Every finding on record at Complete Care at Oak Ridge LLC

Based on observations, resident interviews and staff interviews. The facility failed to ensure areas of resident rooms and common areas are kept clean, and sanitary. This was a random opportunity found during the survey process and affected more than a limited number of residents. Facility census 74. Findings include a) Review of maintenance work sheet from their work order management system in direct supply, Technology-Enabled Life Safety. (TELS through direct supply) -Record review of the Managed task form for the facilities work order management system revealed a section for the Heating, Ventilation, and Air Conditioning (HVAC) to be done monthly. b) -On 08/24/2026 at around 1:15 PM during annual survey process, this surveyor observed the Air Conditioning units (A/C units) in following rooms: -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Nurse #50 verified this unit had large amount of dust and debris. -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Nurse #50 verified this unit had large amount of dust and debris. -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Also observed a large layer of dark green, black wooly textured growth under the unit on the wall and large amount of dust and debris on floor near wall and on power cord. Nurse #50 verified this unit had large amount of dust and debris and the large layer of dark green, black growth under the unit reporting, That looks like mold I will let maintenance know immediately. -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Nurse #50 verified this unit had large amount of dust and debris. -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Nurse #50 verified this unit had large amount of dust and debris. -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Nurse #50 verified this unit had large amount of dust and debris. -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Nurse #50 verified this unit had large amount of dust and debris. -room [ROOM NUMBER] the filters of the A/C unit had large amount of dust and debris. Also observed a large layer of black flaky debris on the filters and along the wall where the unit is placed. Nurse #50 verified the filters having large amount of dust and debris also the wall under the unit having black flaky debris, reporting That is definitely mold Resident #55 sitting in room with oxygen on, reports I thought that was mold, I have breathing issues and it worries me. I am on oxygen Husband visiting reports This filter is bad too. With her breathing this is worrisome. Nurse #50 reported, I will let maintenance know. -On 08/24/2026 at around 2:00 PM, this surveyor spoke with the maintenance director. He walked with this surveyor to the rooms concerned and observed the rooms with the filters having large amounts of dust and debris, and rooms [ROOM NUMBERS] with the large layers of dark green , black, wooly textured debris on the walls under the A/C units, verified the filters needed cleaned and the walls needed wiped down reporting, My assistant is supposed to clean all of the A/C units monthly, we have the task in TELS, verified the walls under the A/C units in room [ROOM NUMBER] and 209 having the dark green, black growth. Reporting That looks like mold and on the outside, I will have him get to this asap This surveyor requested any reports that show when the units had been cleaned. -On 08/24/2026 at around 3:30 PM. The Administrator reported, At this time, there is not any type of report to show when the units have been cleaned, he (maintenance supervisor) just marks complete in TELS. We are going to come up with a spread sheet for his assistant to use that breaks down what is expected to be done and he can then sign off -On 08/25/2026 at around 10:30 AM during follow up room observations to room [ROOM NUMBER] and 209. Observed the unit filter remains with large amount of dust and debris, and on the wall under the unit having the dark green, black growth and debris spread along the baseboard and up to unit. On floor near baseboard and on power cord moderate amount of build up dust and debris. Nurse #50 verified the area remains needing cleaned and the filters and wall need cleaned. -On08/25/2026 at around 1:30PM. The Administrator reported to the survey team, the air conditioner unit in room [ROOM NUMBER] is being replaced today and they (maintenance and house keeping ) are checking the other rooms for any signs of excess dust and debris and or mold. c) 100 hall A/C units observations: On 08/24/2026 1:25 PM A/C units observations in the 100 hall following rooms.room [ROOM NUMBER] broken and missing slats and filter screens shredded with buildup of debris. room [ROOM NUMBER] the filters with large amount of dust and debris. front cover hanging loose from the unit. room [ROOM NUMBER] broken and missing slats and the filters with large amount of dust and debris.room [ROOM NUMBER] the filters with large amount of dust and debris.room [ROOM NUMBER] right filter missing and the left filter with large amount of dust and debris. room [ROOM NUMBER] the filters with large amount of dust and debris room [ROOM NUMBER] right sided filter was missing left filter with large amount of dust and debris.room [ROOM NUMBER] had buildup of debris on the top screen 08/24/2026 2:45 PM In a walk through of above listed rooms with the maintenance director, he verified the rooms with the dust and debris on the filters and the shredded and broken screens, broken top slats, and the unit with the loose front encasement. He stated We have them listed to be cleaned monthly, we have the task in TELS> That outer case is loose and falling off, I will have him get to this asap as well as replacing the missing and broken screens. 08/24/2026 3:30 PM Administrator reported, At this time, there is not any type of report to show when the units have been cleaned, he (maintenance supervisor) just marks complete in TELS. We are going to come up with a spread sheet for his assistant to use that breaks down what is expected to be done and he can then sign off Resident Bathrooms 08/24/26 observation #1: During a facility walk through on 08/24/26 at 12:40PM, it was observed in resident bathrooms listed below : room [ROOM NUMBER] - cobwebs built up in the corners, dark brown smears on the right wall and back walls beside the toilet. room [ROOM NUMBER] - cob webs and dirty build up in the bathroom corners also build up of dust bunnies under and around the base of the bathroom door below the hinges room [ROOM NUMBER] - Cob webs and dirty build up in the corners, yellow build up around the base of the toilet room [ROOM NUMBER] - dirty buildup cobwebs corners of bathroom room [ROOM NUMBER] - cob webs and dirty buildup in the corners also dust bunny build up under bathroom door. room [ROOM NUMBER]- base of toilet unclean with a yellowish build up chap stick cap on the floor days 1 and 2 still there. -During these observations when asked CNA # 18, how often the resident rooms and bathrooms were cleaned he stated that resident rooms and bathrooms were to be cleaned daily. 08/25/26 observation #2 of facility walk through at 2:55PM found the same observations had not changed in each room listed above. On 08/25/26 at 3:15PM a facility walk through of the 100 hall was completed with the nurse manager. She verified the cob webs and dusty and dirty build up in the corners, yellow debris build up around the base of the toilets, and the plastic chap stick lid still in the corner, and stated the bathrooms are cleaned daily. She suggested to include the housekeeping director in a walk through. On 08/25/26 at 3:15PM, a walk through of the 100 hall was completed with the housekeeping director. He verified the above listed issues and stated he appreciated it being brought to his attention and he would make a list of these oversights for his crew to do better. In an interview with the facility administrator on 08/26/26 at 10:00AM, he acknowledged the above listed observations in the resident bathrooms and stated the housekeeping supervisor had recently taken the position and will be addressing these issues with the housekeeping staff.

Based on observations, policy review, World Health Organization(WHO) review, staff interview, the facility failed to ensue that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles to including appropriate accessory and cautionary instructions and the expiration date when applicable. This had the potential to affect more than an isolated number of residents. Facility census: 74. a) Findings include: On 08/24/26 at 12:20 PM, one vial of Tubersol/Tuberculin Purified Protein Derivative (PPD) injectable vial was observed in the medication refrigerator. No date was observed on the box or vial. The vial was half empty of liquid serum. Interview with Registered Nurse (RN) Unit Manager (UM) # 116 confirmed there was no date on the box or the vial of Tubersol/Tuberculin vaccine. A review of the facility policy titled Medication Monitoring effective 03/14/23 revealed This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. Policy Explanation and Compliance Guidelines: 4. Medications shall be labeled in accordance with current state and federal guidelines to facilitate consideration of precautions and safe administration of medications. According to the World Health Orgaization (WHO) An opened multidose vial of PPD (Purified Protein Derivative) is good for up to 30 days (30 days or 1 month) from the date it is opened, provided it is stored properly in a refrigerator.

Based on observations, policy reviews, and staff interviews the facility failed to ensure the kitchen equipment, preperation tables, and nourishment room were kept clean and free from possible cross contamination. This was found during the survey process and had the potential to affect more than a limited number of residents. Facility census: 74. Findings include: a) Standard practice reads in part. All dry goods will be stored appropriately in accordance with the FDA Food Code. All Time/Temperature Control for Safety foods, frozen and refrigerated, will be stored appropriately in accordance with guidelines of the FDA Food Code. Guidelines read in part: All foods will be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the policy for safe storage and handling of outside food. Information reads in part: For food receiving and Safe food storage: You must check in at the nurses' station when bringing food in for a resident. Any food that is not going to be consumed immediately must be covered and labeled with the resident's name and the date the food was brought into the facility and placed into the unit refrigerator. Labels and the location of the refrigerator are available at the nurses' station as well as in the pantry area. Any food stored in the refrigerator and not consumed within three (3) days will be discarded by facility staff daily. Any food without the correct labeling will also be discarded. Policy for nourishment storage. Guidelines read in part: Clinical staff will ensure all refrigerated units are free of debris and sanitary. Clinical staff will ensure all items in the refrigerator are labeled with the resident's name and dated appropriately. Review of an email sent to Dining Manager from corporate manager reads. The clinical staff and/or Housekeeping is in charge of the sanitation of the room, cabinets etc. On 08/24/2026 at around 11:30 AM the surveyor along with the Dining Department Manager (DDM), began an initial walk-through of the kitchen area. The Walk- in refrigerator and freezer had been locked out, tagged out due to ceiling failure. The kitchen was using six (6) refrigerators/freezers. The door to the kitchen was propped open. DDM verified it was propped open reported, They forget to ensure it is closed especially when it is hot. OvenObservation inside the oven revealed a large amount of greasy dried build-up debris, sticky to the touch. DDM verified the oven had a large amount of build up debris and needed cleaning. The oven doors had a large amount of dark brown greasy, thick build-up, making the glass not visible due to the dried brown sticky debris. DDM verified this needed cleaning. SteamerObservation of the steamer revealed moderate amounts of food debris on the top, sides, and bottom; dried, sticky residue on top and sides; and dried, sticky debris on the backsplash behind the steamer and stove. DDM verified this needed cleaning. Dry Storage RoomIn the dry storage room, the flour container, and lid, had a moderate amount of sticky and white food debris all over.The salt container, and lid, had a moderate amount of sticky and white food debris all over. The Dining Department Manager verified these containers needed cleaning. Observed a container with cereal inside that had no label. DDM verified this container of cereal needed a label. Observed a container of cereal labeled [NAME] Krispies; DDM reported, This is Cheerios, and it needed to be labeled correctly. It needed to be labeled correctly. On 08/24/26 at around 12:15 PM, observation in nourishment room revealed: Microwave Observation of the microwave revealed food debris on the plate, sides and ceiling; rust along the ceiling edges; and some areas flaking from the ceiling. Nurse #50 verified the microwave needed cleaned and there was rust flakes on the ceiling. Observation in the cabinet revealed a container labeled creamer with no open or use-by dates. Nurse #50 verified there was not a label or date on the container. A loaf of bread was open to the air in the cabinet with no open date. Nurse #50 verified there was not an open date or use by date and the bread was left open to air. Freezer Observed in the freezer was six (6) of eight (8) individual ice creams that had melted with pink, sticky debris underneath them, sticky to the touch.A package of peanut butter and jelly sandwich was open to the air with no open date or use-by date observed. Nurse #50 verified the ice cream had melted and the freezer needed cleaned. On 08/25/26 at around 9:30 AM, the DDM accompanied this surveyor for follow-up observations in the nourishment room. DDM accompanied this surveyor for follow up observations in the nourishment room. Observed the microwave: visible rust persisting on the ceiling and yellow dried debris along the walls; a faint burnt smell was noted. DDM verified this microwave needed to be replaced. Observed in the cabinet: a loaf of bread open with no dates, and food debris laying in the cabinet, the container of creamer still had no label or dates. DDM verified the loaf of bread needed an open date and use by date and the container of creamer needed a label with a date. Observed melted ice cream on the freezer shelf. DDM verified the freezer needed cleaning. Refrigerator Observation in the refrigerator revealed a container of pimento cheese with no label or date, and a bowl of some type of food with no label or date. The Dining Department Manager verified the pimento cheese did not have a resident's name, label or date, and the bowl with food did not have a resident's name, label or date, reporting to this surveyor, With cleaning we just clean the refrigerator, housekeeping is to clean the rest. I will let (the administrator's name) know about the microwave, it is not my responsibility. This surveyor requested a policy or any verification detailing who was responsible for what in the nourishment room. On 08/25/26 at around 10:55 AM, the DDM brought forms from her manager regarding responsibility for nourishment room clean up. The Administrator accompanied this surveyor to the nourishment room, observed the microwave, and reported: This definitely needs replaced, I will get this today. On 08/25/2026 at around 2:30 PM, the Administrator reported to this surveyor, The microwave in nourishment room has been replaced. Looking for any policy regarding responsible party for cleaning nourishment room.

Based on observation and staff and resident interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.with This failed practice was a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 74. a) Findings included: On 08/24/26 at 11:40 AM, during a shower room walkthrough with the Infection Preventionist, they verified and observed dark brown substance splatters on the left back corner wall, dirt on the floor around the drain in the long shower, a dark moldy looking substance around the Emergency pull cord on the wall in the far right shower, and a large clump of hair and lint on top of the center floor drain. The Infection Preventionist acknowledged the above listed issues in the shower room, stated staff should clean the shower room after each resident showered and said she would have the shower room cleaned immediately. In an interview with Resident #61 at 1:25 PM on 08/24/26 when asked if areas of the facility areas were kept clean, she stated the shower room could be cleaner because staff does not always clean up the shower room between residents, she stated she has seen dried BM on the walls when she was taken in for her shower. On 08/24/26 at approximately 12:35 PM during a facility walkthrough, it was observed in the 100 hall shared resident bathrooms that personal products without names or labels were left easily accessible causing cross-contamination. room [ROOM NUMBER] shared bathroom - ointment cream found in handrail of a shared bathroom with ointment spilled on the wall. room [ROOM NUMBER] shared bathroom - creams w/out labels or names easily accessible to (shared bathroom) residents room [ROOM NUMBER] shared bathroom - cream w/out labels or names easily accessible to other residents that share the bathroom During a facility walk thru with the Registered Nurse Manager 08/25/26 at approximately 12:40 PM in the 100 shared resident bathrooms she observed and verified the creams. sprays and lotions in the above listed bathrooms without name labels were easily accessible to residents using these bathrooms causing possible cross contamination. She removed the items from the shared bathroom and stated she would be checking all resident bathrooms across the facility to make sure all were corrected. a) Review of the policy for cleaning and disinfection of environmental Surfaces revealed the following: -Policy Statement reads in part Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities. -Process reads in part Housekeeping surfaces (example- floors, tabletops ) will be cleaned n a regular basis, when spills occur and when these surfaces are visibly soiled. Environmental surfaces will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Walls, blinds and window curtains will be cleaned when these surfaces are visibly contaminated or soiled. Review of deep cleaning check off list for room [ROOM NUMBER] revealed the date for the deep cleaning was initialed on 08/01/26 by Employee #91. The surveyor interviewed the Housekeeping Manager (HM) on 08/25/26 at around 11:00 AM. The surveyor questioned the manager about the frequency of deep cleaning and day-to-day cleaning. The housekeeping manager reported, Every day they clean the rooms, sweep and mop, and change trash can liners. Clean overbed tables, bathrooms. Deep cleaning is done per schedule. On 08/24/26 at around 12:30 PM in room [ROOM NUMBER], observation of floor tile revealed one (1) tile was missing one under the bed and three (3) were loose. Nurse #50 verified these tiles were missing and or loose, reporting I will put this in the Technology-Enabled Life Safety (TELS) for maintenance to repair. Also observed on the floor of room [ROOM NUMBER], were two (2) bags of linens and (1) bag of soiled briefs sitting open to air, and a trash can without liner. Nurse #50 verified the bags should have been closed and removed from room immediately. Observation of the floor in room [ROOM NUMBER] revealed an area near the bed had a moderate amount of sticky dried debris. Nurse #50 reported, I have told housekeeping already, it was spilled supplement from earlier. The nurse verified the spill remained. On 08/24/26 at around 3:30 PM in room [ROOM NUMBER], the floor near the bed continued to have a moderate amount of sticky dried debris, the trash can continued to not have a liner, the bed remained unmade, and the mattress had a moderate amount of dried sticky food and debris. Nurse #50 verified the area had not been cleaned, noting the bed remained unmade with a mattress showing a moderate amount of debris, and reported, I am not sure why they have not come back in to clean. On 08/25/2026 at around 10:00 AM during follow up observation in room [ROOM NUMBER] revealed the dried sticky debris on the floor near the bed remained and the mattress continued to have moderate amount of dried sticky debris and the bed remains unmade. The trash can still did not have a liner. This surveyor requested the Housekeeping Manager be brought in. The Housekeeping manager verified that room [ROOM NUMBER] was not cleaned and reported I will have someone get in there now. On 08/24/26 at around 3:30 PM in room [ROOM NUMBER], the floor near the bed continued to have a moderate amount of sticky dried debris, the trash can continued to not have a liner, the bed remained unmade, and the mattress had a moderate amount of dried sticky food and debris. Nurse #50 verified the area had not been cleaned, noting the bed remained unmade with a mattress showing a moderate amount of debris, and reported, I am not sure why they have not come back in to clean. On 08/25/2026 at around 10:00 AM during follow up observation in room [ROOM NUMBER] revealed the dried sticky debris on the floor near the bed remained and the mattress continued to have moderate amount of dried sticky debris and the bed remains unmade. The trash can still lacked a liner. This surveyor requested the Housekeeping Manager be brought in. The Housekeeping manager verified that room [ROOM NUMBER] was not cleaned and reported I will have someone get in there now. On 08/24/26 at around 12:30 PM in room [ROOM NUMBER], a trash can was observed without a liner and dirty towels in the trash can were observed. Nurse #50 verified they needed liners and reported, I will tell housekeeping.

Based on observation and staff interview the facility failed to ensure residents' right to privacy of sensitive health information. The health information for 2 of 2 residents was visible to passersby on the nurse's computer. Census: 74. Findings included: a) 08/24/26 at 1:18 PM the Medication Cart was parked at the entrance of the 400 Wing hall and between the nutrition room door. The laptop computer screen was open and unsecured with resident information visible in a shared resident and staff area. No nurse was visible at the medication cart. RN Unit Manager (RUN) #116 was called over to the cart and verified the laptop computer screen was open displaying multiple resident's information. 08/25/26 at 9:14 AM the medication cart was parked outside of room [ROOM NUMBER] on the 300 Wing. The laptop computer screen was noted to be open with resident Nurse # 59 was not visible at the cart. Nurse #59 was not visible at the cart. Nurse # 59 exited room [ROOM NUMBER] and approached the cart. The surveyor asked Nurse #59 if this was hermedication cart and Nurse #59 responded Yes. Nurse # 59 verified the computer screen was open and showing Resident #2's health information.

Based on record review and staff interview the facility failed to coordinate with the appropriate State-designated authority, to ensure that individuals with a mental disorder diagnosed after admission received care and services in the most integrated setting appropriate to their needs by failing to complete a Pre admission Screening and Record Reivew (PASARR) that included those new diagnoses. Resident identifier #7. Facility Census: 74.a) Resident #7 Resident #7 was admitted to the facility March 2019.A record review of the PASARR on 08/25/26 at 5:45 PM found the diagnosis of Subacute Drug induced dyskinesia dated 07/24/26 was not captured on the PASARR. Also an earlier diagnosis of Parkinson's disease with dyskinesia dated 10/24/25 was listed in the electronic chart, but the Tardive dyskinesia block was not marked yes on the PASARR.In an interview with the admissions director on 8/26/26 at 10:30AM, when asked if the Box marked Tardive Dyskinesia should have been marked, she stated she had checked with the MDS coordinator and they both verified the diagnosis of drug induced dyskinesia was not updated and captured on the PASARR and that the box for Tardive dyskinesia should have been checked as yes.

Based on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as possible. This failed practice was a random opportunity for discovery. Resident identifier: #5. Facility Census: 74. Findings included:a) Resident #5 During a 100 hall walk through with the nurse manager on 08/25/26 at approximately 12:40 PM, the surveyor and nurse manager both observed in Resident #5's bathroom a putty knife. The putty knife was left lying on the top shelf on the back wall above the toilet. The nurse manager stated she could only imagine it was left there during ongoing repairs. The nurse manager acknowledged he putty knife had sharp edges on the corners and could have caused injury to Resident #5 or anyone else who happened to find it.

Based on record review and staff interviews the facility failed to keep an accurate medical record in the area of blood pressure documentation for Resident #9. This was a random opportunity found during the survey process. Resident identifier: #9. Facility census: 74.Findings includea) Resident #9.Physician orders reads in part. Do not take blood pressure (B/P) in the left arm every day and on the night shift.A review of weights and vitals summary for Resident #9-Dates as marked with obtaining B/P in left arm:08/24/2026 at 08:51 AM08/23/2026 at 09:46 AM08/23/2026 at 6:53 AM08/22/2026 at 9:24 AM08/22/2026 at 5:14 AM08/18/2026 at 8:41 PM08/16/2026 at 5:59 AM08/11/2026 at 8:33 PM08/08/2026 at 10:32 AM08/02/2026 at 8:08 PM08/02/2026 at 5:11 AM07/31/26 at 9:43 PM07/29/26 at 12:30AM07/28/26 at 12:45 AM07/23/26 at 9:22 AM07/22/26 at 5:34 PM07/15/26 at 1:22PMOn 08/26/26 at around 9:10 AM, during Resident #9 Record review, the physician orders read in part. Do not take blood pressure in left arm. The surveyor observed in the vital signs record, Resident #9's blood pressure was marked as being taken on left arm on several dates.On 08/26/26 at around 9:30 AM, during an interview with Resident #9's caregiver, the caregiver reported, They always take the blood pressure in her right arm; the nurses know not to use her left one.On 08/26/26 at around 9:40 AM, during an interview with Nurse #59, she reported, I usually do not work this assignment, but I do know she has a restricted limb. The nurse then reviewed the medical record and reported, Yes, we do not monitor her blood pressure in her left arm. During an Interview with Nurse #59, reports I usually do not work this assignment but I do know she has a restricted limb, The nurse then reviewed the medical record and reported, Yes we do not monitor her blood pressure in her left arm.On 08/26/26 at around 9:50 AM, during an interview with the Director of Nursing (DON) regarding documentation of blood pressures the Director of Nursing verified this was incorrect documentation reporting, We found this also during audits, I may have education for this.On 08/26/26 at around 11:40 AM, The DON reported to this surveyor, I actually don't have any formal education; however, I did add the reminder to their daily schedule sheets.

Based on observation, staff interview, and resident interview the facility failed to ensure residents were treated with respect and dignity, by passing medications, and doing blood pressures in the dining room in a group setting and by not ensuring Resident Council Meeting was conducted with no interruptions. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 71. Findings include: a) Resident council meeting During the Resident Council Meeting on 06/04/25 between 2:30 PM and 3:00 PM, the following staff opened the closed door and entered with residents, or was looking for someone: Registered Nurse (RN) #31 Nursing Assistant (NA) #80 and NA #35 The Resident Council in its entirety said that staff come in all the time while they are doing activities to give them medicine, and check their blood pressure. Resident Council [NAME] President, Resident #19, stated, I don't understand why they can't take us out to do that. During an interview on 06/04/25 at 3:05 PM, confidential employee #1 stated, Yes, they come into activities and give out medications and have checked blood sugars. During an interview on 06/04/25 at 3:30 PM, confidential employee #2 stated, I am not sure what to do about it. Sometimes they are in activities all day so the nurses just come in there to give them their medications. I did forget to put the sign on the door for the Resident Council Meeting, but the door was shut. Confidential employee #1 and # 2 confirmed that medications were being passed in the dining room and that the Resident council meeting was disrupted.

Based on observation, staff interview and resident interview the facility failed to ensure resident grievance forms were easily accessible to residents. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 71. Findings include: During the Resident Council Meeting on 06/04/25 at 2:40 PM, Resident Council members as a whole said that they did not know where to find a form to file a grievance. An observation on 06/04/25 at 3:20 PM, of the front lobby area and the nurses station revealed no grievance forms were out and accessible to residents. During an interview on 06/04/25 at 3:25 PM, The Licensed Social Worker (LSW) stated, We keep them in a box behind the nurses station. The LSW confirmed, the grievance forms were not accessible to residents. .

Based on observation, staff interview, and equipment manual review the facility failed to keep the ice machine in safe operating condition. This has the ability to affect all Residents that get their nutrition from the kitchen, also residents that attend food related activities. Facility Census: 71. Findings Included: a) Ice Machines On 06/05/25 at 9:40 am the tour with the Maintenance Director found the ice machines located in the Kitchen area had a drain pipe running on the floor to a drain and the nutrition room on had no required air gap on the ice machine drains. The drain pipes were touching the drains. On 06/05/25 throughout the tour, the Maintenance Director confirmed the drain pipes / tubing should not be down in the drain or touching the drain. He states that he would get them fixed.

Based on observation and staff interview, the facility failed to maintain a sanitary environment related to a hole in the dining room counter top that would allow garbage into a storage cabinet. Facility census 71. Findings include: a) On 06/02/25 at approximately 12:00 p.m., this surveyor observed a hole in the counter top located in the back of the dining room. Observed in the counter top hole into the cabinet below what appeared to be a a used plastic utensil and opened salt and pepper paper packets located in the hole. b) Interview with the facility's Guest Services director on 06/02/25 at12:10 p.m. verified the finding. The finding was also acknowledged by the facility administrator on 06/02/25 at 12:15 p.m and upon exit on 06/05/25 at approximately 3:00 p.m.

Based upon record review and staff interview, the Facility failed to ensure the PASRR Preadmission Screening and Resident Review) was current and coordinated with the MDS. This was true for one (1) resident of five (5) reviewed during the annual survey process. Resident identifier: #2. Facility census: 71. Findings included: a) Resident #2 Resident #2 was admitted on [DATE]. Resident #2 had a diagnosis of major depressive disorder dated 03/30/16. The resident received medications for depression. There were physician orders for: Quetiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) (Seroquel) Give 1 tablet by mouth two times a day for Episodes of mania and depression r/t Bipolar Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) (Zoloft) Give 1 tablet by mouth two times a day for Depression Pharmacy Active 1/23/2 . The PASRR was completed by facility on 12/26/16. Major depression was not listed on the PASARR. The resident had the diagnosis prior to the PASARR being completed. This was reviewed with the DON on 06/05/25 at approximately 1:10 PM. She had nothing to add. On 06/05/25 at the exit conference, the facility administrator stated that the diagnosis of major depression occurred before the PASARR was completed, and he did not feel the PASARR needed to be updated especially since a Level II screening was not required.

Based on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to collaborate with Hospices services. This was true for one (1) of one (1) resident reviewed for hospice services. Resident identifier #30. Facility Census: 71. Findings Included: a) Resident #30 A medical record review revealed Resident #30 was receiving Hospice Services starting on 03/31/25. A continued record review of physician's orders showed an order: --Order Summary: Resident is on hospice care related to: End of life care due to advanced dementia. Review of Resident # 30's Hospice documentation showed it did not contain an active care plan or collaborating documentation from Hospice Services. During an interview with the Director of Nursing #30 on 06/05/25 at 1:13 PM, she verified that Resident #30 was receiving Hospice Services and had no current coordinated plan of care with the Hospice on her medical record with the provider responsible for performing each or any specific services/functions that have been agreed upon. She stated that she downloaded the documentation from the cloud today. She verified the care staff did not have access to the documentation.

Based on record review, staff interview and observation the facility failed to ensure the environment in which it had control of, was free from accidents and hazards. This failed practice was a random opportunity for discovery and had the potential to effect more than a limited number of residents. Resident identifier #40. Facility census 71. Findings include: a) Resident #40's room An observation on 06/03/25 at 11:25 AM, revealed a gallon jug of Ecolab Lime-A-way underneath Resident #40's sink. The sink did not have an enclosure. During an observation with the Administrator on 06/03/25 at 11:35 AM, The Administration confirmed that the jug of Ecolab Lime-A-way was under the sink and should not be there. The Administrator then stated, I can only assume that the sink was stopped up and they accidently left it in here. I will have maintenance do a house wide sweep to make sure there is nothing else. b) Resident #40 A record review on 06/03/25 at 12:30 PM, revealed that Resident #40 has a diagnosis of Alzheimer's. Further record review revealed a care plan focus that reads as follows: ( Resident #40 named) is at risk for falls: generalized weakness, lack of safety awareness, psychotropic medication use. c) Safety Data Sheet for Lime-A-way A review of the Safety Data Sheet (SDS) on 06/03/25 at 2:00 PM, for the Lime-A-way reads under section 2 Hazards identification as follows: Causes severe skin burns and eye damage. Section 4 First aid measures reads as follows: In case of eye contact, rinse immediately with plenty of water, also under eyelids, for at least 15 minutes. Get medical attention immediately. In case of skin contact, wash off immediately with plenty of water for at least 15 minutes. Use a mild soap if available. Wash clothing before reuse. Thoroughly clean shoes before reuse. Get medical attention immediately. If swallowed, contact the Poison's Information Center. Rinse mouth with water. Do not induce vomiting. Never give anything by mouth to an unconscious person. Seek medical attention immediately. If inhaled, remove to fresh air. Treat symptomatically. Get medical attention.

Based on Observation, resident interview and staff interviews, the facility failed to honor residents drink preferences. This has the potential to affect a more than a limited number of residents. Resident Identifiers #32 and #40. Facility census: 71. Findings included: a) Resident preferences During an observation and interview of dining services on 06/02/25 at 12:45 pm Resident #32 had consumed his coffee and asked this Surveyor if he could have another cup. During an interview with the Activities Assistant (AA) 06/02/25 at 11:46 AM he stated that he was out of coffee and Resident #32 would have to wait until the coffee cart came out in about 15 minutes or so. Continued observation found Resident #32 table mate trying to pour her coffee in his cup. Subsequent observation at 12:05 PM of Resident #40 ask (AA) if he could have a second cup of coffee. AA stated he would have to wait until the drink cart came out. An observation at 12:25 PM found that Residents #32 and #40 had still not received a second cup of coffee. At this time, I ask the Dietary Manager if the residents could have coffee. An observation on 06/03/25 at 11:52 AM found residents in the dining area with empty cups. An interview on 06/04/25 at 12:15 PM the Activities Director stated there is no reason the residents could not have a cup of coffee or other drinks at any time, she stated that they just have to let the kitchen staff know and they would get it.

Based on record review and staff interview the facility failed to ensure it had a complete and accurate medical record. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifiers #48, and #61. Facility census 71. Findings Include: a) Resident #48 A record review on 06/05/25 at 11:55 AM, of Resident #48's orders, revealed an order for Trazodone oral tablet 50 Milligrams (MG) to give (1) one tablet by mouth one time a day for Depression. Further record review of Resident #48's active diagnosis, revealed that Depression was not listed as a diagnosis. During an interview on 06/05/25 at 1:11 PM, Registered Nurse Unit Manager, (UM) stated, It's on the order, but I could not find it in the diagnosis. She confirmed that the diagnosis of Depression was not there as indicated for the Trazodone medication. B) Resident #61 A review of Resident #61's medical record found a physician order for a dysphagia advanced diet. There was a Speech and Language Pathologist evaluation completed on the resident on 04/01/25. This evaluation provided the following diagnoses: Displaced intertrochantric fracture of right femur, subsequent encounter for closed fracture with routine healing Vascular dementia, severe, without behavioral disturbance, mood disturbance, and anxiety Gastro-esophageal reflux disease without esophagitis Cognitive communication deficient Dysphagia, oral phase. A review of the list of active diagnosis contained in Resident #61's medical record found it was void of the Dysphagia diagnosis. On 06/05/25 at approximately 1:12 PM, this was reviewed with the DON. She acknowledged this omission.

Based on observation, resident interview, and staff interviews, the facility failed to post menu timely and adequately. This has the potential to affect a limited number of residents. Facility census: 71. Findings included: a) Menu Posting During an observation of the dining process on 06/02/25 at 11:35 AM, found the posted menu fried chicken, green beans, and potato wedges. During an interview with Resident #51 on 06/02/25 at 11:38 AM she stated, they never get what is on the menu. An observation of Activities assistant going around the dining room with a copy of the posted menu informing the residents in the dining room they were having fried chicken, green beans, and potato wedges. An observation at 06/02/25 at 12:35 PM of the meal served was chicken, potato wedges and okra. During an interview on 06/02/25 at about 12:50 PM the Dietary Manager stated that she never noticed the mistake on the posted menu. When asked how she notifies residents of changes to the menu, she stated that she tells the staff that ask. During an observation on 06/03/25 at about 8:40 AM found no breakfast menus posted. An observation found most residents had completed their meal and had left or were leaving the dining area. During an interview on 06/03/25 at about 8:45 AM the Administrator verified the menus should be posted prior to the meal service.

Based on record review and staff interview the facility failed ensure each resident maintains acceptable perimeters of nutrition. They specifically failed to timely assess and/or address a significant weight loss and the resident continued to lose weight. This failure resulted in actual harm for Resident #14. This was true for 1 (one) of 2 (two) residents reviewed for the care area of nutrition during the the Long Term Care Survey Process. Resident identifier: Resident #14. Facility census: 63. Findings include: a) Resident #14 On 07/24/24 at 10:09 AM, a review of Resident #14's medical record was conducted which revealed the following periods of time when the resident suffered a severe weight loss: -- On 03/05/24 Resident #14 weighed 201.2 pounds and one (1) month later the resident weighed 187.2 on 04/03/24. This is a loss of 6.95 percent, which is considered a severe weight loss in one (1) month. -- On 01/06/24 Resident #14 weighed 205.6 pounds and six (6) months later on 07/03/24 the resident weighed 182.6 pound which was a 12.95 percent, which is considered a severe weight loss in a six month period. -- On 07/09/24 the resident weighed 178.2 pounds. -- On 07/16/24 the resident weighed 177.8 pounds. A further review of the record found the following pertinent information: * Care Plan Note documented on 07/12/24 at 11:30 AM which stated, Nursing will refer resident to Speech Therapy (ST) for poor appetite and weight loss. (This was noted three (3) months after the first severe weight loss in a month.) Further review of the record found this referral was never completed. * Diet order noted for Regular/Liberalized diet Dysphagia Advanced texture, thin consistency, may crush crushable medications/double portions for Gluten Free. noted to be initiated 03/18/24. (This diet was ordered prior to the first severe weight loss occurred.) * Certified Nurse Aide (CNA) documentation of meal intakes which revealed 7 (seven) occurrences of Resident #14 consuming 0-25% of meals (since 06/25/24) . In addition, CNA documentation revealed for the last 30 days (since 06/25/24) Resident #14 had received assistance documented as: Supervision- Oversight, encouragement or cueing for 15 of 90 meals provided, the other 75 meals were documented as Independent-No help or staff oversight at any time. Furthermore, no documentation was noted related to Resident #14 receiving or consuming an evening snack. * Activities of Daily Living care plan revealed Resident #14 requires extensive assistance and cueing for eating, which had an initiated date of 11/04/22 and a revision date of 11/17/22. (This intervention was not consistently carried out by nursing staff.) * The medical record was void of any documentation to indicate a dietary supplement was ordered for Resident #14 to prevent future weight loss. * The medical record was void of any documentation saying the physician had been notified of the residents severe weight loss. On 07/24/24 at 11:45 AM, an interview conducted with the Director of Nursing (DON), Minimum data set coordinator (MDS-C) and Registered Nurse (RN) consultant. During this interview the DON acknowledged the following: 1. The speech therapy referral was not made as documented. 2. Resident #14's physician and/or Nurse Practitioner (NP) was not notified of Resident #14's 6.95 percent weight loss in one (1) month and was not notified of the 12.95 percent of weight loss in six (6) months. 3. No supplements were ordered or provided, the DON does not know why. 4. After reviewing the Certified Nurse Aide (CNA) documentation of meal intakes, there were 7 (seven) occurrences of Resident #14 consuming 0-25% of meals (since 06/25/24) . 5. Resident #14's care plan states resident requires extensive assist with cueing and eating, after reviewing the CNA documentation last 30 days (since 06/25/24) that Resident #14 had received assistance documented as Supervision- Oversight, encouragement or cueing for 15 of 90 meals provided, the other 75 meals were documented as Independent-No help or staff oversight at any time. The DON acknowledged Resident #14 did not receive the assistance required for eating. 6. No labs had been obtained to potentially assess Resident #14's nutritional health. 7. That Resident #14 had no documentation a evening snack provided or consumed. On 7/24/24 at approximately 2:30 PM, a review of Policy and Procedure titled, Weight Monitoring revealed that the physician should be informed of a significant change in weight. On 07/24/24 at approximately 3:00 PM, a review of Policy and Procedure titled, Nutritional Management revealed that care and services shall be provided to ensure that each resident maintains acceptable parameters of nutritional status which includes that resident's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. In addition, this policy and procedure states that a systemic approach is used to optimize each resident's nutritional status: 1. Identifying and assessing each resident's nutritional status and risk factors. 2. Evaluating/analyzing the assessment information. 3. Developing and consistently implementing pertinent approaches. 4. Monitoring the effectiveness of interventions and revising them as necessary. Furthermore, the policy and procedure titled, Nutritional Management states the physician will be notified of significant changes in weight, intake, or nutritional status and lack of improvement towards goals. On 07/24/24 at 3:38 PM, during an additional interview with the Director of Nursing, the DON acknowledged that per facility policy and procedure Resident #14's physician should have been notified of the weight loss and was not. On 07/24/24 at approximately 4:00 PM, an interview was conducted with the facility Registered Dietician (RD), during this interview, the RD stated, she had identified Resident #14's weight loss in April of 2024. The RD stated she hadn't intervened until June 2024 by adding double portions to Resident #14's diet order because Resident #14's Body Mass Index (BMI) indicated Resident #14 was overweight. However, the RD acknowledged Resident #14 had the 12.95% weight loss over the last 6 (six) months. This Surveyor then asked the RD if she communicated with the physician and/or NP, with the RD responding that she was able to communicate with the physician and/or NP however that she did not, stating that the nursing department usually handled communicating with the physician and/or NP. This Surveyor then asked the RD, without the physician and/or NP being notified of Resident #14's significant weight loss and assessing Resident #14, how did the RD know that an underlying condition was not the cause of Resident #14's significant weight loss. The RD did not respond to this question, however, the RD stated that due to the most recently obtained weight for Resident #14, she would be initiating a supplement for Resident #14.

Based on facility record review and staff interview, the facility failed to ensure the facility assessment was modified to make it facility centered to identify the staff competencies required to provide the level and types of care needed for the resident population. This was a random opportunity for discovery during the long term care survey process and had the ability to affect more than a limited number of residents. Identifier: Facility Assessment Tool. Census: 63. Findings included: a) Facility Assessment Tool On 07/24/24 at 10:55 AM during a review of the nursing competency requirements in the facility assessment it is identified that the facility assessment document provided is titled a Facility Assessment Tool. This document update was dated 12/28/23. The Requirement noted for this tool is (typed as written) Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. It further stated that the requirement for the facility assessment may be found in Attachment 1 and denotes the following (typed as written); Attachment 1 *Medicare and Medicaid programs; reform of requirements for long term care facilities. (ii) the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) the staff competencies that are necessary to provide the level and types of care needed for the resident population. In review of the Overview of the Assessment Tool on page 1 it identifies that this as an outlined tool that serves as an optional template provided for nursing facilities and it further states if used, it may be modified. It is further identified that the template has been modified or updated in areas such as the Example 3: Assistance with Activities of Daily Living on Page 6, Example 1. Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each residents needs on page 9, Example 2. Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time. Consider if and how the degree of fluctuation in the census and acuity levels impact staffing needs on page 9 and 10. Other areas of the assessment not identified to be updated was page 10 and 11 of the Facility Assessment tool for the Staff training/educations and competencies states. During an interview with the Administrator on 07/24/25 at 11:30 AM the Facility Assessment Tool was reviewed and the Administrator acknowledged that the staff training/educations and competencies section had not been revised to be center specific for this facility.

Based on observation, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the physician orders. The facility failed to ensure care was delivered for residents who are at high risk of aspiration. Medications were left at the bedside table for the resident to self-administer. This was done without a physician order [REDACTED]. The failed practice affected two (2) of twenty-one (21) residents. Resident identifiers: #3 and #413. Facility census: 71. Two immediate jeopardies were called for this deficient practice. 1. Immediate Jeopardy #1 A nurse failed to remain in Resident #413's room during the administration of medications. This resident had a history of [REDACTED]. Consultation with the State Agency, on 12/03/19 at 1:15 PM, revealed that a determination of Immediate Jeopardy was identified. The Immediate Jeopardy was called with the facility's Administrator at that time. An acceptable Plan of Correction (P[NAME]) was approved and the immediacy of this deficient practice was abated on 12/03/19 at 3:35 PM. The P[NAME] included the following interventions: -The Nurse Practioner evaluated Resident #413 at 2:45 PM to ensure respiratory status remained baseline there was no evidence of aspiration and no correction required. -The Licensed Practical Nurse (LPN) #11 was re-educated regarding not leaving medications at the bedsides as per policy by the unit manager immediately upon discovery at 10:00 AM. -All residents of the facility had the potential to be affected. Director of Nursing (DON) and Unit Managers conducted rounds of all residents' rooms on 12/03/19 at 1:45 PM and no additional medication was left at the bedsides. - All licensed and certified nursing staff and dietary staff including agency on duty will be re-educated starting on 12/03/19 at 2:00 PM by the Practice Development Specialist with a posttest to validate understanding regarding ensuring the resident environment remains free of accident hazards. -Starting 12/03/19 the DON/designees will conduct observation rounds to include meal tray and room observations daily, across all shifts two (2) times including weekends, then three (3) times weekly for two (2) weeks then randomly thereafter to ensure licensed nurse does not leave medications at the bedsides. -Results of the observations will be reported to the DON/designee monthly to the Quality improvement Committee for additional follow up and an or in-servicing until the issue is resolved. Consultation with the State Agency, , revealed that a determination of Immediate Jeopardy was identified. The Immediate Jeopardy was called with the facility's Administrator at that time. An acceptable Plan of Correction (P[NAME]) was approved and the immediacy of this deficient practice was abated . The P[NAME] included the following interventions: An acceptable Plan of Correction (P[NAME]) was approved on 12/03/19 at 1:15 PM and the immediacy of this deficient practice was abated on 12/03/19 at 3:30 PM. The survey team began monitoring the implementation of the abatement P[NAME] at 1:15 PM. The scope and severity of the deficient practice was reduced to a [NAME] upon the acceptance of the abatement plan of correction. 2. Immediate Jeopardy #2 Consultation with the State Agency, on 12/03/19 at 3:45 PM, revealed a determination of Immediate Jeopardy was identified for this practice affecting Resident #3 and #413. The Immediate Jeopardy was called with the facility's Administrator at that time. The Abatement P[NAME] included the following interventions: --The nurse Practioner evaluated resident #3 at 4:30 PM and Resident #413 at 2:45 PM to ensure respiratory status remained baseline there was no evidence of aspiration and no correction required. --The Director of Nursing (DON) and all Unit Managers conducted rounds of all residents' rooms 12/03/19 at 3:45 PM to ensure residents who has no straw orders were without straws at bedside without any corrective action immediately upon discover. --All licensed and certified nursing staff and dietary staff including agency on duty will be re-educated starting on 12/03/19 at 4:00 PM by the Practice Development Specialist with a post test to validate understanding regarding the facility must ensure the resident receives treatment and care in accordance with professional standards of practice. --Starting 12/03/19 the DON/designees will conduct observation rounds to include meal tray and room observations daily, across all shifts two (2) times including weekends, then three (3) times weekly for two (2) weeks then randomly thereafter. --Results of the observations will be reported to the DON/designee monthly to the Quality improvement Committee for additional follow up and an or in-servicing until the issue is resolved. An acceptable Plan of Correction (P[NAME]) was approved at 4:15 PM on 12/03/19 and the immediacy of this deficient practice was abated on 12/03/19 at 5:20 PM. The survey team began monitoring the implementation of the abatement P[NAME] at 4:15 PM. The scope and severity of the deficient practice was reduced to a [NAME] upon the acceptance of the abatement plan of correction. Findings included: a) Resident #413 - Immediate Jeopardy #1 A policy review titled, NSG305 Medication: Administration: General with revision date 11/01/19, was reviewed on 12/04/19. The policy stated, Remain with patient until administration is complete. Do not leave medications at the patient's bedside. An interview with the Resident, on 12/02/19 at 11:00 AM, revealed the nurses leave medications at the bedside table for self-administration on most days. An observation at the time of the interview, on 12/02/19 at 11:00 AM, revealed an empty plastic medication cup on bedside table in front of the Resident. An interview with Speech Therapist (ST) #70, on 12/03/19 at 8:40 AM, revealed a modified [MEDICATION NAME] swallow test had been completed on the Resident on 10/24/19. The test was completed because of the resident's history of aspiration and swallowing issues. The ST stated the test showed decreased laryngeal elevation and incomplete laryngeal vestibular closure. The Resident is a 2 on the Aspiration Scale meaning thin liquids do enter the airway. A record review, on 12/03/19, at 9:00 AM, revealed no self-administration of medications on the Physician Orders, Kardex, or Care Plan. Further observation, on 12/03/19 at 9:20 AM, revealed Resident #413 was self-administering his own medications. The nurse was not in the room at the time of the observation. An interview with the Resident at the time of the observation, on 12/03/19 at 9:20 AM, revealed the nurse left my medications for me to take. Continued observation, on 12/03/19 at 9:21 AM, revealed Licensed Practical Nurse (LPN) #11 walked into the Resident's room. LPN #11 was interviewed and asked if the Resident self-administered his own medication. The LPN replied, Yes, I check back periodically to make sure he took them all. An Interview with Director of Nursing (DoN), on 12/03/19 at 10:55 AM, confirmed Resident #413 does not have a physician order [REDACTED]. An interview with LPN #11, on 12/03/19 at 11:10 AM, confirmed the list of medications that were given to the Resident at 9:00 AM. LPN #11 confirmed the following medications were self- administered. -Aspirin 81 mg -Duloxetine [MEDICATION NAME] Capsule delayed release 60 milligrams (mg) -[MEDICATION NAME] 5 mg [MEDICAL CONDITION] Do not handle med if pregnant or may become pregnant - [MEDICATION NAME] 25 mg give 0.5 tablet 2 X [MEDICAL CONDITION] to 125 mg - Tylenol 500 mg - Vitamin D3 400 units - [MEDICATION NAME] 25-100 mg II b) Resident #3 - Immediate #2 A record review, on 12/03/19 at 2:20 PM, revealed a [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Care Plan stated, Provide diet as ordered/tolerated- Regular/liberalized Dysphasia advance. 2 handle sip cup w/ lid, no straws. The care plan, with revision date of 07/17/19, stated, Resident has impaired decline in cognitive function or impairment thought processes with a global deterioration score of four (4) related to cognitive loss/dementia. Resident #3 lacks capacity. A Nutritional Assessment, completed on 12/03/19, stated, Diet order: dysphasia advance Intakes excellent x lookback- 100% Food snacks BID b/t meals House supplement ordered TID- consuming 75-100% per [DATE] handle sip cup w/ lid, no straws Fluids encouraged per staff . An observation of the Resident's room, on 12/03/19 at 2:35 PM, revealed an 18-ounce water bottle with a straw that sat on the bedside table over the Resident's bed. The water bottle had 10 ounces of water in it. A four (4) ounce Vanilla Shake Supplement with Resident's name label on the carton was also on the bedside table. The Vanilla Shake Supplement was open with a straw in the carton. The Vanilla Shake Supplement was observed to be half empty. Both containers of fluid were easily accessible to Resident #3. A two handled sip cup was not observed to be available in the room at the time of the observation. An interview and observation with the Administrator, on 12/03/19 at 2:55 PM, in the Resident's room, confirmed there were straws in the Resident's water bottle and supplement on the Resident's bedside table. The Administrator immediately removed the water bottle and the half empty Vanilla Shake Supplement carton with straw from the resident's room. The Administrator stated the straws should not have been available for the Resident. The Administrator stated the Nurses Aides pass the water and supplements out to residents and would have provided the straws. c) Resident #413 - Immediate Jeopardy #2 An interview with the Resident, on 12/02/19 at 11:00 AM, revealed I am not supposed to have straws the speech therapist said don't drink out of straws because of trouble swallowing and aspiration. The Resident stated, the staff continues to bring me straws after I have voiced many concerns to them about not being allowed to have them. An observation of the Resident's Room, on 12/02/19 at 11 AM, revealed two (2) straws on the bedside table. One (1) straw was lying on the bedside table and the other straw was in the provided water bottle. The Resident demonstrated what happened when he drank from a straw which resulted in a coughing episode. Another interview with the Resident, on 12/03/19 at 8:20 AM, revealed the Resident was provided a straw for fluid intake. The Resident stated, I was given a straw again. Further observation of the Resident's Room, on 12/03/19 at 8:20 AM, revealed a straw in the Resident's water pitcher. A dietary tray slip with the Resident's name on it was on the bedside table. The dietary slip was immediately reviewed and stated, NO STRAWS. An interview with Speech Therapist (ST) #70, on 12/03/19 at 8:40 AM, revealed a modified [MEDICATION NAME] swallow test had been completed on the Resident on 10/24/19. The test was completed because of the resident's history of aspiration and swallowing issues. The ST stated the test showed decreased laryngeal elevation and incomplete laryngeal vestibular closure. The Resident is a 2 on the Aspiration Scale meaning thin liquids do enter the airway. The speech therapist confirmed a physician's orders [REDACTED]. A medical record review, on 12/03/19 at 9:05 AM, revealed the Resident's Kardex and Care Plan did not include the order for no straw use which was dated for 10/28/19. The Resident was admitted to the facility on [DATE] with assessments completed upon admission. Resident #413 scored a 13 on the Brief Interview for Mental Status (BIMS) Assessment demonstrating little to no cognitive impairment. The Resident also had a [DIAGNOSES REDACTED]. An interview with Registered Nurse (RN) #18, on 12/03/19 at 9:16 AM, revealed the Kardex is the main communication tool concerning patient care for all Nurse Aides. An interview with the Dietary Manager (DM), on 12/03/19 at 9:18 AM, revealed a diet order was provided to her in (MONTH) of 2019 for the Resident not to have straws. The DM then stated the order was communicated daily and with each meal on a Diet Tray Ticket which included the words NO STRAWS. An interview with Nurse Aide (NA) #105, on 12/03/19 at 9:24 AM, revealed she was the aide caring for the Resident. When asked about the Resident's straw restriction the NA stated, I have no idea if he is allowed to have straws or not. The NA further stated, I will have to check with the nurse. An interview with Licensed Practical Nurse (LPN) #11, on 12/03/19 at 9:25 AM, revealed Resident #413 does have a physician's orders [REDACTED]. The LPN stated he should not have straws, but it is no big deal if he does. She then further stated he is a grown man and can make his own decisions. The LPN stated the straw restriction was not on the current care plan would expect to see the straw restriction included. Interview with Director of Nursing (DON), on 12/03/19 at 10:55 AM, stated he was unaware of the Resident's physician order [REDACTED]. The facility failed to ensure care was delivered for residents who are at high risk of aspiration. Straws were being provided to residents who were ordered not to use them due to their risk of aspiration. The risk of aspiration pose an immediate risk to the health and life of the residents. In addition, a resident was identified as self-administering medications without monitoring/oversigtn, an assessment or physician order. This resident was identified through assessment and diagnostic testing as an aspiration risk. The lack of monitoring/oversight, assessment or a physician order [REDACTED].

Based on record review and staff interview, the facility failed to follow the recommended physician's order/recommended care of the [MEDICAL CONDITION] from the transferring facility to ensure Resident #73 received the necessary [MEDICAL CONDITION] care and respiratory services related to her [MEDICAL CONDITION] (TBI). The lack of necessary [MEDICAL CONDITION] care and respiratory services caused actual harm requiring an unplanned hospitalization . This was true for one (1) of one (1) resident reviewed for [MEDICAL CONDITION]. Resident identifier: #73. Facility census: 72. Findings include: a) Resident #73 Review of Resident #73's medical records on [DATE] at 1:00 p.m., found the resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS), completed on the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE], score was 15, indicating the resident was cognitively intact. Review of the transferring facility's discharge orders/recommendations found the following [MEDICAL CONDITION] and respiratory orders/recommendations: -- Keep patient on room air (RA) during the day as tolerated to keep oxygen (O2) at 90 percent (%) or above and humidified 35% fraction of inspired oxygen (FIO2) via [MEDICAL CONDITION] (trach) collar overnight. -- Continue to obtain oxygen saturation (O2 sat) to maintain oxygen level at 90% or above. -- Suction when necessary (PRN). --[MEDICAL CONDITION] twice a day and PRN -- [MEDICAL CONDITION] for signs/symptoms of infection every shift -- [MEDICAL CONDITION] twice daily and PRN -- [MEDICAL CONDITION] using sterile technique -- [MEDICAL CONDITION] weekly on day shift Resident #73's admission physician orders dated [DATE], had orders for oxygen use and/or O2 saturation monitoring. On [DATE], Resident #73 was examined and an admission history and physical (H&P) was completed by the attending physician and new orders given to consult with a respiratory therapist (RT) for evaluation and treatment of [REDACTED]. The RT consult, dated [DATE] at 1:29 p.m., included new orders for FIO2 at 35% [MEDICAL CONDITION] at all times. Review of the Treatment Administration Record (TAR) for [DATE], found no evidence [MEDICAL CONDITION] including the inner cannula was performed on [DATE], [DATE], [DATE], or [DATE] on the ,[DATE] shift. The facility's [MEDICAL CONDITION] care policy/procedure included: -- Perform [MEDICAL CONDITION] (trach) care at least twice a day and PRN as ordered. -- Evaluate patients heart rate, respiratory rate, breath sounds, and cough effort. Evaluate sputum amount, color, and consistency prior [MEDICAL CONDITION] and after the procedure. --Document the date and time of procedure, observation at stoma site, heart rate, respiratory rate, breath sounds, and cough effort pre and post procedure and patient's response to procedure. There was no evidence in the resident ' s medical record to indicate staff implemented the facility ' s policy and procedure [MEDICAL CONDITION]. Additional review of Resident #73's nursing progress notes found an entry by Registered Nurse (RN) #53 on [DATE] at 4:25 p.m. The nurse documented (typed as written), Heard loud sounds coming from resident's room as if objects were being thrown, entered room to see objects flying off of the bed onto the floor, resident had the head of her bed up around 30 degrees and was leaned back on bed. Face and hands blue, had jerking motions of her head to the left side and was struggling to breathe/ her mouth was open with clear/foamy sputum coming out. checked for carotid pulse/positive/jugular distention to the right side. Yelled out for help from staff who came to assist me. Another progress note by Licensed Practical Nurse (LPN) #11, on [DATE] at 4:44 p.m., noted (typed as written), Resident became unresponsive at about 4:20 p.m., crash cart accessed, O2 sat, 911 called, family notified (husband) resident became responsive at about 4:40 p.m., sent to (Name of Hospital) for further assessment. Another progress note entered by LPN #11 on [DATE] at 4:35 p.m., stated (Resident #73 name) transferred to hospital-unplanned for evaluation and treatment . Resident became unresponsive and shallow breathing.[MEDICAL CONDITION] repeatedly. Vitals ,[DATE]- blood pressure, heart rate (HR) 110 and O2 sats 95%. Became responsive. Emergency Medical Squad (EMS) arrived at 4:30 p.m. and transferred to the hospital. Review of the EMS report found on [DATE] at 4:51 p.m., the EMS arrived on the scene due to a report of an unconscious, apneic (not breathing) and pulseless female and resident was assessed and transported to local hospital and arriving at the hospital at 5:03 p.m. On [DATE] at 6:00 p.m., review of Resident #73's emergency room (ER) reports found, .She was unable to breath and blacked out and apparently they may or may not have done cardiopulmonary resuscitation (CPR) but she did not have any chest tenderness. She was sent here after they bagged her for a while or did something else to get the air back in her, it is unclear in their report verbal or otherwise and here, it was noted she was getting increasingly dyspneic (difficulty breathing) and pulling a lot of negative inspiratory pressure. We took out the cannulated portion of [MEDICAL CONDITION] part that is removable and found a large obstructing mucus plug and cleaned that out, put it back in and she did a lot better The resident ' s respiratory distress and resulting emergency transfer to the hospital constituted actual harm. During an interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m., when asked if the resident had received [MEDICAL CONDITION] and oxygen as recommended by the transferring facility, he said, It doesn't appear she did. He was unable to provide any further details concerning [MEDICAL CONDITION] and respiratory services provided Resident #73's during her stay at the facility ([DATE] through [DATE]).

Based on record review and staff interview the facility failed to ensure Resident #23, who was admitted to the facility without pressure ulcers, did not develop avoidable pressure ulcers after admission to the facility. The resident was identified at risk for developing pressure ulcers; however, the the facility failed to implement interventions to prevent pressure ulcers. This failure resulted in harm to the resident, as she developed four (4) avoidable deep tissue injury pressure ulcers after readmission to the facility. Resident Identifier: #23. Facility Census: 71. Findings Include: a) Resident #23 A review of Resident #23's medical record at 9:27 a.m. on 06/24/15, found this [AGE] year old female was readmitted from the hospital on [DATE]. Her original admitted to the facility was 10/23/14. The nursing readmission assessment, dated 06/05/15 at 12:50 a.m., indicated the resident had no skin impairments present upon her readmission to the facility on [DATE]. By 06/09/15, the resident had developed in-house acquired pressure ulcers. A review of Resident #23's care plan found a focus statement initiated on 10/24/14, with a target date of 09/17/15: Resident is at risk for additional skin breakdown as evidenced by fragile skin and limited mobility. With a goal of, The resident will show no signs of skin breakdown through the next review. The care plan contained the following interventions, 1. Assist resident in repositioning and turning as needed. 2. Encourage resident to consume all fluids during meals. 3. Evaluate for skin risk factors per protocol. 4. Float Heels While in bed. 5. Monitor skin for signs and symptoms of skin breakdown, i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. 6. Observe skin condition with ADL (activities of daily living) care daily and report abnormalities. 7. Pressure redistribution surfaces to bed per protocol. 8. Pressure redistribution surfaces to chair per protocol. 9. Utilize positioning devices as appropriate to prevent pressure over bony prominence. 10. Weekly skin assessment by license nurse. Further review of Resident #23's medical record found a nurse progress note, dated 06/09/15 at 3:26 p.m. which read, Resident found to have three (3) small DTIs (Deep Tissue Injuries) and one moderately sized DT on coccyx and hips. It is believe (sic) that these wounds were present when resident returned from hospitalization . Additionally, on 06/09/15, Nurse Practitioner #99 saw Resident #23 and noted the four (4) DTIs, described as: Coccyx:DTI/Unstageable: 1.8 X 1.8 CM; intact dark purple skin; does no blanch;no open areas or drainage. L(Left) Upper Hip: DTI/Unstageable: 1 X 1 CM; intact dark purple skin; does not blanch; no open areas or drainage. R (Right) Hip: DTI/Unstageable: .8 X .8 CM; intact dark purple skin; does not blanch; no open areas or drainage. L (left) lower hip: DTI/Unstageable: 1X1 CM; intact dark purple skin; does not blanch; no open areas or drainage. Review of the Skin integrity sheets found Resident #23 had four (4) wounds discovered on 06/09/15. The wound care nurse described each of the wounds: -- DTI to Coccyx measuring 1.8 X 1.8 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. -- DTI to Left upper hip measuring 1 X 1 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. -- DTI to Right Hip measuring .8 X .8 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. -- DTI to left lower hip measuring 1 X 1 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. An interview with Corporate Resource Nurse (CRN) Registered Nurse (RN) #98, at 1:34 p.m. on 06/24/15, revealed the facility protocol for identifying residents at risk for developing pressure ulcers was to look at the whole picture for each resident. She stated it included completing a Braden Scale for Predicting Pressure Sore Risk, looking at the the resident's nutritional status and bed mobility, and performing a weekly skin check to help identify problem areas which may need more attention. Review of Resident #23's medical record found a Braden scale completed on readmission to the facility on [DATE]. It identified Resident #23's nutrition as probably inadequate - eats only about half of any food offered. Review of the resident's meal consumption percentages for May 2015, as calculated by the facility, found Resident #23 ate 25% or less of the meals provided 72% of the time, or 67 of the 93 meals provided. According to the records, this indicated Resident #23's nutrition was very poor- never eats a complete complete meal, rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was a moderate risk for developing pressure ulcers. Resident #23 had another Braden Scale, completed on 06/12/15. It indicated her nutrition was Adequate - Eats over 1/2 of all meals. Review of Resident #23's meal percentages from 06/05/15 through 06/11/15 found that out of 21 meals provided, Resident #23 only ate 1/2 or more of the meals seven (7) times or 33% of the time. At the remaining 67% percent of the time, Resident #23 ate 25% or less, indicating poor nutrition status - never eats a complete meal rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was at moderate risk for developing pressure ulcers. A Braden Scale completed on 06/19/15, indicated Resident #23's nutrition was Adequate - Eats over 1/2 of all meals. Review of her documented meal percentages from 06/05/15 through 06/18/15 found Resident #23 ate 1/2 of her meal or more on 12 of the 42 meals offered or 29% of the time. This indicated Resident #23's nutrition was poor - never eats a complete meal and rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was at mild risk for developing pressure ulcers. During the interview with CRN-RN #98, at 1:34 p.m. on 06/24/15, she was asked if Resident #23's nutritional status on the three (3) Braden scales completed in June were accurate. She reviewed each Braden scale and the documented meal percentages. CRN-RN #98 stated they were all inaccurate, as each should have been marked as poor nutritional status. CRN-RN #98 was asked if the resident's Braden Score would have been lower, indicating a higher risk of developing pressure ulcers, if the assessments had been completed accurately. She affirmed it would have decreased the scores and have shown a greater risk for developing pressure ulcers. When asked what other preventative measures for the development of pressure ulcers were put in place for Resident #23, CRN-RN #98 stated they did weekly skin checks every Sunday. She said Resident #23 should have had one completed on 06/07/15. When asked for the results of this skin check, CRN-RN #98 stated, It appears they did not do one on that date. She stated the first note about any skin checks or concerns was on 06/09/15, when it was noted Resident #23 had four (4) deep tissue injuries identified during ADL care. CRN -RN #98 was asked if Resident #23 was compliant with turning and repositioning. She reviewed the the medical record and found no evidence Resident #23 was non-compliant with turning and repositioning. When asked what types of interventions were put in place to prevent residents from developing pressure ulcers, CRN-RN #98 stated upon admission each resident was placed on a pressure reducing mattress. She stated it was standard protocol to use a pressure reliving mattress to all beds and a pressure relieving cushion to all wheel chairs regardless of the resident's risk for developing pressure ulcers. CRN-RN #98 stated. they floated Resident #23's heels while in bed, and the resident did not develop pressure ulcers to her heels. CRN-RN #98 indicated she could find no other individualized interventions, for the prevention of pressure ulcers for Resident #23, between her readmission on 06/04/15 and 06/09/15, when the pressure ulcers were identified. In addition, since the Braden Scales were inaccurate and the required skin check on 06/07/15 was not completed, the facility failed to fully implement interventions to prevent the development of pressure ulcers for the resident. This was confirmed by CRN-RN #98.

Based on record review, staff interview, resident observation, and resident interview, the facility failed to provide the necessary care and services to maintain or attain the highest practicable physical, mental and psychosocial well-being for three (3) of fifteen (15) residents reviewed during Stage 2 of the Quality Indicator Survey. A physician ordered urinalysis with culture and sensitivity (UA C&S) was not completed for Resident #23, to rule out a urinary tract infection [MEDICAL CONDITION]. She subsequently had worsening confusion, agitation, and a fall requiring an emergency room (ER) The [DIAGNOSES REDACTED]. The failure of the facility to obtain the lab when originally ordered resulted in a delay in treatment. This was determined as harm to the resident because her condition worsened and hospitalization was required. In addition, the facility failed to ensure an effective pain management program for Resident #26, who was receiving Hospice services. For Resident #134, the facility failed to provide services for positioning while in her wheelchair. Resident Identifiers: #23, #26, and #134. Facility Census: 71. Findings Include: a) Resident #23 A review of Resident #23's medical record, at 12:23 p.m. on 06/24/15, revealed a physician's orders [REDACTED]. The medical record contained no evidence the repeat UA C&S was obtained on 05/29/15 as ordered. Further review of Resident #23's medical record found a Physician & NP (Nurse Practitioner) & PA (Physician Assistant) Note dated 06/01/15 which was authored by NP #99. The note read, . Worsening confusion. I last saw the resident on 05/28, and ordered a UA C&S to be obtained at that time due to increased confusion even though she had just completed a 7 day course of [MEDICATION NAME] for a UTI (Urinary Tract Infection); however, it appears that the specimen was not obtained. This afternoon she is up in her power chair and is screaming about, getting out of here and actively trying to get out of the building. She is very confused today; . This afternoon, her son is with her at bedside; she is hysterically crying and asking him to take her home. She keeps repeating that she is feeling nervous; her son is requesting she be given a one time dose of medication for anxiety. Further review of the nursing progress notes, found the following notes all dated 06/01/15, -- 1:42 p.m., New order to obtain UA C&S due to confusion. Urine obtained and Sent to (name of lab). -- 9:42 p.m., Resident very confused, agitated and combative for most of the day. (name of attending physician) ordered [MEDICATION NAME] .5 f/(for) 1 (one) time dose which did not calm her down. Dr. (doctor) notified of such and told to send her out to ER (emergency room ). -- 9:47 p.m. Change in condition: Resident had been confused combative and yelling most of the day, resident stated she is leaving this place if she has to crawl. -- 11:02 p.m., ord (order) rec'vd (received) for [MEDICATION NAME] 250 mg (milligram) po (by mouth) bid (twice a day) X (times) 7 (seven) days & (and) [MEDICATION NAME] .5 mg tb X1 po now. -- Late entry for 6/1/15 at 8:16 a.m., (Resident Name) transferred to hospital- unplanned for evaluation and treatment via ambulance to (Name of Local Hospital) Physician notified to transfer (name of attending physician) Responsible Party notified of transfer (name of son) copy of advance directives sent. Resident had a mental status change with hallucinations. See transfer form for additional clinical findings. Additional review of the medical record found a discharge summary from a local hospital dated 06/04/15. The discharge summary indicated Resident #23 was admitted to the hospital on [DATE] with an admitting [DIAGNOSES REDACTED]. The discharge summary indicated Resident #23's confusion returned to baseline during her stay at the hospital. Review of accident reports for Resident #23 found she had a fall on 06/01/15 at 5:10 p.m. The incident report indicated the resident was found on the floor beside her bed. Her condition at the time of the fall was noted as confused, agitated, and combative. Review of Resident #23's physician's orders [REDACTED]. An interview with the Assistant Director of Nursing (ADON) Registered Nurse (RN) #91 at 1:27 p.m. on 06/24/15, confirmed the facility failed to obtain Resident #23's UA C&S on 05/29/15. She stated NP #99 identified the lab had not been obtained when she saw the resident for worsening confusion on 06/01/15. The ADON confirmed Resident #23's confusion continued to worsen until 06/01/15. The ADON also confirmed Resident #23 was sent to the ER and was admitted to the hospital on [DATE] related to her increased confusion/agitation and was admitted to he hospital with a [DIAGNOSES REDACTED]. b) Resident #26 Record review, on 06/24/15 at 9:00 a.m., found Resident #26 began receiving Hospice services on 10/31/14 for end of life care. The resident was receiving Hospice services for advanced stages of dementia. The most recent minimum data set (MDS), a quarterly MDS with an assessment reference date (ARD) of 05/05/15 indicated the following: -- Section B was coded the resident rarely ever understands others. -- Section C1000, indicated the resident's cognition was severely impaired. -- Section C1600 was coded there was no acute onset in mental status change. Review of the Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. (For verbal patients) are you free of pain or hurting? If no, indicate response through chart code PI every day shift. The response on the MAR for every day for the months of March, April, May and June 2015 was a Y, indicating, the resident's response was, yes. [MEDICATION NAME] 5-325 was administered on (10) ten different occasions in March 2015: -- 03/02/15 at 9:00 p.m. -- 03/03/15 at 9:00 p.m. -- 03/04/15 at 10:18 p.m. -- 03/05/15 at 10:00 p.m. -- 03/07/15 at 9:00 p.m. -- 03/12/15 at 10:38 p.m. -- 03/28/15 at 9:00 p.m. -- 03/29/15 at 8:00 p.m. -- 03/30/15 at 10:00 p.m. -- 03/31/15 at 10:00 p.m. [MEDICATION NAME] 5-325 was administered on fifteen (15) occasions in April 2015: -- 04/01/15 at 10:00 p.m. -- 04/02/15 at 10:00 p.m. -- 04/03/15 at 9:50 p.m. -- 04/04/15 at 10:00 p.m. -- 04/05/15 at 10:00 p.m. -- 04/10/15 at 9:00 p.m. -- 04/11/15 at 9:00 p.m. -- 04/12/15 at 9:00 p.m. -- 04/13/15 at 9:00 p.m. -- 04/14/15 at 9:00 p.m. -- 04/16/15 at 10:00 p.m. -- 04/22/15 at 9:00 p.m. -- 04/27/15 at 10:00 p.m. -- 04/29/15 at 9:00 p.m. -- 04/30/15 at 9:00 p.m. [MEDICATION NAME] 5-325 mg. was administered on ten (10) occasions in May 2015: -- 05/02/15 at 10:00 p.m. -- 05/03/15 at 9:00 p.m. -- 05/04/15 at 9:00 p.m. -- 05/05/15 at 9:00 p.m. -- 05/06/15 at 9:00 p.m. -- 05/08/15 at 9:00 p.m. -- 05/11/15 at 9:00 p.m. -- 05/13/15 at 9:00 p.m. -- 05/14/15 at 9:00 p.m. -- 05/25/15 At 9:00 p.m. On this occasion, the nurse providing the medication documented the effect of the medication after giving and indicated non-pharmacological interventions were used before giving the medication. The specific interventions were not indicated. As of 06/24/15, [MEDICATION NAME] 5-325 mg. was given on only one (1) day in June, on 06/19/15. The use of non-pharmacological interventions (but not the specific interventions) and the effect of the pain medication were documented by the nurse At 10:41 a.m. on 06/24/15, the assistant director of nursing (ADON) #91 was interviewed. The ADON was asked the following questions: -- How could the nursing staff ask Resident #26 if she was in pain when the MDS indicated the resident would be unable to comprehend this question? -- What were the non-pharmacological interventions attempted before administering the pain medications? -- Where is the evidence the facility was monitoring the effectiveness of the pain medication after administration? -- What was the location of the resident's pain? The ADON stated the nursing staff should have been completing a PRN pain management flow sheet every time a dose of [MEDICATION NAME] was administered. She found only one (1) occasion in which this flow sheet was completed. It was completed for the 06/19/15 dose of [MEDICATION NAME]. The ADON confirmed nursing staff had not been indicating the pain rating before administration, the non-pharmacological interventions used prior to administration of the pain medicine, the location of the pain, or the effectiveness of the pain medication. She also reviewed the nursing notes and could find no evidence of this information in the nursing notes. The ADON was also unable to explain how nursing staff could have interviewed the resident, due to her confusion, to determine if she was in pain. Review of the facility's pain management policy, revised on 01/02/14, found: Purpose - To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain . 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document: 8.1 Effectiveness of PRN medications. 8.2 Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/medical provider notification; 8.3 Side effects, if present, and notification of physician/mid-level provider; 8.4 Non - pharmacological interventions and effectiveness . At 2:22 p.m. on 06/25/15, an interview with the ADON and Employee #98, a registered nurse (resource nurse), confirmed the facility had not followed the pain management policy. At the close of the survey on 06/26/15 at 12:30 p.m., facility staff had not provided evidence to substantiate the resident's pain was being effectively evaluated and managed. c) Resident #134 Observations of Resident #134 having lunch in the dining room, on 06/23/15 at 12:35 p.m., revealed the resident was attempting to consume her meal. She was leaning to the left side of her wheelchair. When the resident was asked if she had difficulty standing up straight, she stated, Yes. The resident was observed in the same position until she finished her meal at 12:59 p.m. At no time did any staff member attempt to position Resident #134 into a more comfortable position. A review of Resident #134's care plan, on 06/23/15 at 6:00 p.m., revealed a care plan that indicated the resident exhibited or was at risk for alteration in comfort related to a history of recent right humerus fracture, [MEDICAL CONDITION] in her lower extremities, and [MEDICAL CONDITION]. The intervention in the care plan was to assist the resident to a position of comfort, utilizing pillows as an appropriate positioning device. This care plan was initiated on 02/09/15. ¿@ Observation, on 06/23/15 at 6:16 p.m., revealed Resident #134 sitting in her wheelchair in her room. She was leaning to the left side of her chair. No pillows were observed in the resident's wheelchair to assist the resident to a comfortable position. When asked how long she had been leaning to her left side, she said, I came in here in January 2015, and I had a problem since January, but the leaning has gotten worse over the last month. ¿@ Observation of Resident #134, on 06/24/15 at 8:15 a.m., revealed the resident sitting in her wheelchair beside her bed. She was leaning to the left side of her chair. No pillows were observed in her wheelchair to assist the resident in being comfortable. ¿@ Observation of Resident #134 at her doorway of her room, on 06/24/15 at 10:30 a.m., revealed the resident was leaning to the left side of her wheelchair. No pillows were observed to assist in the resident's comfort. Observation of Resident #134 at lunch in the dining room, on 06/24/15 at 12:30 p.m., revealed the resident was sitting in her wheelchair. She was leaning to the left side attempting to consume her meal. No pillow or other device was present in her wheelchair to assist the resident to a comfortable position. No staff attempted to reposition Resident #134 to a comfortable position. ¿@ In an interview at the entrance of the dining room, on 06/24/15 at 12:35 p.m., with Resident #134's family member (FM), she was asked how long Resident #134 had been leaning to the left side when she was sitting in her wheelchair. The FM stated . has been leaning to the left side really bad in her wheelchair for about a month. She came to the facility leaning to the left side of her wheelchair in January 2015. The FM stated, They finally are going to order some kind of pad to put in her chair to help her to sit up straighter. In an interview on 06/24/15 at 1:00 p.m., with the physical therapy-program manager (PT-PM) #84, she stated early this week the therapy department received a physical therapy (PT) request for Resident #134 to be evaluated. PT-PM stated the referral indicated the resident was having trouble last week in transferring. The PT-PM said when the occupational therapist (OT) evaluated Resident #134; the OT noticed the resident was not sitting straight in her wheelchair. The OT ordered a device to help the resident's core (mid-section of her body) to be able to stand up straighter. The OT stated she had started doing core exercises with the resident, and the resident could correct the position, but she was unable to hold the position for very long. ¿@ In an interview on 06/24/15 at 1:45 p.m., with nursing assistant (NA) #43, she was asked what type of positioning assistance she provided to help Resident #134 from leaning to the left side. The NA stated, I remind the resident to sit up straight. The NA was asked if there was any other intervention used to prevent the resident from leaning. The NA shook her head no. ¿@ In an interview with Licensed Practical Nurse (LPN) #12, on 06/24/15 1:33 p.m., the LPN was asked what interventions she used to prevent Resident #134 from leaning to the left side. The LPN stated, I tell the resident to reposition herself in the wheelchair. The LPN was asked if there was any other intervention that she or the staff used to keep the resident in proper alignment. She replied, No, I just tell her to straighten her back up. The LPN was asked if there was something staff could do to prevent the resident from leaning to the left side. The LPN stated, No. At that time, the LPN was informed there was an intervention in the care plan to assist the resident to a position of comfort by utilizing pillows as positioning devices; however, the Kardex (the nursing assistants' means of identifying the care for to provide each resident) only said to assist the resident in repositioning. The intervention for positioning with pillows was not on the NAs' Kardex. LPN #12 looked at the care plan and the Kardex, and agreed. She confirmed staff had not been providing this intervention for Resident #134. The LPN also stated, The NAs would not have known to apply the pillow since the intervention was not brought over onto the Kardex. ¿@ In an interview with OT #87, on 06/25/15 at 9:15 a.m., when asked about Resident #134's posture in the wheelchair, the OT said the resident had a pelvis deformity. The OT stated, The resident has been leaning to the left side since she was admitted here in January 2015. ¿@ Observation of Resident #134, on 06/25/15 at 11:40 a.m., revealed the facility had provided the resident a lap buddy to assist in positioning; however, the resident was still leaning to the left side of her wheelchair.

Based on review of facility documents, medical record review, review of information from hospital records, observation, resident interview, and staff interview, the facility failed to assess a resident ' s clinical and mental status, failed to monitor the resident ' s response to treatment, and failed to obtain laboratory studies as ordered by the physician. These deficits in care resulted in a finding of actual harm to Resident #73. It was also determined a potential for more than minimal harm existed for Resident #60, by the facility ' s failure to implement a physician ordered fluid restriction. Two (2) of nine (9) residents on the sample were affected. Resident identifiers: #73 and #60. Facility census: 71. Findings include: a) Resident #73 1) Review of a facility document, dated 02/13/12, entitled "Record of Customer and Family Concerns," found the social worker, Employee #79, contacted the resident's daughter after the resident's admission to the hospital on [DATE]. Employee #79 documented the daughter "had some concerns about resident's condition prior to admission to hospital (sic)". Employee #79 further documented the nursing home administrator and director of nursing were informed. Employee #79 documented the daughter reported Resident #73 had bilateral pneumonia. Employee #79 further documented the daughter was upset with the facility "...because we did not check on her often because if we did this wouldn't have happened." Employee #79 documented the daughter stated, "...she came in on Wed. 01/31/12 and her mother appeared dehydrated, (her mouth was dry and tongue sticking to roof of mouth). (The Daughter) notified a nurse (couldn't recall name or identify), however nurse shrugged it off. (The daughter) gave her mother water and she seemed better. Monday 2/6/12, (the daughter) came to see (Resident #73) again (around end of dinner) and found her shaking and appearing dehydrated. (The daughter) also reports that her tube feed was dated for 2/4/12 and crusted around opening at stomach. (The daughter) reports that her mother was not talking or acknowledging her presence. (The daughter) went to get a nurse, but felt the nurse shrugged it off and ignored her concerns. (The daughter) continued to express concerns to nurse. (The daughter) said nurse told her she was shaking due to [MEDICAL CONDITION] Dx (diagnosis). (The daughter) told nurse she did not have [MEDICAL CONDITION]. Nurse took vitals and agreed to contact physician. (The daughter) stated she insisted that facility send her mother out. When (Resident #73) arrived @ (at) the hospital, (The Daughter) reports, the physician told her to call in family because (Resident #73) was almost dead. (The Daughter) reports that ER (emergency) physicians cautioned her against sending her back to (the facility)...". 2) Nursing entries for Resident #73 Review of the medical record found the treating physician determined this resident retained the capacity to make medical decisions. Review of nursing notes on 01/29/12 and 01/31/12 found the resident described as "alert and oriented." On 02/01/12 at 7:45 p.m., a registered nurse, Employee #31, obtained a telephone order from the treating physician for intravenous (IV) fluids. Normal saline IV at 100 cc/hr for 24 hours was ordered, along with an order to obtain a urinalysis with culture and sensitivity, a complete blood count (CBC) and a comprehensive metabolic panel (CMP). Review of the medical record found no nursing note authored by Employee #31 documenting any assessment of the resident's medical condition which prompted the call to the treating physician. Furthermore, the medical record contained no nursing notes or any other evidence nursing staff had started the ordered IV or obtained the ordered blood work. The medical record contained no further nursing notes until 1:18 p.m. on 02/02/12. This note, authored by licensed practical nurse (LPN) #1, contained no assessment of the resident's condition beyond "Alert, no distress noted, [DEVICE] intact, head of bed elevated, meds via [DEVICE], iv intact." There was no assessment of the resident's hydration or respiratory status. There were no nursing notes in the medical record for 02/03/12. On 02/04/12 at 12:08 p.m., an LPN, Employee #12, documented the resident was alert with noted confusion. The resident was noted to be sitting up in geri-chair with no signs or symptoms of pain or distress. The nursing note contained no assessment of the resident's respiratory status or lung sounds. The note did not contain an assessment of the resident's hydration status or any other nursing assessment following the administration of IV fluids. There were no nursing notes in the medical record for 02/05/12. The medical record contained a physician's telephone order, dated 02/06/12 at 7:15 p.m., to transfer the resident to the emergency room for treatment and evaluation. The order was signed by an RN (Employee #31). Employee #31 did not write a nursing note related to the resident's condition which necessitated transfer to the hospital until 1:43 a.m. on 02/07/12. The entry noted the resident had been transferred for increased temperature, congestion, and elevated blood pressure. 3) Laboratory studies Review of the medical record found no evidence the facility had obtained the urinalysis with culture and sensitivity, CBC, and CMP as ordered by the physician at 7:45 p.m. on 02/01/12, prior to the resident being transferred to the emergency roiagnom on [DATE]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview was conducted with the Director of Nursing (DON), Employee #6, on 02/29/12 at 2:10 p.m. She was asked to provide the results from the laboratory work ordered by the physician on 02/01/12. She was unable to provide evidence the facility had obtained the ordered laboratory services. 4) emergency room Review of the emergency room physician assessment found the following, "[MEDICAL CONDITIONS] exacerbation. The patient's BNP (Brain Natriuretic Peptide test, indicative of heart failure) is 260, a few weeks ago it was in the 60's. Also on physical exam, there are diffuse crackles/rales and expiratory wheezes. At this point, I would give 40 mg of IV [MEDICATION NAME] (a diuretic)...". Resident #73 was admitted to the hospital with [REDACTED]. The resident remained hospitalized as of the 03/01/12 exit from the facility. ========== b) Resident #60 Review of the medical record found a physician's orders [REDACTED]. An interview with the Director of Nursing (DON), Employee #6, on 02/29/12 at 3:40 p.m., elicited that "free water" meant plain water. Resident #60's room was entered at 3:41 p.m. Observation revealed a pitcher of ice water was present on her bedside table. The resident was alert and oriented. She was asked if she was allowed to have water. The resident responded, "I can have all the water I want." The facility provided no evidence the resident or staff members were educated concerning the physician's orders [REDACTED]. Further review of the medical record found that the physician's orders [REDACTED]. .

Based on record review, staff interview, and observation, the facility failed to provide care and services necessary to maintain a resident's highest practicable physical well-being, including adequate assessment, monitoring, and/or prompt intervention in response to the identification of abnormal findings on a resident assessment instrument. On 04/22/11, Resident #40 was noted to have had two (2) bowel movements; however, staff failed to identify that Resident #40 did not have a bowel movement for three (3) consecutive days thereafter, and failed to implement to facility's Bowel Protocol, which indicated staff was to administer milk of magnesia (MOM) if a resident has had no BM after three (3) days. The facility's registered nurse assessment coordinator (RNAC) later identified, on a resident assessment instrument, that Resident #40 had not had a BM during a 7-day assessment reference period ending on 04/30/11. (This was unusual for her, as the resident's bowel elimination pattern had previously identified she had BMs every other day.) However, staff did not intervene by collecting information about her physical health status and/or by initiating the physician's standing order for constipation at that time. On 05/04/11, after the nurse surveyor questioned staff about the resident's lack of BMs for a period of twelve (12) days, staff administered the first step of the facility's Bowel Protocol, a 30 cc dose of MOM (which was to be given after a resident had no BM for three (3) days), without completing a physical assessment of the resident. When a physical assessment of the resident was completed at the nurse surveyor's request, the resident moaned, stating, "My stomach hurts." Resident #40 continued to moan and had a look of discomfort on her face. Staff later administered an enema, after which the resident expelled an extra large BM. The deficient practice resulted in actual harm to one (1) of six (6) sampled residents and has the potential to result in harm to more than an isolated number of the facility's residents. Facility census: 73. Findings include: a) Resident #40 1. Record review, on 05/04/11, revealed Resident #40, who had been admitted to the facility on [DATE], had a bowel retraining assessment dated [DATE], which identified her usual bowel elimination pattern as having a BM every other day. This assessment also revealed she did not have a history of constipation. Review of Resident #40's interdisciplinary care plan, dated 04/25/11, found this resident was identified as being at risk for gastrointestinal symptoms or complications related to the use of a gastrostomy tube ([DEVICE]). The interventions associated with this problem included: "Assess for and report signs and symptoms of nausea / vomiting, abdominal distention, decrease in bowel movements, decrease in bowel sounds, and abdominal pain." Another intervention stated: "Monitor and record bowel movements." These were the only interventions in the care plan related to this resident's bowel elimination. Review of Resident #40's medical record revealed a Medicare 14-Day MDS, with an assessment reference date (ARD) of 04/30/11, in which the assessor encoded "9" in section H0400 to indicated the resident's bowel continence was not rated, because either the resident had an ostomy or the resident did not have a BM for the entire 7-day assessment reference period. Further record review revealed the resident did have an ostomy (a gastrostomy, not a [MEDICAL CONDITION] or other bowel diversion). The record also indicated her last recorded BM occurred on 04/22/11. A review of this resident's April 2011 activities of daily living (ADL) flow record revealed this resident had an extra large BM and a small BM on 04/22/11. Further review of the ADL flow sheet for April 2011 revealed she did not have another BM during the remainder of the month - a total of eight (8) days. The ADL flow sheet for May 2011, when reviewed, revealed this resident had not had a BM the first four (4) days of that month. This was a total of twelve (12) consecutive days with no bowel movement. The medication administration records (MARs) for both April and May 2011, when reviewed, found no evidence this resident had received a laxative or any type of medication for constipation at any time during these two (2) months. The nursing notes for Resident #40 contained no mention of any issues with constipation or any acknowledgement that she had not been having BMs. -- 2. During an interview with the RNAC (Employee #73) on 05/04/11 at 10:50 a.m., she verified she completed the above-mentioned MDS for Resident #40. She stated she encoded this MDS item as "9", because there was no evidence this resident had a BM for the 7-day assessment reference period. When questioned as to what actions she took after identifying the resident had had no BM during the 7-day assessment reference period, she stated she always tells the nurse on the hall when a resident has not had a BM, but she could not remember which nurse she told. She confirmed she had not documented having to told the nurse this anywhere, and she verified that the last BM this resident had recorded in her medical record (as of this date - 05/04/11) was on 04/22/11. -- 3. During an interview on the morning of 05/04/11, the nurse assigned to care for Resident #40 (a licensed practical nurse (LPN - Employee #3)) was questioned about the facility's process for identifying residents who were experiencing constipation and how the nurses were made aware of the need to further assess residents for constipation. She stated the clerk at the desk reviews the books containing the BM records and lets the nurses know if the residents need something, or sometimes the nursing assistants let them know. She said the nurses used to check the books, but they don't any more. When questioned about Resident #40, Employee #3 stated she was not aware the resident had not had a BM, because no one had said anything to her. When asked about the facility's bowel protocol, Employee #3 stated that, if a resident has not had a BM in three (3) days, they give 30 cc of MOM. If the resident does not have a BM within eight (8) hours after receiving the MOM, they give the resident a suppository ([MEDICATION NAME] rectal suppository). If the resident does not have a BM within eight (8) more hours, they notify the doctor. -- 4. An interview was conducted with the RN unit manager (Employee #83) at 11:45 a.m. on 05/04/11. She stated that, if constipation had been identified for Resident #40, the interventions should be recorded on the MAR. She stated the nursing assistants record the residents' BMs on the ADL flow sheets, then they report to the nurse or the unit manager. She stated the MDS nurses also bring this to their attention. When asked if anyone else monitors this, she said not that she is aware of. She stated the facility's Bowel Protocol is in front of every MAR book. She stated if this protocol is initiated, the nurses pass it on during report at shift change. -- 5. A nurse administered MOM to Resident #40 at 3:15 p.m. on 05/04/11. However, review of the resident's medical record found no evidence that a physical assessment had been completed on the resident. Employee #83 was asked to complete a physical assessment of Resident #40 with this nurse surveyor present. The resident was in bed at that time. Employee #83 told the resident what she was going to do. The nurse listened to her bowels and reported that bowel sounds were present. As she touched the resident's abdomen with her stethoscope, the resident started moaning. The nurse then felt her stomach, and the resident was moaning, stating, "My stomach hurts." Resident #40 continued to moan and had a look of discomfort on her face. Employee #83 asked Resident #40 if she had a BM today, and the resident answered, "No." Employee #83 then asked if her bowels moved yesterday, and she again said, "No." The resident told the nurse, "I thought they were going to move, but they didn't." -- 6. The director of nursing (DON - Employee #76) was notified, on 05/04/11 at 3:30 p.m., of these observations, including the resident's moaning and complaints of stomach pain when assessed. The DON was also made aware of the resident having had no BMs for the preceding twelve (12) days. She responded that she reviewed the resident's medical record and saw that she had complained of stomach pain when she came in. This nurse surveyor told the DON that, according to the resident's MAR, Resident #40 had received a dose of MOM. However, the facility's Bowel Protocol indicated that MOM was to be given when a resident has had no BM in three (3) days, and Resident #40 had had no BM in twelve (12) days. The nurse surveyor asked the DON to have someone notify the physician of Resident #40's condition. The DON returned at 4:00 p.m. and informed this nurse surveyor that the nurses gave Resident #40 an enema, and she had extra large results. .