Every finding on record at Durham-Hensley Health and Rehabilitation

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure the call light was in reach for 1 resident (Resident #50) of 63 residents observed.The findings include:Review of the facility's policy titled, Call System, dated 7/2025, revealed .the call light should be easily accessible to the Resident at all times .Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Dementia, Left Femur Fracture, and Syncope.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and was dependent on staff for ADL's [Activities of Daily Living] and mobility. Review of a comprehensive care plan dated 8/29/2025, revealed Resident #50 had .cognitive impairment .need help with activities of Daily Living .assistance extensive .During an observation on 6/8/2026 at 11:38 AM, revealed Resident #50 was sitting up in Broda chair (tilt in place wheelchair designed to provide positioning support, comfort, and pressure reduction) approximately 4 feet from bed and quarter size rail was in the up position. Further observation revealed the resident's call light was wrapped around the bed rail out of the resident's reach.During an observation on 6/8/2026 at 3:37 PM, revealed Resident #50 was sitting up in Broda chair approximately 4 feet from bed and quarter size rail was in the up position. Further observation revealed the resident's call light was wrapped around the bed rail out of the resident's reach.During an observation and interview on 6/8/2026 at 3:45 PM, with Certified Nurse Assistant (CNA) A in Resident #50's room, CNA A confirmed the call light wrapped around the side rail and out of Resident #50's reach. CNA A confirmed call lights should be within residents' reach at all times. During an interview on 6/8/2026 at 3:49 PM, Director of Nursing (DON) stated staff was to ensure call lights were within reach of the resident at all times.

Based on medical record review and interviews, the facility failed to notify the Long-Term Care (LTC) District State Ombudsman of resident discharges and transfers from the facility for 4 residents (Resident #7, Resident #1, Resident #37, and Resident #90) of 4 residents reviewed for discharges and transfers. The findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Sepsis, Diabetes Mellitus, and Urinary Tract Infection. Further review revealed the resident was transferred from the facility on 3/23/2026 and readmitted to the facility on [DATE].Review of an Interdisciplinary Progress note for Resident #7 dated 3/23/2026, revealed .resident to transfer to .ER [Emergency Room] via EMS [Emergency Medical Services].Review of a nursing home discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7's discharge assessment-return anticipated. Further review revealed the discharge status was a short-term general hospital.Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Infection, Dementia, and Sepsis. Further review revealed Resident #1 was transferred from the facility on 4/17/2026 and readmitted to the facility on [DATE].Review of an Interdisciplinary Progress note for Resident #1 dated 4/17/2026, revealed .sending resident out to .ER .EMS called .Review of a nursing home discharge MDS assessment dated [DATE], revealed Resident #1's discharge assessment-return anticipated. Further review revealed the discharge status was a short-term general hospital.Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Quadriplegia, Persistent Vegetative State, and Tracheostomy. Further review revealed Resident #37 was transferred from the facility on 4/3/2026 and readmitted to the facility on [DATE].Review of an Interdisciplinary Progress note for Resident #37 dated 4/3/2026, revealed .new order .resident to ER .EMS arrived for transfer .Review of a nursing home discharge MDS assessment dated [DATE], revealed Resident #37's discharge assessment-return anticipated. Further review revealed the discharge status was a short-term general hospital.Review of the medical record revealed Resident #90 was admitted to the facility on [DATE] with diagnoses including Sepsis, End Stage Renal Disease, and Acute Respiratory Failure. Further review revealed Resident #90 transferred from the facility on 3/19/2026 and did not return. Review of an Interdisciplinary Progress note for Resident #90 dated 3/19/2026, revealed .change in condition .send to .ER .Review of a nursing home discharge MDS assessment dated [DATE], revealed Resident # 90's discharge assessment-return anticipated. Further review revealed the discharge status was a short-term general hospital.During an interview on 6/10/2026 at 9:42 AM, the Social Service Director stated the Business Office Manager was responsible for notifying the (LTC) State District Ombudsman of all transfers and discharges. During an interview on 6/10/2026 at 9:45 AM, the Business Office Manager stated she had not notified the (LTC) State District Ombudsman of resident transfers or discharges since November of 2025 and confirmed transfers and discharges for Resident #7, Resident #1, Resident #37, and Resident #90 had not been reported to the (LTC) State District Ombudsman. During an interview on 6/10/2026 at 10:45 AM, the State District Long Term Care Ombudsman confirmed she had not received monthly notification of transfers and discharges since November of 2025 and stated the expectation is for monthly notification of all transfers and discharges.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain a medication error rate less than 5 percent when medications were omitted and not administered timely for 1 resident (Resident #10) of 5 residents observed for medication administration, resulting in 4 medication errors out of 42 medication administration opportunities, an error rate of 9.52%.The findings include:Review of the facility's policy titled, Medication Administration-Unit Dose Cart System, reviewed on 1/2026, revealed .correctly administer medications as prescribed .Utilize the 6 rights of medication administration .Verify right ordered time for administration .Review of the facility's policy titled, Medication Administration: Errors/Drug Reactions, reviewed 3/2026, revealed .ensure safe medication administration .A medication error is defined as .The wrong time (should not vary more than 60 minutes from established time schedule) .Omission of ordered medication . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hypertension, Obstructive and Reflux Uropathy, and Type 2 Diabetes Mellitus.Review of the Medication Record for Resident #10 dated 6/1/2026 - 6/9/2026, revealed an order for Isosorbide Mononitrate (medication used to prevent chest pain in people with heart disease) 30 mg (milligrams) by mouth once daily at 8:00 AM; Metformin Hydrochloride (medication used to manage high blood sugar in patients with Type 2 Diabetes) 850 mg by mouth daily at 8:00 AM; Metoprolol Tartrate (medication used to treat high blood pressure) 25 mg by mouth every 12 hours at 8:00 AM and 8:00 PM; and Oxybutynin (medication used to treat overactive bladder) 10 mg by mouth daily at 10:00 AM.During an observation on 6/9/2026 at 8:13 AM, with Registered Nurse (RN) B during the 8:00 AM medication pass, RN B prepared and administered Oxybutynin 10 mg by mouth. RN B did not administer the 8:00 AM doses of Isosorbide Mononitrate 30 mg; Metformin Hydrochloride 850 mg; Metoprolol Tartrate 25 mg.During an interview on 6/9/2026 at 12:08 PM, RN B confirmed Resident #10's Oxybutynin 10 mg tablet was scheduled for 10:00 AM. RN B stated medications could be given 1 hour before the scheduled time or 1 hour after (the 10:00 AM medication could be given between 9:00 AM - 11:00 AM) to be considered on time. RN B confirmed the Oxybutynin 10 mg tablet had been administered with the 8:00 AM medications at 8:13 AM and had been given early. RN B confirmed the 8:00 AM doses of Isosorbide Mononitrate 30 mg, Metformin Hydrochloride 850 mg, and Metoprolol Tartrate 25 mg were held because they used to be scheduled for a different time and she assumed had already been administered. RN B stated she had not checked the Medication Record to determine if the medications had been administered. During an interview on 6/9/2026 at 12:11 PM, the Director of Nursing (DON) confirmed medications were to be given no earlier than an hour before the scheduled time and no later than 1 hour after the scheduled time. The DON confirmed Resident #10's Oxybutynin 10 milligrams was given early. During an interview on 6/9/2026 at 2:23 PM, the DON confirmed Resident #10's Isosorbide Mononitrate 30 mg, Metformin Hydrochloride 850 mg, and Metoprolol Tartrate 25 mg medications were scheduled to be administered at 8:00 AM and were not given within the 1-hour window before or after the scheduled time. The DON confirmed medication not given within the prescribed time or omitted was considered a medication error. The DON confirmed Resident #10 was being monitored and suffered no negative outcomes from the medication omissions.

Based on facility policy review, medical record review and interview, the facility failed to monitor for side effects of anti-coagulant medications for 2 residents (Resident #29 and Resident #46) of 5 residents reviewed for anti-coagulant medication use. The findings include: Review of the facility's policy titled, Anticoagulation-Clinical Protocol, revised 3/2017, showed .The nurse will be responsible for .Observe to [for] symptoms of bleeding .Notify physician of any signs and symptoms of bleeding . Record review showed Resident #29 was admitted on [DATE] with a diagnosis of Atrial Fibrillation. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], showed Resident #29 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had no cognitive impairment. Further review showed Resident #29 had an active diagnosis of Atrial Fibrillation and had received an anti-coagulant medication for 6 or 7 days. Review of the comprehensive care plan dated 10/26/2022, showed Resident #29 needed an anti-coagulant medication (Warfarin) to help with diagnosis. Review of the Active Orders Report dated 8/23/2023, showed Warfarin Sodium 1 milligram (mg) at bedtime for Atrial Fibrillation. Record review showed Resident #46 was admitted on [DATE] with a diagnosis of Peripheral Vascular Disease (PVD). Review of the Annual MDS dated [DATE], showed Resident #46 scored a 12 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Further review showed Resident #46 had an active diagnosis of Peripheral Vascular Disease and had received an anti-coagulant medication for 7 of 7 days. Review of the comprehensive care plan dated 6/10/2021, showed Resident #46 needed an anti-coagulant medication (Eliquis) to help with diagnosis. Review of the Active Orders Report dated 8/22/2023, showed Eliquis 5mg twice daily for PVD. Review of the Medication Administration Records (MAR) from 8/1/2023-8/22/2023, showed no anti-coagulant medication monitoring or the monitoring of side effects for the anti-coagulant medications had been ordered for Resident #23 and Resident #46. During an interview on 8/23/2023 at 8:02 AM, the Licensed Practical Nurse (LPN) #1 stated there was no anti-coagulation side effect monitoring in place for Resident #46. LPN #1 stated the facility does not document anti-coagulation medication side effects in the medical record. During an interview on 8/23/2023 at 8:07 AM, LPN #2 stated there was no anti-coagulation medication side effect monitoring in place for Resident #29. During an interview on 8/23/2023 at 8:13 AM, the Nurse Manager confirmed there was no anti-coagulation medication side effect monitoring on the medical record for Resident #29. During an interview on 8/23/2023 at 1:23 PM, the Director of Nursing (DON) confirmed there was no anti-coagulation medication side effect monitoring on the medical record for Resident #46.

Based on facility policy review, record review, observation and interview, the facility failed to develop a comprehensive care plan to meet the trauma informed care needs of 1 resident (Resident #9) of 29 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Trauma Informed Care, dated 7/2023, showed .Trauma survivors must receive .trauma-informed care .the interdisciplinary team .will develop a care plan to identify triggers and interventions to minimize .effect of the trigger for the resident . Resident #9 was admitted to the facility on [DATE] with diagnoses including Transient Cerebral Ischemic Attacks and Post Traumatic Stress Disorder (PTSD). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 was cognitively intact and had no behaviors. Review of a care plan showed Resident #9 needed psychotropics to help with mental diagnoses including PTSD. No description of triggers was documented. Review of Social PTSD Screen dated 5/2/2023 showed no description of triggers documented. Review of physician orders showed Ativan (a medication used for anxiety) 0.5 milligrams (mg, a unit of measure) twice a day, dated 7/11/2023 and Trazodone (a medication used for insomnia) 150 mg at bedtime, dated 5/23/2023. Review of a Psychiatric Evaluation dated 7/18/2023, showed Resident #9 had a diagnosis of PTSD. Orders were documented for staff to monitor for changes in mood and behaviors and to continue medications as prescribed, because the resident was stable on the current doses. During an observation and interview on 8/21/2023 at 11:02 AM, Resident #9 stated she had a trauma in her life, and loud noises were one of the triggers for her PTSD. The resident stated she knew staff members that she could talk to when upset, and they wouldn't talk at her, but they listened to her and calmed her. The resident also stated she had no problems or distress from her PTSD during her stay at the facility. No behaviors were noted during the observation. During an interview on 8/23/2023 at 10:55 AM, Certified Nursing Assistant #2 stated she cared for Resident #9 frequently and had never witnessed any behaviors or distress related to PTSD from the resident. During an interview on 8/23/2023 at 3:13 PM, the MDS Coordinator stated when a resident had a diagnosis of PTSD, the facility ensured a care plan was complete and the resident's needs were met. The MDS Coordinator reviewed the care plan and stated no triggers were identified. The MDS Coordinator stated based on the policy, triggers should be described on the care plan and confirmed no triggers were described to make it a person-centered, trauma informed care plan.

Based on facility policy review, observation and interview, the facility failed to ensure garbage and refuse was properly contained in 1 of 2 dumpsters. The findings include: Review of facility policy titled, Trash Disposal, dated 2/27/2020, showed .The Food Service department will dispose of trash appropriately and maintain the dumpster area for cleanliness and prevention of rodents . During an observation and interview with the Certified Dietary Manager on 8/21/2023 at 10:56 AM, showed 1 dumpster containing several bags of refuse and absent of a dumpster drain plug allowing rodents access into the dumpster. The Certified Dietary Manager confirmed the dumpster drain plug was missing allowing possible access of rodents.

Based on record review and interview the facility failed to resubmit a timely Level l (one) Pre-admission Screening and Resident Review (PASRR) for 1 resident (#40) of 6 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Pre-Admission Screening & Resident Review (PASRR), dated ,d+[DATE], showed .Level l's are submitted- For everyone regardless of pay source admitting to a Medicaid certified Nursing Facility .Expiration of a time-related stay .Submit a new level l no less than 10 days before expiration date . Resident #40 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, General Anxiety Disorder, and Post-Traumatic Stress Disorder. Record review of a PASRR dated [DATE] showed .Your level l screen shows evidence of serious mental illness or intellectual/ development .Further PASRR review is not needed because you meet criteria for a short-term convalescence stay. This means you are approved for up to 60 days in a nursing home .If you or your care provider thinks you need to stay longer than sixty (60) days, then a nursing home staff member must submit a new Level l screen . Record review from [DATE] - [DATE] showed no additional PASRR had been completed or submitted by the facility. Review of a PASARR dated [DATE] showed .Please be advised: This review is a federal compliance issue due to untimeliness of submission with an expired approval .an onsite Level ll will be initiated . Interview with the Director of Nursing (DON) on [DATE] at 9:11 AM, in the conference room, confirmed the facility failed to resubmit a timely Level l PASARR for Resident #40.

Based on facility policy review, observation and interview, the facility failed to distribute and serve food under sanitary conditions for 1 of 2 halls observed for dining. The findings include: Review of the facility policy titled, Hand Hygiene, revised 10/2022, showed .the facility considers hand hygiene to be the single most important factor in control of infection .an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations .After contact with objects .in the immediate vicinity of the resident .Before and after eating or handling food . During an observation on 8/21/2023 at 12:01 PM, the Certified Nursing Assistant (CNA) #1 had left room [ROOM NUMBER]A, failed to sanitize her hands, and opened the dining cart to retrieve another resident's meal tray. CNA #1 delivered the meal tray to the resident in room [ROOM NUMBER]B. CNA #1 had brought 48B's breakfast tray out of the room and placed it in the bottom of the dining cart. CNA #1 retrieved a new lunch tray from the dining cart, without sanitizing the hands, and delivered the lunch tray to the resident in room [ROOM NUMBER]. The resident in room [ROOM NUMBER] refused the meal tray. CNA #1 returned the refused tray to the dining cart and failed to sanitize the hands. CNA #1 retrieved another meal tray from the dining cart and entered room [ROOM NUMBER]. CNA #1 assisted Resident #9 with meal tray setup and had exited the room into the hallway. CNA #1 was stopped prior to entering any additional rooms. During an interview on 8/21/2023 at 12:07 PM, CNA #1 stated she was only required to sanitize her hands after delivering a meal tray to every 3rd resident. CNA #1 confirmed she did not sanitize her hands after carrying 3 different trays into 3 resident rooms, handling Resident #9's utensils, and touching objects in resident rooms. During an interview on 8/23/2023 at 10:49 AM, the Certified Dietary Manager (CDM) stated it was the expectation of staff handling or delivering meal trays to sanitize the hands after leaving a resident room. The CDM confirmed CNA #1 did not maintain a sanitary food delivery environment due to inadequate hand hygiene.

Based on facility policy review, record review, observation and interview, the facility failed to implement interventions to prevent accidents for 1 resident (Resident #32) of 3 residents reviewed for accidents. The findings include: Review of the facility's policy titled, Fall Prevention Program, dated 4/2023, showed .Program is designed to ensure a safe environment for all Residents .When fall occurs .pertinent interventions will be identified and placed by staff . Resident #32 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Unspecified Dementia and Psychotic Disorder with Delusions. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #32 was severely cognitively impaired and required extensive assistance of 2 staff with bed mobility and transfers. Review of a facility investigation dated 5/8/2023, showed Resident #32 had an unwitnessed fall. The resident was assessed, no injury was found, and there was no change in cognition. The new intervention was fall mats to both sides of bed. Review of a care plan for Resident #32 showed a risk for falls due to weakness and an intervention of fall mats to the floor on both sides of resident's bed. Review of current physician's orders for Resident #32 showed a safety intervention of fall mats to the floor on both sides of the resident's bed. During an observation and interview on 8/23/2023 at 1:25 PM, with the Director of Nursing (DON) in Resident #32's room, the resident was in bed and no fall mats were observed on the floor. The DON stated if an intervention of fall mats to the floor was on the care plan, he expected the mats to be on the floor when the resident was in bed. The DON confirmed there were no fall mats on the floor, and the fall intervention was was not place.

Based on review of facility policy, medical record review, and interview, the facility failed to immediately report an injury of unknown origin for 1 resident (#1) of 3 residents reviewed for accidents. The findings include: Review of facility policy Abuse Protocol - Tennessee Facilities revised 8/28/2020 revealed .IDENTIFICATION .following possible indicators .Suspicious injuries of unknown origin .Report any allegation of abuse of abuse immediately but not more than 2 hours after the allegation was made .State Licensing Agency . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) Annual assessment dated [DATE] showed Resident #1 was cognitively intact,1 person assistance for walking in his room and required 2 person assistance for bed mobility, transfer and toilet use. Review of a SBAR Communication Form and Progress Note for Resident #1 dated 3/25/2021 showed .resident was observed by CNA to not be acting baseline. upon assessment resident was slumped over in chair grunting with eyes fixed. o2 sat 77% on 3 L o2, bp- 210/130, p- 132, resp 25bpm. called ems for transfer to ED, notified NP, DON, family, and resident . Review of hospital Emergency Department records dated 3/25/2021 for Resident #1 revealed .Closed fracture of both hips .Pneumonia . Review of a hospital Trauma History and Physical Exam dated 3/25/2021 for Resident #1 revealed .evaluated and found to have left [MEDICAL CONDITION] . During a telephone interview on 3/31/2021 at 8:40 AM the Patient Liaison stated she gets hospital records daily. She stated Resident #1's hospital records were printed and given to the Executive Director (ED) and the Director of Nursing (DON) on 3/26/2021 and updates given on 3/29/2021. During a telephone interview on 3/31/2021 at 9:00 AM the Power of Attorney (POA) for Resident #1 stated she was notified by the hospital of [MEDICAL CONDITION] on 3/25/2021. She stated she called the DON on 3/25/2021 and reported the fractures. The POA stated the facility was unaware of any falls for Resident #1 and had no idea of the cause of the fractures. During a telephone interview on 3/31/2021 at 9:20 AM the DON stated Resident #1's POA telephoned her the afternoon of 3/25/2021 and reported that the resident had [MEDICAL CONDITION]. The DON stated an investigation was started on 3/26/2021 and the injury of unknown origin was not reported to the state agency. During a telephone interview on 3/31/2021 at 10:10 AM the ED stated she was made aware Resident #1 had a [MEDICAL CONDITION] on the evening of 3/25/2021. She looked at hospital records on 3/26/2021 and began an investigation. The Executive Director stated she had not reported the injury of unknown origin to the state facility.

Based on review of the medical record and interview, the facility failed to immediately notify the resident representative of a newly developed pressure ulcer for 1 resident (Resident #1) of 3 residents reviewed for pressure ulcers. The findings included: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a New Skin Finding Notification dated 9/27/2020, revealed a new pressure ulcer development of .Approximately 2-3 cm (centimeters) in diameter, skin is sheared, no drainage noted . In the section asking was family notified of wound, the box was marked no. Interview with the Wound Care Nurse and the Director of Nursing (DON) on 10/27/2020 at 3:30 PM, while reviewing the weekly wound care logs, confirmed a new wound for Resident #1 had been discovered on 9/27/2020. The Wound Care Nurse and the DON both stated the family had not been notified of the new wound for Resident #1. Interview with the Licensed Practical Nurse (LPN)/Wound Care Nurse on 10/28/2020 at 8:33 AM, confirmed the LPN did not notify the sister or family member of the shearing wound on 9/27/2020.

Based on review of the facility policy, observation, and interview, the facility failed to distribute and serve food under sanitary conditions for 1of 3 halls observed for dining. The findings include: Review of the facility policy, Hand Hygiene, revised 12/16, revealed .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . After contact with objects .in the immediate vicinity of the resident; .Before and after eating or handling food; . Observation on 1/22/19 at 11:54 AM, on the(NAME)Hall, revealed Certified Nursing Assistant (CNA) #1 delivered a lunch tray in the resident's room, elevated the head of the resident's bed, moved the resident's bedside table, and failed to sanitize the hands prior to seting up the resident's lunch tray. Further observation revealed CNA #1 retrieved a lunch tray, delivered a lunch tray to a second resident's room, moved the resident's bedside table, failed to sanitize the hands prior to seting up the resident's tray, and exited the room without performing hand hygiene. Interview with CNA #1 on 1/22/19 at 11:59 AM, on the(NAME)Hall, confirmed CNA #1 failed to perform hand hygiene after contact with objects in the resident's rooms during the lunch meal tray pass. Interview with the Director of Nursing on 1/24/19 at 9:14 AM, at the(NAME)Hall nurse's station, confirmed the facility failed to follow the facility policy on hand hygiene.

Based on medical record review, observation, and interview, the facility failed to ensure weight loss interventions were implemented for 1 resident (#42) of 4 residents reviewed for nutrition of 23 sampled residents. The findings include: Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 9 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate cognitive impairment. Further review revealed Resident #42 required extensive assist of one with eating. Medical record review of Resident #42's weights revealed he had lost 8% of his weight from 12/20/18 to 1/21/19. Further review revealed the resident had been included in the Nutrition at Risk meeting and weights were reviewed weekly. Medical record review of a Physicians Telephone Order dated 12/28/18 revealed .90 ml (milliliters) med pass 2.0 (nutritional supplement) TID (three times a day) . Medical record review of the (MONTH) (YEAR) Medication Record (MAR) revealed the resident had been administered the nutritional supplement as ordered from 12/28/19 through 12/31/18. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. Continued medical record review revealed the resident had been admitted to the hospital on [DATE] and returned to the facility the evening of 1/18/19. Further review revealed the house supplement had not been re-ordered when the resident returned from the hospital. Interview with the Assistant Director of Nursing on 1/24/19 at 11:21 AM, in the Director of Nursing's office, confirmed the facility had failed to administer the house supplement to Resident #42 (MONTH) 1st through (MONTH) 17th 2019.

Based on review of the facility policy, medical record review, observation, and interview, the facility failed to revise the Comprehensive Care Plan to include a new intervention for nutrition at risk/weight loss for 1 resident (#42) of 4 residents reviewed for nutrition of 23 sampled residents. The findings include: Review of the facility policy Nutrition at Risk date revised 3/18 revealed .dietary interventions ordered by the Physician .must also be documented on the Care Plan . Review of the facility policy Care Plans last date revised 11/18 revealed .The Care Plan shall reflect the following: a. PROBLEMS .any area of .concern .d. INTERVENTIONS: .The specific .intervention the staff will take to assist the Resident in meeting/achieving goals .Care Plans will be updated as changes occur. New problems will be added as they occur . Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 9 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate cognitive impairment. Further review revealed Resident #42 required extensive assist of one with eating. Review of Resident #42's Comprehensive Care Plan last reviewed 12/27/18 revealed the care plan had not been revised to include nutrition at risk/weight loss. Medical record review of Resident #42's weights revealed: 12/20/18 162 pounds 1/21/19 149 pounds. Interview with the Assistant Director of Nursing on 1/24/19 at 10:49 AM, at the(NAME)nurse's station, revealed the facility had reviewed Resident #42 in the Nutrition at Risk (NAR) meeting on 12/27/18 and recommended house supplement 90 ml (milliliters) TID (three times a day). Further interview revealed the supplement had been ordered by the Nurse Practitioner. Medical record review of a Physicians Telephone Order dated 12/28/18 revealed .90 ml med pass 2.0 (nutritional supplement) TID . Interview with the DON on 1/24/19 at 11:20 AM, in the DON office, confirmed the facility failed to revise Resident #42's Comprehensive Care Plan to include nutrition at risk/weight loss. Interview with the Minimum Data Set (MDS) Coordinator on 1/24/19 at 1:40 PM, in the MDS office, confirmed the facility failed to revise Resident #42's Comprehensive Care Plan to include nutrition at risk/weight loss.

Based on facility policy, medical record review, and interview, the facility failed to schedule a specialty physician appointment as ordered by the physician for 1 resident (#16) of 22 residents reviewed. The findings included: Review of the facility policy, Transcription of Doctors Orders and Documentation, revised 8/15 revealed .The administrative nurse will check the order for accuracy of the transcription the following day, as well as follow-up on other orders .labs, x-rays, etc . Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone Order dated 1/10/18 revealed .F/U (follow up) c (with) urology (specializing in urinary problems) . Continued review revealed the order was signed by 2 nurses. Medical record review of a nursing progress note dated 1/10/18 revealed .cath (catheter) Replaced D/T (due to) No void after 8 hrs (hours) .Will Make Appt (appointment) with Urology per MD (medical doctor) . Medical record review revealed no documentation of Resident #16 had been seen by a Urologist (physician specializing in urinary problems). Interview with the Registered Nurse (RN) Manager on 3/14/18 at 8:14 AM, at the Hensley Hall Nursing Station, confirmed she had never seen the physician's order in (MONTH) and no attempt was made to schedule a urology appointment. Continued interview revealed the nurse who signed the order should have given the RN Manager a copy of the order in order to get the appointment scheduled. Interview with the Director of Nursing (DON) on 3/14/18 at 8:20 AM, in the DON office, revealed the physician or nurse who signed the physician order should have given the Nurse Manager a copy of the order. Continued interview revealed the Nurse Manager was responsible to schedule appointments after receiving the order. Further interview revealed the nurse who signed off on the order was ultimately responsible to ensure the appointment was made. Continued interview confirmed no appointment was scheduled for Resident #16 in (MONTH) (YEAR).

Based on review of the facility policy, observation, and interview, the facility failed to prevent the opportunity of cross contamination by having unlabeled toiletry items available for resident use in 3 of 3 shower rooms observed. The findings included: Review of the facility policy Standard Precautions revised 11/16, revealed .ensure .single use items are properly discarded . Review of the facility policy Infection Prevention & (and) Control Program revised 11/16 revealed .procedures .to prevent cross-contamination .when performing tasks among individuals which provide the opportunity for cross-contamination to occur . Observation with the Registered Nurse (RN)/Supervisor on 2/22/17 at 9:00 AM, in the(NAME)Shower Room, revealed, in an opened double cabinet, the following unlabeled items available for use: 5 combs, 3 opened partially used tubes of protective skin barrier lotion,1 opened protective barrier for irritated skin lotion,1 unwrapped toothbrush in a lower half of a toothbrush holder, 3 bottles of opened mouthwash, 1 used roll-on cream antiperspirant, and 1 perfumed body lotion. Observation with the RN/Charge Nurse on 2/22/17 at 9:10 AM, in the(NAME)Shower Room, revealed, in a double cabinet, the following unlabeled items available for use: 1 opened protective skin barrier lotion, 5 combs, 1 pick comb, 1 opened dry skin lotion, 1 tube of skin irritation lotion,1 hairbrush with gray strands, and in a basin, 1 opened spilled bottle of conditioner coating a total of 6 lotions, conditioners, and shampoos. Observation with the RN/Charge Nurse on 2/22/17 at 9:20 AM, in the Hospice Shower Room, revealed, in a double cabinet, the following unlabeled items available for use: 1 pink bag with 1 opened mouthwash, 1 toothbrush holder, and a headband. Further observation of the cabinet revealed 1 opened roll-on deodorant and a comb. Interview with the Director of Nursing (DON) on 2/22/17 at 9:30 AM, in the DON Office, confirmed the facility failed to prevent the risk of cross contamination by having unlabeled toiletries available for resident use.

Based on facility policy review, observation, and interview, the facility failed to maintain a sanitary environment in 2 of 2 kitchen observations made. The findings included: Review of facility policy Pots and Pans Hot Water, not dated, revealed .when items are dry, store in proper storage area . Review of facility policy Dishwashing Procedure, not dated, revealed .clean and soiled dishes, utensils and pot and pans must be separated . Observation with the Dietary Manager (DM) on 2/8/16 at 9:05 AM, in the kitchen, revealed 4 full size baking sheets were stored wet on a clean and ready to use equipment shelf. Continued observation revealed dietary manuals were stored in a cabinet with drinking glasses. Interview with the DM on 2/8/16 at 9:10 AM, in the kitchen, confirmed the baking sheets were stored wet on an equipment shelf and were available for use. Continued interview confirmed the dietary manuals should not be stored with the clean drinking glasses. Observation on 2/8/16 at 11:20 AM, in the kitchen, revealed the facility owner entered the kitchen through a back door, and without washing his hands, retrieved a styrofoam container sitting on a shelf over the steam table and exited the kitchen through the back door. Observation on 2/8/16 at 11:30 AM, in the kitchen, revealed the entrance and exit area to the dishwashing area was approximately 3 feet wide. Further observation revealed dirty dishes were sitting on the counter beside the dishwasher. Continued observation revealed a dietary worker brought a clean rack of glasses back through the dirty dish area and placed them in a cabinet. Interview with the DM on 2/8/16 at 11:45 AM, in the kitchen, confirmed the facility owner did not wash his hands and the clean dishes were brought through the dirty dish wash area .because there is no exit from the clean area .have to come back out that way . Interview with the Administrator on 2/9/16 at 3:30 PM, in the Administrator's office, confirmed .they are supposed to wash a load of dishes and when that load is done and put away .they are to go get another load to run through the washer .they aren't supposed to do that (bring clean dishes through the dirty area) .

Based on observation and interview, the facility failed to provide adequate outside ventilation during smoking times, resulting in the smell of cigarette smoke in the facility, for 1 of 3 halls. The findings included: Observation on 2/8/16 at 10:35 AM, revealed there was a smell of cigarette smoke on Durham hall (around two corners and down a corridor from the smoking area) at the shower room across from room 10. Observation on 2/8/16 at 1:35 PM, revealed there was a smell of cigarette smoke at the Durham nursing station (around the corner from the smoking area). Continued observation of the outside smoking area revealed 3 residents sitting near the door smoking. Observation of the smoking area on 2/9/16 at 1:53 PM, revealed 3 residents and 1 staff member smoking. Continued observation revealed a smell of cigarette smoke directly in front of the door to the smoking area. Observation on 2/9/16 at 3:10 PM of the smoking area revealed 7 residents and 1 staff member smoking. Continued observation at the Durham Nursing station revealed there was a smell of cigarette smoke at the station. Interview with Licensed Practical Nurse (LPN) #2 on 2/9/16 at 3:15 PM, at the Durham nursing station, confirmed .have to go around the corner a lot to get away from the smell . Interview with the Social Worker on 2/9/16 at 3:50 PM in the hallway outside the Director of Nursing (DON) office confirmed .if the wind is blowing like it was yesterday, you can smell it at the nursing station . Interview with the Maintenance Director on 2/9/16 at 4:05 PM, in the maintenance office, confirmed if the door is held open to get the wheelchairs in and out of the smoking area, then smoke is sucked in and can be smelled at the nursing station which is approximately 60 feet away from the smoking area.

Based on facility policy review, observation, and interview, the facility failed to ensure hand hygiene during a blood glucose check for 2 residents (#77 and #99) of 2 residents reviewed and during a meal tray pass for 2 residents of 12 residents observed. The findings included: Review of a facility policy titled Hand Hygiene dated 9/08 revealed .All employees shall utilize proper hand hygiene for each of the following conditions .before performing invasive procedures .before and after administering treatments .before preparing or serving food .after contact with a Resident .After contact with Resident-contaminated supplies and equipment .after contact with blood .broken skin or after handling any item potentially contaminated with any Resident's blood .NOTE: The use of gloves does not replace hand hygiene. Once gloves are removed, proper hand hygiene should be performed . Observation of a blood glucose test for Resident #73, obtained by Licensed Practical Nurse (LPN) #1 on 2/8/16 at 11:50 AM, revealed LPN #1 did not wash the hands before donning gloves, after doffing the gloves or before cleaning the blood glucose monitor. Continued observation of a blood glucose test for Resident #99, obtained by LPN #1 on 2/8/16 at 11:55 AM, revealed LPN #1 did not wash the hands before donning new gloves, after doffing the gloves or before cleaning the blood glucose monitor. Interview with LPN #1 on 2/8/16 at 12:00 PM, in Hensley Hall, confirmed LPN #1 did not wash the hands between, before or after obtaining the blood glucoses. Interview with the interim Director of Nursing (DON) on 2/9/16 at 4:08 PM, in the DON office, confirmed .should wash hands between patients . Observations of staff serving meal trays on 2/8/16 at 12:05 PM, in the activity/dining room, revealed Certified Nursing Assistant (CNA) #1 serving meal trays to 2 residents of 12 residents in the activity/dining room. Further observation revealed CNA #1 carried a meal tray to one resident, uncovered the plate, seasoned the food, adjusted the resident's wheelchair to the table, and without washing or sanitizing his hands, returned to the food cart. Continued observation revealed CNA #1, without washing or sanitizing his hands, carried a meal tray to a second resident, delivered it to the table, uncovered the plate, seasoned the food, adjusted the resident's chair at the table, touched his own hair, and then returned to the food cart, without washing or sanitizing his hands, and opened the food cart to deliver another resident's tray. Interview with CNA #1 on 2/8/16 at 12:10 PM, in the hallway beside the restorative dining room, confirmed he had not washed or sanitized his hands after delivering food trays to the two residents, and confirmed he was preparing to deliver a food tray to a third resident without washing or sanitizing his hands. Further interview with the CNA revealed he knew he was supposed to wash his hands but was hurrying and forgot. Interview with the DON on 2/9/16 at 4:00 PM, in her office, confirmed staff must wash or sanitize their hands between contact with residents when delivering meal trays and assisting with residents' dining.

Based on observation and interview, the facility failed to store medications properly in one of two medication carts. The findings included: Observation on October 14, 2013, at 3:00 p.m., at the Hensley Nurse's Station revealed one medication cart with the following: 1. Five nasal sprays stored with oral medications in a divided compartment in drawer #1. 2. Three inhalers stored with nasal sprays in a divided compartment in drawer #2. 3. Two inhalers stored with oral medications and nasal sprays in a divided compartment also in drawer #2. 4. Five bottles of eye medication stored with nasal sprays in a divided compartment in drawer #3. Interview with Licensed Practical Nurse #2 at the time of the observation confirmed the medications were not stored properly.