Every finding on record at Gardens at St Henry the

Based on observations, staff interview and facility policy review, the facility failed to maintain a safe sanitary kitchen. This had the possibly to affect 23 out 25 residents who receive food from the kitchen. The facility identified Resident #1 and #2 did not receive food from the kitchen. The facility census was 25. Findings Include: Observation of the kitchen on 09/02/25 at 9:48 A.M. revealed the trash can by the food serving table had a flip lid. The here was observed multiple areas of thick food particles on the can. Observation of the kitchen freezer revealed the door handles had a red sticky substance on them as did the surface of the refrigerator behind the door handles. These findings were verified with Dietary Manager #106 at the time of the observation. Facility policy Cleanliness, undated, revealed purpose to keep the kitchen and servery as clean as possible during and after operations.

Based on observation, medical record review, staff interview, and policy review the facility failed to follow infection control procedures for residents in isolation. This directly affected one resident, (#12), and had the potential to affect five residents, #01, #02, #12, #16, and #33, on isolation. The facility census was 25.Findings Include:Review of the medical record of Resident #12 revealed an admission date of 03/18/25. Diagnoses include urinary tract infection and Extended-Spectrum Beta-Lactamase in urine. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #12 to be cognitively intact. The assessment indicated no isolation. Review of the physician order dated 08/26/25 revealed an order for contact isolation. Observation on 09/02/25 at 8:45 A.M. revealed a sign on the door to Resident #12's room indicating enhanced barrier precautions. Personal protective equipment was available for use. Observation on 09/02/25 at 9:00 A.M. revealed Registered Nurse (RN) #110 entered the room of Resident #12 along with this surveyor. RN #12 did not don gloves nor gown and proceeded to touch the midline catheter dressing on Resident #12's right upper arm, without gloves. RN #110 exited the room and returned with gloves and a disposable isolation gown. RN #110 donned the items and proceeded to initiate the administration of an antibiotic intravenously. Observation on 09/02/25 at 1:00 P.M. revealed the signage at the entrance to Resident #12's room had been changed to indicate contact isolation in place of the enhanced barrier precautions. Interview on 09/02/25 at 2:00 P.M. with RN #110 provided verification the signage had been changed to the increased restrictive isolation, and it should have been contact isolation for a while now. Review of the policy titled Enhanced Barrier Precautions undated revealed gloves and gowns are to be worn with high contact with residents.

Based on observation, staff interview, and policy review the facility failed to ensure medications were securely stored. This had the potential to affect two residents, (#18 and #19), identified by the facility as being confused and independently mobile residents. The facility census was 25. Findings Include:Observation on 09/02/25 at 8:50 A.M. an antibiotic was noted on the medication cart which was located in the hallway. The cart was unattended. Registered Nurse (RN) #110 was observed to exited a resident room and verified the medication had been lying on the medication cart unattended. The medication was labeled Resident #12 and contained Ertapenem sodium (antibiotic) solution reconstituted 1 gram. Review of the policy titled Medication Storage, undated, revealed medications will be stored in a manner that ensures the safety of the residents. All medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel.

Based on observation, medical record review, staff interview, and policy review the facility failed to provide care for peripherally inserted central catheter. This directly affected one resident, #12, of one reviewed for intravenous catheters. The facility census was 25.Findings Include:Review of the medical record of Resident #12 revealed an admission date of 03/18/25. Diagnoses include urinary tract infection and Extended-Spectrum Beta-Lactamase in urine. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #12 to be cognitively intact. The assessment indicated no intravenous catheter. Review of the physician order dated 08/25/25 revealed an order to change the midline dressing every week. The order indicated this should occur on Mondays. Interview and direct observation of Resident #12 on 09/02/25 at 8:45 A.M. revealed a peripherally inserted central catheter (PICC) in the right upper arm. The dressing was loose and dated 08/25/25. Direct observation and interview on 09/02/25 at 9:00 A.M. with Registered Nurse (RN) #110 provided verification the dressing was loose and overdue to be changed. Review of the policy titled Midline Dressing Changes, dated 01/17/19, revealed the midline catheter dressings will be changed every five to seven days.

Based upon observation and interview the facility failed to properly place a catheter bag. This affected one (#33) of one residents in the facility with a catheter. Census was 25. Records Reviews for Resident #33 revealed resident was admitted on [DATE] with diagnosis fracture of shaft of humerus and left arm, major depressive disorder, anxiety, and panic disorder.The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact and was admitted with suprapubic catheter due to neuromuscular dysfunction of bladder. Observation of Resident #33 on 09/02/25 at 10:38 A.M. revealed suprapubic catheter bag laying on the floor folded in half beside Resident #33's bed.Interview with RN #101 verified suprapubic catheter bag was laying on the floor beside the bed.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was free from the unnecessary medications regarding the use of an antibiotic medication without an adequate indication for use. This affected one (#17) of six residents reviewed for unnecessary medications. The census was 24. Findings include: Review of Resident #17's medical record revealed an admitted d of 01/06/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired, required extensive staff assistance with activities of daily living (ADL's), and did not have a urinary tract infection ([CONDITION(S)]) in the last 30 days. Review of MDS assessments dated 01/13/22, 04/11/22, 07/12/22, and 09/30/22 revealed Resident #17 had not had a [CONDITION(S)] within the last 30 days of those assessments. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 09/14/22. Review of medication administration revealed Resident #17 received [MEDICATION(S)] 50 mg daily starting on 03/09/22. Resident #17 continued to receive [MEDICATION(S)] 50 mg daily through 09/14/22. [MEDICATION(S)] 800-160 mg was started on 09/16/22 and continued to be given through 11/07/22. Review of progress notes dated 03/08/22 revealed a new order was received for [MEDICATION(S)] 50 mg daily indefinitely prophylactically for a history of an [CONDITION(S)]. Review of a facsimile dated 09/12/22 revealed [MEDICATION(S)] was suggested to be changed to [MEDICATION(S)] by Resident #17's neurologist. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #17's medical record revealed no documentation of any [CONDITION(S)]'s or symptoms of [CONDITION(S)] from admission 01/06/22 through 11/07/22. Interview with the Director of Nursing (DON) 11/09/22 08:35 A.M. confirmed there was no documented justification for the continued use antibiotic for Resident #17. The DON confirmed that Resident #17 has not had any signs of an [CONDITION(S)] since admission to the facility. The DON confirmed the the continued use of Resident #17's antibiotic had not been addressed with Resident #17's primary care physician through the facility's antibiotic stewardship program. Review of the facility's undated policy titled Antibiotic Stewardship Program revealed residents without proof of review of infection symptoms prior to the initiation of an antibiotic will be reviewed for antibiotic holiday, culture and sensitivity results will be obtained/reviewed for sensitivity. The results of the testing ant eh recommendation for treatment will be discussed with the primary care physician (PCP) to ensure antibiotics are utilized in a responsible effective manner. Prescribers will be required to document dose, duration, and indication for all antibiotic use.

Based on medical record review, observations, staff interview and review of the facility's policy, the facility failed to ensure residents oxygen tubing was changed according to the physicians orders and the facility policy. This affected one (#15) of one resident reviewed for oxygen use. The facility census was 24. Findings include: Review of the medical record for Resident #15 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/07/22 at 11:36 A.M., revealed Resident #15's oxygen tube was dated as being changed on 10/29/22. Observation on 11/09/22 at 10:15 A.M., revealed Resident #15's oxygen tube was dated as being changed on 10/29/22. Interview on 11/09/22 at 12:48 P.M., revealed Licensed Practical Nurse (LPN) #20 verified Resident #15's oxygen tubing was dated as being changed on 10/29/22. Interview on 11/09/22 at 1:00 P.M., with the Director of Nursing (DON) verified Resident #15's oxygen tubing is supposed to be changed according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Oxygen Therapy, no date, revealed oxygen tubing must be dated/initialed and changed weekly per the oxygen company.

Based on medical record review and staff interview, the facility failed to ensure physician ordered laboratory tests were obtained in a timely manner. This affected two (#1 and #2) of three resident reviewed for change of condition. The census was 23. Findings include: 1. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a five-day minimum data set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired cognition. Review of a progress note dated 04/09/21 at 11:36 P.M. revealed the physician was notified via fax of Resident #1 having multiple loose, reoccurring bowel movements with a prominent foul odor that could be detected from the hallway area. The bowel movements were described as yellowish brown in color. A history of c-diff was noted. Documentation revealed Resident #1 reported abdominal discomfort and nausea periodically. Review of the medical record dated 04/10/21 to 04/12/21 revealed the record for Resident #1 contained no evidence of an attempt to obtain a stool sample for stool culture. Additionally, there was no documentation of the resident not having a bowel movement. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a laboratory test result, culture for c-diff, specimen collection date 04/13/21, revealed on 04/15/21 the results for the stool culture completed for Resident #1 was positive for c-diff deoxyribonucleic acid (DNA). Interview on 08/27/21 at 12:25 P.M. with the Director of Nursing (DON) revealed it was the DON's expectation facility staff would obtain a stool sample for culture the day the culture was ordered or as soon as the resident had a bowel movement. The DON verified the progress notes for Resident #1 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further verified the order for the stool culture for c-diff was written on 04/12/21, three days after the order was received and the stool specimen was obtained on 04/13/21. The DON verified the stool sample for culture for Resident #1 was not obtained timely. The DON verified Resident #1 was not provided timely laboratory services to ensure timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE], revealed Resident #2 had intact cognition. Review of a progress note dated 08/11/21 at 8:00 P.M. revealed Resident #2 was visiting with family. The resident's family member reported the resident was short of breath at times. The family member requested a potassium level be obtained. Documentation revealed the resident's lung sounds were clear and oxygen saturation was 99 percent on room air. Review of the progress note revealed the physician was notified of the families request for potassium level. Review of a progress note dated 08/12/21 at 1:20 P.M. revealed a new order was received for a basic metabolic panel (BMP) on 08/12/21. Review of the medical record for Resident #2 from 08/12/21 to 08/16/21 revealed there was no evidence of the laboratory test BMP being completed. Review of the medical record revealed the laboratory test BMP was obtained for Resident #2 on 08/17/21 with results reported to the facility on [DATE]. The results were abnormal (chloride 112 reference range 98-110 milliequivalents per liter (meq/l) urea [MEDICATION(S)] 29 reference range 7-25 meq/l, creatinine 1.5 reference range 0.6-1.3 milligrams per deciliter (mg/dl), glomerular filtration rate (GFR) - African American 55 ml per minute (min) reference range less than 60 ml/min, and GFR - Non-African American 45 ml/min). Review of the medical record revealed the physician was notified of the BMP results. Interview on 08/27/21 at 12:25 P.M. with the DON revealed contracted laboratory employees come to the facility on time a week, on Tuesday, to obtain blood samples of resident's with physician ordered laboratory tests. The DON verified the BMP ordered for Resident #2 on 08/12 /21 was obtained on 08/17/21. Continued interview with the DON revealed the laboratory staff would have been at the building to obtain blood on Tuesday 08/10/21, two days prior to Resident #2's BMP order, and would not have been scheduled to return to the building until Tuesday 08/17/21, five days after the BMP order was written. The DON reported when laboratory employees only coming to the facility on e time a week it was difficult to obtain timely laboratory results. The DON verified the BMP ordered for Resident #2 was not obtained in a timely manner. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interview, the facility failed to ensure a prescription medication ordered for the treatment of [CONDITION(S)] (c-diff) was available for administration in a timely manner. This affected one (#1) of three resident reviewed for change of condition. The census was 23. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses include heart failure, [CONDITION(S)], enterocolitis, c-diff, acute kidney failure, chronic kidney failure stage three diabetes mellitus type two, and chronic [CONDITION(S)]. Review of a five-day minimum data set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired cognition. Review of a progress note dated 04/09/21 at 11:36 P.M. revealed the physician was notified via fax of Resident #1 having multiple loose, reoccurring bowel movements with a prominent foul odor that could be detected from the hallway area. The bowel movements were described as yellowish brown in color. A history of c-diff was noted. Documentation revealed Resident #1 reported abdominal discomfort and nausea periodically. Review of a laboratory test result, culture for c-diff, specimen collection date 04/13/21, revealed on 04/15/21 the results for the stool culture completed for Resident #1 was positive for c-diff deoxyribonucleic acid (DNA). Review of a progress note dated 04/16/21 at 10:29 A.M. revealed the physician was updated in regard to the residents positive c-diff results. A new order was received for the medication [MEDICATION(S)] (macrolides medication used to treat c-diff associated diarrhea) 200 milligram (mg) two times a day for ten days. Documentation revealed the manufacturer was called and the prescription was sent. The facility was waiting for the medication. Review of a physician order dated 04/16/21 revealed Resident #1 was ordered the medication [MEDICATION(S)] 200 mg one tablet/capsule by mouth twice a day for 10 days, when the medication arrives. Review of the medication administration record (MAR) dated 04/21 revealed the medication [MEDICATION(S)] was started and administered to Resident #1 beginning on 04/22/21. Interview on 08/27/21 at 12:25 P.M. with the Director of Nursing (DON) revealed the facility did not receive the [MEDICATION(S)] for administration until 04/22/21. The DON verified the [MEDICATION(S)] was not obtained timely from the pharmacy. The DON revealed Resident #1 was not provided timely care and services for the treatment of c-diff. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interview, the facility failed to ensure current physician orders [REDACTED].#2, #4, #11, #13, #14, #15, #16, #19, #20, #21, #23, and #26) of 20 resident records reviewed. The facility census was 24. Findings include: Review of the medical records for Residents #2, #4, #11, #13, #14, #15, #16, #19, #20, #21, #23, and #26 revealed no current physician orders [REDACTED]. Additionally Residents #4, #13, #15, #16 and #21 had no orders listed for (MONTH) (YEAR). Interview on 08/13/18 at 4:27 P.M. with the Director of Nursing (DON) provided verification of the lack of current physician orders [REDACTED].

Based on observation, staff interview and manufacturers recommendations, the facility failed to ensure all medications and biologicals were disposed of properly. This had the potential to affect 11 residents (#3, #8, #11, #16, #17, #19, #20, #21, #22, #23 and #25) who were admitted after the vial of [MEDICATION NAME] purified protein derivative should have been discarded. The facility census was 24. Findings include: Observation on 08/15/18 at 7:55 A.M. in the medication storae room revealed an opened vial of [MEDICATION NAME] purified protein derivative with an opened date of 02/19/18. Interview on 08/15/18 at 7:55 A.M. with Registered Nurse (RN) #50 provided verification of the opened date being well past the 30 day time frame recommended. Review of the manufacturers product insert revealed the vial should be discarded 30 days after opening. Review of the facility policy titled Preparation and General Guidelines: Vials and [MEDICATION NAME] of Injectable Medications dated 08/2014 revealed vials of injectable medications are to be stored and disposed of in accordance with the manufacturer' recommendations.

Based on observation, medical record review, staff interview and policy review, the facility failed to protect a resident from verbal abuse and intimidation by a staff member. This affected one resident (Resident #17) of one resident reviewed for mood/behavior. The facility identified six residents (Resident #14, # 2, #17, #19, # 20, #7) with behavioral healthcare needs. The facility census was 24. Findings include: Medical record review of Resident #17 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 07/08/18 admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of five. The score indicated the resident had a severe cognitive deficit. The resident was admitted to skilled nursing from the assisted living due to increased confusion and behaviors. Continued review of the medical record for Resident #17 revealed a current care plan was in place for behavior issues (agitation/motor restlessness), pacing, yelling out and repetitive questions, impaired cognition, impaired thoughts, as well as, psychosocial well-being problems related to inability to concentrate and recent admission. Interventions outlined to assist the resident included: Provide emotional support and reassurance as needed to help decease/resolve anxiety, talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior, allow (resident) time to answer questions and to verbalize feelings, perceptions and fears as needed, when conflict arises, remove (resident) to a calm , safe environment and allow to vent/share feelings. If strategies are not working, leave and reapproach later if safe to do so (list of interventions not all-inclusive). Further medical record review revealed a progress note entry of concern for Resident #17. On 07/14/18 at 7:04 P.M., Licensed Practical Nurse (LPN) #200 documented, Resident disruptive whole shift, causing commotion in dining room, creating poor atmosphere for others trying to eat. Continued after supper. Resident was told by nurse very sternly that she had to sit down at the nurses station and stop her yelling for help. Attempted interjection, but was motioned by nurse to be quiet every time. Was able to sit at front desk for about half hour, but nurse had to pass meds from cart at front desk. Resident still occasionally trying to interrupt and making it difficult to concentrate on med pass. Another progress note entered by LPN #200 on 08/12/18 at 7:17 P.M. stated, Resident becoming more and more loud in her calling out Help another resident across hall from her attempted to tell her to stop yelling. Resident won't get up or do anything for herself even though she has no problems doing so. Hour of sleep (HS) care given early and medications given to aid in quieting her down. Observation of Resident #17 was conducted on 08/14/18 at 3:52 P.M. The elderly resident was observed to be anxious and confused. Unsure where she was, spoke of wanting to go home, said her parents would be worried about her. Resident #17 stated, I'm worrying myself sick. A nursing assistant was seated beside the resident attempting to provide 1:1 distraction and comfort. Random observations were conducted throughout the survey dates of 08/13/18 - 08/16/18. The resident was noted to have a behavior of calling out, help me, periodically. When staff responded the resident often did not remember yelling, or have a need for assistance. Staff interview with the Director of Nursing (DON) on 08/16/18 at 11:37 A.M. revealed they were not aware of the incidents documented by LPN #200 in Resident #17's chart. Upon reading and reviewing entries in the progress notes dated 07/14/18 at 7:04 P.M., the DON stated, This is not acceptable. During continued interview, the DON agreed LPN #200 mistreated Resident #17 and the incident on 07/14/18 would be viewed as abusive. The DON reported she had not been aware of the incident or the nurses behavior. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Resident Property, dated (MONTH) (YEAR) revealed the Policy statement the facility corporation will not tolerate abuse. The definition of abuse in the policy included the actions of unreasonable confinement intimidation and verbal abuse. Additionally, the policy stated, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain or mental anguish.

Based on observation, medical record review, staff interview and policy review, the facility failed to follow its policy and protect a resident from verbal abuse and intimidation by a staff member. This affected one resident (Resident #17) of one residents reviewed for mood/behavior. The facility identified six residents (Resident #14, # 2, #17, #19, # 20, #7) with behavioral healthcare needs. The facility census was 24. Findings include: Medical record review of Resident #17 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 07/08/18 admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of five. The score indicated the resident had a severe cognitive deficit. The resident was admitted to skilled nursing from the assisted living due to increased confusion and behaviors. Continued review of the medical record for Resident #17 revealed a current care plan was in place for behavior issues (agitation/motor restlessness), pacing, yelling out and repetitive questions, impaired cognition, impaired thoughts, as well as, psychosocial well-being problems related to inability to concentrate and recent admission. Interventions outlined to assist the resident included: Provide emotional support and reassurance as needed to help decease/resolve anxiety, talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior, allow (resident) time to answer questions and to verbalize feelings, perceptions and fears as needed, when conflict arises, remove (resident) to a calm , safe environment and allow to vent/share feelings. If strategies are not working, leave and reapproach later if safe to do so (list of interventions not all-inclusive). Further medical record review revealed a progress note entry of concern for Resident #17. On 07/14/18 at 7:04 P.M., Licensed Practical Nurse (LPN) #200 documented, Resident disruptive whole shift, causing commotion in dining room, creating poor atmosphere for others trying to eat. Continued after supper. Resident was told by nurse very sternly that she had to sit down at the nurses station and stop her yelling for help. Attempted interjection, but was motioned by nurse to be quiet every time. Was able to sit at front desk for about half hour, but nurse had to pass meds from cart at front desk. Resident still occasionally trying to interrupt and making it difficult to concentrate on med pass. Another progress note entered by LPN #200 on 08/12/18 at 7:17 P.M. stated, Resident becoming more and more loud in her calling out Help another resident across hall from her attempted to tell her to stop yelling. Resident won't get up or do anything for herself even though she has no problems doing so. Hour of sleep (HS) care given early and medications given to aid in quieting her down. Observation of Resident #17 was conducted on 08/14/18 at 3:52 P.M. The elderly resident was observed to be anxious and confused. Unsure where she was, spoke of wanting to go home, said her parents would be worried about her. Resident #17 stated, I'm worrying myself sick. A nursing assistant was seated beside the resident attempting to provide 1:1 distraction and comfort. Random observations were conducted throughout the survey dates of 08/13/18 - 08/16/18. The resident was noted to have a behavior of calling out, help me, periodically. When staff responded the resident often did not remember yelling, or have a need for assistance. Staff interview with the Director of Nursing (DON) on 08/16/18 at 11:37 A.M. revealed they were not aware of the incidents documented by LPN #200 in Resident #17's chart. Upon reading and reviewing entries in the progress notes dated 07/14/18 at 7:04 P.M., the DON stated, This is not acceptable. During continued interview, the DON agreed LPN #200 mistreated Resident #17 and the incident on 07/14/18 would be viewed as abusive. The DON reported she had not been aware of the incident or the nurses behavior. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Resident Property, dated (MONTH) (YEAR) revealed the Policy statement the facility corporation will not tolerate abuse. The definition of abuse in the policy included the actions of unreasonable confinement intimidation and verbal abuse. Additionally, the policy stated, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain or mental anguish.

Based on observation, record review, and staff interview, the facility failed to ensure a resident was treated in a dignified manner when he did not receive needed assistance with a meal. This affected one (#1) of 14 residents observed during lunch meal service in the dining room. The facility identified 19 residents requiring assistance of one or two staff with meals. The facility census was 20. Findings include: Review of Resident #1 ' s medical record revealed he was admitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL) updated care plan dated 03/20/17, revealed the resident had fluctuations at times with his ability to feed himself and may need staff to feed or cue him. Review of the resident ' s nutrition care plan dated 04/04/17 revealed he was to be provided assistance at meals as needed. During observation of lunch service on 05/30/17, Resident #1 was served his lunch tray at 11:50 A.M. The resident did not attempt to eat or drink any of his meal. Staff did not address the resident until 12:43 P.M., 53 minutes after his tray was served, when State tested Nursing Assistant (STNA) #100 asked the resident why he did not eat. She then fed him a bite of jello which he accepted. The STNA encouraged him to feed himself, however he would not. He did take a drink of water when the cup was placed directly in front of him and he was encouraged to do so. STNA #100 proceeded to sit by the resident and fed him 75% of his meal. The resident's meal was not reheated. Interview with STNA #100 on 05/30/17 at 12:56 P.M. verified she did not attempt to assist Resident #1 until 12:43 P.M. She stated the staff did have to feed him sometimes. She verified the resident ate nothing on his own and ate 75% with her assistance.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to notify the physician when a physician's order was not fulfilled and when there was a change in a resident's pressure ulcer. This affected one resident (#22) of two residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The facility census was 23. Findings include: Review of Resident #22's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment, dated 02/25/16, revealed the resident had moderate impairment in cognition and had a stage two pressure ulcer present on admission. Review of the physician's orders revealed an order dated 02/23/16 for the skin integrity nurse to evaluate the resident. Continued review of the resident's medical record revealed [REDACTED]. There was no documentation indicating the physician was notified this order was not fulfilled as written. Review of the resident's Pressure Skin Grid revealed the resident had a stage two pressure ulcer to the left heel present on admission. It was described as 2.0 centimeters (cm) by 2.6 cm and raised 0.2 cm, with no drainage and no tunneling. Continued review of this document revealed the resident's wound was described as unstageable on 03/09/16. The wound measured 3.0 cm by 2.0 cm, had no blister, and the wound bed was a black circle with intact edges. Review of the nursing notes revealed an entry on 03/12/16 indicating the nurse applied skin prep to the resident's left heel where the blister was is black. The nurse checked the box on the front of the nursing note indicating notification not required, Medical Doctor already aware. Further review of Resident #22's medical record revealed no documentation of the physician being notified regarding the change in the resident's pressure ulcer on 03/09/16. Interview with the Director of Nursing (DON) on 03/31/16 at 10:14 A.M. revealed Resident #22 still had intact skin so they were just continuing to protect the skin. The DON stated she would expect the nurses to notify the physician when there was any change in the wound condition. She further verified the resident's pressure ulcer was assessed as unstageable on 03/09/16 and there was no indication the physician was notified of the change in condition. Interview with Regional Nurse #200 on 03/31/16 at 11:13 A.M. revealed she had contacted the physician on 03/31/16 and he was not aware of the change in Resident #22's pressure ulcer and requested to see the resident on 03/31/16 for further evaluation. Regional Nurse #200 also verified the physician was not notified when the skin integrity nurse did not see the resident. She stated the skin integrity nurse did not see the resident as the resident was under skilled payment and the skin integrity nurse does not see skilled residents. Review of a facility policy titled Notification of Change Policy, dated 07/15, revealed the facility is to keep the physician notified of any change of condition of the resident.

Based on medical record review and staff interview, the facility failed to follow physician orders [REDACTED]. This affected one resident (#22) of two residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The facility census was 23. Findings include: Review of Resident #22's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment, dated 02/25/16, revealed the resident had moderate impairment in cognition and had a stage two pressure ulcer present on admission. Review of the physician's orders [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. Review of the resident's Pressure Skin Grid revealed the resident had a stage two pressure ulcer to the left heel present on admission. It was described as 2.0 centimeters (cm) by 2.6 cm and raised 0.2 cm, with no drainage and no tunneling. Continued review of this document revealed the resident's wound was described as unstageable on 03/09/16. The wound measured 3.0 cm by 2.0 cm, had no blister, and the wound bed was a black circle with intact edges. Interview with Regional Nurse #200 on 03/31/16 at 11:13 A.M. verified the physician was not notified when the skin integrity nurse did not see the resident. She stated the skin integrity nurse did not see the resident as the resident was under skilled payment and the skin integrity nurse does not see skilled residents.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed medications for anxiety, behaviors, and pain. This affected three (#1, #5, and #11 ) of five residents reviewed for unnecessary medications. The facility identified all 23 residents to have as needed medication orders. Findings include: 1. Review of Resident #5's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment, dated 03/18/16, revealed the resident had mild cognitive impairment. Review of Resident #5's physician's orders [REDACTED]. A review of the resident's Medication Administration Record [REDACTED]. Continued review of the medical record revealed no documentation of non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Interview with Regional Nurse #200 on 03/31/16 at 3:21 P.M. verified Resident #5's medical record did not contain documentation indicating non-pharmacological interventions were attempted prior to the administration of as needed [MEDICATION NAME]. 2. Review of Resident #1's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the resident's MDS assessment dated [DATE] revealed the resident had mild cognitive impairment. Review of Resident #1's physician's orders [REDACTED]. A review of the resident's Medication Administration Record [REDACTED]. Continued review of the medical record revealed no documentation of non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Interview with Regional Nurse #200 on 04/01/16 at 11:25 A.M. verified Resident #1's medical record did not contain documentation indicating non-pharmacological interventions were attempted prior to the administration of as needed [MEDICATION NAME]. Review of a facility policy titled Episodic Charting, dated October 2012, revealed all non-pharmacologic interventions attempted and lack of effectiveness were to be documented prior to administering as needed medications. 3. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment, dated 01/01/16, revealed the resident had intact cognition. Further review, revealed a physician order [REDACTED]. Review of Resident #11 Medication Administration Record [REDACTED]. The resident received twelve doses in March on 03/02/16, 03/03/16, 03/04/16, 03/05/16, 03/07/16, 03/08/16, 03/09/16, 03/10/16, 03/12/16, 03/15/16, and 03/17/16. Review of Resident #11's medical record failed to provide any evidence of the attempt of non pharmacological interventions prior to the administration of the pain medication [MEDICATION NAME]. Review of the nurses notes for February and March 2016 revealed the absence of non pharmacological interventions documented prior to pain medications given. Interview on 04/01/16 at 11:25 A.M. with Regional Nurse #200 verified non-pharmacological interventions had not been attempted prior to the administration of the pain medication [MEDICATION NAME] for Resident #11 for the months of February and March 2016.

Based on a review of the resident trust fund accounts, review of the trust fund account balance sheet, and staff interview, the facility failed to maintain a bank account exclusively for the trust fund money of nursing facility residents. This had the potential to affect 22 residents (#1, #3, #5, #6, #8, #10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #21, #22, #23, #24, #25, #26, and #29) that had trust fund accounts. The facility census was 24. Findings include: On 04/23/14 at 3:00 P.M. a review of the resident trust fund accounts noted the Trust-Current Account Balance sheet dated 04/23/14 identified the resident trust fund bank account contained $13,302.42. The nursing home residents had $5,781.99 in the account. An interview on 04/23/14 at 3:00 P.M. with the business office manager revealed the $7,620.43 remaining in the account balance belonged to the residents from the assisted living area of the building. The business office manager stated the nursing facility residents and assisted living residents shared the same bank account for the personal fund accounts. The facility trust fund list identified 22 residents (#1, #3, #5, #6, #8, #10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #21, #22, #23, #24, #25, #26, and #29) to have a personal trust fund account.

Based on observation, staff interview, and review of the dietitian's contract with the facility, the facility failed to ensure the dietitian provided oversight to the kitchen staff. The dietary staff did not receive ongoing department related in-services. In addition, there were no recipes or spread sheets for planned meals to ensure the appropriate meals were served. This had the potential to affect all 25 residents who reside in the facility. Findings include: On 01/15/13 at approximately 8:30 A.M., Dietary Aide #20 was running the dishwashing machine but was unable to tell the surveyor what the appropriate temperatures for the machine were. On 01/16/13 at approximately 3:40 P.M., Dietary Aide #23 was observed to fill a small bucket with sanitizing solution. When asked to test the concentration, she stated she did not know how to do that, though she did know where the test strips were located. Dietary Aide #23 tested the concentration for 30 seconds (directions called for 10 seconds) but did not know how to read the test strip. The facility provided unsigned copies of computer generated menus for the week of survey, provided by the facility's food service provider. On 01/16/13 at 3:30 P.M., Cook #8 was observed to puree green bean casserole and breaded chicken breast. When she was pureeing the chicken, she stated she needed half a cup of water. She was unable to identify the portion size. She was observed to add one and a half cups of water to reach the desired texture. Cook #8 had no recipe for pureeing the chicken. After pureeing the foods she placed them on four individual divided plates, covered them with plastic wrap, and placed in a warming oven. Approximately one and a half hours later, when Cook #8 removed the plates from the oven, the water had separated from the meat leaving the meat with a dry, coarse appearance. Cook #8 had also prepared a chicken based gravy for adding moisture to the pureed and mechanical soft meats. The gravy was very thick with many small lumps. Cook #8 stated she was not good at making gravy. At 5:48 P.M. on 01/16/13, Cook #8 was asked to see her recipes to which she replied she did not need a recipe because she had been cooking for so long. On 01/17/13 at 8:25 A.M., Dietary Manager #10 was asked for recipes. She stated that they had only been using the winter menus for two weeks and the recipes were not ready yet. On 12/24/12, the dietitian conducted a food safety and sanitation audit in which she noted there were no spreadsheets available. During interview on 01/17/13 at 8:55 A.M., the administrator stated there were no specific dietary inservices. He stated they provide training at hire and are involved in general facility wide inservices. The administrator indicated the dietitian does not oversee the kitchen other than doing monthly audits as "that is not their job". He further stated the dietitian reviews residents who are nutrition at risk (NAR), new admissions, and periodic review of resident records. The menus are prepared by their food service provider. The facility had a contracted dietitian from an independent consulting group. The contract noted the consultant (dietitian) would provide support in the areas of clinical nutrition and educational programs. It further noted the dietitian would assist in providing inservices as agreed on by the facility and the dietitian, with an additional hourly consulting fee.

Based on observation, staff interview, review of dietitian audits, and review of computer generated recipes, the facility failed to have recipes or spreadsheets available to ensure the appropriate meals were served. In addition, the menu failed to determine portion size or appropriate substitutes. This had the potential to affect 24 of 25 residents who ate in the facility. Findings include: The facility provided unsigned copies of computer generated menus for the week of survey, provided by the facility's food service provider. On 01/15/13, the noon menu was for chicken and dumplings; however, the residents were served chicken noodle soup. On 01/16/13 at 3:30 P.M., Cook #8 was observed to puree green bean casserole and breaded chicken breast. When she was pureeing the chicken, she stated she needed half a cup of water. She was unable to identify the portion size. She was observed to add one and a half cups of water to reach the desired texture. Cook #8 had no recipe for pureeing the chicken. After pureeing the foods she placed them on four individual divided plates, covered them with plastic wrap, and placed in a warming oven. Approximately one and a half hours later, when Cook #8 removed the plates from the oven, the water had separated from the meat leaving the meat with a dry, coarse appearance. Cook #8 had also prepared a chicken based gravy for adding moisture to the pureed and mechanical soft meats. The gravy was very thick with many small lumps. Cook #8 stated she was not good at making gravy. At 5:48 P.M. on 01/16/13, Cook #8 was asked to see her recipes to which she replied she did not need a recipe because she had been cooking for so long. On 01/17/13 at 8:25 A.M., Dietary Manager #10 was asked for recipes. She stated that they had only been using the winter menus for two weeks and the recipes were not ready yet. On 01/16/13, the evening meal was observed. The menu documented oven fried chicken breast (no size/weight specified), a baked potato (no size specified), a tossed salad, wax beans for all diet types except regular/no added salt/controlled carbohydrates who were to receive green bean casserole, diced pears, margarine, and 2% milk. All of the residents were observed to receive green bean casserole, apricots, no milk and no tossed salad. At 5:55 P.M., the residents in the attached assisted living dining room were being offered tossed salads. When Cook #8 was asked why the nursing home residents did not get salad, she replied that assisted living residents had a choice to receive the salads but that was not an option for the nursing home residents. She did not have a spreadsheet to follow for meal preparation. During interview on 01/17/13 at 8:25 A.M., Dietary Manager #10 was asked for recipes. She stated they had only been using the winter menus for two weeks and the recipes were not ready yet. On 01/17/13, Dietary Manager #15 provided copies of recipes provided by the facility's food service provider. Review of the recipes for 01/16/13 was for raw chicken breast but the facility used a pre-breaded, pre-cooked chicken breast that weighed four ounces. The recipes did not have information on adjusting the menus to the facility's need. On 12/24/12 the dietitian conducted a food safety and sanitation audit in which she noted there were no spreadsheets available.