5/19/16 for Resident #17 revealed that Resident #17 was admitted to the facility for rehabilitation on 4/8/16 following a hospitalization for left total shoulder replacement. Review of the Total Shoulder Arthroplasty/Hemiarthroplasty Protocol discharge instruction from the orthopaedic physician revealed the following; Precautions: . Sling should be worn for 4 weeks for comfort . Sling should be used sleeping and removed gradually over the course of the four weeks, for periods throughout the day. .While lying supine a small pillow or towel roll should be placed behind the elbow to avoid shoulder hyperextension/anterior capsule/subcapularis stretch. Avoid shoulder active range of motion. No lifting of objects. No excessive shoulder motion behind back. No excessive stretching or sudden movements (particularly external rotation) No supporting of body weight by hand on involved side. Keep incision clean and dry (no soaking for 2 weeks) No driving for 3 weeks . Further record review on 5/20/16 revealed no documentation in the care plan or on the treatment sheet for the Total Shoulder Arthroplasty/Hemiathroplasty Protocol discharge instructions from the orthopaedic physician for precautions to be implemented for Resident #17 to prevent any complications postoperatively following the left total shoulder arthroplasty. During interview on 5/20/16 with Staff A (Registered Nurse) at approximately 10:45 a.m. after Staff A reviewed the above listed post operative instruction protocol, care plan and treatment sheets, Staff A verbally confirmed that the total shoulder precaution protocol was not incorporated into the comprehensive plan of care for Resident #17.",2019-03-01
851,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2016-05-20,280,D,0,1,8O7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to update a comprehensive care plan for 1 resident in a standard survey sample of 17 residents. (Resident identifier is #9.) Findings include: Record review on [DATE] of the current comprehensive care plan for Resident #9 with an initiated date of [DATE] revealed a care plan indicating Resident #9 as a Full Code with a written goal of In the event of a code, CPR (cardiopulmonary resuscitation) will be initiated . Further record review revealed that Resident #9 was admitted to the facility on [DATE] following a hospitalization for impacted right femoral neck fracture from a fall sustained at home. A PORTABLE DO NOT ATTEMPT RESUSCITATION ( P-DNR ) ORDER dated [DATE] was in place and on Resident #9's medical record. Further record review on [DATE] of the RESIDENT CARE PLAN developed at the time of admission on [DATE] revealed a DNR care plan dated [DATE] and a second RESIDENT CARE PLAN indicating FULL CODE dated [DATE]. During interview with Staff A (Registered Nurse) on [DATE] at approximately 10:00 a.m. after Staff A reviewed the above three listed care plans findings, Staff A verbally indicated that Resident #9 had a DNR status and that the current care plan indicating FULL CODE was incorrect. Staff A telephoned the activated DPOAH (Durable Power of Attorney for Health) in this surveyor's presence to verify the correct Code status indicating DNR on [DATE].",2019-03-01
852,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2016-05-20,281,D,0,1,8O7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow the professional standard of practice for the administration of medications for 2 residents in a survey sample of 17 residents. (Resident identifiers are: #2 and #13.) Findings include: Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009 Chapter 35 Medication Administration, Right Documentation on pages 709 - 713 and page 688 for Guidelines for Safe Narcotic Administration and Control reveals the following: After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care. The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed .Use the record to document the client's name, date, time of medication administration, name of medication, dose and signature of nurse dispensing the medication . If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurse's notes. Some agencies require the nurse to circle the prescribed administration time on the medication record or to notify the physician when a client misses a dose . Resident #2 Record review on 5/18/16 and 5/19/16 revealed the following physician orders [REDACTED]. and [MEDICATION NAME]-[MEDICATION NAME] 5 MG (milligram)-325 MG Tablet For>[MEDICATION NAME] 2 Tabs by mouth every 4 hours as needed for pain greater than or equal to 6/10. Further review of Resident #2's April's Medication Administration Record (MAR) dated 4/1/16-4/30-16 the front side of the MAR and back side of the MAR and review of the Narcotic book revealed the following : [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) administered for the month of (MONTH) reveals the following: On 4/12/16 Staff D License Practical Nurse (LPN) signed out the MAR for two doses. The Narcotic book has no doses signed out for 4/12/16. The Nacrotic Book has two doses signed out on 4/13/16 by Staff D. The MAR had no corresponding doses written out for 4/13/16 and to document it was administered to the resident. On 4/15/16 at 2 p.m. Staff F (RN) signed out [MEDICATION NAME] in the Narcotic Book but did not sign either the front or the back side of the MAR for a corresponding doses and to document it was administered to the resident. On 4/16/16 at both 3 p.m. and 10:15 p. m. Staff D signed the Narcotic Book, the front of the MAR but not the back of the MAR. On 4/22/16 at 9 p.m. Staff E, (LPN) signed the Narcotic Book, back of the MAR but not the front of the MAR. On 4/23/16 at 7:45 a.m. Staff E signed the Nacrotic Book, back of the MAR at 10:00 a.m. and did not sign the front of the MAR. On 4/27/16 Staff E at 9:10 a.m. signed in the Nacrotic Book. No doses were shown to be given on 4/27/16. On 4/28/16 Staff E signed the MAR at 9:10 a.m. that [MEDICATION NAME] was given. On 4/29/16 Staff D signed the Nacrotic Book for three different doses signed the back of the MAR for three of the doses and signed the front of MAR for one of the doses. [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) administered for the month of (MONTH) reveals the following On 5/14/16 Staff D signed the Nacrotic Book for two different doses signed the back of the MAR for two of the doses and signed the front of MAR for one of the doses. On 5/18/16 Staff D signed the Nacrotic Book for four different doses signed the back and front of the MAR for three of the doses only. Interview with Staff A (RN Unit Manager) on 5/19/16 after Staff A reviewed the above listed MAR, and Narcotic Book, for (MONTH) and (MONTH) for Resident #2, Staff A verbally confirmed that the documentation for the administration of [MEDICATION NAME] was not complete and accurate. Resident #13 Record review on 5/20/16 revealed the following physician orders [REDACTED]. Further review of the Medication Administration Record (MAR) for Resident #13 dated 4/1/16-4/30/16 the front side of the MAR and back side of the MAR and review of the Narcotic book revealed the following : [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) administered for the month of (MONTH) reveals the following: On 4/22/16 at HS Staff G signed the Narcotic Book, back of the MAR but not the front of the MAR. [MEDICATION NAME] administered for the month of (MONTH) reveals the following: On (MONTH) 1st, 5th, and 6th at HS Staff G, signed the Narcotic Book, back of the MAR but not the front of the MAR. On 5/2/16 there is no documentation to indicate that the above ordered medication was given at the scheduled time. No signature was noted in the Narcotic Book, back of the MAR or the front of the MAR to indicate that the medication was administered to the resident. Interview with Staff B (RN Unit Manager) on 5/20/16 after Staff B reviewed the above listed MAR, and Narcotic Book, for (MONTH) and (MONTH) for Resident #13, Staff B verbally confirmed that the documentation for the administration of [MEDICATION NAME] was not complete and accurate.",2019-03-01
853,COURVILLE AT NASHUA,305037,22 HUNT STREET,NASHUA,NH,3060,2016-05-20,514,B,0,1,8O7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain clinical records to include pain scale parameters for the use of pain medication for 1 of 17 sampled residents. (Resident identifier is #14.) Findings include: Record review on 5/20/16 revealed that Resident #14 did not have written pain scale parameters for any of the prescribed medications. The physician orders [REDACTED].#14 received any of the mentioned medication for pain, this nurse confirmed that there are no pain scale parameters indicated with either order. Record review on 5/20/16 revealed that Resident #14 did not have a comprehensive care plan with interventions related to pain. (Cross Reference F279) The record indicated the excision of a left upper arm squamous cell [MEDICAL CONDITION] that was performed on 4/26/16. The resident also had the coded [DIAGNOSES REDACTED].",2019-03-01
854,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,160,B,0,1,4ZUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of resident trust funds and interview, it was determined that the facility failed to convey resident funds within 30 days to the estate of the individual or probate jurisdiction administering the resident's estate for 2 out of 5 sample residents. Findings include: Review of the resident trust fund on [DATE] at approximately 1:30 p.m. with Staff L (Business Office Manager) revealed that the facility failed to convey 2 resident's personal funds within 30 days of discharge from the facility. Review of the accounts revealed the following: Resident #24 had expired at the facility on [DATE] with $1,647.56 remaining in the account. The probate was filed [DATE]. Resident #25 had expired at the facility on [DATE] with $168.01 remaining in the account. The probate was filed [DATE]. Interview on [DATE] at approximately 1:30 p.m. with Staff L, confirmed that Resident #24 and Resident #25 funds had not been conveyed within 30 days of the residents' death, to the estate of the individual or probate jurisdiction administering the residents' estates.",2019-03-01
855,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,241,B,0,1,4ZUY11,"Based on observation and interview, it was determined that the facility failed to provide an environment that promotes residents dignity and respect for 2 of 4 dinning areas. Findings include: Observation on 3/7/17 at approximately 8:00 a.m. in the Matthew(NAME)Lane during a dining observation revealed multiple residents who required assistance with eating as indicated by Staff B (Licensed Practical Nurse) at the time of this observation. The staff that were assisting and cueing residents with eating were doing so by standing next to the residents seated and providing small portions of food to the residents. One staff member knelt down to the floor next to a resident and proceeded to assist this resident with eating of breakfast foods. Further observation at this time showed staff walking between 4 individual tables with 3 to 5 residents sitting at these tables and the staff standing to cue and assistant residents with eating. Observation on 3/8/17 at approximately 8:20 a.m. during a breakfast dining observation revealed 6 individual tables with multiple residents at each table who required assistance with eating as indicated by Staff C (LPN). The majority of these residents had white cloth bibs attached around their necks covering the upper front portion of their clothes during this meal observation. Staff O (Registered Nurse) stated at the time of this observation that she was unaware if the residents were asked if they preferred to wear the white bibs. Further observation at this time showed a corner table with multiple residents seated and one staff member seated between two residents alternating assisting residents with their breakfast food and beverages and having ongoing conversation with other staff members while assisting these residents. Beside this table another staff member was observed standing up against a window glass frame and cueing other residents at this table to eat their breakfast. Interview at the time of this observation with Staff O (Registered Nurse) confirmed that most of the residents observed need assistance with eating.",2019-03-01
856,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,281,D,0,1,4ZUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility policy and procedure, it was determined that the facility failed to follow the professional standard of practice for ensuring medications are locked and failed to have parameters for the administration of medications for 2 residents in a survey sample of 20 residents. (Resident identifier is #4 and #8.) Findings include: Review of the facility policy and procedure titled Medication Cart Use with a revision date of (MONTH) 2008 revealed the following; FUNDAMENTAL INFORMATION Security . The medication cart and its storage bins are kept locked until the specific time of medication administration . - no medications are kept on top of the cart . References are: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Pages 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Pages 719-723 .Do not leave medications unattended. Nurse is responsible for safekeeping of drugs . Resident #8 Review on 3/7/16 of Resident #8's Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet 325 MG (milligram) Give 2 tablets by mouth every 4 hours as needed for Pain 1-5 on Pain Scale PRN (as needed) and [MEDICATION NAME] .Tablet 15 MG Give 15 mg by mouth every 6 hours as needed for pain management .PRN. Interview on 3/8/17 with Staff O (Registered Nurse) reviewed the above listed MAR for Resident #8, Staff O confirmed that there were no pain parameters following a pain scale listed for the physician order of [MEDICATION NAME] 15 mg PRN for Resident #8. Observation on 3/7/17 at approximately 8:20 a.m. during medication pass with Staff N (Licensed Practical Nurse) showed an open 100 capsule bottle of the medication Acidophilus on top of a unattended medication cart. Interview with Staff N at the time of this observation confirmed that the opened bottle of stock Acidophilus was left on top the unattended medication cart by Staff N. Resident #14 Review on 3/8/17 of Resident #14's Medication Administration Record [REDACTED]. Orders read as follows: [MEDICATION NAME] (Concentrate) Solution 20 mg/ml (milligrams/milliliter) Give 0.25 ml by mouth every 2 hours as needed for pain/SOB(short of breath) Tylenol Tablet 325 mg ([MEDICATION NAME]) Give 650 mg by mouth every 4 hours as needed for pain or discomfort may give suppository. Interview on 3/8/17 with Staff B (Licensed Practical Nurse) reviewed the above findings and Staff B confirmed that there should be parameters for use written in the order as a pain scale of 1-5 for the Tylenol and a pain scale of 6-10 for the [MEDICATION NAME]. Observation on 3/6/17 at approximately 9:45 a.m. during tour of the Physical Therapy room revealed 4 medications that were in an unlocked cabinet to the right of the entrance door. The following medications were in the unlocked cabinet:[MEDICATION NAME] mg (milligrams), mucus relief, airborne OTC (over the counter), Halls.",2019-03-01
857,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,353,E,0,1,4ZUY11,"Based on interviews, it was determined that the facility failed to provide sufficient staff to provide nursing and related services to its residents.(Resident identifiers are #21, #22 and Resident #24 unsampled residents). Findings include: Interview on 3/6/17 with Resident #24 and Resident #24's spouse revealed that on the evening of 3/4/17 Resident #24 rang their call bell for help to go to the bathroom. Resident #24 said that for between 30-45 minutes no one responded to the ringing call bell. Resident #24 stated that after 30-45 minutes had passed Resident #24 couldn't hold it anymore and defecated in their bed. Resident #24 said that after having to defecate in bed they called their spouse at home. Resident #24's spouse confirmed this and stated after talking with Resident #24 they called the facility to get Resident #24 assistance. Resident #24 felt embarrassed having to defecate in their bed because no one would answer their call bell. Interview on 3/6/17 at 1:30 p.m. with resident counsel revealed that 20 Residents and 2 family members who were present with permission from the group were in attendance. All residents voiced many concerns related to shortage of staffing. These concerns were: rooms not being cleaned in a timely fashion, missing laundry, unmade beds and family members of residents helping to care for their loved ones including assisting with meals. Three residents expressed concern with having to wait anywhere up to 40 minutes for their call lights to be answered. All residents were in agreement that the current staff do the best they can and are wonderful but are not able to take care of so many residents. The group revealed that staffing is worse on the weekends, mornings and the night shift. One resident revealed that on a recent Sunday, there was 2 LNAs (Licensed Nursing Assistant) and 2 nurses to care for more than 40 residents. Another resident revealed that the nurses often work as LNAs (Licensed Nursing Assistants) and pick up extra shifts to fill the needs. One family member asked if there were any staffing number regulations and expressed the same concerns as the residents regarding appropriate care. Interview on 3/8/17 at 10:10 a.m. with Resident #22 and Resident #22's family member revealed that the family and resident stated that the facility was understaffed. When you ring the buzzer you never know if it will b 5 minutes to 2 hours for someone to come. Interview on 3/6/17 at 2:10 p.m. with Resident #21 revealed that Resident #21 stated, I have to make my bed all the time because there is nobody to do it. My dirty clothes are still sitting there from this morning to be picked up. Observation on 3/6/17 at 2:10 p.m. of the Resident #21's room showed 2 bags of linens next to the trash barrel and Resident #21's bed was unmade. Resident #21 stated, Time of day, day of week, none of that matters, it's the same problem here day in and day out with the help. Interview on 3/8/17 at 12:53 p.m. Staff H (Registered Nurse) and Staff I (Licensed Practical Nurse) both stated, in part; this is a 44 bed unit and most Sundays are so short staffed; 2 LNAs on the unit for all 3 shifts. It's been so bad that we have had 1 LNA and 1 nurse for 44 resident's and most of them require 2 person assist with transfers, toileting and care. Interview on 3/8/17 at 1:00 p.m. Staff G (Registered Nurse) revealed Staff G has worked as an LNA. Staff G stated the Facility is very short staffed for LNAs. I fill in a lot as an LNA, sometimes there are only 1-2 LNAs on each unit. The facility keeps hiring nurses, but we don't have enough LNAs. Interview on 3/8/17 at 1:10 p.m. Staff B (Licensed Practical Nurse) stated, The staffing is horrible, we need help here! A couple of weeks ago we had to run the entire unit with 1 LNA.",2019-03-01
858,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,356,B,0,1,4ZUY11,"Based on observation and interview, it was determined that the facility failed to maintain an accurate daily staffing posted in a prominent place readily accessible to residents and visitors with the facility name, the current date, the total number and actual working hours with the number of licensed and unlicensed nursing staff directly responsible for resident care per shift and the resident census for each date and shift. Findings include: Observation and interview on 3/8/17 with Staff O (Registered Nurse) revealed no posting of the required daily nursing staff information. Staff O was unable to provide any required daily nurse staffing information posted since the last yearly recertification survey.",2019-03-01
859,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,371,F,0,1,4ZUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of manufacturer's policy and interview, it was determined that the facility failed to follow proper sanitization and food handling practices and failed to not commingle employee food with resident's food in the main kitchen and all three kitchenettes. Findings include: Observation on 3/5/17 at 8:45 a.m. of the kitchen with Staff D (Food Service Director) revealed the following: Dry food shelves- 1 box of opened undated instant potatoes, 1 bag of opened undated marshmallows and 1 package of opened undated spaghetti. Walk in cooler- 1 tray of cornbread no date noted and 1 tray of cornbread USB (use by date) date 3/3/17, 2 cucumbers with white growth noted, 2 lemons brown in color and soft, apple-orange-cranberry juice in pitchers without dates. Walk in freezer- Box of charbroiled rib eye patties opened without any covering, box of chicken patties opened without any covering, a box of corn on the cob opened without any protective covering, Refrigerator -undated apple juice in pitcher, nutritional shakes undated. Review of manufacturers policy is USB 14 days after being thawed. Frosting USB 3/2/17, opened iced coffee. Per Staff D, the iced coffee belonged to an employee. Observation on 3/5/17 at 8:45 a.m. of the kitchen revealed that 5 kitchen staff workers were in the kitchen without hairnets on. There was open food containers from breakfast on the counter and lunch was on the stove without lids on the pots. Interview on 3/5/17 at 9:00 a.m. with Staff D, reviewed the above finding and Staff D stated that containers of sausage, bacon and eggs were from breakfast and uncovered. Staff D also confirmed that there was opened undated cheese with corner of package hardened and discolored. Staff D confirmed that staff should be wearing hair nets and have their hair pulled back off their shoulders. Staff D confirmed all the above findings. Observation on 3/5/17 at approximately 9:15 a.m. of the kitchenette on the skilled unit revealed the following: Pastries on top of microwave, in plastic wrap undated, inside of microwave was noted to have large areas of what appeared to be dried food, there was dry cereal in a plastic container not dated, and there also were 2 coffee pots with a dark brown film covering on the inside of the pot. Observation on 3/5/17 at approximately 9:20 a.m. of the east unit kitchenette revealed the following: 4 dry cereal plastic containers undated, canister of opened [MEDICATION NAME] undated, the inside of microwave was noted to have large areas of what appeared to be dried food, strawberries in a plastic container opened and undated, and 14 nutritional shakes undated. Observation on 3/5/17 at approximately 9:25 a.m. of the west unit kitchenette revealed the following: Diet gingerale 1 liter bottle opened and not dated, lemon cookies opened and undated, vanilla wafers opened and undated, 2 cereal containers were not dated, and the inside of the microwave was noted to have large areas of what appeared to be dried food Observation on 3/6/17 at approximately 9:30 a.m. of the Physical Therapy revealed in the freezer that there were resident used body ice packs and resident ice cream in the same freezer. Interview on 3/6/17 at approximately 9:30 a.m. with Staff J (Director of Rehabilitation Services) reviewed the findings in the therapy room and Staff J confirmed these findings.",2019-03-01
860,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,431,D,0,1,4ZUY11,"Based on observation and interview, it was determined the facility failed to keep medications safe and secure from authorized personnel on the medication cart and in the medication room. Findings include: West Wing Observation on 3/7/17 during a medication pass at approximately 8:00 a.m. revealed that Staff F (Registered Nurse) left the medication cart in the resident hallway while Staff F went into a resident's room out of sight of the medication cart. Interview at the time of this observation, with Staff F on 3/7/17, Staff F confirmed that the medication cart was left unlocked and unattended in the resident hallway. Interview on 3/7/17 at approximately 8:30 a.m. with Staff O (Director of Nurses) the surveyor and Staff O had a discussion about the unattended medication cart and the surveyor requested the policies and procedures for medications administration and security. MSU Unit Observation on 3/7/17 at approximately 9:30 a.m. during a medication pass revealed that Staff E (Registered Nurse) left the medication cart in the resident hallway unattended. The medication cart was being checked for expired medications when Staff E walked away to attend to another patient and stated, When you are done can you lock the cart? This surveyor also found that there were 2 bottles of Acidophilus with pectin in the medication cart that had been opened and used. Interview on 3/7/17 at the time of this observation with Staff E, Staff E confirmed the medications were in the drawers and that the Acidophilus with pectin should be refrigerated as manufacturer instructions state. Staff E also confirmed that Staff E walked away from the cart and left it unattended. Observation on 3/7/17 at approximately 8:20 a.m. during medication pass with Staff N (Licensed Practical Nurse) showed an open 100 capsule bottle of the medication Acidophilus on top of a unattended medication cart. Interview with Staff N at the time of this observation confirmed that the opened bottle of stock Acidophilus was left on top of the unattended medication cart by Staff N.",2019-03-01
861,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,441,E,0,1,4ZUY11,"Based on observation, review of manufacturer's instructions and interview, it was determined that the facility failed to maintain and follow infection control practices during medication pass and with the cleaning of glucometers. Findings include: West Wing Observation on 3/7/17 at 8:00 a.m. with Staff F, (Registered Nurse), during medication pass it was observed that Staff F was wearing gloves whiling preparing medications. Staff F removed the gloves, went into a room to answer a resident that was calling out and assist that resident. Staff F proceed to come out of that room and don on gloves and remembered that Staff F needed to get a temperature for the resident that Staff F was preparing the medication for. Staff F took off gloves and took the resident's temperature. Staff F left the medication cart unlocked while Staff F went to the resident's room. Staff F put on a new pair of gloves and poured more oral pills and then remembered that Staff F needed a set of vitals for the resident for the parameters. Staff F took vitals and gave all medications. Staff F put on a new pair of gloves and went to the next patient medication, Staff F proceed to then use sanitizer that was on the side of cart. Interviewed on 3/7/17 at approximately 8:20 a.m. a.m. with Staff F reviewed how Staff F cleans the glucometer after use and care of the glucometer Staff F stated that the glucometer would be cleaned with alcohol wipes and if no alcohol wipes available then Staff F would use the bleach wipes. MSU Interview on 3/7/17 at approximately 9:25 a.m. with Staff E (Registered Nurse) revealed that Staff E cleans the glucometer with alcohol wipes after each patient use. Review on 3/7/17 of the facility GLUCOMETER DECONTAMINATION Policy revised 9/2015 revealed the following, The glucometer shall be decontaminated with the facility approved wipes following use on each resident. Gloves will be worn and the manufacturer's recommendations will be followed. Review of the manufacturers instructions for cleaning of the (Meter name omitted) on 3/7/17 reveals the following: 4. To disinfect the meter, clean the meter with one of the validated disinfecting wipes listed below. Other EPA (Environmental Protection Agency) registered wipes may be used for disinfecting the (pronoun omitted) system, however these other wipes have not been validated and could affect the performance of the meter. Observation on 3/7/17 at approximately 7:30 a.m. during medication pass with Staff P (Licensed Practical Nurse) and at 8:15 a.m. with Staff N (Licensed Practical Nurse) showed a lack of hand hygiene before and after the administration of medications to multiple individual residents. Staff P was observed taking a residents blood pressure prior to the administration of medication. Staff P exited the resident room after taking the blood pressure returned blood pressure cuff to the medication cart and proceeded to dispense multiple medications without performing hand hygiene after the taking of the blood pressure and before the preparation of the residents multiple medications. Observation on 3/7/17 at approximately 8:15 a.m. with Staff N revealed that Staff N administered another medication to a resident with fluids and the resident reported having pain and requested pain medication to Staff N. Staff N returned to the medication cart checked for the pain medication order and proceeded to unlock the medication cart and to unlock the narcotic drawer to obtain the PRN (as needed) pain medication. Staff N returned to the resident room and administered the oral pain medication with fluids. Staff N exited the room and returned to the medication cart to document the narcotic pain medication. No hand hygiene was observed before or after the administration of this medication to the resident. Staff N was observed administering multiple oral medications to a resident exited the residents room and proceeded to the medication cart to prepare medications for a second resident. No hand hygiene was observed after administering medications to the first resident and preparing medications for the next resident.",2019-03-01
862,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2017-03-08,456,D,0,1,4ZUY11,"Based on observation, review of documentation and interviews, it was determined that the facility failed to operate and maintain patient care equipment per the manufactures instructions for 3 of 3 nursing units and the Rehabilitation room. Findings include: Observation on 3/6/17 of the East Unit glucose control solutions, revealed a package expiration date of 7/2015 located on the box surface. Interview on 3/6/17 at 9:30 am with Staff A (Licensed Practical Nurse) confirmed that the glucose control solutions were currently being used and that the package had an expiration date of 7/2015. MSU Wing Observation on 3/6/17 revealed that the O2 (oxygen) concentrators had O2 cannula tubing attached to the concentrator that were not dated and also revealed one O2 concentrator that had no filter on the O2 concentrator. Interview on 3/6/17 Staff A, (License Practical Nurse) confirmed by while on tour, that both O2 Concentrator tubings were not dated and that one O2 concentrator had no filter. Staff A confirmed it was a weekly assignment. West Wing Observations on 3/7/17 at approximately 8:45 a.m. of the West Wing Unit revealed that the glucometer test strips were not labeled on the bottle when they were opened. Interview on 3/7/17 at approximately 8:50 a.m with Staff F (Registered Nurse), Staff F confirmed the bottle of glucometer test strips were not dated on the bottle and Staff F did not know when the bottle had been opened. Review on 3/7/17 of the manufacturers instructions for dating test strips reveals the following : Record the 'date opening' on the bottle label. Discard the bottle and any reminding (sic) test strip after 6 month date of opening. Review on 3/6/17 of the user manual for the (Name omitted) Hydroculator revealed the Hydroculator should be cleaned at least every two weeks per manufacturer's instruction. Interview on 3/6/17 at approximately 9:30 a.m. with Staff J (Director of Rehabilitation services), Staff J stated that routine cleaning on the hydroculator was yearly.",2019-03-01
863,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2016-03-11,281,D,1,0,FMH211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to follow the professional standard of practice for the administration of medications for i resident and failed to follow physician orders [REDACTED]. (Resident identifiers: #1 and #7.) Findings include: Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009 Chapter 35 Medication Administration, Right Documentation on pages 709 - 713 and page 688 for Guidelines for Safe Narcotic Administration and Control reveals the following: After administering the medication, indicate which medications were given on the client's MAR (Medication Administration Record) to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care. The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines .Use a special inventory record each time a narcotic is dispensed .Use the record to document the client's name, date, dose and signature of nurse dispensing the medication . If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurse's notes. Some agencies require the nurse to circle the prescribed administration time on the medication record or to notify the physician when a client misses a dose . Resident #7 Record review on 3/10/16 and 3/11/16 revealed the following physician orders [REDACTED]. A new order was received on 1/3/16 for [MEDICATION NAME] 10 mg/1 ml 4 mg SQ (subcutaneously) every hour prn for left hip pain. A third order for [MEDICATION NAME] (MS04) 10 mg/1 ml Administer MSO4 10 mg/1 ml SQ Q (every) 30 min prn for pain, SOB (shortness of breath), air hunger, agitation restlessness for Resident #7. Further review of the Medication Adminsitration Record (MAR) for Resident #7 dated 01/01/16 the front side of the MAR and back side of the MAR and review of the Narcotic book revealed the following : [MEDICATION NAME] administered on 1/4/16 on the front of the MAR showed 12 doses administered and 15 doses documented in the Narcotic book. [MEDICATION NAME] administered on 1/5/16 on the front of the MAR showed 1 dose encircled with no documentation indicating reason for not administered. A total of 8 doses given on 1/5/16 on the MAR and 10 doses documented in the Narcotic Book. [MEDICATION NAME] administered on the 1/6/16 on the front of the MAR for Resident #7 showed a total of 4 doses given and no documentation in the Narcotic Book for any of the 4 doses given on 1/6/16. Interview with Staff B (Director of Nursing) on 3/11/16 after Staff B reviewed the above listed MAR, Narcotic Book and nursing notes for Resident #7, Staff B verbally confirmed that the documentation for the administration of [MEDICATION NAME] was not complete and accurate. Resident #1: Physician's wound care orders for Resident #1 are as follows: 11/13/15 physician's orders [REDACTED]. 11/19/15 physician's orders [REDACTED]. 12/16/15 physician's orders [REDACTED]. 12/30/15 physician's orders [REDACTED]. 1/13/16 physician's orders [REDACTED]. 2/10/16 physician's orders [REDACTED]. Discharge home on current medications . Wound care notes and sheets indicate that the resident's dressings were changed on the following dates: 11/19/15, 11/21/15, 11/26/15. 12/1/15, 12/3/15, 12/9/15, 12/10/15, 12/12/15, 12/14/15, 12/15/15, 12/16/15, 12/18/15, 12/19/15. 1/4/16, 1/7/16, (1/9/16: there was a note that states resident refused the dressing change on this date), 1/13/16 (went to podiatrist for dressing change), 1/16/16, 1/18/16, 1/23/16, 1/30/16, and 2/7/16. Resident was discharged to home on 2/10/16 with an unresolved wound on the right foot. An interview took place with Staff A (Unit Manager) on 3/10/16, and notes, wound sheets and other documentation was requested to support that dressing changes had been done according to physician's orders [REDACTED].#2's wound. The documents were received prior to this surveyor's departure from the facility on 3/10/16. The documents that were recieved, together with the documentation already found during the investigation, included only the above dates for dressing changes for this resident.",2019-03-01
864,MERRIMACK COUNTY NURSING HOME,305056,325 DANIEL WEBSTER HIGHWAY,BOSCAWEN,NH,3303,2016-03-10,371,E,0,1,FCTK11,"Based on observations and interview, the facility failed to maintain sanitary conditions in the food preparation areas and by properly store ice and ice scoops. Findings include: Observsations during tour of the main kitchen, kiosks (kitchettes in the dining rooms on each unit), and nourishment kitchens on 3/8/16 between 9:20 am and 11:00 am, revealed the following: The ventless cooking station, which is adjacent to the toaster, had a buildup of dust on the lip in the front of the unit over the stovetop and on top of the same unit in all 6 of 6 of the kiosks. Ice scoops had a brown or pink substance on them in 2 of the 12 Nourishment Kitchens (3200F, 2200F). The plastic on the ice cooler was cracked inside near the top with the cooler insulation exposed in 1 of 12 of nourishment kitchens (4300F). The ice cooler inside covers had coffee and juice stains in 3 of the 12 Nourishment Kitchens (3100F, 3400F, 2200F). The ice coolers had drain holes (without plugs) in the bottom to allow water from melted ice to drip from the cooler to a bucket below the cooler. There was a buildup of substances on the outside bottom of the cooler at the drain holes in 4 of 12 Nourishment Kitchens. In kitchen # 4300F and #2200F, the substance was dark black. In kitchen #3300F, the substance was thick and slippery and a dark red color. In kitchen #2600F, the substance was pink. The above substances could be partially removed with a paper towel. Interview with Staff A (Director of Food Services) during the above tour confirmed the above findings and revealed the ice mentioned above was for patient consumption.",2019-03-01
865,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2016-03-24,278,B,1,0,72ZY11,"> Based on record review and interview, in was determined the facility failed to ensure MDS assessments were accurate, for 2 residents in a standard survey sample of 13 residents. (Resident identifiers are #5 and #11.) Findings include: Resident #5 Review of this resident's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/22/15 revealed that the resident's Pneumococcal Vaccine was up to date in Section O0300. However, review of a subsequent MDS, the Quarterly with an ARD of 1/19/16 revealed that the resident is coded at O0300 as declined the Pneumococcal vaccine. Resident #11 Review of the Significant Change MDS with an ARD of 5/30/15, and the Quarterly MDS with an ARD of 2/11/16 revealed, on both Assessments, that the resident coded as being on Hospice care While a Resident in Section O0100. However, both assessments coded that the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months in Section J1400. Interview with Staff F, nurse, on 3/23/16 revealed this resident is currently on hospice and has hospice LNA (licensed nursing assistant) three times a week. Review of the hospice Physician Verbal Order document dated 3/22/16 reveals that the resident's hospice care was recertified on 3/15/16, relating the patient's prognosis is six months or less if the disease runs its normal course. Subsequent to survey exit, the facility provided documentation of the Hospice Certification and Plan of Care with a Start of Care Date 5/30/15.",2019-03-01
866,SAINT ANN REHABILITATION AND NURSING CENTER,305069,195 DOVER POINT ROAD,DOVER,NH,3820,2016-03-24,281,E,1,0,72ZY11,"> Based on medical record review, Schedule II/III narcotic and Schedule IV Controlled substance dispensing logs, interviews, and the self-reported statement, it was determined that the facility failed to document the need for and the effectiveness of Schedule II/III narcotic medications and Schedule IV Controlled Substances in four residents out of a standard survey sample of 13 Residents. (Resident identifiers are #1, #3, #6, and #11) Findings include: Evaluating the effectiveness's of a pain intervention requires you to evaluate the client after an appropriate period of time. pg 1082, Fundamentals of Nursing 7th ed, Potter Perry. On 12/17/15 the facility reported to the New Hampshire Office of Long Term Care Ombudsman that on 12/16/15 they were presented with a letter in which LPN (Staff H) related drug diversion. In the body of the letter Staff H describes the diversion sequence in which Staff H would offer four specific residents (Resident #1, #3, #6, and #11) if they wanted pain medication and when they declined, Staff H would take the medication. Staff H related this activity occurred since approximately the beginning of (MONTH) (YEAR). Record review of narcotics/controlled substances logs, the Medical Administration Records (MAR's) for the months of (MONTH) and (MONTH) (YEAR) of Residents revealed a pattern of schedule II/III narcotics and schedule IV controlled substances signed out for the residents identified. There was no documentation why each medication was needed, that the medications were in fact administered, and the effect each medication dose had on each resident. Documentation is absent in 27 of 33 entries in the narcotics/controlled substances logs that were identified. A records review of the Residents #1, #3, #6, and #11 nurses progress notes found only two entries in which Staff H medicated a resident for pain and recorded the effect of the medication. Interview on 4/1/16 at approximately 2:45p.m. Staff A confirmed findings of the record review of nurses progress notes, MAR's, Schedule II/III narcotic and Schedule IV Controlled substance dispensing logs.",2019-03-01
867,SAINT FRANCIS REHABILITATION AND NURSING CENTER,305070,406 COURT STREET,LACONIA,NH,3246,2015-11-24,309,D,0,1,88IX11,"Based on medical record review and interview it was determined that the facility failed to establish a coordinated hospice plan of care which included identifying the care and services the facility and individual hospice would provide in order to be responsive to the unique needs of the resident and failed to ensure that the facility and the individual hospice are aware of the other's responsibilities in implementing the individualized plan of care for 1 hospice resident in a survey sample of 12. (Resident identifier is #6.) Findings include: Review of medical records on 11/23/15 for Resident #6 revealed that the facility and the individual hospice agency failed to establish a coordinated plan of care for Resident #6 that detailed a description of the scope and frequency of physician ordered services provided by the individual hospice agency for frequency of the skilled nurse, licensed nursing aide, social worker, spiritual and volunteer hospice staff providing services to these residents. Review of Resident #6's medical record revealed incomplete documentation of a collaborated plan of care with assessments, measurable goals and interventions for the individual disciplines listed above and the delineation of the palliative and supportive care that is to be provided and a determination of the disciplines at the facility and/or the hospice agency who will provide these services. Interview on 11/24/15 at 8:30 a.m. with Staff A (Administrator) and Staff B (DON) reviewed Resident #6's hospice plan of care and confirmed that although the facility and hospice agency meet regularly to coordinator care, the plan of care needed to be individualized and needed to be integrated between the hospice provider and facility explaining what each provider is responsible for doing for each hospice resident.",2019-03-01
868,SAINT FRANCIS REHABILITATION AND NURSING CENTER,305070,406 COURT STREET,LACONIA,NH,3246,2015-11-24,514,D,0,1,88IX11,"Based on record review and interview, it was determined that the facility failed to ensure that the care plan section of the medical record was complete for 1 resident in a survey sample of 12. (Resident identifier is #11.) Findings include: Resident #11 Review of Resident 11's care plan section of the medical record on 11/24/15 revealed that it did not include a complete description or interventions to support a comprehensive approach to managing the pain regime for this resident based on diagnosis. Interview on 11/24/15 with Staff C (ADON) confirmed the above findings.",2019-03-01
869,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2016-01-29,431,D,0,1,TLJT11,"Based on observation and interview the facility failed to ensure all drugs and biological's were kept in locked compartments and permit only authorized personnel to have access to medications on 1 of 2 medication carts on the second floor. Findings include: On 01/28/16 at 8:45am during observation of the medication administration pass, Staff A (LPN) left Floristar 250mg caps and Vitamin B1 100mg tabs both in separate bottles on top of the medication cart unattended. The nurse was away from the cart in a residents room. Staff A (LPN) confirmed the above and immediately put both bottles in the cart and locked it.",2019-03-01
870,"HARRIS HILL CENTER, GENESIS HEALTHCARE",305078,20 MAITLAND STREET,CONCORD,NH,3301,2016-01-29,441,D,0,1,TLJT11,"Based on observation and interview, the facility failed to ensure surfaces of patient equipment were intact for proper disinfection and infection control prevention. Findings include: During tour of the second floor on 1/29/16 at 11:00 a.m., four wheelchairs were observed to to have padded arms that were worn on the edges and tops so that inside material was visible. Breaches in integrity of wheelchair arm padding can prevent proper disinfection. Interview with Staff B (Unit Manager) at 11:10 a.m. confirmed the above finding. Staff B revealed that wheelchairs are loaned out by the physical therapy department. Interview with Staff C (Occupational Therapist) at 11:15 a.m. revealed that when wheelchairs are in need of repair they would notify maintenance. During tour of the third floor shower room on 1/26/16 at 1:30 p.m., a tub transfer chair had worn edges and several cracks in the surface of the padding so that the inside material was visible. Interview with Staff D (Director of Nursing) confirmed the above finding.",2019-03-01
871,LANGDON PLACE OF KEENE,305085,136 A ARCH STREET,KEENE,NH,3431,2015-10-22,281,D,0,1,X9RW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to provide services according to accepted standards of clinical practice for 1 out of sample resident. (Resident identifier is #11.) Findings include: Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following , pages 719-723 revealed the following: .Do not leave medications unattended. Nurse is responsible for safekeeping of drugs . Observation of the morning medication pass on 10/21/15 at 7:45 a.m. with Staff A (Licensed Practical Nurse), revealed that Resident #11 was given potassium chloride 20 MEq (Milie-equivalent) powder mixed with water. Review of Resident #11's medical record confirmed this was according to physician's orders [REDACTED]. Staff A stated to Resident #11 I will leave it here on your table to finish later and assisted Resident #11 to the dining room for breakfast. It was brought to Staff A's attention that the cup of medication had been left at the bedside. Staff A confirmed this and immediately removed it.",2019-03-01
872,LANGDON PLACE OF KEENE,305085,136 A ARCH STREET,KEENE,NH,3431,2015-10-22,371,E,0,1,X9RW11,"Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food under sanitary conditions. Findings include: Observation on 10/20/15 at 9:45 p.m. of the tour of the kitchen with Staff B (Food Service Director) revealed the following: Staff C (Dietary Aide) and Staff D (Dietary Aide) not wearing either a hair net or other acceptable type of hair covering. Interview at this time with Staff B confirmed Staff C and Staff D were not wearing hair nets or any other type of acceptable hair covering to prevent the hair from contacting exposed food to prevent food borne illness. It was also observed in the small refrigerator in the kitchen that there was a metal container covered in plastic wrap that contained a dark brown substance. This item did not have a label listing the date of preparation or disposal or what the contents were. Staff B pulled this metal container out of the fridge and stated that it was hot fudge and that it should have contained a date of preparation or discard. In this same refrigerator was a bottle of water with Staff C's name written on the bottle. Interview at this time with Staff A who confirmed that staff food/beverages are not allowed to be stored in the same refrigerator as resident food/beverage. Observation of the walk-in cooler in the kitchen revealed 4 pies that were not dated or covered; Jello that was not dated or covered; cupcakes that were not dated; sliced deli type ham in a plastic container that was not completely covered with plastic wrap; sliced white cheese that was in a plastic container that was not dated or covered; a bag of shredded cheese that was not sealed and left open to the air; and the salad bar fixings containing olives, onions, tomatoes, mushrooms, cucumbers and carrots were stored in individual metal containers that were not covered or dated. Interview at this time with Staff A revealed that she/he was aware that all foods need to be covered when stored. Observation on 10/21/15 at approximately 2:30 p.m. of the kitchen revealed Staff E (Maintenance Personnel) in the food prep area of the kitchen with no hair net or any other type of acceptable hair covering to prevent the hair from contacting exposed food to prevent food borne illness. Interview with Staff B confirmed that Staff E was not wearing hair covering.",2019-03-01
873,"AURORA SENIOR LIVING OF DERRY, LLC",305095,20 CHESTER ROAD,DERRY,NH,3038,2016-06-16,309,D,0,1,EV6B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to have a coordinated hospice plan of care which included the care and services the facility and hospice would provide in order to be responsive to the needs of the resident for 2 of 5 hospice residents in a survey sample of 15. (Resident identifiers are #1 and #10.) Findings include: Review on 6/15/16 and 6/16/16 of Resident #1 and #10's current facility hospice care plans revealed the following interventions: Assess (resident's name omitted) coping strategies and respect (pronoun omitted) wishes. Encourage (resident's name omitted), as (pronoun omitted) is able, to express feelings, listen with non-judgmental acceptance, [MEDICATION NAME]. These were the only interventions listed for what the facility and hospice were going to provide these two residents in regards to hospice services. The plan of care did not include the frequency and types of services provided by the hospice agency for the skilled nurse, licensed nursing assistant, social worker, spiritual and volunteer staff nor were the care plan interventions individualized. Interview on 6/16/16 at 10:30 a.m. with Staff A (Director of Nurses) in which the above findings were reviewed, Staff A confirmed that the care plans did not include interventions from hospice nor did they include the frequency of services provided. Staff A also confirmed that currently documentation of what occurs during each hospice visit is provided to the facility approximately 2 days after the visit.",2019-03-01
874,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2016-07-24,176,D,0,1,0OKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to ensure that a resident was assessed for self-administration of medications for 1 resident in a survey sample of 13 residents. (Resident identifier is #8.) Findings include: Observation on 7/23/16 at approximately 5 p.m. during medication pass with Staff E (Licensed Practical Nurse) revealed that Staff E left the following medications at the bedside of Resident #8: Senna 8.6 mg - 2 tablets [MEDICATION NAME] 0.50 mg - 1 tablet Tylenol 325 mg - 2 tablets Calcium 600 mg with vitamin D 400 mg - 1 tablet Interview on 7/23/16 at approximately 5:10 p.m. with Staff E revealed that she/he was instructed during orientation to the residents to leave this resident's medications at this resident's bedside. Staff E confirmed that the resident's medical record did not have an assessment done for the resident to self administer medications and there was not a physician's orders [REDACTED]. Interview on 7/24/16 with Staff C (Director of Nursing) stated that this has been the practice by some nurses as the resident is alert and oriented but that Staff C always stays with the resident when she/he is doing medication pass.",2019-03-01
875,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2016-07-24,279,D,0,1,0OKM11,"Based on medical record review and interview, it was determined that the facility failed to develop a coordinated/integrated plan of care for 2 of 2 residents receiving hospice services and failed to develop comprehensive care plans for 1 residents in a survey sample of 13 residents. (Resident identifiers are #10 and #13.) Findings include: Review of Resident #10 and #13's medical record revealed that Resident #10 and #13 were receiving hospice services. Further review revealed that the facility failed to show a coordinated plan of care as evidenced by not including or documenting the hospice goals and interventions in order to ensure that facility staff is providing consistent care when hospice staff are not scheduled in the facility. Interview on 7/24/16 with Staff B (Registered Nurse) and Staff C (Director of Nursing) it was confirmed that neither the facility nor the hospice plan of care documents a coordinated/integrated plan of care to ensure Resident's #10 and #13's care needs are being provided and are met by either the facility staff or hospice staff as ordered. Resident#10 Review on 7/23/16 of Resident #10's Physician/Prescriber document revealed a Medication Order dated 6/7/16 (MONTH) use sippy cups with all drinks. Review of Resident #10's hospice care plan with a date of 5/20/16 revealed the following: Problem Hospice End of life Care for advance Dementia: Goal: 1. Food and Fluids as tolerated 2. Tolerate texture of diet without diff chew/swallow. Goal date 8-23-16. Approach: Diet as ordered 2. Monitor food and fluid intake 3. Assist with intake. The sippy cup was not added to this care plan on 6/7/16. This care plan does not coordinated/integrated with the hospices plan of care. The hospice care plan does not include the sippy cup in their current certification period. Neither care plan has the sippy cup integrated in the care plan even though the physician ordered it on 6/7/16.",2019-03-01
876,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2016-07-24,281,D,0,1,0OKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #3.) Findings include: Review of Resident #3's medical record revealed a physician's orders [REDACTED].>6/10 unrelieved by [MEDICATION NAME].Review of Resident #3's medical record revealed on (MONTH) 12th, (MONTH) 25th, (MONTH) 10th and (MONTH) 19th that [MEDICATION NAME] HCL 5 MG was given before [MEDICATION NAME] was administrated. Interview on 7/24/16 with Staff C (Director of Nurses) confirmed the above findings.",2019-03-01
877,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2016-07-24,356,D,0,1,0OKM11,"Based on observation and interview, it was determined that the facility failed to post the nurse staffing data specific to the nursing facility. Findings include: Observation on 7/23/16 at approximately 10 a.m. revealed that the only posted staffing was located outside of the nurses station on each of the 2 units, Main House and Manor House by way of a dry erase board. The staffing that was documented on the dry erase boards were specific to the current shift and did not include the name of the facility, the total number and actual hours worked by the categories of licensed and unlicensed nursing staff directly responsible for resident care per shift and the resident census was also not listed on either dry erase boards. Interview on 7/23/16 at approximately 10:15 a.m. with Staff C (DON) revealed that the daily staffing was posted outside each nurses station on the dry erase board. Interview on 7/24/16 at approximately 3:30 p.m. with Staff D (Administrator) and Staff C (Director of Nursing) reviewed the Federal regulation requirements for daily staffing and the components specific to the regulation. Staff C confirmed that she was not aware of this regulation.",2019-03-01
878,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2016-07-24,431,D,0,1,0OKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to ensure all drugs and biologicals were kept in locked compartments and only authorized personnel had access to medications on 1 of 2 units for 1 resident in a survey sample of 13 residents. (Resident identifier is #8.) Findings include: Observation on 7/23/16 at approximately 5 p.m. during medication pass with Staff E (LPN) revealed that Staff E left the following medications at the bedside for Resident #8: Senna 8.6 mg - 2 tablets Xanax 0.50 mg - 1 tablet Tylenol 325 mg - 2 tablets Calcium 600 mg with vitamin D 400 mg - 1 tablet Interview on 7/23/16 at approximately 5:10 p.m. with Staff E revealed that she/he was instructed during orientation to the residents to leave this resident's medications at this resident's bedside. Staff E confirmed that the resident's medical record did not have an assessment done for the resident to self administer medications and there was not a physician's orders [REDACTED]. Interview on 7/24/16 with Staff C (Director of Nursing) stated that this has been the practice by some nurses as the resident is alert and oriented but that Staff C always stays with the resident when she/he is doing medication pass.",2019-03-01
879,WOODLAWN CARE CENTER,305097,84 PINE STREET,NEWPORT,NH,3773,2016-07-24,441,E,0,1,0OKM11,"Based on interview and review of the facility infection control program, it was determined that the facility failed to implement an infection control program to address the prevention of infections and failed to ensure an environment that is safe and sanitary by not implementing a facility wide surveillance of infection control practices throughout the facility to prevent, recognize and control the onset and spread of infection. Findings include: Review of the facility Infection Prevention and Control Program revealed the following: This facility has developed and maintains an infection prevention and control program that provides a safe, sanitary and comfortable environment to help prevent the development and transmission of infection. This program will: . Develop prevention, surveillance and control measures to protect residents and personnel from healthcare-associated infections . Perform surveillance activities to monitor and investigate causes of infection and manner of spread in order to prevent infections in the facility . Maintain a separate record of infection for each resident who has an infection. . Analyze, in a timely manner, clusters or trends of infection, changes in prevalent organisms and any increase in the rate of infection . . Maintain records of incidents and corrective actions related to infection prevention and control . The infection control program will be monitored quarterly or as indicated by the Infection Prevention and Control Committee. Review of the facility policy & procedure titled Policy for Environmental Rounds revealed the following: It is the policy of this facility that the infection preventionist or other appropriate designee complete environmental rounds on a regular basis. Environmental rounds will be an integral part of the daily routine and also will be performed regularly throughout the entire facility, with detailed reporting to all units and departments as needed. (It is suggested that a selection of individual units as well as the dietary, laundry and housekeeping department be specifically identified for closer each month.) The infection preventionist will generate reports identifying areas of noncompliance. This report and a corrective action form will be distributed to the supervisors of each area. The corrective action form will be completed by the supervisor and will outline the corrective actions to be taken and the anticipated completion dates . Interview on 7/24/16 with Staff B (Infection Control Nurse) and review of the facility infection control line listings from (MONTH) (YEAR) through (MONTH) (YEAR) revealed lack of documentation to show date of infection, the causative agent, the origin or site of infection, measures to prevent the spread of infection, resolution of the infection to enable the facility to analyze changes in prevalent organisms and to recognize an increase in the rate of infection in a timely manner. Interview on 7/24/16 with Staff B revealed Staff B was not able to provide documentation for the facility wide infection control environmental surveillance rounds. Staff B stated during this interview that the dietician looks at the kitchen and that maintenance takes care of the laundry area adding if there were problems they would communicate with Staff B. Staff B confirmed at this time that no infection control environmental surveillance rounds are done in the laundry addressing: linen handling, how linens are stored, transported and processed to prevent the spread of infection. Interview on 7/24/16 with Staff B revealed Staff B could provide no evidence of the residents' immunizations. The residents' immunizations were located with the Director of Nursing. Interview on 7/24/16 with Staff C (Director of Nursing) revealed Staff C could provide no systematic record of the current resident immunizations. Staff C stated that a house audit of each individual resident chart would have to be done to determine that each resident was provided and/or given the required immunizations (ex. influenza, pneumoccocal and TB).",2019-03-01
880,GREENBRIAR HEALTHCARE,305005,55 HARRIS ROAD,NASHUA,NH,3062,2016-05-05,441,E,0,1,UG0E11,"Based on observation and interview it was determined that the facility failed to ensure that Infection Control Standards of Practice were followed for 2 out of sample residents with Precaution Instructions posted on the individual resident room door frames indicating the Personal Protective Equipment (PPE) to be utilized before entering the room, before giving personal care and before performing treatments. (Resident identifiers are #31 and #34.) Findings include: Observation during the initial 3 East unit tour with Staff B (Registered Nurse) on 5/3/16 revealed signage posted on individual resident door frames indicating infection control precautions to be used for each individual. Resident #34 Further observation at this time showed signage on Resident #34's door frame with the following infection control instructions: CAUTION EVERYONE SEE BELOW FOR REQUIRED PPE (personal protective equipment) ALL PPE MUST BE REMOVED & DISPOSED OF BEFORE LEAVING THE ROOM! HANDWASHING MUST BE DONE THE SAME WAY YOU DID IT BEFORE ENTERING THE ROOM! BEFORE ENTERING THE ROOM HANDWASHING WITH SOAP & WATER YES (checkmark indicating yes in box) HANDWASHING WITH ANTIMICROBIAL GEL &/OR ALCOHOL HANDRUB NO (checkmark indicating no in box) GLOVES YES GOWN YES MASK NO MASK WITH SHIELD NO . This observation showed a visitor identified by Staff B as a family member, walking around in resident's room, moving individual resident care items from tabletop to bureau top and on and off room chair. Also in the room at this time was a child laying in the resident's bed. Neither one of these two individuals had a gown or gloves on as required by the infection control instructions posted on the resident's room door frame. Interview with Staff B, Staff B confirmed that the signage posted should be utilized as indicated. Resident #31 Observation during a medication pass with Staff A (Registered Nurse) on 5/4/16 revealed signage on Resident #31's door frame with the following infection control instructions; CAUTION EVERYONE SEE BELOW FOR REQUIRED PPE (personal protective equipment) ALL PPE MUST BE REMOVED & DISPOSED OF BEFORE LEAVING THE ROOM! HANDWASHING MUST BE DONE THE SAME WAY YOU DID IT BEFORE ENTERING THE ROOM! BEFORE ENTERING THE ROOM HANDWASHING WITH SOAP & WATER YES (checkmark indicating yes in box) HANDWASHING WITH ANTIMICROBIAL GEL &/OR ALCOHOL HANDRUB NO (checkmark indicating no in box) GLOVES YES GOWN YES MASK NO MASK WITH SHIELD NO . This observation revealed a visitor, identified by Staff A as a family member, assisting Resident #31 with eating breakfast food. This individual was assisting Resident #31 to eat. Staff A was wearing the proper PPE and handed the oral medication to the visitor who helped in the administration of the oral medication. The visitor didn't have a gown or gloves on while attending to Resident #31 as required by the infection control instructions posted on the resident's room door frame. The facility failed to ensure appropriate infection control practices were done according to the PPE signage posted on these two resident's room door frame's to prevent and protect cross contamination of infections.",2019-02-01
881,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2016-02-11,241,D,1,0,EFGK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of two facility reported investigations as part of the survey Abuse & Neglect prevention protocol it was determined the facility failed to ensure 2 residents were treated with dignity and respect at all times. (Resident identifiers are: #23 & #24) Findings include: Review of two facility investigation reports revealed incidents dated 10/8/15 documenting Staff C LNA, had taken a video of Resident #23( diagnosed with [REDACTED]. The facility investigation confirmed the video was posted on social media. The LNA taking the video can be heard laughing. Review of the second facility investigation report also dated 10/8/15 involved two LNA's Staff C & Staff D posing at the bedside of another Resident #24, taking a still photograph of themselves with the resident. During the facility investigation, the LNAs from each incident were interviewed and admitted to taking the video, and to taking the photo and to posting it to snap-chat to a group of friends. During review of the investigation there was no verbal or written permission discoverd from the residents' or their responsible parties granting permission to video or photograph the residents or to post online. Interview during survey on 2/11/16 with Staff # E, Administrator, confirmed the allegations and indicated both LNAs were terminated. Families notified. Staff education held to re-emphasize protecting residents dignity, privacy and abuse prevention including prohibiting cell phone/device use in the facility.",2019-02-01
882,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2016-02-11,465,B,1,0,EFGK11,"> Based on observation and interview the facility failed to provide a comfortable environment as it pertains to the bathing water temperatures in the facility tub rooms, and failed to provide a sanitary environment as it relates to ensuring that all products available for Resident consumption were within the allowable date frames. Findings include: During the Resident council meeting on 2/10/16 it was identified by several residents from multiple units that during bathing activities the water is not warm enough to allow the Resident to be rinsed off without becoming cold due to the cool temperature of the bath water. On 2/11/16 at approximately 2:00P.M. this surveyor along with the second floor unit manager tested the water in the units tub room. The water initially felt warm at 105 degrees, but within 2-3 minutes the water temperature had dropped to 95 degrees which did not feel like a sufficient temperature for bathing. During the kitchenette tour on 2/9/16 on the facility's second floor this surveyor identified approximately 10-12 containers of fortified shakes both regular and diabetic. The first 6 containers that were pulled for inspection were labeled as being outdated by 2 through 6 days. Unit staff were made aware.",2019-02-01
883,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2015-10-29,252,B,0,1,0U9B11,"Based upon observations made on a 10/29/15 tour of the facility, the doors of residents' rooms in 3 of 4 units were scarred and in need of repair. Findings include: Resident's room doors in 3 of 4 units were scarred and in need of attention for rooms #109,#114,#201,#206,#207,#208,#209,#213,#215,#216,#219,#301,#303 and #305.",2019-02-01
884,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2015-10-29,280,D,0,1,0U9B11,"Based on medical record review and interview it was determined that the facility failed to update resident care plans for 1 resident out of a standard survey sample of 24 residents. (Resident identifier is #15.) Findings include: Review on 10/29/15 of Resident #15's medical record revealed a Potential Skin breakdown . care plan with a target date of 12/22/15. The facility failed to update the care plan when Resident #15 had developed a new actual skin breakdown related to pressure ulcer, incontinence, limited mobility, Friction/Shear Stage II pressure ulcer on 10/23/15 that would require a care plan. Review on 10/29/15 of the medical record revealed a nurse's note on 10/23/15 for a new onset/change in skin integrity as evidenced by ulcer-pressure .Physician notified of change in condition .New orders obtained. Interview on 10/29/15 at approximately 2:30 p.m. with Staff D (License Practical Nurse) confirmed the above care plan has not been updated.",2019-02-01
885,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2015-10-29,281,D,0,1,0U9B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to clarify a medication order for 1 resident and failed to administer medication according to physician order for [REDACTED].#25 and #26.) Findings include: Review of Fundamentals of Nursing,Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, St. Louis, Missouri, revealed the following: On page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #25. Reconciliation of medication for Resident #25 following the medication pass observation on 10/28/15 at 9:30 a.m., revealed a physician order for [REDACTED]. Interview on 10/28/15 at 8 a.m. with Staff B (LPN) indicated the medication will be administered after Resident #25 had breakfast because Resident #25 had a habit of not eating breakfast and Staff B did not want Resident #25 to bottom out. Staff B also confirmed the medication had been administered after meals on previous days when the CBG's were Resident #26. Observation on 10/28/15 at 8:32 a.m. with Staff C (Registered Nurse) revealed the preparation of [MEDICATION NAME] Power (Polyethylene [MEDICATION NAME] 3350) Give 17 gram in 8 ounces of water. Staff C was observed administering this 8 ounce cup to Resident #26 at which time Resident #26 was unable to finish. Staff C proceed to leave the cup of [MEDICATION NAME] medication with the resident and exited the room. Interview at this time with Staff C regarding the above listed observation confirmed that there was no physician order to self-administer this medication for Resident #26. Reconciliation of medication for Resident #26 following the medication pass revealed no assessment for self-administration for the [MEDICATION NAME] or a physician order to leave at bedside.",2019-02-01
886,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2015-10-29,371,E,0,1,0U9B11,"Based on interview, record review and observation the facility failed to maintain the proper rinse temperature of the dishwasher to ensure sanitization and failed to maintain sanitary conditions in the kitchen. Findings include: Tour of the kitchen on 10/27/15 at 9:05 a.m. revealed that the high temperature dishwasher reached a temperature of 172 degrees Fahrenheit (F) during the rinse cycle. Review of the (MONTH) temperature log for the high temperature dishwasher revealed the minimum temperature for the rinse cycle is 180 degrees F and the kitchen records the rinse temperature each day at breakfast, lunch and dinner. The only rinse temperature in (MONTH) that was below 180 degrees F was taken at dinner time on 10/25/15. Interview with Staff E (Director of Food Services) on 10/27/15 at 9:05 a.m. confirmed the rinse temperature the rinse temperature was too low during tour and that the minimum temperature for the rinse cycle is 180 degrees F. Staff E revealed Staff E was not notified and that no action was taken on 10/25/15 when the temperature for the rinse cycle was below 180 Degrees F. Tour of the kitchen on 10/27/15 at 9:10 a.m. revealed flying insects in a doorless closet in the corner of the dish room of the kitchen. This closet area contained broken tiles on the floor. When weight was applied to the floor, water seeped up through the cracks in the tile. There was also a drain in the floor that contained debris. Interview with the Staff F (Maintenance Director) on 10/28/15 at 12:00 p.m. confirmed the above findings and revealed that the flying insects have been an ongoing issue in the kitchen and pest traps had been set up. Record review confirmed the facility has a current contract with a pest service and that pest services had provided the facility with traps and services at least quarterly for over a year. Tour of the kitchen on 10/27/15 at 9:00 a.m. revealed that the vent above the food service tray line had round grayish spots on the exterior. Return visit on 10/28/15 at 12:00 p.m. revealed that the spots had been cleaned from the vent. Tour of the kitchen on 10/28/15 at 12:00 p.m. revealed that there were a number of serving trays in queue for use near the food service tray line that were chipped and worn so that proper sanitizing is compromised.",2019-02-01
887,BEDFORD HILLS CENTER,305060,30 COLBY COURT,BEDFORD,NH,3110,2015-10-29,431,D,0,1,0U9B11,"Based on observation, interview and review of the facility's policy it was determined that the facility failed to ensure that 1 out of 8 medication carts was locked and secure from access by unauthorized personnel. Findings include: Review of the facility policy and procedure titled 5.3 Storage and Expiration Dating of Drugs, Biologicals, Syringes, and Needles : with REVISION DATE: 05/16/11 revealed the following: Policy: Drugs, biological, syringes, and needles are stored under proper conditions with regard to sanitation, temperature, light, moisture, ventilation, segregation, safety, security, and expiration date as directed by state and federal regulations and manufacturer/supplier guidelines. Purpose .To Prevent theft, loss, or access by non-authorized staff or patients. Process . 2.2 All drugs and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessible by patients and visitors. During a medication administration pass on 10/27/15 at approximately 4:05 p.m. with Staff A (Registered Nurse), Staff A was observed to leave the medication cart unlocked and unattended in the resident hallway in the Frost Unit. Staff A was observed to proceed down the hallway and into a resident's room to administer medications. Upon returned from the medication pass interview with Staff A confirmed the observation of the unlocked, unattended medication cart.",2019-02-01
888,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-02-10,156,C,1,0,JTW811,"> Based on observation and interview it was determined that the faility failed to follow the requirement that facilities who serve clients of the Centers for Medicare & Medicaid Services (CMS) display contact information for residents, their families, friends, and facility employees, who desire to raise concerns about the safety of/and the care residents are receiving at the facility, can do so with a high level of anonimity. Findings include: On initial entry to the facility, at approximatly 0920 on 2/9/16, there were no postings that contained the contact information of the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. During the group resident interview, on 2/9/16 in the afternoon, the residents were asked about seeing the results of the last survey inspection, and the response indicated they didn't know where that survey report is located. When asked about contacting an advocacy agency such as the Ombudsman, the response indicated they would ask at the desk for the phone number.",2019-02-01
889,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-02-10,356,C,1,0,JTW811,"> Based on observation and interview, the facility failed to provide information to residents, family, and friends regarding the number of staff assigned to work and care for residents on any of the shifts.The facility must post the staffing information on a daily basis. Findings include: Observation on entry to the facility on two consecutive days, 2/9/16 and 2/10/16, the staffing information located on a small table front left documented the staffing information for 2/8/16. On 2/10/16 Staff A, House Administrator, cofirmed the above observation.",2019-02-01
890,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2016-06-24,281,E,0,1,WSDL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #3, #7, #9, #16 and #17.) Findings include: Reference for the professional standard of practice is, Fundamentals of Nursing, 7th Edition, Potter-Perry, Mosby, Elsevier, Evolve, 2009. On page 336 - Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physicians orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Reference for the professional standard of practice for medication documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009, . Chapter 35 Medication Administration, Right Documentation on pages 709 - 713 and on page 688 for Guidelines for Safe Narcotic Administration and Control reveals the following: After administering the medication, indicate which medications were given on the client's MAR ( Medication Administration Record [REDACTED]. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care. The nurse is responsible for following legal provisions when administering controlled substances or narcotics, which are carefully controlled through federal and state guidelines . Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used and remaining as well as information about narcotics that are wasted. Use the record to document the client's name, date, time of medication administration, name of medication, dose, and signature of nurse dispensing the medication. Reference for pain scale is the Northeast Healthcare Quality Foundation (NHCQF), Pain tool indicates 0 - No Pain, 1-4 Mild Pain, 5-6 Moderate Pain and 7-10 Severe Pain. Resident #7. Record review on 6/24/16 of the physician orders [REDACTED]. [MEDICATION NAME] Solution 100 mg/ml Give 0.5 ml by mouth every 1 hours as needed for mild-moderate pain/shortness of breath and [MEDICATION NAME] Solution 100 mg/ml Give 0.75 ml by mouth every 1 hours as needed for severe pain/shortness of breath. Further review of the 5/1/16 and the 6/1/16 MAR indicated [REDACTED]. These documented pain ratings indicate severe pain and not moderate pain. Review of the 6/1/16 MAR indicated [REDACTED]. During interview on 6/24/16 with Staff B (Licensed Practical Nurse) at approximately 2:00 p.m. after Staff B reviewed the above listed MAR's Staff B verbalized that a nurse would be unable to determine which [MEDICATION NAME] dose would be given to Resident #7 with the current orders. Staff B verbally confirmed the above listed findings during this interview. The facility failed to follow the physician orders [REDACTED].#7. Record review of the 6/1/16 MAR for the administration of the narcotic [MEDICATION NAME] to Resident #7 revealed that [MEDICATION NAME] was given to Resident #7 on 6/7, 6/8, 6/16 and 6/17. Review of the facility narcotic book revealed no documented evidence of the [MEDICATION NAME] administered to Resident #7 on 6/7, 6/8, 6/16 and 6/17. During interview on 6/24/16 with Staff B at approximately 2:00 p.m. Staff B verbally confirmed the above listed findings that the Narcotic Book had no documentation for the narcotic [MEDICATION NAME] given to Resident #7 on the days listed above. The facility failed to ensure accurate documentation of narcotic medication for Resident #7. Resident #16, who according to their comprehensive care plan has a [DIAGNOSES REDACTED]. Resident #16 complained during a resident group interview of 6/23/16 that the facility on 5/10/16 had run out of this resident's scheduled pain medication of [MEDICATION NAME] ER Tablet Extended Release 100mg to be given three times a day. Resident #16 confirmed this during a 6/24/16 individual interview and stated that two consecutive doses of the [MEDICATION NAME] ER Tablet Extended Release 100mg were not administered to Resident #16 on 5/10/16 which caused Resident #16 to experience uncomfortable and unrelieved levels of pain because this scheduled pain medication wasn't administered on 5/10/16. Resident #16 stated that Resident #16 was told by an unidentified staff member that the facility had run out of the scheduled [MEDICATION NAME] doses of [MEDICATION NAME] ER Extended Release 100mg Tablets on 5/10/16 and this was confirmed through a review of a 5/10/16 nurses note and by examining the Medication Administration Record. A review of the Medication Administration Record [REDACTED]. A nurses note of 5/10/16 at 00:09:55 states that the [MEDICATION NAME] dose of 100mg was not available and instead notes a dose of [MEDICATION NAME] Tablet 15mg 1 tablet by mouth prn q 4 hours had been given to Resident #16. There was no documentation the facility notified Resident #16's physician that the [MEDICATION NAME] dose of 100mg was not available. The Medication Administration Record [REDACTED]. There was no corresponding nursing documentation, as Staff A(Director of Nursing) stated, during an 6/23/16 interview, should have been written addressing the reason why this dose of [MEDICATION NAME] ER Tablet Extended Release 100mg was not given. Resident #3 Review of the physician's orders [REDACTED]. Further review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #9 Review of the physician's orders [REDACTED]. Further review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #17 Review of the physician's orders [REDACTED]. Further review of the MAR indicated [REDACTED].m An Administration note for 5/20/16 at 14:33 indicated that the scheduled doses of [MEDICATION NAME] was not given at that time because it was not available.",2019-01-01
891,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2016-06-24,309,D,0,1,WSDL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon a resident group interview, an individual resident interview and resident record review, it was determined that the facility failed to ensure a resident received their scheduled pain medication which caused the resident to experience discomfort and unrelieved pain until the scheduled pain medication doses were again made available to this resident for 1 resident in a survey sample of 18 residents. (Resident identifier is #16.) Findings include: Resident #16, who according to their current comprehensive care plan has a [DIAGNOSES REDACTED]. Resident #16 said during this meeting that not having this routine dose of [MEDICATION NAME] caused uncomfortable and unrelieved pain. Resident #16 confirmed this during a 6/24/16 individual interview and stated that two consecutive doses of the [MEDICATION NAME] ER Tablet Extended Release 100 mg were not administered to Resident #16 on 5/10/16 which caused Resident #16 to unnecessarily experience pain because of the unavailability of Resident #16's scheduled pain medication which wasn't administered twice on 5/10/16. Resident #16 stated that Resident #16 was told by an unidentified staff member that the facility had run out of the scheduled [MEDICATION NAME] doses of [MEDICATION NAME] ER Extended Release 100 mg Tablets on 5/10/16 and this was confirmed through a review of a 5/10/16 nurses note and by examining the Medication Administration Record. There was no documentation Resident #16's physician was notified that Resident #16's scheduled [MEDICATION NAME] had run out. The Medication Administration Review record revealed that on 5/10/16 at 00:00:01 the scheduled dose of [MEDICATION NAME] ER Tablet Extended Release 100 mg was not given. A nurses note of 5/10/16 at 00:09:55 states that the [MEDICATION NAME] dose of 100 mg was not available and instead notes a dose of [MEDICATION NAME] 15 mg prn q 4 hours had been given to Resident #16. The Medication Administration Review record further revealed that on 5/10/16 the 08:00 dose of [MEDICATION NAME] ER Tablet Extended Release 100 mg was not given. There was no corresponding nursing documentation, as Staff A(Director of Nursing) stated, during an 6/23/16 interview, should have been written addressing the reason why this dose of [MEDICATION NAME] ER Tablet Extended Release 100 mg was not given.",2019-01-01
892,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2016-06-24,329,E,0,1,WSDL11,"Based on record review and interview it was determined that the facility failed to adequately monitor residents for the effects and potential adverse consequences of the medication regimen for 3 residents in a survey sample of 18 residents. ( Resident identifiers are #1, #7 and #9.) Findings include: Record review on 6/22/16 through 6/24/16 of the behavior monitoring records for Resident's #1, #7 and #9 showed that Document occurrence intervention and outcome for target behavior . every shift for Monitoring of behavior interventions . This record has standardized chart list of codes to indicate interventions and outcomes . Further review of these behavior monitoring records revealed a X or a 0 documented for various shifts and days. The standardized chart list does not indicate to document with an X or a 0 for behaviors, interventions or outcomes. During interview on 6/23/16 with Staff A (Director of Nursing) at approximately 3:30 p.m. after Staff A reviewed the above listed behavior monitoring sheets Staff A verbally confirmed that the facility staff are not utilizing the behavior monitoring sheets accurately and are documenting X or 0 which Staff A was not able to indicate whether the targeted behavior had occurred or not occurred. The facility failed to monitor residents for the effects & potential adverse consequences of the medication regimen in order to determine the efficacy of the medications.",2019-01-01
893,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2016-06-24,425,E,0,1,WSDL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interview and medical record review, it was determined that the facility failed to ensure that scheduled medications were available for 3 residents and that expired medications stored in the medication cart drawers were not being used for residents for 3 residents in a survey sample of 18. (Resident identifiers are #16, #17 and #18). Findings include: Resident #16, who according to their current comprehensive care plan has a [DIAGNOSES REDACTED]. Resident #16 confirmed this during a 6/24/16 individual interview and stated that two consecutive doses of the Morphine Sulfate ER Tablet Extended Release 100 mg were not administered to Resident #16 on 5/10/16 which caused Resident #16 pain. Resident #16 stated that Resident #16 experienced uncomfortable and unrelieved levels of pain because this scheduled pain medication wasn't administered twice on 5/10/16. Resident #16 stated that Resident #16 was told by an unidentified staff member that the facility had run out of the scheduled Morphine doses of Morphine Sulfate ER Extended Release 100 mg Tablets on 5/10/16 and this was confirmed through a review of a 5/10/16 nurses note and by examining the Medication Administration Review record. The Medication Administration Review record revealed that on 5/10/16 at 00:00:01 the scheduled dose of Morphine Sulfate ER Tablet Extended Release 100 mg was not given. A nurses note of 5/10/16 at 00:09:55 states that the Morphine Sulfate dose of 100 mg was not available and instead notes a prn dose of Morphine Sulfate 15 mg had been given to Resident #16. The Medication Administration Review (MAR) record further revealed that on 5/10/16 the 08:00 dose of Morphine Sulfate ER Tablet Extended Release 100 mg was not given. There was no corresponding nursing documentation, as Staff A(Director of Nursing) stated, during an 6/23/16 interview, should have been written addressing the reason why this dose of Morphine Sulfate ER Tablet Extended Release 100 mg was not given. Resident #18 During a medication observation pass on the morning of 6/23/16, Staff D, LMNA, (Licensed Medication Nursing Assistant) was observed to look for a medication, Eliquis 5 mg. to administer to Resident #18. After an extensive search in the cart it was determined that there was no Eliquis in any of the compartments. Staff D then went to the Medication Room to see if it was in stock for immediate use. After an extensive search Staff D, determined there was no Eliquis in stock. She then notified her Director of Nurses (DON) as to the apparent lack of this medication and also stated that the physician and Pharmacy would also be contacted. Review of the eMAR (electronic) Medication Administration note, dated 6/23/16 reveals the Eliquis 5 mg tablets were ordered at 8:52 a.m. on this date. Review of the Pharmacy (pharmacy name intentionally withheld) Shipping Manifest dated 6/23/16 reveals that a card of 28 Eliquis 5 mg tablets were received at 5:12 p.m. by Dover Center for Health and Rehabilitation. Review, on 6/23/16, of the Medication Administration Record [REDACTED]. Review of the MAR printed on 6/24/16 reveals Resident #18 received the 8:00 p.m. dosing of Eliquis on 6/23/16. Expired medications: [REDACTED] Observation on 6/23/16 during the medication pass with Staff D (LMNA) revealed the following medications that were expired, stored in the medication cart drawers, and available to be used for resident care: Tamsulosin HCL, 0.4 mg, a 30 pack bubble card with 4 tan and light blue/green capsules remaining, having an expiration date of 5/24/16; Ondansetron 4 mg. with an expiration date of 3/21/16; and Aspirin 81 mg with an expiration date of 5/16. Observation on 6/23/16 at approximately 9:00 a.m. of the medication pass with Staff C (Licensed Practical Nurse) revealed that the following medications were expired and available to be used for resident care: 100 tablet bottle of Stool Softener and 100 tablet bottle of Naproxen with expiration date of 05/16 and a bottle of Vitamin D3 5000 units with an expiration date of 4/16. All of these expired medications were confirmed as expired by Staff C at the time of this medication pass. Resident #17 Interview with Resident #17 on 6/23/16 at approximately 1:00 p.m. revealed that the Resident was concerned about not receiving all of their scheduled medications on a day in (MONTH) (YEAR). Resident stated that they were told that the facility had run out of that medication and they would order it from the pharmacy. Review of Resident #17's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED].m Review of Resident #17's Medication Administration note for 5/20/16 at 14:33 indicated that the scheduled dose of Baclofen was not given at that time because it was not available.",2019-01-01
894,DOVER CENTER FOR HEALTH & REHABILITATION,305018,307 PLAZA DRIVE,DOVER,NH,3820,2016-06-24,514,E,0,1,WSDL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to maintain accurate, complete and organized resident records for three residents in a survey sample of 18 residents. (Resident identifier's are #1, #7 and #9.) Findings include: Resident #7. Record review on 6/24/16 of the physician orders [REDACTED]. [MEDICATION NAME] Solution 100 mg/ml Give 0.5 ml by mouth every 1 hours as needed for mild-moderate pain/shortness of breath and [MEDICATION NAME] Solution 100 mg/ml Give 0.75 ml by mouth every 1 hours as needed for severe pain/shortness of breath. Further review of the 5/1/16 and the 6/1/16 MAR indicated [REDACTED]. These documented pain ratings indicate severe pain and not moderate pain. Review of the 6/1/16 MAR indicated [REDACTED]. During interview on 6/24/16 with Staff B (Licensed Practical Nurse ) at approximately 2:00 p.m. after Staff B reviewed the above listed MAR's Staff B verbalized that a nurse would be unable to determine which [MEDICATION NAME] dose would be given to Resident #7 with the current orders. Staff B verbally confirmed the above listed findings during this interview. Record review of the 6/1/16 MAR for the administration of the narcotic [MEDICATION NAME] to Resident #7 revealed that [MEDICATION NAME] was given to Resident #7 on 6/7, 6/8, 6/16 and 6/17. Review of the facility narcotic book revealed no documented evidence of the [MEDICATION NAME] administered to Resident #7 on 6/7, 6/8, 6/16 and 6/17. During interview on 6/24/16 with Staff B at approximately 2:00 p.m. Staff B verbally confirmed the above listed findings that the Narcotic Book had no documentation for the narcotic [MEDICATION NAME] given to Resident #7 on the days listed above. The facility failed to ensure accurate documentation of narcotic medication for Resident #7. Resident #1. Record review of the facility care plan and hospice care plan on 6/23/16 revealed that the facility and the individual hospice agency failed to establish a coordinated plan of care for Resident #1 that detailed a description of the scope and frequency of physician ordered services provided by the individual hospice agency for the frequency of the skilled nurse, licensed nursing aide, social worker, spiritual and volunteer hospice staff providing services to Resident #1. Further review of Resident #1's medical record revealed incomplete documentation of a collaborated plan of care with assessments, measurable goals and interventions for the individual disciplines listed above and the delineation of the palliative and supportive care that is to be provided and a determination of the disciplines at the facility and/or Hospice agency who will provide these services. During this review the individual hospice agency plan of care/certification documentation revealed the certification period for Hospice services was 3/23/2016 Through 6/20/2016 for Resident #1. No Hospice documentation could be found for the Hospice recertification with plan of care for Hospice services to continue after 6/20/2016. During interview with Staff A (Director of Nursing) and Staff B (Licensed Practical Nurse ) on 6/29/16 both staff reviewed the above listed hospice and facility plans of care and verbally confirmed that these plans of care need to be individualized and need to be integrated between the hospice provider and facility explaining what each provider is responsible for doing and what each of the hospice disciplines were doing to meet the goals and provide the interventions for Resident #1. Residents #1, #7 and #9. Record review on 6/22/16 through 6/24/16 of the behavior monitoring records for Resident's #1, #7 and #9 showed that Document occurrence intervention and outcome for target behavior . every shift for Monitoring of behavior interventions . This record has standardized chart list of codes to indicate interventions and outcomes . Further review of these behavior monitoring records revealed a X or a 0 documented for various shifts and days. The standardized chart list does not indicate to document with an X or an 0 for behaviors, interventions or outcomes. During interview on 6/23/16 with Staff A (Director of Nursing) at approximately 3:30 p.m. after Staff A reviewed the above listed behavior monitoring sheets Staff A verbally confirmed that the facility staff are not utilizing the behavior monitoring sheets accurately and are documenting X or 0 which Staff A was not able to indicate whether the targeted behavior had occurred or not occurred. The facility failed to monitor residents for the effects & potential adverse consequences of the medication regimen in order to determine the efficacy of the medications. Resident #9 Review of progress notes revealed that Resident #9 sustained a broken pelvis resulting from a fall at the facility on 4/24/16. There was no documentation that the Resident's status when discovered after the fall was evaluated. The first progress note to mention the fall was from 4/25/16 at 4:45 a.m. when the Resident returned from the hospital. Interview with Staff B (Unit Manager) on 6/23/16 at 9:30 a.m. confirmed the above finding. Interview revealed that an incident report was completed for the fall but it did not contain documentation of the Resident's status or evaluation when discovered after the fall. Resident #1 Record review on 6/23/16 of the facility care plan and hospice care plan revealed that the facility hospice plan of care for Resident #1 did not detail the frequency of physician ordered services provided by the individual hospice agency for the skilled nurse, social worker, spiritual and volunteer hospice staff. During this review the individual hospice agency plan of care/certification documentation revealed the certification period for Hospice services was 3/23/2016 Through 6/20/2016 for Resident #1. No Hospice documentation could be found for the Hospice recertification with plan of care for Hospice services to continue after 6/20/2016.",2019-01-01
895,HANOVER TERRACE HEALTH & REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-01-15,333,G,1,0,WHWY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to keep one resident free of a significant medication error, in a survey sample of 16 residents, resulting in that resident being temporarily hospitalized and intubated. (Resident identifier is #15.) Findings include: Review of Resident #15's nurses notes reveals that a medication error occurred on 12/15/15 and resident was transported to the emergency room . A subsequent nurses note of 12/18/15 revealed the resident was intubated for a day and a half and returned from the hospital on [DATE]. Interview with Staff G, Administrator, on 1/15/16 revealed that Staff J, who made the medication error was working at the facility only a few months, and that training when Staff J was hired was a weak point. As a result of the medication error, Staff J reviewed education materials and took an exam and was monitored when they first passed meds again. Staff G related that now Staff J is all clear and no further monitoring is to be done. Record review of the Medication Pass Observation document reveals it was done on 12/21/15.",2019-01-01
896,HANOVER TERRACE HEALTH & REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-07-20,279,E,0,1,J98N11,"Based on medical record review and interview, it was determined that the facility failed to develop individualized, patient centered, goal oriented care plans that include measurable goals for 16 residents in a survey sample of 18 residents. (Resident identifiers are #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17 and #18.) Findings include: Review of care plan documentation for 16 of 18 residents revealed that the care plans in 16 of the 18 resident records reviewed, were not developed to reflect individualized care. Goals were not written in such a way that resident progress toward goals could be measured. Interview on 7/19/16 with Staff A (Administrator) and Staff B (Director of Nursing), confirmed that the care plans did not reflect interventions that were based on individual assessment of each resident reviewed, and were not resident centered. Staff A and Staff B agreed with findings. Several randomly selected examples of elements in the care plans that were not patient centered, and/or measurable, and/or individualized are as follows: This is not a complete list; however, are examples of the above findings. Resident #3: Goal: Minimize Skin Breakdown. This goal is unspecific and not measurable as stated. Goal: Will maintain dignity. This goal is unspecific and not measurable as stated. Resident #7: Goal: Will have needs met by staff. This goal is unspecific and not measurable as stated. Goal: Will receive adequate sleep. This goal is unspecific and not measurable as stated. Resident #14: Goal: Maintain nutritional intake. This goal is unspecific and not measurable as stated. Goal: Will improve range of motion. This goal is unspecific and not measurable as stated.",2019-01-01
897,HANOVER TERRACE HEALTH & REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-07-20,309,D,0,1,J98N11,"Based on medical record review and interview, it was determined that the facility failed to provide documentation to demonstrate the coordination of care between the facility and the hospice agency for 2 residents out of a survey sample of 18 residents. (Resident identifiers are #7 and #17.) Findings include: Resident #7 Review of resident's record and hospice notes on 7/19/16 revealed that there was no record of communication between the staff at the facility and the staff from the hospice agency concerning arrival and departure times. Also there were no progress notes as to what transpired during the hospice visit. Interview with Staff C (Unit Manager of Reflections Unit) confirmed the above findings. Resident #17 Review of Resident #17's medical record revealed no sign in/sign out documentation for visits. Interview on 7/20/16 with Staff C, (Reflections Unit Manager), revealed that The Hospice Staff visiting (Resident #17), come and go. Also during interview with Staff C, Staff C made the following statement: Often they touch base with nurses on the floor before and after visits to discuss patient needs, often they set up expectations in advance. Additionally, Staff C confirmed there was no formal sign in/sign out process to track who is coming in or leaving and what type of service had been rendered for these shared clients.",2019-01-01
898,HANOVER TERRACE HEALTH & REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-07-20,323,D,0,1,J98N11,"Based on observation and interview, it was determined that the facility failed to properly secure Intravenous (IV) and Blood draw (BD) implements in a locked storage room that residents and facility personal would not have access to. Findings include: Observation on 7-18-16 of the New Horizons unit revealed there was a door marked Storage Room off to the left of the Nurses Station. Inside the room there was a rolling cart with 5 drawers. Inside the drawers were various implements for IV access to provide hydration or medication and implements to draw blood to conduct diagnostic testing. Among the items noted were as follows 22 gage connectors used in the process of transferring the blood accessed by the butterfly needle to the collection tube. 23 gauge butterfly start sets 5 cc syringes IV tubing Interview with Staff F (LPN) revealed that the lab draw personal from Dartmouth Hitchcock use the room and Staff F closed the door and locked it.",2019-01-01
899,HANOVER TERRACE HEALTH & REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-07-20,441,D,0,1,J98N11,"Based on medical record review, observation and interview, it was determined that the facility failed to follow the facility's infection surveillance criteria. Additionally the facility failed to provide a barrier to the possible spread of organisms from a food scoop handle to stored food product as well as failing to ensure the light cover over the stove was free of dust. Findings include: Review of the facility's infection line listings revealed that in (MONTH) (YEAR) there were 18 identified infections within the facility. Of those 18 infections, 15 received an antibiotic without a culture or any other form of confirmation of the pathogen being treated. For (MONTH) (YEAR) there were 16 identified infections within the facility. Of those 16 infections, 9 received an antibiotic without a culture or any other form of confirmation of the pathogen being treated. For (MONTH) (YEAR) there were 12 identified infections within the facility, of those 12 infections, 6 received an antibiotic without a culture or any other form of confirmation of the pathogen being treated. For (MONTH) (YEAR) there were 6 identified infections within the facility, of those 6 infections, 4 received an antibiotic without a culture or any other form of confirmation of the pathogen being treated. Interview on 7/20/16 with Staff B (Director of Nursing/Infection Control Nurse) confirmed that the above information were correct. Staff B explained that she/he seldom receives the antibiotic reports sent by the pharmacy and often has to ask for them. Staff B was unable to produce the last antibiotic report received. Staff B explained that the facility uses the McGeer's criteria as the resource they use regarding the use of antibiotics. Based on the above information, the facility is not following their identified infection surveillance criteria. The McGeer's criteria which the facility utilizes has specific steps to be followed when an infection it identified and when to culture. Interview on 7/20/16 with Staff A (Administrator) confirmed that McGeer's criteria has not been met based on the antibiotic use documented in the line listings. Interview on 7/20/16 with Staff B revealed that while on walking round she/he does not go into the kitchen and that when she/he is out and about she/he does look into the laundry room as she/he walks by. Walking rounds should include all areas of the facility as infection control is not specific to just certain areas. Interview on 7/20/16 with Staff A confirmed that walking rounds should include the kitchen as well as the laundry areas. Observation on 7/18/16 in late morning of the kitchen with Staff D (Kitchen Director) revealed a stack of food storage containers that contained items such as rice, sugar, etc. In the rice container, a scoop could be seen lying directly on the rice with the handle in full contact with the rice. Additionally, the light located over the stove in the stove hood was observed to be full of dust.",2019-01-01
900,HANOVER TERRACE HEALTH & REHABILITATION CENTER,305020,49 LYME ROAD,HANOVER,NH,3755,2016-07-20,456,D,0,1,J98N11,"Based on medical record review and interview, it was determined that the facility failed to ensure that all glucometer test results were within the manufacturers specified test ranges for 2 of 4 glucometer test logs reviewed. Findings include: Review on 7/20/16 at approximately 4:30 p.m. of the glucometer test logs for the 2 glucometers in use on units 1&2 was done. The Assure Platinum glucometer having serial number 1040- 87, for the month of July, (YEAR) test log was reviewed. Review of the manufacturers imprinted information revealed that the test strip lot number is 6A, and the normal control Assure Dose testing solution acceptable range for test results is 84 - 104. The high control Assure Dose testing solution acceptable range is 206 to 257. On 7/15/16 the 11-7 nurse recorded a high control result of 200, outside the acceptable range and indicated on the result sheet that no corrective action was needed. Also, it should be noted that there were several instances of difficult to read handwriting on this Assure Platinum Blood Glucose Monitoring System:Quality Control Record. The glucometer test log utilized on units 3 & 4, with the Assure Platinum glucometer having serial number 1040- 92, for the month of July, (YEAR) test log were reviewed. Review of the manufacturers imprinted information revealed that the test strip lot number is 6A, and the normal control Assure Dose testing solution acceptable range for test results is 84 - 104. The high control Assure Dose testing solution acceptable range is 206 to 257. On 7/15/16 the 11-7 nurse recorded a high control result of 205, outside the acceptable range, and indicated on the result sheet that no corrective action was needed. Again, it should be noted that there are several instances of difficult to read handwriting on this Assure Platinum Blood Glucose Monitoring System: Quality Control Record. Interview on 7/20/16 at approximately 4:50 p.m. with the Staff C (Licensed Practical Nurse) confirmed that the 2 values mentioned above were both outside the high control range.",2019-01-01
901,PLEASANT VALLEY NURSING CENTER,305039,8 PEABODY ROAD,DERRY,NH,3038,2016-01-12,254,E,1,0,81MQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide bed linens to a resident. Findings include: During tour on 12/18/15 at 10:30 am a resident in room [ROOM NUMBER] was observed lying clothed on the bare mattress of her bed with out sheets or a blanket. During interview after the above observation Staff A, B, C, D, E, and F indicated a lack of linens, misplaced clothing and laundry back up. Staff A (LNA) stated there is not enough linens to do what needs to be done. Staff B (LPN) stated there is a laundry shortage and they cant keep up with it. Staff C (LNA) stated we run short on sheets often and resident personal laundry does not get delivered quick enough. Staff D (LNA) stated laundry gets backed up. There's never enough sheets and resident clothing takes awhile to get back. Staff E (LNA) stated clothing gets misplaced and there's never enough washed clothes or sheets. Staff F (LNA) stated there is never enough linen and clothing is misplaced. An interview with Staff G (Housekeeping Director) indicates that the facility is down 2 staff in the department and concurs with the above staff that it had been difficult to keep up with the laundry. Resident personal clothing is sometimes misplaced and sheets, washcloths and towels are not always available when they are needed.",2019-01-01
902,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-17,655,E,0,1,AKV711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for the resident to receive quality care within 48 hours of admission for 3 residents in a standard survey sample of 21 residents. (Resident identifier are #76, #79 and #84.) Findings include: Resident #84 Review on 5/16/18 of Resident 84's medical record it reveal that Resident #84 was admitted to the facility on [DATE]. Review of the care plan section of the medical record identified that the first smoking care plan that had been developed for Resident #84 had been developed and initiated on 4/11/18. Review on 5/16/18 of Resident #84's smoking assessment was completed on 4/5/18. The smoking assessment revealed that Resident #84 was to be a supervised smoker. The care plan indicated that Resident #84 was to be an independent smoker. Review on 5/16/18 of Resident #84's nurse's notes revealed that Resident #84 was actively smoking on 4/2/18. Interview on 5/16/18 at approximately 11:30 a.m. with Staff G (Director of Nurses)confirmed that the smoking care plan was initiated on 4/11/18, 6 days after the smoking assessment was completed. In addition to being late this initial baseline care plan did not match the smoking assessment for the time period indicated. Review on 5/16/18 of Resident 84's medical record it reveal that Resident #84 was admitted to the facility on [DATE]. Review of the care plan section of the medical record revealed that the first smoking care plan that had been developed for Resident #84 had been developed and initiated on 4/11/18. A smoking assessment was completed on 4/5/18. The smoking assessment revealed that Resident #84 was to be a supervised smoker. The care plan indicated that Resident #84 was to be an independent smoker. Review on 5/16/18 of Resident #84's nurse's notes revealed that Resident #84 was actively smoking. Resident #79 Review on 5/16/18 of Resident #79's MDS (Minimum Data Set) revealed that Resident #79 was admitted to the facility on [DATE]. Review on 5/16/18 of Resident #79's current care plan revealed that there were three care plan entries made on 4/12/18. One entry was for Advanced Directive and/or DNR (Do Not Resuscitate) order in place, one for Resident is at risk for falls: [MEDICAL CONDITION] and one for Resident is at risk for skin breakdown as evidenced by limited mobility. The review also revealed that an entry for Resident/patient has potential LTC .(Long Term Care) was not entered until 4/16/18. The review also revealed that the next entry was made on 4/17/18 for While in the facility, resident states that it is important that she has the opportunity to engage in daily routines that are meaningful . The entry for Resident is at nutritional risk: r/t compromised skin integrity was also not entered until 4/17/18. The review further revealed that an entry for impaired decline in cognitive function . was not entered until 4/23/18, Further review of Resident #79's care plan revealed that no other care plan entries were made until 5/3/18 when an entry was made for Resident /Patient requires assistance/is dependent for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: Limited mobility . and an entry for Resident exhibits or is at risk for alterations in comfort related to [MEDICAL CONDITION]. Interview on 5/16/18 at approximately 9:30 a.m. with Staff J (Licensed Practical Nurse)confirmed that there had been no interim admission care plan in place within 48 hours of admission for Resident #79 for the following problems: Potential for LTC (Long Term Care), opportunity to engage in daily routines that are meaningful, nutritional risk related to compromised skin integrity, impaired decline in cognitive function, assistance with ADL (Activities of Daily Living), and alteration in comfort related to [MEDICAL CONDITION]. Resident #76 Review on 5/15/18 of Resident #76's Entry MDS (Minimum Data Set) revealed that Resident #76 was admitted to the facility on [DATE]. Review on 5/15/18 of Resident #76's care plan revealed that there were no care plan entries until 1/19/18 when an entry was made for Resident/patient has potential for long term care . The review revealed that the next entry was made on 1/26/18 for Resident/patient has impaired/decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION] . The review also revealed that no other risks or problems, including assistance with ADL's (Activities of Daily Living,) Advance Directives, Risk for dehydration, Risk for Dental care problems, Risk for falls, Risk for distressed mood, Risk for alterations in comfort, Risk related to [MEDICAL CONDITION] drug use, Risk for skin breakdown, and Incontinence were entered into the care plan until 1/30/18. Interview on 5/16/18 at approximately 8:15 a.m. with Staff B (Unit Manager) confirmed that there had been no interim admission care plan in place for Resident #76 and that there should have been one in place. Staff B also confirmed that most of the problems for Resident #76 were not care planned for until 1/30/18.",2019-01-01
903,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-17,656,E,0,1,AKV711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to develop and implement care plans for weight loss, pressure sores, behaviors, an intravenous line and isolation precautions for 4 residents in a standard survey sample of 21 residents. (Resident identifiers are #15, #76, #453 and #447.) Finding include: Resident #15 Interview on 5/14/18 at approximately 10:30 a.m. with Resident #15 revealed that Resident #15 had a pressure sore on their bottom. Observation on 5/14/18 at approximately 10:30 a.m. of Resident #15, while they were laying in bed, revealed that Resident #15's heels, which were visible because the top bed sheet was pulled back, were laying on the mattress with nothing to offload them. Review on 5/14/18 of Resident #15's Skin -Pressure Ulcer . form revealed that Resident #15 had a pressure sore on the coccyx that started on 2/14/18 as a Stage 2, but deteriorated to an unstageable area on 3/5/18. Review on 5/15/18 of Resident #15's current care plan revealed that Resident #15 had a care plan in place for Resident has actual skin breakdown related to fragile skin . The review revealed that there was no documentation in the care plan of what the breakdown was, where it was located or what the Stage of the breakdown was. Observation on 5/16/18 at approximately 8:15 a.m. of Resident #15 with Staff B (Unit Manager) present, revealed that Resident #15's heels were laying directly on the bed with no offloading. Interview on 5/16/18 at approximately 8:20 a.m. with Staff B confirmed that there were no details on Resident #15's care plan about the pressure sore and that there should have been. Resident #76 Interview on 5/14/18 at approximately 2:45 p.m. with Resident #76 revealed that Resident #76 had a weight loss. Review on 5/15/18 of Resident #76's weight summary form revealed that Resident #76 had a weight loss from 207.5 pounds on 3/22/18 to 160 pounds on 5/7/18. Review on 5/16/18 of Resident #76's Nutritional Assessment, dated 4/24/18, revealed that Resident #76 had a 23% weight loss in 1 month. Review on 5/16/18 of Resident #76's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 4/25/18 revealed that Section K0300 Weight Loss was checked for Yes, not on a physician-prescribed weight-loss regimen. Review on 5/16/18 of Resident #76's current care plan revealed that there was no care plan for either weight loss or nutrition for Resident #76. Interview on 5/16/18 at approximately 8:20 a.m. with Staff B confirmed that Resident #76 has had a significant weight loss and that there was no care plan in place for Resident #76's nutritional status. Staff B also confirmed that there should have been a care plan in place to address this issue for Resident #76. Resident #453 Observation on 5/14/18 at approximately 9:15 a.m. revealed a precautions cart outside of Resident #453's room. Interview on 5/14/18 at approximately 9:30 a.m. with Staff H (Unit Manager) revealed that Resident #453 was [MEDICAL CONDITION] precautions. Review on 5/15/18 of Resident #453's medical record in the [DIAGNOSES REDACTED].#453 was admitted on [DATE] [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aerus) bacteremia status [REDACTED].#453 also had a PICC (peripherally inserted central catheter) line in place for intravenous antibiotics. Care plans revealed that Resident #453 did not have a care plan [MEDICAL CONDITION] precautions or the PICC line. Interview on 5/16/18 at approximately 9:20 a.m. with Staff I (Licensed Practical Nurse) confirmed that there were no care plans for [MEDICAL CONDITION] or Picc line. Resident #447 Interview on 5/14/18 at approximately 9:15 a.m. with Staff H, revealed that Resident #447 had behaviors and would become agitated if interviewed. Observation on 5/14/18 while touring the unit throughout the day revealed Resident #447 yelling out frequently and exhibiting agitation. Review on 5/15/18 of Resident #447's medical record revealed the resident was admitted on [DATE] and that Resident #447 is followed by psychiatric services. Review on 5/15/18 of Resident #447's Medication Administration Record [REDACTED]. Review on 5/16/18 of Resident #447's care plans revealed that there were no care plans for behavioral/emotional or antipsychotic medication. Interview on 5/16/18 at approximately 9:40 a.m. with Staff G (Director of Nurses) confirmed that there were no care plans for behavioral/emotional or antipsychotic medication.",2019-01-01
904,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-17,761,E,0,1,AKV711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of manufacturer's instructions, it was determined that the facility failed to safely store and label medications on 2 out of 4 nursing units (West Unit and Tuck Unit) and 1 out of 2 medication rooms. (Resident identifiers are #10, #11, #16, #48, #66, and #88.) Findings include: Observation on [DATE] at approximately 1:20 p.m. of the medication room (medication room located between The West Unit and The Transitional Care) unit revealed the following medications were expired: In the refrigerator in the medication room were the following: Cephalaxin oral suspension, do not use beyond use date of [DATE] Cephalaxin oral suspension, do not use beyond use date of [DATE] Cephalaxin oral suspension, do not use beyond use date of [DATE] On the shelf in the medication room was the following: [MEDICATION NAME] oral suspension, do not use beyond use date of [DATE]. Interview on [DATE] at approximately 1:20 p.m. with Staff A (Licensed Practical Nurse) confirmed that the above medications were expired. Review on [DATE] of the manufacturer's instructions for Cephalaxin, revision date (MONTH) (YEAR), revealed: .Storage: .Discard any unused portion after 14 days. Observation on [DATE] at approximately 1:35 p.m. of the West Unit medication cart revealed the following undated and opened vials of insulin: 2 vials of Humalog 100 unit per milliliter insulin (Resident #66) 1 vial of [MEDICATION NAME] 100 unit per milliliter insulin (Resident #11) 2 vials of [MEDICATION NAME] 100 unit per milliliter insulin (Resident #48) 1 pen of [MEDICATION NAME] (Resident #10) Interview on [DATE] at approximately 1:40 p.m. with Staff D (Licensed Practical Nurse) confirmed that the above insulins were opened and undated. Staff D also confirmed that these vials of insulins were the ones being administered. Interview on [DATE] at approximately 1:45 with Staff E (Nurse Practice Educator) confirmed that the above insulins were opened and undated. Observation on [DATE] at approximately 1:50 p.m. of the Tuck Unit medication cart revealed the following insulins opened and not dated: 1 vial of Humalog 100 unit per milliliter insulin (Resident #88) 1 vial of [MEDICATION NAME] 100 unit per milliliter insulin (Resident #16) Interview on [DATE] at approximately 1:50 p.m. with Staff F (Registered Nurse) confirmed that the vials of insulin were opened and undated. Review on [DATE] of the manufacturer's instructions for Humalog insulin, revision date (MONTH) (YEAR), revealed: .Storage: .Throw away all insulin [MEDICATION NAME] in use after 28 days, even if there is insulin left. Review on [DATE] of the manufacturer's instruction for [MEDICATION NAME] insulin, revision date (MONTH) (YEAR) revealed: .Storage: .Throw away all insulin [MEDICATION NAME] in use after 28 days, even if there is insulin left. Review on [DATE] of the manufacturer's instruction for [MEDICATION NAME], revision date (MONTH) (YEAR) revealed: .Storage: .Discard all containers in use after 28 days, even if there is insulin left. Observation on [DATE] at approximately 7:30 a.m., during the medication pass, revealed that Staff C (Licensed Practical Nurse) walked away from the medication cart, which was located halfway down the West wing hallway, to look for a medication for a resident that was not in the medication cart. When Staff C walked away, a bottle of [MEDICATION NAME] nasal spray that was ordered for Resident #59 was left sitting on top of the medication cart. Staff C went to the medication room and was gone for approximately 5 minutes. Interview on [DATE] at approximately 7:35 a.m. with Staff C confirmed that the nasal spray was left unattended on top of the medication cart and that it should have been locked inside the medication cart.",2019-01-01
905,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-17,812,D,0,1,AKV711,"Based on observation and interview, it was determined that the facility failed to follow proper sanitization and food handling practices and failed to not commingle employee food with resident's food in one kitchenette. (Resident identifies is Resident #22.) Findings include: Observation on tour 5/14/18 at approximately 9:29 a.m. revealed an ice pack in the freezer on the Tuck Unit with the name for Resident # 22. Also, observed in the refrigerator was a lunch box with no name on it. Staff K asked Staff M, LPN (Licensed Practical Nurse) whose lunch box it was. Interview on 5/14/18 at approximately 10:00 a.m. with Staff K (Administrator) indicated that Staff K did not know whose lunch box was in the refrigerator and why the ice pack would be in the freezer. Staff K removed ice pack and lunch box. Staff K indicated the lunch box was a staff members and it should not be in the refrigerator on the floor but in the staff lounge refrigerator. Also, the ice pack should be in the rehabilitation freezer.",2019-01-01
906,OCEANSIDE SKILLED NURSING AND REHABILITATION,305055,22 TUCK ROAD,HAMPTON,NH,3842,2018-05-17,880,D,0,1,AKV711,"Based on observation and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during 1 of 2 medication pass observations. (Resident identifiers are #56 and #59.) Findings include: Observation on 5/15/18 at approximately 7:40 a.m., during the medication pass observation, revealed that Staff C (Licensed Practical Nurse) administered medications to 2 different residents. Upon completion of the administration to the first resident, Resident #59, Staff C did not wash their hands or use hand sanitizer, but went on to administer medications to the second resident, Resident #56. Review on 5/16/18 of the facility's policy, titled .LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual ., dated 12/1/07, revised 1/1/13, revealed a procedure which read .Prior to preparing or administering medications, authorized and competent Facility staff should follow Facility's infection control policy (e.g., handwashing.) . Interview on 5/15/18 at approximately 7:50 a.m. with Staff C confirmed that Staff C had not washed their hands or used hand sanitizer between administering medications to 2 residents and that Staff C should have either washed their hands or used hand sanitizer.",2019-01-01
907,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2016-02-11,156,E,0,1,EFGK11,"Based on record review and interview the facility failed to ensure that residents on antipsychotic medications have documented evidence that the risks and benefits of the medication had been explained to them, which includes the black box warning for 7 of 22 residents in a standard survey sample. (Resident identifiers are #3, #8, #9, #11, #13, #20 and #22). Findings include: Record review on 2/9/16 revealed that above residents were receiving anti-psychotic medication(s). Further record review revealed that the facility failed to inform the resident/activated durable power of attorney for the residents of the potential or actual adverse consequences and risk factors to include the manufacturer's Black-box warnings for the antipsychotic medication. Interview on 2/11/16 with Staff A, (LPN Unit Manager) indicated that the forms are the anitpsychotic forms they have always used. They review side effects like tardive dyskinesia but not death. Is this something new? with the patients or their represtentives. Resident #13 Record review on 2/10/16 revealed that Resident #13 was receiving an antipsychotic medication. Further record review revealed the facility failed to inform the resident/activated Durable Power of Attorney (DPOA) of the potential or actual adverse consequences and risk factors to include the manufacturer's Black - Box warnings for the antipsychotic medication. Interview on 2/10/16 at approximately 2 pm with Staff E (RN/ADON) who confirmed that the currently utilized Antipsychotic Consent Form does not contain the manufacturer's Black - Box warning. Resident #20 Record review on 2/10/16 revealed that Resident #20 was receiving an antipsychotic medication. Further record review revealed the facility failed to inform the resident/activated Durable Power of Attorney (DPOA) of the potential or actual adverse consequences and risk factors to include the manufacturer's Black - Box warnings for the antipsychotic medication. Interview on 2/10/16 at approximately 2 pm with Staff E (RN/ADON) who confirmed that the currently utilized Antipsychotic Consent Form does not contain the manufacturer's Black - Box warning.",2019-01-01
908,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2016-02-11,160,B,0,1,EFGK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident trust fund and interview it was determined that the facility failed to convey resident funds within 30 days to the estate of the individual(s) probate jurisdiction administering the residents estates for 7 of 10 out of sample residents and 1 in sample resident . (Resident identifiers are #23, #25, #26, #27, #28, #29, #30, and #31). Findings include: Review of the following accounts revealed the following: Resident #23 had expired on [DATE] with a balance of $101.30 remaining in this resident's account. Probate paperwork for Resident #23 was filed on [DATE]. Resident #25 had expired on [DATE] with a balance of $1263.51 remaining in this resident's account. Probate paperwork for Resident #25 was filed on [DATE]. Resident #26 had expired on [DATE] with a balance of $592.59 remaining in this resident's account. Probate paperwork for Resident #26 was filed on [DATE]. Resident #27 had expired on [DATE] with a balance of $1539.88 remaining in this resident's account. Probate paperwork for Resident #27 was filed on [DATE]. Resident #28 had expired on [DATE] with a balance of $99.13 remaining in this resident's account. Probate paperwork for Resident #28 was filed on [DATE]. Resident #29 had expired on [DATE] with a balance of $21.03 remaining in this resident's account. Probate paperwork for Resident #29 was filed on ,[DATE]. Resident #30 had expired on [DATE] with a balance of $6.38 remaining in this resident's account. Probate paperwork for Resident #30 was filed on [DATE]. Resident #31 had expired on [DATE] with a balance of $65.03 remaining in this resident's account. Probate paperwork for Resident #25 was filed on [DATE] Interview on [DATE] at approximately 2 p.m. with Staff F (BOM/Business Office Manager) who confirmed that the appropriate paperwork for probate had not been filed within 30 days for those residents listed above.",2019-01-01
909,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2016-02-11,364,B,0,1,EFGK11,"Based on interview and test tray the facility failed to ensure that the temperatures of all hot foods at the time of serving had maintained a temperature that was preferable to the individual resident. Findings include: During the Resident council portion of the recertification survey on 2/10/16 it was reported to this surveyor by several of the Residents in attendance that the meals that they receive are often cold. When questioned the Residents responded that eggs, pork and vegetables are frequently not hot enough. The residents did state that the staff would heat up a meal if they had time. Results of a test tray done on 2/11/16 identified that the temperatures for hot foods has a significant drop in temperature from the time is tray preparation to the time of serving, while the cold foods remained cold.",2019-01-01
910,SALEMHAVEN,305058,23 GEREMONTY DRIVE,SALEM,NH,3079,2016-02-11,514,D,0,1,EFGK11,"Based on observation, interview and resident record review it was determined the facility failed to ensure documentation of checking and releasing a Seatbelt restraint at least every 2 hours for one resident reviewed in the survey sample of 22. Resident identifier is #9. Findings include: Observation of Resident #9 on 2/10/16 -2/11/16 revealed the resident in a wheel chair with seat belt buckled. Review of the Care plan record dated 1/15/16 confirmed the velcro seat belt was discontinued and a seatbelt with buckle alarm was implemented 1/15/16. Interview with Staff B (Unit Manager) confirmed Resident #9 attempts to get up at will, however can no longer walk safely and confirmed Resident #9 has been able to open the velcro safety belt has a recent history of falling as the reason a seat belt Restraint with alarm, and motion sensor in room were implemented 1/15/16. Survey record review of Resident #9's Care Plan indicates under category - Falls Management the Care Plan documents the following in support of the need for the seat belt restraint w/ alarm: Significant hx (history of falls) .Fall (with) (L) (left) hip fx (fracture) in 12/15 (decreased) mobility r/t (related to) .hip fx (fracture) (with) repair 1/15/16 - Pt (patient with increased safety) concerns- removesvelcro seatbelt at side so (no) alarm heard & self transfering unsafely - (increased) Fall Risk 1/15/16 1 (discontinue) velcro seatbelt 2 buckle alarm seatbelt (will not) be able to remove @ will 1/19/16 Found on Floor 2/3/16 Patient fell in Br 2 (secondary to increased) agitation & noncompliance (with) assistance. Hit head landed in awkward position ( with question) of injury. 2/5/16 unwitnessed fall to knees attempting to self (transfer) from bed to (wheelchair no) injury. .Motion sensor when in bed, 15 (min checks indefinite) The notes listed above concern Resident #9's attempts to get up or self transfer unassisted for the dates: 1/15/16, 1/19/16, 2/3/16 and 2/5/16 which supports Staff B's implementation of the seat belt restraint. There is no documetned evidence that Resident #9 was released and monitored every 2 hours from the seat belt to re-position for comfort while staff are present to assist Resident #9.",2019-01-01
911,LANGDON PLACE OF DOVER,305089,60 MIDDLE ROAD,DOVER,NH,3820,2016-01-25,224,D,1,0,4VCI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of self reported complaint/incident, record review, and interview with Staff A (Administrator), it was determined that the facility failed to prevent the misappropriation of scheduled 2 narcotic medications for 2 discharged skilled residents, and 1 skilled resident who was receiving rehabilitative services at the time of the alleged violation. (Resident Identifier is #1). Findings include: The facility reported that on 11/25/15: 2 staff nurses alleged that an 11 p. m.-7 a.m. staff nurse/co-worker had tampered with, and/or diverted schedule 2 narcotics. Both the nurses visualized that medication blister pack/bingo cards had been tampered with and the medication inside 3 of the cards was not the original medication, or was not the medication indicated on the prescription label. On further inspection, they found that there were three cards found to have the back edges lifted slightly and tampered with .Identifier RX # was for [MEDICATION NAME] tablets on the pills in three blister packs/bingo cards that were for schedule 2 narcotics. The 2 nurses stated that a newly opened bottle of [MEDICATION NAME] (allergy medication)-that contains 30 tablets had only 10 pills left in the bottle and no residents were scheduled or had asked for PRN (as needed) [MEDICATION NAME] during the 11-7 shift. On 1/25/16, and onsite investigation was conducted by the State Agency regarding the above allegations. This investigation revealed that the facility had conducted a full and thorough investigation within the required time frames. Resident # 1 had received her pain meds at approximately 11:30 pm on 11/21/16. She then requested her PRN (as needed) pain meds in the morning of 1/22/16 at 7:05, and was told by the oncoming Med Tech that she was not comfortable medicating again as it was documented that the resident had received her pain medication at 4:55 am according to the Medication Administration Record. Staff D (Staff RN) had signed out pain medication for resident #1 throughout the early morning hours of 1/22/16 complete with a documented pain assessment, but did not actually medicate the resident. The resident stated that she was up two times during the night to use the bathroom and never requested pain medication as she wasn't in any pain. This resident was alert and oriented, with no cognitive impairment according to facility records. As the discrepancy in Blister packs was identified immediately and the cognitive status of the resident was not in question, the resident was medicated for pain with good effect.",2019-01-01
912,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2015-12-01,463,E,1,0,19V111,"> Based on observation, record review, and interview, the facility failed to ensure its resident calls communication system was effective for the timely answering of call bells. (Resident identifiers are #1, #7, #8, and #11.) Findings include: Record review of the Resident Council Minutes for 11/2/15 revealed that Call Bell Response issues had come up at Resident Quality Assurance meetings. Interview with Staff A, Administration, on 12/1/15 revealed Resident Quality Assurance is a resident committee that meets monthly, Staff A believes, and reports to QAPI (Quality Assessment, Performance Improvement). Record review revealed some comments in the Resident Council Minutes included that there were isolated instances when it felt like a long time had passed before the bell was answered, but that the situation was generally improved; and that there were times when one commenter is told she has to wait for assistance because the aide said she was taking care of someone else at the moment. 11/25/15 interview with Staff A revealed that Staff A was aware there were problems with answering call bells timely, and this was especially a problem at meal times, the facility addressed this by staggering meal times and assigning one LNA (Licensed Nursing Assistant) to monitor and respond to call lights during the meal or right after the meal, and this went into effect, Staff A thought, maybe 3 months ago. Resident #8 Interview with this resident late afternoon during survey revealed that Resident #8 needs to have someone get them out of bed as their left foot doesn't work good; the resident can ring the call bell to go to the bathroom, however the resident related they can't reach it (the call bell) so they have to wait for someone to come along, and sometimes the resident has accidents, and has to wait a long time. Observation during the interview revealed no call bell button was visible within reach of the resident. Interview with this resident during a subsequent afternoon, on 12/1/15, revealed that Resident #8 cannot find their call bell and observation revealed no call bell within reach of the resident who was in a wheelchair in their room. The surveyor related this issue to nursing, Staff D and Staff D was then observed to pick up the call bell button which was on the floor between the bed and the wall, on the side of bed the resident was not at, and Staff D connected the call bell button to the resident's chair. Resident #11 Interview 11/30/15 with Resident #11 revealed the resident doesn't like that you wait (per the resident) about an hour after you ring the bell to go to the bathroom. Resident #11 related an incident where the resident dropped a paper and rang and nobody came, they rang and rang and after (per the resident) half an hour Resident #11 bent over to get it as nobody came, and they broke their left leg, the same leg affected by the stroke that cause them to be admitted here. The resident doesn't get out of bed by themselves, they have to ring for help. Resident #11 related all the residents complain of how long it takes when you ring a bell. Resident #1 During interviews with staff on 11/30/2015 it was indicated that turnover and call outs at time causes chaos. During interviews, several residents stated that it sometimes takes the staff a long time to answer their call bells. Specifically interview on 11/30/2015 with Resident #1 at approximately 4:30 p.m identified that sometimes they are slow getting to us and I have had an accident at times .but when they get here they are wonderful and take very good care of us.Resident #1 could not recall how long they had waited. Interview on 11/30/2015 with Staff A (Administrator) identified that the facility had no system for monitoring call bell activity or knowing how long it took for staff to respond to resident calls for assistance. Resident #7 Interview with Resident #7 on 11/25/15 at about 2:55 p.m., Resident #7 complained that the call lights were not answered much. That on 11/24/15 they were sitting in their (Resident #7) feces from 5pm to 9pm with no help. When I asked how often this happens, the reply was that it was dependant of how often they had a bowel movement. Other Interview/Observation Interview with Resident on 11/25/15 at about 3:00 pm, Resident stated they feel the callouts causes stress amongst the staff and that the residents are made aware for the short staffing. On occasion staff could be overheard argueing with each other. If they are incontinent of bowel and/or bladder, they have a long wait. On 11/25/15 at about 5:10 pm to 5:30 pm while having the unit under general observation by this surveyor, several call lights were in action. Staff C (Registered Nurse) had to inform Staff L (Licensed Nursing Assistant) and another LNA that a call light near where they were conversing needed to be responded to. At that point they ended the conversation and went into the room.",2018-12-01
913,GOLDEN VIEW HEALTH CARE CENTER,305044,19 NH ROUTE 104,MEREDITH,NH,3253,2015-12-01,514,B,1,0,19V111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for 8 residents in a survey sample of 10 residents. (Resident identifiers are #1, #2, #3, #5, #6, #8, #9, and #10.) Findings include: Resident #1 Record review of this resident's Point of Care History for the period 10/1/15 - 11/25/15 revealed 5 showers, on 10/13, 10/20, 11/3, 11/10, and 11/24, and a complete bed bath on 11/22. Review of the Point of Care ADL Report for (MONTH) (YEAR) revealed that while assistance for personal hygiene was provided most days, bathing is documented as not occuring on 22 days. Review of the whirlpool check sheet revealed this resident had a whirlpool on 11/24/15, with weight 254.5, and 12/1/15 with a weight of 161.5; interview on 12/1/15 with the LNA (licensed nursing assistant) who did the bath record, Staff S, revealed that the 12/1 weight was an error and the weight is 261.5 pounds. Resident #2 Review of this resident's Point of Care ADL Report for the period 11/17/15 - 11/24/15 revealed that while assistance for personal hygiene was provided most days, bathing did not occur or is undocumented. Resident #3 Review of this resident's Point of Care History for the period 10/1/15 - 11/25/15 revealed 5 baths over the 8-week period: 10/7, 10/13, 11/4, 11/12, and 11/18. Resident #5 Record review revealed this resident was admitted on [DATE]; a paper whirlpool record for Resident #5 was not found. Interview with Staff C during survey revealed that a whirlpool check document for residents was initiated on 11/23/15, but Staff C could not find the sheet for Resident #5, so this resident's last shower/bath was before 11/23/15. Resident #6 Review of this resident's Point of Care History for the period 10/1/15 - 11/25/15 revealed that bathing care was documented for only one date: a shower on 11/1. Interview with Staff C, Unit Manager and Staff A, Administration during survey revealed that this resident returned from the hospital on [DATE]. No (MONTH) dates for bathing are documented on the above Point of Care History. Resident #8 Review of this resident's Point of Care History for the period 10/1/15 - 11/25/15 revealed that bathing care was document for two dates: partial bed bath on 11/21 and shower on 11/19. No bath dates are documented for October. Resident #9 Review of this resident's record revealed on the Point of Care History that for the period 10/23/15 - 11/25/15 the resident had bathing on two dates: a shower on 11/5 and a shower on 11/12. Record review of the whirlpool check sheet revealed the resident had a whirlpool on 11/26 but the resident's weight was not recorded, and the nurse didn't cosign this record. Interview with Staff C, on 12/1/15 revealed the resident's last weight was on 11/11. Resident #10 Record review of this resident's Point of Care History for the period 10/1/15 - 11/25/15 revealed the resident had bathing on two dates: a shower on 10/23 and a shower on 11/20. Record review of the whirlpool check sheet revealed that the resident had a whirlpool on 11/27/15 and weight was recorded as 145. Interviews, with Staff C, Unit Manager, and with Staff A, Administration, and Staff B, Director of Nursing/Nurses on 11/25/15, identified that the facility was aware of issues with point of care documentation including baths, so they started with a new bath sheet on 11/23/15. During this complaint survey an allegation which had been sent to the department was investigated. The investigation alleged that the complainant, Staff L, marked a depends on 11/17/2015 at approximately 9:30 P.M. The complainant further alleges that the next day when they came in for the their shift ( 11/18/2015) at 3:00P.M. Resident #2 was still wearing the same Depends with the mark which had not been changed in almost 18 hours. There is no documentation from Staff L (LNA) to identify the condition of Resident #2's Depend nor is there documentation that Staff L made an allegation of abuse or neglect to anyone at the facility as a result of this alleged occurrence Based on review of electronic record, there is a notation that Resident #2 had a bowel movement with Depend change on 11/17/15 at 10:52 PM almost 2 hours post marking of her depends by Staff L. The record shows that Staff R, (LNA) made the documentation. Based on interviews the afternoon of 12/1/15 with staff that were on duty after 18 hour period in question, none of them (Staff I (Lead LNA for the shift), Staff P (LPN), Staff Q (RN)) recall any report of or complaint of neglect with the care of Resident #2. Interview with Staff B at the same approximate time reveals that they (Staff B) received no report of possible neglect on 11/18/15 with regards to residents care. According to the facility policy regarding the reporting of the the suspected abuse and neglect of facility residents, suspected neglect needs to be reported immediately , but not more that 24 hours.",2018-12-01
914,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2015-09-17,156,B,0,1,BEH511,"Based on interview and review of the admission packet the facility failed to include and to provide written information to new residents and their responsible parties informing them of the Medicaid Spousal Impoverishment Provision. Findings include: Review of the facility Admission packet on 9/17/15 revealed no information concerning the Medicaid Spousal Impoverishment Provision. The Medicaid Spousal Impoverishment Provision informs the spouse who remains residing at home of the right to a resource assessment of assets and to have the assets split to prevent impoverishment of the spouse who continues to reside at home. Interview on 9/17/15 with Staff C, (Administrator) and Staff B (Director of Nurses), Staff C confirmed there was no Spousal Impoverishment information in the Admission Packet and Staff #C indicated this information was supposed to be in the packet and reviewed with new residents and their responsible parties at the time of admission. When Staff C checked with Admissions and Social Services he indicated it used to be included in the facility Admission packet but it it no longer was being included.",2018-12-01
915,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2015-09-17,329,D,0,1,BEH511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents on antipsychotic medications have documented evidence that the risks and benefits of the medication had been explained to them, which includes the black box warning for 3 of 24 residents in a standard survey sample. (Resident identifiers are #2, #9, #10). Findings include: Record review on 9/16/15 revealed that Resident #2 was receiving the anti-psychotic medication [MEDICATION NAME]. Further record review revealed that the facility failed to inform the resident/ activated durable power of attorney for Resident #2 of the potential or actual adverse consequences & risk factors to include the manufacturer's Black-box warnings for the antipsychotic medications [MEDICATION NAME]. Record review on 9/17/15 revealed that Resident #9 was receiving the anti-psychotic medication [MEDICATION NAME]. Further record review revealed that the facility failed to inform the resident/ activated durable power of attorney for Resident #9 of the potential or actual adverse consequences & risk factors to include the manufacturer's Black-box warnings for the antipsychotic medication. Record review on 9/16/15 revealed that Resident #10 was receiving the anti-psychotic medications [MEDICATION NAME] for severe agitation/[MEDICAL CONDITION] and Zyprexia for delusions. Further record review revealed that the facility failed to inform the resident/ activated durable power of attorney for Resident #10 of the potential or actual adverse consequences & risk factors to include the manufacturer's Black-box warnings for the antipsychotic medications [MEDICATION NAME] and Zyprexia. During interview with Staff B (Registered Nurse) on 9/17/15 at approximately 3:00 p.m., Staff B verbally indicated that the facility did not have a protocol in place to show that the resident's/activated durable power of attorney was informed of the potential or actual adverse consequences & risk factors to include the manufacturer's Black - box warnings for the use of antipsychotic medications.",2018-12-01
916,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2015-09-17,371,D,0,1,BEH511,"Based a tour of the kitchen and interview the facility failed to maintain the cleanliness above and around the grill, inside the walk in freezer and on two steam tables keeping these areas free of dust, grease, ice, snow spillage and buildup. Findings include: On a 9/15/15 tour of the facility kitchen a large amount of dust was observed on the hood panels above the grill. Dust and grime buildup was also observed in back of the grill and on the tops of the wheeled warmers heating storage units used to maintain the temperatures of cooked foods. According to Staff A (Food Service Manager) the hood panels were last cleaned professionally in (MONTH) of (YEAR). In addition Staff A stated that the food service staff are responsible for keeping the hood panels clean by putting them through the dishwasher and for keeping the warmers clean. Inside the facility walk in freezer there was a large amount of snow covering the freezer entrance floor. The snow made the freezer floor slippery and hazardous. There was what appeared to be ice and snow buildup along the whole ceiling of the freezer and along the pipes inside the freezer. Freezer floors must be kept clean and free of spillage. Steam tables on both the Granite and Maple units were observed to be greasy particularly in the area above where the food had been stored.",2018-12-01
917,GRAFTON COUNTY NURSING HOME,305053,3855 DARTMOUTH COLLEGE HIGHWAY,NORTH HAVERHILL,NH,3774,2015-09-17,441,E,0,1,BEH511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain a record of infection for 10 out of 24 sampled residents. (Resident identifiers are #7, #24, #29-#37) Finding include: Review of the Infection Control Program revealed 10 residents who were treated for [REDACTED]. Interview with Staff C (RN) on 9/17/15 who confirmed there were 10 residents whom Staff C had not included in his/her line listings and therefore was not monitoring or investigating the the cause and manner of transmission to prevent further infections within the facility.",2018-12-01
918,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2015-05-05,155,D,0,1,ET2G11,Based upon a review of a 5/4/15 facility investigation report and a staff interview the facility failed to ensure that 1 of 17 sampled residents exercised their right to refuse medication. (Resident identifier was #5) Findings include: Resident #5 according to a 5/4/15 facility investigation report was continually spoon fed medication contained in pudding even though Resident #5 repeatedly told staff that Resident #5 didn't want this medicine. The nurse who gave Resident #5 this medication simultaneously held their hand over Resident #5's hand during this incident. Staff C(Administrator) said that another unnamed staff member(LNA) had witnessed this incident collaborating Resident #5's account of what occurred.,2018-12-01
919,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2015-05-05,156,C,0,1,ET2G11,"Based on observation and interview it was determined that the facility failed to post all pertinent State client advocacy groups and failed to display written information on how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits. Findings include: Observation all three days of the recertification survey conducted on 5/3/15 through 5/5/15 revealed no facility postings of the names, addresses and telephone numbers of all pertinent State client advocacy groups and no display of the written information on how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits. During interview on 5/5/15 with Staff C (Administrator) after observations of facility posted information, Staff C agreed that there were no State client advocacy groups posted and that the Medicare and Medicaid written information on how to apply and use these benefits and how to receive refunds for previous payments covering these benefits was not displayed in the facility.",2018-12-01
920,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2015-05-05,160,D,0,1,ET2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon a review of resident accounts the facility failed following the death of four residents to convey their personal funds deposited with the facility within 30 days to the individual or probate jurisdiction administering each estate (Resident identifiers are #21,#22, #23 and #24). Findings include: Resident #21 died on [DATE] and the facility has no documentation that Resident #21's resident account balance of $1,848.44 was sent to the jurisdiction administering Resident #21's estate. Resident #22 died on [DATE] and the facility has no documentation that Resident #22's resident account balance of $695.60 was sent to the jurisdiction administering Resident #22's estate. Resident #23 died on [DATE] and the facility has no documentation that Resident #23's resident account balance of $3,206.55 was sent to the jurisdiction administering Resident #23's estate. Resident #24 died on [DATE] and the facility didn't send Resident #24's resident account balance of $1,836.72 to the jurisdiction administering Resident #24's estate until [DATE].",2018-12-01
921,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2015-05-05,278,B,0,1,ET2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to have complete and accurate assessments for three residents in a survey sample of 17 residents. (Resident identifiers are #2, #8, and #15.) Findings include: Resident #2 Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/24/15 revealed that Section C for Cognitive Patterns, Section D for Mood, Section J0300 - J0850 for Pain Assessment, and pertinent portions of Section Q for Participation in Assessment and Goal Setting, were not assessed. Interview with Staff G, MDS Coordinator, on 5/4/15 revealed that Cognitive, Mood and Pain were not assessed timely (by the ARD) and so it didn't populate these areas on the MDS. Resident #8 Review of Resident #8's Quarterly MDS with an ARD of 2/5/15 revealed in section O0300 that the resident's Pneumococcal vaccination was not up to date, as it had been declined. However, the Admission MDS with an ARD of 10/23/14 recorded in section O0300 that the resident's Pneumococcal vaccination was up to date. This discrepancy was pointed out to Staff G, (MDS Coordinator) during 5/4/15 interview, and Staff G related the coding in the Quarterly MDS was an error, it should have been coded as up to date, and a correction will be sent in. Resident #15 Review of Resident #15's Significant Change MDS with an ARD of 3/3/15 revealed that the care are of Visual Function had triggered and would be assessed for a care plan decision. Review of this Care Area Assessment (CAA) revealed that the resident had [MEDICAL CONDITION] and visual function would be care planned. However, review of the resident's care plans revealed no care plan for vision. Interview on 5/5/15 with Staff G (MDS Coordinator), confirmed that the care plan for vision was not there. Staff G related that the CAA was in error and should have documented the decision to not care plan.",2018-12-01
922,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2015-05-05,280,D,0,1,ET2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to update the resident comprehensive care plan for three resident's in a survey sample of 17 resident's. (Resident identifiers are #2, #8 and #11.) Findings include: Resident #11. Review of the comprehensive care plan for Resident #11 with a creation date of 6/12/14 and a target date of 7/1/15 revealed in the section titled Resident requires [MEDICAL TREATMENT] (specify; [MEDICAL TREATMENT] related to [MEDICAL CONDITION]) in the area for Interventions Location of Access Device: left arm .No B/P (blood pressure) left arm due to access placement . Review of a readmit Note: dated 6/5/14 revealed that Resident #11 had gone to .(hospital) for AV Shunt placement in RT. (right) arm .Resident has Left sided shunt which is not working. During interview with Staff D (LPN) Staff D informed this surveyor that Resident #11 [MEDICAL TREATMENT] access was an AV shunt located in the right arm. The facility failed to update the current comprehensive care plan with the placement of the [MEDICAL TREATMENT] access AV shunt located on the right arm and not to take B/P in the right arm due to access placement. Resident #2 Record review of Resident #2's care plan with a target date of 4/10/15 revealed the resident was listed as a Full Code. Review of Resident #2's portable DNR (Do Not Resuscitate) revealed it was signed by the physician on 4/6/15. Interview with Staff D, on 5/4/15 revealed that this is not the resident's current care plan, it was confirmed by record review and interview that the resident's care plan was not updated timely on 4/6/15 with the change from Full Code to Do Not Resuscitate. Resident #8 Review of Resident #8's Order Summary Report dated 4/9/15 revealed that a Pacemaker Apical pulse check is done daily. Review of Resident #8's Minimum Data Sets reveals a Discharge Return Anticipated 4/2/15, and review of Resident #8's face sheet reveals an admitted [DATE]. Interview with Staff F (LPN) during survey revealed that this resident had a pacemaker placed on 4/6/15. Review of Resident #8's current care plans revealed no care plan addressing goals and interventions for a pacemaker, with the exception of a care plan that addresses the pacemaker wound. Interview with Staff E (RN) on 5/4/15 confirmed that the resident has no pacemaker care plan and that a care plan for the pacemaker will be put in on 5/4/15.",2018-12-01
923,WESTWOOD CENTER,305062,298 MAIN STREET,KEENE,NH,3431,2015-05-05,281,D,0,1,ET2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow the professional standard of practice for pronouncing at the time of death for 1 resident. (Resident identifier is #14). The facility failed to ensure that physician's orders [REDACTED].#11), and the facility failed to ensure that the physician order [REDACTED].#15.) Findings include: Reference is Fundamentals of Nursing, 7th Edition, MOSBY/ELSEVIER, 2009, Evolve, pages 479 - 480, reveal the following: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care . Documentation of death provides a legal record of the event. Follow agency policy and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death . Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting Documentation of End-of-Life Care . Time and date of death and all actions taken to respond to the impending death Name of health care provider certifying the death Persons notified of the death (e.g. health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death .Time of body transfer and destination Any other relevant information or family requests that help clarify special circumstances. Resident #14 Record review on 5/5/15 revealed a nurses' note written on 2/10/15 at 12:15 a.m. by Staff A (LPN), that stated Res. passed at 2250 RN pronounced Family, hospice, dr. updated, Interview with Staff B (Director of Nursing) on 5/5/15 at approximately 1:15 p.m., confirmed that there was no documentation of who was present or responded to the death and who pronounced the death. The facility failed to follow the professional standards of practice for the pronouncing with end of life care for Resident #14. Resident #11. Record review on 5/5/15 of the physician orders [REDACTED]. [MEDICATION NAME] Tablet Give 2 mg by mouth every 4 hours as needed for moderate Pain rating 4-5 PRN (as needed) and [MEDICATION NAME] Tablet Give 4 mg by mouth every 4 hours as needed for severe Pain rating 6-10 PRN. Further review of this MAR indicated [REDACTED]. This was given although the order was written for [MEDICATION NAME] 2 mg as needed for a pain rating of 4-5. Another entry on this MAR for Resident #11 showed Hydrmorphone 4 mg was given on 5/2/15 with a pain rating of 5. This was given although the order was written for [MEDICATION NAME] 4 mg as needed for a pain rating of 6-10. During interview on 5/5/15 with Staff B (Director of Nursing) after review of the above listed MAR, physician order [REDACTED].#11, Staff B agreed that the PRN physician pain medications orders were not administered following the parameters of pain rating and no documentation was found to indicate that Resident #11 had requested the specific individual dosage of the [MEDICATION NAME] outside of the pain rating parameters ordered. Resident #15 Record review of Resident 15's Order Summary Report dated 4/2/15 revealed an order for [REDACTED]. These findings were reviewed with Staff A (LPN) on 5/5/15. Review of the Order Summary Report reveals on Page 4 of 4 that it was signed under the statement I have approved these orders for by the practitioner on 4/21/15.",2018-12-01
924,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2015-11-18,152,D,0,1,6HIW11,"Based on record review and interview the facility failed to obtain DPOA consent for medical care/treatment for 1 resident in a survey sample of 17. (Resident #6) Findings include: Record review revealed a physician activated DPOA change for Resident #6 on 5/17/13 from the primary DPOA to the secondary DPOA. Activated DPOA statement from the read, .is incapable of making independent informed healthcare decisions. On 10/18/15 an informed consent for the Influenza vaccine was signed for approval with an X by the resident and documentation on this consent by Staff E (RN) stated, Resident could not sign name, made an X and was witnessed by Staff E. Interview with Staff A (DON) on 11/17/15 at approximately 1:15 p.m. who confirmed that Resident #6 continues to have a DPOA who is the authorized person to make informed healthcare decisions regarding this resident.",2018-12-01
925,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2015-11-18,309,E,0,1,6HIW11,"Based on medical record review and interview it was determined that the facility failed to establish a coordinated hospice plan of care which included identifying the care and services the facility and individual hospice would provide in order to be responsive to the unique needs of the resident and failed to ensure that the facility and the individual hospice are aware of the other's responsibilities in implementing the individualized plan of care for 4 hospice residents in a survey sample of 17. (Resident identifiers are #1, #2, #5 and #12.) Findings include: Review of medical records on 11/16/15 thru 11/18/15 for Residents #1, #2, #5 and #12 revealed that the facility and the individual hospice agency failed to establish a coordinated plan of care for Residents #1, #2, #5 and #12 that detailed a description of the scope and frequency of physician ordered services provided by the individual hospice agency for frequency of the skilled nurse, licensed nursing aide, social worker, spiritual and volunteer hospice staff providing services to these residents. Review of these 4 hospice residents' medical records revealed incomplete documentation of a collaborated plan of care with assessments and measurable goals and interventions for the individual disciplines listed above and the delineation of the palliative and supportive care that is to be provided and a determination of the disciplines at the facility and/or the hospice agency who will provide these services. Interview on 11/17/15 at 12:40 p.m. with Staff A (Administrator) reviewed the above listed hospice plans of care and Staff A confirmed that although the facility and hospice agency meet regularly to coordinator care, these plans of care need to be individualized and need to be integrated between the hospice provider and facility explaining what each provider is responsible for doing for each hospice resident.",2018-12-01
926,MINERAL SPRINGS,305084,1251 WHITE MOUNTAIN HIGHWAY,NORTH CONWAY,NH,3860,2015-11-18,441,D,0,1,6HIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview the facility failed to clean resident shared equipment with proper cleaning techniques for 1 of 3 glucometers. Findings include: References: Obtained on-line 11/20/15 at http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#unsafe, under Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration - Blood Glucose. Also, in the above document under Additional Information on pages 7 and 8 refers to the following resource: FDA Communication: Leter for Manufacturers of Blood Glucose Monitoring Systems Listed with the FDA most current update (MONTH) 2, 2012 and is found on-line at http://www.fda.gov/MedicalDevices/Productsand MedicalProcedures/InVitroDiagnostics/ucm 5.htm. Page 2 under section 2 Validated cleaning and disinfection procedures states: .Please note that 70% [MEDICATION NAME] solutions are not effective against viral bloodbourne pathogens . A list of Environmental Protection Agency (EPA) registered disinfectants effective against Hepatitis B can be found at the following website: http://www.epa.gov/oppadpp1/list_d_hepatitisbhiv.pdf. Interview with Staff D (LPN) on 11/17/15 at 9:15 a.m. revealed that she/he cleans the shared resident glucometers between resident use with alcohol wipes. Interview with Staff A (DON) on 11/18/15 during infection control interview with Staff E (Corporate staff) present, both Staff A and Staff E confirmed that the facility staff are required to use bleach wipes between resident use of the glucometers. On 11/17/2015 at 9:05 am two interviews were conducted regarding the disinfection process of resident shared glucometers. Staff C (MNA) stated we clean glucometers with either bleach or alcohol wipes and Staff D (LPN) stated we clean glucometers with alcohol wipes. Staff A (DON) stated the nursing staff are to clean with bleach wipes",2018-12-01
927,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2015-11-04,155,D,0,1,MYEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to adhere to the State of New Hampshire's Chapter 137-J, WRITTEN DIRECTIVES FOR MEDICAL DECISION MAKING FOR ADULTS WITHOUT CAPACITY TO MAKE HEALTH CARE DECISIONS, Section 137-J:5 for 3 residents in a standard survey sample of 18 residents. (Resident identifiers are #7, #12 and #13.) Findings include: Review of New Hampshire state law for Advance Directives, Section 137-J:5, effective (MONTH) 21, 2009 reveals the following: - II. An agent's authority under an advance directive shall be in effect only when the principal lacks capacity to make health care decisions, as certified in writing by the principal's attending physician or APRN, and filed with the name of the agent in the principal's medical record. When and if the principal regains capacity to make health care decisions, such event shall be certified in writing by the principal's attending physician or APRN, noted in the principal's medical record, the agent's authority shall terminate, and the authority to make health care decisions shall revert to the principal. Resident #7 Record review on 11/2/15 of the document titled physician progress notes [REDACTED].#7 dated 1/12/14 was not complete and failed to have the section indicating It is my opinion that the above named resident is incapable of making informed decisions due to: . This section was not completed by the physician to indicate the reason why Resident #7 lacks the capacity to make health care decisions. Resident #12 Record review on 11/4/15 of the document titled physician progress notes [REDACTED].#12 dated 10/12/15 was not complete and failed to have the section indicating It is my opinion that the above named resident is incapable of making informed decisions due to: . This section was not completed by the physician to indicate the reason why Resident #12 lacks the capacity to make health care decisions. Resident #13 Record review on 11/4/15 of the document titled physician progress notes [REDACTED].#13 dated 10/14/13 was not complete and failed to have the section indicating It is my opinion that the above named resident is incapable of making informed decisions due to: . This section was not completed by the physician to indicate the reason why Resident #13 lacks the capacity to make health care decisions. During interview with Staff A (Director of Nursing) on 11/4/15 at approximately 9:40 a.m. Staff A reviewed the above listed document as well as the clinical records and verified that there was no documentation of assessments to determine that Resident #7's, Resident #12's and Resident #13's capacity for decision-making and no written statement by the physician to certify that residents lacked the capacity to make health care decisions prior to activating the Durable Power of Attorney for Health Care (DPOA-HC).",2018-12-01
928,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2015-11-04,223,G,0,1,MYEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon a facility investigation the facility failed to keep a resident from being verbally and emotionally abused resulting in the resident being agitated and falling resulting in a facial fracture for 1 out of sample resident in a standard survey sample of 18. (Resident identifier is #19.) Findings include: Review of the Resident #19's medical record revealed a nurse's note written by Staff H(LPN), on 3/29/15 revealed, .Resident fell at approximately 2145. (Resident) was sitting outside (pronoun omitted) room .and saw a staff member who (Resident) had been upset with earlier in the shift. (Resident) quickly stood and began yelling at (staff member), and started to turn towards .room, when .lost .balance, falling face forward into .room.face smashed into the floor with an audible crack Resident continued to be agitated at the sight of LNA, so prn (as needed) ABH ([MEDICATION NAME] and [MEDICATION NAME]) gel given at 2245 with little effect. Continue to monitor. Review of the X-ray reports with a triage date of [DATE], (YEAR) revealed a comminuted right hygrometric fractures with hemorrhage involving the right maxillary sinus as described. Review of the written synopsis by Staff J, (Former DON) revealed that on late Saturday (MONTH) 28, (YEAR), Staff I, LNA helped Resident #19 to the bathroom when other staff heard Staff I yelling at the Resident #19. Two nurses went to investigate and instructed Staff I not to go near Resident #19. Staff I continued to to be visible to Resident #19. Observation at this time revealed that Resident #19 was upset and agitated. Staff I was instructed several more times to not be visible at the nurses' desk due to the fact this was upsetting and agitating Resident #19. Staff I failed to follow these instructions. Resident #19 saw Staff I became agitated and stood up from chair falling face first onto the floor. On (MONTH) 30, (YEAR) call was placed to Staff I for immediate suspension pending investigation for abuse. Review of written warning dated 3/31/15 by Staff J revealed that the Resident was upset and agitated with (Staff I) 2 nurses heard (Staff I) yell at resident. Every time resident saw (Staff I) (Resident #19) became agitated , yelling and tried to get up out of w/c (wheel chair) to get to this LNA. (Resident #19) stated (pronoun omitted) 'was afraid of (Staff I) and wanted a restraining order' (Staff I) was told multiple times to keep away + out of sight + (Staff I) would not. (Resident #19) finally fell sustaining injury. The facility failed to protect the resident from verbal and emotional abuse.",2018-12-01
929,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2015-11-04,226,D,0,1,MYEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy, review of the incident report and interview the facility failed to protect and do a thorough investigation after a fall for 1 out of sample resident in a standard survey sample of 18 resident's. (Resident identifier is #19.) Findings include: Review of the Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy . 6 . a. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring . 7. The facility conducts a timely though investigation of any allegations of abuse, neglect, mistreatment, including injuries of unknown source, and/or misappropriate of resident property in accordance with all state and federal regulations 8. The facility protects residents from harm during the investigation a. This protection may include the suspension of employee(s)if alleged perpetrator(S). b. This protection may also include the removal of an employee from a care area to ensure the protection of the resident during the investigation process if the employees is an an alleged perpetuator. c. The facility makes referrals to the appropriate state agencies as appropriate to ensure the or resident property. A review of the Accident/Incident Management Policy New Hope Health Care System (Former Owner) Effective Date: (MONTH) 2011. Policy and Procedure reveals: 8. THE DNS (Director of Nurses) or designee conduct a thorough investigation of incident/accident. 9. The DNS or designee implements appropriate interventions to protect the resident and prevent re-occurrence. Review of the Resident #19's medical record revealed a nurse's note written by Staff H (LPN), on 3/29/15 revealed, .Resident fell at approximately 2145. (Resident) was sitting outside (pronoun omitted) room .and saw a staff member who (Resident) had been upset with earlier in the shift. (Resident) quickly stood and began yelling at (staff member), and started to turn towards .room, when .lost .balance, falling face forward into .room.face smashed into the floor with an audible crack Resident continued to be agitated at the sight of LNA, so prn (as needed) ABH ([MEDICATION NAME] and [MEDICATION NAME]) gel given at 2245 with little effect. Continue to monitor. Review of the X-ray reports with a triage date of [DATE], (YEAR) revealed a comminuted right hygrometric fractures with hemorrhage involving the right maxillary sinus as described. Review of the written synopsis by Staff J, (Former DON) revealed that on late Saturday (MONTH) 28, (YEAR), Staff I, LNA(Licensed Nurses Assistant ) helped Resident #19 to the bathroom when other staff heard Staff I yelling at the Resident #19. Two nurses went to investigate and instructed Staff I not to go near Resident #19. Staff I continued to to be visible to Resident #19. Observation at this time revealed that Resident #19 was upset and agitated. Staff I was instructed several more times to not be visible at the nurses' desk due to the fact this was upsetting and agitating Resident #19. Staff I ignored these instructions. Resident #19 saw Staff I became agitated and stood up from chair falling face first onto the floor. On (MONTH) 30, call was placed to Staff I for immediate suspension pending investigation for abuse. Review of written warning dated 3/31/15 by Staff J revealed that upset and agitated with (Staff I) 2 nurses heard (Staff I) yell at resident. Every time resident saw (Staff I) (Resident #19) became agitated , yelling and tried to get up out of w/c (wheel chair) to get to this LNA. (Resident #19) stated (pronoun omitted) 'was afraid of (Staff I) and wanted a restraining order' (Staff I) was told multiple times to keep away + out of sight + (Staff I) would not. (Resident #19) finally fell sustaining injury. During interview with Staff A, DON was unable to find the full investigation of the above noted incident. Staff A verbalized that it was reported to the Board of Nursing.",2018-12-01
930,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2015-11-04,279,D,0,1,MYEX11,"Based on record review and interview it was determined that the facility failed to develop a coordinated/integrated Plan of Care for 2 of 2 residents receiving Hospice services in a survey sample of 18 residents. (Resident identifier's are #5 and #13.) Findings include: Record review from 11/2/15 through 11/4/15 revealed that Resident's #5 and #13 were receiving Hospice services. Record review revealed that the facility failed to show a coordinated Plan of Care as evidenced by not including or documenting the Hospice goals and interventions in order to ensure that facility staff is providing consistent care when Hospice staff are not scheduled in the facility. During interview with Staff A (RN) and Staff B (RN) on 11/4/15 after review of Resident's #5 and #13 medical record and review of each individual Hospice medical record it was determined that neither the facility nor the Hospice Plan of Care documents a coordinated/integrated Plan of Care to ensure Resident's #5, and #13's care needs are being provided and are met by either the facility staff or Hospice staff as ordered.",2018-12-01
931,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2015-11-04,431,B,0,1,MYEX11,"Based on observation and interview, it was determined that the facility failed to store medication properly in two medication carts on the West Wing and failed to discard outdated medications in one West Wing medication cart and in the facility medication room located on the West Wing. Findings include: Tour on 11/4/15 of one medication cart on the West Wing with Staff D, (RN), revealed a opened bottle of Acidophilus that stated Refrigerate once opened. Staff D indicated that no one no longer uses it. Tour of the second medication cart on the West Wing revealed 2 bottles of Acidophilus and a bottle of Folic Acid 400 mcg (micrograms) that had expired on 10/2015. Staff F, (LPN) indicated that no one no longer uses the Acidophilus and that the medication carts are gone through at least once a week for expired medications. Tour of the facility medication room revealed a 500 mg Calcium 100 tab bottle that expired on 10/15. Interview with Staff D at this time Staff D indicated that the facility medication room gets a spot check weekly by staff and then by the pharmacist.",2018-12-01
932,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2015-11-04,465,D,0,1,MYEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the manufacturer's instructions the facility failed to maintain the facility [MEDICATION NAME] in a safe operating condition. Findings include: Review of the facility's Tropic Heater ., Ability One [MEDICATION NAME] manufacturer's cleaning instructions provided at the time of survey revealed that Routine Cleaning should be done every 2 weeks or as needed. Review on 11/4/15 of the facility [MEDICATION NAME] MANAGEMENT logs that indicate the DATE, TEMPERATURE, WATER ADDED, CLEANING/WATER CHANGE, SIGNATURE from 2/23/15 through 10/30/15 revealed no evidence of completed cleaning every 2 weeks of the [MEDICATION NAME] unit during this time period. During interview with Staff C (Director of Rehabilitation of Operational Duties) on 11/4/15 at approximately 3:00 p.m., Staff C reviewed the above listed [MEDICATION NAME] logs and manufacturer's instructions. Staff C agreed that the hydocollator log was not accurate in that there was no evidence that this unit was cleaned every 2 weeks. The facility failed to follow the manufacturer's instructions to clean the facility [MEDICATION NAME] every 2 weeks.",2018-12-01
933,BEDFORD NURSING & REHABILITATION CENTER,305086,480 DONALD STREET,BEDFORD,NH,3110,2015-11-04,503,B,0,1,MYEX11,Based on review of the facility Clinical Laboratory Improvement Amendment (CLIA) certificate it was determined that the CLIA certificate was not current and updated. Findings include: Review of the facility CLIA certificate provided at the time of the recertification survey conducted from 11/2/15 through 11/4/15 revealed the following information: LAUREL CENTER NEW HOPE HEALTHCARE SYSTEM BEDFORD LLC . The facility failed to update the CLIA certificate for the present long term care facility during the transition of new ownership.,2018-12-01
934,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2015-09-23,154,B,0,1,L6TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined the facility failed to fully inform representatives of residents diagnosed with [REDACTED]. (Resident identifiers are #6, #12, #13, and #14) Findings include: Resident #12 Review of Resident #12's record revealed a Physician's telephone Medication Order dated 6/26/14 documented begin [MEDICATION NAME] 2.5 mg. q (each) day @ bedtime. Review of the Medication Administration Record [REDACTED]. 1 tab by mouth at bedtime for [MEDICAL CONDITION] (medication atypical class). Further review of Resident #12's MEDICATION ORDERS FOR [REDACTED]. 1 tab by mouth to be given every day PRN (as needed) for [MEDICAL CONDITION]. Review of the facility document entitled INFORMED CONSENT FOR THE USE OF PSYCHOACTIVE MEDICATIONS ZYPREXZA / [MEDICATION NAME] documents: The drug is used for the following reasons: SHORT TERM treatment of [REDACTED]. The consent form also documents: It is also important that you know that though this drug may help control or alleviate certain behaviors and /or symptoms that it also has several side effects should be considered. These could include but are not limited to the following: [MEDICAL CONDITION] NEUROLEPTIC, MALIGNANT SYNDROME, TIA-([MEDICAL CONDITION]), STROKE, IN ELDERLY PATIENTS WITH DEMENTIA, HALLUCINATIONS, DREAMING and TREMORS I understand the drug [MEDICATION NAME] is being used in the treatment of [REDACTED].#12.) This is signed by Resident #12's representative on 6/26/2014. There was no evidence to support that the resident or resident's representative was informed the Black Box warning specific to the increased risk of mortality in patients who have a [DIAGNOSES REDACTED]. Resident #6: Record review on 9/21-23/15, and interview 9/22/15 with Staff #A (DON), revealed that there was no evidence to support that the resident or resident's representative was informed of the increased risk of mortality in patients who have a [DIAGNOSES REDACTED]. Black Box Warning). The INFORMED CONSENT FOR THE USE OF PSYCHOACTIVE MEDICATIONS for [MEDICATION NAME]/QETIAPINE [MEDICATION NAME] does not contain wording to indicate the increased risk. The top section of the consent form indicates the customary warnings for any person taking [MEDICATION NAME], and was signed by the resident's representative. There is a section at the bottom of this consent form for the resident or resident's representative to sign indicating that they had received the information on this increased risk (Black Box Warning). The section was not signed. On 9/21/15 [MEDICATION NAME] was discontinued for Resident #6. Resident #14: Record review and interview with Staff #A DON, revealed that there was no evidence to support that the resident or resident representative was informed of the increased risk of mortality in patients who have a [DIAGNOSES REDACTED]. The INFORMED CONSENT FOR THE USE OF PSYCHOACTIVE MEDICATIONS for [MEDICATION NAME]/[MEDICATION NAME] does not contain wording to indicate the increased risk. As per interview with Staff #A DON, the consent form for the [MEDICATION NAME] was an older form and did not have a place for the responsible party to sign indicating that they had received information on the increased risk of mortality in patients with dementia who are prescribed antipsychotic medications. Resident #13 Record review and interview with Staff A it was determined the facility failed to fully inform Resident #13's DPOAH of the 'black box' warning by the Food & Drug Administration (FDA) regarding the use of [MEDICATION NAME]. Review of Resident #13's medical record revealed: A) A document titled Informed Consent For The Use of Psychoactive Medications dated 3-1-15 had documentation that the Durable Power of Attorney for Healthcare (DPOAH) was notified of the order and verbal permission was given. Signature of staff present. No date and time of the signature was present. At the bottom of the document at the section FDA Letter, no documentation was present that the letter was discussed with the DPOAH over the phone. B) Progress Notes with entry dated 3-1-15 and timed for '1640' indicates that the author of the note spoke with the DPOAH regarding the use of [MEDICATION NAME]. No documentation was noted that the DPOAH was made aware of the FDA Letter warning.",2018-12-01
935,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2015-09-23,281,D,0,1,L6TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review of medical record and the facility's Policy & Procedure it was determined that the facility failed to follow the professional standard of practice for 1 resident in a survey sample of 20 residents. (Resident identifier is #3.) Findings include: Medical record review for Resident #3 revealed in the Physician order [REDACTED]. Current Mountain View Community Policy titled Medication Administration-Enteral; section Procedure; Step #3 Each medication is to be prepared for separate administration, unless the physician has authorized that medications may be co-administered or 'cocktailed'. Step #6 Check the placement of the tube by aspiration of contents or auscultation. Review of the Medical Administration Record (MAR) for the month of (MONTH) (YEAR) and Physician orders [REDACTED]. Observation of 9/22/15 during a medication pass with Staff D (Licensed Practical Nurse) at approximately 8:10 a.m., Staff D collected the medications to be administered to Resident #3, crushed them individually, mixed them together, then diluted the combined powder with water. Staff D then flushed the [DEVICE] with water and then administered the medication cocktail. After the medication cocktail had been instilled, the tube was then flushed with water. During this observation Staff B did not ascultate for placement of the [DEVICE] nor did Staff D aspirate for residual stomach contents.",2018-12-01
936,MOUNTAIN VIEW COMMUNITY,305087,93 WATER VILLAGE ROAD,OSSIPEE,NH,3864,2015-09-23,371,F,0,1,L6TM11,"Based on observation and interview the facility failed to store, prepare, distribute and serve food under sanitary conditions. Findings include: On 9/21/15 at approximately 10 a.m. during tour with Staff C (Food Service Director) of the facility's kitchen it was observed that the can opener and meat slicer contained dried on food particles on the areas that come into direct contact with food during food preparation. It was also observed that the sanitation sink for pots and pans, when tested for required PPM (parts per million) of sanitizer (iodine), the litmus paper did not change color which indicates the lack of sanitizer. Interview with the Staff C on 9/21/15 at approximately 10:30 a.m. confirmed these findings.",2018-12-01
937,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-02-10,154,D,0,1,JTW811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide written information regarding the side effects and the potential for increased mortality (Black Box Warning) to 2 of 4 residents receiving [MEDICAL CONDITION] medications. (Resident identifiers are: #8 and #11 ) Findings include: Resident #8 On 2/10/16 at 9:30am record review and interview with Staff C (RN) indicated a psychoactive medication informed consent form indicating I do desire to receive this medication, signed by the Resident #8 on 10/30/14. This form did not include a black box warning. Staff C produced a separate form that described the side effects and the potential for increased mortality (Black Box Warning). Verbal consent had been given from the DPOA as described on the bottom right hand corner of the fact sheet but it did not indicate the date of notification. This documentation was not signed by the DPOA. Resident #11 Review of this resident's Psychoactive Medication Informed Consent for prescribed [MEDICATION NAME] (an antipsychotic medication) reveals that this patient has Dementia w/Behavior Disturbance. The verbal consent was obtained by Staff C whose name is printed (as confirmed by interview with Staff C on 2/10/16) on the form as the Person Completing This Form, but the form lacks Staff C's signature and date of signature. Also, Possible Side Effects/Risks are listed as lethargy, gait instability, and a third illegible entry, but there is no documented information alerting patient's representative as to [MEDICATION NAME]'s Black Box Warning or increased risk of death in some persons.",2018-12-01
938,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-02-10,278,B,0,1,JTW811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview it was determined that the facility failed to coordinate the care between the LTC facility and the [MEDICAL TREATMENT] facility for 1 out of 12 residents, failed to properly assess for restraints for 1 out of 12 residents, and failed to correctly assess and document the continence status of 2 out of 12 residents. (Resident identifier's are #1, #3 and #9). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] with a stage 1 pressure ulcer (PU) which developed into a stage II PU while at the facility. The care plan in place states that there is a communication book that is to travel back and forth between the facility and the [MEDICAL TREATMENT] Center. A review of the communication book revealed [MEDICAL TREATMENT] Communication Forms that are to be filled out by the facility and the [MEDICAL TREATMENT] Center. At the top of the form there is a section that states: TO BE COMPLETED BY THE NURSING HOME, which has a section for vital signs (temperature, blood pressure, pulse, respiration rate and blood pressure) and also: ACUTE PROBLEMS SINCE LAST APPOINTMENT: (i.e., falls, skin tear, infection or significant incident). Forms were reviewed from date of admission to date of survey. The ACUTE . section was left blank on all the communication forms. On 1/18/16, the form returned to the facility from the [MEDICAL TREATMENT] center with the following comments: Patient complained of pain in coccyx throughout treatment-repositioned the patient several times-? (question) premedicating patient with pain meds pre treatment. There was nothing in the note to indicate that the [MEDICAL TREATMENT] center was aware of the pressure ulcer on the patient's coccyx area. Nutrition notes from 1/26/16 and 2/10/16 state respectively: .Attempted to contact [MEDICAL TREATMENT] RD/[MEDICAL TREATMENT] centers to review resident labs, diet and possible interventions for wound healing (unable to reach at this time); and, Attempted to reach RD at [MEDICAL TREATMENT] center to review resident labs and diet orders. Unable to reach RD at this time. Plan: will attempt to f/u at a later date. There were no notes from the nutritionist conveying these concerns via the [MEDICAL TREATMENT] communication book, nor was the nutritionist successful in contacting the [MEDICAL TREATMENT] center via other means. As a result of the lack of two way communication regarding the pressure ulcer on Resident #3's coccyx area, the resident sat for a complete [MEDICAL TREATMENT] treatment on 1/18/16 complaining of discomfort. The resident's care plan includes: Follow up with [MEDICAL TREATMENT] RDN to review therapeutic diet, labs, meds, weights, with follow up as needed. There are no care plan follow up directions for [MEDICAL TREATMENT] concerning the resident's pressure ulcer and care. Resident #9 Review of the clinical record on 2/10/16, revealed a Bladder and Bowl Assessment completed on 2/6/16 that indicates the resident is Always Continent in section A1: Urinary Continence and Always Continent in section A2: Bowel Continence. In section B4, the assessment indicated that the resident has been incontinent of bladder for over 1 year. In section B4a, the assessment indicated that the resident has been incontinent of bowel for over 1 year. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident is frequently incontinent of bladder and continent of bowel. Interview with Staff C (DON) on 2/10/16 at 4:30 p.m. revealed that the resident is occasionally incontinent of bladder and bowel. Resident #1 Review of this resident's Annual MDS assessment with an ARD (Assessment Reference Date) of 8/30/15 revealed that the resident was occasionally incontinent of bowel, and frequently incontinent of urine. The Quarterly MDS with an ARD of 11/12/15 revealed that the resident on this assessment was frequently incontinent of both bowel and urine. On both MDS assessments it was coded that the resident did not have a toileting program. Interview with Staff C, RN during survey revealed that this resident takes instruction well and Staff C thinks the resident could benefit from a toileting program, and that it was an oversight and after it triggered on the MDS for increased incontinence the resident would normally have had a 3-day bowel and bladder (assessment), which the resident didn't get but Staff C related it would be started. Observation of Resident #1's room on 2/9/16 and 2/10/16 revealed their bed was positioned against the wall. Review of the Physician Admitting Orders of 10/1/14 reveals an order for [REDACTED]. Review of Restraint/Positioning Assessments reveals that Item 5.E. Is the Residents bed against the wall? was correctly documented as Yes on the 10/1/14, 12/11/14, and 8/14/15 assessments, but incorrectly documented as No on the assessments of 3/6/15, 5/21/15, 11/5/15, and 2/2/16.",2018-12-01
939,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-02-10,279,D,0,1,JTW811,"Based on record review and interview, it was determined that the facility failed to develop a care plan that was comprehensive for 1 resident in a survey sample of 12 residents. (Resident identifier is #1.) Findings include: Resident #1 Review of this resident's Annual Minimum Data Set assessment, with an Assessment Reference Date of 8/20/15 revealed that one of the Care Areas that triggered was Mood State, and in the related Care Area Assessment it was revealed the resident has a history of depression and the Care Area of Mood State would be care planned. Subsequent review of the resident's current care plans revealed there was no care plan developed for Mood State. There was a comprehensive care plan for antidepressant medication, but its interventions did not include non-pharmaceutical interventions to address the patient's Mood State. Interview with Staff C, RN on 2/10/16 confirmed that there was no mood/depression care plan and it was not done due to oversight. Record review reveals the facility initiated a mood issues care plan on 2/10/16.",2018-12-01
940,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-02-10,281,D,0,1,JTW811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, it was determined that the facility failed to ensure professional standards of clinical practice were followed for administration of medications, for one out-of-sample resident and one sampled resident, in a survey sample of 12 residents. (Resident identifiers are #11 and #13.) Findings include: Resident #11 Review of this resident's Medication Record for the month of (MONTH) (YEAR) revealed two orders for [MEDICATION NAME]: [MEDICATION NAME] 650 mg orally three times daily, and Tylenol suppository 650mg rectally every 4 hours as needed for pain or temp greater than 101F, not to exceed 2GM/24HRS. On 2/1/16, the MAR indicated [REDACTED]. This was confirmed by interview on 2/10/16 with Staff C, RN. These four doses total more than the 2 gram daily maximum listed on the Medication Record. Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following: On page 336-Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Resident #13 During observation of the morning medication pass and record review on 2/9/16 at 10:00am, Staff E (MNA) did not give the prescribed medication [MEDICATION NAME] 250mg. Give one capsule orally twice a day x 1 month to Resident #13. Staff E confirmed that this medication was not available and had not been ordered. A review of the Medication Administration Record [REDACTED]. Staff E indicated that she had been able to borrow pills from another house stock bottle for the morning doses but there were not any left as of this morning the 9th of Feb.",2018-12-01
941,COLONIAL POPLIN NURSING HOME,305091,442 MAIN STREET,FREMONT,NH,3044,2016-02-10,441,E,0,1,JTW811,"Based on observation and interview the facility failed to establish infection control measures in the therapy department as indicated by breaches in the integrity of an exercise foam mattress. Findings include: Observation on 2/9/16 at 9:30 am of a raised exercise mat located in the Therapy gym, revealed 3 tears on the right side edges and one tear in the middle of the mat, all about an inch in length. The foam beneath the vinyl covering was exposed. Interviews on 2/9/16 with Staff F (Director of Rehab), Assistant, Staff G (Maintenance) and Staff A (Administrator) were not aware of the breach of the integrity of the mat and confirmed the above.",2018-12-01
942,BEL-AIR NURSING AND REHAB CENTER INC,305096,29 CENTER STREET,GOFFSTOWN,NH,3045,2015-12-01,223,D,1,0,0VO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to protect 1 resident from sexual abuse and other residents from potential abuse. Resident #1. Self reported incident received via fax on 10/31/15 and follow up to investigation was completed and submitted via fax on 11/4/15. Staff A (LNA) entered Resident #1's room to find the curtain 1/2 drawn - on the resident side of the curtain she witnessed Staff B (LNA) with his mouth on the breast of an [AGE] year old female resident. Staff B was asked to leave the resident's room and Staff A made a report to the RN supervisor. Staff C (RN Supervisor) called Staff D (DON) and notified of the incident that was just witnessed by Staff A. Staff D advised Staff C to escort Staff B out of the building pending an investigation. Local police were notified and arrived at the facility to investigate this report of sexual abuse. A site visit was made to the facility based on a self report of sexual abuse by a facility employed LNA where it was determined that Staff B did in fact, put his mouth on the resident's breast. Staff B's employee file was reviewed and found to be in order with training's (abuse, fire, infection control, etc.), as well annual evaluations were average, references were all positive and Staff B got along well with others and provided good care to the residents. Staff B had been employed at this facility since 2012 and did have 1 disciplinary document in his personnel file that was not related to this type of incident. This incident was documented as having taken place at 11:30 a.m. - according to a phone interview on 12/1/15 at 12:15 p.m. with Staff A who confirmed that she had Staff B assist with transferring the resident out of bed and into the resident's wheelchair after the incident. Staff A then transported the resident to the activity room for lunch. Staff A stated that she made a phone call before reporting the incident to the RN Supervisor but that the phone call only lasted a few seconds. When asked where Staff B was while she was making the phone call and notifying her supervisor Staff A stated, (Staff B) was still transporting residents to the dining room for lunch. When asked what time Staff B was escorted out of the facility she stated she did not remember. Staff C (RN Supervisor) confirmed on 12/1/15 at 12 noon that Staff A requested to make an important phone call to one of Staff A's family member. Interview with Staff C revealed that Staff A called the family member to obtain advise on what to do and was told by the family member to report this incident immediately. Upon Staff A reporting the incident to Staff C, Staff C called Staff D (DON) to notify of the incident and receive instructions. When Staff C was asked where Staff B was from the time he was observed with his mouth on the resident's breast until he was escorted out of the facility, Staff C stated that Staff B was assisting in the dining room as it was lunch time and You can't have a staff person leave without having a replacement. A copy of Staff B's time card revealed he punched out at 12:20, which was 50 minutes after the incident was witnessed by Staff A. Staff B admitted to Staff C that he had in fact put his mouth on the residents breast and stated I know it's sick - I need help. Staff C was asked what care was provided to the resident following this incident, Staff C stated that she assessed the resident for injury/s and found no bruising or mark (s) noted to them (breasts). The resident did have a change in behavior but documentation supports the resident had recently had a Gradual Dose Reduction (GDR) of her antipsychotic medication(s) and it was believed that this change in behavior was directly related to the GDR and not the abuse. These behaviors did resolve shortly after they started.",2018-12-01
943,BELKNAP COUNTY NURSING HOME,305101,30 COUNTY DRIVE,LACONIA,NH,3246,2015-12-09,282,D,1,0,UP8011,"> Based on review during the Abuse & Neglect protocol of a facility investigation and Interview with Staff A, Social Services, it was determined the facility failed to ensure a resident plan of care was followed resulting in a fall for 1 resident in a standard survey sample of 18. (Resident Identifier is #1) Findings include: Review of Resident #1's care plan goal dated 1/27/15, in the Section Activities of Daily Living reveals, it addresses eating and after eating - specific to use of the the Tilt and Space (Broda Chair), Eating - Total assist, encourage (Resident #1's) participation as able. Must be in Tilt and Space chair for all meals. Tilt and Space chair to be tilted to setting 25 (upright position) when eating. Supervise at all times when in this position. Hold resident's head in midline as (Resident #1) allows and assist with feeding as needed. Further review- of the Care Plan directs .Return Tilt chair to prior position after meals. Keep Tilt and Space chair in full tilt when not eating or participating in activities . During the Abuse & Neglect protocol interview with Staff A, Social Services confirmed the facility investigation regarding Resident #1's fall, determined that on 11/29/15 The LNA Staff #B brought Resident #1 to the dayroom at 9:24 a.m.for breakfast Staff #B assisted feeding Resident #1 then left the dayroom. The facility Investigation reports; Resident #1 was seated in the Broda chair which was in the upright position as care planned for during meals; however the facility determined the chair was not reclined as required following the meal. Review revealed Resident #1 reached for the cup of coffee leaning too far forward. Resident #1 fell out of the Broda Chair on 11/29/15 at approximately 11:00 a.m. The investigation documents the table appeared to break the fall, and Resident #1 sustained an abrasion to the lip and bruise to the right arm. Staff B failed to follow the Resident's Plan of Care to ensure the Resident's Broda chair was returned to the full tilt reclined position following meals failing to prevent an accident.",2018-12-01
944,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2015-11-04,154,C,0,1,F58C11,"Based on medical record review and interview, it was determined that the facility failed to ensure that residents on antipsychotic medications have documented evidence that the risks and benefits of the medication had been explained to them including the black box warnings for 11 residents in a survey sample of 23. (Resident identifiers are #1, #2, #3, #4, #7, #8, #9, #10, #11, #18 and #22.) Findings include: Review of the consent form for antipsychotic medications for Residents #1, #2, #3, #4, #7, #8, #9, #10, #11, #18 and #22 revealed the following statement: I have been notified of each of these drug actions and their most common side effects. I do understand I have the right to question the doctor or nurse for further clarification. This consent form did not include a list of risks and benefits of the medication(s) nor did it include the black box warning for the medication(s). Interview on 11/3/15 10:30 a.m. with Staff A (Director of Nursing) reviewed the antipsychotic medication consent form and confirmed that the consent form did not include risks and benefits nor the black box warning for the use of the medication(s).",2018-12-01
945,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2015-11-04,356,C,0,1,F58C11,"Based on observation and interview the facility failed to post daily nurse staffing data to include name of the facility, current date, total numbers of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift and resident census in a prominent place where residents and visitors can view. Findings include: On 11/2/2015 during observation of the facility entrance and on all units, no daily staffing data was posted. Staff A, DON confirmed the above.",2018-12-01
946,GLENCLIFF HOME FOR THE ELDERLY,3e+60,393 HIGH STREET,GLENCLIFF,NH,3238,2015-11-04,465,D,0,1,F58C11,"Based on observation and interview the facility failed to provide an environment that is safe for residents. Findings include: During tour of the first level Green unit on 11/02/15 at 10:30am, the tub room was observed to contain 2 spray bottles of disinfectant (Oxivir 516 concentrate) hanging from a wire wrack next to the tub. Staff B (Housekeeping), Staff C (LNA) and Staff D (RN) confirmed the observation and the disinfectant was removed and put in a locked cabinet. Review of MSDS (Material Safety Data Sheet) indicates this product may be harmful if swallowed and causes moderate eye irritation.",2018-12-01
947,COOS COUNTY NURSING HOSPITAL,3e+77,136 COUNTY FARM ROAD,WEST STEWARTSTOWN,NH,3597,2015-10-29,160,C,0,1,NZOD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident trust fund and interview it was determined that the facility failed to convey resident funds within 30 days to the estate of the individual probate jurisdiction administering the resident estate for 7 out of sample residents. (Resident identifiers are #17, #18, #19, #20, #21, #22 and #23). Findings include: Review of deceased resident's accounts on [DATE] at approximately 12:30 p.m. revealed that Resident's #17, #18, #19, #21, #22, and# 23's probate paperwork had been filed after the 30 day limit. Review of accounts revealed the following: Resident #17 had expired on [DATE] with a balance of $40.97 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #18 had expired on [DATE] with a balance of $25.12 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #19 had expired on [DATE] with a balance of $419.43 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #20 had expired on [DATE] with a balance of $94.34 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #21 had expired on [DATE] with a balance of $581.68 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #22 had expired on [DATE] with a balance of $1433.66 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #23 had expired on [DATE] with a balance of $94.34 remaining in this resident's account. Probate paperwork was filed on [DATE]. Interview with Staff D (Business Office Manager) on [DATE] at approximately 12:45 p.m., verbally confirmed the facility failed to convey resident funds within 30 days of demise.",2018-12-01
948,COOS COUNTY NURSING HOSPITAL,3e+77,136 COUNTY FARM ROAD,WEST STEWARTSTOWN,NH,3597,2015-10-29,458,B,0,1,NZOD11,"Based on interview and observation the facility failed to have 6 resident bedrooms with the minimum required 80 square feet per resident. Findings include: Observations during survey on 10/27/15-10/29/15, revealed that residents' rooms #230, #304, #305, #312, #314, and #321 had limited space available and did not meet the regulatory requirement for square footage in a bedroom. Interview with Staff A (Administrator) on 10/27/15 at 11:00 a.m., confirmed that the aforementioned rooms do not meet the minimum requirement of 80 square feet per resident in a multiple resident room. The State Survey Agency has granted a waiver for the aforementioned rooms.",2018-12-01
949,"RIDGEWOOD CENTER, GENESIS HEALTHCARE",305052,25 RIDGEWOOD ROAD,BEDFORD,NH,3110,2016-01-08,281,D,0,1,QRK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to check placement of a [DEVICE] prior to administration of medication for 1 of 2 residents. (Resident #11). The Lippincott Manual of Nursing Practice, Ninth edition, in the box labeled Procedure Guidelines 20-1 on page 751, states, under nursing action, Preparatory phase . Using the catheter tipped syringe, inject 20-30cc of air while listening with a stethoscope positioned at the epigastric areas. Auscultation of a . bubbling sound assists in confirmation of proper tube placement. Findings include: Observation of medication administration to a [DEVICE] (Gastrostomy Tube) for Resident #11 on 1/6/16 at approximately 10 a.m. with Staff A (LPN) revealed that Staff A did not check for [DEVICE] placement prior to administration of medications. Interview with Staff A immediately after observation, Staff A stated she/he believed there was an order to check placement for Resident #11. Interview with Staff B (RN/Unit Manager) on 1/6/16 at approximately 10:45 a.m, who stated there is a policy in place for checking placement of [DEVICE]s and that Resident #11 does have an order for [REDACTED]. Review of facility policy and procedure entitled Medication Administration: Enteral with an effective date of 01/01/04, Revision date of 01/02/14, page 2 of 3 under #4 Verify tube placement and 4.1 entitled, For gastrostomy tube ([DEVICE]), percutaneous endoscopic gastrostomy (PEG) tube or nasogastic under section 4.1.2, states the following: Inject 10 ml air into the tube while listening for whooshing sound, section 4.1.2.1 states, If no whooshing sound is heard, stop procedure and notify physician/mid-level provider.",2018-11-01
950,MORRISON NURSING HOME,305094,6 TERRACE STREET,WHITEFIELD,NH,3598,2015-10-23,154,B,0,1,YIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to include the required FDA Black Box Warning notifying Residents and their representatives of an increased risk of Sudden Death associated with the use of Anti-Psychotic Medications for 3 of 5 sampled Residents diagnosed with [REDACTED].#6, #10, and #14. Findings include: The Centers for Medicare & Medicaid released Survey & Certification Letter S&C 13-35 dated (MONTH) 24, 2013, which applies a mandatory FDA Black Box Warning to Nursing Home Providers for nursing home residents with [DIAGNOSES REDACTED]. Resident #6 Review of medical records revealed a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. BY MOUTH EVERY MORNING (DX: DEMENTIA), and [MEDICATION NAME] (QUEtiapine [MEDICATION NAME]) 25 MG Tablet 2 Tabs (50 mg). BY MOUTH AT BEDTIME (DX: Dementia) Order date: 07/23/2014. Further record review revealed that there was no FDA Black Box Warning concerning use of [MEDICATION NAME] (QUEtiapine [MEDICATION NAME]) when prescribed for a Resident diagnosed with [REDACTED]. Resident #10 Record review on 10/23/15 revealed an INFORMED CONSENT FOR THE USE OF PSYCHOACTIVE MEDICATIONS for the antipsychotic [MEDICATION NAME]/[MEDICATION NAME] to be used in the treatment of [REDACTED]. Review of this consent form revealed verbal permission was given by the activated Power of Attorney on 9/22/13 for Resident #10. No dosage or frequency was listed for the antipsychotic [MEDICATION NAME] at this time. A second notation on this consent form revealed Med increased to TID (three times a day) with verbal permission listed by the Power of Attorney on 11/25/14. It should be noted that the 11/25/14 permission consent did not indicate the dosage for the antipsychotic [MEDICATION NAME]. Further review of this INFORMED CONSENT FOR THE USE OF PSYCHOACTIVE MEDICATIONS revealed no documented evidence that the Power of Attorney was informed of the FDA BLACK BOX WARNING for the increased risk of sudden death with the use of the antipsychotic [MEDICATION NAME]. Resident #14 Review of medical record on 10/13/2015 indicates a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. TABS I.E. [MEDICATION NAME] 1 TAB 0.5MG. BY MOUTH TWICE DAILY (a.m. and p.m.) FOR AGGRESSIVE/ INAPPROPRIATE BEHAVIOR *SHORT CYCLE MED* Order date 8/5/2015. Review of the Informed Consent for USE OF PSYCHOACTIVE MEDICATIONS does not fully inform the residents and/or their Representatives of the medication's risks, as the facility fails to document and include the required FDA BLACK BOX WARNING of an increased risk of death associated with the use of Antipsychotic medications used to treat residents diagnosed with [REDACTED]. Interview with Staff D (Administrator) on 10/23/2015 revealed that the facility's plan is to wait until the time each resident's quarterly Plan of Care meetings are held to fully inform and to obtain residents' and/or Resident representatives' signatures on a new Informed Consent which will include the FDA required Black Box warning. Staff D indicated the designated resident and or representatives signatures would be completed over the next 3 months/quarter. The Survey & Certification Letter 13-35 mandating the Black Box Warning requirement was released in (MONTH) 2013 with an effective date within 30 days of the (MONTH) 24, 2013 release date. Staff D confirmed there are 10 residents receiving Antipsychotic medication who are diagnosed with [REDACTED].",2018-11-01
951,MORRISON NURSING HOME,305094,6 TERRACE STREET,WHITEFIELD,NH,3598,2015-10-23,161,B,0,1,YIWW11,"Based on record review of the Resident Trust Fund and interview it was determined that facility failed to ensure that the Surety Bond was in the amount necessary to protect resident funds for 47 residents out of 52 whose funds are handled by the facility. Findings include: Review on 10/23/15 at approximately 10:00 a.m. of the Resident Review Trust Fund revealed that this account currently had a total of $18,779.24. Review of the Surety Bond, revealed that it was for $35,000 of coverage for the Resident Trust Fund. Review on 10/23/15 at approximately 10:15 am of the (MONTH) (YEAR) through (MONTH) (YEAR) bank statements daily ledger balances for the Resident Trust Fund revealed there were 19 days that the amount in the account was higher than the amount covered by the Surety Bond. The days of higher amounts were: 7/2/15 = $36,100.63, 7/7/15 = $36, 353.80, 7/9/15 = $36,383.80, 7/10/15 = $36,336.80, 7/14/15 = $35,637.80, 7/15/15 = $35,557.80, 8/3/15 = $39,417.56, 8/4/15= $38,512.13, 8/4/15 = $38,312.13, 8/7/15 = $38,192.13, 8/10/15 =$38,491.53, 8/11/15 = $38,199.53, 8/13/15 = $36,623.26, 8/14/15 = 37,460.65, 9/3/15 = .36, 9/4/15 = 36,805.36, 9/9/15 = $38,077.36, 9/10/15 =$37, 294.56, 9/11/15 = $37,183.56. Interview on 10/23/15 at approximately 10:30 am with Staff E (Finance Director) confirmed that on these days the amount was higher than the amount covered by the Surety Bond.",2018-11-01
952,MORRISON NURSING HOME,305094,6 TERRACE STREET,WHITEFIELD,NH,3598,2015-10-23,281,D,0,1,YIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow the professional standards of practice for the administration of narcotic medication for 1 Resident in a survey sample of 14 Residents. (Resident identifier is #12) Findings include: Resident #12 Review of the facility policy and procedure for the professional standard of practice for the administration of narcotic medications revealed the following: CONTROLLED SUBSTANCES Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility, in accordance with federal and state laws and regulations. Procedures . D. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and/or the medication administration record (MAR): 1. Date and time of administration. (MAR, Accountability Record) 2. Amount administered. (Accountability Record) 3. Remaining quantity. (Accountability Record) 4. Initials of the nurse administrating the dose, completed after the medication is actually administered. (MAR, Accountability). Record review on 10/22/15 of the facility Narcotic Book on the(NAME)Unit revealed on page #50 the medication order for [MEDICATION NAME] 5MG TABLET 1-2 Tabs (5-10MG) BY MOUTH EVERY 6 HOURS AS NEEDED FOR PAIN for Resident #12 . Further review revealed the following: Date;10/18/15, Time 0245; Amount on Hand 31, Amount Used one, Method PO (by mouth), Amount left 30 Date 10/20/15, Time 0500, Amount on Hand 30, Amount Used one, Method PO (by mouth), Amount left 28. The above listed documentation revealed that the amount of [MEDICATION NAME] left were 30 tablets on 10/18/15 and the next entry on 10/20/15 revealed One [MEDICATION NAME] given at 0500 which would leave 29 and not 28 tablets as documented in the Narcotic Book on page #50. During interview and review of the above listed findings by Staff A (Director of Nursing) and Staff B (Assistant Director of Nursing) on 9/22/15, Staff A and Staff B verbally confirmed that the documentation of the tablet count for [MEDICATION NAME] on 10/20/15 is incorrect and that 30 tablets minus one would equal 29. During this interview, the back of the Medication Administration Record (MAR) for Resident #12 was reviewed with Staff A and Staff B and revealed that on 10/20/15 at 0500 PRN OXY 5 mg po for pain 8/10 was given to Resident #12. This documentation did not indicate one tablet or two tablets. The documentation in the Narcotic Book for Resident #12 revealed one tablet given and the total [MEDICATION NAME] tablet count 28 on 10/20/15 at 0500. The facility failed to accurately document the amount (number of tablets) [MEDICATION NAME] given to Resident #12 in the Narcotic Book and back of the MAR and failed to ensure that the remaining quantity of [MEDICATION NAME] tablet count was correct with the given documented findings listed above for Resident #12.",2018-11-01
953,MORRISON NURSING HOME,305094,6 TERRACE STREET,WHITEFIELD,NH,3598,2015-10-23,465,D,0,1,YIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the manufacturer's instructions it was determined that the facility failed to maintain the facility [MEDICATION NAME] in a safe operating condition. Findings include: Review of the manufacturer's instructions for use of the facility Chattanooga [MEDICATION NAME] revealed the following: SAFETY PRECAUTIONS . Never adjust the thermostat too high. The recommended operating temperature is 160 degrees F to 165 degrees F (71 degrees to 74 degrees C). The temperature of the water should be checked with a thermometer after every adjustment, before using the HotPac. Always allow sufficient tie for the water temperature to stabilize . MAINTENANCE . Water is constantly lost during operation due to evaporation. Therefore, it is essential that water be added daily. The tank should also be drained and cleaned systematically, at a minimum every two (2) weeks . Chlorine means death to stainless steel. No bleach or any cleaner with high chlorine content . Cleaning Tips 1. The interior of the unit should be scoured, usually every two weeks, using a low abrasive bathroom cleaner. Check for low or no chlorine content in your cleaner and make sure that the residue is thoroughly rinsed away with water . Observation on 10/23/15 in the rehabilitation room revealed a facility Chattanooga [MEDICATION NAME] unit. Review of the facility [MEDICATION NAME] TEMPERATURE AND CLEANING CHECKS schedule revealed that on 9/8 the temperature was 171 degrees with the intervention turned down thermostat. On 9/9 the temperature was documented as 162 degrees and crossed out with the intervention Held pt tx patient treatment, another entry on 9/9 documented 162 degrees with the intervention listed as turned up a little. Further review of this schedule revealed on 9/14 the temperature was 168.3 degrees with the intervention added H2O (water), on 9/15 the temperature was 168.0 degrees with the intervention Turned down a little, on 10/14, 166.7 degrees, on 10/16, 166.7 degrees, on 10/19 166.7 degrees and on 10/20 168.3 degrees with no interventions listed for theses dates. The schedule revealed on 10/21 this unit was CLEANED, on 10/22 the temperature was 168.5 and the intervention was :Turned down/Disinfected and on 10/23 the temperature was 72.8 with the intervention listed as turned up. The facility failed to maintain this [MEDICATION NAME] within the acceptable temperature ranges, failed to ensure that the temperature of the water was safe and within range after any adjustment and failed to clean the [MEDICATION NAME] at least every two weeks from 9/8/15 through 10/20/15. During interview with Staff C (Director of Rehabilitation) on 10/23/15 at approximately 12:00 noon, Staff C verbally confirmed the above listed findings and was unable to show that any follow up temperature's were done when an intervention was completed following an out of range temperature. Staff C was not able to provide any other documentation for temperature, interventions and cleaning done on this facility [MEDICATION NAME] before 9/8/2015 as listed in the above findings.",2018-11-01
954,"LACONIA CENTER, GENESIS HEALTHCARE",305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2015-06-12,226,E,0,1,NC8Y11,"Based on record review and interviews, the facility failed to follow its policy and procedure on training employees on procedures related to abuse prohibition practices for 4 of 10 sampled employees. Findings include: During an interview with Staff B (Housekeeper) on 6/11/15 at 2:00 pm, Staff B revealed that she did not receive abuse training or review an abuse policy or protocol. Staff B had been working at the facility approximately one year. During an interview with Staff C (Housekeeper) on 6/11/15 at 2:30 pm, Staff C revealed that she did not receive abuse training or review an abuse policy or protocol. Staff C had been working at the facility approximately 3 weeks. During an interview with Staff D (Housekeeper) on 6/11/15 at 2:45 pm, Staff D revealed that she did not receive abuse training or review an abuse policy or protocol. Staff D had been working at the facility approximately one year. During an interview with Staff E (Housekeeping/Laundry Manager) on 6/11/15 at 3:30 pm, Staff E revealed the abuse policies are part of the employee handbook and employees sign off that they have read and understand the handbook prior to working. Review of employee records on 6/11/15 revealed that Staff B, Staff C, and Staff D did not sign their employee handbooks.",2018-10-01
955,"LACONIA CENTER, GENESIS HEALTHCARE",305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2015-06-12,281,D,0,1,NC8Y11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #17). Findings include:During review of the medical record for Resident #17 a physician's orders [REDACTED]. [MEDICATION NAME] level every week (Wednesday) at [MEDICAL TREATMENT].Review of Resident #17's medical record revealed the last [MEDICATION NAME] level was drawn on 2/18/15. Staff A (Registered Nurse) was interviewed at the time of finding who confirmed the above finding. Staff A called the [MEDICAL TREATMENT] unit to see if other [MEDICATION NAME] levels had been drawn; but was told that no other levels had been drawn.,2018-10-01
956,"LACONIA CENTER, GENESIS HEALTHCARE",305040,175 BLUEBERRY LANE,LACONIA,NH,3246,2015-06-12,456,D,0,1,NC8Y11,"Based on record review and interview the facility failed to ensure that the daily monitoring for blood glucose meters was being completed and documented on a daily basis. Findings include: During the recertification survey on 6/10/15 and review of the facility's BLOOD GLUCOSE TESTING QUALITY CONTROL RECORD from JANUARY through FEBRUARY (YEAR), it was identified that there were many inconsistencies and lapses in documentation on the quality logs. Interview with Staff A (Registered Nurse) confirmed the above finding.",2018-10-01
957,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2015-09-30,154,C,0,1,XO8O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon resident record review the facility failed to inform 6 of 30 sampled resident's receiving antipschotic medication of the black box warning that the use of these medications increased their risk of serious side effects including death(Resident identifiers are #6,#8,#15,#23,#25 and #29) Findings include: Resident #29 Medical record review revealed an order for [REDACTED]. Resident #8 Medical record of review on 09/28/15 revealed Resident #8 has the following diagnoses; [MEDICAL CONDITION] and Senile Dementia. Resident #8's physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. by mouth at bedtime for agitation related to UNSPECIFIED [MEDICAL CONDITION] (298.8) Order date 6/26/2015. Record review of the facility form titled INFORMED CONSENT for USE OF [MEDICAL CONDITION] MEDICATIONS under the section Reason for use (list targeted behaviors/ symptoms: documents awake all noc (night). Under the Section Expected Benefits from use of the above medication(s): lists-improve sleep; decrease agitation, and decrease Hallucinations. Under the Section titled Possible side effects/risks associated with medication use: Documents the following, H/A- (head ache),dizziness, agitation, weakness, dry mouth, abd. (abdominal) pain. The consent is signed by Resident #8's representative dated 6/3/15. The above document does not fully inform the resident representatives of the medication's risks, as the facility fails to document and include the required FDA BLACK BOX WARNING of the increased risk of death associated with the use of Antipsychotic medications used to treat residents diagnosed with [REDACTED]. Resident #25 Review on 9/30/15 of Resident #25's medical record indicates Resident #25 is diagnosed with [REDACTED]. Review of Medication Administration Record [REDACTED]. Give 1 tablet by mouth at bedtime related to MAJOR [MEDICAL CONDITION] RECURRENT EPISODE (296.3); DEMENTIA CCE W/BEHAVIORAL DISTURBANCES (294.11) Order date 2/12/2015 and ([MEDICATION NAME]) QUEtiapine [MEDICATION NAME] Tablet Give 25 mg. by mouth as needed for agitation related to DEMENTIA CCE W/BEHAVIORAL DISTURBANCES (294.11) daily PRN (as needed). Review of the facility form titled INFORMED CONSENT for USE OF [MEDICAL CONDITION] MEDICATIONS under the section titled Possible side effects/risks associated with medication use: Documents the following: H/A (Head Ache), dizziness, sleepiness, agitation, dry mouth, upset stomach, abd pain (abdominal pain),NV (Nausea/vomiting), wt. gain, abnormal involuntary movements. The above form does not fully inform Resident #25 and/or representatives of the risks associated with the use of the atypical Antipsychotic medication [MEDICATION NAME]- (QUEtiapine [MEDICATION NAME]) as the facility fails to document and include the required FDA BLACK BOX WARNING of the increased risk of death associated with the use of Antipsychotic medications when used to treat residents diagnosed with [REDACTED]. Resident #15. Record review on 9/29/15 of the facility form titled INFORMED CONSENT for USE OF [MEDICAL CONDITION] MEDICATIONS for Resident #15 dated 5/18/15 revealed that Resident #15 had a medical [DIAGNOSES REDACTED]. and was prescribed the antipsychotic Risperdone. Record review and review of this consent form revealed that the facility failed to inform Resident #15 of the black box warnings associated with the use of antipsychotic medications. Resident #6 Record review on 9/28/15 & 9/29/15 revealed 2 forms titled Informed Consent for Use of [MEDICAL CONDITION] Medications. Consent form 1 reveals Resident #6 is currently on Trazadone for Dementia and [MEDICATION NAME] for [MEDICAL CONDITION]. Consent form 2 is for the use of [MEDICATION NAME] and [MEDICATION NAME]. Consent had been given by the Durable Power Of Attorney (DPOA) for the use of these medications. There was no documentation that the DPOA was informed of the Food & Drug Agency (FDA) black box warning regarding the use of these medications. Resident #6 is currently not on either of these medications. Resident #23 Record review on 9/29/15 & 9/30/15. revealed a form titled Informed Consent for Use of [MEDICAL CONDITION] Medications. Resident #23 on admission 11/10/14, had been prescribed [MEDICATION NAME] and [MEDICATION NAME]. Consent had been given by DPOA. There was no documentation that the DPOA was informed of the FDA black box warning regarding the use of these medications. Both medications eventually targeted for Gradual Dose Reduction (GDR). Last doses noted to be given were on 12/31/14.",2018-10-01
958,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2015-09-30,281,D,0,1,XO8O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, services were not provided according to accepted standards of clinical practice. Standard of Practice. (Follow MD Order) The Potter-Perry, 2009, Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's order [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Record review on 9/29/15 for Resident #31 revealed a medication order for [MEDICATION NAME] 50 mg 1 tab daily, but hold if heart rate under 55. During observation of the morning medication pass on 9/29/15 at 7:30 am, Staff A (RN) was observed to give Resident #31 the above ordered medication but did not check the residents Apical Pulse.",2018-10-01
959,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2015-09-30,323,D,0,1,XO8O11,Based on observation and interview it was determined that the facility failed to ensure that the environment was free of hazards to prevent accidents. Findings include: Observation on 9/28/15 during the initial tour of the second floor Unit B2 at approximately 9:30 a.m. revealed a spray bottle located on the hand washing sink in the unlocked resident Tub room A. The spray bottle was labeled as Quat Disinfectant Cleaner 5L identified at this time by Staff C (Housekeeping aide) as the disinfectant spray bottle utilized by nursing. Further observation of Tub room A revealed a single unattached bolt like metal screw located on the seat portion of a white bathroom shower chair and an unattached single sharp edged Z shaped piece of metal on the shower stall floor. Staff C confirmed this observation. Observation of the unlocked second Tub room B located on the second floor Unit B2 revealed an unlocked wallmounted multi-shelve cabinet with a disinfectant spay bottle identified at this time by Staff D (Registered Nurse) as a spray bottle of Quat Disinfectant Cleaner 5L. Observation with Staff D of the unlocked Soiled B Biohazard Utility room on this unit revealed an unlocked wall mounted multi-shelve cabinet with a large container labeled Dispatch disinfectant. The facility failed to ensure that the resident's environment was free of hazards by not preventing the access to hazardous chemical disinfectants and loose metal objects.,2018-10-01
960,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2015-09-30,431,D,0,1,XO8O11,"Based on observation of the unit medication pass, the storage of drugs and biologicals were found to be in an unlocked medication cart which is required to be locked and permit only authorized personnel to have access to the keys. Findings include: During observation of the morning medication pass on 9/29/15 at 8:30 am, Staff B (RN) left the medication cart unlocked as she proceeded into a resident's room to administer medications.",2018-10-01
961,HILLSBOROUGH COUNTY NURSING HOME,305048,400 MAST ROAD,GOFFSTOWN,NH,3045,2015-09-30,441,D,0,1,XO8O11,"Based on observation, the medication nurse did not maintain Infection Control procedures designed to prevent the development and transmission of disease and infection during her medication pass. Findings include: Reference for the professional standard of practice for the administration of medication is the 7th Edition Fundamentals of Nursing, Potter-Perry, pages 719-723 which revealed the following: Prepare Medications: - . Perform hand hygiene. Observation during the medication pass on 9/29/15 at 7:30 am, Staff A (RN), was observed changing gloves between the three residents, but did not wash her hands between each resident. Staff A confirmed the above observation.",2018-10-01
962,EXETER CENTER,305064,8 HAMPTON ROAD,EXETER,NH,3833,2015-05-29,441,D,0,1,4R9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were adhered to for one resident in a survey sample of 17 residents during the medication pass. (Resident identifier is #16.) Findings include: Review of this resident's current orders during survey on 5/27-29/15 revealed that the resident was actively receiving [MEDICATION NAME] 2 grams via I.V. (intravenous) every 6 hours. Observation of the resident's room during the 3:30 p.m. medication pass revealed on 5/28/15 a sign by the entrance to Resident #16's room that identified Contact Precautions, which in part includes, per the facility's CONTACT PRECAUTIONS form, wear gown and gloves and change gloves and gowns during care if come in direct contact with infectious material. Observation on 5/28/15 revealed that Staff A (RN) was hanging the [MEDICATION NAME] for Resident #16 at 3:50 p.m. when Staff A reached under Staff A's gown and went into his/her pocket to get a pen to label the time and date on the bag. Staff A then proceed to recheck the IV site and then replaced the pen back into his/her pocket. Interview with Staff A at the time of medication pass revealed that pen should be left in the room and that Staff A should not be reaching underneath his/her gown in a precaution room.",2018-10-01
963,SAINT VINCENT DE PAUL REHABILITATION & NURSING CTR,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2015-07-10,281,D,0,1,F2UV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy and procedure for Medication Administration it was determined that the facility failed to follow the professional standard of practice to follow physician order's for 1 out of sample resident in a survey sample of 15 resident's. (Resident identifier is #19.) Findings include: Reference for the professional standard of practice is: Potter-Perry, 2009, Review of the Fundamentals of Nursing, Patricia Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients . Review of the facility policy and procedure titled Medication Administration General Guidelines dated 2007 revealed the following: Medication Administration 1. Medications are administered in accordance with written orders of the prescriber . 2. Obtain and record any vital signs as necessary prior to medication administration . Observation of 7/9/15 during a medication pass with Staff B (Licensed Practical Nurse) at approximately 8:30 a.m. revealed the following physician medication order for Resident #19: [MEDICATION NAME] 50 mg. (milligrams) 1 tab (tablet) p.o. (by mouth ) qd (every day) (Hold AP Further observation at this time revealed that Staff B had prepared one 50 mg. tablet of [MEDICATION NAME] in a plastic medication cup for Resident #19 separate from another plastic medication cup containing numerous other physician ordered medications which did not have to be held if the pulse rate was below the 60 rate parameter. Staff B proceeded to administer all of these prepared medications to Resident #19 including the [MEDICATION NAME]. No observation was made during this medication administration of Staff B taking Resident #19's pulse rate prior to the administration of physician ordered [MEDICATION NAME] 50 mg to Resident #19. During interview on 7/9/15 with Staff B after this observed medication administration, Staff B verbally acknowledged that the pulse rate for Resident #19 was not taken before the administration of the 50 mg [MEDICATION NAME] with the physician order to hold this medication when the pulse rate was",2018-10-01
964,SAINT VINCENT DE PAUL REHABILITATION & NURSING CTR,305066,29 PROVIDENCE AVENUE,BERLIN,NH,3570,2015-07-10,441,D,0,1,F2UV11,"Based on observation it was determined that the facility failed to follow standard infection control protocols by not consistently performing hand washing and by administering medications to a resident with a potentially contaminated utensil. (Resident identifiers are #4 and #18.) Findings include: Resident #4. Observation on 7/9/15 during medication pass with Staff A (Registered Nurse) revealed Staff A utilizing a disposable plastic spoon to retrieve prepared dispensed medications from a plastic medication cup and placing a medication into the medication splitter located on the medication cart. After placing this medication into the medication splitter Staff A placed this plastic spoon on top of multiple pieces of handwritten papers located on top of this medication cart. After splitting the medication Staff A added this medication to the disposable medication cup containing multiple medications for Resident #4. Staff A proceeded to add applesauce on top of the medications in this medication cup, picked up the spoon mentioned above on the handwritten pieces of paper and placed this spoon in the applesauce stirring the applesauce and medications in this cup. Staff A proceeded to administer this applesauce and medications to Resident #4 with a potentially contaminated disposable spoon. The facility failed to provide Resident #4 with a safe environment by not adhering to medical asepsis or clean technique. Resident #18. Further observation on 7/9/15 during this medication pass with Staff A revealed that Staff A removed a blood pressure cuff from the attached side container on the medication cart and proceed into Resident #18's room. Staff A applied this blood pressure cuff to Resident #18's left arm and proceeded to take a blood pressure reading with the use of a stethoscope also. Following this reading Staff A exited Resident #18's room replaced the blood pressure cuff in the holder on the medication cart. No handwashing or use of hand sanitizer was observed by Staff A following contact with Resident #18. The facility failed to follow infection control prevention protocols by not utilizing a hand sanitizer or performing handwashing after contact with Resident #18's intact skin when taking a blood pressure.",2018-10-01
965,GOOD SHEPHERD REHABILITATION AND NURSING CENTER,305072,20 PLANTATION DRIVE,JAFFREY,NH,3452,2015-08-27,371,E,0,1,TOT411,"Based on record review and interview, the facility failed to maintain hold temperatures on the tray line at the location food is served and store dinnerware under sanitary conditions. Findings include: During record review of temperatures taken on the tray line from 7/1/15 to present for the dinner service, it was discovered that dining staff did not maintain and serve cold foods at or below 41 F on three days. On 7/2/15 dining staff recorded the temperature of the turkey salad sandwich at 51 F . On 8/7/15 the dining staff recorded the temperature of the macaroni salad at 54.1 F and the egg salad sandwich at 52.3 F. On 8/8/15 the dining staff recorded the temperature of the tuna salad at 64.5 F . During initial tour of the kitchen on 8/25/15 at 10:30 a.m., it was discovered that the vent above the clean dish drying and storage area had a heavy buildup of dust and debris. Interview with Staff A (Director of Food Services) on 8/26/15 at 9:30 a.m. confirmed the above findings.",2018-10-01
966,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2014-11-25,279,D,0,1,8DQL11,"Based on medical record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #1.) Findings include: Review on 11/24/14 of the Care Area Assessment (CAA) Worksheet for Resident #1 with an Assessment Reference Date (ARD) of 4/10/14, revealed that vision was triggered from the Minimum Data Set (MDS) and nursing staff decided to proceed to care plan for this problem area. Review of the comprehensive care plans on 11/24/14 for Resident #1 revealed that a care plan for vision was not developed. Interview on 11/24/14 with Staff D (LPN) at approximately 11:00 a.m., Staff D confirmed that a care plan was not developed for vision.",2018-09-01
967,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2014-11-25,280,D,0,1,8DQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to update comprehensive care plans to accurately reflect: care and/or, interventions, and/or, goal dates for 2 residents in a standard survey sample of 15 residents. (Resident identifiers are #1 and #9.) Findings include: Resident #9 Review on [DATE] & [DATE] of Resident #9's physician progress notes [REDACTED]. Review on [DATE] of Resident #9's comprehensive care plan revealed a care plan which documented; (Resident #9) at risk for side effects from antipsychotic med psychoative use. (antipsychotic medication [MEDICATION NAME]) Problem Need - Problem Onset dated [DATE], Section: Goal:Resident will be at lowest therapeutic dose. & Target Date [DATE], (sic x 90 days)review- [DATE], [DATE].Approaches : * Discuss Side effects of [MEDICATION NAME] w/resident's guardian. * Observe resident for adverse side effects, document, & report to MD: blood pressure changes, gait disturbances, cognitive impairment, behavior impairment, ADL decline, (Activities of Daily Living) decline in appetite, abnormal in-voluntary movement or s/s (signs/symptoms) of depression. *Administer Resident's meds as ordered by MD. Dose Reduction [DATE] [MEDICATION NAME] 12.5 mg po (orally) at HS- (Hour of sleep) * Monitor and record resident s/s (signs & symptoms) [MEDICAL CONDITION], has h/o (history of) extreme agitation and delusions. Report onset or increase to MD. Interview on [DATE] with Staff C (RN, DON) confirmed the antipsychotic medication [MEDICATION NAME] had been discontinued and the care plan for Resident #9 had not been updated. Since [DATE], the antipsychotic medication was still listed as an intervention on the care plan although it was no longer being administered, so the care plan was not updated. Resident #1 Review on [DATE] of Resident #1's ADL care plan which was last updated on [DATE] with an expired target date of [DATE] revealed no documentation of problem resolution. Resident #1's Skin/Pressure Ulcer care plan was last updated on [DATE] with no target date listed and no documentation of problem resolution. [DIAGNOSES REDACTED] care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. The Hypertension care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. The Pain care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. The Mobility care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. The [MEDICAL CONDITIONS] care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. The Falls care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. The Rejection of Care care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. The Daily Preferences care plan was last updated on [DATE] with an expired target date of [DATE] and no documentation of problem resolution. Interview on [DATE] at approximately 11 a.m. with Staff D (LPN) verbally confirmed that all of Resident #1's care plans contained expired target dates; therefore, none of the care plans were active.",2018-09-01
968,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2014-11-25,281,D,0,1,8DQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure medications were administered based on professional standards of quality for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #6.) Findings include: References: Obtained online 12/8/14 at http://www.cdc.gov/mmwr/preview/mmwrhtml/ 711.htm under Prevention and Control of [MEDICAL CONDITION] in Facilities Providing Long-Term Care to the Elderly Recommendations of the Advisory Committee for Elimination of [MEDICAL CONDITION] page #3 states, Skin tests should be administered to all new residents and employees as soon as their residency or employment begins unless they have documentation of a previous positive reaction. A two-step procedure is advisable for the initial testing of residents and employees in order to establish a reliable baseline. The most current update of this document was (MONTH) 13, 1990. Resident #6 Review of Resident #6's medical record revealed Resident #6 was admitted on [DATE] with a doctor's order dated 11/22/14 for a Mantoux on admission and physician orders [REDACTED].(Staff E (RN)). Medication Administration Record [REDACTED]. Interview on 11/24/14 at approximately 9:30 a.m. with Staff F (RN) confirmed that Resident #6 had not received a Mantoux test on admission.",2018-09-01
969,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2014-11-25,329,D,0,1,8DQL11,"Based on medical record review and interview, it was determined that the facility failed to adequately monitor the use of antipsychotic medication for 1 of 2 resident on antipsychotic medications in a standard survey sample of 15 residents. (Residents identifier is #6.) Findings include: Review on 11/24/14 of Resident # 6's medical record revealed that staff had not completed an AIMS test on Resident #6 since his/her admission on 11/21/14. Interview on 11/24/14 at approximately 11:00 a.m. with Staff D (LPN) confirmed that the AIMS test had not been completed on Resident #6 and should have been done to establish a baseline.",2018-09-01
970,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2014-11-25,441,E,0,1,8DQL11,"Based on observation and interview, it was determined that the facility failed to ensure the cleanliness of Oxygen tubing for 3 of 15 residents on 2 of 2 units. (Resident identifiers are #3, #16, #17.) Findings include: Resident #17 During tour of the MSU (Medical Services Unit) on 11/24/14 it was observed that Resident #17's oxygen (O2) tubing was missing a date and time of when it was last changed. Interview on 11/24/14 at approximately 9:00 a.m. with Staff G (RN) confirmed that O2 tubing was not dated or timed indicating when it was last changed. Interview on 11/25/14 at approximately 2:40 p.m. with Staff A confirmed that O2 tubing is required by the facility to be changed weekly and is to include the date and time of each weekly change. Observation on 11/25/14 of the resident rooms on the BMU (Basic Medical Unit) with oxygen delivery systems revealed two residents as having oxygen tubing with outdated or undated oxygen tubing. Resident #3 During a tour on 11/25/14 of Resident #3's room with Staff A (RN) it was observed that Resident #3's oxygen tubing on the oxygen concentrator had a handwritten self-stick label dated 11/14/14. The other oxygen tubing, on the BMU, with one exception, was all dated 11/21/14. Resident #16 During a tour on 11/25/14 Resident #16's room with Staff A, it was observed that Resident #16's oxygen tubing, attached to the oxygen cylinder on the back of Residents #16's wheelchair, was not dated. The tubing on Resident #16's oxygen concentrator; however, was dated 11/21/14. Interview on 11/25/14 with Staff A revealed that the facility had a person who comes in on a weekly basis and who changes all of the oxygen tubing in the whole building. Staff A was aware at the time of these findings that the oxygen was a week out of date for Resident #3 and that Resident #16's wheelchair oxygen tubing was undated, as described above.",2018-09-01
971,HACKETT HILL HEALTHCARE CENTER,305038,191 HACKETT HILL ROAD,MANCHESTER,NH,3102,2014-11-25,456,E,0,1,8DQL11,"Based on medical record review and interview, it was determined that the facility failed to ensure that any out of range glucometer test values were properly reviewed and properly followed up, on both the BMU (Basic Medical Unit) and the MSU (Medical Surgical Unit). Findings include: During a review of the Glucometer testing logs for the BMU it was noted that the BMU has 3 Medication Administration carts, each with its own glucometer. Review of the Medline EvenCare G2 Glucose Control Solutions product information sheet, included with each box of paired low control and high control solutions, one vial of each per box, reveals at the sub heading INTENDED USE- The purpose of the control solution test is to validate the performance of the EvenCare G2 Blood Glucose Monitoring System using a testing solution with a known range of Glucose. A control test that falls within the acceptable range indicates the user's technique is appropriate and the test strip and meter are functioning properly. Further review of the Medline EvenCare G2 Glucose Control Solutions product information sheet, included with each box of paired low control and high control solutions reveals: Newly opened bottles of control solutions must be marked on the space provided on the control solutions (sic) label with the date that it was opened. Check the (manufacturer's) expiration date of the control solutions to make sure that they have not expired. Discard any unused control solutions 90 days after opening or after expiration date (whichever comes first) Refer to (the Medline EvenCare G2) Users Guide (pages 25 through 29) for instructions in using EvenCare G2 control solutions with meter. Additional review of the Medline EvenCare G2 Glucose Control Solutions product information sheet, included with each box of paired low control and high control solutions reveals at the EXPECTED VALUES sub heading: The EvenCare G2 Glucose Control Solutions testing should provide results within the expected range indicated on the test strip bottle. If results are not within the acceptable ranges, the user should carefully review each step of their technique before performing another test. Any error in technique or meter use could cause results to be outside the acceptable range. If the control test values continue to be outside the acceptable range and technique is proper, use a strip from a previously unopened bottle and repeat the test. If readings are still not within the acceptable range, please call . And, reviewed at the subheading CAUTION: If results continue to be out of range after all the instructions have been followed, the system is not functioning properly. DO NOT use the system to test (word deleted) blood glucose until you get a reading that is within the acceptable range. Review of the EvenCareG2 Control Solution Testing guidelines, page 25, reveals: The purpose of the control solution testing is to make sure the Evencare G2 Meter and Test Strip are working properly. Review of the glucometer test results for the 3 medication administration carts on the BMU for the months of (MONTH) and (MONTH) 2014 revealed the following concerns: Review of the glucometer testing log for the medication administration cart designated Cart #1, Long Hall for the month of October, 2014, reveals that 1 of 24 Low Range testing values and 1 of 24 High Range testing values fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. Further review of the glucometer testing log for the medication administration cart designated Cart #1, Long Hall for the month of October, 2014, reveals no glucometer testing results for Low Range or High range values for the following dates: 10/3/14, 10/8/14, 10/9/14, 10/14/14, 10/16/14, 10/17/14 and 10/23/14. Review of the glucometer testing log for the medication administration cart designated Cart #1, Long Hall for the month of November, 2014, reveals that there were no Low Range testing values outside designated ranges and 2 of 19 High Range testing values that fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. Further review of the glucometer testing log for the medication administration cart designated Cart #1, Long Hall for the month of November, 2014, reveals no glucometer testing results for Low Range or High range values for the following dates: 11/13/14, 11/14/14, 11/17/14, 11/18/14, 11/21/14, and 11/23/14. Also, 11/3/14 is stated twice, and 11/4/14 is missing. Review of the glucometer testing log for the medication administration cart designated Cart #1, Center Hall for the month of October, 2014, reveals that there were no Low Range testing values that fell outside the range and 4 of 24 High Range testing values that fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. Further review of the glucometer testing log for the medication administration cart designated Cart #1, Center Hall for the month of October, 2014, reveals no glucometer testing results for Low Range or High range values for the following dates: 10/3/14, 10/8/14, 10/9/14, 10/15/14, 10/16/14, 10/17/14 and 10/23/14. Review of the glucometer testing log for the medication administration cart designated Cart #1, Center Hall for the month of November, 2014, reveals that there were 1 of 19 Low Range testing values that fell outside the ranges and no High Range testing values that fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. Further review of the glucometer testing log for the medication administration cart designated Cart #1, Center Hall for the month of November, 2014, reveals no glucometer testing results for Low Range or High range values for the following dates: 11/13/14, 11/14/14, 11/17/14, 11/18/14, 11/21/14 and 11/23/14. Review of the glucometer testing log for the medication administration cart designated Cart #2, Long Hall for the month of October, 2014, reveals that 2 of 23 Low Range testing values and 3 of 23 High Range testing values fell outside the designated ranges with 1 value not entered. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. Further review of the glucometer testing log for the medication administration cart designated Cart #2, Long Hall for the month of October, 2014, reveals no glucometer testing results for Low Range or High range values for the following dates: 10/3/14, 10/8/14, 10/9/14, 10/14/14, 10/16/14, 10/17/14, 10/21/14 and 10/23/14. Review of the glucometer testing log for the medication administration cart designated Cart #2, Long Hall for the month of November, 2014, reveals that there were no Low Range testing values that fell outside the designated ranges and 2 of 16 High Range testing values that fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. Further review of the glucometer testing log for the medication administration cart designated Cart #2, Long Hall for the month of November, 2014 reveals no glucometer testing results for Low Range or High range values for the following dates: 11/4/14, 11/11/14, 11/12/14, 11/13/14, 11/14/14, 11/17/14, 11/18/14, 11/21/14 and 11/23/14. Interview on 11/25/14 at approximately 3:45pm with Staff B (LPN, BMU) concurred that there were issues with test result numbers outside of the manufacturer's stated Low and High test result ranges. Interview on 11/25/14 at approximately 7:00 p.m. with Staff C (RN, DON) stated it was her expectation that the glucometers were each to be tested for accuracy 1 time every day. Review of Genesis Corporation Policy and Procedure # NSG217 Glucose Meter effective 06/01/96, revised 12/08/14 reveals, in part, under the section entitled Policy: To ensure the accuracy and validity of blood glucose monitoring, blood glucose meters will be disinfected before patient use and quality control tested daily according to manufacturers guidelines. During a review of the Glucometer testing logs for the MSU (Medical Surgical Unit) it was noted that the MSU has 3 Medication Administration carts, each with its own glucometer. Review of the glucometer test results for the 3 medication administration carts on the MSU for the months of (MONTH) and (MONTH) 2014 revealed the following concerns: Review of the glucometer testing log for the medication administration cart designated Long Hall #1 - EG 7 for the month of October, 2014, reveals that 5 of 27 Low Range testing values and 6 of 27 High Range testing values fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. Further review of the glucometer testing log for the medication administration cart designated Long Hall #1 for the month of October, 2014, revealed 1 of 27 glucometer testing results for Low Range or High range values was missing for 10/27/14. The following days testing was not completed for the the month of (MONTH) 2014 for the Long Hall #1 glucometer: 10/8/14, 10/26/14, 10/28/14, and 10/29/14. The glucometer testing log for the medication administration cart designated Cart #1, Long Hall - EG 7 for the month of November, 2014 reveals that 4 of 27 Low Range testing values and 1 of 27 High Range testing values fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals one entry of a Low Range testing value that was low and one entry of a Low Range testing value that was high. Further review shows the following days testing was not completed for the month of (MONTH) 2014: 11/3/14, 11/8/14, and 11/19/14. Review of the glucometer testing log for the medication administration cart designated Vent - EG 5 for the month of October, 2014, reveals that there were 6 of 27 Low Range testing values that fell outside the range and 6 of 27 High Range testing values that fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. The following days testing was not completed for the the month of (MONTH) 2014 for the Vent - EG 5 glucometer: 10/8/14, 10/26/14, 10/28/14, and 10/29/14. Review of the glucometer testing log for the medication administration cart designated Vent for the month of November, 2014, reveals that there were 4 of 23 Low Range testing values that fell outside the ranges and 1 of 23 High Range testing values that fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals that 2 of the 4 Low Range testing values was low and 1 of 4 High Range testing values was high. Further review shows the following days testing was not completed for the month of (MONTH) 2014: 11/3/14, and 11/8/14. Review of the glucometer testing log for the medication administration cart designated Vent for the month of October, 2014, reveals that 5 of 31 Low Range testing values and 5 of 27 High Range testing values fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there are no entries to indicate what corrective action was taken. The following days testing was not completed for the the month of (MONTH) 2014 for the glucometer: 10/8/14, 10/26/14, 10/28/14, and 10/29/14. Review of the glucometer testing log for the medication administration cart designated Vent for the month of November, 2014, reveals that there were 4 of 20 low Range testing values fell outside the designated ranges and 1 of 20 High Range testing values fell outside the designated ranges. Review of the right hand column on the glucometer testing log entitled Action Taken reveals there were 2 entries to indicate the Low Range testing values were low. Further review shows the following days testing was not completed for the month of (MONTH) 2014: 11/3/14, 11/8/14, 11/12/14, 11/15/14, and 11/16/14. Interview on 11/25/14 at approximately 3:30 p.m. with Staff D (LPN, MSU) concurred that there were issues with test result numbers outside of the manufacturer's stated Low and High test result ranges.",2018-09-01
972,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2015-08-19,160,B,0,1,0NKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident funds and Staff interview, the facility failed to convey within 30 days of death or discharge from the facility, the final accounting of funds for 11 of 12 out of sample residents. (Resident identifiers are #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27) Findings include: On [DATE] at 3:00 pm financial record review revealed and staff interview confirmed the following related to deceased residents' accounts and residents who had transferred out of the facility with accounts with remaining funds. Resident #17 died on [DATE]. Staff C confirmed the Resident #17's account balance of $72.00 confirmed there was no documentation that an affidavit to probate or check was sent to the jurisdiction administering the resident's estate; and confirmed the remaining balance was not sent within 30 days, that remaining funds were to be dispersed to the Resident's spouse. The remaining funds had not been sent from [DATE] until current on [DATE], 8 months 19 days. Resident #18 died on [DATE]. Staff C confirmed the affidavit to probate was not sent within 30 days, that it was signed and sent to Probate on [DATE]; 5 months and 24 days after death. Resident #19 died on [DATE]. Staff C confirmed the remaining funds were not sent within 30 days; that the affidavit was signed and sent to Probate on [DATE], 34 days after death with an account balance of $647.55. Resident #20 died on [DATE]. Staff C confirmed that the resident's account balance of $250.05 still remains and as of the date of Survey it had not been sent to the jurisdiction administering the resident's estate for 5 months and 9 days after death. Resident #21 died on [DATE]. Staff C confirmed the affidavit was not sent within 30 days, that it was sent to Probate on [DATE], 34 days after death. Resident #22 died on [DATE]. Staff C confirmed the affidavit was not signed and sent to Probate within 30 days, it was sent on [DATE], 2 months and 28 days after death. Resident #23 died on [DATE]. Staff C confirmed the affidavit was signed and sent to Probate on [DATE], 41 days after death with an account balance of $1,821.50. Resident #24 died on [DATE]. There is no documentation that the resident's account balance of $1,106.96 was sent to the jurisdiction administering the resident's estate for 34 days. Resident #25 died on [DATE]. Staff C confirmed the account balance of $63.00 needs to be dispersed to the family and has not been sent for 35 days, to the jurisdiction administering the resident's estate. Staff C confirmed Resident #26 was transferred to another facility. The resident's account balance of $548.63 remains in the resident's account and Staff C confirmed it was not released within 30 days to the Office of Public Guardian (OPG) and the facility still needs to send remaining funds to the OPG to be deposited with the transferring facility or managed on the behalf of Resident #26. Resident #27 transferred to another facility [DATE]. StaffC confirmed Resident #27's account was not transferred within 30 days.",2018-09-01
973,ELM WOOD CENTER AT CLAREMONT,305041,290 HANOVER STREET,CLAREMONT,NH,3743,2015-08-19,387,E,0,1,0NKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide complete documentation of required physician visits (At least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter) for 4 out of 15 sampled residents and 1 out 27 out of sample resdients. (Resident identifiers #1, #8, #12, and #16) Findings include: Resident #8 Record review of paper chart and electronic record on 08/18/15 at 2:00 pm for Resident #8 only contained two documented physician visits dated 12/24/14 and 1/23/15. Resident was admitted to the facility on [DATE]. At 2:15 pm on 08/18/15 during an interview, Staff A (RN) agreed that there were only two documented physician visits for Resident #8 since admission to this facility. At 3:15pm on 08/18/15 and again at 10:30am on 08/19/15 during an interview, Staff B (DON) agreed that the were only two documented physician visits presented for Resident #8 since admission to this facility. As of 8/19/15 from a period of approximately 8 months Resident #8 had not received the minimum requirement of Physician visit services at least every 60 days. Resident #1. Record review of paper chart and electronic record on 8/18/15 for Resident #1 revealed that the resident was admitted to the facility on [DATE]. Resident #1's initial Physician visit occurred on 4/26/14. The first 30 day visit was due by 5/26/14 and then another 30 day visit by 6/26/14. The resident was due for a 60 day recertification visit by 8/26/14. Resident #1's next visit occurred on 9/7/14 and then was not seen again until 12/2/14. There are no other physician visits after 12/2/14. Interview on 8/19/15 at approximately 1 p.m. with Staff B (RN DON),who confirmed these are the only visits this resident has received since admission. Resident #12. Record review of paper chart and electronic record on 8/18/15 for Resident #12 revealed that the resident was admitted to the facility on [DATE]. Resident #12's initial Physician visit occurred on 12/23/14. The second 30 day visit was due by 1/23/15 and then the last 30 day visit was due by 2/23/15. The resident was due for a 60 day recertification visit by 4/23/15 and 6/23/15. There are no other physician visits after 12/30/14. Interview on 8/19/15 at approximately 1 p.m. with Staff B who confirmed these are the only visits this resident has received since admission. Resident #16 During interview with Resident #16 on 08/19/15 at approximately 2:00 p.m. Resident #16 said (pronoun omitted) had not been feeling well and said (pronoun omitted) needed to see (pronoun omitted) Physician, and that (pronoun omitted) had been asking many times to see (pronoun omitted) doctor but he had not come in for a long time. MDS (Minimum Data Set) record review revealed a cognitive assessment (MONTH) (YEAR) indicates Resident #16 scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the highest score for Resident #16's cognitive function as not impaired. Confidential interview with Unit staff, concerning Resident #16's requests to see the physician, confirmed that Resident #16 had not been feeling well and had been requesting to see (pronoun omitted) MD and confirmed Resident #16's Physican had not been in to see Resident #16 since 12/2/14. During interview with Staff D RN,Unit Manager, Staff D also confirmed Resident #16 had not been feeling well, was receiving [MEDICAL TREATMENT] services 3 times per week, and had been having some episodes of vomiting. This surveyor requested a copy of Resident 16's last Physician visit note, however Staff D was unable to locate a recent Physician's visit note however stated it may have been as far back as (MONTH) or (MONTH) 2014 since Resident #16 had been seen by her physician. As of 8/19/15 from a period of approximately 8 months or longer Resident #16 had not received the minimum requirement of Physician visit services at least every 60 days; and the facility failed to notify the Physician of Resident #16's requests for sick visits.",2018-09-01
974,KENDAL AT HANOVER,305042,80 LYME ROAD,HANOVER,NH,3755,2015-07-02,281,D,0,1,1NM611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that the facility failed to administer medication appropriately for 3 residents, and the facility failed to ensure an interim care plan addressed initial care areas for one resident, in a survey sample of three residents. (Resident identifiers are #1, #2, and #3.) Findings include: Fundamentals of Nursing Patricia A. Potter & Anne Griffin Perry, Mosby, 2009, 7th Edition, reveals the following: On page 269, under Planning Nursing Care, You design a written plan to direct clinical nursing care and to decrease the risk of incomplete, incorrect, or inaccurate care. As the client's problems and status change, so does the plan. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in evaluation. The written plan communicates nursing care priorities to other health care professionals The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care A correctly formulated nursing care plan makes it easy to continue care from one nurse to another Resident #3 Review of Resident #3's record revealed an admission date of [DATE]. The physician orders [REDACTED]. Review of Resident #3's electronic MAR (Medication Administration Record) revealed the resident was receiving scheduled [MEDICATION NAME] every eight hours, and PRN (as needed) [MEDICATION NAME] for hip pain, with a dose administered on 6/29, 6/30 and 7/1/15. In addition, this resident was ordered to receive [MEDICATION NAME] 30 mg subcutaneously every morning for 28 days. Review of the Pain assessment dated [DATE] revealed a baseline comfort level of 1-3/mild. However, review of the electronic MAR indicated [REDACTED]. Review of the Interdisciplinary Notes revealed this resident was experiencing some pain: 6/30/15 11:30pm back pain when going to bed, PRN [MEDICATION NAME] given, (Note the physician's PRN order was for hip pain.) 7/1/15 6:17:13 am admits to having some pain but 'I expect it to hurt some.' 'It is tolerable.' took scheduled tylenol without issue. Is aware that if needed there is pain medication available 7/1/15 10:58:38 am After approx 1.5 hours . (Resident #3) reported (pronoun omitted) right leg was hurting 'It's quite bad' Review of Resident #3's interim care plan on 7/1/15 revealed that nutrition, mobility and Activities of Daily Living were addressed, but there was no care plan for pain management, ongoing pain assessment, the use of prn [MEDICATION NAME] for non-hip pain, et cetera. Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, page 719. . 7. Prepare medications: [REDACTED] a. Perform hand hygiene. Observation of the 9:45 am, 11:00 am and 2:00 pm medication passes on 7/1/15 revealed Staff A (LPN) did not use hand sanitizer nor did Staff A wash their hands in between administration of medications for Residents #1 ,#2 and #3.",2018-09-01
975,WARDE HEALTH CENTER,305043,21 SEARLES ROAD,WINDHAM,NH,3087,2015-05-19,371,D,0,1,UG9D11,"Based on observations and interviews conducted on 5/18/15 during an initial tour of the main kitchen the Facility failed to ensure that food was prepared under sanitary conditions. Findings include: During the initial tour of the of the main kitchen on 5/18/15 this State Agency (SA) Surveyor accompanied by the SA Life Safety Inspector were joined by Staff A (Facility Cook Supervisor) and Staff B (Administrator). During the initial tour of the main kitchen, on 5/18/15 at approximately 9:44 a.m. it was observed that there were numerous particles of what appeared to be tufts of dried meat under the blade of the food slicer machine. During the initial tour of the main kitchen, 5/18/15, dust and particulate matter were observed: on top of the reach in coolers, on top of a hot box (used to keep foods hot, after preparation and before serving), on top of paper towel dispensers attached to the walls, on the top edge of a small bulletin board attached to a reach-in cooler, on the floor under and behind the range, and on the floor under the preparation table. Also observed on 5/18/15 during the initial tour of the kitchen were the two steam tables that had both been in service. Upon opening the sliding doors on the bottom of the main body of the portable steam table it was noted that there was a stack of plastic plates with lipped (built up) edges on the left side of the bottom shelf. It was further noted that the plates were surrounded by a thick layer of dust and what appeared to be particles of dry food crumbs. Observed to the right side of the shelf was an electric cable. Dust and particulate matter were observed in this location as well. Upon reviewing the components of the serving line for the main dining room it was noted that the lower shelf of the stationary steam table was coated in a layer of dust and particulate matter as well as a dark stain. Upon asking kitchen staff, on 5/18/15 at approximately 10:25 a.m., who was responsible for the cleaning of this lower shelf we were told by Staff C (cook) that maintenance had told kitchen staff they shouldn't clean that area due to the proximity of a square electrical junction box mounted in the approximate center of the shelf. (CROSS REFER TO F456) On interview Staff B stated that the stationary steam table was built in 1952. Observation of the left side of the serving line revealed a lower shelf with a hot beverage dispenser labeled Tea and an unlabeled hot beverage dispenser. This stainless steel shelf was noted to be dusty and to have a large area of darkened stain to the left of the above noted dispensers. During a subsequent tour, 5/18/15, of the dishwashing room it was observed that 2 vent ducts; a larger diameter duct attached to a ventilation hood over the automatic dishwasher (ADW) and a smaller diameter duct which appeared to exhaust excess steam to the outside. Behind the larger diameter duct was a metal strap, extending down from the ceiling, coated with a large amount of dust down its entire length (approximately 6 to 8 inches). On the back of the large diameter duct was some short, hanging, ribbons of dust. On top of each of these ducts was a thin layer of dust. Please note that these ducts pass over the back edge and along the left end of the clean exit side of the ADW, posing a potential for dust to end up on clean dishes.",2018-09-01
976,WARDE HEALTH CENTER,305043,21 SEARLES ROAD,WINDHAM,NH,3087,2015-05-19,456,D,0,1,UG9D11,"Based on observations and interviews the Facility failed to ensure that all essential electrical equipment was in safe operating condition. Findings include: Upon reviewing the components of the serving line for the main dining room it was noted that the lower shelf of the stationary steam table was coated in a layer of dust and particulate matter as well as a dark stain. Upon asking kitchen staff, on 5/18/15 at approximately 10:25 a.m., who was responsible for the cleaning of this lower shelf we were told by Staff C (cook) that maintenance had told kitchen staff they shouldn't clean that area due to the proximity of a square electrical junction box mounted in the approximate center of the shelf. On interview Staff B (Administrator) stated that the stationary steam table was built in 1952. Further observation of the electrical junction box in question revealed that it was open at one of the inlet ports. Several black insulated wires could be visualized. As a precaution the Facility took this steam table out of service until the electrician could effect repairs. It is noted that the electrician installed a new, intact, waterproof box above the spot where the old one had been mounted.",2018-09-01
977,RIVERWOODS AT EXETER,305049,7 RIVERWOODS DRIVE,EXETER,NH,3833,2015-07-01,226,D,0,1,HP9M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy, review of the incident report and interview, the facility failed to conduct a thorough investigation after a fall for 1 resident out of 15 in a standard survey. (Resident identifier is #8.) Findings include: Review of the Abuse Prevention & Reporting Policy and Procedure with a revised Date of 6/2012 under the section Investigation: In the case of alleged abuse or unwitnessed injury, the Director of Nursing or his/her designee will conduct an internal investigation which shall include: A review of the accident/incident report. An interview with the resident. An interview with the person (s) reporting the incident. An interview with the accused (in the case of alleged abuse). Interviews with any witness to the incident. A review of the resident's medical record. A review of all circumstances surrounding the incident. Review of the Resident #8's medical record revealed a nurse's note written by Staff A (RN) for the 7-3 shift on 2/25/15 revealed, .was sitting on floor in middle of room. (pronoun omitted) was getting ready to come out for breakfast, was already dressed & washed. ROM (Range of Motion) assessment: c/o (complaint of) increase pain in Left hip. Skin tear to (R) lower leg. 13 cm. Edges approximated .Res (resident) was assisted to chair x 2 aides. c/o (complained of) of increased pain L hip. Unable to bear weight. Sent to (hospital). Late entry on 3/30/15 IDT (Inter Disciplinary Team) note re: falls 2/23/15 and 2/25/15 the events were reviewed on 2/25/15 and 2/26/15 respectively. It was noted that on 2/25/15 at 7:55 a.m. resident was found on floor in bedroom, dressed and with new skin tear on right lower extremities. wound treated and resident assessed by nurse vital sign, resident complained of pain in left hip pain and unable to bear weight. Resident transported to ER (emergency room ). Review of the Accident/Incident report written on 2/26/15 by Staff A revealed that Resident #8 has Dementia and (he/she) was found sitting in middle of floor. ROM assess res c/o pain to her/his L hip area, Also skin tear on R (right) Lower leg 13 cm. skin tear cleansed with ns (normal saline) [MEDICATION NAME] applied. Skin tear edges approximated, 4 steri strips applied. vs (vital signs) 119/61, 68 24 T 98.6 O2 97% room air Res was assisted to chair with assist of 2 LNA (licensed nurses assistance), res. c/o pain to L hip. Unable to bear weight. Sent to (hospital) ER . 2/25/15 11 am call from daughter that left hip is fracture and will have surgery. Review of the Falls Questionnaire that was completed on 2/25/15 by Staff A revealed the following: Under the section Describe exactly what happened when the resident fell ; (What was the resident attempting to do?) Found on floor in room (number omitted). Found in sitting position. res was getting ready to come out for breakfast. Already dressed and washed. Under the section Vital Signs reveals,Pain L hip, ROM pain L hip . Under the section Evaluation of Assessment Skin tear to R lower leg. 13 cm. edges approximated & 4 steri strips applied. wrapped with gauze. c/o pain to L hip. Plan of Nursing Action Sent out to (pronoun omitted) ER for evaluation. Unable to bear weight on L leg. increase pain. Interview with Staff B (DON) on 6/30/15 indicated that the she would speak with the nurse and aides involve with the incident again and get a clearer understanding of when Resident #8 was moved or complained of pain to left hip area. Staff B did not believe that Staff A would move Resident #8 from the floor with a complaint of pain. Review of Resident #8's medical record reveals a late entry written on 7/1/15 by Staff A, correction and clarification to entry on 2/25/15 7:55 am 7-3 shift regarding fall. Resident was found sitting on floor in middle of (resident) room by LNA. Denied pain. ROM assessed +. VSS (Vital signs stable) .A large skin tear (13 cm) noted on (R) lower leg .Assisted up to chair X 2 assist. Denied pain skin tear cleaned NS (normal saline), edges approximated 4 steri strips applied. [MEDICATION NAME] & Kling wrap applied. Resident 'dozed off' during skin tear treatment, then awoke stating 'why does my leg hurt' ROM (range of motion) reassessed (+). Palpation assessment reveals res unable to identify exact location of any pain. Resident was helped to feet X 2. assist to better area of pain. Found to not be able to bear weight on L leg. (Resident) was assisted back to chair. This nurse felt needed further evaluation . Review of an statement written on 7/1/15 by Staff C (LNA) revealed Call to (Resident #8's) room by another aide reporting resident fell . went to get the nurse, because resident was on the floor. The nurse came in and evaluated the resident. (Resident) said I don't know how I got here Nurse asked if anything hurt. (Resident) said no. So we assisted (pronoun omitted) up into chair with gait belt. 2 assist. That when we saw blood on (pronoun omitted) pant leg. We found skin tear. Then the nurse took care of it. Review of Staff D's (LNA) written statement dated 7/1/15 revealed that Resident #8 .was sitting in chair and that I was going to assist with (Resident #8's) walker to stand. Resident #8 'grimised' (sic) .having trouble bearing weight. the nurse then evaluated (pronoun omitted.) Interview with Staff B on 7/1/15 after reviewing the late entry and the differences and the nurses notes Staff B indicated the Staff A wanted to be thorough with the note. That the first note was a summary of the event.",2018-09-01
978,RIVERWOODS AT EXETER,305049,7 RIVERWOODS DRIVE,EXETER,NH,3833,2015-07-01,279,D,0,1,HP9M11,"Based on record review and interview, it was determined that the facility failed to develop a comprehensive plan of care for 1 resident out of 15 in a standard survey sample. (Resident identifier is #2.) Findings include: Review of the most recent comprehensive MDS (Minimum Data Set) dated 5/30/2015 revealed that Resident #2 triggered for the vision care area and indicated this area would be care planned for. Review of all Resident #2's care plans revealed there was no care plan created for vision nor were vision needs addressed in any of the current care plans for this resident. Interview on 6/30/15 with Staff F (RN/MDS Coordinator) confirmed that a care plan for vision had not been developed for Resident #2.",2018-09-01
979,RIVERWOODS AT EXETER,305049,7 RIVERWOODS DRIVE,EXETER,NH,3833,2015-07-01,281,D,0,1,HP9M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, it was determined the facility failed to follow appropriate medication administration practices while preparing a resident's dose of medication for 1 out of sample resident. (Resident identifier #16.) Findings include: Fundamentals of Nursing 7th ed., Potter/Perry pg. 720, section Administering Medications , step H Do not touch medication with fingers . Rationale: Maintains clean technique required of medication administration. Review of Riverwoods Policy & Procedure, Administering Medications, reveals the following on pg. 6, #22, Staff shall follow established infection control procedures (e.g., gloves .) for the administration of medication, as applicable. On 6/30/15 during the medication administration pass observation at approximately 08:15, Staff E (RN) was observed preparing Resident 16's medication of [MEDICATION NAME] 2.5 tabs. Staff E failed to put on gloves prior to cutting one of the tablets in half . Staff E then used bare hands and placed one half tab in the medicine cup and followed by placing two whole pills in the same cup. Interview on 6/30/15 at 08:25 with Staff E, Staff E confirmed not using gloves while physically handling the medication.",2018-09-01
980,RIVERWOODS AT EXETER,305049,7 RIVERWOODS DRIVE,EXETER,NH,3833,2015-07-01,371,E,0,1,HP9M11,"Based upon observations and interview, it was determined the facility failed to maintain temperatures for dishwashers in 2 of 3 buildings surveyed both high temperature machines were consistently not reaching the minimum rinse temperature of 180 degrees Fahrenheit and that 2 of the 6 kitchens contained dented cans. Findings include: In the Monadnock building the Main Machine Temperature Log for (MONTH) (YEAR) documented that the dishwasher rinse temperatures were either below 180 degrees Fahrenheit or not recorded during morning temperature checks for eighteen of twenty-nine days. Rinse temperatures for this dish machine were either below 180 degrees Fahrenheit or not recorded during afternoon temperature checks for twenty of twenty-eight days. Rinse temperatures for this dish machine were either below 180 degrees Fahrenheit or not recorded during evening temperature checks for twenty-one of twenty-eight days. In the Boulders building the Main Machine Temperature Log for (MONTH) (YEAR) documented that the dishwasher rinse temperatures were either below 180 degrees Fahrenheit or not recorded during morning temperature checks for twenty-six of twenty-nine days. Rinse temperatures for this dish machine were either below 180 degrees Fahrenheit or not recorded during afternoon temperature checks for twenty-seven of twenty-eight days. There were no evening temperature checks recorded during the month of (MONTH) (YEAR) for this machine. Observation during tour of the kitchens on 6/29/15 revealed that there were dented cans in two of the six kitchens. There was one dented can at the Woods main kitchen in dry storage and one dented can at the Boulders Main kitchen in dry storage. Interview with Staff F (Sous Chef) at the Woods and Staff G (Director of Dining Services) at the Boulders on 6/29/15 confirmed the above finding and revealed that it is the policy of the facility to remove dented cans from dry storage return them to the distributor.",2018-09-01
981,SAINT TERESA REHABILITATION AND NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2015-08-19,356,D,0,1,M60C11,"Based on observation and interview it was determined that the facility failed to maintain an accurate daily staffing posted in a prominent place readily accessible to residents and visitors with the facility name and total number, actual working hours, of licensed and unlicensed nursing staff directly responsible for resident care per shift and the resident census for each date and shift. Findings include: Observation on 8/19/15 of the facility posted DAILY NURSING STAFF revealed a clipboard with multiple individual pages hanging on a wall adjacent to the nursing station desk on the Bridge unit. Review of this daily posting revealed from 2/17/15 through 7/26/15 to include the dates of survey that this information did not include the facility name and had inconsistent information on multiple numerous days lacking documentation of the census, total number and actual hours for the licensed and unlicensed nursing staff directly responsible for resident care per shift. During interview on 8/19/15 with Staff F (Administrator) and Staff G (Director of Nursing) both Staff F and G verbalized that the DAILY NURSING STAFF posting was incomplete and was located as listed in the above findings.",2018-09-01
982,SAINT TERESA REHABILITATION AND NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2015-08-19,368,C,0,1,M60C11,"Based on observation and interview with staff and residents, there is greater than 14 hours between the evening meal and breakfast the following day at the facility and the facility does not offer a nourishing snack at bedtime. Findings include: Review of the dining schedule for the facility revealed in the Main Dining Room, dinner is served at 4:15 p.m. and breakfast is served at 7:00 a.m. (14.75 hours between meals). In the Bridge Dining Room, dinner is served at 5:15 p.m. and breakfast is served at 7:45 a.m. (14.5 hours between meals). In the Trinity Cafe, dinner is served at 5:00 p.m. and breakfast is served at 8:15 a.m. (15.25 between meals). Interview with Staff D (Director of Culinary Services) on 8/17/15 at 2:00 p.m. confirmed the above finding and revealed that the kitchen offers snacks at approximately 10:00 a.m. and 2:30 p.m. but not after dinner. Interview with Resident #6 confirmed there are no snacks offered after dinner. Resident #15. During interview on 8/19/15 Resident #15 verbalized that she was not aware of snacks being offered after the evening meal. Resident #15 verbalized that if a cart for snack goes around she was not aware of one because they don't come to me. Resident #15 also added that she can have something if I want but I would have to ask for it .they don't ask you if you want something.",2018-09-01
983,SAINT TERESA REHABILITATION AND NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2015-08-19,371,E,0,1,M60C11,"Based on observation and interview with staff, the facility failed to take temperatures on the tray line at the location food is served, and failed to rotate bread products prior to expiration. Findings include: During observation on tour of the kitchen and kitchenettes on 8/17/15, bagels with the expiration date of 7/20/15 were discovered in the Main kitchen and raisin bread with the expiration date of 8/13/15 was discovered in the kitchenette on the Bridge unit. Interview with Staff D (Director of Culinary Services) on 8/17/15 at 2:30 p.m. confirmed the above findings. During interview with Staff E (Dietary Aide) on 8/18/15 at 8:30 a.m., it was discovered that dining staff do not measure or record the temperature of food on the tray line at the final destination of meal service on the Bridge unit. On observation of the individual Bridge and Trinity resident kitchenettes revealed on both units that the ice scoops utilized on these units were left on a plate on top of the kitchenette shelve not covered or protected from physical contaminants. Staff D confirmed that the facility ice scoops utilized to dispense ice to residents were not stored in a manner to prevent physical contamination.",2018-09-01
984,SAINT TERESA REHABILITATION AND NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2015-08-19,431,D,0,1,M60C11,"Based on observation and interview the facility failed to ensure all drugs and biological's were stored in locked compartments. Findings include: Observation on 8/19/15 at about 2:20 p.m. of the medication room revealed an empty sharps container loose on the counter. Interview on 8/19/15 at approximately 2:30 p.m. with Staff B (ADON), revealed when asked about the disposal of the sharps containers that Staff C (Maintenance Director) removed the full containers from the floor and stored them, In the garage. The boxes get picked up every quarter Observation on 8/19/15 at approximately 2:30 p.m. in the garage revealed 5 unsecured cardboard boxes that contained individual red needle and sharps containers as well as any other biohazard waste. Staff C revealed that maintenance and the person who maintains the lawn has access to the garage.",2018-09-01
985,SAINT TERESA REHABILITATION AND NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2015-08-19,463,E,0,1,M60C11,"Based on record review, resident interviews and Policy/Procedure review, it was determined the facility failed to follow the standards of practice for resident safety, dignity, and basic hygiene care. During the Resident Group Interview meeting conducted at 11:00am on 8/17/15 by two surveyors, it was stated by several attendees at the meeting that their call lights were not being answered in a timely fashion. During a resident interview on 8/19/15 at 0900 with Resident #13 (Out of Sample), they indicated that they were instructed by the night staff to Go in (pronoun omitted) bed and they will clean it up. During an interview with a family member of Resident #14 (Out of Sample) at 1:00pm on 8/19/15, it was mentioned that the Staff is limited on the weekends and Just that they need more help on the weekends. During medical record review of Resident #6 on 8/18/15, it was documented in clinical notes .Patient later found in room crying again about the call bell taking too long to be answered. Patient stated 'it took 10 minutes for someone to come and check on me and I had an accident.' During interview with Resident #6 on 8/18/15 at 2 p.m., the resident stated they often waited 15-20 minutes for someone to respond to the call bell. Resident stated that there was not enough staff. The resident also stated I went to the bathroom by myself even though I'm not supposed to after waiting for a response to their call bell.",2018-09-01
986,SAINT TERESA REHABILITATION AND NURSING CENTER,305071,519 BRIDGE STREET,MANCHESTER,NH,3104,2015-08-19,465,D,0,1,M60C11,"Based on observation, staff interview and Policy/Procedure review, it was determined the facility failed to maintain a safe environment for the residents in one of two units. On 8/18/15 at approximately 2:05 pm, an unattended housekeeping cart was observed in the hallway of the Trinity wing, across from the dining room. Several spray bottles were noted to on the cart, located on a lower shelf. At approximately 2:15, Staff A (Custodian), was seen walking down a long hallway and moved the cart to be able to enter a room. At 2:20 Staff A was seen walking away from the area with a bag of refuse and exited the building. Staff A reentered the building and proceeded towards the cart. This surveyor inquired if they were assigned to the cart. Staff A replied Yes. This surveyor inquired about the contents of the spray bottles. Staff A replied that one had DMX floor cleaner and the other was a wax stripper. Interview with Staff B (Assistant Director of Nurses) at about 2:25 pm. Staff B indicated that all cleaning agents and hazardous materials had to be locked up when leaving the cart. Review of St. Teresa's Policy & Procedure, Porter/Custodian, Section 3 'Functions and Risk Classifications', sub-section A, paragraph 18 pg. 2: Assure that work/assignment areas, tools, supplies, etc., are properly stored at all times, as well as before leaving such areas for breaks, mealtimes, and at the end of the day work.",2018-09-01
987,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2015-06-11,425,D,0,1,ZLDH11,"Based on observation, interview and the facility policy and review of the procedure for Disposal/Destruction of Expired or Refused, Discontinued and Expired Medications it was determined that the facility failed to discard medications in a safe manner. Review of the facility policy and procedure titled Disposal/Destruction of Refused, Discontinued and Expired Medication dated 08/01/02 revealed the following: POLICY The Center adheres to all federal, state and local regulations regarding drug destruction when discarding any medication and/on medical waste . PR[NAME]ESS 1. For refused/dropped medications: [REDACTED] 1.1 When a patient refuses a dose that has already been prepared for administration by Center staff or if a dose is deemed unusable (e.g., dropped on floor), document the refusal on the MAR (Medication Administration record). 1.2 Immediately dispose of the dose by mixing the dose in water or alcohol to make unusable and dispose of dose in trash, sink drain or toilet . Observation on 6/10/15 during a medication pass with Staff A (Licensed Practical Nurse) at approximately 7:15 a.m. revealed that Staff A, donned with right gloved hand, administered multiple medications from a plastic medication cup into a resident's hand. This resident was observed having difficulty putting these hand held multiple medications into her mouth and one of the medications fell out of her hand and landed on the floor. Staff A proceeded to retrieve this medication from the floor and discarded the medication into the resident's bedside open trash container. During interview with Staff A (LPN) 6/10/15 following this medication pass at approximately 11:30 a.m. Staff A was asked how medications are disposed of in the facility. Staff A responded that she did realize that the medication listed in the findings above was discarded in the resident's bedside open trash container . Staff A continued by verbalizing that this dropped medication should of been discarded in (the open) trash container on the medication cart. The facility failed to follow the policy and procedure for the proper and safe disposal of dropped medications administered to one resident.",2018-09-01
988,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2015-06-11,441,D,0,1,ZLDH11,"Based on a medication pass observation it was determined that the facility failed to implement proper hand hygiene during the administration of medications to prevent the spread of infection and prevent cross-contamination. Findings include: Observation on 6/10/15 with Staff A (Licensed Practical Nurse) at approximately 7:15 a.m. showed that Staff A was at the medication cart and proceeded into a resident's room and was observed performing a apical/radial pulse with a stethoscope. Staff A exited this room after performing this task and returned to the medication cart with out performing any hand hygiene. Further observation at this time showed that Staff A, after returning to the medication cart documented this apical/radial pulse, unlocked the medication cart and proceeded to prepare multiple medication's for this resident, no hand hygiene was observed at this time. Staff A proceeded to the resident's room and administered multiple medication's with a single gloved hand by taking each individual medication out of the plastic medication cup and placing them in the resident's hand. Staff A also prepared and helped administer a hand held inhaler with medication to the resident. During this observation Staff A retrieved a medication from the resident's room floor that had fallen from the resident's hand and discarded this medication into the bedside (open trash) container and after checking with the resident to verify her current health status Staff A proceeded to discard the one glove from her hand and exited the resident's room without performing any hand hygiene. Staff A then returned to the medication cart. The facility failed to implement proper hand hygiene practice to reduce the spread of infection and prevent cross-contamination during the above listed observation Cross reference F425.",2018-09-01
989,"COUNTRY VILLAGE CENTER, GENESIS HEALTHCARE",305076,91 COUNTRY VILLAGE ROAD,LANCASTER,NH,3584,2015-06-11,456,E,0,1,ZLDH11,"Based on interview and review of the manufacturer's instructions for the facility glucometer testing solutions and test strips it was determined that the facility failed to maintain and utilize the glucometer testing solutions and test strips according to the manufacturer's instructions. Findings include: Review of the facility EvenCare G2 Glucose Control Solutions manufacturer's instructions revealed the following: STORAGE AND HANDLING . Do not use if the expiration date has passed Discard any unused control solution 90 days after first opening or after expiration date . TO PERFORM A TEST WITH CONTROL SOLUTIONS FOLLOW THESE STEPS: 1. Newly opened bottles of control solutions must be marked on the space on the control solutions label with the date that it was opened. Check the expiration date of the control solutions to make sure they have not expired. Discard any unused control solutions 90 days after opening or after expiration date . Review of the facility EVEN CARE G2 Blood Glucose Test Strips manufacturer's instruction revealed the following: WARNING AND PRECAUTIONS . Do not use test strips after their expiration date. Please check the expiration date on the test strip bottle. STORAGE AND HANDLING . Use within 6 months after first opening . Review of the facility glucometer and Glucometer Quality Control Record on 6/10/15 at approximately 4:00 p.m. for the Hampshire Wing revealed the following: Staff B (Registered Nurse) provided the hand held glucometer and Glucometer Quality Control Record for the Hampshire Wing. This hand held glucometer had no identification indicating this was the Hampshire Wing glucometer. Review and observation of the individual High and Low Control Solution bottles revealed they were not dated with a date for the time of opening and the Control Lot #'s for the High and Low control bottles listed on the Glucometer Quality Control Record did not match the bottles provided. Staff B (RN) at this time provided the hand held glucometer and Glucometer Quality Control Record for the Coos Wing. This hand held glucometer had no identification indicating this was the Coos Wing glucometer. Staff B (RN) provided the hand held glucometer and Glucometer Quality Control Record for the Coos Wing. Review and observation of the individual High and Low Control Solution bottles revealed they were not dated with a date for the time of opening and the Control Lot #'s for the High and Low control bottles listed on the Glucometer Quality Control Record did not match the bottles provided. Staff B (RN) at this time provided the hand held glucometer and Glucometer Quality Control Record for the Upper Notchway Wing. This hand held glucometer had no identification indicating this was the Upper Notchway Wing glucometer. Staff B (R N) provided the hand held glucometer and Glucometer Quality Control Record for the Upper Notchway Wing. Review and observation of the individual High and Low Control Solution bottles revealed they were not dated with a date for the time of opening and the Control Lot #'s for the High and Low control bottles listed on the Glucometer Quality Control Record did not match the bottles provided. Staff B (RN) provided the hand held glucometer and Glucometer Quality Control Record for the Lower Notchway Wing. This hand held glucometer had no identification indicating this was the Lower Notchway Wing glucometer. Review and observation of the Glucometer Quality Control Record for this Wing revealed a glucometer serial # listed at the top of the record but the serial # on the Glucometer for the Lower Notchway Wing did not match this record number. During this observation and review Staff B (RN) verbally confirmed the above listed findings for the hand held glucometers and the GLUCOMETER QUALITY CONTROL RECORD's for all 4 of 4 facility glucometers. The facility failed to properly identify the 4 individual facility glucometers to ensure the glucometer testing solutions and test strips were done on the appropriate glucometer according to the manufacturer's instructions. Additionally, the facility failed to maintain the proper documentation and labeling of the control solution bottles and test strips to correspond with the individual unit hand held glucometer documentation to ensure that these glucometers are maintained in a safe operating condition.",2018-09-01
990,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2015-06-05,281,D,0,1,3Q0R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon a review of a facility incident report and staff interview the facility failed to ensure that a resident who had fallen remained on the floor until the arrival of an ambulance (Resident identifier is #3). Findings include: On 9/22/14 at 10:15 am Resident #3, according to a facility accident and incident report, was found on the floor beside her bed. Resident #3's left leg was found to be rotated and shortened and Resident #3 complained of pain while clutching her leg. Despite this Resident #3 was moved into her bed before going to the hospital at 11:20 am where it was revealed that Resident #3 had sustained a left [MEDICAL CONDITION]. Staff B, DON (Director of Nurses) during a 6/5/15 interview acknowledged that Resident #3 should have been left on the floor, not moved before the ambulance arrived to take Resident #3 to the hospital.",2018-09-01
991,"LAFAYETTE CENTER, GENESIS HEALTHCARE",305077,93 MAIN STREET,FRANCONIA,NH,3580,2015-06-05,456,D,0,1,3Q0R11,"Based on observation, manufacturer's instructions, facility's policy and logs and interview, it was determined that the facility failed to maintain the proper labeling of the glucose control solution by not labeling the glucometer control solution bottle for 1 of 2 units. Findings include: Observation on 6/3/15 of the Blood Glucose control solution for the Spruce unit, revealed that the both the high and low Control Solution bottles were not labeled with a discard date. The bottles had no date when they had been opened. Interview on 6/3/15 with Staff A, Unit Manager RN (Registered Nurse), stated the bottles would be discarded with the manufacturer's printed expiration date on the bottle. Review of the Precision Q.I.D. Blood Glucose Testing System for the months of March-June reveals inconsistentl testing of the control solutions. Review of the manufacturer's instructions for the EvenCareG2 (Glucose Control Solutions) revealed under the section STORAGE AND HANDLING .Discard any unused control solution 90 days after first opening or after expiration date. Review of the facility's Glucose Meter policy revision date 6/1/15 revealed the following: . 3. Check expiration date on reagent strips package and control solution. Replace if outdated . 3.2 Each time a new bottle of control solution is opened, date the bottle. Bottle is to be discarded according to manufacturer's recommended time frame .5. Document testing on the 'Blood Glucose Meter Control Results Log' 5.1 Designated staff will audit quality control logs monthly for completion. Interview on 6/3/15 in the afternoon, with the Staff B, DON (Director of Nurses) confirmed the above findings.",2018-09-01
992,VILLA CREST,305079,1276 HANOVER STREET,MANCHESTER,NH,3104,2015-09-04,281,B,0,1,EWM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to ensure that physician's orders were clear and complete for 3 residents in a survey sample of 24 residents. (Resident identifiers are #13, #14, and #21) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates The physician is responsible for directing medical treatment. Nurses follow physicians ' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary And on page 708 it relates The prescriber often gives specific instructions about when to administer a medication The text also relates on page 707 The six rights of medication administration include . The right medication . The right dose . The right route . The right time and on page 691 Excess amounts of a medication within the body sometimes have lethal effects, depending on the medication's action The facility made available for review an undated Administration of Drugs Policy Statement which states, in part, All medications ordered will be administered orally unless otherwise indicated by the provider. Resident #14 Review of Resident #14's (MONTH) (YEAR) Physician's Orders sheets, signed by the physician on 8/17/15 reveals two prn (as needed) pain medication orders with no parameter provided to specify when one medication should be selected over the other: [MEDICATION NAME] 650 mg by mouth every 4 hours, and [MEDICATION NAME] 50 mg by mouth every 6 hours. Review of documented Physician's Orders reveals an 8/10/15 order for Healthshakes daily which lacks a dose. Resident #21 Review of Resident #21's (MONTH) (YEAR) Physician's Orders sheets, signed by the physician, reveals an order for [REDACTED]. Resident #13 Review of Resident #13's Physician orders on the Medication Administration Record [REDACTED] pg 1 [MEDICATION NAME]: NOT TO EXCEED 3 GM/24HRS FROM ALL SOURCES dated 2/9/12 pg 2 [MEDICATION NAME] ([MEDICATION NAME]) 500MG CAPLET IC:Tylenol 2 CAPLETS (1000 MG) BY MOUTH THREE TIMES A DAY - MAX ACETAM 3-4 g (grams); ck DAILY TOTAL dated 10/2/14 pg 4 [MEDICATION NAME] (GENEBS) 325MG TABLET IC:Tylenol 325MG 2 TABS (650MG) PO (by mouth) EVERY 4 HOURS AS NEEDED PAIN/TEMP 101 OR > (GREATER) dated 6/5/09 The MARs' documents [MEDICATION NAME] 2 Caplets (1000mg) were administered 3 times per day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #13 received 3000mg or 3 grams per day for the months June, (MONTH) and (MONTH) (YEAR). If the order for scheduled Tylenol 1000 mg is followed and given 3 times per day the Resident #13 will have received the 3 grams or 3000 mg maximum as noted on pg 1. If the PRN (as needed) dose of 650 mg order (pg 4) is administered in addition to the scheduled dose of total 3000mg/ 3 grams the facility will exceed the Physicain parameter not to exceed 3 grams in 24 hours. If a second PRN dose of 650 mg were given the Resident dose of 3000mg plus 2 doses of 650 would exceed the 4 Gram or 4000 mg limit noted on page 2. If the PRN orders were to be administered the facility would be exceeding either the 3 gram limit (pg 1) and or 4 gram limit (pg2); violating the Physician's ordered parameters.",2018-09-01
993,VILLA CREST,305079,1276 HANOVER STREET,MANCHESTER,NH,3104,2015-09-04,371,E,0,1,EWM711,"Based on observations and interviews the facility failed to maintain food preparation equipment, store ice scoops in clean areas and monitors temperatures to ensure sanitary conditions. Findings include: Observation during the initial tour of the kitchen on 9/2/15 at 8:00 a.m. revealed that the electric meat slicer had pieces of dried meat on the shelf under the meat slicer. Inspection of the kitchen mixer revealed dried food caked along the back splash. Interview with Staff A (Food Services) at 8:15 a.m. confirmed the above findings. Staff A revealed it would be the kitchen's policy to clean equipment immediately following use and that neither the meat slicer or kitchen mixer had been used that morning. Observation on 9/2/15 at 8:30 a.m. of the portable ice coolers kept on the units revealed that there were ice scoops that were not stored in clean areas. On the south unit, the ice scoop was laying horizontal in its holder touching a brown moist substance on the bottom of the holder. On the special care unit, the ice scoop was in a vertical scoop holder and the scoop end was touching water that had accumulated in the bottom of the holder. The ice scoop holder on the special care unit also had a brown substance on the bottom of the holder. Interview with Staff B (Assistant Food Services Supervisor) on 9/2/15 at 8:50 a.m. confirmed the above findings and revealed that the ice from the coolers on the units were for consumption. Staff B was able to wipe away the brown substance from the scoop holder on the south unit. Interview with Staff B on 9/2/15 at 9:00 a.m. revealed temperatures are not taken from the food on the food tray line or the high temperature dishwasher in the kitchenette on the special care unit. Interview also revealed that breakfast, lunch, and dinner are served from the special care unit food tray line and the special care unit dishes are cleaned in the kitchenette's high temperature dishwasher.",2018-09-01
994,SULLIVAN COUNTY HEALTH CARE,305093,5 NURSING HOME DRIVE,UNITY,NH,3743,2015-05-14,281,D,0,1,1SWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that physician orders [REDACTED]. (Resident identifiers are #3 and #21.) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates The physician is responsible for direct-ing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the client suffers ; and on page 707 relates The six rights of medication administration include . The right dose . The right route . The right time Resident #21 Record review of the (MONTH) (YEAR) eMAR (electronic Medication Administration Record) revealed an order for [REDACTED]. Record review revealed orders for [MEDICATION NAME] Patch, [MEDICATION NAME] and [MEDICATION NAME] as follows: [MEDICATION NAME] 12 MCG (micrograms)/hr patch, [MEDICATION NAME] 325 mg (milligram) tablet two tables (sic) every 12 hours after 1st patch placement, and [MEDICATION NAME] 300 MG capsule. The above are not complete orders as they are all missing the frequency of administration and the [MEDICATION NAME] order is not clear specific to its statement of after 1st patch placement. Interview with Staff A (DON) confirmed that the above orders are not complete orders and Staff A stated the software used for Physician orders [REDACTED].",2018-09-01
995,SULLIVAN COUNTY HEALTH CARE,305093,5 NURSING HOME DRIVE,UNITY,NH,3743,2015-05-14,441,D,0,1,1SWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to maintain the managing of the facility resident immunization program by not monitoring and documenting the resident immunization status for 1 resident in a survey sample of 24 residents. (Resident identifier is #16.) Findings include: Record review on 5/14/15 of the Medication Administration Record (MAR) for Resident #16 dated (MONTH) 2014 revealed the following immunization order; [MEDICATION NAME] 5T UNITS/0.1 ML VIAL - ADMINISTER 1ST STEP PPD ON ADMISSION AND READ IN 48-72 HOURS . Further review of this MAR revealed that Resident #16 was administered the 1st Step PPD on 9/2/14 the day of admission to the facility. On 9/3/14 documentation on this MAR revealed a red N indicating that results (reading) of this PPD was not done on 9/3/14. Review of the paper form titled [MEDICATION NAME] and Immunization Record for Resident #16 revealed that the 1st step PPD was given on 9/2/14 and the section for the results (reading) was blank and not complete. No other documentation could be found to confirm the results (reading) of the 1st Step PPD administered to Resident #16 on 9/2/14. During interview on 5/15/15 with Staff A (Director of Nursing) and Staff B (Infection Control Registered Nurse) both reviewed the above listed MAR, the electronic record to include the Immunization section, MAR and Nurses Notes. Staff A and Staff B verbalized that no documentation could be found to show that the 1st Step PPD was read to show the results of this immunization administered on 9/2/14 to Resident #16.",2018-09-01
996,SULLIVAN COUNTY HEALTH CARE,305093,5 NURSING HOME DRIVE,UNITY,NH,3743,2015-05-14,514,D,0,1,1SWB11,"Based on record review and interview the facility failed to accurately document and complete the medical record for 2 residents in a survey sample of 24 residents. (Resident identifiers are #11 and #15.) Findings include: Resident #15. Record review on 5/14/15 of the Pharmacy MEDICATION REGIMEN REVIEW for Resident #15 revealed incomplete documented information. This MEDICATION REGIMEN REVIEW was not complete with individual sections completed and had no documentation of Resident #15 name and no year listed for the months of (MONTH) and (MONTH) (YEAR). During interview on 5/14/15 with Staff C (Licensed Practical Nurse, Unit Manager) at approximately 11:45 a.m., Staff C verbalized that the above indicated MEDICATION REGIMEN REVIEW was in the pharmacy section of Resident #15's record and that individual sections were not completed and there was no documentation of Resident #15's name and no year indicated for the months of (MONTH) and (MONTH) (YEAR). The facility failed to maintain and accurately document the pharmacy regimen review for Resident #15. Resident #11 Record review of the Medication Regimen Review for this resident revealed unintelligible dates for calendar year for entries reviewed from (MONTH) 2014 through (MONTH) (YEAR). In addition, review of the 9/30/14 review reveals that the box for See report for any noted irregularities and/or recommendations is not check, yet interview with Staff A, Director of Nursing on 5/12/15 revealed that the pharmacist did make recommendation(s) on this date. On the 4/24/15 review there is a mark adjacent to the box for See report for any noted irregularities and/or recommendations but interview with Staff A on 5/12/15 revealed this is an error and that the box for NI (no new irregularities) should have been checked.",2018-09-01
997,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2015-02-19,278,B,0,1,L6C411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that the MDS (Minimum Data Set) Assessment was accurate for 1 Resident in a standard survey of 17 Residents. (Resident identifier is #15.) Findings include: Resident #15. Review on 2/19/15 of this resident's Quarterly MDS Assessments with ARDs (Assessment Reference Dates) of 10/06/2014, 01/06/2015 and a significant change on 07/14/2014 revealed that under Section O 0100 (Special Treatments & Programs while a Resident?) Resident #15 did not code for being on [MEDICAL TREATMENT]. In an interview on 2/19/15 in the afternoon with Staff B (RN/MDS Coordinator), Staff B confirmed that [MEDICAL TREATMENT] was not in Section O100(j) in the MDS's. Staff B did not know why since Resident #15 has been on [MEDICAL TREATMENT] for a long time.",2018-08-01
998,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2015-02-19,279,D,0,1,L6C411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to develop a complete comprehensive care plan for 1 resident in a survey sample of 17 residents (Resident identifier #1). Findings include: Record review 2/18/15 of the CAA Worksheet for Resident #1 with an ARD (Assessment Reference Date) of 1/21/15 revealed that [MEDICAL CONDITION], Urinary Incontinence, Behaviors, Dental and Psychiatric Medications were triggered from the MDS and nursing staff decided to proceed to care plan for these problem areas. Review of the comprehensive care plans on 2/18/15 for Resident #1 revealed that care plans for [MEDICAL CONDITION], Urinary Incontinence, Behaviors, Dental and Psychiatric Medications were not developed. During interview with Staff C (Unit Manager A Unit) on 2/19/15, Staff C verbally confirmed that a care plan was not developed for [MEDICAL CONDITION], Urinary Incontinence, Behaviors, Dental and Psychiatric Medications.",2018-08-01
999,ROCHESTER MANOR,305024,40 WHITEHALL ROAD,ROCHESTER,NH,3867,2015-02-19,329,E,0,1,L6C411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to ensure that residents on antipsychotic medications have documented evidence that the risks and benefits of the medication had been explained to them, which includes the black box warnings. Findings include: Record review revealed a generic form for all psychoactive medication that is filled out. The form is as follows: Date .Your family member (name) has been prescribed the Psychoactive Medication (name of medication with dosage) by their Physician. The following side effects may be experienced: Constipation, [MEDICAL CONDITION], Confusion, Lethargy, Tremors (hands, arms, head), Involuntary Movement (mouth, tongue, jaw), Motor Mouth, Skin Rash, Drowsiness. As the responsible person for this resident, it is important that you are informed and aware of all aspects of their care. If you have any questions, please call (name omitted). Please sign this form and return it as soon as possible. If we do not hear from you within the next week, it will be understood that you are in agreement with this plan of care . Interview with Staff A, (LPN), indicated that this form is to inform the patient, and/or representative that the medication is started or an increased or decreased. Staff A was unaware of informing the residents and/or their representative about the Black Box warning. Staff A confirmed that this is the only formed used to inform them about the antipyschotic medications.",2018-08-01
1000,RIVERSIDE REST HOME,305047,276 COUNTY FARM ROAD,DOVER,NH,3820,2015-08-07,272,D,0,1,NZWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to complete a comprehensive Nutrition Assessment (protein needs, dietary intake, weight loss; and relevant risk factors; interventions, etc,) for one resident in a survey sample of 30 residents. Resident Identifier is #15. Findings Include: Record review indicated Resident #15 was admitted to the facility on [DATE]. Review of the Facility Weekly Vital Signs & Weight sheet documents Resident #15's weight on 05/14/15 as 168.2 lbs. Record review of Resident #15's Dietary Progress Note dated 06/05/15, reveals Resident #15's weight on 6/4/15 to be 156.6 lbs. Resident #15's weight is decreased 6.8% x 21 days. Resident #15's weight decreased 11.6. lbs. The Dietary Progress note 6/5/15 documents Resident #15 is a very slow eater, but has a good appetite and further notes: will take no action at this time secondary to (resident) BMI is within Normal limits at his time. Record review revealed a Laboratory Report dated 5/5/15 which documented a Lab result for Total Protein level at 5.5 for Resident #15; noted to be L (Low) and the lab report documents the normal range is 6.4 to 8.3. Record Review of the Physician's Progress Note dated 6/17/15 documents, (Resident #15) continues to have a problem with being tired almost all the time and sometimes sleeps through meals .weight has declined since admission on (MONTH) 14, (YEAR) from 168 lbs. to 151 lbs. on most recent weight. Records reviewed above indicates Resident #15 weight has declined 17 pounds indicating a significant weight loss, approximately 10% weight loss in just over a month (35 days). The Dietary Progress notes dated 6/5/15 does not include or provide a Comprehensive Nutritional Assessment of Resident #15 nutrition needs. The note does not address risk factors or provide intervention for the Low Total Protein lab value level @ 5.5 (normal Total Protein value is 6.4-8.3); And the Dietary note also doesn't consider or address increased sleeping in relation to intake decline. An observation of Resident #15 at lunch time on 08/6/15 showed unit Staff attempting to encourage Resident #15 to eat while Resident #15 was sleepy. Interview on survey with the Administrator and Director of Nursing between 3:30- 4:00 pm concerning the need for comprehensive Nutrition Assessment of Resident #15 risk factors and interventions related to nutrition, and total Protein requirements for Resident #15.",2018-08-01