Every finding on record at Cedar Valley NSG & Rehab CTR

Based on record review, interview, and review of the facility policy titled Care Plans, Comprehensive Care Plans, the facility failed to revise the comprehensive care plan to include the use of an anticoagulant (blood thinner) for one of 25 sampled residents (Resident (R)2) reviewed for care planning. This had the potential for the resident not to be monitored for potential bleeding and have unmet care needs. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Care Plans, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/2025 and located in the electronic medical record (EMR) under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS revealed the resident was admitted on [DATE] with diagnoses to include long-term use of anticoagulants, personal history of pulmonary embolism, personal history of other venous thrombosis and embolism; the resident receives an anticoagulant.Review of R2's physician Orders located in the EMR under the Orders tab revealed an order from 4/3/2025 for apixaban oral tablet 5 milligrams (mg) [an oral anticoagulant] to be taken twice a day.Review of R2's EMR located under the Care Plan tab, a comprehensive care plan with an initiated date of 3/12/2025, did not display the use of an anticoagulant for R2. During an interview on 8/13/2025 at 11:00 am, Licensed Practical Nurse (LPN)1 stated yes, an anticoagulant should be on the care plan to help communicate the care needed for that resident. During an interview on08/13/2025 at 12:40 pm, the MDS Coordinator (MDSC) stated that an anticoagulant should be on the care plan so that staff know the needs of the R2. It looks like someone resolved it; so, it doesn't show on the care plan.During an interview on 8/14/2025 at 1:15 pm, the Director of Nursing (DON) stated that an anticoagulant should have been on R2's care plan to let the staff know that the anticoagulant was being used and how to monitor for it. The DON stated the care plan lets all nursing staff know how to properly take care of a resident.

Based on observations, staff interviews, record review, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to maintain a clean and homelike environment in five of 52 resident rooms and one of 30 resident bathrooms as evidenced by dirty packaged terminal air conditioner (PTAC) filters in resident rooms (110, 121, 203, 207, and 209) and one malfunctioning light switch in the bathroom in room [ROOM NUMBER]. Findings include: Review the facility policy titled Safe and Homelike Environment revealed in accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 1. Observation on 2/20/2024 at 11:03 am revealed PTAC units with dusty filters and a black substance across the upper rim of the filters. Observation on 2/21/2024 at 11:25 am revealed PTAC units with dusty filters and a black substance across the upper rim of the filters. 2. Observation on 2/20/2024 at 9:50 am revealed in room [ROOM NUMBER] that the light switch in the bathroom was not working. There was a piece of tape holding up the light switch to keep the light from turning off. Observation on 2/22/2024 at 9:15 am revealed in room [ROOM NUMBER] that the light switch in the bathroom was not working. There was a piece of tape holding up the light switch to keep the light from turning off. Observation on 2/22/2024 between 9:40 am and 9:53 am revealed dirty PTAC filters in rooms 110, 121, 203, 207, and 209. Observation/interview on 2/22/2024 at 10:35 am with the Maintenance Assistant (MA), he confirmed the damaged light switch in room [ROOM NUMBER]. He stated the PTAC units in rooms 110, 121, 203, 207, and 209 were last cleaned on 2/16/2024. After removing the filters, the MA acknowledged the PTAC filters and internal structures needed to be cleaned. 49138

Based on observation, interview, and review of the facility policy titled, Resident's Rights Under Federal Law, the facility failed to provide maintenance services necessary to maintain a safe, orderly, and comfortable interior by failing to repair drywall, air conditioner frames, and an area behind a resident's bed on one (Wing 2) of two wings. Findings include: Review of a policy titled, Resident's Rights Under Federal Law revealed, that the facility will present a 'Homelike Atmosphere. Each resident has the right to a safe, clean, comfortable, and homelike environment, and to use his or her personal belongings to the extent possible. Each resident has the right to housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; clean bed and bath linens that are in good condition; private closet space in their room; adequate and comfortable lighting levels in all areas; comfortable and safe temperature levels; and comfortable sound levels. Observation of rooms 207 and 209 on Wing 2 on 4/5/22 at 9:44 a.m. revealed that the air conditioners had no frames. Observation of room 207 on Wing 2 on 4/5/22 at 9:45 a.m. revealed that there was a board behind the window bed lying on the floor. Further observation revealed there was cracked drywall around an electrical outlet under the window next to the air conditioner. Observation of room 210 on Wing 2 on 4/5/22 at 9:56 a.m. revealed that the caulking around the sink had come loose and the sink/vanity was unstable and there was no frame around the air conditioner. Observation of room 211 on Wing 2 on 4/5/22 at 9:59 a.m. revealed the framing around the air conditioner was loose and staff could see through cracks to the outside of the building. Observation of room 214 on Wing 2 on 4/5/22 at 10:01 a.m. revealed there were no personal effects. Further observation revealed at the bottom right-hand side of the bathroom was an area that had a foam filler around the baseboard. An interview on 4/6/22 at 8:50 a.m. with Licensed Practical Nurse CC revealed that when maintenance issues arise staff can input requests through the maintenance software online system. On 4/7/22 10:13 a.m. a tour of Wing 2 with Maintenance Director, Administrator, and Director of Nursing (DON) were shown above mentioned areas of concern. The administrator stated that the owners have plans to relocate residents to another facility. The other facility is being renovated and remodeled to accommodate long term care residents. The building that is being remodeled is a vacant assisted living facility. The administrator further revealed that there was not a definite date on when the opening and transfer of the residents would occur. Interviews with Maintenance Director, Administrator and DON confirmed the missing air conditioning frames, the unstable sink/vanity, loose board lying in the floor and the foam filler in the baseboard area were in need of repair. On 4/7/22 at 11:17 a.m. interview with the administrator revealed that there was no staff in maintenance for about a month, but they had a corporate environmental staff that was at the facility daily until the current maintenance director was hired.

Based on observations, staff interviews, review of the Dietary Services Policy and Procedure for Personal Hygiene & Dress Code and review of the Dietary Services Policy and Procedure for Food Storage, Prep, Sanitation & Best Practice, the facility failed to ensure opened food items were properly labeled and dated in the refrigerators, freezer, and dry storage for two (2) of four (4) days of the survey; and failed to ensure that dietary staff's facial hair was covered to prevent contamination. This deficient practice had the potential to effect all eighty (80) residents receiving an oral diet. Findings include: Observation on 05/02/16 at 10:45 a. m. of the two (2) door reach-in refrigerator in the food preparation area revealed an opened eight (8) ounce glass jar of maraschino cherries, an opened one (1) gallon container of lemon juice, an opened one (1) gallon container Worcestershire sauce, an opened one (1) gallon container of white vinegar, an opened six (6) pound white plastic container of sliced strawberries, and an opened sixteen (16) ounce container of Cool Whip topping. None of those food items had dates when they were opened. Observation on 05/02/16 at 11:10 a. m. of the dry storage area revealed a clear plastic bin with a five (5) pound bag of Fudge Brownie Mix that was opened with no date. Continued observation revealed that there was a thirty-five (35) ounce bag of Rice Cereal in a green plastic tote that was opened with no date when it was opened. Further observation of the dry storage area revealed that in another green plastic bin there was an opened bag of Barilla spiral pasta that did not have an open date. Observation on 05/02/16 at 11:15 a. m. of the chest freezer revealed an opened one (1) gallon container of vanilla ice cream that did not have a date of when it was opened. Observation on 05/04/16 at 11:55 a. m. of the two (2) door reach-in refrigerator near the food preparation area revealed a white Styrofoam container. The Styrofoam contained grits, scrambled eggs, bacon, and a white plastic fork. The container did not have a label or date. Observation on 05/04/16 at 12:00 p. m. of the chest freezer revealed that the opened gallon container of vanilla ice cream continued to have no label or date. Observation on 05/04/16 at 12:05 p. m. revealed Dietary Aide FF had a full beard and mustache which was not covered. FF was observed in the dry storage area at that time stocking shelves as well as walking through a section of the kitchen to get to the main dining area. During an interview on 05/02/16 at 11:30 a. m. with the Dietary Manager (DM), she confirmed that the maraschino cherries, Worcestershire sauce, white vinegar, sliced strawberries and Cool Whip topping in the two (2) door reach-in refrigerator were all opened with no dates. The DM confirmed that the Fudge Brownie Mix, Rice Cereal, and spiral pasta in the dry storage area were opened with no dates. She confirmed that the gallon container of vanilla ice cream in the freezer was opened with no date. The DM revealed that she expected staff to label and date all food items after opening and before storage. Interview on 05/04/16 at 12:05 p. m. with Dietary Aide FF revealed that he had been educated by the dietary manager to wear a beard protector over his facial hair. During an interview on 05/04/16 at 12:10 p. m. with the DM, she confirmed that the white Styrofoam container containing breakfast food items on the bottom of the two (2) door reach-in refrigerator did not have a label or date. The DM revealed that the Styrofoam container should not even be in the refrigerator. Continued interview with the DM, at this time, revealed that she did not date the container of vanilla ice cream that was noted on Monday because the ice cream was from activities and she had not discussed with the Activity staff about labeling and dating food items. Further interview with the DM revealed that she did expect male dietary staff with facial hair to cover it with a hair net. She revealed that she had told her male staff with facial hair that they did not need to have their facial hair covered if they were in the dry storage area placing supplies on the shelves. Continued interview revealed that they only needed to wear a facial hair restraint if they were serving meals from the steam table. However, the DM confirmed that Dietary Aide FF walked through a section of the kitchen where food was prepared when going from the dining area to the dry storage area. Review of Dietary Services Policy and Procedure for Personal Hygiene & Dress Code revealed that facial, or other exposed long body hair (arm hair) must be covered. Review of Dietary Services Policy and Procedure for Food Storage, Prep, Sanitation & Best Practice revealed that staff should date refrigerated, commercially prepared, ready-to-eat potentially hazardous food when opened. Those food items should be discarded after seven (7) days. Continued review revealed that all prepared food should be covered, labeled, and dated. Review of the In-service documentation revealed that dietary staff were educated on 04/18/16 regarding labeling and dating food items in the cooler.

Based on observations, interview, and policy review, the facility failed to ensure that staff washed/sanitized their hands between residents when serving and setting up meals and beverages for three (3) of four (4) dining observations in the main dining room and on two (2) of two (2) halls (100 Hall and 200 Hall). The census was eighty (80) residents. Findings include: Observation on 05/02/16 at 12:35 p.m. of the first meal service in the main dining room revealed Registered Nurse (RN) DD approached a resident sitting at a dining table and touched the resident's left elbow. Continued observation of the RN revealed that DD then touched her hair and walked to the area with assembled resident lunch meal trays. Without washing or sanitizing his/her hands, DD obtained another lunch meal tray and delivered it to another resident. Observation on 05/02/16 at 1:30 p.m. of the second meal service in the main dining room revealed that three (3) Certified Nursing Assistants (CNAs) grabbed chairs from various other dining tables and moved them to assist residents with feeding. Further observation revealed that the three (3) CNAs did not wash or sanitize their hands before feeding the residents. Observation on 05/04/16 at 8:15 a.m. of Certified Nursing Assistant (CNA) CC revealed that she delivered a breakfast meal tray to the resident in room [ROOM NUMBER]-A. While in the room, CC touched the resident's privacy curtain closest to the door to the hallway. CC exited the room and did not wash or sanitize her hands before she delivered a breakfast tray to the resident in room [ROOM NUMBER]-A. CC touched and adjusted the resident's bedside table and did not wash or sanitize her hands prior to exiting the room. Observation on 05/04/16 at 8:20 a.m. of CNA EE revealed that EE delivered a breakfast meal tray to the resident in room [ROOM NUMBER]. While in the room, EE was observed touching two (2) empty clear plastic drinking glasses from the resident's bedside table before placing the meal tray down. The CNA exited the room with the empty glasses and placed them on an empty shelf on the food cart. Without washing/sanitizing her hands, EE obtained another meal tray from the cart and delivered it to the resident in room [ROOM NUMBER]-B. Without washing or sanitizing her hands EE then obtained another meal tray from the cart and delivered it to the resident in room [ROOM NUMBER]. Observation on 5/4/16 at 8:30 a.m. of CNA CC in the main dining room revealed that CC touched curtains, meal trays, residents, and then without washing or sanitizing her hands, prepared toast with jelly for one (1) resident. Observation on 5/4/16 at 8:40 a.m. revealed CNA BB picked up a carton of supplement after dropping it on the floor. CNA BB then walked to room [ROOM NUMBER] and placed the cartoon of supplement on the resident's meal tray. Observation on 05/04/2016 at 8:50 a.m. of Licensed Practical Nurse (LPN) AA in the main dining room revealed that he/she touched a wheelchair, moved another resident's meal tray items around on the table, went to the hydration cart and prepared a beverage for another resident. LPN AA was not observed to wash or sanitize his/her hands until after he/she had finished assisting the residents with lunch. An interview with the Infection Control nurse on 05/05/2016 at 9:54 a.m. revealed that she would expect staff to wash or sanitize their hands before serving another tray if they touched a resident's equipment, personal items or the resident. Continued interview revealed that she would also expect staff to wash or sanitize their hands if staff touched their face, hair, or another potentially contaminated object. Review of the facility's guidelines for handwashing, Infection Control Basics , revealed that hand hygiene was the single most important measure in preventing the spread of infection. Continued review revealed that handwashing with soap and water was indicated when the hands were visibly soiled, dirty or contaminated. Sanitizing with an alcohol based preparation may be used when the hands were not visibly soiled, dirty or contaminated. Further review revealed that staff were supposed to wash or sanitize their hands before, during (if necessary) and after resident contact; after handling potentially contaminated items; and before and after handling or serving food. Interview with the Infection Control nurse on 5/5/16 at 9:54 a.m. revealed that new employees were provided the Infection Control Basics guidelines during orientation. Review of the handwashing inservice dated 7/29/15 revealed that education was provided to nineteen (19) employees on that date. Continued review revealed that, of all the staff cited above, only CNA CC had attended the inservice.

Based on review of resident trust accounts and staff interview the facility failed to ensure that acceptable accounting principles were maintained related to withdrawal of resident 's monies from fifteen (15) (#97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #108, #109,#110 and #111) of fifty-one (51) Medicaid resident accounts reviewed. Findings include: Review of the resident trust accounts conducted 2/4 /2015 at 9:00 AM with resident trust/business office manager staff " AA " , revealed the facility had given family members monies from Medicaid resident trust accounts without obtaining receipts to ensure the money was used for the resident. 1. Review of the trust account for resident #97 revealed that on 7/11/2014 the family was given a withdrawal of $1500.00. " AA " indicated she did not know what the family member did with the money. 2. Review of the trust account for resident #98 revealed that on 10/21/2014 monies were given to the family for a total of $209.52. " AA " had no receipts and was unwarned of how the money was use 3. Review of the trust account for resident #99 revealed that on 10/13/2014 and 10/30/2014 monies were given to the family for a total of $200.00. "AA" did not know what was purchased with these monies and she had no receipts. 4. Review of the trust account for resident #100 revealed that on 8/5/14 and 11/17/14 monies were given to the family for a total of $150.00. "AA" indicated the money was used to pay premiums but she has no receipts and does not know what the premiums were for. 5. Review of the trust account for resident #101 revealed that on 9/17/14 the family was given $446.28. "AA" did not know what was purchased with the money and she had no receipts or any other evidence of what might have been purchased with the money. 6. Review of the trust account for resident #102 revealed that on 12/10/14 the family was given a cash withdrawal of $894.82. "AA" indicated that she was told the money was needed for burial arrangements but she was not aware of a burial arrangement account. 7. Review of the trust account for resident #103 revealed that on 10/17/14 the family was given $200.00. "AA" indicated that she refunded the family member for clothes and personal needs for the resident, but she had no receipts. 8. Review of the trust account for resident #104 revealed that on 10/6/14 the family was given $500.00. "AA" was not aware of what was purchased with the money, and she had no receipts. 9. Review of the trust account for resident #105 revealed that on 10/8/14 the family was given $1500.00. "AA" indicated that she was told the money was for insurance premiums and clothing but that she did not have any receipts or any evidence of a policy. 10. Review of the trust account for resident #106 revealed that on 7/7/14, 8/6/14, 9/4/14, 10/3/14, 11/3/14, and 12/5/14 monies for a total of $240.00 were withdrawn from the account. "AA" revealed that the family takes out $40.00 a month for cigarettes, but she does not have any receipts. 11. Review of trust account for resident #107 revealed that on 7/23/14 the family was given $150.00 to purchase a rolling walker but she has no receipt. 12. Review of trust account for resident #108 revealed that on 9/4/14, 10/3/14, 11/3/14 and 12/5/14 monies were given to the family for a total of $100.00. "AA" revealed that the family had $25.00 withdrawn every month for resident's laundry, but there is no receipt. 13. Review of trust account for resident #109 revealed that on 7/25/14, 11/14/14, and 12/5/14 monies were given to the family for a total of $600.00. "AA" was not aware if used for the resident and there were no receipts for the use of these monies. 14. Review of trust account for resident #110 revealed that on 10/3/14, 11/3/14, and 12/5/14 monies were given to the family for a total of $750.00. "AA" revealed that she believed it was to pay for insurance yet she has no evidence of any policy. 15. Review of trust account for resident # 111 revealed that on 7/3/14, 8/1/14, and 9/3/14, after the resident's liability is paid, the responsible party retains/withdraws $734.00 from resident's account. This left a zero balance in the account Interviewed with the Administrator on 2/5/15 at 1:00 PM revealed that the facility had always given the family monies to family members of residents when they have requested it. She further indicated that it was not the facility normal practice to ask families to provide receipts.

Based on record review, resident, staff interviews and facility procedures, the facility failed to develop a comprehensive dental care plan for two (2) residents (#18, #57), from a sample of forty one (41) sampled residents. Findings include: 1. Record review for resident #57 revealed a Minimum Data Set ( MDS) Admission assessment dated [DATE], which assessed the resident as having no natural teeth or tooth fragment(s) edentulous. The Care Area Assessment (CAA) revealed that dental triggered and would be care planned. Review of the resident resident care plan revealed that there was no care plan for dental care. Further review revealed that under Activities of Daily Living (ADL) one of the interventions was to arrange a dental consult as needed. Interview with the MDS Coordinator conducted 2/4/15 at 3:00 pm revealed resident was not care planned for dental care and had not had a dental consult. 2. Record review for resident #18 revealed Annual Minimal Data Set assessments date 2/5/2014 and 1/14/2015, which assessed the resident as having obvious or likely cavity or broken natural teeth. Review of the Care Area Assessment (CAA) Summary for each of these assessments revealed the resident triggered for dental problems and would be care planned. Review of the resident's plan of care initiated on 3/4/14 and revised on 2/4/15 revealed the resident was care planned for alter nutritional status and one (1) of the interventions was to arrange a dental consulted as indicated. This was the only dental intervention on the resident care plan. Interview with MDS coordinator conducted on 2/4/2015 at 3:00 p.m. revealed that no interventions were made to address resident dental problems. She further revealed that she thought putting the intervention of dental consult as indicated in the nutrition care plan was addressing resident dental problems.

Based on observations, record review, review of facility protocol, and staff interviews, the facility failed to obtain dental services for two (2) residents (#18, #57), from a sample of forty one (41) residents. Findings include: 1. Observations on 2/2/2015 at 12:40 p.m. and 2/5/2015 at 9:00 a.m. revealed resident # 18 had multiple stain, decayed /and or broken lower teeth and missing upper teeth. Review of the Annual MDS Assessments dated 2/5/2014 and 1/14/2015 revealed obvious or likely cavity or broke natural teeth and dental would be care planned. Interview with the Social Services Director (SSD) on 2/4/2015 at 3:10 p.m. revealed that the resident's dental insurance was canceled in 2012. She also revealed that the facility has a consulting dentist who visit the facility monthly basis, however, resident #18 have not been seem by the dentist since his admission to the facility in 2007 . Review of facility dental schedules for the months from January 2014 to January 2015 revealed no evidence resident #18 had was seen by the dentist during his monthly visits. Follow-up interview with SSD on 2/5/2015 at 8:30 a.m. revealed that she contacted the family who request that resident #18 be seen by the dentist on his next visit and they agreed to pay for service. Review of the facility protocol for routine and emergency dental care revealed that if the dental problems are noted during admission assessments or during monthly nursing assessments the physician would be notified for orders. The resident or responsible party would be contacted to ascertain whether resident has regular dentist. Dentist of choice would then contacted for further orders and appointment. Interview and observation of resident's mouth with Certified Nursing Assistant (CNA) "GG" on 2/5/2015 at 9:00 a.m., revealed that resident had no visible upper teeth and that the bottom teeth were brown stain, and broken. She revealed that the resident received a mechanical soft diet. During this observation resident had some difficulty biting a piece of toast. 2. Observation of resident # 57 on 02/04/14 at 12:45 p.m., during lunch, revealed resident consumed ninety percent (90%) of this meal, which consisted of thinned liquids. During this observation the resident indicated her son had her dentures but she can gum her food but would like her dentures. Further observations on 02/04/14 at 1:40 p.m. and on 02/05/14 at 09:00 a.m. revealed resident was in wheelchair in hallway near room calling out to staff and no dentures were noted. Interview conducted 2/4/15 at 1:50pm with Certified Nursing Assistant (CNA) "EE" revealed that the resident has not had any dentures since admitted to the facility. Interview conducted 2/4/15 at 2:41pm with Licensed Practical Nurse (LPN) "HH" revealed the resident has never had dentures since admission and the resident's three (3) sons visit every night. They have never brought the resident her dentures. Record review revealed an nursing monthly summary dated 1/28/15 which indicated under dental that resident had her own teeth. Interview conducted 02/04/15 at 3:15 p.m. with Social Services Director (SSD) revealed that she was not aware that the resident had dentures prior to admission and that no attempt had been made to follow-up with the resident's sons. At this time, the SSD contacted one (1) of the resident's sons and left a message inquiring about the resident's dentures. Interview on 02/05/15 at 08:00 a.m. with the Director of Nursing (DON) revealed the resident's son returned the phone call and brought resident's dentures last evening.

Based on observations and staff interviews, the facility failed to ensure the facility was free of accident hazards on one (1) of two (2) units and in two (2) of two (2) common shower rooms. Findings include: 1. Observation conducted on 6/17/13 at 9:45 a.m. revealed three (3) or four (4) drops of water on the floor under the air conditioner vent outside of room 219. Observation conducted on 6/17/13 at 1:45 p.m. revealed drops of water on the floor under the air conditioner vent outside of room 207. Observations conducted on 6/19/13 at 8:05 a.m. and 6/20/13 at 8:12 a.m. revealed a towel on the floor under the air conditioner vent with a 'Wet Floor" sign over the towel in the following areas: * outside of room 208; * outside of room 211; * outside of room 216; and * outside of room 219. Observation conducted on 6/19/13 at 12:16 p.m. revealed housekeeping staff replacing a towel on the floor under the air conditioner vent outside of room 219; she replaced the wet floor sign over the towel. Interview with the Maintenance Director on 6/19/13 at 2:10 p.m. revealed condensation had been dripping from the air conditioner vents when it was humid. Continued interview revealed that the air conditioner people had come out and recommended insulation three (3) years ago, which had been done, but the condensation still drips and rooms 206 through 226 are affected. Interview with the head of Housekeeping/Floor Techs/Laundry on 6/20/13 at 10:06 a.m. revealed her staff try to make sure the towels stay in the correct place to catch the condensation drips. Interview with the administrator on 6/20/13 at 11:55 a.m. revealed the housekeeping staff usually try to mop up the water as it collects on the floor from the air conditioner vents. She revealed they have tried putting a pan under the leaks, but that interferes with air circulation. There were no current plans to address the problem. 2. Observation conducted on 6/19/13 at 2:45 p.m. during environmental rounds with the Maintenance Director revealed the Electrical Room/Main Fire Alarm Panel room door was unlocked. There was a sign on the door "This Door is to Remain Locked at All Times". The room contained numerous covered electrical panel boxes and one box of breakers behind a face plate. Interview with the Maintenance Director on 6/19/13 at 2:45 p.m. revealed the room should be kept locked at all times.. Interview with the administrator on 6/19/13 at 4:40 p.m. revealed the door to the electrical room should have been locked. 3. During initial tour conducted on 6/17/13 at 9:45 am the following safety hazards were observed: Common shower #1- Toilet seat was loose and moved two (2) to three (3) inches side to side. Common shower #2 Toilet seat was loose and moved two (2) to three (3) inches side to side, the entire toilet rocked side to side, and slid side to side four (4) to five (5) inches. Interview with Certified Nursing Assistant (CNA) "AA" on 6/20/13 at 12:15pm revealed it is not infrequent that a resident would need to use the toilet when having a shower/bath. Of the thirty eight (38) to forty two (42) residents that were bathed on Monday, 6/17/13, ten (10) could have used the toilet. Most showers are done in Common Shower #2. Interview with the Administrator on 6/20/13 at 12:30pm revealed that the Shower #1 is only used by Hospice residents. Shower #2 was utilized by approximately seventy-five (75) residents per week.

Based on record review, and staff interviews the facility failed to ensure that the pharmacist Medication Record Review (MRR) identified errors related to parameters for Blood Pressure medication administration for one (1) resident (#87) from a sample of twenty-nine (29) residents. Findings include: Review of the physicians order for resident #87, dated 3/26/13, revealed an order for Hydralazine twenty-five (25) milligrams (mg) by mouth twice per day (bid). Parameters were to hold the medication if systolic pressure (SBP) was less than one hundred and ten (110). Review of the Medication Administration Records (MARs) for April, May, and June, 2013 revealed the following: The written order for April 2013 indicated to hold Hydralazine for SBP less than 110. Both the May and June 2013 MARs printed by the pharmacy indicated to hold Hydralazine if SBP was greater than 160. Review of the Blister pack for Hydralazine 25mg indicated to hold if SBP was greater than 160. Interview with Licensed Practical Nurse (LPN) "BB" on 6/19/13 at 11:05am revealed that she had been charge nurse for resident #87 for approximately two (2) weeks, and had thought BP parameters were high but had never inquired about or questioned the printed order. Interview with the Staff Development Coordinator "CC" on 6/19/13 at 12:30pm revealed that when checking the monthly Physician order [REDACTED]. Two (2) different nurses had missed the parameter transcription errors made by the pharmacy. Interview with the Pharmacy Consultant on 6/19/13 at 4:15pm revealed the resident's BP was very labile. If the SBP reached 120 the resident become lethargic. Parameters for May and June of 2013 to hold Hydralazine if SBP was greater than 160, were a pharmacy medical record printing error.

Based on observations and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a safe and sanitary environment for two (2) of two (2) units and two (2) of two (2) commons shower rooms. Findings include: During an environmental tour of the facility with the Maintenance Director on 6/19/13 from 2:05 p.m. until 3:15 p.m. the following concerns were revealed: * Room 119 - The cove molding to the left of the door, just inside the door was loose. * Room 126 - There was a large hole in the plaster on the wall, at the head of the bed. * Bathroom between rooms 211 and 212 - a tile used as molding was missing; there was a broken area of plaster on the wall. * Room 219 - There was an area of broken plaster on the wall, at the head of the bed. * Room 222 - The cove base was loose on the right side of the window. * Room 223 - The plaster on the left side of the window was broken. * Hall 1 shower room - The handwashing sink was leaking. There was no paper towel dispenser. Interview with the Maintenance Director on 6/19/13 at 3:15 p.m. confirmed the above issues should be addressed; he further revealed the plaster on the left side of the window in room 223 had just been repaired a week ago however, was broken again.

Based record review, hospital document review, and staff interview, the facility failed to immediately report an allegation of sexual abuse to the State survey and certification agency for one (1) resident (#1) in a survey sample of five (5) residents. Findings include: Record review for Resident #1 revealed a Nurse's Notes entry of Sunday, 03/04/2012 at 8:00 p.m., which documented the resident had been transferred to the hospital for evaluation, and a Nurse's Notes entry of 03/05/2012 at 3:00 a.m. which documented that the resident had been admitted to the hospital. A hospital social services document which referenced the resident's hospital admission documented, in the Objective Description of Event View section, that upon admission, the resident was noted to have a bruised area on the right groin and a light discoloration noted on the left groin. It was further documented that upon inquiring from the resident about the previous discoloration, the resident alleged that she had been "raped" by multiple males on Saturday. In a 03/12/2012 written statement provided by facility Nurse "AA", this nurse documented that she had spoken with a nurse at the hospital on [DATE] at approximately 2:50 p.m. and that the hospital nurse had made her aware of the resident's allegation of having been "raped" by multiple males. However, further record review revealed no evidence to indicate that the facility had notified the State survey and survey agency of this resident's allegation of sexual abuse, as of the 03/12/2012 date of this complaint survey. During an interview with Nurse "AA" conducted on 03/12/2012 at 1:30 p.m., this nurse acknowledged that the facility had not immediately reported this allegation of abuse involving Resident #1 to the State survey and certification agency.

Based on observation, record review and staff interview, the facility failed to insure that the assessment for one (1) resident (#19) adequately reflected the resident's status from a sample of thirty-three (33) residents. Finding includes: Record review of quarterly Minimum Data Set ((MDS) dated [DATE], 8/24/11 and annual MDS dated [DATE] revealed resident #19 was assessed as having no impairment to upper extremities only to bilateral lower extremities. Review of the restorative notes for November and December 2011 revealed PROM was being done to bilateral upper extremities, which was started 11/15/11. Interview with charge nurse "EE" conducted 1/4/11 at 2:15pm revealed the resident has bilateral hand contractures. During interview with the MDS coordinator conducted 1/4/11 2:50pm, she revealed resident was incorrectly assessed as having no limited range of motion in the upper extremities.

Based on observations, record reviews and staff interviews, the facility failed ensure that a decline did not occur for two (2) residents (# 19 and #100) with limited range of motion from a sample of thirty-three (33) residents. Finding includes: 1. Record review for resident #19 revealed [DIAGNOSES REDACTED]. Further record review revealed physician's orders [REDACTED]. Review of quarterly Minimum Data Set ((MDS) dated [DATE], 8/24/11 and Annual MDS dated [DATE] revealed the resident was assessed as having no impairment to upper extremities only to bilateral lower extremities (BLE) Review of the restorative notes for November and December 2011 revealed PROM was being done to BUE, which was started 11/15/11 Interview with charge nurse "EE" conducted 1/4/11 at 2:15pm revealed the resident has bilateral hand contractures. Joint range of motion and mobility screening conducted 11/17/11 revealed that the resident had limited joint mobility effecting hip, knee, ankle, shoulder, elbow, wrist and fingers. The form indicated that here was no change for the last screening done 8/22/11. Observation conducted 1/4/12 at 3:20pm with restorative nurse "CC" revealed the resident was lying quietly in bed with her arms across her chest. Bilateral extensive hand contractures were noted. "CC" further indicated that the resident had been feeding herself up until the last several years ago buy holding the spoon, now she cannot even hold a spoon. 2. Record review for resident #100 revealed the resident was admitted to the facility July 7, 2006 and has [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of December physician's progress note revealed this resident is bed/chair bound, and has generalized weakness. The Quarterly Minimum Data Set ((MDS) dated [DATE] assessed the resident as having impairment on both sides for upper and lower extremities. The annual MDS dated [DATE] ROM was assessed the same as 10/21/11 quarterly. Review of restorative notes for December revealed PROM for all extremities started 12/31/11. Further review revealed previous restorative record dated March 2011 which indicated PROM was done to all extremities March 1- 22, 2011 and February 25, 26, and 27, 2011. There was no evidence that any further PROM was conducted until 12/31/11, nine (9) months later. Record review revealed a joint range of motion mobility screen conducted 10/21/11 which revealed limited mobility in hip, knee, shoulder, elbow and wrist but with no significant change from last screen conducted 8/23/11. During interview conducted 1/4/12 at 9:30am with restorative staff "CC" , she was asked why PROM was stopped after March 2011 and then resumed 12/31/11. She replied that PROM was only done for thirty days, not on a continuous basis. When asked about how would the facility prevent or assess decline if you stop and then resume months later, she indicated she was unaware of why PROM was done for 30 days then stopped. A further interview with "CC" conducted 1/5/12 at 3pm revealed that she was not aware of any reevaluation of residents ' PROM being conducted after 30 days. She indicated that she assesses residents quarterly. Review of facility policy " Passive Range of Motion/Splint Program" revealed that policy does not address performing PROM for only thirty (30) days or any evaluation after its completion. Observation conducted 1/5/12 at 2:45pm revealed the resident has very limited joint mobility on her hands. Her right hand was lying by her side with her fingers straight and she was using her left hand to rub her mouth. This observation revealed is able to use her hands per herself.

Based on record review, review of the care plan, resident and staff interviews, the facility failed to ensure the care plan interventions were followed for one (1) resident ("T") from a sample of thirty three (33) residents. Findings include: During an interview with resident "T" on 1/3/12 at 11:25am the resident revealed her left leg had [MEDICAL CONDITION] Arthritis, and she had taken [MEDICATION NAME] for thirty (30) years. The medication relieved some of the pain but not all and she felt she might need a different pain medication. Review of the resident's latest history/physical by the new Medical Director dated 8/9/11 indicated the resident had multiple chronic medical problems, a history of chronic pain, currently received a [MEDICATION NAME] 50mcg/hr patch with [MEDICATION NAME] for break through pain. The resident had an [MEDICATION NAME] back injection on 7/29/11 for her chronic back pain and would refer to the pain clinic if no improvement is reported. The resident received [MEDICATION NAME] 10-650 mg (1) po 5:00am, 10:30am, 4:30pm, and 9:00pm, and a [MEDICATION NAME] 50mcg every third day. Review of the Care Plan dated 11/26/11 indicated goals and interventions for risk of decline in Activities of Daily Living (ADLs) related to pain. The interventions were as follows: Pain Interventions: 1. Using a 1 to 5 pain scale assess severity/ frequency of pain before medications are given. 2. Return at thirty (30) minutes, one (1) hour and two (2) hours past medications to assess degree of pain relief. 3. Document pain relief. 4. Consult the physician if pain medications do not provide pain relief. Interview with the Licensed Practical Nurse (LPN) "AA" on 1/5/12 at 10:20am revealed pain was monitored by observation of the resident's involvement in ADLs, smoking, ambulation verses using a wheel chair, was the resident guarded, or rubbing pain areas. The resident never exhibited symptoms of distress except verbally. The resident had an appointment scheduled for the pain clinic to see the Physician's Assistant (PA) on 1/9/11. There was usually no return orders or documentation of the visit, and the same medications were continued. "AA" further revealed she did not always follow the interventions listed. Review of nursing notes dated 8/30/11 through 1/4/12 indicated four (4) entries of pain, with no follow up assessments or evidence the care plan intervientions had been followed. Further review of pain assessments dated 10/31/11, 11/28/11, 12/2/11, and 12/30/11, indicate daily moderate to severe, constant pain. The pain quality was described as aching, throbbing, penetrating, and cramping. Interview with the resident on 1/5/12 at 11:00am revealed her pain level was a two (2) from a one (1) to five (5) pain scale with five (5) being the worst pain. The resident was very proud she had walked further today, felt like there was some improvement.

Based on review of the facility's Grievance Log, the Policy on Filing Grievances/Complaints, and residents' and staff interviews, the facility failed to follow the facility's policy and document grievances and ensure that residents received timely response to grievances for two residents ("X" and "T" ) from a sample of thirty three (33) residents. Findings include: 1. During an interview with resident "X" on 1/4/12 at 8:25am, the resident indicated had been missing bottom set of dentures for approximately 6 weeks. The resident reported it to one of the counselors and was told they would report it to the office however, has never received a response back on the missing dentures. The resident further revealed that approximately 4 to 5 weeks ago a new pair of blue jeans and 3 or 4 other pants that family had brought were missing. The resident indicated that they were aware that staff had looked for them in the laundry but no one had found them. Review of the Grievance Log revealed no evidence of the missing dentures and clothes. Interview with housekeeping/laundry staff "BB" on 1/5/12 at 1:00pm revealed that she could not remember every complaint of missing clothes because they receive so many but, she does remember looking for missing teeth. Interview with the Administrator on 1/5/12 at 1:04pm revealed that a form should be completed anytime a concern is voiced and the item cannot be found. Further, the facility has replaced dentures before but not for resident "X". Interview on 1/5/12 at 1:55pm with the Hospitality Ambassador, "FF" revealed that it is part of her job to help with setting up appointments to see the Dentist. "FF" further revealed that resident "X" had not reported the missing teeth or missing clothes to her but was aware of them missing. "FF" was aware that staff had looked in the laundry for the clothes and the Social Worker had asked "FF" to see about getting the resident on the Dentist list. 2. During an interview with resident "T" on 1/3/12 at 11:23am, the resident revealed that one (1) pair of red satin pants and one (1) new pair of gray sweat pants had been missing for approximately six (6) weeks. The missing clothes were reported to laundry staff "BB", and the clothes are still missing. There has been no response from the facility. Interview with the Housekeeping/Laundry Manager "BB" on 1/5/12 at 1:00pm revealed that the resident had reported the missing pants. "BB" did not remember colors, but it was two (2) pairs. The no name rack was searched for the reported missing items, and they were not found. No further action was taken. Interview with the Administrator on 1/5/12 at 1:05pm revealed that when social services receives a complaint or grievance, it is forwarded to the Administrator. The information is then taken to morning report, all management staff are informed of the issue. Resident grievance form is kept by the Administrator. The Department Head responsible for the issue investigates the concern. The concern is either resolved or the family or resident is given the option of a refund, either from a purchase receipt, or money from the facility. It usually takes two (2) to three (3) day wait for the refund. The Administrator was not aware of the concern of missing clothes for this resident. Review of the facility Grievance Log indicated no evidence of the resident's complaint. Review of the facility policy on Filing Grievances/Complaints indicated the following: Any resident, responsible party, family member, or appointed advocate, may file a grievance or complaint with out fear of threat or reprisal in any form. The grievance or complaint can be filed in writing or orally. The Administrator has delegated responsibility of grievance/complaint investigation to Social Services Director Upon receipt of a complaint/or grievance, social services will investigate and submit a report to the administrator. The resident or person filing the complaint/grievance will be informed of the findings of the investigation. The report will be made orally by the social worker or designee. A summary will also be provided to the resident and a copy maintained in the social services office.

Based on observation, review of physician's orders, and staff interview, the facility failed to ensure physician's orders were followed for one (1) resident (#2) from a sample of sixteen (16) residents. Findings include: Observation made during a skin assessment on 5/11/10 at 1:30pm, conducted with a Certified Nursing Assistant (CNA) "CC" revealed an [MEDICATION NAME] to the right lower abdomen dated 5/4/10, a second [MEDICATION NAME] patch to the left lower abdomen dated 5/8/10, and a Nitro Dur patch on the right chest dated 5/10/10. Review of the physician's orders dated 1/7/10 indicated a Nitro Dur Patch 0.8 milligrams (mg) was to be applied at bedtime and removed every morning. The physician's order was for [MEDICATION NAME] Patch 3.9 mg one (1) patch, two (2) times weekly. Interview with the Licensed Practical Nurse (LPN) "AA" conducted 5/11/10 at 1:50pm revealed the Nitro Dur patch should have been removed this morning and that the [MEDICATION NAME] Patch dated 5/4/10 should have been removed on 5/8/10 when the new Patch was applied.

Based on review of the medical records, physician's orders, and staff interviews, the facility failed to ensure laboratory tests were completed in a timely manor for two (2) residents ( #2 and #12) from a sample of sixteen (16) residents. Findings include: 1. Record review for resident #2 revealed an physician's order dated 1/7/10 for a Complete Blood Count (CBC) every month. No March 2010 CBC results was not found in the medical record. Interview with a Licensed Practical Nurse (LPN) "BB" conducted 5/10/10 at 2:00pm revealed, that after consulting with the Laboratory, no CBC was done for March 2010. 2. Record review for resident #12 revealed a physician's order dated 2/1/10 for Liver Function Tests (LFT) every three (3) months. There were no laboratory results for a LFT found for February 2010. There was a LFT results for April 20 and May 6, 2010. Interview with a LPN "BB" conducted 5/12/10 at 9:45am revealed that the only order found on the chart for LFT was 2/1/10, and there was no laboratory test done at that time. "BB" confirmed with the Laboratory that there was no LFT completed prior to 4/20/10. "BB" concluded that the original order for 2/1/10 was missed, and was not completed until 4/20/10.

Based on record review, and staff interviews, the facility failed to obtain physician's orders for laboratory tests completed for one (1) resident (#12) from a sample of sixteen (16) residents. Findings include: Record review revealed a physician's order dated 3/6/09 for Lipids yearly. Further record review for laboratory results revealed Lipids completed 1/7/10 and 3/9/10. Interview with a Licensed Practical Nurse "BB" on 5/12/10 at 9:45am revealed "BB" was not sure why the Lipids were completed two (2) months apart, Lipids had been done 3/1/09 prior to admission to the facility on [DATE], therefore would be due again March 2010 according to the order. There was no order found in the medical record for the Lipids completed 1/7/10.