Every finding on record at Gardens at Celina

Based on medical record review, resident interview, and staff interview, the facility failed to ensure a resident received ordered medications timely after admission to the facility. This affected (#31) of five residents reviewed for medications. The census was 21. Findings include:Review of Resident #31's medical record revealed an admission date of 12/18/25. Diagnoses listed low back pain, chronic obstructive pulmonary disease, hypertension, anxiety disorder, hypertension, and lumbar disc degeneration.A Minimum Data Set (MDS) assessment had not yet been completed.Review of physician orders revealed an order dated 12/18/25 for the antidepressant medication Buproprion hydrochloride (HCL) oral tablet extended-release (ER) 24-hour 300 milligrams (mg). Give 700 mg by mouth in the morning for depression. The order was discontinued 12/22/25. An order dated 12/22/25 was for Buproprion HCL oral tablet ER 24-hour 300 mg. Give 700 mg by mouth in the morning for depression. The order was discontinued 12/23/25. Review of medication administration notes dated 12/19/25 at 8:02 A.M. revealed Buproprion HCL oral tablet ER 24-hour 300 mg. Give 700 mg by mouth in the morning for depression was on order and needed clarification from the provider.Review of a facsimile (fax) dated 12/18/25 revealed pharmacy requested for Buproprion HCL oral tablet ER dose and strength to be clarified. A hand-written note on the fax had the dose clarified by the nurse practitioner to 300 mg daily.Review of medication administration records (MAR) revealed Buproprion was not administered on 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25.Interview with the Director of Nursing (DON) on 12/23/25 at 11:08 A.M. confirmed Resident #31 had not received Buproprion on 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25 due to the order not being clarified timely. The order was clarified on 12/23/25.Interview with Resident #31 on 12/23/25 at 10:03 A.M. revealed he takes an antidepressant medication at home and was unsure of the name and dose. Resident #31 was unaware that he was not receiving the antidepressant medication at the facility.

Based on medical record review, observation, staff interview, and facility policy, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open wound. This affected one (Resident #01) of three residents review for EBP. The facility census was 21.Findings include:Record review revealed Resident #01 was admitted on [DATE] with diagnoses including pleural effusion, chronic obstructive pulmonary disease (COPD), and diabetes mellitus type II.Review of the weekly wound assessment dated [DATE] revealed Resident #01 had a stage III pressure ulcer on the coccyx. Observation of Registered Nurse (RN) #148 on 12/24/25 at 9:48 AM revealed RN #148 provided wound care to Resident #01's open coccyx wound without the use of complete personal protective equipment (PPE). RN #148 applied gloves but did not don (apply) a gown for the wound care treatment. Interview with RN #148 at the time of observation confirmed she did not wear a gown during the wound care treatment for Resident #01 and she should have. RN #148 further confirmed there was no signage posted that identified Resident #01 needs EBP during high-contact care activities.Interview on 12/24/25 at 10:11 AM with the Director of Nursing (DON) revealed there was no EBP order in place for Resident #01 and acknowledged that EBP should have been implemented due to her open wound.Review of the facility policy titled, Enhanced Barrier Precautions (EBP), dated 04/01/24, revealed that Enhanced Barrier Precautions are required for residents with wounds. The policy further directs that staff must don gowns and gloves during high-contact resident care activities.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were handled in a hygienic manner. This affected five residents (#01, #02, #13, #14, and #25) of five reviewed for medication administration. The facility census was 25. Findings include: Observation on 11/05/24 from 7:10 A.M. to 7:45 A.M. revealed Registered Nurse (RN) #100 administering medications to facility residents. RN #100 obtained the medications for Resident #01 to include Calcium (supplement) 600 milligrams (mg) with Vitamin D3 (vitamin) tablet, Acidophilus (probiotic) capsule, and Iron (supplement) 325 mg tablet. RN #100 opened the Acidophilus capsule with ungloved hands and poured the powder into a dish of applesauce and administered the medications to Resident #01. RN #100 returned to the medication cart did not perform hand hygiene and prepared medications for Resident #14 which consisted of Iron 325 mg, Metoprolol (used to lower blood pressure) 25 mg, and Keppra (anticonvulsant) 750 mg, touching the medications with ungloved hands. RN #100 the administered the medications to Resident #14 and returned to the medication cart without performing hand hygiene. RN #100 prepared medications for Resident #02 which consisted of Vitamin B12 (vitamin) 500 mg two tablets and Tramadol (opiate) 25 mg. RN #100 handled the medications with ungloved hands and administered the medications to Resident #02. RN #100 returned to the medication cart, without performing hand hygiene and began to prepare medications for Resident #25 consisting of two Acetaminophen (analgesic) 325 mg tablets, Amiodarone (antiarrhythmic) 200 mg, Amlodipine (used to lower blood pressure) 10 mg, Vitamin C (vitamin) 500 mg, Vitamin D 1000 international units, Eliquis (anticoagulant) 2.5 mg, Ocular vitamin, Lasix (diuretic) 40 mg, and Lisinopril (used to lower blood pressure) 2.5 mg, touching many of the medications with ungloved hands, and administered the medications to Resident #25. RN #100 returned to the medication cart, without performing hand hygiene and began preparing medications for Resident #13 consisting of Acidophilus, Aspirin (non-steroidal anti inflammatory) 81 mg, Calcium 600 mg with Vitamin D3, Multivitamin, Acetaminophen 500 mg two tablets, Pantoprazole (proton pump inhibitor) 40 mg, Zyvox (antibiotic) 600 mg, and Losartan (used to lower blood pressure) 100 mg, touching many of the medications with ungloved hands, and administered the medications to Resident #14. Interview immediately after the observation, RN #100 verified she had not performed hand hygiene and had touched many of the medications with ungloved unwashed hands prior to administering the medications to the residents. Review of the policy titled Hand Hygiene undated, revealed staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.

Based on review of staffing tool and staff interview, the facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours daily. This affected all 22 residents residing in the facility. Findings include: Review of the staffing tool from 11/06/22 to 11/12/22 revealed on 11/11/22 (Friday) the facility had an RN on duty for only one hour and on 11/12/22 (Saturday) the facility had an RN on duty for only six hours and 15 minutes. Interview on 11/23/22 at 11:55 A.M. with Administrator provided verification of the lack of RN coverage on the two days. Administrator additionally indicated the DON worked 16 hours on 11/10/22 (Thursday) and DON did not work any hours on 11/11/22.

Based on staff interview, record review, and review of the Certification and Survey Provider Enhanced Reporting system (CASPER), the facility failed to have an effective quality assurance program to address repeated concerns identified during three consecutive annual surveys. This affected all residents in the facility. The facility census was 22. Findings include: Review of the Certification and Survey Provider Enhanced Reporting system (CASPER) report dated 10/28/22 revealed the facility received a deficiency for failing to be free from unnecessary psychotropic medications during the annual surveys completed in October 2018 and November 2019. Review of the medical records during the annual survey conducted 11/21/22 through 11/23/22 for three residents (#14, #124, and #126) revealed the facility failed to have appropriate diagnoses in place for psychotropic medications. Interviews on 11/23/22 at 9:47 A.M. and 10:20 A.M. with Regional Nurse Consultant #240 confirmed the diagnoses for psychotropic medications for Resident #14, Resident #124, and Resident #126 were in appropriate.

Based on observations, staff interviews, and review of the facility policies, the facility failed to store and prepare food in a sanitary manner, failed to completely cover hair during meal service, and failed to accurately monitor sanitizer levels in the sanitation buckets used to clean the kitchen. This had the potential to affect all residents in the facility except one (#5) who was identified as receiving no food by mouth. The facility census was 22. Findings include: 1. Observations during the initial tour of the kitchen on 11/21/22 at 8:07 A.M. revealed unsealed ham, unsealed hotdogs, an undated opened package of ham, and pizza sauce dated 11/02/22 in the walk-in refrigerator. Further observation revealed omelets open to the air in the freezer. Concurrent interview with the Dietary Manager #237 confirmed the observations. Further interview revealed food should be labeled with a date and sealed. Observation on 11/22/22 at 10:20 A.M. of the refrigerator designated for residents' food revealed a package of pepperoni with a fuzzy appearance on it consistent with mold, an unlabeled, thawed commercially prepared meal with instructions to keep frozen, an undated quart-size container of thickened cranberry juice, approximately 1/4 full, and an undated, unlabeled frozen meal encrusted with ice. Concurrent interview with STNA #209 confirmed the findings. Observation of meal service on 11/22/22 beginning at 10:52 A.M. revealed the Cook #212 wearing plastic gloves on both hands while preparing meal trays. Further observation revealed she opened the oven, opened the refrigerator, used the sink, used the food processor, and used serving utensils to serve the meal. Continued observation revealed she prepared a grilled cheese sandwich and placed her gloved hand on the left side of the sandwich to hold it in place while she used the spatula to cut the sandwich. Interview at that time with the Cook #212 stated the last time she changed her gloves was before the surveyor entered the kitchen at 10:52 A.M. Continued observation at that time revealed the Cook #212 continued to prepare meal trays. Subsequently, the Cook #212 began to prepare a deli turkey sandwich and asked the surveyor if she should change her gloves again. 2. Observation during meal service on 11/22/22 beginning at 10:52 A.M. revealed the cook wearing a hairnet with her bangs exposed. Further observation at that time revealed the Director of Environmental Services #223 walking in the immediate vicinity of food service wearing a hairnet with his ponytail coming out from underneath. Concurrent interview on 11/22/22 at approximately 11:15 A.M. with the Dietary Manager #237 confirmed both staff were wearing hairnets in a way that did not cover all of their hair while standing near food being plated for residents. 3. Observation on 11/22/22 at 1:22 P.M. of the Dietary Manager #237 testing the sanitation level in the sanitizer buckets revealed she used pH (a quantitative measure of the acidity or basicity of aqueous or other liquid solutions) strips rather than testing for parts per million (PPM) which tests the solute load of solution. Concurrent interview with the Regional Dietary Manager (RDM) #241 confirmed the strips were pH strips. Interview on 11/22/22 at 2:59 P.M. with the RDM #241 confirmed the facility used the wrong test strips for the sanitation buckets. Further interview revealed she spoke with the chemical company who would send PPM strips the following day. Review of the undated facility policy titled Food Storage Cold revealed refrigerated items will be labeled and dated. Review of the undated facility policy titled Food Safety and Sanitation Review revealed open foods are sealed, labeled, and dated in storage areas, all foods are covered, labeled, and dated, proper hand washing practices are followed, gloves are used when handling ready to serve items, and employees are to have hair restrained appropriately during their shift.

Based on medical record review and staff interview the facility failed to have accurate diagnoses for psychotropic medications. This affected two residents (#14, and #124) of five reviewed for unnecessary medications. The facility census was 22. Findings include: 1. Review of the medical record of Resident #124 revealed an admitted [DATE]. Diagnoses include acute respiratory failure, atrial fibrillation, hypertension chronic kidney disease osteoarthritis, type II diabetes mellitus, polyneuropathy, hyperlipidemia, major depressive disorder, and gastroesophageal reflux disease. The record was silent for any diagnosis for anxiety. Review of the physician orders for Resident #124 revealed an order for Buspar (an anti-anxiety) five milligrams (mgs) twice daily for depression. An order for Hydralazine (vasodilator) 10 mg three times daily for anxiety. Interview on 11/23/22 at 10:20 A.M. with Regional Director of Nursing (R-DON) #240 provided verification of the incorrect diagnoses for the Buspar and Hydralazine. 44815 2. Review of the medical record for Resident #14 revealed an admitted [DATE] and a readmitted [DATE] with medical diagnoses of a fracture of her left ankle, type two diabetes mellitus, congestive heart failure, acute and subacute hepatic failure, hyperkalemia, acute kidney failure, and anxiety disorder. Review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #14 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, and toileting, extensive assistance of one person for hygiene, and supervision with setup help only for eating. Review of a physician order dated 11/15/22 revealed Resident #14 was prescribed Mirtazapine (anti-depressant) tablet 7.5 milligrams, one tablet by mouth at bedtime for anxiety. Interview on 11/23/22 at 9:47 A.M. with the Regional Nurse Consultant #240 confirmed the treatment diagnosis of anxiety was an inappropriate indication for Mirtazapine for Resident #14. Review of the product label for Mirtazapine, available at (https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020415s023s024.pdf), accessed 11/25/22, revealed it was indicated for the treatment of major depressive disorder. Review of the facility policy titled Psychotropic Medications revealed all orders for psychoactive medications will include an appropriate diagnosis.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure finger nail care was provided to a resident that was dependent on staff for personal hygiene. This affected one resident (#5) of two residents reviewed for activities of daily living (ADLs). The census was 22. Findings include: Review of Resident #5's medical record revealed an admitted [DATE]. Diagnoses included other specified intracranial injury, duodenal ulcer, gastrostomy status, adjustment disorder with depressed mood, post traumatic seizures, and hyperlipidemia. Review of the most recently completed Minimum Data Set (MDS) assessment completed 10/02/22, revealed Resident #5 had severely impaired cognitive skills for daily decision making and required total dependence with two-plus persons physical assistance with personal hygiene, and was assessed with no rejection of care. Review of an ADLs deficit care plan dated 10/27/20, revealed Resident #5 needed hands on assistance with most ADLs tasks due to having uncoordinated muscle movements. Observation on 11/22/22 at 9:12 A.M., revealed Resident #5 sitting in his wheelchair in his room with his arms and hands folded over his lap. Observation of Resident #5's right hand revealed the thumb nail was nearly one-half inch long and was partially torn from left to right. Resident #5's left hand had finger nail length between one-fourth and one-half inch on the thumb, fourth, and fifth fingers. Interview on 11/22/22 at 9:15 A.M., with Registered Nurse (RN) #216 stated sometimes Resident #5's family complained to her about Resident #5's finger nails being too long and then the staff would cut them. RN #216 stated usually the night shift staff get Resident #5 up for the day and perform his personal hygiene. Observation of Resident #5's long finger nails on 11/22/22 at 9:15 A.M., during interview with RN #216 verified Resident #5's finger nails needed trimmed and stated it appeared some of Resident #216's finger nails were not trimmed for a long time. Review of an undated ADLs policy revealed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on staff interview, record review, and review of the facility policy, the facility failed to accurately complete baseline care plans. This affected two residents (#14, and #175) of the four residents review for baseline care plans. Facility also failed to complete baseline care plans for residents. This affected one resident (#126) of four records reviewed for baseline care plans. The facility census was 22. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE] and a readmitted [DATE] with medical diagnoses of a fracture of her left ankle, type two diabetes mellitus, congestive heart failure (CHF), acute and subacute hepatic failure, hyperkalemia, acute kidney failure, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, and toileting, extensive assistance of one person for hygiene, and supervision with setup help only for eating. Review of the baseline care plan for Resident #14 revealed it was undated. Review of the comprehensive care plan for Resident #14 revealed it was initiated 10/24/22. Interview on 11/22/22 at 10:12 A.M. with Licensed Practical Nurse (LPN) #204 confirmed Resident #14's baseline care plan was undated and therefore could not verify if it was completed within 48 hours of admission. 2. Review of the medical record for Resident #175 revealed an admitted [DATE], with medical diagnoses of pulmonary hypertension, anemia, hypoosmolality and hyponatremia, hypothyroidism, chronic atrial fibrillation, anorexia, and irritable bowel syndrome. Review of the MDS assessment dated [DATE], revealed Resident #175 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, walking, and toileting, and required extensive assistance of one person for dressing and hygiene. Review of the baseline care plan for Resident #175 revealed it was undated. Review of the comprehensive care plan for Resident #175 revealed it was initiated 11/11/22. Interview on 11/22/22 at 4:10 P.M. with the Social Services Director #205 confirmed Resident #175's baseline care plan was undated and therefore could not verify if it was completed within 48 hours of admission. 35031 3. Review of the medical record of Resident #126 revealed an admitted [DATE]. Diagnoses include benign prostatic hypertrophy, atrial fibrillation, heart failure, and hypertension. The MDS assessment had not been completed. Review of the medical record for Resident #126 revealed the baseline care plan had not been completed as of 11/23/22. Interview on 11/23/22 at 10:00 A.M. with LPN #204 provided verification no baseline care plan had not been completed to date. Review of the undated facility policy titled Baseline Care Plan revealed the facility would develop a baseline care plan within 48 hours of a resident's admission.

Based on observations, interviews with staff and resident's representative, and medical record review, the facility failed to ensure physician orders were followed to treat edema. This affected one resident (#4) of the one resident reviewed with edema. Facility also failed to initiate interventions for treatment of a fistula (an abnormal connection between two body parts). This affected one resident (#13) of the four residents reviewed with wounds. The census was 22. Findings include: 1. Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses included congestive heart failure, mild cognitive impairment, anxiety, metabolic syndrome, major depression, unspecified psychosis, and unspecified dementia with mild mood disturbance. Review of the most recent Minimum Data Set (MDS) assessment completed 10/19/22 revealed Resident #4 was assessed with severely impaired cognitive skills for daily decision making, was not assessed to reject care, and required extensive one-person physical assistance with dressing and personal hygiene. Review of a physician order dated 04/08/22 revealed Resident #4 was ordered compression stockings to bilateral legs to be applied in the morning and off at night for edema. Interview on 11/21/22 at 12:40 P.M. with Resident #4's representative, they stated Resident #4 was supposed to have on compression stockings during the day and the facility was not putting them on consistently. Resident #4's representative stated resident was in the facility on 11/19/22 and Resident #4 did not have on compression stockings. Observation 11/21/22 at 3:50 P.M., on 11/22/22 at 8:01 A.M., at 9:59 A.M., at 11:07 A.M., and at 2:07 P.M. revealed Resident #4 was not wearing compression stockings. Interview on 11/22/22 at 2:09 P.M. with Registered Nurse (RN) #216 stated no one reported to her that Resident #4 refused any care on 11/22/22. Observation on 11/22/22 at 2:15 P.M. with RN #216 revealed Resident #4 standing in her bedroom at the bedside. RN #216 had Resident #4 sit down in her reclining chair and lifted both of her pant legs revealing no compression stockings on Resident #4's legs. Resident #4's bilateral ankles were noted to be slightly swollen with no indentation or weeping noted. Interview on 11/22/22 at 2:19 P.M. with RN #216 stated Resident #4 was usually dressed in the mornings before she got to work, and no one told her she did not have the compression stockings on. Interview on 11/23/22 at 11:17 A.M. with Regional Nurse Consultant (RNC) #240 stated the facility did not have a policy for treatment of edema. 35031 2. Review of the medical record of Resident #13 revealed an admitted [DATE]. Diagnoses include chronic peripheral venous insufficiency, low back pain, essential hypertension, osteoarthritis, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 required extensive assistance of two staff for bed mobility, dressing and personal hygiene and was totally dependent on staff for transfers. Review of the care plan initiated 09/18/20 for Resident #13 revealed a potential for pressure ulcer development related to disease process and immobility. Interventions include to apply a cream every shift and turn and reposition every two hours. Review of the general surgeon consult note dated 11/22/22 for Resident #13 revealed resident was diagnosed with a fistula, was ordered Augmentin (antibiotic) 875 milligrams (mg) twice daily for 14 days and a sitz bath (a warm water bath you sit in to relieve discomfort in the perineal region) to be given twice daily. Review of the physician orders for Resident #13 revealed an order for the Augmentin but orders were silent for sitz baths being ordered. Interview on 11/23/22 at 8:40 A.M. with State tested Nursing Assistant #209 revealed she had been told about the sitz bath but not how to complete them. STNA #209 added the facility did not have a bathtub so they could not do sitz baths. Interview on 11/23/22 at 8:45 A.M. with Registered Nurse (RN) #216 verified the general surgeon had ordered for Resident #13 to receive sitz baths and verified the sitz baths had not been ordered. RN #216 stated the facility did not have bathtub and therefore could not do sitz baths. RN #216 stated Resident #13 was unable to sit due to poor trunk control. RN #213 indicated she was going to discuss with the Certified Nurse Practitioner (CNP), on how to best accomplish sitz baths.

Based on observations, staff interviews, record reviews, and review of the facility policy, the facility failed to notify the physician or the non-physician practitioner (NPP) and failed to notify the residents representative when a change of conditions occurred. This affected two residents (Resident #14 and #6) of two residents reviewed for a change in condition. The facility census was 22. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE] and a readmitted [DATE] with medical diagnoses of a fracture of her left ankle, type two diabetes mellitus, congestive heart failure (CHF), acute and subacute hepatic failure, hyperkalemia, acute kidney failure, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition, required extensive assistance of two people for bed mobility, transfers, dressing, and toileting, extensive assistance of one person for hygiene, and supervision with setup help only for eating. Review of Resident #14's care plan revealed a care area for activities of daily life (ADL) deficits was initiated 11/17/22 and included a goal for Resident #14 to maintain her ability to feed herself. Review of a progress note dated 11/20/22 revealed Resident #14 went to the emergency room at 8:58 P.M. for complaints of chest pain. Review of a progress note dated 11/21/22 revealed Resident #14 returned from the hospital at 5:35 A.M. Interview on 11/21/22 at 10:22 A.M. with Resident #14 revealed she was unable to stay awake long enough to complete an interview with the surveyor. Observations on 11/21/22 from 11:23 A.M. to 11:50 P.M. revealed Resident #14 was unable to stay alert long enough to consume her noon meal. Interview on 11/21/22 at 12:05 P.M. with Physical Therapist #245 revealed Resident #14 usually ate her meals independently and this level of fatigue was unusual. Observation on 11/22/22 at 8:23 A.M. revealed Resident #14 sleeping with her breakfast tray in front of her. Continued observation at that time revealed State tested Nurse's Aide (STNA) #209 entered Resident #14's room and offered to assist with her breakfast meal. Interview on 11/22/22 at 9:09 A.M. with STNA #209 revealed she fed Resident #14 her breakfast. STNA #209 further revealed Resident #14 was often tired the morning after dialysis. Interview on 11/22/22 at 9:38 A.M. with Registered Nurse (RN) #216 revealed staff had not reported any changes in condition to her about Resident #14. Observation on 11/22/22 at 11:56 A.M. revealed STNA #217 removing Resident #14's noon meal tray from her room. Interview at that time revealed STNA #217 fed Resident #14 her lunch, and stated it was unusual for Resident #14 to require assistance with eating. Interview on 11/22/22 at 3:43 P.M. with RN #216 revealed she was unable to safely administer Resident #14's afternoon medications because Resident #14 could not stay awake long enough to swallow them. Further interview revealed no staff reported a change in condition to RN #216 regarding Resident #14. Continued interview revealed Resident #14 was able to feed herself the previous week. Review of progress notes dated 11/22/22 at 3:44 P.M. and 4:11 P.M. revealed Resident #14 did not receive three afternoon medications as they were unable to be given safely. Interview on 11/23/22 at 8:15 A.M. with RN #216 revealed she did not report Resident #14's inability to take her medications on 11/22/22 but waited until the morning of 11/23/22 to notify the Nurse Practitioner when she was in the facility. 2. Review of the medical record for Resident #6 revealed an admitted [DATE] with medical diagnoses of hemiplegia affecting left nondominant side, nontraumatic intracerebral hemorrhage, and contracture of the left hand. Review of the quarterly MDS dated [DATE] revealed Resident #6 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, and toileting, extensive assistance of one person for eating, and total dependence of two people for transfers. Review of a progress note dated 11/04/22 revealed Resident #6 had a reddened area on her coccyx with top layer of skin sloughing off. Further review revealed the resident's representative was not notified of the change in condition. Review of a progress note dated 11/09/22 revealed Resident #6's reddened area on her coccyx opened. Further review revealed the resident's representative was not notified. Review of a skin assessment dated [DATE] revealed Resident #6 had a stage two pressure (partial thickness loss of dermis) ulcer to her coccyx. Interview on 11/23/22 at 8:10 A.M. with the Regional Nurse Consultant #240 confirmed the record revealed no indication Resident #6's representative was notified when the reddened area on her coccyx appeared on 11/04/22, or when it worsened to a stage two on 11/09/22. Review of the undated facility policy titled Notification of Changes revealed the facility would consult with the resident's physician and notify the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status, and when there is a need to alter treatment or commence a new form of treatment.

Based on record review and staff interview, the facility failed to investigate an injury of unknown origin. This affected one resident (#6) of twelve records reviewed. The facility census was 22. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with medical diagnoses of hemiplegia affecting left nondominant side, nontraumatic intracerebral hemorrhage, and contracture of the left hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, and toileting, extensive assistance of one person for eating, and total dependence of two people for transfers. Review of a progress note dated 11/09/22 revealed Resident #6 had a bruise and abrasion to right lower leg. Review of the active physician orders for Resident #6 revealed no treatment orders for resident's left lower leg. Review of the facility's self-reported incidents (SRIs) revealed no incident reported for Resident #6's bruise and abrasion noted on 11/09/22. Interview on 11/23/22 at 8:10 A.M. with the Regional Nurse Consultant #240 revealed the facility could not determine the origin of Resident #6's bruise and abrasion to her left lower leg. Further interview confirmed the facility did not investigate the origin of the bruise and abrasion. Review of undated facility policy titled Abuse revealed the facility would investigate all injuries of unknown sources.

Based on observation, staff interview, and medical record review, the facility failed to ensure a gastrostomy tube stoma (insertion site of gastrostomy tube) dressing was in place as ordered. This affected one resident (#5) of one resident reviewed with g-tubes tubes. Resident #5 was the only resident in the facility with a gastrostomy tube. The census was 22. Findings include: Review of Resident #5's medical record revealed an admitted [DATE]. Diagnoses included other specified intracranial injury, duodenal ulcer, gastrostomy status, adjustment disorder with depressed mood, post traumatic seizures, and hyperlipidemia. Review of the most recently completed Minimum Data Set (MDS) assessment completed 10/02/22 revealed Resident #5 had severely impaired cognitive skills for daily decision making, was assessed with a feeding tube, and was assessed with no rejection of care. Review of a nutritional risk care plan dated 08/17/20 revealed an intervention to provide Resident #5's feeding tube site care per physician orders. Review of a physician order dated 10/07/22 revealed Resident #5 was to have his feeding tube site cleansed with soap and water, rinsed, patted dry, and a dressing applied two times daily. Observation on 11/22/22 at 9:04 A.M. revealed Registered Nurse (RN) #216 removed Resident #5's abdominal binder to administer his scheduled supplemental nutrition through his feeding tube. Further observation revealed no dressing was in place at the feeding tube site. Resident #5's feeding tube site was free from redness and drainage. Interview on 11/22/22 at 9:05 A.M. with RN #216 stated Resident #5 was supposed to have a dressing around the feeding tube insertion site and verified it was not in place. RN #216 stated no one told her Resident #5 did not have a dressing on feeding tube site. Interview on 11/23/22 at 11:17 A.M. with Regional Nurse Consultant (RNC) #240 stated the facility did not have a policy related to treatments for feeding tubes.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident's received influenza vaccinations upon request and failed to offer pneumococcal vaccinations per the facility policy. This affected two residents (#14 and #127) of five residents reviewed for vaccinations. The census was 22. Findings include: Review of Resident #127's medical record revealed an admitted [DATE]. Diagnoses included unstable angina, heart failure, chronic kidney disease, essential hypertension, and generalized anxiety. Review of influenza documentation in the medical record revealed Resident #127 last received the influenza vaccine on 09/29/21. Review of a document titled, Influenza Flu Vaccine Risk/Benefits and Consent, dated December 2016, revealed Resident #127 indicated she would like the influenza vaccine to be administered and signed the document on 11/09/22. An unidentified Licensed Practical Nurse (LPN) signed the document as a witness with a date of 11/09/22. Review of physician orders, medication administration records, and treatment administration records from November 2022 revealed no documentation Resident #127 received an order to administer the vaccine or any documentation the vaccine was administered. Interview on 11/23/22 at 9:38 A.M. with Regional Nurse Consultant (RNC) #240 verified Resident #127 signed an influenza consent form on 11/09/22 indicating she wanted the influenza vaccination and there was no documentation Resident #127 received the influenza. RNC #240 stated the influenza vaccine was available in the facility on 10/03/22 and could be administered right away. 2. Review of Resident #14's medical record revealed an original admitted [DATE] and a most recent admitted [DATE]. Diagnoses included chronic kidney disease, diabetes mellitus type II, congestive heart failure, anxiety, and hyperkalemia. Review of Resident #14's face sheet dated 11/21/22 revealed a date of birth 05/12/57 ([AGE] years old). Review of Resident #14's immunization history revealed no documentation of a pneumococcal vaccination. Review of Resident #14's medical record revealed no documentation of Resident #14 being offered the pneumococcal vaccination upon admission or receiving the vaccination during her stay in the facility. Interview on 11/23/22 at 10:01 A.M. RNC #240 verified residents should be offered pneumococcal vaccinations on admission and verified there was no documentation Resident #14 previously received the pneumococcal vaccine or was offered the vaccination in the facility. Review of a facility policy titled, Influenza and Pneumococcal Vaccine Policy, revised 07/25/07, revealed all newly admitted residents will be assessed for pneumococcal vaccine status upon admission. Residents without proof of previous pneumococcal vaccination should receive one dose of pneumonia vaccine per CDC (Centers for Disease Control and Prevention) guidelines if consent and physician orders are obtained. Educational material will be provided to resident/representative so that informed decision can be made. Influenza immunization must be offered annually beginning in the fall if vaccine is available.

Based on observations, staff interview and review of online resources from the Centers for Disease Control (CDC) guidelines, the facility failed to ensure appropriate infection control techniques were performed during wound care. This affected one resident (#124) of the three residents reviewed for wounds. Facility census was 22. Findings included: Review of the medical record of Resident #124 revealed an admitted [DATE]. Diagnoses include acute respiratory failure, atrial fibrillation, hypertension chronic kidney disease osteoarthritis, type II diabetes mellitus, polyneuropathy, hyperlipidemia, major depressive disorder, and gastroesophageal reflux disease. The minimum data set assessment had not been completed. Review of the baseline care plan, undated, revealed resident had a coccyx pressure injury with a goal to heal the injury. Interventions included resident to have a specialty mattress and perform wound care as ordered. Review of the admission assessment for Resident #124 revealed resident had an open area to the coccyx measuring one centimeter (cm) by one cm without any description as to color, depth, odor, or drainage. Review of the physician orders for Resident #124 revealed an order dated 11/17/22 for collagenase ointment (used to remove damaged tissue from chronic skin ulcers) 250 units per gram to be applied to resident's coccyx wound daily for wound healing and cover wound with Mepilex. Observation on 11/22/22 at 3:20 P.M. revealed Registered Nurse (RN) #216 prepared supplies to complete wound care for Resident #124. RN #216 washed her hands, applied gloves, and asked Resident #124 to stand from her recliner. RN #216 pulled Resident #124's pants down to her knees and removed the contaminated Mepilex dressing from the resident's coccyx wound. RN #216 opened a three-milliliter (mL) vial of normal saline, moistened a four by four (4x4) gauze, and cleaned resident's coccyx wound with normal saline. Continued observation revealed RN #216 applied a small amount of collagenase ointment to her contaminated gloved finger and spread it on and around the resident's coccyx wound. RN #216 opened a new Mepilex dressing and applied it over the coccyx wound. RN #216 assisted Resident #124 to pull her pants back up and sit down in recliner. RN #216 removed gloves and washed her hands. Interview on 11/22/22 at 3:40 P.M. with RN #216 verified the above wound care techniques. RN #216 verified she did not change gloves and perform hand hygiene when she removed the contaminated dressing and before she applied collagenase ointment with her contaminated gloves and applied the new dressing. Review of CDC website titled Hand Hygiene Guidance (https://www.cdc.gov/handhygiene/providers/guideline.html) dated 01/30/20, revealed the core infection prevention and control practices for safe care delivery in all healthcare settings recommends healthcare personnel should use an alcohol based hand rub or wash with soap and water before moving from soiled body site to a clean body site on the same patient.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record reviews, observations, hospital medical record review, facility investigation review, facility policy review, in-service review, facility corrective action plan review, resident and staff interviews, the facility failed to ensure adequate supervision was provided to prevent the elopement of a resident with cognitive impairment who was assessed as being at risk for elopement. This resulted in Actual Harm when Resident #01 left the facility and was found in a residential neighbor's driveway with a closed fracture of the right hand and facial abrasions from a fall. This affected one (#01) of three residents (#02, #03) reviewed for being at risk for elopement. The facility identified a total of four residents assessed as being at risk for elopement. The facility census was 18 Findings include: Review of Resident #01's medical record revealed and admitted [DATE], with diagnoses including: displaced cervical fracture, [CONDITION(S)], dizziness, history of falls, and dementia. Review of the comprehensive Minimum Data Set, (MDS) assessment dated [DATE], revealed the resident was assessed as having impaired cognition and displaying the behavior of wandering. Review of the nursing admission assessment dated [DATE], revealed the resident was identified as an elopement risk but was not exhibiting dangerous behaviors to himself or others. Review of Resident #01's care plans dated 03/04/21, revealed there was a risk of elopement due to impaired cognition. Interventions included to redirect the resident when ambulating, check WanderGuard (electronic alarm bracelet) per shift, distract the resident from entering other resident rooms, and frequent checks every 30-minutes. Review of the fall/elopement investigation for Resident #01, dated 04/05/21, revealed at 1:00 P.M., Resident #01 had completed his therapy session. At 1:20 P.M., the resident approached the Administrator and asked if he could go outside and sit on the front porch. The Administrator entered the exit code on the alarm pad and allowed Resident #01 to go outside. The Emergency Medical Services, (EMS), had contacted the facility to inform them at 1:35 P.M., they had begun treatment to Resident #01, who had fallen outside and was being transported to the hospital. The local law enforcement was notified and interviewed the facility staff regarding the incident. At 2:00 P.M., Resident #01 was at the hospital being treated. Review of Resident #01's hospital records dated 04/05/21, revealed the resident was treated at the hospital for a closed fracture to the right hand and facial abrasion post fall. Resident #01's chest x-ray and a Magnetic Resonance Image, (MRI), of head revealed no acute findings. Resident #01 had a cast placed on his right hand with discharge instructions for care. Observation on 04/20/21 at 1:30 P.M., of Resident #01 revealed the resident did not appear to be in any distress or pain. Resident #01 was observed ambulating throughout the facility with no issues, a cast on the right hand and WanderGuard was in place on the leg, at the time of the observations. Staff were observed monitoring Resident #01 while he was ambulating and offering him distractions per his care plan interventions. Interview at this time, with Resident #01 revealed the resident was alert and appeared oriented but was unable to give details of dates and incidents due to medical condition. Interview on 04/20/21 at 1:35 P.M., with Licensed Practical Nurse (LPN) #111 stated on 04/05/21, Resident #01 had just finished a therapy session and usually will ambulate back to his room independently. On 04/05/21, the resident approached the front door and asked the Administrator to let him outside to sit on the porch. LPN #111 stated the resident was wearing a WanderGuard that was in working order. However, if a staff member enters the exit code on the doors, it disengages the alarm for the WanderGuard. LPN #111 stated Resident #01 can cover his WanderGuard, so it is was not visible and could appear oriented to someone who doesn't know him. LPN #111 stated since the 04/05/21 incident, there has been increased education and monitoring of residents who are elopement risks and with Wandergaurds. Interview on 04/20/21 at 3:10 P.M., with Resident #01 revealed the resident stated he does like to go outside and walk around. Resident #01 stated he does not remember how he hurt his wrist or why there is a cast on it and denied any pain in his arm. Resident #01 stated he feels safe in the facility and the staff are very nice to him and he feels free to walk around and visit with others. He stated he likes to talk with the other residents throughout the day. Resident #01 does not remember leaving the facility on 04/05/21 and he doesn't remember talking to the Administrator that day or the injuries from the fall. Interview on 04/21/21 at 10:30 A.M., with the Administrator revealed on 04/05/21 the Administrator was at the facility for his first day of employment with the facility. The Administrator stated when Resident #01 approached him, he was unaware the resident was an elopement risk and was wearing a WanderGuard. The Administrator stated Resident #01 appeared to be alert and oriented in short periods. He stated the resident asked him to let him out the door to sit on the porch. The Administrator stated he entered the exit code in the front door, watched Resident #01 walk to the front porch and sit in a chair on the porch. The Administrator stated he then went back to his office. Per the Administrator he has since been educated on resident with elopement risks and utilizing WanderGuards. Interview on 04/21/21 at 10:50 A.M., with the Director of Nursing (DON) revealed during the incident investigation it was discovered Resident #01 had walked to the backyard of the facility, crossed over to the neighbor's back yard, and was seen by a neighbor in the neighbor's backyard. When the neighbor saw the resident, she called the police and went outside to find Resident #01 had fallen in the front driveway. The DON stated the resident had been out of the facility and out of sight of staff for 20 minutes before the neighbor called the local law enforcement. The DON verified Resident #01 had sustained a closed fracture to the right hand and abrasions to his face from the fall. Review of facility policy titled Wandering Resident, dated 06/2018, revealed the facility will ensure the safety of all residents with wandering risks, and staff are to report any residents with exiting seeking behavior. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 04/06/21: · On 04/05/21 at 2:00 P.M., the resident was at the local hospital receiving treatment. · On 04/05/21 at 2:00 P.M., an immediate head count of all residents to ensure they were present in the facility. · On 04/05/21 at 2:05 P.M., an emergency Quality Assurance and Performance Improvement (QAPI) meeting was conducted, and correction action plan was developed. Current policies and procedures were reviewed to ensure appropriate procedures are in place. · On 04/05/21 at 2:05 P.M., checklist and audit/monitoring tools were implemented to ensure alarms were checked, elopement risk were identified, and in-servicing was completed by the DON and QAPI team. · On 04/05/21 at 2:10 P.M., all exit doors were checked to ensure proper functionality of alarms. · On 04/05/21 at 2:20 P.M., the Administrator was in-serviced by the Corporate Nurse about resident at risk for elopement, WanderGuards and facility policy and procedures for elopement. · On 04/05/21 at 2:30 P.M., all staff in-service began to re-educate staff on elopement policies and procedures, residents being at risk for elopement and the use of WanderGuards by the Director of Nursing. All staff were in-serviced by the end of the day on 04/06/21. · On 04/05/21 at 2:45 P.M., all residents with WanderGuards were checked to ensure the proper function of the WanderGuard. · On 04/05/21 at 3:00 P.M., Resident #01's care plan was updated and a new order for the WanderGuard transmitter to be checked twice daily. · On 04/05/21 at 3:15 P.M., all residents were assessed for elopement risk and care plans updated accordingly by the DON or designee. · On 04/05/21 at 4:45 P.M., Resident #01 returned to the facility and 15-minute checks were initiated for 24 hours. · On 04/05/21 at 5:00 P.M., the elopement risk resident log was checked and updated for residents who were at risk for elopement. · On 04/06/21, a second QAPI meeting was held to review plan of action progress. · On 04/06/21, the DON or designee will audit all new admission for elopement risk and ensure proper interventions are implemented per assessment findings. · On 04/06/21, all new employees will be educated on wandering, elopement, and resident safety by the DON or designee. · On 04/20/21, review of the facility in-service records revealed all staff was in-serviced by the DON or designee on elopement policies and procedures, residents being at risk for elopement and the use of WanderGuards. · On 04/20/21, review of the facility audits and check list revealed the facility is completing weekly checks of door alarms, daily checks of WanderGuards, and daily audits of new admits for elopement risk. · On 04/20/21 and 04/21/21, at random times, interviews were conducted with multiple staff to verify the education was provided. · On 04/21/21, review of two additional Residents (#02 and #03) for supervision and elopement risk revealed no concerns. This deficiency substantiated Complaint Number OH 746.

Based on medical record review, review of the facility policy and staff interview, the facility failed to ensure a resident with a history of falls had interventions marked on their baseline care plan. This affected one (Resident #1) of three residents reviewed for baseline care plans. The facility census was 19. Findings include: Review of the medical record for Resident #1 revealed the resident was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a five-day Medicare Minimum Data Set (MDS) 3.0 assessment, dated 06/29/20, revealed the resident had one fall in the last two to six months. Review of the progress notes, dated 05/17/20, revealed the resident was sent to the hospital. On 06/07/20, the resident returned to the facility. Review of a fall risk assessment, dated 06/07/20, revealed the resident was at high risk for falls. Review of the baseline care plan, dated 06/07/20, revealed Resident #1 had a history of [REDACTED]. Review of the progress note, dated 06/12/20, revealed the resident was attempting to crawl out of bed and was transferred to the hospital on [DATE] for a non related illness. The progress note, dated 06/22/20, revealed Resident #1 returned to the facility on this date. The fall risk assessment, dated 06/22/20, revealed the resident was still high risk for falls. The baseline care plan, dated 06/22/20, again documented the resident had a history of [REDACTED]. Review of the resident progress notes, dated 06/30/20, revealed the resident was found on the floor of her room, was sent to the hospital with a [MEDICAL CONDITION] hip. The progress note, dated 07/04/20, revealed the resident returned to the facility on this date. A fall risk assessment, dated 07/04/20, continued to reveal the resident was high risk for falls. A baseline care plan, dated 07/04/20, documented the resident had a left [MEDICAL CONDITION]. No interventions were included for safety precautions. Interview with MDS Nurse #50 on 10/27/20 at 5:00 P.M. revealed baseline care plans were developed for temporary care plans with new admissions within 48 hours of their admission. Interview with the Administrator on 10/29/20 at 4:00 P.M. verified the baseline care plans did not have specific resident interventions for fall prevention and also verified the resident was a high risk for falls. Review of the facility's policy titled Falls/Fall risk Management Policy, dated 08/2016, revealed based on previous evaluations and current data, the staff was to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff were to identify appropriate interventions to reduce the risk of falls. If falling recurred despite initial interventions, staff was to implement additional or different interventions or indicate why the current approach remained relevant. If underlying causes would not be readily identified or corrected, staff was to try various interventions based on assessment of the fall until falling was reduced or the reason for the continuation of falling was identified as unavoidable. This deficiency substantiates Complaint Number OH 359.

Based on record review, observation, staff interview, family interview, review of Centers for Disease Control and Infection guidelines and facility policy review, the facility failed to decrease the risk of the spread of an infection when staff and family members failed to wear personal protective equipment when entering the room and providing care to Resident #13. This affected one (#13) of one resident reviewed for transmission based precautions and had the potential to affect all the residents residing in the facility. The facility census was 23. Findings include: 1. Review of the medical record of Resident #13 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/12/19, revealed Resident #13 was cognitively intact, required limited assistance of one staff for bed mobility, transfers, toileting and personal hygiene. Review of the medical revealed Resident #13 was in contact isolation related [MEDICAL CONDITION] infection to the right gluteal fold. Observation on 11/18/19 at 11:45 [NAME]M. revealed Registered Nurse (RN) #201, State tested Nursing Assistant (STNA) #212 and Physical Therapy Assistant (PTA) #248 went into the room of Resident #13 and no one had on personal protective equipment (PPE), gloves or gown. PTA #248 was seated on the unmade bed of Resident #13 atop of the used incontinence protective pad. RN #201 used an automatic blood pressure cuff to obtain the blood pressure. After obtaining the reading, RN #201 placed the device in the pocket of her uniform top. STNA #212 was assisting Resident #13 with getting seated in the recliner for lunch. None of the staff members had on disposable gloves or protective gowns. A family member was also in the room and was not utilizing PPE. Interview on 11/18/19 at 11:55 [NAME]M. with Director of Nursing (DON), Clinical Resource Nurse (CRN) #247 and RN #201 provided verification of the staff and family member not utilizing PPE when in the room of Resident #13. RN #201 verified she had not cleaned the blood pressure cuff prior to placing the device in her pocket, contaminating her pocket. RN #201 was under the assumption that as long as the wound was covered, PPE was not required. Interview on 11/18/19 at 1:20 P.M. with two of Resident #13's daughters revealed they were informed no PPE was required as the wound was covered. Review of the Centers for Disease Control and Infection (CDC), dated 01/07/16, revealed contact precautions included to wear PPE, including gloves and gown, when in contact with the resident and/or the resident's environment. It also stated to clean and disinfect dedicated resident equipment, including a blood pressure cuff. 2. Observation on 11/19/19 at 9:55 [NAME]M. of the dressing change completed on Resident #13 by Licensed Practical Nurse (LPN) #226 revealed LPN #226 and CRN #247 donned gown and gloves and entered the room of Resident #13. CRN #247 was only assisting Resident #13 with positioning. LPN #226 removed the soiled dressing from the right gluteal fold of Resident #13 and placed the dressing in the clear trash bag-lined bin beside the recliner. LPN #226 proceeded to cleanse the wound using sterile water, patted the wound dry and placed the gauze into a red-biohazard lined trash bin. LPN #226 then applied the ordered ointment to the wound and placed a clean dressing on the wound. LPN #226 removed the red biohazard trash bag from the room, leaving the soiled dressing in the clear bag beside Resident #13's recliner. Interview on 11/19/19 at 10:15 [NAME]M. with CRN #247 and LPN #226 provided verification of the soiled dressing having been placed into a clear trash bag and not into the biohazard bag. The soiled dressing remained in the room. Review of the facility's Nursing Skills Checklist, dated 07/2018, revealed dressings will be discarded of appropriately.

Based on record review, observation, resident interview, staff interview and review of the facility policy, the facility failed to ensure the resident had the right to have her personal care products close at hand in her bathroom. This affected one (Resident #20) of one resident reviewed for choices. The facility census was 23. Findings included: Review of the medical record for Resident #20 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 11/04/19, revealed Resident #20 was assessed as being cognitively intact, with the need for extensive assistance of one-person physical assistance and frequently incontinent of bladder. Review of the plan of care, dated 11/18/19, revealed a plan for activity of daily living deficit related to becoming easily fatigued. The interventions included for toileting management, to encourage as independent a level of functioning as possible within the confines of the disease process and to provide hands on assistance as needed. Observations on 11/19/19 at 11:03 [NAME]M. in the room of Resident #8 revealed the personals were in a stand, by the door which was on the other side of the room. The resident was in a semi private room without a roommate currently. Interview with Resident #20 on 11/18/19 at 10:02 [NAME]M. revealed the facility staff took her pads and pull ups out of her bathroom because they said the State (Survey State Agency) was coming. She said she didn't want these items taken out of her bathroom because once she gets in the bathroom, she didn't want to come out into her room with a bare bottom to get her personal items. Interview on 11/19/19 at 11:07 [NAME]M. with Registered Nurse #21 verified Resident #8 has her personals which included perineal pads and depends in the closet. If she had a private room, there would be a cabinet underneath the sink where they can put them in, but if not in private room, they can call for staff to take it in there for them. They could have pouches on their walker, but she does not have that but cannot keep those in her bathroom. Interview on 11/19/19 at 11:24 [NAME]M. with the Director of Nursing (DON) revealed the residents were not allowed to just keep pads or depends in the bathroom due to infection control. They need to be stored in the closet and she (Resident #8) can call for help to take them to the bathroom when she needs it. She has discussed this with her about not leaving her personal items in there because she had a roommate up until one week and half ago. The DON said she was not allowed to store her items in the bathroom in case another resident in moved into the room. She said the resident has been deemed independent by therapy and will be going home on Friday. She then said the staff were taking her to the bathroom, and they would take the products in when they went in there and again re-iterated, she just became independent with mobility in the last week. Review of the facility's policy titled Peregrine Health Services, Inc; Residents Rights Policy, dated 02/2015, revealed the standard is to assure that the resident's dignity, well-being, and self-determination is maintained to assure that residents are knowledgeable to their rights and responsibilities in this regard.

Based on record review, observation, staff interview and policy review, the facility failed to ensure Resident #4 ingested her physician ordered medication in the presence of the administering nurse and failed to ensure medications were secured when not in the presence of a nurse. The facility identified two residents, #22 and #123, as being independently mobile and confused. The facility census was 23. Findings include: 1. Review of the medical record of Resident #4 revealed an admission date of [DATE] and re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED].), one capsule of acidophilus (supplement), one tablet of [MEDICATION NAME] (treats high blood pressure) 10 mg., one tablet of [MEDICATION NAME] (treats allergies [REDACTED]., one tablet of iron 325 mg. (supplement), one tablet of [MEDICATION NAME] (supplement), one tablet of [MEDICATION NAME] (treats high blood pressure) 100 mg., one tablet of [MEDICATION NAME]. (treats [MEDICAL CONDITION] reflux disease) 40 mg., one tablet of potassium chloride (supplement) 20 milliequivalent (mEq.), one tablet of [MEDICATION NAME] (treats [MEDICAL CONDITION]) 0.5 mg., one tablet of [MEDICATION NAME] (cholesterol lowering medication) 80 mg., one tablet of Requip (treats [MEDICAL CONDITION]) two mg., one tablet of Senna (stool softener 8.6 mg., one half tablet of Vitamin B-12 (supplement) 100 mcg., and one tablet of [MEDICATION NAME] (antibiotic) 875 mg. by mouth. Observation on 11/20/19 at 7:30 [NAME]M. revealed a small, clear, plastic cup with numerous medications, sitting on the bedside table in the private room of Resident #4. Interview on 11/20/19 at 7:30 [NAME]M. with Licensed Practical Nurse (LPN) #210 verified she had left the medications in the room of Resident #4 that morning. 2. Observation on 11/20/19 at 2:45 P.M. revealed a vial of [MEDICATION NAME] purified protein derivative (a diagnostic antimicrobial) was left, unattended, on top of the medication cart. The medication cart was located at the west end of the nurse's station. Interview on 11/20/19 at 2:45 P.M. with Director of Nursing and Clinical Resource Nurse #247 provided verification of the unattended vial of [MEDICATION NAME] purified protein derivative on the medication cart. The facility identified two residents, #22 and #123, as being independently mobile and confused. Review of the facility's policy titled Medication Storage in the Facility, dated 08/2014, revealed medications and biologicals are to be stored safely, securely, and properly and accessible only to licensed personnel.