Every finding on record at Auburn Skilled Nursing and Rehab

Based on observation, interview, record review and review of the facility policy, the facility failed to maintain the unit refrigerator in a sanitary manner that followed acceptable standards of food safety. This had the potential to affect 37 residents receiving meals from the kitchen as Resident #14 and Resident #35 were ordered nothing-by-mouth (NPO). Facility census was 39 residents.Findings include:Observation on 02/20/26 at 10:15 A.M. with Licensed Practical Nurse (LPN) #130 revealed a refrigerator on the unit used for resident food which contained an undated opened bottle of Amish orange juice, an undated and unlabeled tub of tuna salad and an undated and unlabeled tub of egg salad in addition to a black Styrofoam container with the date 02/11/26 and Resident #17's last name on it. LPN #130 verified the unlabeled and undated foods at the time of observation and indicated housekeeping staff was responsible for maintaining this refrigerator.Interview on 02/20/26 at 10:20 A.M. with Housekeeping and Laundry Supervisor (HLS) #103 revealed the observed egg salad and tuna salad was from the previous weekend and confirmed they should have been removed from the refrigerator prior to the observation. HLS #103 stated housekeeping staff were to check this refrigerator daily when recording the temperature and to go through the food inside at that time. HLS #103 showed the surveyor the sheet used for documenting the temperatures and confirmed this sheet did not contain a sign off or cue for staff to go through undated or expired foods in the refrigerator.Review of this provided document, Storage Room Temperature Log, dated February 2026 revealed daily temperatures of the refrigerator and freezer were documented on the log. The log contained no guidance or staff sign off on checking food items in the refrigerator for labels and dates as well as disposing of expired or unlabeled food.During an interview on 02/20/26 at 10:28 A.M. the Director of Nursing (DON) was made aware of the above findings and shared Residents #14 and #35 were NPO thus were not able to utilize the unit refrigerator.Review of the facility policy titled, Food Receiving and Storage, revised October 2017, revealed food services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer would be covered, labeled and dated.This deficiency represents noncompliance investigated under Complaint Number 2651150.

Based on record review, observation, and interview, the facility failed to maintain proper food storage in the kitchen to prevent potential contamination and spoilage. This had the potential to affect all residents who receive food from the kitchen. The facility identified three residents (Resident #9, Resident #6, and Resident #5) as NPO (Nothing by mouth), who were not affected. The facility census was 42.Findings include: On 09/02/2025 at 8:50 A.M., an observation of the kitchen revealed a 16-ounce (oz) box of Barley which was opened and uncovered in the dry pantry. This was verified at that time by DM #165. On 09/02/2025 at 8:52 A.M., an observation of the kitchen revealed a dented 50 oz can of Campbell's Chicken Noodle Soup on the dry pantry shelf. This was verified at that time by DM #165.On 09/02/2025 at 9:00 A.M., an observation of the stand-up freezer revealed a package of approximately 25 frozen hot dogs, which was opened and unsealed, exposing the hot dogs to the freezer air. This was verified at the time of observation by the DM #165.On 09/02/2025 at 9:01 A.M., an observation of the kitchen revealed a large box of frozen seasoned beef patties, which was approximately 3/4 full, to be open and unsealed in the stand-up freezer. This was verified at the time of the observation by the DM #165.On 09/02/2025 at 9:06 A.M., an observation of the kitchen revealed white, crusted debris around the outer aspects of the ice machine and on the inside of the lid, which was flakey and would fall off when touched. An interview at that time with the DM #165 revealed this happened often and would run down the sides of the machine as well. On 09/03/25 at 10:55 A.M., an observation of the kitchen revealed a large box of frozen seasoned beef patties, which was approximately 3/4 full, to be open and unsealed in the stand-up freezer. This observation was verified by DM #165 on 09/03/25 at 11:00 A.M. A review of the facility policy titled, Food Receiving and Storage, revised October of 2017, revealed food services, or other designated staff, will maintain clean food storage areas at all times. It further revealed all foods stored in the refrigerator or freezer would be covered, labeled and dated.

Based on record review, observation, interview, review of the Centers for Disease Control and Prevention (CDC) Guideline for Isolation Precautions, and review of facility policy, the facility failed to timely implement orders for contact isolation for Resident #9 and ensure staff donned adequate personal protective equipment (PPE) when entering isolation rooms. This affected one resident (#9) of five reviewed for infection control. In addition, the facility failed to ensure staff performed appropriate hand hygiene during medication administration. This affected four residents (#7, #16, #21 and #27) of 10 observed for medication administration. The facility census was 42.Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 08/01/25 with diagnoses including dementia, atrial fibrillation, and dysphagia. Review of the progress note dated 08/13/25 at 12:56 A.M. revealed Resident #9 had a loose stool or diarrhea and the physician was notified. The note dated 08/14/25 at 10:36 P.M. revealed Resident #9's lab results indicated a positive result for clostridium difficile (c. diff). The note dated 08/15/25 at 1:28 P.M. revealed Resident #9 was placed on precautions (unspecified what kind of precautions) until further notice due to testing positive for c. diff and the resident's son was notified. The note dated 08/18/25 at 10:05 A.M. revealed Resident #9 was receiving antibiotics due to c. diff and remained on isolation. The note dated 08/22/25 at 3:37 P.M. revealed Resident #9 was receiving antibiotics due to c. diff and remained on isolation. On 09/02/25 at 10:07 A.M., an observation of Resident #9's room revealed a bin of personal protective equipment (PPE) outside the door, a red sign with EP on the door frame, and a red sign indicating to see the nurse prior to entering the room. There was no sign indicating contact precautions were in place. On 09/02/25 at 10:08 A.M., an interview with Registered Nurse (RN) #105 stated Resident #9 was on full contact precautions for c. diff. Review of the physician's orders revealed an order for contact isolation was created on 09/02/25 at 10:46 A.M. by the Director of Nursing (DON) with an effective date of 08/14/25. There was no evidence of prior orders for transmission-based precautions or isolation. On 09/02/25 at 5:30 P.M., an interview with the DON verified Resident #9's order for contact precautions was not added until 09/02/25 and the progress notes written prior to the order did not specify what type of transmission-based precautions were implemented. On 09/04/25 at 9:35 A.M, an observation of Resident #9's room revealed Housekeeper #163 was cleaning the room without wearing a gown. At this time, Resident #9 was sitting in a chair in the room. On 09/04/25 at 9:39 A.M., an interview with Housekeeper #163 confirmed no gown was worn while cleaning Resident #9's room. Housekeeper #163 stated she did not have to gown up because she was not providing direct care to Resident #9. On 09/04/25 at 10:10 A.M., an interview with Assistant Director of Nursing (ADON) #160 confirmed Resident #9 was still on contact precautions and housekeeping staff should wear gowns. Further review of the physician's orders revealed the order for contact isolation was active until Resident #9 discharged on 09/08/25. Review of the facility ' s policy titled Isolation - Initiating Transmission-Based Precautions, revised August 2019, revealed transmission-based precautions, including contact precautions, droplet precautions, and airborne precautions, were initiated when a resident developed signs and symptoms of a transmissible infection, arrived for admission with symptoms of an infection, or had a laboratory confirmed infection and was at risk of transmitting the infection to other residents. Transmission-based precautions remained in effect until the attending physician or infection preventionist discontinued them after criteria for discontinuation had been met. Review of the facility ' s policy titled Isolation - Categories of Transmission-Based Precautions, revised September 2022, revealed transmission-based precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection, arrived for admission with symptoms of an infection, or had a laboratory confirmed infection and was at risk of transmitting the infection to other residents. The policy indicated contact precautions were implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident ' s environment. Contact precautions included use of gloves and gown when entering the room and removing both before leaving the room, with hand hygiene performed after removing gloves. Review of the CDC's 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, revised September 2024, revealed contact precautions were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the patient or the patient's environment. The guidelines included that contact precautions would be used when there was a possibility of unintentional contact with contaminated environmental surfaces. 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, and donning PPE upon room entry and discarding PPE before exiting the room was done to contain pathogens that had been implicated in transmission through environmental contamination, such as c. diff. Appendix A, included in the guidelines, indicated c. diff required contact and standard precautions for the duration of the illness. 2. Observation of medication administration on 09/04/25 at 10:38 A.M. with Licensed Practical Nurse (LPN) #138 revealed no hand hygiene was completed prior to preparing Resident #27's medications. LPN #138 administered Residents #27's medications and walked back to her cart. No hand hygiene was completed. LPN #138 began prepared Resident #21's medications. LPN #138 walked into Resident #21's room and administered the medication and walked back to her cart. No hand hygiene was completed. LPN #138 prepared Resident #7's medications, walked into his room and administered the medications. LPN #138 walked back to the cart. No hand hygiene was completed. LPN #138 began preparing Resident #16's medications. LPN #138 placed the medications in a drawer, in Resident #16's room, for Resident #16 to self administer with lunch. LPN #138 walked out of the room and did not perform hand hygiene. Interview on 09/04/24 at 11:00 A.M. with LPN #138 verified she did not perform hand hygiene prior or between residents. LPN #138 stated she was required to sanitize after providing care to three residents. Interview on 09/04/25 at 11:05 A.M. with the Director of Nursing (DON) stated hand washing or sanitizing must be completed prior to preparing medications. Review of the facility policy titled Handwashing Hand Hygiene revised August 2019 revealed the use of an alcohol-based hand rub or an approved non-alcohol-based hand sanitizer or soap and water is used before preparing or handling medications.

Based on record review, observation and interview, the facility failed to ensure the call light was within reach, and failed to provide functional furniture to accommodate resident needs. This affected two (Resident #12 and Resident #16) of two residents reviewed for accommodation of needs. The facility census was 42.Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/02/23. Diagnoses included but were not limited to alopecia; cognitive communication deficit; unsteadiness on feet; hyperlipidemia; generalized anxiety disorder; essential hypertension; glaucoma; and cataracts.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of a possible 15, indicating intact cognition. Section B of the MDS indicated the resident had moderate difficulty hearing with a device, her speech was unclear, and her vision was moderately impaired with no corrective lenses. On 09/02/2025 at 9:00 A.M., an observation of Resident #16's room revealed her call light was not in reach. The call light with a cord connected to a round orange object was lying on the floor behind her nightstand, out of reach of the resident. There was noted to be a long string, with a blue circle attached to the end, on the arm of her recliner.On 09/02/2025 at 11:50 A.M., observation revealed Resident #16 was in recliner in her room. Her call light was out of reach. When asked how she would call for help, the resident picked up a blue round object that was connected to a cord for the light, pulled it, and the light turned off. The cord for the call light was connected to an orange round object and out of reach of the resident.On 09/02/2025 2:02 P.M., interview with Registered Nurse (RN) #105 confirmed the resident could not reach her call light. The cord she indicated to be her call light was the light switch/cord.On 09/04/25 at 9:28 A.M., an interview with the Director of Nursing (DON) revealed the cord for Resident #16's call light and the cord for the overhead light were difficult to distinguish and the call light was out of reach for the resident. 2. Review of the medical record for Resident #12 revealed an admission date of 08/13/25. Diagnoses included but were not limited to bilateral primary osteoarthritis of knee, presence of left artificial knee joint, other unilateral secondary osteoarthritis of knee, post-traumatic osteoarthritis left shoulder, pulmonary embolism, aortic aneurysm of unspecified site, depression, benign neoplasm of brain, anxiety disorder, and aftercare following joint replacement surgery.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of a total score of 15 which indicated intact cognition. Further review of the MDS revealed the resident had no behavioral issues. The resident indicated in Section F of the MDS that choices for personal care were very important to her. Section GG of the MDS indicated the resident used a walker for mobility and needed substantial/maximal assistance for upper and lower body dressing as well as toileting hygiene. She required partial/moderate assistance to shower or bathe, and to put on and take off footwear. Resident #12 also was assessed to have occasional pain, which she rated a five on a 0-10 scale, with zero being no pain and ten as the worst pain one could imagine.Review of a care plan for Resident #12, dated 08/19/25, revealed the resident was identified as having an alteration in musculoskeletal status following her joint replacement. One intervention read, anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Interventions also included changing the surgical incision dressing per order and PRN (as needed) and modifying the environment to meet the resident's needs.On 09/02/2025 at 11:43 A.M., observation revealed the call light was observed under the covers of Resident #12's bed. The resident was in a recliner and not able to reach the call light from where she was sitting. There was a string for another call light on the floor out of the resident's reach. She indicated if she needed assistance, she would pull the string which was on the arm of the recliner. This string was for the room light.On 09/02/25 at 1:59 P.M., an observation of Resident #12's room revealed the string for the light was on the recliner and the recliner was in the reclined position. The other call light for the room was under the bed covers. Resident #12 was observed in a wheelchair. Her recliner was in the reclined position, and she reported she had issues getting out of the chair and could not get out without the assistance of her son. The footrest of the recliner would not close without significant force.On 09/02/2025 at 2:03 P.M., an observation and interview with RN #105 confirmed Resident #12's call lights were on the floor and on the bed and they were out of reach of the resident. RN #105 also confirmed Resident #12's recliner was too difficult for the resident to close and a resident who had knee surgery should have a functional chair for safety.On 09/04/2025 at 9:01 A.M., an interview with the DON revealed Resident #12 and Resident #16 had call lights which were easily confused with the light cords. She further confirmed Resident #12's recliner in her room was too difficult for a resident post knee surgery to operate safely.Review of facility policy titled Call System, Resident, dated September 2022, revealed residents were provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. The policy further revealed each resident would be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on record review and interview the facility failed to address pharmacy recommendations for medication dosage adjustments for three of five Residents (Resident #04, #25, #1) reviewed for gradual dose reduction (GDR) monitoring. The facility census was 42.Findings include: 1.Review of the medical record for Resident #25 revealed admission to facility on 02/25/25 with diagnosis including heart attack, dementia with moderate agitation, protein malnutrition, repeated falls, high blood pressure, cancer of abdomen, heart failure, anxiety. Review of Resident #25's most recent quarterly Minimum Data Set 3.0 (MDS 3.0) completed on 07/02/25 revealed the brief interview of mental status (BIMS) score of 5 out of 15 indicating severe impairment. Further review of Resident #25's medical record revealed a pharmacist note dated 05/19/25 which recommended a gradual dose reduction for Trazodone (antidepressant) 50 milligrams (mg) by mouth once daily at bedtime for sleep. Further record review revealed a physician note by the primary care provider dated 05/30/25 stating to see Via [NAME] (contracted psychiatric services at the facility) for GDR recommendations. Via [NAME] first initial psychiatric evaluation to address GDR was completed on 07/02/25. Trazadone was increased to 100 mg by mouth daily at bedtime for sleep on 07/02/25. Interview on 09/08/25 at 11:42 A.M. with Psychiatric Nurse Practitioner (Psych NP) #171 stated she did not get GDR requisitions for the facility because the primary care physician handled all of that. She also stated she did not review any pharmacy recommendations. Psych NP #171 further stated the notes template she used included a section on GDR contraindications that was included on all notes as part of the standard template. 2. Review of the medical record for Resident #4 revealed an admission date of 02/05/21 and re-admission date of 10/10/23. Diagnoses included suicidal ideations, schizoaffective disorder bipolar type, depression, post-traumatic stress disorder, anxiety, insomnia, cerebral infarction, dementia, and brief psychotic disorder. Review of the pharmacy monthly medication regimen reviews revealed the following: On 10/21/24, the pharmacy identified there was no gradual dose reduction (GDR) attempt for Depakote (Divalproex) and Topiramate. A GDR was recommended unless clinically contraindicated, in which case documentation was needed to indicate such. The provider response, dated 11/20/24, was disagree due to followed by psychiatric services for GDR. On 01/21/25, the pharmacy identified there was no GDR attempt for Aripiprazole. A GDR was recommended unless clinically contraindicated, in which case documentation was needed to indicate such. The provider response, dated 01/29/25, was other due to the resident was followed by psychiatric services for GDR and there was no indication as to whether they agreed or disagreed with the recommendation. On 05/19/25, the pharmacy identified Venlafaxine was due for a GDR attempt unless clinically contraindicated, in which case documentation was needed to indicate such. The provider response, dated 05/30/25, was see ViaQuest notes with no indication as to whether they agreed or disagreed with the recommendation. On 05/19/25, the pharmacy identified there was no GDR attempt for Divalproex. A GDR was recommended unless clinically contraindicated, in which case documentation was needed to indicate such. The provider response, dated 05/30/25, was see ViaQuest notes with no indication as to whether they agreed or disagreed with the recommendation. Review of the psychiatric services notes for Resident #4 revealed there was no indication that pharmacy recommendations were reviewed or addressed. Review of the annual Minimum Data Set (MDS) assessment, dated 07/28/25, revealed Resident #4 was cognitively intact and had indicators of moderately severe depression. The assessment indicated Resident #4 received medications including antipsychotic, antidepressant, and anticonvulsant with no gradual dose reduction (GDR) attempted. Review of the physician's orders for September 2025 identified orders for Topiramate oral tablet 50 milligrams (mg) to give one tablet once daily for schizoaffective disorder bipolar type (06/21/25), Prazosin Hydrochloride (HCl) oral capsule 1.0 mg to give one capsule daily at bedtime for schizoaffective disorder bipolar type (07/10/25), Aripiprazole oral tablet 10 mg to give one tablet daily for schizophrenia (07/16/25), Divalproex Sodium oral tablet delayed release 250 mg to give one tablet three times daily for depression (08/20/25), and Venlafaxine HCl oral tablet 75 mg to give 150 mg once daily for depression (08/21/25). On 09/08/25 at 11:42 A.M., an interview with Psychiatric Nurse Practitioner (Psych NP) #171 stated she did not get GDR requisitions for the facility because the primary care physician handled all of that. She also stated she did not review any pharmacy recommendations. Psych NP #171 further stated the notes template she used included a section on GDR contraindications that was included on all notes as part of the standard template. On 09/08/25 at 2:21 P.M., an interview with the Director of Nursing (DON) confirmed the provider responses to the pharmacy recommendations for Resident #4 indicated to see the psychiatric services notes for GDR documentation. The DON said Psych NP #171 reviewed medications and GDRs on all visits to the facility however, there was no documentation to support the review. 3. Review of the medical record for Resident #1 revealed an admission date 04/04/24 with diagnoses including depression, anxiety, type II diabetes, chronic obstructive pulmonary disease, respiratory failure, malnutrition and cerebral infraction a stroke. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition and was dependent on staff for activities of daily living. The resident had a Patient Health Questionnaire (PHQ) score of 15, a mood assessment indicating a high severity of symptoms. Please evaluate for worsening depression. The recommendation on 08/01/25. Review of the pharmacy recommendation dated 07/31/25 stated the resident was receiving antidepressant therapy with Cymbalta 60 milligram and had a recent PHQ score that was elevated indicating a significant risk of depression symptom. The form did not indicate if the provider agreed disagreed or other. There was a note stating that was deferred to psychiatric service and was signed on 08/01/25. There was no documentation that the recommendation was addressed. Interview with the Director of Nursing (DON) on 09/04/25 at 3:32 P.M. stated the physician did not want to be responsible for the pharmacy recommendation and referred it to psychiatric services. On 09/08/25 at 11:42 A.M., an interview with Psychiatric Nurse Practitioner (Psych NP) #171 stated she did not get GDR requisitions for the facility because the primary care physician handled all of that. She also stated she did not review any pharmacy recommendations. Psych NP #171 further stated the notes template she used included a section on GDR contraindications that was included on all notes as part of the standard template. Review of the facility policy titled Medication Regimen Reviews revised May 2019 revealed The pharmacists ' recommendations will be addressed timely by the physician. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record.

Based on observation, interview, and policy review, the facility failed to ensure residents had access to paper towels. This affected one (Resident #8) of three residents reviewed for environment. The facility census was 42.Findings include: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including collapsed vertebra of the thoracic region, diabetes mellitus, concussion, depression, morbid obesity, and asthma. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 08/25/25, revealed Resident #8 had intact cognition. The MDS further revealed Resident #8 required staff assistance with activities of daily living (ADLs). Review of the Care Plan, dated 08/25/25, revealed Resident #8 had the potential for an alteration in activities with interventions including to allow the resident the opportunity to express opinions of activities of choice and to interview the resident quarterly and as needed for activities of choice. Interview on 09/02/25 at 11:56 A.M. with Resident #8 revealed she did not have any paper towels in her bathroom and had told nursing staff early yesterday that she was out and needed more, however, the dispenser was still empty. Observation on 09/02/25 at 11:59 A.M. of Resident #8's bathroom revealed the paper towel dispenser was empty. Interview on 09/02/25 at 12:05 P.M. with Certified Nursing Assistant (CNA) #157 revealed Resident #8's paper towel dispenser was empty and she would notify housekeeping to refill it. Interview on 09/08/25 at 1:52 P.M. with Housekeeping Supervisor #163 revealed it was housekeeping's responsibility to check the paper towels located in the resident's bathroom daily. Review of the facility policy titled, Quality of Life-Homelike Environment, dated May 2017, revealed the residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, policy review, and staff/Resident interviews, the facility failed to maintain the dignity and privacy of one resident (Resident #07) of five residents reviewed for dignity and privacy. The facility census was 42.Findings Include: Review of medical record of Resident #07 revealed initial admission to facility on 04/22/25 for diagnosis including metabolic encephalopathy, pneumonia, chronic respiratory failure, high blood pressure, major depression and anxiety, spinal cord injury, and chronic lung disease. Review of the medical record for Resident #07 revealed the Minimum Data Set 3.0 (MDS 3.0) indicated Resident #07 required moderate to substantial assistance with personal care and was dependent on wheelchair for mobility. Observation on 09/02/25 at 9:50 A.M. revealed Resident #07 in bed with bilateral heel boots on and flannel pajama pants noted to be pulled down to below the resident ' s knees, above the boots and a sheet laying across the resident's midsection. Resident #07 reported that they do this at night in case I have an accident, and I need changed, it makes it easier. Resident #07 then adjusted his sheet to cover up the pulled down flannel pants. Observation on 09/03/25 at 8:24 A.M. revealed Resident #07 lying in bed covered with a linen sheet with heel boots on bilaterally. Observation of Resident #07 revealed he was wearing flannel pajama pants pulled down to below the knees and above the boots. Resident #07 reported this was done at night to make it easier to change him if he had an accident since he was wearing heel boots while in bed. Interview on 09/03/05 at 8:26 A.M. with Assistant Director of Nursing (ADON) #160 confirmed Resident #07 pajamas being pulled down below knees and above boots. ADON #160 was not able to explain reason for this and stated the aides must be doing it. Review of facility policy titled Quality of Life-Dignity revised August 2009 revealed all residents will be treated with dignity and respect at all times including, providing for bodily privacy during assistance with personal care and during treatments procedures.This deficiency represents non-compliance investigated under Complaint Number 2578619.

Based on observation, record review and interview the facility failed to ensure medications were properly stored for residents identified as being able to self-administer medications. This affected one resident (Resident #16) of one residents reviewed for secured medication. The census was 42.Findings include:Review of the medical record for Resident #16 revealed an admission date of 12/02/23. Diagnoses included but were not limited to alopecia; cognitive communication deficit; unsteadiness on feet; hyperlipidemia; generalized anxiety disorder; essential hypertension; glaucoma; and cataracts.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 13 to 15 points would suggest cognitive intactness. Section B of the MDS indicated the resident had moderate difficulty hearing with a device, her speech was unclear, and her vision was moderately impaired with no corrective lenses.Record review of a hard chart for Resident #16 provided by the facility revealed a form titled Self-Administration Skills Assessment, dated 04/16/2025. This assessment indicated Resident #16 demonstrated correct technique for administrating all medications, knew the name, strength, and frequency of all medications, was able to recognize the color and shape of medications, could state the side effects of her medications, could correctly secure (open and close medication containers) medications, and had demonstrated the ability to self-administer medications safely. The assessment indicated the resident did not have any topicals, creams, transdermal patches, ear drops, suppositories, inhalers, or injections.An observation on 09/05/25 at 10:45 A.M. of Resident #16 ' s lunch time medication administration revealed Licensed Practical Nurse (LPN) #138 prepared pills and placed them in a small medication cup. LPN #138 went into Resident #16 room and asked if she wanted her pills. Resident #16 stated to place the medications in the nightstand, and she would take them with her lunch. LPN #138 opened the nightstand drawer, placed the white cup of pills in the drawer, closed the drawer and walked out of the room.On 09/08/25 at 11:40 A.M., an interview with Resident #16 revealed she took her medications that were left in a white medication cup after each meal. She reported she could not identify what the pills were. Resident #16 also reported the cabinet drawer was never locked or she would not be able to access her medications.On 09/08/25 at 11:48 A.M., an observation of Resident #16's room revealed an unlocked cabinet beside her recliner. The cabinet contained a white cup with seven pills; a bottle of eye drops and several pill bottles which held cough drops. This was confirmed by LPN #138. On 09/08/25 at 11:42 A.M., an interview with Nurse Manager #160 revealed Resident #16 ' s medications were placed in her top drawer by the medication nurse. The drawer had a lock on it; however, he confirmed the drawer was not locked throughout the day when the medications were in it allowing unauthorized access to the medications.

Based on record review and staff interview the facility failed to accurately document influenza, pneumococcal, and Covid-19 vaccination consents for three residents (Residents #07, #12 and #15) of the five residents reviewed for vaccinations. The facility census was 42Findings Include: 1. Review of medical record of Resident #07 revealed initial admission to facility on 04/22/25 with diagnoses including metabolic encephalopathy, pneumonia, chronic respiratory failure, high blood pressure, major depression and anxiety, spinal cord injury, and chronic lung disease.Review of Resident #07's influenza/pneumococcal vaccination consent signed on 04/23/25 revealed a question asking if Resident #07 had received the influenza/pneumococcal vaccine prior. There was a check marked by the word No after this question. No dates were entered for prior pneumococcal vaccinations. Resident #07 declined the pneumococcal vaccine. Further review of the consent revealed the Vaccine Information Sheet (VIS) was provided on 04/23/25 for the pneumococcal vaccine and 04/23/25 for the influenza vaccine.Review of a second influenza/pneumococcal vaccination consent signed on 09/02/25 revealed a question asking if Resident #07 had received the influenza/pneumococcal prior. There was a check marked by the word Yes. There was a date for the Pneumovac vaccine received on 04/09/25 and the Prevnar 20 vaccine received 05/21/25. Further review of the consent reveal the Vaccine Information Sheet (VIS) was provided on 05/29/25 for the pneumococcal vaccine and 1/31/25 for the influenza vaccine.2. Review of the medical record for Resident #12, revealed an admission date of 08/13/25. Diagnoses included but were not limited to: bilateral primary osteoarthritis of knee, presence of left artificial knee joint; other unilateral secondary osteoarthritis of knee, post-traumatic osteoarthritis left shoulder, pulmonary embolism, aortic aneurysm of unspecified site, depression, benign neoplasm of brain, anxiety disorder, and aftercare following joint replacement surgery.Review of Resident #12 influenza/pneumococcal vaccination consent signed on 08/13/25 revealed no answer marked the question if the resident received the pneumococcal vaccine prior. The VIS was provided on 05/29/25 for the pneumococcal vaccine and 01/31/25 for the influenza vaccine.3. Review of the medical record for Resident #15 revealed an admission date of 07/14/25. Diagnoses included but were not limited to osteoarthritis of knee, muscle weakness, repeated falls, chronic pain, anemia, depression, age-related physical debility; atherosclerotic heart disease of native coronary artery with angina pectoris, occlusion and stenosis of unspecified carotid artery, pure hypercholesterolemia, malaise and fatigue, osteoarthritis of hipReview of Resident #15's influenza/pneumococcal vaccination consent signed on 07/09/25 revealed the VIS was provided on 05/29/25 for the pneumococcal vaccine and 1/31/25 for the influenza vaccine.Interview on 090825 at 9:50 A.M. with Assistant Director of Nursing (ADON) #160 revealed verification that the above documentation for vaccination consents for Residents #07, #12, and #15. ADON #160 further verified discrepancies with duplicate copies on pneumococcal/influenza consents signed and dated by Resident #07 on 04/23/25 and 09/02/25.

Based on record review, policy review, and interview, the facility failed to complete an activities assessment timely to ensure residents participated in group activities and/or preferred activities. This affected one (Resident #8) of one resident reviewed for activities. The facility census was 42.Findings include: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including collapsed vertebra of the thoracic region, diabetes mellitus, concussion, depression, morbid obesity, and asthma.Review of the 5-Day Minimum Data Set (MDS) assessment, dated 08/25/25, revealed Resident #8 had intact cognition. The MDS further revealed Resident #8 required staff assistance with activities of daily living (ADLs). Review of the Care Plan, dated 08/25/25, revealed Resident #8 had the potential for an alteration in activities with interventions including to allow the resident the opportunity to express opinions of activities of choice and to interview the resident quarterly and as needed for activities of choice. Interview on 09/02/25 at 11:52 A.M. with Resident #8 revealed she had not attended any activities since her most recent admission and that she was bored and would like to go to an activity.Interview on 09/03/25 at 10:28 A.M. with Activities Director (AD) #106 revealed activities assessments are documented in the electronic medical record (EMR) and confirmed Resident #8's EMR did not contain an activities assessment. AD #106 further confirmed although she had spoken to the resident and knew her likes and dislikes, she had not yet completed an activities assessment following the resident's recent admission. When asked whether the resident had attended any activities, she stated yes, the resident always attended activities. Review of Resident #8's written Activities Individual Participation Record (documented on paper) and not located in the EMR and provided by AD #106 revealed the resident ' s activities were primarily individual activities and not group activities.Review of the facility policy titled, Activities Documentation, dated 2018, revealed the AD is responsible for maintaining appropriate departmental documentation. The following records are maintained by the AD personnel: Activity assessment, attendance records, activity progress notes.

Based on observation, record review, interview, recipe review and policy review, the facility failed to ensure Resident #6's diet consistency was provided as ordered by the physician. This affected one (Resident #6) of three residents reviewed for food and nutrition. The census was Findings include: Review of Resident #6's medical record revealed an admitted [DATE] with diagnoses including non-traumatic intracerebral hemorrhage, pneumonia, encephalopathy, intellectual disabilities, and Parkinson's disease. Review of Resident #6's physician order, dated 08/29/23, revealed an order for a regular diet, mechanical soft texture, and thickened liquids. Observation on 09/07/23 at 12:48 P.M. revealed Resident #6 sitting in the common area, beside the nursing station and was served a solid piece of fried fish which was not a mechanically soft texture as indicated in the physician orders. During interview on 09/07/23 at 12:50 P.M., Licensed Practical Nurse (LPN) #202 confirmed Resident #6 was served a piece of fried fish and it was not a mechanically soft texture. LPN #202 further confirmed Resident #6's piece of fish was the exact texture of the fish served to the residents on a regular diet. During interview on 09/07/23 at 12:59 P.M., Dietary Manager #300 confirmed Resident #6 was served a piece of fried fish with a regular consistency, which was an error and should have been minced and/or softened with gravy based on the physician order. Review of the facility's Quantified Recipe for fish (fried and ground) dated 05/05/23 (which DM #300 indicated was the recipe used for the mechanical soft diet) revealed one fish fillet should be ground in a food processor to desired texture and served with two ounces of gravy. Review of the facility policy titled, Therapeutic Diets, dated October 2017, revealed therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on observation, medical record review, and interview, the facility failed to remove a female resident's long facial hairs. This affected one (Resident #13) of two residents reviewed for activities of daily living. The facility census was 37. Findings include: Review of Resident #13's medical record revealed diagnoses including left sided weakness and paralysis following a stroke, dementia, depression, and generalized muscle weakness. A care plan initiated 08/28/20 indicated Resident #13 required limited to extensive assistance for most activities of daily living. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was moderately cognitively impaired and required extensive assistance with personal hygiene. An Occupational Therapy discharge summary dated 07/25/23 indicated Resident #13 required modified independence for hygiene and grooming. On 07/31/23 at 3:23 P.M., Resident #13 was observed propelling herself in the wheelchair in the hall. Resident #13 was confused. Long facial hairs were observed on her cheek and chin. On 08/01/23 at 2:37 P.M., Resident #13 was observed to continue to have long facial hairs. On 8/01/23 at 2:50 P.M., State tested Nursing Assistant (STNA) #604 stated Resident #13's need for assistance with activities of daily living varied from day to day. Upon request, STNA #604 observed Resident #13 and verified she had facial hairs. STNA #604 offered to shave Resident #13 who agreed, stating she did not want a beard. During an interview on 08/07/23 at 7:58 A.M., Certified Occupational Therapy Assistant (COTA) #809 indicated modified independence for hygiene and grooming indicated Resident #13 required items to be set up or intermittent supervision and cues. COTA #809 stated if Resident #13 knew she had facial hair she would have the dexterity to remove it but she was unsure that between Resident #13's vision and the mirror placement she would have been able to ascertain she actually had facial hair.

Based on observation, medical record review, and interview, the facility failed to ensure a resident who developed a pressure ulcer was evaluated for a modification of interventions to prevent further pressure ulcers and to enhance healing. This affected one (Resident #26) of two residents reviewed for pressure ulcers. The facility census was 37. Findings include: Review of Resident #26's medical record revealed diagnoses included Alzheimer's disease, osteoarthritis, weakness, and history of breast cancer. A care plan initiated 04/10/23 indicated Resident #26 was at risk for impaired skin integrity related to fragile skin, incontinence, and impaired mobility. Interventions included providing barrier cream/ointment after each incontinent episode, performing skin assessments as ordered and providing pressure reduction devices if ordered. All of the interventions were dated 04/10/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26 was severely cognitively impaired, required extensive assistance of two for bed mobility and did not walk. The MDS indicated Resident #26 was at risk for the development of pressure ulcers. No skin and ulcer injury treatments were indicated. Review of a nursing note dated 07/12/23 at 3:33 A.M. revealed Resident #26 was observed to have redness to the buttocks with a small open area to the sacrum area measuring 3.5 centimeters (cm) x 0.5 cm x 0 cm. The area was cleansed and a foam border dressing was applied. The order was for the treatment to be changed every three days and as necessary until the area resolved. Review of a Braden scale assessment dated [DATE] did not reveal a risk for pressure ulcer development. Review of a wound grid dated 07/13/23 revealed the open area was assessed as a stage II (shallow) pressure ulcer to the sacrum measuring 3.56 cm x 0.5 cm x 0.1 cm with 100% epithelial tissue (thin layer of tissue that covers the body). Review of a wound grid dated 07/27/23 revealed the size of the ulcer had decreased to 2.1 cm x 0.5 cm x 0.1 cm. The wound bed was assessed as 100% epithelial tissue with scant serosanguineous drainage (clear, pale red or pink drainage). On 08/02/23 at 8:27 A.M., Resident #26 was observed sitting in a wheelchair without a pressure relief or pressure redistribution surface. State tested Nursing Assistant (STNA) #604 transferred Resident #26 to bed and verified there was no device to offer pressure relief in the wheelchair. On 08/02/23 at 12:10 P.M. Resident #26 was sitting in the wheelchair in the dining room for lunch with no pressure relief or redistribution device noted. On 08/02/23 between 1:00 P.M. and 1:30 P.M., the Director of Nursing (DON) was interviewed regarding the lack of pressure relief surfaces in Resident #26's wheelchair. The DON stated pressure relief cushions were provided in accordance with physician orders and Resident #26 did not have an order. The DON was interviewed regarding the development of the pressure ulcer with the interventions that were currently in place (minus the treatment order) and how the facility planned to prevent any further pressure ulcers or decline in the pressure ulcer if interventions were not changed. The DON stated she would review the information but generally any resident with skin breakdown had pressure relief cushions. On 08/03/23 at 1:30 P.M., the DON was interviewed regarding the development of the pressure ulcer and stated she understood the concern that although Resident #26 had been assessed as not having a risk for pressure ulcer development on 07/12/23 she developed a pressure ulcer the same day. Staff should have recognized the interventions that had been in place had not been effective in preventing pressure ulcers and Resident #26 should have been evaluated for further additional interventions which would aid in reducing risk for future pressure ulcers/aid in healing of the current pressure ulcer. A cushion had been applied to the wheelchair after the interview on 08/03/23. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00144817.

Based on observation, record review and interview, the facility failed to provide adequate pain relief for one (Resident #90) of two residents reviewed for pain. The facility census was 37. Findings include: Review of Resident #90's medical record revealed diagnoses including heart failure, chronic obstructive pulmonary disease, type two diabetes mellitus, and anxiety disorder. An admission nursing assessment dated [DATE] indicated Resident #90 was assessed with an unstageable pressure ulcer (full thickness tissue loss in which actual depth of the ulcer is completely obscured) to the sacrum and suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the right heel. Pain was assessed using facial scales with a designation it hurt a little more than a little bit. The location of the pain was listed as the coccyx, sacrum with the pain described as pressure/burning. Nothing was listed for alleviation of pain or worsening of pain. A baseline care plan indicated interventions to monitor for pain and report unrelieved pain as indicated. Review of the August 2023 Medication Administration Record (MAR) revealed Resident #90 had received tramadol 25 milligrams (mg) on 08/01/23 at 5:30 A.M. for pain rated a 10 on a scale of 0-10 that was documented as being ineffective. On 08/01/23 at 9:03 A.M., Resident #90 was able to be heard moaning from her bed into the hall while Licensed Practical Nurse (LPN) #107 was preparing routine medications for administration. Resident #90's medications (no pain medication) were administered at 9:03 A.M. Resident #90 was noted with facial consternation. LPN #107 inquired if Resident #90 was in pain. After Resident #90 verified she was in pain, LPN #107 stated she would see if there was anything she could give Resident #90. LPN #107 returned to the med cart to sign off medications and indicated it was too early for Resident #90 to receive pain medication. The Director of Nursing (DON) had approached on an unrelated matter and LPN #107 asked what time the doctor was supposed to be in to do rounds and the DON indicated she did not have a time. On 08/01/23 at 9:45 A.M., LPN #107 was interviewed regarding the MAR indicating Resident #90 had received the ordered pain medication being administered at 5:30 A.M. which was documented as ineffective and Resident #90 remaining in pain. LPN #107 stated that was why she asked the DON when the physician was supposed to visit so she could have the pain addressed. LPN #107 confirmed she could phoned the physician's office instead of waiting on his visit (time unknown). Further review of the August MAR indicated ultram 50 mg was administered on 08/01/23 at 10:36 A.M. with a pain level of 3 recorded. On 08/01/23 at 11:00 A.M., LPN #107 was followed into Resident #90's room and LPN #107 informed Resident #90 she had a stronger dose of ultram for her and proceeded to raise the head of the bed. Resident #90 moaned and grimaced with the movement. On 08/01/23 at 2:46 P.M., Resident #90 was observed lying in bed with a relaxed facial expression, stating the pain medication helped. Resident #90 verified the pain medication given at 5:30 A.M. had been ineffective and described the pain she had been experiencing as terrible. Review of the facility's Pain Assessment and Management policy (revised March 2015) revealed a resident's pain was to be assessed routinely as needed for acute pain or significant changes in levels of chronic pain or stable chronic pain. Staff were instructed to observe a resident (during rest and movement) for physiological and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain included verbal expressions such as groaning, crying, and screaming and facial expressions such as grimacing, frowning, clenching of the jaw. Ask the resident if he/she was experiencing pain. Review the medication administration record to determine how often the individual requested and received pain medication and to what extent the administered medications relieved the resident's pain. Reassess the resident's pain and consequences of pain routinely. If pain had not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Significant changes in the level of a resident's pain and prolonged, unrelieved pain despite care plan interventions were to be reported to the physician or practitioner.

Based on observation, record review and interview the facility failed to maintain an adequate infection control program to ensure all housekeeping staff were knowledgeable regarding disinfectant products to use to prevent the spread of infection. This had the potential to affect all 38 residents residing in the facility. Findings include: On 08/25/21 at 1:27 P.M. Housekeeper #107 was observed providing housekeeping services. An interview Housekeeper #107 at the time of the observation revealed Clean by Peroxy was the disinfectant the facility used. Housekeeper #107 revealed she had no idea if Clean by Peroxy required a certain contact time to be effective in disinfecting surfaces. The label did not indicate if the product was effective in disinfecting surfaces, what microorganisms it was effective against or if there was a required contact time. Housekeeper #107 revealed this was the only disinfectant product used, even if a resident had a [CONDITION(S)] infection. There were no residents who had [CONDITION(S)] at the time of the survey. Housekeeper #107 revealed she had received two days of orientation and she had worked at the facility four days. On 08/25/21 at 1:30 P.M. a request was made to Vice President of Operations (VPO) #108 for information regarding the facility disinfectant. VPO #108 revealed Housekeeper #107 was new to the position but acknowledged she was working independently and should be knowledgeable about the products and how to use them. On 08/25/21 at 4:25 P.M. VPO #108 provided product information on Diffense disinfecting cleaner and indicated this was the product staff were supposed to use if there was a resident with [CONDITION(S)]. Otherwise, the facility general disinfectant (Super HDQ) was to be used which was effective against the coronavirus. VPO #108 indicated the facility did also use Clean by Peroxy as an all-purpose cleaner. On 08/26/21 at 8:10 A.M. review of the product information provided for the Clean by Peroxy revealed it was an all purpose [MEDICATION(S)] cleaner. The information did not indicate what, if any microorganisms, the product killed or prohibited the growth of.

Based on observation, facility policy and procedure review and interview the facility failed to ensure all food items were held at a safe holding temperature and at point of service to prevent potential food borne illness. This had the potential to affect 30 residents who received meals from the kitchen and excluded Resident #26, #13 and #19 who received nothing by mouth (NPO) and Resident #15, #8, #34, #10 and #36 who received an alternative meal item during the 08/25/21 evening meal. The facility census was 38. Findings include: On 08/25/21 at 4:46 P.M. observation of tray line service for the evening meal with Dietary Supervisor #132 was completed. At 5:25 P.M. the temperature of the food items were obtained which included potato salad that was 55 degrees Fahrenheit (F). Dietary Manager (DM) #105 then re-tested the potato salad with a second thermometer because she thought the first thermometer was not calibrated correctly. The potato salad was 53 degrees F. DM #105 then tested the potato salad directly from the line tray in both a plastic bowl and then on a Styrofoam plate because DM #105 revealed she thought the plastic bowl temperature might have been heated and brought up the temperature of the potato salad. The potato salad in both the plastic bowl and the Styrofoam plate when re-tested were 52 degrees F. Interview on 08/25/21 at 5:35 P.M. with DM #105 confirmed the temperature of the potato salad was not below 52 degrees F despite the multiple testings. The facility identified 30 residents who would received the potato salad with their meal on this date. Of the total 38 residents residing in the facility, Resident #26, #13 and #19 received nothing by mouth (NPO) and Resident #15, #8, #34, #10 and #36 received an alternative meal item to the potato salad during the 08/25/21 evening meal and were therefore not affected. Review of the facility policy titled Food Preparation and Service, revised 04/2019 revealed proper hot and cold temperatures were to be maintained during food service. Cold food items should be held at 41 degrees F or below.

Based on record review and staff interview the facility failed to refer Resident #32, with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #32) of one resident reviewed for PASARR. Findings include: Review of Resident #32's medical record revealed an admitted [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 07/15/21 quarterly Minimum Data Set Assessment (MDS) revealed the resident had adequate hearing, clear speech, was sometimes understood and understands and had adequate vision and corrective lenses. The resident was moderately impaired for daily decision making. The resident had trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, moving or speaking so slowly that other people could have noticed or the opposite - being so fidgety or restless that you have been moving around a lot more than usual seven to eleven days of the review period. The resident was on insulin, antipsychotics, antianxiety, and antidepressant seven days a week. The resident had a pre-admission screen and PASARR completed on 03/15/17 and 06/16/17. Neither assessment reflected a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASARR was checked no, does the individual have a documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's last PASARR was dated 10/12/17, after a significant change admission to a psychiatric unit. The PASARR did not include the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASARR was checked no, does the individual have a documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In the section does the individual have a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 08/24/21 at 10:22 A.M. with Social Service #128 verified none of the completed PASARR assessments included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . SS #128 revealed prior to her becoming the facility social service designee the resident was given the new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental disorder, intellectual disability or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs.

Based on observation, record review and interview the facility failed to ensure Resident #40, who required staff assistance for activities of daily living including set up assistance with eating received adequate and timely assistance with meals. This affected one resident (#40) of two residents reviewed for activities of daily living. Findings include: Review of Resident #40's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated 03/29/21 indicated Resident #40 required set up assistance for meals. The care plan indicated Resident #40 was at risk for decline with activity of daily living function. Interventions included assisting Resident #40 with activities of daily living as needed. A significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 indicated Resident #40 required set up help for meals. On 08/24/21 when lunch was served, an unidentified staff member called Resident #40's name four times to wake her to eat. The staff member then left the room. At 12:02 P.M., Resident #40 had her eyes closed and she had not attempted to eat. Staff called Resident #40's name. After about two minutes staff left the room. At 12:05 P.M., Resident #40's eyes were closed. Resident #40's roommate told the surveyor, staff seldom stayed in the room to provide assistance to Resident #40 to eat. Family would feed her when present at meal time. Resident #40 continued to lay in bed with her eyes closed with no attempts to feed herself. At 12:26 P.M. Activity Assistant #155 arrived at the doorway and spoke to Resident #40's roommate. Resident #40 remained in bed with her eyes closed, the lunch tray in front of her and the food untouched. Continuous observations of Resident #40 between 12:05 P.M. and 12:52 P.M. revealed no staff arrived to provide assistance or to attempt to ensure Resident #40 remained awake long enough to eat. During an interview on 08/24/21 at 12:52 P.M., State tested Nursing Assistant (STNA) #139 reported Resident #40 was dependent for many of her activities of daily living. STNA #139 revealed staff were constantly waking Resident #40 to eat. STNA #139 indicated staff needed to start feeding Resident #40 but felt the resident needed a nutritionist to evaluate her. STNA #139 was observed of the above observations in which staff were only observed entering the room once after lunch was served to awake Resident #40. STNA #139 did not deny the accuracy of the observations. After the interview, STNA #139 walked down the hall without intervening to provide assistance or encourage meal intake for Resident #40. On 08/25/21 at 1:34 P.M. interview with Rehab Tech #148 verified Resident #40 fell asleep a lot. Rehab Tech #148 indicated Resident #40 had to be awakened frequently during meals and she would place utensils in Resident #40's hand to encourage intake. Rehab Tech #148 revealed she did not stay in the room to try to keep Resident #40 awake and encourage intake or provide assistance because Resident #40 was physically able to feed herself and she was not on the list of residents who needed fed. On 08/25/21 at 3:05 P.M. interview with Licensed Practical Nurse (LPN) #164 revealed Resident #40 had several admissions and had not had a good appetite. LPN #164 acknowledged Resident #40 slept a lot. LPN #140 was informed of the observations of Resident #40 sleeping during meals without staff intervention. LPN #140 revealed residents did not have to be on a list to be fed for staff to offer assistance or stay in the room to ensure the resident stayed awake for meals.

Based on observation, record review and interview the facility failed to provide a comprehensive and individualized activity program to meet the total care needs of Resident #40. This affected one resident (#40) of three residents reviewed for activities. Findings include: Review of Resident #40's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission care plan dated 01/07/21 revealed a goal for Resident #40 to attend/participate in activities of interest. Interventions included evaluating the time awake and readiness for activity, providing a calendar of activities, and providing supplies for activities as needed. A significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #40 was able to understand others and had adequate vision without the use of corrective lenses. The assessment indicated it was somewhat important for Resident #40 to have reading material, listen to music she liked, be around animals such as pets, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh air when weather was good, and participate in religious services or practices. The primary respondent for activity preferences was Resident #40. The assessment indicated Resident #40 required extensive assistance for transfers and locomotion on the unit. Observations of Resident #40 on 08/23/21 at 10:57 A.M., 11:59 A.M., 12:02 P.M., 12:53 P.M. 1:25 P.M. and 2:18 P.M., on 08/24/21 at 8:53 A.M., 11:17 A.M., between 12:05 P.M. and 12:52 P.M. and at 1:50 P.M. and on 08/25/21 at 8:18 A.M., 9:15 A.M., 11:10 A.M. and 2:40 P.M. revealed no activities being offered or provided for Resident #40. There was no television or radio/music player in the room except the roommate's television which was out of view of Resident #40. On 08/24/21 at 2:39 P.M. interview with Activity Assistant (AA) #155 revealed Resident #40 had been spending more time in bed. AA #155 revealed prior to that, Resident #40 would participate in socials, go to court chat and green thumb activities and watch television in the common area. On 08/25/21 at 1:34 P.M., Rehab Tech #148 was interviewed regarding activities she had observed Resident #40 be provided and/or participated in. Rehab Tech #148 revealed Resident #40 probably received one to one visits but she was unsure how often. Rehab Tech #148 verified she had not heard any music playing but added Resident #40 would probably benefit from having music to listen to. On 08/25/21 at 3:15 P.M., activity participation records and the most recent activity assessment (on the MDS) were reviewed with Activity Director #128. Activity Director #128 was informed of the above observations of Resident #40 with no activity stimulation except for a family visit and no evidence of activities of interest being provided over three days of observations. Activity logs revealed daily active participation in viewing television/radio was documented. When it was discussed that Resident #40 did not have a television or radio in her room and that with the privacy curtain pulled between Resident #40 and her roommate's bed it would not be possible for Resident #40 to view her roommate's television, Activity Director #128 revealed she thought Resident #40 had a television in her room. Activity Director #128 was accompanied to Resident #40's room and verified Resident #40 did not have a television/radio and would not be able to view her roommate's. Activity Director #128 was interviewed regarding how Resident #40's interest in having reading material was addressed. Activity Director #128 indicated she was uncertain if Resident #40 could see to read but acknowledged books on tape could be offered. Activity Director #128 verified the assessment indicated it was somewhat important for Resident #40 to listen to music she liked and to keep up with the news but no plans were in place to provide a means to do so unless current events were brought up during one on one visits. Activity Director #128 indicated Resident #40 loved animals and she used to have a cat. Activity Director #128 did not know what happened to the cat or if it would be an option for the family to take the cat in to visit if they still had it. Review of activity participation logs revealed one pet visit (04/11/21) and Activity Director #128 verified the facility just had a pet parade on 08/24/21. Activity Director #128 verified she had access to get books on tapes, music, and possibly a television to help meet Resident #40's stated interests. On 08/26/21 at 8:03 A.M. interview with Vice President of Operations (VPO) #108 revealed Resident #40's activity preference was reassessed the evening of 08/25/21 and her interests were pretty much the same. Resident #40 was provided a television and music player at that time. On 08/26/21 at 10:12 A.M. interview with Licensed Practical Nurse (LPN) #137 verified there had been no comprehensive activity care plan developed for Resident #40. The admission care plan had not been updated to reflect areas of interest or additional interventions to ensure areas of activity interests were met.

Based on record review and interview the facility failed to ensure Resident #191 was free of a significant medication error. Resident #191, who had a critical potassium level (low potassium) did not receive Potassium medication as ordered resulting in a significant medication error for the resident. This affected one resident (#191) of nine residents observed for medication administration. Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 08/22/21 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The first dose was scheduled for 8:00 P.M. on 08/23/21. The resident's potassium level was 5.0 mEq/L on 08/18/21. On 08/23/21 at 3:15 A.M. a potassium level was drawn. A critical potassium level of 2.8 mEq/L, normal 3.5-5.3 mEq/L, was reported at 3:23 P.M. A fax was sent at 3:50 P.M. to the physician. A return fax included a note written with orders indicating a call to increase the potassium to twice a day and give orange juice and bananas. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. before the 08/23/21 8:00 P.M. dose was administered. The potassium was rewritten to be administered twice a day on rising and in the afternoon. The first dose was scheduled to be administered the afternoon of 08/24/21. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed no potassium had been administered to the resident by the facility since the critical potassium level was reported the day prior. Interview on 08/24/21 at 12:38 P.M. with Vice President of Operations #108 and Registered Nurse (RN) #132 verified the resident should of been administered potassium the day prior and the morning of 08/24/21 for the 2.8 mEq/L critical potassium level. RN #132 revealed when the new order for potassium twice a day was entered into the computer system it defaulted to be administered for the first time the next afternoon. RN #132 indicated the order should have been manually changed to administer the first dose the day of the order entry. The resident should have received doses of the potassium by the time of the interview.