Every finding on record at Hermitage Health Center

Based on Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, medical record review, observations, and interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 2 residents (Resident #14 and Resident #5) of 16 residents reviewed for MDS assessment accuracy. The findings include: Review of Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .primary purpose as an assessment instrument is to identify resident care problems .the assessment [MDS] accurately reflects the resident's status .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Unspecified Psychosis, Moderate Intellectual Disabilities, and Major Depressive Disorder. Review of a Notice of PASRR Level II Outcome for Resident #14 dated 9/8/2022, revealed .You had a Level II PASRR evaluation .you need special services for your mental health .your PASRR Level II evaluation remains good during your stay . Review of an annual MDS assessment dated [DATE], revealed Resident #14 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review of the MDS assessment revealed Resident #14 was not coded as having a Level II PASRR. During an observation and interview on 9/16/2026 at 9:05 AM, the Licensed Practical Nurse (LPN)/MDS Coordinator reviewed the Level II PASRR dated 9/08/2022 and last comprehensive MDS assessment dated [DATE]. The LPN/MDS Coordinator stated the MDS assessment was not coded to reflect the Level II PASRR status for Resident #14. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD), Bipolar Disorder, Insomnia, and Alcohol Abuse. Review of a Level II PASRR for Resident #5 dated 11/12/2024 revealed .You are approved for nursing facility services. You need specialized services for your disability . Review of a Level I PASRR for Resident #5 dated 5/18/2026 revealed .Your Level I screen was submitted for a potential status change. After review, your previous PASRR screen is accurate and remains active . Review of an annual MDS assessment dated [DATE], revealed Resident #5 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? .no . During an interview on 9/16/2026 at 12:54 PM, the MDS Coordinator and the Administrator confirmed Resident #14 and Resident #5 were not coded as having a [NAME] II PASRR status on the MDS.

Based on Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #23) of 5 residents reviewed for unnecessary medications. The findings include: Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, updated 10/2023, revealed .MEDICATIONS .The intent of the items in this section is to record the number of days, during the last 7 days .that .select medications were received by the resident .Antiplatelet .Check if an antiplatelet medication (e.g., [example] aspirin .) was taken by the resident at any time during 7-day observation period . Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] and 3/19/2025 with diagnoses including Atrial Flutter, Need for Assistance with Personal Care, Anxiety, Dementia, and Hypertension. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 re-entered the facility from a Short-Term General Hospital on 3/19/2025. Continued review revealed .Check if the resident is taking any medications by pharmacological classification .during the last 7 days or since admission/entry or reentry . It was noted that Resident #23 received antiplatelet medications during the previous 7 days. Review of the Medication Administration Record (MAR) dated 3/1/2025 - 3/31/2025, revealed an order for .Aspirin .81 MG [milligrams] .by mouth one time a day .Start Date .06/03/2024 .D/C [discontinue] Date .03/19/2025 . Resident #23 received the medication daily from 3/1/2025 - 3/16/2025 and did not receive any doses after 3/16/2025. During an interview on 5/20/2025 at 9:50 AM, MDS Coordinator A stated Resident #23's 5-day MDS assessment dated [DATE] revealed the resident received antiplatelet medications during the 7-day look back period. MDS Coordinator A stated Resident #23 was taking Aspirin (antiplatelet) daily. Resident #23 was hospitalized from 3/16/2025 to 3/19/2025 and it was not continued upon readmission to the facility on [DATE]. MDS Coordinator A confirmed Resident #23 last received Aspirin on 3/16/2025. MDS Coordinator A confirmed the 3/26/2025 MDS assessment had been coded incorrectly and Resident #23 had not received antiplatelet medication during the 7-day look back period as indicated on the MDS assessment. During an interview on 5/20/2025 at 12:34 PM, the Director of Nursing (DON) stated she or the Assistant Director of Nursing (ADON) signed off on MDS assessments. The DON confirmed it was her expectation that MDS assessments were accurate and Resident #23's MDS assessment dated [DATE] was not accurate related to antiplatelet medications.

Based on medical record review and interview, the facility failed to ensure the medical record was accurate for 1 resident (Resident #33) of 18 residents reviewed for medical records. The findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Anxiety, Dementia, and Prediabetes. Review of the Comprehensive Admission Skin assessment dated [DATE], revealed .upper denture .natural lower . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. Resident #33 did not have mouth or facial pain, discomfort or difficulty chewing. Review of the Long Term Care Evaluation dated 4/30/2025, revealed .Teeth/dentures .Has dentures .Has no teeth .Lower Dental Appliance .Lower Full .Upper Dental Appliance .Upper Full . During an observation and interview on 5/19/2025 at 8:01 AM, Resident #33 was seated on the side of the bed eating breakfast with no concerns noted. Resident #33 had top dentures and poor dentition on the bottom with missing teeth. Resident #33 denied pain or difficulty chewing. Review of the Social Services note dated 5/19/2025, revealed .Spoke with daughter .about her mom's teeth. She states that she [Resident #33] threw her bottom set away at the hospital when her husband passed. She states that resident did not want to get another pair of bottom teeth . During an interview on 5/19/2025 at 3:36 PM, the Director of Nursing (DON) and Administrator stated Resident #33 had a top plate denture and some natural teeth on the bottom. Resident #33's daughter reported the resident threw away her bottom denture plate prior to admission in 2022. The DON confirmed the Long Term Care Evaluation dated 4/30/2025 stated the resident had upper and lower dentures and was not accurate and Resident #33 did not have lower dentures. During an interview on 5/19/2025 at 3:46 PM, the DON confirmed it was her expectation that nursing assessments were complete and accurate.

Based on medical record review and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) timely after a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level I Form Pre-Admission Screening and Resident Review dated 7/16/2021, showed .DIAGNOSIS .Psychotic/Delusional Disorder .[CONDITION(S)] Disorder .Anxiety Disorder .Level I Outcome: No Status Change .A Level II evaluation is not required and this Level I is approved with a Level I No Status Change. Should there be an exacerbation related to mental illness or a discrepancy in the reported information, a Status Change should be submitted to Ascend for further evaluation . Review of the medical record showed Resident #32 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #32 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .and received antidepressant medications on all 7 days of the 7 day look back period. During an interview on 8/9/2022 at 10:44 AM, the Social Services Director stated he was responsible for PASRRs. The Social Services Director confirmed Resident #32 had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Level I PASRR should have been re-submitted .right after . the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review and interview, the facility failed to maintain an accurate medical record for insulin administration for 1 resident (#34) of 4 residents reviewed for insulin administration. The findings include: Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 70-30 [a combination of intermediate acting and short acting insulin] 100 UNIT/ML [milliliters] GIVE 40 UNITS SUBCUTANEOUSLY [a route of medication administration where medication is injected into the skin] TWICE DAILY BEFORE LUNCH AND DINNER; HOLD IF BLOOD GLUCOSE < [less than] 200 . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #34 had Type 2 Diabetes Mellitus and had received insulin on 7 days of the 7 day look back period. Review of the Medication Record Administration (MAR) for 7/2022, showed Licensed Practical Nurse (LPN) #1 administered the dinner time (5:00 PM) dose of [MEDICATION(S)] 70-30 on 7/4/2022 with a blood glucose level of 129. Continued review showed LPN #2 administered the dinner time dose of [MEDICATION(S)] 70-30 on 7/9/2022 with a blood glucose level of 199 and 7/23/2022 with a blood glucose level of 189. Review of the MAR for 8/2022, showed Registered Nurse (RN) #1 administered the lunch time (11:00 AM) dose of [MEDICATION(S)] 70-30 to Resident #34 on 8/9/2022 with a blood glucose level of 193. During an interview on 8/10/2022 at 10:52 AM, RN #1 stated Resident #34 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34's blood glucose level was checked prior to administration of the medication and the insulin was not administered if the resident's blood glucose level was less than 200. RN #1 confirmed Resident #34's lunch time blood glucose level on 8/9/2022 was 193 and the [MEDICATION(S)] 70-30 was not administered. During a telephone interview on 8/10/2022 at 11:36 AM, LPN #1 was aware of the order to hold Resident #34's [MEDICATION(S)] 70-30 insulin for blood glucose level less than 200. LPN #1 confirmed Resident #34's 7/4/2022 5:00 PM [MEDICATION(S)] 70-30 was not administered because the resident's blood sugar was less than 200 and stated .it would have bottomed her out . During a telephone interview on 8/10/2022 at 11:43 AM, LPN #2 stated Resident #34's [MEDICATION(S)] 70-30 was not administered for blood glucose level less than 200. LPN #2 confirmed Resident #34's 7/9/2022 and 7/23/2022 5:00 PM [MEDICATION(S)] 70-30 was not administered because her blood sugar was less than 200. LPN #2 stated when documenting the administration of the [MEDICATION(S)] 70-30, the blood glucose level was entered and if the medication was held, there was a box that had to be manually checked to indicate the medication was not administered and .I must have accidently not clicked that the med (medication) wasn't administered . During an interview on 8/10/2022 at 11:50 AM, the Director of Nursing (DON) confirmed Resident #34's medical record was not accurate and the [MEDICATION(S)] 70-30 administration on 7/4/2022, 7/9/2022, 7/23/2022, and 8/9/2022 was documented as administered in error by the nurses in the facility.

Based on facility policy review, medical record review, resident funds accounts review, and interviews, the facility failed to provide conveyance of personal funds within 30 days of discharge, transfer, or death for 2 residents (Resident #1 and Resident #2) of 3 residents reviewed for resident funds accounts. The findings included: Review of the facility policy Resident AR Refund Policy, revised 11/11/2020 revealed .all credit balances for appropriate refund within 30 days . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #1 passed away on 12/24/2020. Review of the Month-end Aged Analysis Detail dated February 2021 revealed Resident #1 had $2000.00 remaining in the personal funds account. Review of facility checks register dated 3/15/2021, 81 days after Resident #1's death, showed an amount of $2000.00 was dispersed from the facility's checking account to the estate of Resident #1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #2 passed away on 4/23/2021. Review of the Interim Aged Analysis Summary dated May 2021 showed Resident #2 had $2500.00 remaining in the personal fund account. Review of facility checks register dated 6/1/2021, 39 days after Resident #2's dealth, showed that an amount of $2500.00 was dispersed from the facility's checking account to the estate of Resident #2. Interview with the Business Office Manager on 6/1/2021 at 8:36 AM, in the conference room, confirmed they typically did refund a resident's estate within 30 days. Interview with the Administrator on 6/1/2021 at 10:33 AM, in the conference room, confirmed . Resident #1 and Resident #2 refunds were not credited . Interview with the Administrator on 6/1/2021 at 3:20 PM, in the conference room, confirmed the facility failed to refund Resident #1's and Resident #2's account balances to their estates within 30 days of their death. Interview with the Chief Clinical Officer on 6/1/2021 at 3:30 PM, in the conference room, confirmed the facility failed to credit account balances for Resident #1 and Resident #2 to their estates within 30 days of their death.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain infection control practices for 1 resident (#63) of 17 residents sampled. The findings include: Review of the facility policy [MEDICAL CONDITION] (a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), revised 10/2018, revealed .Precautions are taken while caring for residents with [DIAGNOSES REDACTED]icile ([MEDICAL CONDITION]) to prevent transmission to others (other) residents .staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR (alcohol based hand rub- hand sanitizer) for the removal of [DIAGNOSES REDACTED]icile spores from hands . Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 10/31/19 revealed .I have an infection CDiff ([MEDICAL CONDITION]) .isolation until 11/5/19 if stool formed . Medical record review of a physician's order dated 10/31/19 revealed .CONTACT ISOLATION (precautions used to prevent the spread of infections) FOR RECURRENT [MEDICAL CONDITION] UNTIL 11/5/19 IF STOOL IS FORMED . Observation on 11/04/19 at 10:33 AM, of Resident #63's room, revealed a cart outside of the door containing gowns, gloves, and shoe covers. Continued observation revealed a sign on the door of the room which stated to see nurse before entering and contact precautions (contact isolation). Observation of the Assistant Director of Nursing (ADON) on 11/4/19 at 12:57 PM, outside Resident #63's room, revealed the ADON donned gown, gloves, and shoe covers and then entered the room to deliver the lunch meal tray. Continued observation revealed the ADON assisted Resident #63 to sit up on the edge of the bed to eat. Further observation revealed the ADON then removed the gloves and washed the hands in the bathroom. Continued observation revealed the ADON then removed the gown and the shoe covers with the bare hands, exited the room, and used hand sanitizer outside the resident's room. Further observation revealed the ADON obtained a tissue, walked down the hallway, opened 2 doors using the tissue, and then washed the hands with soap and water. Interview with the ADON on 11/4/19 at 1:05 PM, in the hallway, confirmed she did not wash her hands with soap and water prior to exiting the room after she removed the gown and boot covers with ungloved hands. Observation on 11/4/19 at 3:28 PM, outside of Resident #63's room, revealed Nursing Assistant (NA) #1 exited Resident #63's room with ungloved hands and no gown or shoe covers on carrying the resident's water pitcher. Continued observation revealed NA #1 placed the water pitcher on the ice cart, filled the pitcher with ice, and returned the water pitcher to the residents over bed table. NA #1 exited Resident #63's room and applied hand sanitizer to her hands without washing the hands with soap and water. Interview with NA #1 on 11/4/19 at 3:32 PM, in the hallway, confirmed she had brought Resident #63's water pitcher out of the room, placed it on the ice cart, filled the water pitcher with ice and returned it to the room. Continued interview confirmed the NA had not donned gloves, gown, or shoe covers while in the room. Further interview confirmed an isolation sign was on Resident #63's door .the door was open and I didn't see it . Continued interview confirmed the ice cart was removed from the hall and cleaned prior to filling other residents ice pitchers after NA #1 failed to follow infection control practices for Resident #63. Interview with the ADON on 11/5/19 at 3:46 PM, in the ADON's office, confirmed it was her expectation for staff caring for a resident with [MEDICAL CONDITION] to don shoe covers, gown and gloves prior to entering the room. Continued interview confirmed it was her expectation for staff to remove the shoe covers, gown, then gloves, and then wash the hands with soap and water after caring for the resident. Continued interview confirmed it was her expectation for the water pitchers of residents with isolation precautions to not be brought out of the resident's room to be refilled with ice.

Based on medical record review, observation, and interview, the facility failed to implement the comprehensive care plan to monitor for adverse reactions related to polypharmacy (use of 4 or more medications) for 1 Resident (#37) of 16 residents reviewed for care plans of 29 residents sampled. The findings include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a care plan dated 5/2/18 revealed .administer medication per MD (Medical Doctor) order .Review resident's medications .proper dosing, timing and frequency of administration .supporting diagnosis .Review PRNs (as needed) in the process . Medical record review of a physician's orders [REDACTED].Stop Date 9/24/18 . Medical record review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 10/17/18 at 3:15 PM, in the conference room, confirmed the PRN [MEDICATION NAME] was administered after the discontinued date and the comprehensive care plan was not followed.

Based on medical record review, observation, and interview, the facility failed to identify, evaluate and implement an appropriate assistive device 1 Resident (#30) of 4 residents reviewed for positioning and mobility of 29 sampled residents. The findings include: Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not conducted as the resident was rarely or never understood. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, required total dependence of 2 staff with transfers, and required extensive assistance of 1staff with dressing and hygiene. Medical record review of a care plan dated 6/27/18 revealed the resident required assistance with activities of daily living (ADLs) and was at risk for falls with interventions of concave mattress with bed in low position, rock and go wheelchair with dycem, and body pillows to assist with positioning PRN (as needed). Observation of Resident #30 on 10/15/18 at 8:30 AM, 11:00 AM and 4:26 PM, in the resident's room, revealed the resident was sitting in a rock and go wheelchair (a wheelchair that tilt, rocks and reclines) in a reclined position without foot pedals in place. Continued observation revealed the resident's bilateral lower extremities (BLE) were dangling freely and unable to touch the floor. Observation of Resident #30 on 10/16/18 at 9:13 AM, in the resident's room, revealed the resident was sitting in the rock and go wheelchair. Further observation revealed the resident was leaning forward and toward the left with her upper body positioned over the left arm rest. Observation and interview with Registered Nurse (RN) #2 on 10/16/18 at 9:30 AM, in Resident #30's room, confirmed the resident was leaning forward and to the left in the rock and go wheelchair. Further interview revealed the resident routinely leans forwards and at times to the point of .laying her head on her own knees . Interview with Certified Nursing Assistant (CNA) #2 on 10/17/18 at 8:17 AM, on the Unit 2 hall, revealed the resident gets up .almost daily . Continued interview confirmed the resident's rock and go wheelchair did not have foot pedals. Further review revealed the resident was no longer able to propel in the rock and go wheelchair. Interview with the Physical Therapist Rehabilitation Manager on 10/17/18 at 8:29 AM, in the Physical Therapy (PT) office, revealed Resident #30 had been in a rock and go wheelchair for over a year. Continued interview revealed the resident had not been assessed for a different positioning device since that time. Further interview revealed .when passing by . the resident would be seen .usually leaning forward . Continued interview revealed the resident could benefit from .something different like a Broda chair (wheelchair with upper body support, with tilt, recline, and adjustable foot rest), something that would elevate her legs . Further interview revealed Physical Therapy could evaluate for positioning if the resident were referred. Interview with CNA #1 on 10/17/18 at 8:50 AM, on the Unit 2 Hall, revealed the resident was in the rock and go wheelchair daily. Continued interview revealed the resident no longer propeled herself in the wheelchair. Further interview revealed the resident began a physical decline approximately 2 months ago. Interview with RN #1 Unit 2 Manager on 10/17/18 at 10:15 AM, at the nurse's station, revealed Resident #30 had the rock and go wheelchair for .about a year and was able to propel herself until recent decline over the past 6-8 weeks . Continued interview revealed the resident would lean forward in the rock and go wheelchair. Continued interview confirmed an alternate positioning device should have been considered. Interview with the Director of Nursing (DON) on 10/17/18 at 10:25 AM, at the nurse's station, confirmed the resident would benefit from foot pedals for the rock and go wheelchair and a physical therapy evaluation for appropriate positioning recommendations. Continued interview confirmed the facility failed to properly assess Resident #30 for an appropriate assistive device.

Based on medical record review, observation, and interview, the facility failed to ensure a [MEDICAL CONDITION] medication was not administerd without a physician's order for 1 Resident #37 of 5 residents reviewed for unnecessary medications of 29 residents sampled. The findings include: Medical record review of the facility policy Medication Administration revised 3/16/15 revealed .5. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route . Medical record review revealed Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Continued review revealed the resident received antipsychotic medications. Medical record review of a physician's order dated 9/10/18 revealed [MEDICATION NAME] (anti-anxiety medication) 0.5 mg (milligram) by mouth twice daily as needed for anxiety .Stop Date 9/24/18 . Medical record review of a physician's progress note dated 9/10/18 revealed .Restart PRN (as needed) [MEDICATION NAME] 0.5 mg PO (by mouth) bid (twice daily) for cont. (continued) anxiety. Stop date in 2 weeks for re-eval (re-evaluation) . Medical record review of the Medication Administration Record [REDACTED]. Interview with the DON on 10/17/18 at 3:15 PM, in the conference room, confirmed the PRN [MEDICATION NAME] was administered after the medication was discontinued. Further interview confirmed the facility failed to ensure Resident #37 was free from an unnecessary [MEDICAL CONDITION] medication.

Based on observation and interview, the facility failed to provide a comfortable temperature for bathing in 1 of 4 resident shower rooms and failed to provide a comfortable temperature for 1 resident room of 12 rooms on Hall 1. The findings included: Observation and interview with Resident #59 on 11/16/15 at 11:05 AM, in the resident's room, revealed the resident in bed wearing a sweater. Interview with Resident #59 revealed, The shower room is so cold. There is no heat in the room and you get cold when they give you a shower .I've told everyone . Observation and interview with Resident #68 (roommate of Resident #59) on 11/16/15 at 11:25 AM, in the resident's room, revealed the resident was seated in her wheelchair wearing a red sweater. Interview with Resident #68 revealed, It's cold when they give me a shower .I freeze to death .I have told everyone . Interview with the Maintenance Director on 11/17/15 at 7:45 AM, walking through the facility, revealed the facility had 4 shower rooms for resident bathing; 3 shower rooms on Hall 2, and 1 shower room on Hall 1. Further interview confirmed the 3 shower rooms on Hall 2 had auxiliary heating elements. Interview continued and confirmed the resident shower room on Hall 1 did not have an auxiliary heating element. Interview with the Maintenance Director on 11/18/15 at 8:10 AM, in the Hall 1 shower room, revealed the temperature of the air flow from the vent was 71 degrees Fahrenheit. Continued interview confirmed the temperature in the Hall 1 shower room was regulated by the same heat source that provided heat to the resident rooms and hallway located on Hall 1. Continued interview confirmed there was no way to adjust the temperature in the shower room other than the general heating source for Hall 1. Observation and interview with Resident #68 on 11/17/15 at 1:30 PM, in the resident's room, revealed the resident seated in her wheelchair wearing a sweater. The resident's response to the investigation of the shower room temperature revealed, It's cold in the entire building all the time. I freeze to death . Continued interview revealed, I've told everybody .good luck . Observation with the Maintenance Director on 11/17/15 at 2:00 PM, in the room of Resident #59 and Resident #68, revealed the temperature in the room ranged from 68 to 70 degrees Fahrenheit in different locations within the room. Interview with the Maintenance Director on 11/18/15 at 8:10 AM, in the Hall 1 shower room, confirmed the room temperatures taken on 11/17/15 in the residents' room was below the regulatory guidance of 71-81 degrees Fahrenheit.

Based on medical record review, review of facility policy, and interview, the facility failed to notify three residents (#3, #10, #55), of fifteen residents interviewed, of a roommate change prior to the arrival of the roommate. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 11, with 15 being the highest possible score. Interview with the resident in the resident's room on November 1, 2011, at 8:39 a.m., confirmed the resident had not been notified prior to the arrival of a new roommate. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident was cognitively intact, with a BIMS score of 15, with 15 being the highest possible score. Interview with the resident in the resident's room on October 31, 2011, at 11:46 a.m., confirmed the resident had not been notified prior to the arrival of a new roommate. Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident was cognitively intact, with a BIMS score of 12, with 15 being the highest possible score. Interview with the resident in the resident's room on October 31, 2011, at 12:34 p.m., confirmed the resident had not been notified prior to the arrival of a new roommate. Review of the facility document on Resident Rights, section B, # 11, revealed "...The Center must promptly notify the resident and, if known, the Resident's legal representative or interested family member when there is: a. A change in room or roommate..." Interview with the Director of Social Service, in the Social Service office, on November 3, 2011, at 4:50 p.m., confirmed there was no documentation in the medical record verifying the residents had been notified of a roommate change.

Based on medical record review, observation, facility policy review, and interview, the facility failed to develop a comprehensive care plan for one (#10) of three reviewed for Rehabilitation; for one (#67) of one reviewed for Pressure Ulcer; and one (#95) of four residents reviewed for Pain Recognition and Management, of thirty-three residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident's room on November 2, 2011, at 10:10 a.m., revealed the resident in the recliner. Continued observation revealed an elbow splint and a wrist splint on the bedside table. Continued observation revealed the resident had a contracture of the left arm and wrist. Observation on November 3, 2011, at 7:48 a.m., revealed the resident was in a wheelchair in the dining room for the breakfast meal. Continued observation revealed the resident was observing while the Certified Nursing Assistant (CNA #2) buttered the toast; opened the milk carton; added sugar to the oatmeal; and removed the lid from the thickened juice container. Interview in the hall with CNA #1 (assigned to care for resident #10) on November 3, 2011, at 1:45 p.m., revealed, resident #10 "Needs extensive assist to get dressed...we have to set up (resident's) tray and remove the lids from the drinks...cannot do it without help...Don't know anything about the splints in the room..." Continued interview revealed the CNA was unaware the resident was able to perform activities using both hands. Review of the care plan dated August 22, 2011, revealed an identified 'Problem/Need' of Rehabilitation and the intervention of Speech Therapy (ST), Occupational Therapy (OT), and Physical Therapy (PT) to evaluate and treat. Continued review revealed no measurable goals, no interventions, and no revision since admission (August 22, 2011). Review of the OT notes for September and October, 2011, revealed the resident was "completing 2-handed activities" and encouraged by therapy staff to use the contracted hand. Interview with the Certified Occupational Therapy Assistant (COTA #1) in the dining room on November 3, 2011, at 1:52 p.m., revealed the resident "has made a lot of progress...needs encouragement...wants to become more independent to be able to go home." Continued interview revealed the splints (in the resident's room) came with the resident from home. Interview with COTA #1 revealed "it certainly would not hurt at all for the splints to be worn at night...have not talked to nursing about the splints." Interview with the Director of the Therapy Department on November 3, 2011, at 4:10 p.m., revealed resident #10 remains in OT and PT and is continuing to meet short-term goals. Interview with the Director revealed, "When we (therapy department) refer residents to the Restorative nursing department we will talk with them (nursing) regarding the resident's functional ability". Review of the facility policy (un-numbered) titled Care Plans-Comprehensive, revealed, "Each resident's comprehensive care plan has been designed to build on the resident's strength; reflect treatment goals and objectives in measurable goals...5. Care plans are revised as changes in the resident's condition dictates." Interview with the Resident Assessment Nurse on November 3, 2011, at 11:03 a.m., revealed the nursing department and the therapy department usually talk every day and "Try to work together to establish interventions to help the resident achieve their goals." Continued interview verified the staff should encourage the resident to do as much as possible to strive to achieve independence as evaluated by the therapy department. Continued interview confirmed the facility failed to develop a care plan to include therapy. Resident #67 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's re-admission orders [REDACTED]. Medical record review of the Departmental Notes dated October 7, 2011, revealed "...noted stage two to sacrum, new treatment orders received and noted..." Medical record review of the Wound Care Flow Sheet dated October 7, 2011, revealed "...T/R (turn and reposition) Q 1 hour and PRN (as needed) ^ (up) for meals..." Medical record review of the Wound Care Flow Sheet dated October 13, 2011, revealed "...T/R Q1-2 hours & PRN, pillows used for comfort & support...Bilateral (both) hands with 1+ [MEDICAL CONDITION] noted & LE's (lower extremities) bilaterally with 1+ [MEDICAL CONDITION]- Bilateral lower legs are firm to touch...BLE's elevated, moisturizing lotion applied to BLE's..." Medical record review of the Wound Care Flow Sheet dated October 20, 2011, revealed the pressure ulcer had declined to a stage 3. "...LAL (low air loss) mattress in use..." Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with bed mobility; transfers; and eating, was non-ambulatory, and was no longer receiving physical (PT) or occupational (OT) therapy. Medical record review of the resident's current care plan revised on November 2, 2011, revealed "...resident to be treated by PT/OT, Extensive asst. provided with ambulation...At risk for impaired skin integrity and risk for further skin impairment...Diet: NAS Mechanical Soft ..." Further review revealed no problem for the stage 3 pressure ulcer; approaches for the resident's decline and was non-ambulatory; no longer being treated by PT or OT; the resident's diet change; the resident required extensive assistance with bed mobility, transfers, and eating; the resident required to be turned and repositioned every 1-2 hours and PRN. Interview on November 3, 2011, at 7:30 p.m., in the conference room with the Director of Nursing confirmed the resident's care plan was not revised to include the resident's decline including the stage 3 pressure ulcer. Resident #95 was readmitted to the facility on [DATE], and discharged to the hospital on October 16, 2011, with complaints of chest and abdominal pain. Medical record review revealed the resident was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored 13 of 15 on the Brief Interview for Mental Status indicating the resident's cognitive abilities were intact. Review of the initial skin assessment dated [DATE], revealed the resident had 36 abdominal staples, midline from the [MEDICATION NAME] area to the pubis area, and 14 staples in the left and right groin areas. Observation in the resident's room on November 1, 2011, at 8:01 a.m., revealed the resident exhibited several episodic jerking movements accompanied with facial grimacing during the resident interview. Review of the resident's Interim Care Plan dated October 15, 2011, revealed no documentation pain management had been addressed on the resident's care plan. Interview with the Director of Nursing in the MDS office on November 3, 2011, at 3:35 p.m., confirmed the interim care plan had not been revised to address pain management.

Based on observation, manufacturers recommendations, and interview, the facility failed to dispose of expired medications on one medication cart (200 hall) of two medication carts observed. The findings included: Observation with Licensed Practical Nurse (LPN) #1 on November 2, 2011, at 10:44 a.m., of the medications stored on the 200 hall medication cart revealed a 50 ml (milliliter) bottle of Lidocaine, three-fourths full, opened, and dated September 28, 2011. Interview with the Director of Nursing in the conference room on November 2, 2011, at 1:38 p.m., confirmed, after reviewing the manufacturers recommendations, the Lidocaine should have been discarded twenty-eight days after the bottle was opened.