Every finding on record at Holston Health & Rehabilitation Center

Based on interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse to the state survey agency within the required timeframe for 1 of 3 allegations of abuse, including misappropriation of resident property, reviewed. Specifically, an allegation of staff-to-resident physical and verbal abuse for Resident #89 was not reported to the state survey agency within two hours. Findings included: A facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, indicated, Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in abuse or serious bodily injury. A Resident Face Sheet revealed the facility admitted Resident #89 on 01/06/2026. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of muscle weakness, difficulty in walking, and severe dementia with agitation. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/07/2026, revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. Resident #89's Care Plan History, included a problem statement, initiated 01/06/2026, for Activities of Daily Living (ADL). Interventions directed staff to provide Resident #89 with the assistance of two staff members for ADL, (initiated 01/06/2026). A facility document titled Facility Reported Incident for Certified Nursing Homes, dated 01/14/2026 at 2:57 PM, indicated the submission of an allegation of staff-to-resident physical abuse to the state reporting agency that occurred on 01/12/2026 at 12:00 PM. The Facility Reported Incident for Certified Nursing Homes revealed that Resident #89 became combative during perineal care, and witnesses observed that Certified Nurse Aide (CNA) #4 struck and pinched the resident several times, held the resident by the resident's wrists, made threatening comments, and used inappropriate language. A witness statement signed by CNA #3, dated 01/14/2026, revealed that on 01/12/2026 during the provision of resident care CNA #4 took both of [Resident #89's] arms very roughly and was cursing at the patient. A witness statement signed by CNA #5, dated 01/14/2026 at 3:00 PM, indicated that on 01/12/2026 during the provision of resident care Resident #89 hit CNA #4 on the arm, and CNA #4 got very aggressive. CNA #5's witness statement revealed CNA #4 grabbed both wrists slamed [sic] them down on [Resident #89's] chest and said I am not the one you want to [expletive] with! I will [expletive] you up. I will put your [expletive] in a pysch [psychiatric] ward Try me! An undated witness statement signed by CNA #6 revealed, on 01/13/2026 during the provision of resident care, Resident #89 started to hit and pinch and grabbed the back of CNA #4's arm. CNA #6's witness statement revealed CNA #4 got really mad grabbed [Resident #89's] arms and got in [Resident #89's] face told [Resident #89] not to do that, look at me do you hear me! [CNA #4] was very aggressive towards [Resident #89]. [Resident #89] then tried to hit [CNA #4] again [CNA #4] grabbed [Resident #89] again told [Resident #89] [he/she] belonged in a [expletive] physch [sic] ward as [CNA #4] pushed [Resident #89's] arms into [Resident #89's] chest. [CNA #4] proceeded to grab [his/her] are [sic] from behind and told [Resident #89] do you like how that feels? Then don't do it to me. During an interview on 04/22/2026 at 2:46 PM, the Director of Nursing (DON) stated on 01/14/2026 CNA #3, CNA #5, and CNA #6 reported allegations of abuse from CNA #4 to Resident #89. The DON stated CNA #3 and CNA #5 reported allegations from 01/12/2026, and CNA #6 reported allegations from 01/13/2026. During an interview on 04/22/2026 at 3:11 PM, the DON stated her expectation was that allegations of abuse were to be reported immediately. During an interview on 04/22/2026 at 3:14 PM, the Administrator (ADM) stated he was approached by CNA #3, CNA #5, and CNA #6, and they stated CNA #4 was rough and loud when providing care to Resident #89. During an interview on 04/23/2026 at 3:36 PM, the ADM stated his expectation was that staff were to report allegations of abuse immediately and no later than two hours from when the abuse occurred. The ADM stated the facility had two hours to report the allegation of abuse to the state reporting agency. The ADM stated CNA #3, CNA #5, and CNA #6 did not report timely.

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure 1 resident (Residents #51) was free from physical abuse when 1 resident (Resident #84) hit Resident #51 on the left arm of 81 residents sampled for abuse. The findings include: Review of the facility's policy titled, Patient Protection and Response policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, revealed .Abuse .will not be tolerated by anyone .including .patients .The patient has the right to be free from abuse .Abuse .includes .physical abuse .Willful .as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse .includes hitting .slapping . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Dementia, Adult Failure to Thrive, Anemia, and Palliative Care. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. Further review of the quarterly MDS assessment revealed Resident #51 utilized a wheelchair for mobility. Review of the Nursing Progress Notes for Resident #51 dated 6/20/2023 at 11:32 PM, revealed .Notified by .[CNA C-certified nursing assistant] .the resident [Resident #51] was in her room when another resident [Resident #84] came in to get .shoes [Resident #84 thought Resident #51 had taken her shoes] .when [Resident #51] refused to give [Resident #84] the shoe [Resident #84] hit [Resident #51] on the left arm .Assessed resident for injury .Resident denies any pain . Review of the Nursing Progress Notes for Resident #51 dated 6/21/2023 at 1:50 PM, revealed .Left arm w/ [with] no bruising .no c/o [complaints] of pain or discomfort . Review of the medical record revealed Resident #84 was admitted to the facility on [DATE], with diagnoses including Adult Failure to Thrive, Altered Mental Status, Depression, Adjustment Disorder, Dementia with Severe Agitation, Mood Disturbance, and Anxiety. Review of a quarterly MDS assessment dated [DATE], revealed Resident #84 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #84 utilized a wheelchair for mobility and exhibited no behaviors. Review of a comprehensive care plan for Resident #84 dated 4/27/2023, revealed .Behavioral Symptoms .Wandering in hallway and [in] other patients [patients'] rooms .Approach [intervention] .Direct resident to safe activities .Guide patient back .if she is self-propelling in a wheelchair . Review of the Nursing Progress Notes for Resident #84 dated 6/20/2023 at 10:00 PM, revealed .[CNA C] .reported that she was in [Resident #51's room] when [Resident #84] came into [Resident #51's room] accused [Resident #51] of taking her [Resident #84] shoes and hit her [Resident #51] on the left arm .Promptly removed .[Resident #84] from [Resident #51's] room . Review of a witness statement dated 6/20/2023, revealed .[Resident #51] was sitting in her wheelchair in her room .[Resident #84] was very aggravated about her [Resident #84's] shoes came in [Resident #51's room] saying [Resident #51] had her shoes .and smacked [Resident #51] on her left arm . Further review revealed CNA C signed the witness statement. Review of the Nursing Progress Notes for Resident #84 dated 6/20/2023 at 10:00 PM, revealed .Resident transported to [name of hospital] for evaluation . Resident #84 was placed in 1 on 1 supervision until transferred to the hospital. Review of the Hospital Progress Note for Resident #84 dated 6/21/2023 at 2:04 PM, revealed the resident presented to the Emergency Department (ED) with agressive behaviors. While in the ED, Resident #84 was diagnosed with an Urinary Tract Infection (UTI), treated with antibiotics, and once her behaviors stabilized was transferred back to the long term care facility. Review of the Nursing Progress Notes for Resident #84 dated 6/21/2023 at 11:51 PM, revealed .Returned to facility .order for Cephalexin [medication used to treat UTI] 500 mg [milligram] every 8 hours for 5 days for UTI . Review of the Nurse Practitioner Progress Notes for Resident #84 dated 6/22/2023 at 1:43 PM, revealed Resident #84 was evaluated after a return visit from the ED for agressive behaviors and hitting Resident #51. During an interview on 12/11/2024 at 9:15 AM, Licensed Practical Nurse (LPN E) stated she was familiar with Resident #84 and recalled the resident versus resident altercation between Residents #51 and #84 which occurred on 6/20/2023, but did not witness the altercation. LPN E stated CNA C reported Resident #84 wandered into Resident #51's room and swatted Resident #51 on the left arm. LPN E stated Resident #51 recalled the event the night of the incident and denied pain after the altercation. LPN E stated Resident #84 was placed with 1 on 1 supervision until Emergency Medical Services (EMS) arrived to transport the resident to the hospital. LPN E stated Resident #84 did not exhibit behaviors towards other residents prior to or after the incident on 6/20/2023. During an interview on 12/11/2024 at 11:10 AM, the Administrator stated he was aware of a resident-versus-resident altercation between Resident #51 and Resident #84. The facility initiated an investigation and based on CNA C's witness statement the resident-versus-resident altercation between Resident #51 and Resident #84 had occurred.

Based on facility policy review, medical record review, observations, and interviews the facility failed to implement a comprehensive care plan for fall interventions for 1 resident (Resident #60) of 5 residents reviewed for falls and failed to develop a comprehensive care plan for anticoagulant medication for 1 resident (Resident #23) of 18 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Section VII: Patient Care Plans, dated 11/2023, revealed .The center will ensure an interdisciplinary and comprehensive approach to the development of the patient's care plan of care .goals for care .Problems are patient care conditions .Approaches serve as instructions for patient care .Approaches [interventions] Care Plan Approaches are specific individualized steps partners and Patients will take together to assist the patient .Approaches serve as instructions for patient care and provide for continuity of care by all partners . Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including History of Falls, Orthostatic Hypotension, Anemia, and Anxiety. Review of the comprehensive care plan for Resident #60 dated 1/22/2024, revealed the resident was care planned for falls with interventions to include a tab alarm [an alarm attached to resident's clothing that monitors patient movement and alerts facility staff when patients leave their beds] effective 5/9/2024, a low bed [a specialty bed which lowers to the floor] effective 6/8/2024, and 2 fall mats effective 10/19/2024. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review of the quarterly MDS assessment revealed Resident #60 had multiple falls. During an observation on 12/9/2024 at 10:17 AM, Resident #60 was observed lying in a regular bed which was not in the lowest position. Further observation revealed the resident had 1 fall mat which was placed on the resident's right side and a tab alarm was in place and was not attached to the resident's clothing. During an interview and observation on 12/10/2024 at 1:20 PM, Certified Nursing Assistant (CNA) F stated Resident #60 was at risk for falls. The CNA stated Resident #60's bed was not a low bed and the regular bed was not in the lowest position. CNA F stated Resident #60 had 1 fall mat in place, was not sure if the resident required 2 fall mats or required a low bed. During an interview on 12/10/2024 at 1:50 PM, Licensed Practical Nurse (LPN) G stated Resident #60 was a a high risk for falls. LPN G stated the resident did not require a low bed and only required 1 fall mat. LPN G stated tab alarms were used for residents with falls, and the alarms were to be clipped to the resident's clothing. During an observation on 12/11/2024 at 9:50 AM, Resident #60 was observed lying in a regular bed which was not in the lowest position. Further observation revealed the resident had 1 fall mat which was placed on the resident's right side, a tab alarm was in place and was not attached to the resident's clothing. During an observation and interview in Resident #60's room on 12/11/2024 at 10:00 AM, CNA H stated Resident #60's bed was not a low bed, and stated the regular bed was not in the lowest position. CNA H stated she was not aware if Resident #60 required more than 1 fall mat. During an observation, record review, and interview in Resident #60's room on 12/11/2024 at 10:05 AM, with the Assistant Director of Nursing (ADON) revealed Resident #60 lying in bed with 1 fall mat placed on Resident #60's right side of bed, the tab alarm was in place; not attached to the resident's clothing, and the regular bed was not in the lowest position. The ADON reviewed Resident #60's comprehensive care plan, confirmed the resident was a falls risk and the resident had the following interventions care planned, a tab alarm, 2 fall mats, and a low bed. The ADON confirmed Resident #60's tab alarm was not attached to the resident's clothing, and the resident had 1 fall mat in use and not the 2 as developed on the care plan. The ADON confirmed the resident was lying in a regular bed and the bed was not in the lowest position. 49568 Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Anxiety, and Dementia. Review of a comprehensive care plan for Resident #23 initiated 11/26/2024, revealed the resident did not have a care plan for anticoagulant medication (blood thinning medication). Review of the Physician's Order for Resident #23 dated 11/26/2024, revealed .warfarin [a blood thinning medication] 2 mg [milligram] tablet at bedtime on Thursday .warfarin 4mg tablet at bedtime on Sunday, Monday, Tuesday, Wednesday, Friday, and Saturday . Review of an admission MDS assessment dated [DATE], revealed Resident #23 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further record review revealed the resident received an anticoagulant medication. During an interview on 12/11/2024 at 12:30 PM, MDS Coordinator B confirmed Resident #23's care plan had not been developed to include anticoagulant medication.

Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to protect the resident's right to be free from misappropriation and/or exploitation when a staff member deliberately used a resident's personal monetary funds without consent for personal gain for 1 resident (Resident #287) of 81 sampled residents reviewed for misappropriation of personal funds. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, revealed .the patient had the right to be free from abuse .misappropriation of property .definitions .misappropriation of property: the deliberate misplacement .temporary or permanent use of a patient's belongings or money without the patient's consent . Review of the medical record revealed Resident #287 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Chronic Kidney Disease, and Malnutrition. Further review revealed the resident discharged home on 12/22/2022. Review of the Activities of Daily Living (ADL) documentation for Resident #287 dated 12/15/2022 through 12/22/2022, revealed Certified Nursing Assistant (CNA) A cared for Resident #287 on the following dates: 12/16/2022, 12/20/2022, 12/21/2022, and 12/22/2022. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #287 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility's documentation dated 1/24/2023, revealed the facility reported the following information to the state designated authority: .allegation type .misappropriation of resident property .staff became aware of the incident .1/24/2023 at 1:00 PM .alleged victim [Resident #287] .alleged perpetrator [CNA A] .relationship to the alleged victim .caregiver .date and time when alleged incident occurred .12/20/2022 at 2:17 PM [date and time checks were cashed/deposited] .victim [Resident #287] called the facility today with a representative from her bank to report that two checks [amount unknown] had been cashed and the name on the check was a staff member [CNA A] . Review of a police report dated 1/24/2023, revealed .offenses .theft from building .complainant [Resident #287] .suspects [CNA A] .properties .check .value: $525.00 .case notes .on 1/24/2023 .complainant .report [reported] that two checks were stolen out of her purse .the victim was at [facility name] from 12/15/2022 to 12/22/2022 .the suspect [CNA A] was the victim's CNA and had been in the room multiple times .at one point the suspect told the victim her [Resident #287's] purse had fallen off the table and she [CNA A] had picked up the contents and put it back [inside the purse] .the victim was notified by her bank that two of her checks were deposited at [bank name] .made out to the suspect [CNA A] . Review of the facility's investigation summary dated 1/27/2023, revealed .patient [Resident #287] discharged from facility on 12/22/2022 .on 1/24/2023 [bank representative and Resident #287] called [the Administrator] about 2 checks that were written and fraudulent in nature while [Resident #287 was a patient at the facility] .the employee involved [CNA A] was immediately placed on administrative leave .on 1/27/2023 [CNA A] resigned via [by way of] phone call with [the] Administrator . Review of a Facility Action and Abuse Report dated 5/2023, revealed CNA A was added to the abuse registry for abuse: exploitation. During an interview on 12/11/2024 at 8:28 AM, the Administrator stated Resident #287 and her bank representative called the facility on 1/24/2023 (specific time unknown) to inform the facility of an occurrence of check fraud which involved a staff member. The bank representative stated Resident #287 had 2 personal checks written out to CNA A and was cashed. The Administrator stated the bank reimbursed the resident the money stolen by CNA A. The Administrator stated CNA A was placed on administrative leave pending investigation however she called the Administrator back on 1/27/2023 to immediately resign. The Administrator stated during a follow up phone call with Resident #287, the resident had told him she remembered CNA A one night (date and time unknown) awakened and observed CNA A looking through her purse. The resident stated she asked CNA A what she was doing, and CNA A responded to Resident #287 that her [Resident #287's] purse fell on to the floor, and she (CNA A) was placing the contents back inside the purse. The Administrator stated Resident #287's two personal checks were stolen and cashed by CNA A sometime during the resident's stay in December 2022 however the resident was not aware of the missing funds until she received her bank statement in January 2023. The Administrator stated Resident #287 recognized the employee's name [CNA A] when the bank representative told her the name the checks were written out to and initiated a fraud alert on her bank account. The Administrator confirmed the facility failed to protect Resident #287 from a deliberate act of misappropriation of property when CNA A had taken 2 personal checks for personal gain without Resident #287's consent. Interview with the Administrator on 12/11/2024 at 9:18 AM, confirmed the facility had identified the misappropriation of property to Resident #287 and had taken actions to correct the non-compliance. A plan of correction was developed from 1/24/2023-2/1/2023 to address the deficient practice identified. The corrective actions were validated on-site by the surveyor on 12/9/2024-12/11/2024 through interviews and review of facility documents. The facility's Plan of Correction for the Freedom of Abuse, Neglect, and Exploitation dated 1/27/2023, was presented to the survey team and documented the following corrective actions were implemented: On 1/24/2023, interviews were conducted by the Social Services Director and with all residents (and or their responsible parties) to inquire for any items that may have been lost or stolen. Results concluded no other patients were identified as having any checks or money missing. On 1/24/2023-2/1/2023, the 75 active employees received education to address financial exploitation and misappropriation of resident property. Audits for any allegation of misappropriation of property of sampled residents were completed by the Administrator or designee on 3/2023-6/2023 and confirmed there were no issues observed with misappropriation of property. 1. Surveyor interviewed the Administrator on 12/11/2024 at 9:18 AM, in the Administrator's office. Interview confirmed there had not been any further incidents involving misappropriation of resident property or exploitation. 2. Surveyor interviewed multiple staff members (in various departments) from 12/9/2024-12/11/2024 for knowledge of the in-services provided in the corrective action plan, and no knowledge deficits were identified. The deficient practice was cited as past noncompliance for F-602 and the facility is not required to submit a plan of correction.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 10 residents (#2, #17, #18, #25, #33, #52, #63, #67, #183, and #185) of 77 residents reviewed for dignity. The findings include: Review of the facility policy titled, PATIENTS RIGHTS, dated 6/2006, showed .The rights of patients are codified in both federal and state statutes with the intent of further protecting each patient's civil, religious, and human rights while they reside in a health care center. Health care centers that receive federal funds must comply, at a minimum with the federal regulations .The right to respect and dignity are requirements of partners .Protection of confidentiality is a requirement of partners . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], showed the resident had moderate cognitive impairment. During observations on 3/21/2022 at 9:55 AM and 3/22/2022 at 10:00 AM, 1 sign was posted above Resident #2's bed that read, Heel Protectors While in Bed. The signage was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:56 PM, in Resident #2's room, the Director of Nursing (DON) confirmed the signage was present above Resident #2's bed and was visible to anyone who entered the room. Review of the medical record showed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment. During observations on 3/21/2022 at 11:03 AM and 3/22/2022 at 8:12 AM, 4 signs were posted above Resident #17's bed. The 1st sign read, Please keep water where [Resident #17's name] can reach it. Thank You. The 2nd sign read, 605B Dentures need to be taken off @ [at] Bedtime + [and] need to be cleaned! The 3rd sign read, Heel Protectors while in Bed. The 4th sign read, Please put food trays on patient's right side for meals. The signs were visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:50 PM, in Resident #17's room, the DON confirmed the signage was present above Resident #17's bed and was visible to anyone who entered the room. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], showed Resident #18 was cognitively intact. During an observation on 3/22/2022 at 3:30 PM, 2 signs were posted at the head of Resident #18's bed. The 1st sign read, Ms. [Resident #18's name] is a dependent diner, and requires tray set up and feeding by staff. Please make sure to encourage and assist resident with feeding at all meals. Thank You! 3/15/22 [3/15/2022]. The 2nd sign read, Heel Protectors While in Bed. The signs were visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:47 PM, in Resident #18's room, the DON confirmed the signage was present above Resident #18's bed and was visible to anyone who entered the room. Review of the medical record showed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment dated [DATE], showed Resident #25 had severe cognitive impairment. During observations on 3/21/2022 at 10:35 AM and 3/22/2022 at 11:00 AM, 1 sign was posted above Resident #25's bed that read, HEEL PROTECTORS WHILE IN BED PLEASE. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:58 PM, in Resident #25's room, the DON confirmed the signage was present above Resident #25's bed and was visible to anyone who entered the room. Review of the medical record showed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], showed Resident #33 had severely impaired cognitive skills for daily decision making. During an observation on 3/22/2022 at 3:35 PM, 3 signs were posted at the head of Resident #33's bed. The 1st sign read, KEEP HEAD OF BED AT 30 DEGREES OR GREATER AT ALL TIMES. ABDOMINAL BINDER MUST BE ON AT ALL TIMES. The 2nd sign read, PLEASE HAVE MRS.[Resident #33] UP BY 11AM ON THE FOLLOWING DAYS: SUNDAY TUESDAY THURSDAY HER HUSBAND WILL BE HERE TO SEE AND WOULD LIKE TO HAVE HER UP IN WHEELCHAIR THANK YOU!! The 3rd sign read, RESIDENT IS NPO [nothing by mouth]!!!! ABSOLUTELY NOTHING BY MOUTH!!! The signs were visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:45 PM, in Resident #33's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], showed Resident #52 had moderate cognitive impairment. During an observation on 3/22/2022 at 3:40 PM, a sign was posted at the head of Resident #52's bed. The sign read, HEEL PROTECTORS WHILE IN BED THANK YOU. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:42 PM, in Resident #52's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], showed Resident #63 had severe cognitive impairment. During a observations on 3/21/2022 at 10:15 AM and 3/22/2022 at 10:45 AM, 1 sign was posted above Resident #33's bed that read, HEEL PROTECTORS WHILE IN BED THANK YOU. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:57 PM, in Resident #63's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #67 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], showed Resident #67 had severe cognitive impairment. Observations on 3/21/2022 at 10:00 AM and 3/22/2022 at 8:15 AM, showed 1 sign posted above Resident #67's bed that read, I ALWAYS NEED MY BED ALARM. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:48 PM, in Resident #67's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #183 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment dated [DATE], showed Resident #183 was cognitively intact. During observations on 3/21/2022 at 10:55 AM and 3/22/2022 at 11:35 AM, 1 sign was posted at the head of Resident #183's bed that read, Heel Protectors While in Bed. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:54 PM, in Resident #183's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #185 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment dated [DATE], showed Resident #185 had moderate cognitive impairment. During observations on 3/21/2022 at 9:30 AM and 3/22/2022 at 7:45 AM, 1 sign was posted on Resident #185's bathroom door that read, Keep Your Head Up AT LEAST 30 Degrees while Tube Feeding is Running. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:53 PM, in Resident #185's room, the DON confirmed the signage was present and visible to anyone who entered the room. During an interview on 3/23/2022 at 11:19 AM, the DON stated it was the expectation of the facility that signage including resident medical information would not be visibly posted in the resident's rooms unless requested by the resident or family. The DON confirmed no documentation was available to show that Residents #2, #17, #18, #25, #33, #52, #63, #67, #183, and #185 or their families had requested any signage to be placed in their rooms.

Based on facility policy review, facility documentation review, and interview, the facility failed to ensure the Infection Preventionist attended the 11 scheduled Quality Assurance and Performance Improvement (QAPI) meetings from 2/16/2021-2/15/2022. The findings include: Review of facility documentation titled, QUALITY IMPROVEMENT COMMITTEE MEMBERS, undated, revealed the Infection Preventionist was not a member of the committee. Continued review showed the QAPI meetings were held on the 3rd Tuesday of each month. Review of the facility policy titled, QAPI PLAN, undated, revealed the Infection Preventionist was not a member of the QAPI leadership or committee. Continued review showed .All Department Managers will be educated on the QAPI Plan and expectations for leadership in the process. All partners will be educated on the QAPI concepts and empowered to participate in PIPs [Performance Improvement Plans] which directly impact their area of care . Review of the QAPI Committee Minutes dated 2/16/2021, 3/16/2021, 4/20/2021, 5/18/2021, 6/15/2021, 7/20/2021, 8/17/2021, 9/21/2021, 10/19/2021, 11/16/2021, and 2/15/2022 showed the signature lines for the Infection Preventionist was blank which indicated the Infection Preventionist had not attended the 11 scheduled QAPI meetings. During an interview on 3/22/2022 at 8:29 AM, the Infection Preventionist stated she had been the Infection Preventionist since 12/2021 and had not attended any QAPI meetings. During an interview on 3/23/2022 at 1:30 PM, the Administrator stated he was not aware the Infection Preventionist was required to attend the QAPI meetings. Continued interview revealed a part time Infection Preventionist had been employed at the facility since 11/27/2018 and a full time Infection Preventionist had been employed in that position since 12/2021. The Administrator further confirmed neither Infection Preventionists had attended the 11 scheduled QAPI meetings for the past 12 months.

Based on the facility policy review, medical record review, and interview the facility failed to ensure falls interventions were implemented to prevent falls for 4 residents (#1, #4, #6 and #7) and failed to investigate a fall for 1 resident (#1) of 9 residents reviewed for accidents. The findings include: Review of the facility falls policy, revised 7/16/2017 showed .Based on the preceding assessment, the staff and/or physician will identify pertinent interventions to try to prevent subsequent falls .staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses include Dementia with Behavioral Disturbance, Anxiety Disorder, Pneumonia and Difficulty Walking. Review of an Admission Nurse's note dated 3/2/2021 showed Resident #1 arrived to the facility by ambulance. Alarms and floor mats utilized due to a history of falls, agitation and confusion. Review of a falls risk assessment dated [DATE] showed a falls risk score of 22 (score of 13 or greater is high falls risk). Review of the Admission Minimum Data Set, dated dated dated [DATE], showed Resident #1 had severe cognitive impairment, required extensive assistance with bed mobility, transfer, toileting and hygiene. Review of a Nurse's Note dated 3/23/2021 showed .CNA [Certified Nursing Assistant] notified this nurse that resident was found sitting on floor in front her w/c [wheelchair] .assessed for injuries. No injuries noted .educated resident to use call light for help . Review of a facility falls investigation dated 3/23/2021 showed the resident had an unwitnessed fall in the resident's room. The resident was found on the floor with no injuries. The falls investigation showed an intervention was not put in place after the fall on 3/23/2021. Review of a Nurse's note dated 3/26/2021 at 9:00 AM, showed .Called to pt [patient] room, pt sitting on side of bed .Abrasion noted to pt nose and raised area noted to forehead, pt states she don't know what happened .new orders received to send pt to ER [emergency room ] for further evaluation . Review of Resident #1's medical record showed no facility falls investigation was completed and an intervention was not put in place after the fall on 3/26/2021. Review of a Nurse's note dated 3/26/2021 at 11:26 PM, showed Resident #1 returned to the facility. Review of a facility falls investigation dated 3/27/2021 at 11:21 AM, showed Resident #1 had an unwitnessed fall in the resident's room with no injuries noted. The investigation showed the resident was placed in a w/c at the nurse's station without supervision indicated after the fall. Review of Resident #1's care plan dated 3/27/2021 showed a new intervention for the resident to use the call light when in need of assistance (Resident #1 had severe cognitive impairment). Review of a Nurse's note dated 3/27/2021 7:55 PM, showed the resident had a second fall on 3/27/2021 .patient sitting in her wheelchair at the nurses station, patient alarm went off . nurse found patient .small abrasion over lt [left]eye and a older cut on her nose was reopened and bleeding .patient also has a bruise over eyes .np [Nurse Practitioner] ordered patient to ER . During an interview on 4/5/2021 at 9:30 AM, with Licensed Practical Nurse (LPN) #1, stated she found the resident on 3/27/2021 at 11:23 AM. She stated the nurse is responsible to implement an appropriate intervention after a resident fall. LPN #1 stated she did not implement an appropriate falls intervention for Resident #1 due to her cognitive impairment. During an interview on 4/5/2021 at 2:30 PM, with Registered Nurse (RN) #1, stated she was called to Resident #1's room on 3/26/2021 at 9:00 AM. RN #1 stated it is the nurse's responsibility to implement an intervention after a resident falls. She stated the resident was seated on the side of her bed with an abrasion on her nose and a knot on her forehead. RN# 1 stated she did not complete a falls investigation after the fall on 3/26/2021 for Resident #1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], Hallucinations and Falls. Review of Resident #4's Admission MDS dated [DATE], showed the resident had moderate cognitive impairment and required extensive assistance with transfer, dressing, hygiene and toileting. Review of a facility falls investigation dated 3/21/2021 showed the resident had an unwitnessed fall in his room without injury. Review of a Nurse's note dated 3/21/2021 showed .pt. was sitting on the floor in front of bed .alarm unclipped . A new intervention was not put in place after the fall on 3/21/2021. Review of a facility falls investigation dated 3/27/2021 showed Resident #4 had a witnessed fall in the resident's room. Review of a Nurse's note dated 3/27/2021 showed Resident #4 had a witnessed fall in his room and sustained a skin tear to his left hand and knuckle. Review of Resident #4's care plan dated 3/27/2021 showed an added intervention for tab alarm on at all times after the fall on 3/37/2021. Resident #4 had a intervention of a tab alarm prior to the fall on 3/27/2021. A new intervention was not put in place after the fall on 3/27/2021. During an interview on 4/6/2021 at 4:05 PM, with LPN #2 she stated she had been put in charge of falls in the facility. She stated she had not received any additional training for fall management. The LPN stated she is only at the facility on weekends, one other day during the week and sometimes worked on the floor. She stated it was the nurse's responsibility to implement an appropriate intervention after a fall and update the care plan. The LPN stated a new falls intervention was not put in place after Resident #4 fell on [DATE]. Resident #6 was admitted to the facility on [DATE] with diagnoses including Intellectual Disabilities, Conduct Disorder, Anxiety Disorder and [CONDITION(S)]. Review of a Quarterly MDS dated [DATE] showed Resident #6 had moderate cognitive impairment, and required extensive assistance with hygiene, dressing, transfer and bed mobility. Review of a facility falls investigation dated 3/22/2021 showed the resident had a witnessed fall without injury on 3/22/2021 and it was reported by his roommate the next day on 3/23/2021. Review of Resident #6's care plan dated 3/23/2021 showed .Remind resident not to get up without assistance . The resident had cognitive impairment and Intellectual Disabilities. Resident #7 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia without Behavioral Disturbance, Mood Disorder, Intracerbral Hemorrhage, [CONDITION(S)] and [CONDITION(S)]. Review of Resident #7's care plan dated 9/23/2019 showed no new interventions were implemented after the falls on 8/10/2020 and 8/18/2020. Review of a facility falls investigation dated 8/10/2020 showed Resident #7 had an unwitnessed fall without injury in the resident's room. Review of a facility falls investigation dated 8/18/2020 showed Resident #7 had an unwitnessed fall without injury in the resident's room. Review of a Significant Change MDS dated [DATE] showed Resident #7 had severe cognitive impairment and required extensive assistance with hygiene, dressing, transfer and bed mobility. During an interview on 4/7/2021 at 10:00 AM, with the Director of Nursing (DON) stated the nurse is responsible for implementing an appropriate intervention after a fall. She stated the nurse that oversees the facilities falls is only at the facility on weekends, 1 day during the week and may be working on the floor. The DON stated the nurses did not follow the falls policy and implement appropriate falls interventions for Resident #1, Resident #4, Resident #6 and Resident #7 to prevent future falls for the residents.

Based on review of the facility policy, observation, and interview, the facility failed to discard expired medical supplies, failed to prevent storage of medical supplies under a working sink, and failed to separate personal items and medical supplies in 2 of 2 medication storage rooms possibly affecting 77 residents. The findings include: Review of the facility policy Medication Storage in the Facility, Storage of Medications, not dated, revealed .biologicals are stored safely .and properly, following manufacturer's recommendations or those of the supplier .outdated .immediately removed from inventory .medication storage areas are kept clean . Observation and interview with Resident Care Coordinator (RCC) #1 on [DATE] at 2:00 PM, in the East Medication Storage Room, revealed a plastic bag with 11 red and yellow gel top vacutainers expired [DATE]. Further observation revealed under a working sink, seven 16-ounce bottles of medication disposal solution (chemical digestion solution) and 1 half-gallon bottle of medication disposal solution with no cap, open to air. Interview with RCC #1 confirmed the facility failed to remove the expired vacutainers, available for resident use, and failed to remove medical supplies under a working sink. Observation and interview with RCC #2 on [DATE] at 2:40 PM, in the West Medication Storage Room, revealed an opened cardboard box with 25 irrigation trays and bulb syringes and one 250-milliliter of sterile water. Further observation revealed an unlabeled shoe box with 1 pair of shoes on top of the medical supplies. Interview with the RCC #2 confirmed the facility failed to ensure personal items were separated from medical supplies.

Based on medical record review and interview, the facility failed to obtain completed advanced directives for 3 of 18 sampled residents (#231, #232, and #233) reviewed for advanced directives. The findings include: Medical record review revealed Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Tennessee Physician order [REDACTED].#231 revealed no physician signature. Medical record review revealed Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED]. Medical record review revealed Resident #233 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED]. Interview with the Director of Nursing on 9/26/18 at 7:52 AM, in the Conference Room confirmed the facility failed to ensure Residents #231, #232, and #233's POST forms were signed by the physician.

Based on the facility policy review, medical record review and interview the facility failed to provide restorative nursing care for 1 resident (#1) of 3 residents reviewed. The findings included: Review of the facility policy, Restorative Guidelines, undated revealed .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services .physical, occupational or speech therapies . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact and required extensive assistance for bed mobility, transfers, dressing, personal hygiene and toilet use. Medical record review of a Restorative Care Plan dated 6/14/17 revealed .Frequency: 3/day x 8/week (3 days per week for 8 weeks) .BUE (bilateral upper extremities with AROM (active range of motion) .BUE strengthening exercises . Medical record review of a Restorative Care Plan dated 6/15/17, revealed .Frequency: 3/day x 12/week (3 days per week for 12 weeks) .patient will perform AROM/AAROM (Assisted Active Range of Motion) to BLE (Bilateral Lower Extremities) to prevent contractures, and decline in her mobility .BLE .AROM 20 x (20 times) . Medical record review of a Physical Therapy (PT) Discharge Note dated 6/15/17 revealed .patient is d/c (discontinued) from therapy due to patient is not making progress at all; she is declining more due to her dementia is getting worse .Patient discharged to same SNF (Skilled Nursing Facility) with recommendations including restorative to work on ROM (Range of Motion) exercise to BLE to prevent further contractures (permanent shortening of a muscle or joint) . Medical record review of a computerized Restorative Nursing Treatment sheet initiated on 6/15/17 revealed 1 treatment documented on 7/5/17 only. Interview with the Director of Nursing on 5/31/18 at 11:40 AM, in the conference room confirmed the facility failed to provide restorative nursing services for Resident #1.

Based on medical record review, observation, and interview, the facility failed to provide dental services for 1 resident (#118) of 26 residents reviewed. The findings included: Medical record review revealed Resident #118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set assessment dated [DATE] revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status, indicating the resident was independent with daily decision making, required extensive assistance of 1 person with bed mobility, transfer, toilet use, and personal hygiene. Medical record review of the social services progress note dated 2/22/16 revealed .res. (resident) states she wants to see dentist next visit . Medical record review of the OneCare Dental Solutions schedule for the facility visit dated 3/15/16, and 6/20/16 revealed Resident #118 was not on the list to be seen. Observation of Resident #118 on 8/31/16 at 1:07 PM, in the resident's room, revealed the resident eating her lunch, smiling with no upper teeth, and missing multiple bottom teeth. Interview with the Director of Nursing and Social Worker #1 on 8/31/16 at 1:55 PM, in the social services office, confirmed the facility failed to provide dental services for Resident #118.

Based on review of facility's guidance documentation, medical record review, observation, and interview, the facility failed to complete a urinary incontinence screening and initiate interventions to prevent urinary decline for 2 residents (#188, #87) of 5 residents reviewed for urinary incontinence of 26 residents reviewed. The findings included: Resident #188 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Review of facility guidance, Incontinence Assessment /Toileting Plan, undated, . Incontinence screens are completed with admission, change in continence status and annually: toileting plans are individualized based on incontinence screening . Medical record review of the Minimum Data Set (MDS) 5 day assessment dated [DATE] and the Quarterly assessment dated [DATE], revealed the resident was always incontinent of urine, and had a Brief Interview for Mental Status (BIMS - an evaluation of the resident's cognitive status) of 10, indicating the resident had moderate cognitive impairment. Continued review revealed all prior MDS assessments from admission indicated the resident was always continent of urine, and had a BIMS of 14, indicating the resident was cognitively intact. Medical record review of a facility's Incontinence Screening dated 7/12/16, (the date of the resident's return to the facility following a craniotomy), revealed the screening had not been completed. Medical record review of a facility Incontinence Screening dated 8/31/16 revealed the resident was a possible candidate for bladder training as the resident stated she was willing to use a bedpan but the nurse conducting the interview was unsure the resident understood the concept of bladder training. Observation and interview of the resident on 8/30/16 at 3:00 PM, in the resident's room revealed the resident was unable to communicate. Interview with MDS LPN #1 on 8/30/16 at 3:19 PM, in the MDS office revealed no urinary screening had been completed after the Quarterly MDS dated [DATE] documented a decline in urinary status. Continued interview with LPN #1 confirmed a urinary incontinence screening would be initiated after a decline on any resident per facility Incontinence Assessment/ Toileting Plan Guidance. Interview with the MDS Coordinator on 8/30/16 at 3:40 PM, in the MDS office, confirmed a urinary screening had not been completed after the resident's decline, per facility Incontinence Assessment/ Toileting Plan Guidance. Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed Resident #87 had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Continued review revealed the resident was always continent of urine. Medical record review of the Quarterly MDS dated [DATE], revealed Resident #87 was occasionally incontinent (less than 7 episodes of incontinence) of urine. Medical record review revealed no documentation an Incontinence Screening had been initiated after a change in the resident's continence status. Observation and interview with Resident #87 on 8/31/16 at 2:00 PM in the sitting room revealed the resident was continent of urine at all times. Continued interview revealed the resident uses her call light for assistance to use a bedpan during the night because she has [MEDICAL CONDITION] in her feet and prefers not to get out of bed. Interview with the MDS Coordinator on 8/31/16 at 2:45 PM, in the MDS office, confirmed an Incontinence Screening had not been completed per facility Incontinence/Toileting Plan.

Based on review of facility policy, observation, and interview, the facility failed to ensure liquid nutritional products for resident use were maintained within the manufacturer's expiration dates in 1 of 2 resident nourishment refrigerators observed. The findings included: Review of the facility policy, Safety and Sanitation Best Practice Guidelines: Nourishment Pantries, revised 1/2011, Guidelines: #4 .Other items such as beverages, crackers, cookies .will be discarded as appropriate . Observation of the resident nourishment refrigerator on the West hall in the nourishment room, with the Certified Dietary Manager (CDM) on 8/30/16 at 9:19 AM, revealed 7 of 9, 8 ounce cans of [MEDICATION NAME] 1.2 calorie (a liquid nutritional source used for tube feeding) had expiration dates of 4/1/16, and was available for resident' use. The CDM confirmed the 7 cans of [MEDICATION NAME] 1.2 had expired, and should have been discarded per facility policy.

Based on medical record review and interview the facility failed to notify the Family or Physician for changes for 1 (#3) resident of 5 residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a Nurse's Note dated 2/28/16 revealed .large purple bruise noted on L (left) leg posterior to patellar on popliteal, resident denies pain at this time when asked what happened resident responded 'I don't know what could have caused that' supervisor notified. Will cont (continue) to monitor . Interview with RN #1 (Registered Nurse) on 6/8/16 at 4:00 PM by telephone confirmed the bruise noted on the left leg was reported to RN #1. Continued interview confirmed did not notify the family or the Physician. Medical record review of a Nurse's Note dated 3/3/16 revealed .resident has bruising noted on L upper arm . Interview with LPN #1 (Licensed Practical Nurse) (nurse who documented note on 3/3/16) on 6/7/16 at 1:00 PM, at the nursing station confirmed the bruise was light purple, approximately the size of an apple, and reported the bruise to the DON (Director of Nursing). Interview with the DON (Director of Nursing) on 6/7/16 at 2:15 PM, in the private dining room, confirmed the family was not notified of the bruise to the left upper arm noted on 3/3/16 until the next day on 3/4/16. Medical record review of a Weekly Skin assessment dated [DATE] revealed .CNA (Certified Nursing Assistant) asked writer to assess buttock .L buttock with shearing 1x1 triangular shape .denies pain to area .area cleansed [MEDICATION NAME] skin prep padded drsg (dressing) applied . Medical record review of a Weekly Skin assessment dated [DATE] revealed .L buttock shearing resolved barrier cream applied . Medical record review of a Weekly Skin assessment dated [DATE] revealed . buttock (with) open area odd shape .barrier cream applied . Interview with LPN #2 on 6/7/16 at 1:40 PM in the private dining room, confirmed the family had not been notified of the shearing to L buttock with a treatment change on 9/16/15 or the open area noted on12/4/15 on the buttock.

Based on medical record review and interview the facility failed to assess for bladder training and provide appropriate treatment to achieve or maintain as much urinary function as possible for one resident (#111) of thirty-three residents reviewed. The findings included: Resident #111 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], section H, Bladder and Bowel, revealed the resident was always incontinent of urine. Interview with MDS coordinator #2 on April 22, 2014, at 4:20 p.m., in the MDS office confirmed the facility had failed to reassess the resident for bladder training after the change in urinary continence documented in the quarterly MDS dated [DATE].

Based on medical record review and interview, the facility failed to evaluate and provide appropriate treatment and services to maintain or improve functional capacity for one residnet (#111) of thirty-three residents reviewed. The findings included: Resident # 111 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of a Physical Therapy Discharge note, dated January 28, 2014, revealed the resident had failed to progress with treatment goals due to cognitive deficit and inability to follow instructions, was being discharged from physical therapy, and would be referred to restorative nursing for range of motion (ROM) services. Interview with the Physical Therapy Director on April 22, 2014, at 3:51 p.m., in the conference room revealed the resident had been discharged from physical therapy on January 28, 2014, due to the resident's inability to progress, and was referred to restorative nursing for ROM services if the resident was cognitively able to participate. Interview with Restorative Certified Nurse Assistant (RCNA #1), on April 23 , 2014, at 10:47 a.m., in the conference room revealed the RCNA did not have an order for [REDACTED].

Based on medical record review and interview, the facility failed to follow physician's orders for one (#228) resident of thirty-three residents reviewed. The findings included: Resident #228 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged home on October 2, 2013. Medical record review of the Physician's admission orders [REDACTED]...91-150=0 units, 151-200=2 units SQ, 201-250=4 units SQ (subcutaneous), 251-300=6 units SQ, 301-350=8 units SQ, 351-400=10 units SQ...If (greater than) 400 give 10 units SQ. Recheck in 2 hours; if (greater than) 400 call NP/MD for further orders..." Medical record review of the Diabetic Sliding Scale Monitoring Log dated September 2013 revealed the following; September 18, 2013, 12:00 p.m. Blood Sugar-298, 5 units (insulin) administered, 9:00 p.m., Blood Sugar-213, 3 units administered; September 20, 2013, 9:00 p.m., Blood Sugar-267, 5 units administered; September 21, 2013, 5:00 a.m., Blood Sugar-262 5 units administered, 5:00 p.m., Blood Sugar-280, 5 units administered; September 22, 2013, 9:00 p.m., Blood Sugar-292, 5 units administered. Interview on April 23, 2014, at 1:15 p.m., with the Director of Nursing, in the conference room confirmed the physician's orders for the sliding scale insulin had not been followed on September 18, 2013, 12:00 p.m., 9:00 p.m., September 20, 2013, 9:00 p.m., September 21, 2013, 5:00 a.m., 5:00 p.m., and September 22, 2013, at 9:00 p.m. C/O #

Based on medical record review, observation, and interview, the facility failed to revise the care plan for skin integrity, potential for breakdown due to limited mobility, after the development of a stage II pressure ulcer for one resident (#111) of thirty-three residents reviewed. The findings included: Resident #111 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of the care plan, updated March 12, 2014, revealed "...problem priority number 03; Skin Integrity, potential for breakdown due to limited mobility..." had not been revised to reflect actual skin breakdown. Medical record review of a wound care note dated April 4, 2014, revealed the resident had a "...approx. (approximately) 1 cm (centimeter)opened area @ (at) coccyx..." Observation of the wound on April 23, 2014, in the resident's room, with the Wound Care Nurse present, revealed a stage II pressure ulcer approximately 1 cm in diameter and .25 cm deep. Interview with the Medical Director, by telephone on April 23, 2014, at 8:50 a.m., revealed the pressure ulcer was unavoidable due to the resident's age and overall decline in health, related to the [DIAGNOSES REDACTED]. Interview with the Director of Nursing on April 24, 2014, at 10:05 a.m., in the conference room confirmed the care plan had not been updated to reflect the change in skin condition.

Based on medical record review and interview, the facility failed to develop a comprehensive care plan for urinary incontinence for one resident (#111) of thirty-three residents reviewed. The findings included: Resident #111 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of the care plan revealed no plan for urinary incontinence had been developed. Medical record review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], in section H, Bladder and Bowel, revealed the resident was always incontinent of urine. Interview with the MDS Coordinator on April 22, 2014, 4:20 p.m., in the MDS office 4:20 p.m., confirmed the resident's care plan for urinary incontinence had not been addressed.

Based on medical record review and interview, the facility failed to accurately assess one resident (#136) for pressure ulcers of thirty-three sampled residents The findings included: Resident #136 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Five Day Minimum Data Set (MDS) dated [DATE], revealed the resident had no cognitive impairment, required assistance with all activities of daily living, and had no skin conditions. Medical record review of the Admission assessment dated [DATE], revealed, the resident was assessed as having discoloration of the right buttock to the coccyx area and pressure relieving devices were placed in bed and wheelchair. Interview with the Director of Nursing (DON) and Nurse Practitioner in the DON's office on April 22, 2014, at 3:30 p.m., confirmed the resident was admitted with a deep tissue injury which opened up to become an unstageable pressure ulcer. Interview with the MDS Coordinator in the MDS office on April 23, 2014, at 10:20 a.m., confirmed the Five Day MDS dated [DATE], was inaccurate and did not reflect the pressure ulcer.