Every finding on record at Celina Health and Rehabilitation Center

Based on facility policy review, observation, and interview, the facility failed to provide a clean and sanitary environment to ensure cleanliness of a stand-up personal fan for 1 resident (Resident #8) of 61 residents reviewed for a clean and sanitary environment. The findings include: Review of the facility's policy titled, Cleaning and Disinfecting Residents' Rooms, revised 8/2013, revealed .environmental services will be disinfected (or cleaned) on a regular basis .and when surfaces are visibly soiled . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Diabetes, History of a Stroke with Hemiplegia, Pulmonary Edema, and Dysphagia. During observations on 9/2/2025 at 10:55 AM and on 9/3/2025 at 2:30 PM, Resident #8's room revealed a portable stand-up fan by the wall facing toward the bed. The fan blades had a large amount of gray dust and thick debris resembling clumped gray fibers which had accumulated on the protective grille. During an observation and interview on 9/4/2025 at 10:34 AM, the Housekeeping Director confirmed Resident #8's stand-up fan had a large amount of gray dust and thick debris resembling clumped gray fibers which had accumulated on the protective grille, which should not be present with routine cleaning.

Based on facility policy review, medical record review, and interview, the facility failed to complete dialysis communication forms consistently for 1 resident (Resident #37) of 2 residents reviewed for dialysis.The findings include: Review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, dated September 2010, revealed .Agreements between the facility and the contracted ESRD (end stage renal disease) facility include all aspects of how the resident's care will be managed, including .How information will be exchanged between the facilities . Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, and Metabolic Encephalopathy. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 received dialysis services. Review of a comprehensive care plan for Resident #37 revised on 9/3/2025, revealed .I require hemodialysis due to end stage renal failure .I receive hemodialysis three times a week on Monday, Wednesday, and Friday . During a medical record review and interview on 9/4/2025 at 11:15 AM, the Assistant Director of Nursing (ADON) stated there was no documentation of dialysis communication sheets for 4 dialysis visits 8/15/2025, 8/18/2025, 8/20/2025, and 8/22/2025 for Resident #37. During an interview on 9/4/2025 at 11:20 AM, the Director of Nursing (DON) stated it was the facility's expectation to send dialysis communication sheets with residents to dialysis services for each dialysis treatment. The DON confirmed dialysis communication sheets for Resident #37 were not completed.

Based on facility policy review, observations, and interviews, the facility failed to transport and distribute meals in a safe sanitary manner for 2 of 2 meal observations. The findings include: Review of the facility's policy titled, Food Preparation and Service, dated 4/2019 revealed, .Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff adhere to proper .sanitary practices to prevent the spread of food borne illness . Observation on the 100 and 300 halls on 8/22/2022, during the noon meal, at 11:58 AM to 12:25 PM, revealed the dietary staff plated 21 plates of food without a cover. Continued observation revealed the staff transported the uncovered plates down the hallways and distributed the uncovered plates of food to the residents. During an interview on 8/22/2022 at 12:30 PM, the Dietary Manager confirmed the uncovered food plates were transported down the hall and distributed to the residents. Observation on the 100 and 300 halls on 8/22/2022, during the evening meal, at 4:42 PM to 5:20 PM, revealed the dietary staff plated 22 plates of food without a cover. Continued observation revealed the staff transported the uncovered plates down the hallways and distributed the uncovered plates of food to the residents. Observation on the 300 hall on 8/22/2022 at 5:13 PM, revealed a staff member transported an uncovered plate of food to room 312. Continued observation revealed room 312 was 5 rooms down from the food cart. During an interview on 8/22/2022 at 5:25 PM, the Dietary Manager confirmed the plate delivered to room 312 was not covered during transportation and distribution. Continued interview with the Dietary Manager confirmed uncovered plates of food were transported down the 100 and 300 halls and distributed to the residents.

Based on facility policy review, medical record reviews, observations, and interviews, the facility failed to ensure 1 of 22 sampled residents (Resident #1) received necessary treatment consistent with professional standards of practice, to promote healing of pressure ulcers. The findings include: Review of the facility's undated policy titled, Wound Management, revealed, .The Wound Management Program is committed to the assessment, prevention, identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Baseline Care Plan for Resident #1 dated 8/17/2022, revealed, .impaired skin integrity .Pressure Ulcer .St [stage] 1 Rt [right] foot .Elevate heels off of bed .perform rounds for compliance . Review of the Wound Physician's notes dated 8/17/2022, revealed, .pressure wound of the right heel .float heels in bed .off-load wound . Observations in Resident #1's room on 8/22/2022 at 2:00 PM, 3:00 PM, 4:19 PM, 5:01 PM, and 8/23/2022 at 1:00 PM, revealed Resident #1 was in bed with both heels against the bed surface. Continued observation revealed two heel protector boots on A bed and no heels up cushion present in the room. During an interview on 8/23/2022 at 1:50 PM, the Director of Nursing (DON) stated Resident #1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she had observed Resident #1 in bed today and confirmed the resident's heels were not floated on the heels up cushion nor were the resident's heels placed in the heel protector boots She stated the cushion had been taken off with the linen change and was not in the room. She stated she expected the intervention for Resident #1's heel wound to be followed as ordered.

Based on facility policy review, medical record review, and interview, the facility failed to adequately monitor 2 of 9 residents (Resident #36 and #196) receiving anticoagulant therapy. The Findings include: Review of the facility's policy titled, Medication Monitoring and Management, dated 1/1/2018 revealed, .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use .The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis . Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 received an anticoagulant 7 of 7 days during the look back period. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] [anticoagulant] 2.5 mg [milligram] take one tablet by mouth twice daily . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed no monitoring for side effects of anticoagulant. Review of the medical record revealed Resident #196 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Prospective Payment System (PPS) MDS assessment dated [DATE], revealed Resident #196 received anticoagulant 7 of 7 days during the look back period. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 2.5 mg tablet take one tablet by mouth twice daily . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed no monitoring for side effects of anticoagulant. During an interview on 8/24/2022 at 9:13 AM, the Director of Nursing confirmed residents receiving an anticoagulant should be monitored on the MAR for side effects.

Based on facility policy review, medical record review and interview, the facility failed to report an allegation of abuse on 1 resident, Resident #1. The findings include: Review of the facility's undated policy titled, Resident Rights, revealed .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property and exploitation . Review of the facility's undated policy titled, Abuse Investigation and Reporting, revealed .All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Finding of abuse investigations will also be reported . Review of the facility's undated policy titled, Abuse Prevention Policy and Procedure, revealed .The facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of residents property by any facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals .All alleged violations involving abuse .are reported immediately to the Administrator and Director of Nursing. All allegations involving abuse .are reported immediately to the state survey agency, adult protective services and all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but no later than 2 hours after the allegation is made . Review of the Nursing Note by Registered Nurse (RN) #1 dated 12/7/2021 at 2:17 PM revealed, .Spoke with resident's daughter, [named daughter] regarding resident refusing medication and recent wandering in hallways and making statement, I've been raped, and saying an old white haired woman did it. Perineal area inspected with no s/s of trauma, no bleeding, no bruising noted. During an interview on 2/3/2022 at 8:30 AM with the Social Worker (SW) by phone revealed she was familiar with Resident #1 and the allegation of rape. The SW stated, I did receive a call from the insurance Case Coordinator, and I also spoke with Resident #1's daughter. The SW confirmed she did not report the allegation of rape. The SW stated, I did refer her to psychiatric services. The daughter told me she does did this at home and does not believe anything happened. The SW did state the Administrator was aware of the allegation. During an interview on 2/3/2022 at 9:45 AM with the facility Administrator in the conference room revealed she did remember Resident #1 making an allegation of rape and she assisted the nurse in doing the assessment after the allegation. The Administrator stated, She did have a fungal or some type of something going on in her perineal area. We did get orders to treat that. I think that's why she was saying she was raped. We did not see any bleeding or bruising. To her perineal area. The Administrator also stated, I spoke with her daughter, and she didn't think she was raped and felt she received good care at the facility. When questioned about investigating the allegation of rape and reporting the Administrator stated, I really didn't think I had to report since we didn't think anything happened but now that I think about it, I should have reported it. The Administrator confirmed she should have investigated and reported the allegation of rape. During an interview on 2/3/2022 at 10:00 AM by phone with Registered Nurse (RN) #1 revealed she was familiar with Resident #1. She stated, She was yelling she had been raped while walking in the hallway. I spoke with her daughter, and she told me she (Resident #1) had vivid dreams and saw things on the television and though that was what was happening to her. She stated the Administrator was the Abuse Coordinator and she reported the allegation of rape to her, and she assisted in assessment of Resident #1 after the allegation. During an interview on 2/3/2022 at 11:30 AM in the conference room with the Director Of Nursing (DON) revealed she was familiar with Resident #1 and the allegation of rape. The DON confirmed the allegation of rape should have been investigated and reported.

Based on facility policy review, medical record review and interview, the facility failed to investigate an allegation of abuse on 1 resident, Resident #1. The findings include: Review of the facility's undated policy titled, Resident Rights, revealed .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property and exploitation . Review of the facility's undated policy titled, Abuse Investigation and Reporting, revealed .All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Finding of abuse investigations will also be reported . Review of the facility's undated policy titled, Abuse Prevention Policy and Procedure, revealed .The facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of residents property by any facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals .All alleged violations involving abuse .are reported immediately to the Administrator and Director of Nursing. All allegations involving abuse .are reported immediately to the state survey agency, adult protective services and all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but no later than 2 hours after the allegation is made . Review of the Nursing Note by Registered Nurse (RN) #1 dated 12/7/2021 at 2:17PM revealed, .Spoke with resident's daughter, [named daughter] regarding resident refusing medication and recent wandering in hallways and making statement, I've been raped, and saying an old white haired woman did it. Perineal area inspected with no s/s of trauma, no bleeding, no bruising noted. During an interview on 2/3/2022 at 8:30 AM with the Social Worker (SW) by phone revealed she was familiar with Resident #1 and the allegation of rape. The SW stated, I did receive a call from the insurance Case Coordinator, and I also spoke with Resident #1's daughter. The SW confirmed she did not report the allegation of rape. The SW stated, I did refer her to psychiatric services. The daughter told me she does did this at home and does not believe anything happened. The SW did state the Administrator was aware of the allegation. During an interview on 2/3/2022 at 9:45AM with the facility Administrator in the conference room revealed she did remember Resident #1 making an allegation of rape and she assisted the nurse in doing the assessment after the allegation. The Administrator stated, She did have a fungal or some type of something going on in her perineal area. We did get orders to treat that. I think that's why she was saying she was raped. We did not see any bleeding or bruising to her perineal area. The Administrator also stated, I spoke with her daughter, and she didn't think she was raped and felt she received good care at the facility. When questioned about investigating the allegation of rape and reporting the Administrator stated, I really didn't think I had to report since we didn't think anything happened but now that I think about it, I should have reported it. The Administrator confirmed she should have investigated and reported the allegation of rape. During an interview on 2/3 2022 at 10:00AM by phone with Registered Nurse (RN) #1 revealed she was familiar with Resident #1. She stated, She was yelling she had been raped while walking in the hallway. I spoke with her daughter, and she told me she (Resident #1) had vivid dreams and saw things on the television and though that was what was happening to her. She stated the Administrator was the Abuse Coordinator and she reported the allegation of rape to her, and she assisted in assessment of Resident #1 after the allegation. During an interview on 2/3/2022 at 11:30AM in the conference room with the Director Of Nursing (DON) revealed she was familiar with Resident #1 and the allegation of rape. The DON confirmed the allegation of rape should have been investigated and reported.

Based on facility policy review, medical record review, and interview, the facility failed to develop a baseline care plan to address fall precautions for 1 resident (#5) of 4 residents reviewed for falls of 15 sampled residents. The findings include: Review of the facility policy Care Plans - Baseline revised 12/2016 revealed .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident .Policy Interpretation and Implementation .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed .The Interdisciplinary Team will review the healthcare .orders .and implement a baseline care plan to meet the resident's immediate care needs .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician Orders dated 4/12/19 from a local hospital revealed .Transfer patient to .SNF (skilled nursing facility) .Activity .Fall precautions . Medical record review of an undated Baseline Care Plan for Resident #5 revealed the facility failed to develop and implement a plan of care for fall precautions. Interview with Registered Nurse (RN) #1 on 7/22/19 at 2:32 PM, in the conference room, revealed she had completed the admission assessment for Resident #5 on 4/12/19. Further interview confirmed admitting Physician Orders for the resident dated 4/12/19 from a local hospital revealed fall precautions. Continued interview confirmed a baseline care plan had not been developed to include fall precautions for Resident #5. Interview with the Director of Nursing on 7/23/19 at 7:23 AM, in the conference room, confirmed the facility failed to develop a baseline care plan to include fall precautions for Resident #5.

Based on facility policy review, medical record review, observation and interview the facility failed to reassess and revise the effectiveness of the care planned interventions for communication for 1 resident (#54) of 25 residents reviewed. The findings include: Review of the facility's policy Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed .Care plan interventions are chosen .after careful data gathering, careful consideration of the relationship between the resident's problem areas .Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 00 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed Resident #54 had unclear speech, rarely understands and impaired ability to make self-understood. Medical record review of the Comprehensive Care Plan, dated 7/10/19, revealed .Impaired ability to make self understood .Teach resident how to use communication book .Teach resident how to use communication board .Teach resident how to use assistive device .difficulty expressing my ideas or wants and understanding others .refer to speech pathology . Observation and interview with Resident #54 on 7/21/19 at 11:01 AM, in the resident's room, revealed the resident was unable to respond/communicate verbally or non-verbally. Continued observation revealed no communication devices were observed in the resident's room. Interview with Licensed Practical Nurse (LPN) #1 on 7/21/19 at 11:28 AM, at the nurses station, revealed .resident is non-verbal because of a stroke we communicate with her on paper and pencil .she writes down what she wants or needs . Observation of Resident #54 on 7/22/19 at 8:40 AM, in the resident's room, revealed no paper and pencil available for the resident. Interview with the Speech Pathologist on 7/22/19 at 1:17 PM, on the 200 hallway, revealed the resident does not have the cognitive ability to use a communication board or a communication book. Further interview revealed Resident #54 was unable to express her needs verbally and would not be able to write her needs on paper. Observation of Resident #54 on 7/23/19 at 7:55 AM, in the resident's room, revealed the staff delivered the resident's meal tray. Continued observation revealed the staff asked if the resident needed anything and the resident was unable to respond/communicate. Interview with the MDS Coordinator on 7/23/19 at 7:55 AM, in the conference room, confirmed the resident's care plan did not include appropriate interventions on how to communicate with Resident #54. Continued interview confirmed the facility failed to reassess and revise the effectiveness of the resident's care planned interventions. Interview with the MDS Coordinator on 7/23/19 at 7:55 AM, in the conference room, confirmed the resident's care plan did not include appropriate interventions on how to communicate with Resident #54. Continued interview confirmed the facility failed to reassess and revise the effectiveness of the resident's care planned interventions. Interview with the Assistant Director of Nursing (ADON) on 7/23/19 at 8:24 AM, in the ADON's office, revealed .we have a difficult time communicating with (Resident#54) . Interview with the Administrator on 7/23/19 at 9:25 AM, in the Administrator's office confirmed the care plan had not been updated to include person centered interventions.

Based on facility policy review, and interview the facility failed to ensure staff calibrate thermometers weekly and failed to document food temperatures for 11 of 40 evening meals reviewed. The findings include: Review of the undated, Calibrating A Probe Thermometer facility policy, revealed .Probe food thermometer should be calibrated weekly to assure accuracy . Review of the facility policy, Food Temperatures, dated 9/11 revealed .Record reading on Food Temperature Chart .at beginning of the trayline and end of trayline .Take the temperature of each pan of product before serving . Review of the facility Food Temperature Charts dated 7/1/18-8/1/18 revealed evening meal food temperatures were not completed on 7/3, 7/4, 7/5, 7/6, 7/8, 7/9, 7/10, 7/13, 7/14, 7/17 and 7/20. Interview with Cook #1 and Cook #2 on 7/29/18 at 11:30 AM, in the kitchen confirmed they do not calibrate the thermometers on a regular basis and were unsure how often the thermometers were to be calibrated. Interview with the Dietary Manager on 8/1/18 at 8:45 AM, in the conference room, confirmed the facility failed to ensure staff calibrated thermometers weekly and failed to ensure staff document food temperatures as per the facility policy.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to follow professional standards of practice for 1 resident (#9) of 3 residents reviewed for enteral feedings. The findings include: Review of the undated Enteral Feedings - Safety Precautions policy revealed .Preventing errors in administration .2.On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . Medical record review revealed Resident #9 admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 0 indicative of severely cognitively impaired. Continued review revealed no moods or behaviors and resident required total assistance for Activities of Daily Living (ADL). Medical record review of the quarterly care plan updated 7/31/18 revealed potential for falls related to [DIAGNOSES REDACTED], prone to contractures, requires a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube passed into the stomach to provide nutritional support), and depends on staff for all ADL's. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] HN Liquid (a High Calorie Nutritional Formula) @ (at) 38 ml/hr (milliliters/hour) with 51cc (cubic centimeter) water flush via pump x (for) 22 hours, clean PEG Tube Site with Normal Saline .NPO (nothing by mouth) . Observation of resident on 7/30/18 at 11:10 AM, in the resident's room, revealed resident lying in bed with Head of Bed (HOB) elevated 45 degrees with tube feeding (TF) infusing at 38 ml/hr. Continued observation revealed the enteral TF formula bag had no label that indicated the type of formula, the date or time the formula was hung or the nurse initials that it was checked against the physician's orders [REDACTED].>Interview with the Director of Nursing, on 7/30/18 at 2:19 PM, in Resident #9's room, confirmed Resident #9's enteral tube feeding bag did not contain a label and the facility failed to follow the professional standards of practice for enteral tube feeding.

Based on review of facility policy, medical record review, facility investigation, and interview, the facility failed to ensure freedom from abuse/exploitation for 1 resident (#37) of 25 residents reviewed. The findings included: Review of facility policy, Electronic Devices, revealed .Electronic Devices not specifically used in the scope of your job are strictly prohibited inside the Facility .The use of personal electronic devices (including cellphones with cameras) while at work is strictly prohibited as they cause distractions, productivity problems, privacy issues and safety concerns and follows: Dignity/Privacy concerns if an employee is .taking unauthorized pictures without appropriate written consent and only for Facility use violates dignity and privacy rights .Videotaping, recording and picture taking of Residents, Family members or associates must have written consent to do so and must be for Facility use only . Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #37 had a Brief Interview for Mental Status of 13, indicating she was cognitively intact. Review of the medical record revealed no signed consent for photography for Resident #37. Review of the facility investigation and a statement dated 8/12/17 from Certified Nursing Assistant (CNA #1) revealed she witnessed CNA #9 taking a picture with Resident #37. Further review of a statement dated 8/12/17 from Resident #37 revealed .Employee laid on her bed and took a picture of them. She didn't give permission but didn't think anything about the incident . Further review revealed Resident #37 was unable to recall the day or the name of the employee. Continued review of a statement dated 8/13/17 from Resident #37 revealed .'the little girl that wears the boots all the time' climbed into her bed and took a picture of them together. The resident claimed that they gave audible warning to the CNA not to take her picture . Continued review of the facility investigation of a statement dated 8/12/17 from the roommate of Resident #37, revealed .she laid on the bed with (name Resident #37) and took the picture . The roommate named CNA #9 as a person involved. Further review of a statement dated 8/13/17 from the roommate of Resident #37 revealed .a CNA climbed in the bed, laid down next to resident (room number), and held a phone out in front of them, appearing to take a picture . Interview with Resident #37 on 9/18/17 at 3:20 PM in her room revealed an aide did take a picture of her (Resident #37) and the aide. This occurred last month but she was unsure of the exact date or the aide's name. The resident stated the aide laid in the bed with her and took the picture with a cell phone. Resident #37 stated she did not give verbal permission for the picture but did not think the aide would share picture or post for public viewing. Resident #37 stated this incident occurred after dinner because she was in bed with her gown on. Interview with Resident #37's roommate on 9/18/17 at 3:45 PM in her room revealed the roommate witnessed an aide take a picture with Resident #37. The roommate was unsure of the date this occurred but stated it was last month. The roommate was also unsure of the name of the aide who took the picture. Continued interview revealed the picture was taken with a cell phone and the aide laid in the bed with Resident #37 to take the picture. Further interview revealed the resident did not give permission for the aide to take the picture. Interview with CNA #1 on 9/19/17 at 9:00 AM in the Administrator's office revealed last month she observed CNA #9 laid in the bed with Resident #37 and took a picture of Resident #37 and CNA #9 with a cell phone. CNA #1 stated CNA #9 told Resident #37 .we're going to take a picture . Further interview revealed CNA #1 did not feel Resident #37 understood what CNA #9 was doing. CNA #1 stated CNA #2 said she was going to put the picture on Snapchat (social media application). CNA #1 stated Resident #37's roommate was in the room when the picture was taken and Resident #37 was in bed with her gown on and was under the covers when the picture was taken. Interview with CNA #4 on 9/20/17 at 9:50 AM at the nurses station confirmed he had completed an interview with Resident #37 on 8/13/17. Further interview revealed CNA #4 was able to identify the CNA the resident was referring to as CNA #9 because she did wear cowboy boots daily. The facility failed to ensure Resident #37 was free from abuse/exploitation of being photographed without written permission for facility use only.

Based on medical record review, observation, and interview, the facility failed to place new interventions after 1 of 6 falls for 1 (#49) of 18 residents reviewed. The findings included: Medical record review revealed Resident #49 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Fall Risk assessment dated [DATE] revealed a score of 41 with 10 or higher indicated high risk for further falls. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #49 had severe cognitive impairment, required assistance of 2 staff to transfer, and seldom ambulated but when he did, he required extensive assistance of 2 staff. Medical record review of the Resident Incident Report dated 6/28/16 revealed Resident #49 was found on the floor in front of the nurse's station, the fall was unwitnessed but staff thinks he tried to transfer self, lost his balance and fell . Continued review revealed Resident #49 sustained a skin tear on his right elbow, and no emergency room visit was required. Continued review revealed recommendations were to .utilize I pod for diversional activity . Medical record review of the Resident Incident Report dated 7/06/16 revealed Resident #49 was found on the floor in front of the nurse's station, he had attempted several times to stand up and ambulate by himself. Continued review revealed .Resident was sitting in front of nurse's station. Resident stood up et (and) lost balance. Resident was redirected several times by this nurse prior to fall . Continued review revealed a recommendation .Staff education r/t (related/to) musical diversional activities & encourage resd (resident) to be up in dining room for activities .7/12/16- Conts (Continues) to do well with headphones. He listens to blue grass music & calms him down. Conts to go to DR (Dining Room) to receive 1:1 interaction with staff . Medical record review of the Resident Incident Report dated 7/19/16 revealed Resident #49 was found on the floor in the dining room, Resident #49 had attempted to transfer self, and received a skin tear to his left lower arm. The recommendation was to have the .MD consult r/t meds .MD ordered Klonopin 2 (secondary) to increased agitation & behaviors after being consulted. Staff reports slight improvement in behaviors. Conts with impaired cognition & difficulty following commands . Medical record review of the Resident Incident Report dated 9/09/16 revealed Resident #49 .Sitting in w/c (wheel chair) at nurses station stood in front of w/c got weak and fell to floor on his knees .No apparent injury . Continued review revealed a recommendation of .Encourage use of headphones . (see report from 7/6/16). Medical record review of the Resident Incident Report dated 9/11/16 revealed .Resident was trying to stand up and became weak and went to his knees on the ground and then layed on the ground. Resident has no apparent injuries noted .Immediate Post-Incident Action: dyson (dysom is non slip material) placed in chair .encourage diversional activities .9/16/16- Activities dept conts to encourage & engage resd in diversional activities. Difficulty maintaining attention span 2 (secondary to) cognition impairments. Conts @ ^ (high) risk for falls . Medical record review of the Resident Incident Report dated 9/13/16 revealed Resident #49 .was sitting in w/c at nurses station leaned over and slipped out of chair to floor. 3x4 cm (centimeter) Skin tear to Rt/ Elbow .Skin tear cleaned with NS (Normal Saline), steri strips and dsg (dressing) applied .Resident was up in the dining room for supper. After supper he was sitting at the nursing station. He was very nervous & agitated & refused to go to bed .Will seek headphones with built in MP3 player .9/19/16- Headphones ordered awaiting shipment. Conts @ risk for falls . Observation on 9/28/16 at 11:30 AM, revealed Resident #49 was up in the w/c eating his lunch in the dining room, no attempts to stand and transfer self. Interview with Registered Nurse/ MDS Coordinator on 9/28/16 at 12:20 PM, in the conference room confirmed the staff were in serviced to provide Resident #49 headphones after the 6/28/16 fall, they were not doing it referring to placing the headphones on the resident and playing music for diversional activity. Continued interview confirmed the intervention of the use of headphones placed after the fall on 9/9/16 was the same intervention put in place after the 6/28/16 fall.

Based on observation, facility policy review, and interview, the facility failed to dispose of expired medications in one of one medication storage rooms observed. The findings included: Observation in the medication storage room on July 8, 2014, at 1:55 p.m., revealed eleven, one hundred unit (5 milliliter) heparin (blood thinner) syringes with an expiration date of July 1, 2014, in the cabinet. Review of the facility policy, Storage of Medications, effective date June 2011, revealed, "Outdated...medications...are immediately removed from stock...and reordered from the pharmacy..." Interview with the Director of Nursing (DON) on July 8, 2014, at 1:55 p.m., in the medication storage room, confirmed the heparin syringes had expired and had not been disposed of in a timely manner.

Based on medical record review and interview, the facility failed to implement a Gradual Dose Reduction (GDR) ordered by the physician for one resident (#79) of five residents reviewed for unnecessary medications. The finding included: Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Consultant Pharmacist Communication to the Physician dated March 2014, revealed the pharmacist recommended a GDR for [MEDICATION NAME] (antipsychotic) from 5 milligrams to 2.5 milligrams. Continued review revealed the physician approved the recommendation as indicated by a check mark in the "...I AGREE: Please write order(s)...", and signed by the Physician on April 9, 2014. Medical record review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on July 8, 2014, at 3:33 p.m., in the DON's office, confirmed the Pharmacist's recommendation (agreed upon by the Physician) had not been transcribed as a physician's orders [REDACTED].

Based on observation and interview, the facility failed to ensure a sanitary and safe environment related to the storage of food in the three-compartment sink. The findings included: Observation on July 9, 2013, at 11:17 a.m., in the kitchen, revealed one large bowl with fifty-six (56) individual wrapped pieces of cornbread inside the bowl, stored in the sanitizer sink of the three-compartment sink. Continued observation revealed the "eco lab" detergent (used for sanitizing kitchen pans) tubing connected to the detergent with the tubing extended into the three compartment sink where the bowl with the cornbread was stored. Further observation revealed Kitchen Employee #1 took the bowl from the three compartment sink and placed one piece of corn bread on each residents tray stored on a serving cart. Interview with Kitchen Employee #1, on July 9, 2013, at 11:20 a.m., in the kitchen revealed "...we do not use the three compartment sink unless the dishwasher is not working...moved the bowl with the cornbread into the three compartment sink because there was not enough space to place the employee trays on the counter..." Interview with the Dietary Manager, on July 9, 2013, at 11:21 a.m., in the kitchen confirmed the facility had failed to ensure cornbread was stored in a sanitary and safe environment.

Based on observation and interview, the facility failed to follow infection control practices during an ice pass for eight of thirty-three rooms on two of two halls observed. The findings included: Observation on July 9, 2013, at 9:20 a.m., on the 200 hall, revealed Certified Nursing Assistant (CNA) #5 entered a resident room to retrieve a resident's ice pitcher. Continued observation revealed the CNA exited the resident's room and opened the ice chest on the hydration cart, held the resident's personal pitcher over the ice chest and filled the pitcher with ice by placing the ice scoop inside the rim of the ice pitcher. Continued observation revealed the CNA then replaced the scoop by flipping the plastic scoop cover up with the clean ice scoop. Continued observation revealed the CNA then re-entered the resident's room with the residents ice pitcher and returned with the roommate's ice pitcher and repeated the same procedure. Observation on July 9, 2013, from 9:30 a.m. to 9:40 a.m., revealed CNA #5 filled ice pitchers in four rooms on the 200 hall then proceeded to the 100 hall and filled ice pitchers for four more rooms by holding all the residents personal ice pitchers over the ice chest, placing the ice scoop inside the rim of the pitchers and replacing the ice scoop by flipping the plastic scoop cover up with the clean ice scoop. Interview with CNA #5 on July 9, 2013, at 9:45 a.m., on the 100 hall, confirmed CNA #5 was holding the ice pitcher over the ice chest, placing the ice scoop inside the rim of the pitcher, and replacing the scoop by flipping the plastic cover up with the clean ice scoop and did not follow facility procedures for infection prevention. Interview with Registered Nurse #1 on July 10, 2013, at 11:41 a.m., at the nurse's station, confirmed the facility had failed to follow guidelines to prevent the spread of infection.

Based on medical record review, facility policy review, and interview, the facility failed to document a pain assessment for one resident (#1) and failed to document complete and accurate behavior monitoring for one resident (#19) of twenty-six residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record (MAR) for June 2013 revealed a pain assessment documented on the MAR twice daily. Medical record review of the Pain Assessment Flow Sheet for the month of June 2013 revealed no documentation of a Pain Assessment on the form. Medical record review of a fax to the Physician dated January 2, 2013, revealed "...is crying with all movements and ADLs (Activities of Daily Living) - is getting [MEDICATION NAME] (narcotic pain medication)5/500 milligrams (mg) QID (four times daily) - has started screaming when moved or touch. Would you consider a pain patch?..." and the Physician's response was "...NO..." Medical record review of a Physician's note dated June 30, 2013, revealed "...apparent pain on movement and ADLs - will add [MEDICATION NAME] (narcotic [MEDICATION NAME]) patch & reassess may need increase in [MEDICATION NAME] (antidepressant)..." Review of facility policy, Pain Management, revealed "...Pain will be reviewed/scored using a numeric 0-10 scale with 1-3, mild pain, 4-6 moderate pain, 7-10 severe pain..." Interview with Licensed Practical Nurse (LPN #1) on July 10, 2013, at 9:20 a.m., in the nurses' station, confirmed the Pain Assessment Flow Sheet was not completed. Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review ofa physician's orders [REDACTED]. Medical record review of the Psychoactive Medication Monthly Flow Record for May and June 2013 revealed the Target Behavioral Symptom being monitored was anxiety. Continued review of the record revealed many blank spots on the form where behavior was not documented. Review of facility policy, Behavior Assessment and Monitoring, revealed "...the staff will document ongoing reassessments of changes in the individual's behavior, mood, and function..." Interview with LPN #3 on July 9, 2013, at 3:08 p.m., in the nurses' station, confirmed documentation of target behavioral symptoms was missing on many occasions.

Based on medical record review and interview, the facility failed to provide a social services admission assessment and discharge planning services for one resident (#61) of twenty-three residents reviewed. The findings included: Resident #61 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital History and Physical dated March 29, 2013, revealed the resident lived alone, fell at home, and was found by a family member after an unsuccessful attempt to reach the resident by telephone. Medical record review of the Interdisciplinary Departmental Notes dated May 10, 2013 through July 8, 2013, revealed no documentation of a Social Services admission assessment or the initiation of discharge planning for the resident. Interview with the Director of Social Services on July 10, 2013, at 11:55 a.m., in the conference room confirmed facility had failed to complete a Social Services admission assessment or initiation or to initiate discharge planning for resident #61.

Based on medical record review and interview, the facility failed to ensure medications were administered to residents according to physician's orders for one resident (#1) of twenty-six residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders dated October 6, 2012, revealed an order for [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse #2 on July 10, 2013, at 8:40 a.m., in the nurses' station, confirmed the medication was ordered to be administered every three days and confirmed the medication was administered incorrectly every other day during the month of June 2013.