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Based on document review and interview the facility failed to ensure nursing care plans were reviewed, updated, and individualized for 2 of 23 patients (pt. #27 and pt. #33) resulting in the potential of failure to meet patient goals and outcomes. Findings include:

On 10/31/2018 at 1430 during the medical record review of patient #27 nursing care plan it was revealed that the patient's nursing care plan was initiated on 8/27/2018 and had failed to have been updated or reviewed prior to the patient's discharge from the facility on 9/5/2018. The patient's nursing care plan also included the use of acupuncture and massage therapy which the facility does not offer.

On 10/31/2018 at 1435 during the medical record review of patient #33 nursing care plan it was revealed that the patient's nursing care plan was initiated on 8/27/2018 and had failed to have been updated or reviewed prior to the patient's discharge from the facility on 9/1/2018.

On 10/31/2018 at 1440 an interview was conducted with staff A, the nursing manager. Staff A was queried if nursing staff should be reviewing and updating patients nursing care plans. Staff A stated, "yes...it is expected the nurses would review and update nursing care plans for each patient." Staff A was then asked if acupuncture and massage therapy were offered at the facility. Staff A replied, "no." Staff A was then asked if the nursing care plan should include only interventions which could be provided at the facility. Staff A responded, "yes...I think it is a matter of correcting how interventions are selected with our computerized charting."

On 11/1/2018 at 0940 a document review of the policy titled, "Nursing Department Scope of Care", policy stat ID #3124362, dated 9/2016, states, "the plan is reviewed daily and updated as needed to reflect changes in physician orders and/or the patient's condition..."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated November 1, 2018.
K-0100
K-0211
K-0362
K-0363
K-0374
K-0920

Based on observation and interview the facility failed provide and maintain a clean and sanitary environment resulting in the potential for the spread of infectious disease. Findings include:

During tour of the facility on 10/30/2018 at 1017, the medication room was entered and observed to have streaks of dried brownish fluid that had run down the stainless back splash of the wall. Additionally, there was tape residual and residue on the wall beside the door inside of the medication room. Upon leaving the medication room, holes in the drywall were observed to be present behind the door exposing the drywall plaster. These findings were confirmed by Staff B at the time of discovery.

On 10/30/2018 at 1021, three medication carts were observed to be sitting just outside of the nurses station. Two of the three medication carts had chipped paint and all three of the carts had adhesive stickers that were curled at the edges exposing the adhesive backing. These findings were confirmed by Staff B at the time of discovery.

On 10/30/2018 at 1023, the vital sign/admission room was entered and found to have a cloth-framed picture behind the desk that was unraveling at the top left edge. The wall paper above the door was curling back, the top of the computer monitor and the printer were dusty, and there were holes observed to be present in the window molding. Additionally, a camera was observed to be mounted to the back of the computer monitor using several pieces of scotch-tape, some of which had the adhesive part of the tape exposed. These findings were confirmed by Staff B at the time of discovery.

On 10/30/2018 at 1031, a reddish brown smear was observed to be present in the hallway by the nurses station. Staff B was queried on 10/30/2018 at 1031 as to what the smear was to which she stated, "I don't know what it is."

On 10/30/2018 at 1032, Patient Room #138, which was identified by Staff B as being patient ready, was entered and found to have 2 desks present, both of which had cracked veneer exposing the wood underlayment. Additionally, above the door near the ceiling on the inside of the room was cracked plaster. This finding was confirmed by Staff B at the time of discovery.

On 10/30/2018 at 1035, Patient Room #120, which was identified by Staff B as being patient ready, was entered and found to have 2 desks present, both of which had cracked and chipped veneer exposing the wood underlayment. Both bedside tables were also found to have a cracked and chipped veneer exposing the wood underlayment. Additionally, it was observed that some of the paint had peeled off either side of the closet area. These findings were confirmed by Staff B at the time of discovery.

On 10/31/2018 at 1037, the ceiling outside of the cafeteria was observed to have heavy rust on the grid which held the ceiling tiles. This finding was confirmed by Staff B at the time of discovery.

On 10/30/2018 at 1045, the hallway by the Dietary Director's office was entered and was observed to have a large amount of paint which had chipped off of the exit door. Additionally, the plaster was cracked above the double doors heading out of the hallway. These findings were confirmed by Staff B at the time of discovery.






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On 10/30/2018 at 1010 during the initial tour of the in-patient area of the facility high dust was identified on picture frame tops and room door sills throughout the facility. Staff A, the nursing manager confirmed the findings.

On 10/30/2018 at 1040 during the initial tour of the in-patient area of the facility in the med-administration room items were viewed stored beside the clean sink area within the splash zone area. Staff A confirmed the findings.

On 11/1/2018 at 1030 an interview with staff A was conducted. Staff A was queried if high dusting was to be conducted by environmental services. Staff A stated, "yes." A request was made for a cleaning policy. Staff A stated a cleaning policy did not exist for the facility. Staff A then stated cleaning services were contracted and services were outlined in the contract. The cleaning contract outlining provided services was not kept on site and could not be provided.


On 10/30/2018 at 2:00pm during a tour of the facility, the ambulance bay area was entered and found to have a wall behind the sink that was chipping and not cleanable. The area under the sink where the pipe enters the wall was found to have multiple holes in the wall around the pipe. These findings were comfirmed by Staff I at the time of the observation.

Based on record review, interview, and document review, the facility failed to provide necessary medical information when transferring a patient to an acute care hospital for 2 (#32, 33) of 3 patients who were transferred resulting in the potential for unidentified and unmet patient needs. Findings includes:

Review of Patient #32's medical record on 10/31/2018 at 1257 revealed that Patient #32 was admitted on 9/5/2018 for alcohol dependence. Routine lab work dated 9/5/2018 showed a calcium level of 14.2 milligrams/deciliter (mg/dL). Nursing documentation dated 9/6/2018 revealed the patient was transferred to a local emergency department for the high calcium level. No documentation is present regarding the "Patient Transfer Form", any printed documentation from the electronic medical record, or of verbal report being called to the receiving facility. The lack of documentation was confirmed by Staff B on 10/31/2018 at 1530.

Review of Patient #33's medical record on 10/31/2018 at 1247 revealed that Patient #33 was admitted on 8/27/2018 for alcohol dependence. While completing the detoxification process, the patient began yelling, cursing, and barricaded himself in his room. Nursing documentation revealed that 911 was called on 9/1/2018 at approximately 0215. No documentation was present regarding the transfer to the local emergency department including the "Patient Transfer Form", any printed documentation from the electronic medical record, or of verbal report being called to the receiving facility. The lack of documentation was confirmed by Staff B on 10/31/2018 at 1500.

In an interview with Staff B on 10/31/2018 at 1506, Staff B stated, "They do call report, but we don't have documentation of it...That is the expectation that they would document it."

Facility policy #3235250 titled "Transfer Policy" last revised 3/2013 states, "RN/UT (registered nurse/unit technician) prepares patient for transport including...Transfers documents: complete MAR (medication administration record), last 24 hours of nursing and medical notes, H&P (history and physical), most recent labs, any advanced directives. Complete patient transfer form...Places copy in chart...Documents patients transfer in patient record..."