Every finding on record at Coweta Care & Rehab Center

Based on record review and interview, the facility failed to ensure accurate assessments were completed for 2 (#5 and 81) of 28 sampled residents reviewed for accuracy of assessments. The administrator identified 75 residents resided in the facility. Findings: A facility MDS 3.0 policy, revised [DATE], read in part, Everyone completing a portion of the assessment must sign and certify the accuracy of the portion of the assessment they completed. 1. A physician's order for Resident #5, dated [DATE], showed to administer Clopidogrel Bisulfate (an antiplatelet) 75 mg one time a day for blood clot prevention. A quarterly assessment, dated [DATE], showed a BIMS of 10 which indicated Resident #5 had moderate cognitive impairment for daily decision making and diagnoses which included non-Alzheimer's dementia, traumatic brain injury, depression, anemia, and asthma. Section N of the assessment showed an anticoagulant was taken during the look back period and an antiplatelet was not taken. On [DATE] at 9:31 a.m., the MDS coordinator stated they obtained information for the MDS assessment from interview with residents, assessments, and other documentation. The MDS coordinator was asked why the quarterly assessment, dated [DATE], showed Resident #5 had taken an anticoagulant. They stated they would have to check and left the room. On [DATE] at 9:33 a.m., the MDS coordinator returned and stated they had miss coded it. They stated they tried to make sure the assessment was correct while they were going through it. 2. An admission assessment for Resident #81, dated [DATE], showed a BIMS of 13 which indicated the resident was cognitively intact for daily decision making. The assessment showed diagnoses which included anemia, urinary tract infection in the last 30 days, and arthritis. A discharge assessment, dated [DATE], showed Resident #81 died in the facility. A progress note, dated [DATE] at 2:55 a.m., showed Resident #81 was hypoxic, pallor, and short of breath with retractions. The note showed Resident #81 was sent to the hospital at 2:50 a.m. with emergency medical service. A progress note, dated [DATE], showed the emergency room called and informed Resident #81 had a pulmonary embolism and requested a copy of the Do Not Resuscitate (DNR) for Resident #81. On [DATE] at 1:36 p.m., the representative of Resident #81 was called and stated Resident #81 had a blood clot. They reported the facility informed it all happened very quickly. The representative stated a nurse called them early in the morning and informed them they thought Resident #81 had aspirated because they were a green color. The representative stated the facility called an ambulance who took Resident #81 to the hospital where a blood clot was found. They stated Resident #81 died at the hospital. On [DATE] at 10:34 a.m., the MDS coordinator after reviewing the clinical record of Resident #81 stated Resident #81 died in the facility and that sometimes the MDS did not give an option that fit the situation better. They stated it looked like they should have discharged Resident #81 out to the hospital and did a death in facility instead.

Based on observation and interview, the facility failed to ensure pureed food was free of chunks and of a consistency to meet the needs of the residents for 1 of 1 observation. The administrator identified four residents who ate pureed food from the kitchen. Findings: On 09/16/25 at 11:25 a.m. cook #1 was observed to prepare puree for the noon meal. The meatloaf was placed in the food processor with a low sodium beef base paste and hot water. When cook #1 thought the puree was finished, they asked the dietician to check the puree. This surveyor tasted the puree, and it was chunky with bits that required chewing. The dietician was not observed to taste the meatloaf puree and informed cook #1 it was good to serve. [NAME] #1 poured the puree into a container and placed it on the steam table to serve. On 09/16/25 at 11:55 a.m., the pureed meat was observed to be placed in a bowl with gravy added and placed on tray. On 09/16/25 at 11:57 a.m., this surveyor stopped the serving of puree. On 09/16/25 at 11:58 a.m., the dietary manager stated the puree was grainy and not smooth. They pulled the pureed meat off the line. On 09/16/25 at 11:59 a.m., the dietician stated they would have to blend the meat until it was smooth.

Based on observation, record review, and interview, the facility failed to store drugs and biologicals in a locked compartment and permit only authorized personnel to have access for 1 of 3 nurse medication carts observed. The administrator identified 75 residents resided in the facility.Findings:Findings: On 09/17/25 at 8:27 a.m., an observation of a medication cart on the Southwest corridor was made. The cart was unlocked with a set of keys hanging from the lock. There were no staff present in the hall. Three residents were moving in the hallway independently. On 09/17/25 at 4:16 p.m., LPN #1 was observed during a medication pass on the Southwest corridor. LPN #1 obtained Pyridostigmine Bromide (a reversible acetylcholinesterase inhibitor medication) 60 mg and Pepcid (a H2 receptor which decreases gastric acid) 40 mg for Resident #31. LPN #1 removed the medication from the multi-dose pharmacy prepared package, placed the medication in a cup, and entered the resident's room to administer the medication. LPN #1 did not place the multi-dose medication packages back in the locked cart before leaving the medication cart unattended. When LPN #1 returned to the medication cart a resident was sitting in a wheelchair by the medication cart. An undated facility policy titled Medication Storage in the Facility, read in part, Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.On 09/17/25 at 8:31 a.m., LPN #1 stated they were in a hurry, forgot the lock the cart, and left the keys hanging in the lock. On 09/17/25 at 4:17 p.m., LPN #1 stated they were not aware they had left the multi-dose medication packages unlocked and unattended on the medication cart in the hall. On 09/23/25 at 10:00 a.m., the DON stated medication should be stored and medication carts should always be locked when unattended. The DON stated as needed narcotic medications were stored in the nurses' medication carts on the halls.

Based on record review and interview, the facility failed to make a referral to the OHCA after a newly identified serious mental health disorder and a significant change in status assessment for 1 (#13) of 2 sampled residents reviewed for PASRR.The administrator identified 32 residents with mental health diagnoses. Findings: A PASRR level l form, dated 04/25/25, showed Resident #13 did not have a diagnosis of a mental health disorder and a PASRR level ll referral was not needed. An undated medical diagnosis tab in Resident #13's electronic medical record showed a diagnosis of bipolar disorder was added on 06/26/25. A significant change assessment, dated 07/29/25, showed Resident #13 had a BIMS score of 15 which indicated their cognition was intact. The assessment showed the resident was not currently considered by the state PASRR level ll process to have a serious mental illness and/or intellectual disability. On 09/22/25 at 4:41 p.m., the MDS coordinator stated they could not find documentation a referral was made to the OHCA for a PASRR level ll when the resident received the diagnosis of bipolar disorder.

Based on record review and interview, the facility failed to ensure enhanced barrier precautions were provided during incontinent care and failed to ensure hand hygiene was performed during incontinent care for one (#7) of two sampled residents reviewed for incontinent care. The DON identified 16 residents on enhanced barrier precautions and 39 residents who required incontinent care. Findings: A facility policy titled Enhanced Barrier Precautions, reviewed 05/15/24, read in part, .Examples of High-Contact Resident Care Activities requiring Gown & Glove Use for EBP .Changing Briefs or Toileting . A facility policy titled Incontinent Care, reviewed 07/21/22, read in part, .Remove Soiled Brief .Cleanse Perineal Area .Remove Soiled Gloves, Perform Hand Hygiene & Apply Clean Gloves .Apply Clean Brief and Clothing . Resident #7 had diagnoses which included gastrostomy status and acute respiratory failure. On 10/15/24 at 11:19 a.m., CNA #2 was observed providing incontinent care to Resident #7 with the assistance of CNA #3. Neither staff member was observed wearing a gown. CNA #2 was observed to remove the soiled brief, cleanse the perineal area, and apply a clean brief. They did not change gloves or perform hand hygiene after they cleaned the perineal area. On 10/15/24 at 12:32 p.m., LPN #1 stated EBP and hand hygiene should be observed during incontinent care. On 10/15/24 at 12:39 p.m., CNA #2 stated they should have been wearing a gown and they should have changed gloves before putting the clean brief on Resident #7. On 10/15/24 at 12:42 p.m., CNA #1 stated proper infection control techniques should be used during incontinent care. On 10/15/14 at 12:55 p.m., the DON stated that gloves should be changed before a clean brief was placed on a resident and EBP should be followed.

Based on record review, observation, and interview, the facility failed to ensure three of three shower rooms, which contained chemicals were locked and secure. The DON identified 73 residents resided at the facility. Findings: On 04/29/24 at 8:43 a.m., a shower room on hall #2 with unsecured chemicals was observed to not be locked. The following chemicals were observed: a spray bottle with green liquid approximately 18 ounces unlabeled, a spray bottle of bold Power hard surface and glass cleaner approximately 10 ounces, a purple top Sani-cloth tub, both labeled to keep out of reach of children. Three cans of shaving cream, two french lavender body scrub jars 5 ounces each state keep out of reach of children, one and one half gallons of shampoo & body wash, labeled to keep away from children and a razor without a safety cap. On 04/29/24 at 8:53 a.m., the hall #4 shower room door was observed to be unlocked with the following chemicals unsecured: spray bottle with 4oz unlabeled purple liquid, super sani wipes, eve st [NAME] body wash 10 oz approx-keep out of reach of children, sharps box 3/4 full with no cover, on top of the paper towel dispenser with uncapped razors, one medline shave cream labeled to keep out of reach of children, one fresh scent shave cream, labeled to keep out of reach of children, one medline shave cream, labeled to keep out of reach of children, two medline deodorants, labeled to keep out of reach of children, one mainstays universal fragrance oil watermelon approximately three ounces, labeled to keep out of reach of children. The door with key pad was closed and it did not lock and was easily reopened. On 04/29/24 at 8:59 a.m., CNA #2 and CNA #4 stated Resident #79 was a wanderer. On 04/29/24 at 9:01 a.m., the shower room on hall #2 was observed to be unlocked with the door latched closed. On 04/29/24 at 9:02 a.m., CNA #4 stated the hall #4 shower room lock had not been locking for two weeks. They stated chemicals should be locked in the cabinet to prevent access by residents. CNA #4 looked at the cabinet and stated they did not know where the lock was. On 04/29/24 at 9:03 a.m., CNA #3 stated the hall #2 shower door should be locked but sometimes the lock did not work. They stated they had told housekeepers and maintenance. On 04/29/24 at 9:05 a.m., the shower room on hall #3 was observed to be unlocked with the following chemicals unsecured: 3in1 body wash bottle labeled to keep away from children; a 22.5 oz 1-1/2 gal of body wash, labeled to keep away from children; two cans of shaving cream, labeled to keep away from children; a Sani-cloth purple top tub, labeled to keep out of reach of children; a wooden box without a lock contained disinfecting wipes, labeled to keep away from children; fast and easy hard surface cleaner, labeled to keep away from children; k-quat plus spray bottle 1/2 full, labeled hazardous to humans and animals; a bottle of flex fresh and fruity body wash labeled, to keep out of reach of children. The maintenance supervisor approached the shower room and locked the door. On 04/29/24 at 9:05 a.m., in a room by hall #5 and #6 nurses' station was observed to be open with approximately 1/4 of a gallon of hand sanitizer, labeled to keep out of reach of children. On 04/29/24 at 9:06 a.m., the maintenance supervisor stated the staff must have unlocked the key pads to the showers and supply storage. They stated they would need to reset the locks. On 04/29/24 at 9:07 a.m., the maintenance supervisor stated the room near the nurses' station on halls #5 and #6 was a PPE room and it should be locked. On 04/29/24 at 9:10 a.m., the maintenance supervisor locked the hall #2 shower room.

Based on record review and interview, the facility failed to ensure residents on antipsychotic medications were assessed for tardive dyskinesia for three (#3, 34, and #32) of five sampled residents reviewed for unnecessary medications. The administrator identified 50 residents who received psychotropic medications. Findings: The Psychotropic Management Guidelines policy, dated 07/26/23, read in part, .Licensed Nurse will complete Psychoactive Medication Review on Admission, Quarterly, and Annually, and as needed . 1. Resident #3 had diagnoses which included paranoid schizophrenia. The Medical Director/Director of Nursing Consolidated Report from the pharmacist, dated 05/03/23, read in part, .Please ensure AIMS evaluation is done quarterly while taking antipsychotic medications . The Notes to Nursing form from the pharmacist, dated 06/08/23, read in part, .Please ensure AIMS evaluation is done quarterly while taking antipsychotic medications . Review of the electronic clinical record revealed the last AIMS assessment had been completed on 10/08/23. A Physician Order, dated 03/03/24, documented the resident was ordered Seroquel (an antipsychotic medication) 50 mg at bedtime. The quarterly assessment, dated 03/14/24, documented the resident had received an antipsychotic medication on a routine basis. 2. Resident #34 had diagnoses which included schizophrenia. Review of the electronic clinical record revealed the last AIMS assessment had been completed on 09/25/23. The Physician Order, dated 03/18/24, documented the resident was ordered Zyprexa (an antipsychotic medication) 30 mg at bedtime. The quarterly assessment, dated 03/27/24, documented the resident had received an antipsychotic medication on a routine basis. 41809 3. Resident #32 admitted with diagnoses which included, Wernicke's encephalopathy, dysphagia, and dementia. Physician orders documented Resident #32 was ordered Depakote Sprinkle (an antipsychotic medication), Lamictal (an anticonvulsant medication), Lorazepam (an anxiolytic medication), and Zyprexa (an antipsychotic medication). Review of AIMS assessments for Resident #32 revealed missing quarterly assessments in September 2023, December 2023, and March 2024. Review of the clinical record for Resident #32 revealed psychoactive evaluations were not completed. On 05/03/24 at 9:54 a.m., RN #1 stated AIMS assessments were completed by the DON, to monitor for tardive dyskinesia, in the electronic clinical record. They stated they would find out how often AIMS assessments were completed. On 05/03/24 at 10:10 a.m., RN #1 stated they did not complete AIMS assessment but they monitored for side effects and behaviors every shift. On 05/03/24 at 10:27 a.m., the ADON stated the charge nurses were to complete AIMS assessments quarterly. On 05/03/24 at 11:10 a.m., RN #1 stated Resident #3 and Resident #32 did not have monitoring for symptoms of tardive dyskinesia but Resident #34 had involuntary movements listed on their side effect monitoring. RN #1 stated they used to complete AIMS assessments but now only do behavior and side effect monitoring on the treatment records. On 05/03/24 at 11:48 a.m., RN #1 stated they did not find psychoactive medication reviews, indicated in the facility's policy for Resident #3, #34, or Resident #32.

Based on observation, record review, and interview, the facility failed to ensure snacks were offered in the evening for seven (#8, 13, 53, 63, 79, 41, and #39) of seven sampled residents reviewed for snacks. The administrator identified 73 residents who received meals from the kitchen. Findings: The Meals and Snacks policy, dated 03/31/21, read in part, .Nursing shall be responsible for distributing snacks to the residents .An evening snack shall be provided by Nutritional Services and offered to the residents by Nursing .Nursing shall be responsible for offering and/or distributing snacks . On 05/01/24 at 1:30 p.m., Resident #39 and Resident #41 stated staff did not offer snacks in the evening. They stated they had to go to the nurses station to request one. On 05/01/24 at 8:52 p.m., four residents were observed in wheelchairs at the front nurses station requesting a snack. LPN #3 obtained snacks for the residents. Other staff were not observed offering snacks to the residents in their rooms. On 05/01/24 at 8:56 p.m., Resident #79 stated they had not been offered an evening snack. On 05/01/24 at 8:58 p.m., Resident #41 stated they had not been offered an evening snack. On 05/01/24 at 9:00 p.m., Resident #63 stated they had not been offered an evening snack. On 05/01/24 at 9:01 p.m., Resident #53 stated they had not been offered an evening snack but would like to have one. On 05/01/24 at 9:03 p.m., Resident #13 stated they had not been offered an evening snack and had to go to the nurses station to request one. On 05/01/24 at 9:03 p.m., Resident #8 stated they had obtained a snack from the nurses station. On 05/01/24 at 9:07 p.m., LPN #3 stated residents either came to the nurses station to get a snack or they offered snacks when they did evening treatments. On 05/01/24 at 9:12 p.m., CNA #6 stated if residents asked for a snack they knew where to get the snacks. CNA #6 stated they did not know how residents, who were bed bound obtained snacks, but if the resident asked for a snack they would provide a snack for them. On 05/01/24 at 9:16 p.m., CNA #5 exited the room of Resident #53 after assisting them to bed. They stated they had offered every resident a snack on their hall. They were asked if Resident #53 had been offered a snack. CNA #5 stated they had not offered Resident #53 an evening snack. On 05/03/24 at 3:18 p.m., RN #1 stated the nurses were to distribute snacks to make sure residents who were diabetic received one in the evening. RN #1 stated residents could also go the nurses station anytime to request a snack. They stated they knew residents who were diabetic were offered a snack because they had physician's orders and it was on the treatment sheet.

Based on observation, record review, and interview, the facility failed to ensure infection control protocols were followed during medication administration. The administrator identified 73 residents who received medications. Findings: The Super Sani-cloth germicidal disposable wipe directions read in parts, .Special instructions for cleaning and decontamination against HIV-1, hepatitis B virus (HBV) .All blood and other bodily fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Open, unfold and use first germicidal wipe to remove visible soil .Kills HIV-1 .precleaned environmental surfaces .previously soiled with blood/body fluids . On 05/01/24 at 10:55 a.m., LPN #2 entered the room for Resident #36 to check their blood sugar with a glucometer that was not properly sanitized. LPN #2 wiped the glucometer with a Sani-wipe but did not wait the full two minutes and wipe it again to ensure blood borne pathogens were eradicated. LPN #2 returned to the cart, did not sanitize their hands, drew insulin into a syringe, then returned to the room to administer the medication, donned gloves and administered the insulin. On 05/03/24 at 1:04 p.m., RN#1 stated the infection control protocol for glucometers was to follow the manufacturer guidelines of the Sani-wipes. They stated they wipe down the glucometer and let it air dry for two minutes before and after use with purple top Sani-wipes.

Based on record review and interview, the facility failed to ensure mail delivery to residents on Saturdays. The DON identified 73 residents who resided in the facility. Findings: On 05/01/24 at 1:30 p.m., during a resident group meeting, four residents stated mail was not delivered on Saturdays. On 05/02/24 at 4:25 p.m., the activity director stated they obtained mail from the post office and delivered it to the residents Monday through Friday. They stated they did not know if anyone delivered mail to the residents on Saturdays. On 05/02/24 at 4:30 p.m., the administrator stated they delivered mail to the residents Monday through Friday but no one delivered mail to the residents on Saturdays.

Based on record review and interview, it was determined the facility failed to ensure the discharge was documented in the resident medical record for one (#78) of one sampled resident for discharge. The administrator identified 73 residents who resided in the facility. Findings: Resident #78 had diagnoses which included type two diabetes. Review of the medical record for Resident #78 revealed no documentation notification was provided to the physician or resident representative of the transfer. A nurse's note, dated 03/04/24, documented a phone call to an unidentified hospital inquiring about the condition of Resident #78. On 05/01/24 at 1:35 p.m., LPN #1 stated they did not know why Resident #78 was transferred but the reason should be in the medical record. They stated the reason for the transfer could be found in the medical record. After reviewing the medical record LPN #1 stated there was no note regarding the transfer of Resident #78. On 05/02/24 at 9:20 a.m., the administrator stated Resident #78 was transferred during the transition period to an electronic medical record system and the documentation would be in the paper chart. On 05/02/24 at 10:19 a.m., the administrator stated the Resident #78 was transferred on the weekend and the nurse did not document the discharge to the hospital.

Based on record review and interview, the facility failed to ensure assessments were accurate for one (#55) of 24 sampled residents whose assessments were reviewed. The MDS coordinator identified eight residents who received anticoagulant medications. Findings: The MDS 3.0 policy, dated 04/26/23, read in parts, .The MDS coordinator and/or IDT will use the following when completing the assessment as directed by the RAI User's Manual .Documentation in the Medical Record . Resident #55 had diagnoses which included hypertension. The quarterly assessment, dated 02/28/24, documented the resident had received an anticoagulant medication during the seven day look back period. The Medication Administration Record, dated 02/01/24 through 02/29/24, did not reveal Resident #55 had received an anticoagulant medication during the seven day look back period. On 05/02/24 at 11:36 a.m., the MDS coordinator stated they had reviewed the clinical record and had coded the anticoagulant use because the resident was administered Plavix (an antiplatelet medication). They stated they would need to submit a corrected assessment.

Based on observation, record review, and interview, the facility failed to ensure dependent residents were offered/received baths according to preference for one (#15) of one sampled resident who was reviewed for ADLs. The administrator identified 58 residents who were dependent for ADLs. Findings: An ADL Care Bathing policy, dated 07/21/22, read in part, .Nursing staff will assist in bathing Residents to promote cleanliness and dignity . Resident #15 had diagnoses which included colostomy status and acute kidney failure. A quarterly assessment, dated 04/17/24, documented Resident #15 required partial to moderate assistance for bathing and was moderately impaired in cognition for daily decision making. On 04/29/24 at 1:33 p.m., Resident #15 was observed to have oily hair. Resident #15 stated they received approximately one shower per week. A Care Plan, revised 04/30/24, documented Resident #15 required one person assistance with bathing and to offer a bed bath when a shower was not tolerated or was contraindicated. The Task documentation in the electronic clinical record, dated 04/08/24 through 05/01/24, documented bathing on Monday, Wednesday, and Friday on the dayshift. The bathing task documented eight out of 14 opportunities were completed. No refusals were documented in the electronic clinical record. On 05/03/24 at 2:22 p.m., CMA #1 stated Resident #15 received two showers a week with moderate assistance but should receive three. On 05/03/24 at 2:25 p.m., CNA #2 stated Resident #15 received showers on Tuesday, Thursday, and Saturday. They stated they showered and shaved Resident #15 with moderate assistance. CNA #2 stated Resident #15 refused if they had a shower the day before. They stated refusals were documented on paper with signatures of the resident and nurse. On 05/03/24 at 4:45 p.m., the administrator stated they were not aware of issues regarding residents not receiving baths as scheduled.

Based on observation, record review, and interview, the facility failed to ensure range of motion interventions were implemented for one (#47) of one sampled resident who was reviewed for limited range of motion. The administrator identified 20 residents who had limited range of motion. Findings: The Establishment of an Individual Restorative Program policy, dated 01/01/14, read in part, .To provide treatment and services to maintain and improve functional abilities per physician orders . Resident #47 had diagnoses which included impingement syndrome of the right and left shoulders. A Physician Order, dated 09/23/22, documented restorative therapy. The Restorative Training form, dated September 2023, documented to remove Resident #47 from the restorative nursing program. On 04/29/24 at 11:56 a.m., Resident #47 stated the last two fingers on their left hand was contracted. They stated they did not receive splints or devices for the contracture. Resident #47 stated one staff member would provide range of motion exercises at times but not consistently. The Care Plan, revised 04/30/24, documented the resident had ADL self care performance deficit, bilateral contractures, and was on restorative nursing services when the resident would participate. The Care Plan documented the resident had limited physical mobility and was on the restorative program three times per week for contractures. On 05/02/24 at 2:19 p.m., Resident #47 was observed in bed. The last two fingers of Resident #47's left hand was observed to have limited range of motion. Review of the restorative therapy binder did not reveal Resident #47 was receiving restorative nursing services. The Order Summary Report, dated 05/03/24, revealed the order for restorative therapy was an active order. On 05/03/24 at 10:01 a.m., restorative aide #1 stated they had a list of residents on the restorative program but Resident #47 was not on the current list. They stated they were not aware of any interventions for limited range of motion for Resident #47. On 05/03/24 at 10:07 a.m., the MDS coordinator stated Resident #47 had admitted to the facility with contractures and had been on and off of the restorative nursing program. On 05/03/24 at 12:57 p.m., RN #1 stated Resident #47 had requested restorative therapy earlier in the day. They stated the resident had been on restorative previously but had refused. On 05/03/24 at 1:39 p.m., the MDS coordinator stated the care plan was incorrect because Resident #47 was not on the restorative program. They stated they would need to review the clinical record to determine what interventions were in place for the resident's contractures. No further information was provided by the end of the survey.

Based on observation, record review, and interview, the facility failed to ensure the urinary drainage bag was properly positioned for one (#48) of one resident observed for urinary catheter. The Resident Matrix documented six residents who had a catheter. Findings: Resident #48 had diagnoses which included hydronephrosis with renal and ureteral calculus. The Care Plan, revised 02/06/24, documented the resident had a nephrostomy tube related to ureteral obstruction, specimens should be obtained from the nephrostomy tube by gravity, and the drainage bag should be maintained in a position below the level of the kidney at all times. The quarterly assessment, dated 04/17/24, documented the resident was cognitively intact for daily decision making. On 04/29/24 at 1:35 p.m., Resident #48 was observed lying in bed with the nephrostomy drainage bag on a towel, on the bed, by the resident's feet. On 05/01/24 at 3:48 p.m., Resident #48 was observed lying in bed with the nephrostomy drainage bag on a towel, on the bed by the resident's feet. On 05/03/24 at 10:58 a.m., CNA #2 stated they positioned the nephrostomy drainage bag on the bed but there were times they found the bag to be hanging on the bed frame between the bed and the wall. They stated in those instances they moved the drainage bag to the bed to prevent it from getting smashed between the wall and the bed. On 05/03/24 at 10:59 a.m., LPN #2 was observed to provide nephrostomy care. The drainage bag was observed to be on a towel, on the resident's bed by their feet after LPN #2 had completed care. On 05/03/24 at 11:08 a.m., LPN #2 stated they placed the nephrostomy bag on the resident's bed at the same level as the kidney. LPN #2 stated the resident had adequate output when it was positioned on the bed. On 05/03/24 at 11:55 a.m., RN #1 stated they would need to find out where to place the nephrostomy drainage bag for Resident #48. On 05/03/24 at 12:54 p.m., RN #1 stated the nephrostomy drainage bag was to be placed below the kidney, to gravity, but Resident #48 preferred for the nephrostomy drainage bag to be placed on the bed. On 05/03/24 at 3:23 p.m., RN #1 stated the resident's preference related to the drainage bag placement was not documented. On 05/03/24 at 4:18 p.m., the resident denied wanting to have the nephrostomy drainage bag on the bed.

Based on observation and interview, the facility failed to ensure medications were securely stored for two (100/200 hall medication cart and 500/600 hall medication cart) of four medication carts observed. The DON identified four medication carts. Findings: On 04/30/24 at 12:57 p.m., the 500/600 hall medication cart was observed to be by the nurse's station, unlocked, and unattended. On 04/30/24 at 12:59 p.m., LPN #1 entered the nurse's station but had their back to the medication cart which remained unlocked and unattended. On 04/30/24 at 1:11 p.m., CMA #2 approached the medication cart and locked it before leaving it unattended. On 05/01/24 at 10:55 a.m., LPN #2 was observed to enter the room for Resident #36 to perform a fingerstick blood sugar check. LPN #2 was observed to leave the 100/200 hall medication cart unlocked and unattended. On 05/02/24 at 2:30 p.m., LPN #2 stated they were to secure medication carts before leaving them unattended. On 05/03/24 at 10:35 a.m., CMA #2 stated they were to make sure they locked the medication carts when they were unattended. On 05/03/24 at 1:04 p.m., RN #1 stated medication carts were to be secured when they were left unattended.

Based on observation and interview, the facility failed to ensure food was served at a palatable temperature for one (noon meal) of one meal observed for palatability. The administrator identified 73 residents who received meals from the kitchen. Findings: On 04/29/24 at 10:38 a.m., Resident #69 stated their food was served cold to their room and at times the dietary department put their cold salad on the plates with hot food, which wilted the vegetables in the cold salad. On 05/01/24 at 1:30 p.m., during a resident group meeting, Resident #39 and Resident #41 stated they ate their meals in their rooms and their food was often served cold. On 05/01/24 at 12:15 p.m., the last tray on the back hall cart was provided to the survey team. The cornbread, broccoli with cheese, and potatoes were not observed to be served at a palatable temperature when tasted. On 05/03/24 at 4:45 p.m., the adminsitrator stated they had not received any complaints about cold food but would look into the concern.

Based on record review and interview, the facility failed to ensure weights were monitored as recommended by the registered dietitian for one (#56) of one sampled resident for nutrition. The administrator Identified 73 residents who resided in the facility. Findings: Resident #56 had diagnoses which included adult failure to thrive and dementia. The electronic health record, dated 03/07/24, documented a weight of 133.2 pounds. On 04/01/24 the electronic health record documented a weight of 113.2 pounds, a loss of 20 pounds in 30 days. On 05/03/24 at 10:44 a.m., the registered dietician stated they addressed the weight loss of Resident#56 by recommending weekly weights. They stated the weights may have been inaccurate and brought this to the attention of the administrator. The dietician was told the facility had identified the inaccurate weights and were correcting it. On 05/03/24 at 11:50 a.m., RN #1 stated the DON, ADON or administration was responsible for reviewing recommendations made by the registered dietitian. They stated the recommendation was missed and the facility would begin the weekly weights today.

Based on record review and interview, the facility failed to ensure medication orders were implemented in a timely fashion for one (#1) of one resident reviewed for physician orders. The administrator reported the facility census was 73. Findings: Resident #1 had diagnoses which included unspecified psychosis and anxiety disorder. A significant change assessment, dated 12/12/23, documented Resident #1 was moderately impaired for daily decision making. A nurse note, dated 12/12/23 at 3:35 p.m., documented the physician had ordered Resident #1's olanzapine reduced from 10mg twice a day to 5mg at bedtime. A review of Resident #1's physician orders indicated the order for olanzapine 10mg twice a day was discontinued on 12/12/23. The physician orders further documented the order for olanzapine 5mg at bedtime was not entered until 12/15/23. On 01/08/24 at 9:00 a.m., the DON stated she received the order for olanzapine 5mg at bedtime on 12/12/23 but it was not started until 12/15/23.

Based on record review and interview, the facility failed to ensure laboratory tests were completed per physician's orders for one (# 2) of five residents reviewed for laboratory services. The administrator reported the census was 73. Findings: Resident #2 had diagnoses which included diabetes mellitus and cerebral palsy. A quarterly assessment, dated 09/30/23, documented the resident was cognitively intact and required extensive physical assistance from staff. A physician order, dated 12/11/23, documented an A1c laboratory test was to be obtained on 12/11/23 and then every three months. A review of Resident #2's clinical record did not document an A1c was drawn on 12/11/23. A review of Resident #2's clinical record did not document the resident had refused any laboratory tests. On 01/04/24 at 2:23 p.m., the DON stated the ordered laboratory test had not been completed. They stated the order had been put in the lab computer system, but the lab company had not completed the order.

Based on record review and interview, the facility failed to ensure surgical wound treatment orders were obtained and treatments were provided for one (#69) of three residents who were reviewed with wounds. The DON identified one resident with a surgical wound. Findings: A Physician's Orders policy, dated December 2018, read in parts, .At the time each resident/patient is admitted , the facility will have Physician's orders for their immediate care . An Emergency Physician Care policy, dated December 2018, read in part, .Contact the facility's Medical Director or their alternate in the event Physician services are required and the attending and/or on-call Physician cannot be reached . Resident #69 was admitted on [DATE] with diagnoses which included partial traumatic amputation of two or more left toes. The Hospital Discharge Summary, dated 01/25/23, read in part, .Admit Diagnoses .Right foot osteomylitis s/p transmetatarsal amputation w/ subsequent partial wound dehicence [sic] . Review of the discharge paperwork from the hospital, faxed to the facility on [DATE] revealed the resident had previously been on a wound vac and no discharge wound treatment orders had been documented. The hospital discharge paperwork documented on 01/23/23 the surgical wound measured 4.5cm in length, 15.1cm in width, and 2.9cm in depth. A Baseline Careplan, dated 01/25/23, documented the resident had skin integrity issues of the left toes. An Admission Summary note, dated 01/25/23 at 2:48 p.m., documented the resident had a wound on their right foot. A Skin/Wound note, dated 01/25/23 at 4:03 p.m., read in part, Resident admitted to facility from hospital with surgical wound to right foot s/p amputation all toes. Area has c/d/i dressing in place at this time. Will f/u with surgeon for tx orders. Charge nurse and DON aware . An Administrative Progress Note, dated 01/26/23 at 4:00 p.m., read in part, .Nurse from discharging facility called 01/26 at 1600 [4:00 p.m.] stating we did not have [the resident's] wound vac orders then stated 'Wait let me call you back' . A Health Status Note, dated 01/27/23 at 3:13 a.m., read in part, .Resident has a dressing to .right foot r/t amputation of .toes. Dressing currently CDI. Resident mentioned via a visitor .is supposed to have a wound vac in place . A Skin/Wound Note, dated 01/27/23 at 11:08 a.m., read in part, .[Wound physician name withheld] .reports that resident must f/u with surgeon 60-90 days post surgery. If [surgeon] would like a consult visit .[they] must write a referral to do so. Social services reaching out to surgeon to explain the above info. [Wound care physician] will not see resident at this time. DON aware . An Administrative Progress Note, dated 01/27/23 at 2:02 p.m., read in part, .[Wound physician's name withheld] to look at wound in house today. Facility will follow-up with surgeon. Attempted to reach d/c facility nurse to follow-up on wound vac orders/explanation that they had not sent . The Order Summary Report, dated January 2023, read in part, .Surgical wound right foot: Cleanse with normal saline, pat dry, apply medihoney to wound bed, pack with calcium alginate and cover with dry dressing q day and prn soilage, one time a day for wound healing .Order date 01/27/23 .Start date 01/28/23 .Monitor Surgical wound right foot: for s/s of infection q day .Order date 01/27/23 .Start date 01/28/23 . Review of the order summary report did not reveal a treatment order prior to 01/27/23. Review of the January 2023 MAR/TAR revealed the wound care treatment order was first completed on 01/28/23. The Weekly Skin/Wound Assessment, dated 01/28/23 at 3:23 p.m. and signed and locked on 01/29/23 at 5:15 p.m., documented the resident had a surgical incision to the right toes. The assessment read in part, .Surgical incision wound to right amputation site measuring 17cm in length from lateral foot to posterior, lateral wound width is 5.5cm, mid width at top of foot is 5cm, with exposed bone in 3 areas, depth at right posterior tunneling area is 2.5cm, mid tunneling area is 1.5cm. Dark discoloration to top of foot down to lateral is measuring 8cm with small scabbed area, wound bed is approximately 90% slough and 10% necrotic tissue, thick purulent exudate noted . The wound measurements documented in this assessment, which was signed by LPN #4, revealed a decline in the wound when compared to the measurements obtained at the hospital on 01/23/23 as indicated above. This wound assessment was the first documented assessment in the clinical record which included wound characteristics/description since admission on 01/25/23. A Physician Evaluation v2, signed by APRN #1 on 01/29/23, read in parts, .Effective date 01/25/2023 13:05 [1:05 p.m.] .HPI .amputation of the 4th-5th toes on .right foot and was receiving IV cefepime though [sic] 01/14/23. During [the resident's] followup [sic] visit with [Surgeon's name withheld] - amputation, wound vac placement .on 1/6 [01/06/23] for 1 day. wound adhissed [sic] .Subjective/Objective Additional Information right foot osteomylitis klebsiella pneumoniae cirtobacter coag negative staph post partial right foot amputation .right foot cellulitis/wound . A Physician's Telephone Order, dated 01/30/23, read in part, Augmentin 100mg po bid x 30 days. Review of the clinical record did not reveal this medication was provided as ordered by the physician. A Health Status Note, dated 01/30/23 at 1:01 p.m., documented the resident was sent to the emergency room for evaluation and treatment of the open wound to the right foot which had purulent drainage. A Physician Progress Note, dated 01/30/23, read in part, .presented to ER from SNF with worsening R foot infection .the SNF did not do wound care so [the resident's] infection got worse and [the resident] was sent to ER . A Hospital Discharge Summary, dated 02/04/23, read in part, .admitted for evaluation of worsening right foot infection .underwent surgical debriedment, surgical pathology report showed active osteomylitis .' On 03/24/23 at 9:41 a.m., the administrator and ADON was asked about the treatment orders for Resident #69. The administrator stated they had called the referring hospital several times to obtain wound care orders for the resident's surgical wound. The ADON and administrator was asked how the facility's medical director was involved in the resident's care. The administrator stated the medical director had not observed the surgical wound for Resident #69. The ADON and administrator was asked why the resident's physician or the medical director was not contacted for treatment orders for the surgical wound. The ADON stated they should have contacted the facility's physicians when they were unable to contact the surgeon. The administrator and ADON were asked what wound care orders had been obtained from 01/25/23 until 01/27/23. The administrator stated they were able to contact the surgeon on 01/27/23 and completed a dressing change. The administrator was asked where the treatment was documented for the dressing change on 01/27/23. They stated they knew the resident had received a dressing change on 01/27/23 but they dropped the ball on 01/26/23. On 03/24/23 at 12:46 p.m., LPN #4 was asked what the facility's protocol was if a wound was assessed to have purulent drainage. They stated when they had assessed the wound for Resident #69 APRN #1 was at the facility. They stated APRN #1 assessed the surgical wound and was going to contact the resident's physician for antibiotic orders. LPN #4 was asked when the Weekly Skin/Wound Assessment had been completed. They stated they completed the assessment on 01/28/23. On 03/24/23 at 1:16 p.m., APRN #1 was asked about the surgical wound for Resident #69. They stated they had assessed the wound on 01/28/23 or 01/29/23 with LPN #4. APRN #1 stated the wound had dehisced and the hospital had dressed it and sent the resident to the facility. They stated their assessment revealed the wound was open, bone was visible, and necrotic. APRN #1 was asked what interventions had been implemented following their assessment. APRN #1 stated they contacted the physician, obtained antibiotic orders, and was to start the process of to transfer the resident back to the hospital. APRN #1 was asked what antibiotics had been ordered. They stated the order should be in the EMR. They were asked if they had been contacted for treatment orders for Resident #69 prior to the assessment on 01/28/23 or 01/29/23. They stated no. On 03/24/23 at 1:41 p.m., the DON was asked who was responsible to obtain treatment orders for residents with surgical wounds. They stated the charge nurse. The DON was asked who the charge nurse was to obtain the orders from. They stated the referring hospital. They were asked what the protocol was if a resident was sent to the facility without treatment orders. The DON stated the charge nurse was to contact the facility's physicians for orders. The DON was asked what the time frame was to obtain orders for surgical wounds after admission to the facility. They stated they would need to review the protocol. The DON was asked how they ensured treatment orders were obtained and wound treatments were completed. They stated they conducted wound meetings weekly. The DON was asked if an antibiotic had been ordered for Resident #69. They stated they would check the EMR. The DON was asked why wound care orders had not been obtained for the surgical wound before 01/27/23. The DON stated they did not have an answer. On 03/24/23 at 2:12 p.m., the ADON provided a hand-written Physician's Telephone Order, dated 01/30/23, for Augmentin 100 mg bid for 30 days. The ADON was asked why the antibiotic order had not been obtained until 01/30/23, the date Resident #69 had been transferred to the emergency room . They stated they had written the wrong date and it should have been dated for 01/28/23. The ADON was asked why the antibiotic order had not been implemented. They stated the dosage was wrong and they thought LPN #4 was getting a clarification order. They stated they did not know why the antibiotic was not clarified and administered. On 03/27/23 at 5:29 p.m., the DON was asked if they had any further information on why treatment orders for the surgical wound had not been obtained until 01/27/23 and why the first treatment was not completed until 01/28/23. The DON stated, No I do not have any more information.

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for one (#1) of three sampled residents who had experienced falls. Resident #1 experienced a fall on 11/11/13 which resulted in actual harm when the resident sustained [REDACTED]. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A fall care plan, dated 04/08/13, documented, "Problem: falls occurred since last assessment one/two or more with non-injury R/T (blank)...Goal: Resident will have no injury related to falls QD...Approach...Assess for use of: (blank) (adaptive dvice (sic))...Assess resident for safety alternative...Use gait when helping to ambulate..." An annual assessment, dated 10/23/13, documented the resident was moderately impaired with cognitive skills for daily decision making. The resident required extensive assistance to total dependence with two+ persons physical assist with bed mobility, transfers, locomotion on and off unit, toilet use, and bathing. The resident had one fall with no injury since the prior assessment. A fall care plan, updated on 11/01/13, documented, "At risk for falls R/T previous falls...Approach: continue to monitor for falls, Always use 2 people to transfer..." An incident report, dated 11/11/13, documented, "CNA reports...resident...'she fell out of the sit-to-stand'...resident noted lying on floor on R side. CNA states that resident legs began to 'give out' and assisted resident to the floor...Upon visualization of skin (no) redness or discoloration noted. (No) swelling noted to bony prominences on R side resident was lying on...Retrain staff member on sit to stand use." A physician's telephone order, dated 11/12/13, documented, "Clarification: res is (changed) from sit to stand lift to total lift et x 2 staff..." A nurse's note, dated 11/12/13 at 12:00 p.m., documented, "Res c/o pain in R shoulder 10/10 unable to move (upper) extremities s difficulty. Dr. (name deleted) notified. N/O for bi-lat shoulder X-ray..." A nurse's note, dated 11/12/13 at 5:45 p.m., documented, "...Mobile x-ray called c report of R shoulder fx..." A state reportable incident report, dated 11/14/13, documented, "...CNA reports resident slid out of sit to stand. States residents legs gave out and assisted to floor. Resident denied any complaints of pain and no injury noted at that time. The next day resident's husband reported to Administrator that resident had fallen and now she is complaining of shoulder pain...new order received for an x-ray. X-ray reports shows fracture to right shoulder...final protective measure implemented to prevent reoccurrence is as follows: 1. resident will be a hoyer lift transfer. 2. Ortho consult 3. sling to right arm. 4. staff in-serviced if noticing any changes on resident capabilities of transferring to report to charge nurse to re-evaluate. 5. physical therapy referral..." On 12/30/13 at 3:25 p.m., the resident's husband was asked to explain what happened when the resident fell . He stated, "They didn't put her feet on the thing. Her feet went under the bed and down she went." On 01/06/13 at 11:50 a.m., The resident was observed being transferred from the bed to her wheelchair with the hoyer lift and two CNA's assisted. The resident was asked what happened when she fractured her shoulder. She stated, "My feet slipped and got caught and broke my shoulder. Now they get me up with this new lift and it's much better." At 2:46 p.m., CNA #1 was asked to describe what happened on 11/11/13 when the resident fell . She stated, "She didn't fall, I slid her to the floor cause her legs got weak. I was alone with her, we were short handed." She was asked what the procedure for the mechanical lifts were. She stated, "Two people." At 3:28 p.m., LPN #3 was asked what the procedure for the sit to stand lift was. She stated, "There needs to be two people." She was asked if there were two people on 11/11/13 when the resident fell . She stated, "No." At 3:45 p.m., the staff coordinator was asked what the procedure for the sit to stand lift was. She stated, "Two person. All of our lifts are two person."