Every finding on record at Lakebridge, A Waters Community, LLC

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen, which had the potential to affect 95 of 98 residents in the facility. The findings include: Review of the facility policy titled, Cleaning & Sanitation, dated 9/2/2020, showed .The Director of Food and Nutrition Services will develop, implement, and monitor schedules for cleaning, sanitizing, and maintenance .To ensure the food service department is maintained according to state and federal regulations as well as a clean, sanitary, and safe environment .The Director of Food and Nutrition Services monitors the completion of a cleaning schedule including all areas of the kitchen . During an observation on 7/23/2023 at with the Lead Cook (LC) at 10:40 AM, a tour of the kitchen was conducted and the following was observed: 1. The convection oven had brown dried food debris splatter present on the top and inside of both doors which occluded the view of both glass windows of the oven doors. The bottom ledge of the convection oven doors was also covered with the brown dried food debris. 2. The deep fryer was found with a large amount of food debris on the drain ledge which was present from the previous evenings use. 3. 1 Scoop was observed stored in each of the sugar and thickener (powered substance used to thicken liquids) storage bins. During an interview on 7/23/2023 at 11:10 AM, the LC confirmed the kitchen equipment was not in sanitary condition, and the scoops were in the sugar and thickener storage bins.The LC confirmed she was responsible for maintaining the cleanliness and oversight of the kitchen. During an interview on 7/23/2023 at 11:58 AM, the Certified Dietary Manager (CDM) confirmed the kitchen staff did ensure the cleaning and sanitization of kitchen equipment to include the convection oven and the deep fryer. The CDM confirmed the facility did not follow their policy and procedure for cleaning and sanitation of the facility kitchen.

Based on facility policies review, observation, and interview, the facility failed to maintain a sanitary kitchen in 1 of 1 walk in freezer observed, and failed to maintain resident foods in a sanitary manner in 1 of 2 nourishment rooms observed, potentially affecting 88 of 88 residents. The findings include: Review of the facility policy, Cold Storage Areas, dated 3/26/12 revealed .store cold food under safe and sanitary conditions .Date, label and properly secure all products . Review of the facility policy, Food Brought into Facility, dated 12/6/16 revealed .while maintaining the safety and sanitation requirements .set forth by local, federal and state regulations .Outside foods requiring storage .must be dated, labeled and stored per facility and state guidelines . Observation and interview with the head cook on 11/3/19 at 9:56 AM, in the kitchen main walk in freezer revealed: A). 1 box of 46 - 3.6 ounce frozen breaded fish fillets, approximately ¾ full, undated, open to air, and available for resident consumption. B). 1 box of 69 - 3.5 ounce frozen hamburger patties, approximately ½ full, undated, open to air, and available for resident consumption. C). 1 box of 159 frozen sausage links, approximately 1/3 full, undated, open to air, and available for resident consumption. Continued interview with the Certified Dietary Manager (CDM) in the CDM's office, on 11/4/19 at 8:20 AM, confirmed it is her expectation .when food is opened it is to be dated, labeled and sealed .we have zip lock baggies .to seal unused foods . Observation and interview with the CDM on 11/4/19 at 1:22 PM, in the Station 2 Nourishment Room revealed: A). 1 - half gallon container of strawberry and vanilla ice cream that was ½ full, opened, unlabeled, and undated in the freezer. B). 1 - pint container of vanilla ice cream that was ¾ full, opened, unlabeled, and undated in the freezer. Continued interview with the CDM on 11/4/19 at 1:22 PM, in the Station 2 Nourishment Room , confirmed the unlabeled and undated ice creams were brought in from the outside.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a fall intervention was properly maintained for 1 resident (#64) of 3 residents reviewed for falls. The findings include: Review of the Facility's Incidents/Accidents/Falls Policy, undated, revealed .All falls will have a site investigation .to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence . Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the facility's fall investigation dated 6/11/19 revealed .resident observed to be laying in floor next to the bed .Immediate action taken .low bed with mats . Medical record review of the Comprehensive Care Plan dated 6/11/19 revealed .bed in low position with mats at bedside . Observation on 11/4/19 at 8:20 AM, in resident's room, revealed Resident #64 lying in bed with the safety mat rolled up, lying in the floor, at the head of the bed. Observation on 11/5/19 at 8:27 AM, in resident's room, revealed the resident's safety mat was rolled up, lying in the floor, at the head of the bed. Interview with the Director of Nursing on 11/5/19 at 8:45 AM, in the resident's room, confirmed the safety mat should be extended at the resident's beside for the resident's safety.

Based on Center for Medicare and Medicaid (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation and interview the facility failed to develop a care plan for pain for 1 resident (#5) of 20 residents reviewed. The findings include: Review of CMS's RAI Version 3.0 Manual, dated 10/2018 revealed, .Identify and collect information that is needed to identify an individual's conditions that enables proper definition of their conditions, strengths, needs, risks, problems, and prognosis .Identify the individual's response to interventions and treatments . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].PAIN: Monitor AND RECORD Q (every) SHIFT . Medical record review of a physician's orders [REDACTED]. Give 1 tablet every 6 hours as needed for pain with a discontinue date of 7/25/19. Medical record review of a Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicated the resident was cognitively intact and received a scheduled pain medication regimen. Medical record review of a physician's orders [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for pain with a discontinue date of 10/14/19. Medical record review of a physician's orders [REDACTED]. Give 1 tablet by mouth every 6 hours for pain with a discontinue date of 10/31/19. Medical record review of a physician's orders [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for pain and a discontinue date of 11/2/19. Medical record review of the care plan dated 10/31/19 revealed Resident #5 was not care planned for pain. Medical record review of the Electronic Medication Administration Record [REDACTED]. Observation of Resident #5 on 11/3/19 at 12:30 PM revealed the resident seated in the dining room eating his lunch meal independently. Continued observation revealed the resident exhibited no signs of pain or discomfort. Observation of the Resident #5 on 11/4/19 at 9:30 AM revealed the resident propelling himself in a wheelchair in the hallway. Continued observation revealed the resident exhibited no signs of pain or discomfort. Interview with the Director of Nursing on 11/4/19 at 3:30 PM, in the conference room, confirmed Resident #5 was administered regular scheduled pain medication and the facility had not developed a care plan for pain. Interview with the MDS/Care Plan Nurse on 11/4/19 at 3:45 PM, in the conference room, confirmed it was her responsibility to complete and revise care plans. Further interview confirmed Resident #5 was administered regular scheduled pain medication and the facility failed to develope a care plan for pain.

Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 2 residents (#2 and #3) of 5 residents reviewed for abuse. The findings include: Review of facility policy Abuse Prevention Program, last updated 1/19/17 revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents . Review of facility investigation dated 10/2/19 revealed on 10/2/19 at 3:30 PM Resident #2 was seated in a wheelchair in the dining room and rolled up to where Resident #3 was sitting at a table. Further review revealed Resident #2 told Resident #3 to .get out of his (expletive) spot . Further review revealed Resident #3 told Resident #2 that he was sitting there. Continued review revealed Resident #2 then kicked Resident #3 and Resident #3 then hit Resident #2 on the mouth with a closed fist, resulting in a skin tear to Resident #2's mouth. Further review revealed Resident #3 fractured his 5th finger has a result of hitting Resident #2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to an acute care facility on 10/2/19. Review of a Quarterly Minimum Data Set (MDS) for Resident #2 dated 9/4/19 revealed the resident scored a 10 (moderate cognitive impairment) on the Brief Interview of Mental Status (BIMS). Continued review revealed the resident had no history of behaviors during the assessment period. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS for Resident #3 dated 8/16/19 for Resident #3 revealed the resident scored a 12 (moderate cognitive impairment) on the BIMS. Continued review revealed the resident had no history of behaviors. Interview with the Activity Aide on 10/9/19 at 10:00 AM, in the Director of Nursing's (DON) office, revealed .I was passing out BINGO cards in the dining room .(Resident #2) yelled for (Resident #3) to get out of his spot .(Resident #2) kicked (Resident #3) .(Resident #3) hit (Resident #2) in the face with his fist . Interview with the DON on 10/9/19 at 1:00 PM, in the DON's office, revealed .the resident (Resident #3) did hit the other resident (Resident #2) .they hit each other . Continue interview confirmed the facility failed to prevent abuse to Resident #2 and Resident #3.

Based on facility policy review, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of abuse timely for 1 resident (#9) of 8 residents reviewed for abuse of 12 sampled residents. The findings included: Review of facility policy Abuse Prevention Program, last updated on 1/19/17, revealed .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems and was severely impaired for daily decision making skills. Continued review revealed the resident required extensive assist for bed mobility, transfers, and Activities of Daily Living (ADLs) with 1-2 person assist. Review of a facility investigation dated 7/1/19 revealed Licensed Practical Nurse (LPN) #2 alleged she witnessed LPN #4 and LPN #5 be abusive to Resident #9 on 7/1/19 at approximately 1:00 PM in the Station 2 dayroom. Continued review revealed LPN #2 reported the incident to LPN #7, who then provided LPN #2 with the corporate compliance phone number. Further review revealed LPN #2 called the corporate compliance department and reported the incident. Continued review revealed the facility Administrator was notified of the allegation of abuse by the corporate compliance office on 7/1/19 at approximated 6:42 PM (5 hours and 42 minutes after the alleged incident). Interview with LPN #2 on 7/16/19 at 2:30 PM, in the conference room, revealed .(Resident #9) was leaning forward in her wheelchair (LPN #4) grabbed (the resident) by the shoulders and pulled her back into her wheelchair .(Resident #9) grabbed (LPN #4) and dug in her fingernails into (LPN #4's) arm .(Resident #9) continued to be combative .(LPN #5) tried to give (the resident) medicine .she spit it out and threw the water on (LPN #5) .they (LPN #4 and LPN #5) were going to put (Resident #9) in a (reclining wheelchair) .(LPN #5) put his hand in (Resident #9's) face and his thumb went into her (the resident's) left eye .could not tell if (LPN #5) had his hand on (Resident #9's) throat or chest .(LPN #5) was placing pressure .(LPN #5's) face was red and he was clenching his teeth .I felt bad for not reporting it (incident) that day. I thought we had 24 hours . Interview with Certified Nurse Assistant (CNA) #2 on 7/17/19 at 11:15 AM, in the conference room, revealed .(Resident #9) started having behaviors a couple of days before this .on (7/1/19) she got up hitting and kicking we all took turns trying to keep her in her chair .I tried to feed her (Resident #9) lunch and she threw food in my hair .(Resident #9) was in wheelchair in the hallway .(LPN #4) told her (Resident #9) she was acting inappropriately, (LPN #4) grabbed (the resident's) wheelchair and pushed her into the dayroom .heard (LPN #4) telling (the resident) 'you need to stop doing that' . Telephone interview with the (former) Administrator on 7/22/19 at 3:15 PM confirmed she was notified by the corporate office of the allegation of abuse on 7/1/19 at 6:42 PM (5 hours and 42 minutes after the alleged incident). Continued interview confirmed the facility staff failed to report an allegation of abuse timely.

Based on review of the physician's standing orders, medical record review, and interview, the facility failed to implement a bowel protocol for 2 residents (#30 and #49) of 3 residents reviewed for constipation of 25 sampled residents. The findings include: Review of a Physician's Standing Orders, undated, revealed .MEDICATION PROT[NAME]OL .5. Acute Constipation: Check for hard stool, remove if present. L[NAME] (laxative of choice) .or soapsuds enema if no BM (bowel movement) > (greater than) 3 days. 6. Chronic Constipation: Check for hard stool; remove if present. [MEDICATION NAME] 100 mg (milligrams) po (by mouth) bid (twice a day) . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Plan of Care dated 8/30/18 revealed .has an alteration in elimination due to bowel incontinence .Goal .resident will have a regular bowel movements at least once every three days . Medical record review of the resident's BM report dated 9/2018, revealed the resident did not have a BM from 9/21/18 to 9/24/18 (4 days). Medical record review of Resident #30's Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 11/7/18 at 1:12 PM, in the DON's office, confirmed the facility failed to follow a physician's orders [REDACTED]. Medical record review of Resident #49's Plan of Care dated 7/27/18 revealed .Goal .Resident will have a regular bowel elimination pattern as evidenced by soft/formed bowel movements at least once every three days . Medical record review of the resident's BM Report dated 9/2018, revealed the resident did not have a BM from 9/12/18 to 9/18/18 (7 days). Continued review of the BM Report dated 10/2018, revealed the resident did not have a BM from 10/4/18 to 10/10/18 (7 days). Medical record review of Resident #49's MAR for 9/2018 and 10/2018 revealed no documentation the resident received a laxative or an enema. Telephone interview with Resident #49's physician on 11/7/18 at 12:50 PM, confirmed he would have expected the facility to implement the physician's standing order for acute constipation for Resident #49. Interview with the DON on 11/7/18 at 1:03 PM, in the conference room, confirmed the facility failed to follow a physician's orders [REDACTED].

Based on medical record review, observation, and interview, the facility failed to obtain a physician's order for the use of [REDACTED]. The findings include: Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated 10/22/18 revealed .02 (oxygen) at 2L(liters) to maintain sats (oxygen saturation) over 90% (percent) . Continued review revealed no documentation of a physician's order for the use of [REDACTED] Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident's health conditions included shortness of breath while lying, sitting, and on exertion. Continued review revealed the resident's respiratory treatments included the use of a [MEDICAL CONDITION] machine. Observation of Resident #94 on 11/5/18 at 10:15 AM, in the resident's room, revealed a [MEDICAL CONDITION] machine was located in the open top drawer of the resident's bedside table. Interview with the Director of Nursing (DON) on 11/7/18 at 8:23 AM, in the DON's office, confirmed the facility failed to obtain a physician's order for the use of [REDACTED].

Based on review of manufacturer's recommendations, medical record review, observation, and interview, the facility failed to ensure a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) device (a continuous pressure machine to improve oxygen delivery in residents with sleep apnea) was cleaned for 1 resident (#94) of 23 residents reviewed for the use of respiratory equipment of 25 sampled residents. The findings include: Review of the [MEDICAL CONDITION] manufacturer's user guide, undated, reveals .clean the device weekly .wash the water tub and air tubing in warm water using mild detergent .rinse and allow to dry .wipe with a dry cloth .Facemask cleaning .daily-after each use-disassemble the mask components .hand wash mask .use soft bristle brush to clean the vent .rinse with drinking quality water and allow to air dry .weekly-hand wash the headgear and soft sleeves . Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident's health conditions included shortness of breath while lying, sitting, and on exertion. Continued review revealed the resident's respiratory treatments included the use of a [MEDICAL CONDITION] machine. Observation of Resident #94 on 11/5/18 at 10:15 AM, in the resident's room, revealed a [MEDICAL CONDITION] machine with the tubing connected to the facemask and headgear located in the open top drawer of the resident's bedside table. Interview with Licensed Practical Nurse #1 on 11/7/18 at 8:21 AM, at the 200 hallway nurse's station, confirmed .nursing don't document any type of cleaning of the machine that I am aware of . Interview with the Director of Nursing (DON) on 11/7/18 at 2:04 PM, in the DON's office, confirmed the facility failed to clean and sanitize the [MEDICAL CONDITION] per the manufacturer's guidelines.

Based on reveiw of the facility policy, medical record review, and interview, the facility failed to follow a physician's medication order for 1 resident (#200) of 37 residents reviewed. The findings included: Review of the facility policy, Medication Record: Transcription of Doctors Orders and Documentation, date revised 4/16, revealed .Transcribe Physician's written orders to MAR (medication administration record) .Dosage to be administered . Medical record review revealed Resident #200 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #200's admission orders [REDACTED].[MEDICATION NAME] (cholesterol medication) 40 mg TAB (tablet) take one-half tablet (total dose of 20 mg) by mouth at bedtime . Review of the Medication Administration Record [REDACTED].[MEDICATION NAME] Tablet 40 MG Give 1.5 tablet (total of 60 mg) by mouth at bedtime .[MEDICATION NAME] Tablet 200 MG Give 200 mg by mouth two times a day . Interview with the Director of Nursing (DON) on 10/25/17 at 3:46 PM, in the conference room, confirmed the Resident #200 had not received the medication as prescribed by the Physician's Orders. Continued interview confirmed the resident received the wrong dosage of 2 medications, and the facility's policy had not been followed.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure one resident (#129) was free from accident hazards of 37 sampled residents. The findings included: Review of the facility policy Smoking Guidelines and Procedures not dated, revealed .all smoking materials .lighters .matches .are kept in a locked area for single distribution only . Medical record review revealed Resident #129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 10/25/17 at 8:45 AM, in the residents room, revealed the wound nurse completing a dressing change on the resident. Continued observation revealed a lighter fell out of Resident #129's pocket when the wound nurse removed the resident's clothing to complete the dressing change. Interview with the Director of Nursing on 10/25/17 at 9:10 AM, in the conference room, confirmed the resident should not have had the lighter on his person, and the facility's policy for smoking materials had not been followed.

Based on facility policy review, medical record review, and interview, the facility failed to prevent the misappropriation of medication for one resident (#55) of 3 residents reviewed for medication management. The findings included: Review of the facility policy, Controlled Substances, dated November 2016, revealed .b. All .controlled substances .will be counted each shift .both nurses will count the number of packages of controlled substances that are being reconciled during shift to shift count . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident was discharged home on[DATE]. Review of a controlled medication receipt, dated 8/26/17, revealed the facility had received a 30 count of the medication [MEDICATION NAME] (anxiety medication), the day after the resident had been discharged . Interview with the Director of Nursing on 10/25/17 at 10:22 AM, in the conference room, revealed the Assistant Director of Nursing (ADON) discovered the empty medication card in the facility's Sharps container (a hard plastic container used to store needles and other sharp instruments safely) on 9/1/17. Continued interview revealed the medications from the card (30 [MEDICATION NAME] tablets) could not be accounted for. Continued interview with the DON and review of the facility's investigation dated 9/1/17, revealed the charge nurses had failed to count the number of controlled substance cards at the change of shift. Continued interview confirmed the facility's policy for the management of controlled substances had not been followed.

Based on observation and interview, the facility failed to ensure bedtime snacks were available for residents in 2 of 2 nourishment rooms observed. The findings included: Observation on 10/18/16 at 2:45 PM, in the 400-700 hallway nourishment room, revealed no snacks were available for resident use. Observation on 10/19/16 at 10:00 AM, in the 100-400 hallway nourishment room, revealed no snacks were available for resident use. Interview on 10/18/16 at 3:30 PM, with the Dietary Manager, in the dining room, confirmed the kitchen was open from 5:00 AM to 9:00 PM, and after those hours the kitchen was closed. Continued interview confirmed .we do not keep snacks in the nourishment rooms and the residents would not be available to get anything to eat after 9:00 PM . Interview on 10/19/16 at 10:16 AM, with the Registered Dietician, in the conference room, revealed nutritional snacks should be available at all times for the residents. Further interview confirmed the kitchen was closed after 9:00 PM, and snacks are not stocked in the nourishment rooms for the residents.

Based on medical record review, observation, and interview, the facility failed to respond to recommendations from the [MEDICAL TREATMENT] clinic for 1 (#193) resident of 2 residents reviewed for [MEDICAL TREATMENT]. The findings included: Medical record review revealed Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the [MEDICAL TREATMENT] Communication Records used to facilitate communication between the facility and the [MEDICAL TREATMENT] clinic, dated 10/7/16 revealed, .Stop NaHC 3 (Sodium [MEDICATION NAME]) Stop FeS04 (Iron) [MEDICAL TREATMENT] will take care of . and on 10/10/16 Pt (patient) needs to be on Fluid restriction!! Medical record review of Resident #193's Medication Record dated October 2016, revealed the resident was administered the Iron and Sodium [MEDICATION NAME] medications 2 to 3 times a day from 10/7/16 to 10/18/16 (29 doses), except for the 8:00 AM doses on 10/10/16,10/12/16,10/14/16, and10/17/16. Continued review revealed the nurses initials were circled on the front of the Medication Record, and the notation of [MEDICAL TREATMENT] on the back of the Medication Record indicating the medication was not adminsitered at that time. Medical record review of the physician's orders [REDACTED]. Observation in Resident #193's room on 10/17/16, at 11:00 AM, 2:45 PM, 3:30 PM, and on 10/18/16 at 8:00 AM, 8:30 AM, 9:30 AM, 12:45 PM, 1:30 PM, and 2:30 PM, revealed an ice pitcher on the overbed table with ice water. Observation on 10/19/16 at 8:10 AM, in Resident #193's room revealed a breakfast tray with an empty coffee cup, and the water pitcher next to the food tray with ice and 1/3 full of water. Review of the [MEDICAL TREATMENT] Communication Records dated 10/7/16, with Licensed Practical Nurse (LPN) #1 at the nurse's desk on 10/18/16 at 3:15 PM, confirmed the recommendations for discontinuing the Iron and Sodium [MEDICATION NAME] had not been implemented. Continued interview confirmed We don't do fluid restrictions. Interview with the Assistant Director of Nursing (ADON) on 10/18/16 at 3:30 PM, at the nurse's desk, confirmed the recommendations made by the [MEDICAL TREATMENT] clinic had not been implemented. Interview with the Registered Dietician (RD) on 10/19/16 at 10:30 AM, in the conference room, revealed the RD does converse frequently with the [MEDICAL TREATMENT] clinic. Frequently residents are admitted to the facility with no fluid restriction we try not to do any restrictions but if the [MEDICAL TREATMENT] clinic thinks they need to be on a fluid restriction they let us know. Review of the [MEDICAL TREATMENT] Communication Records dated 10/7/16 and 10/10/16 with the RD revealed the RD was not aware of the clinic's recommendations.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure complete medical records for five residents (#105, #22, #46, #25, and #74) of thirty-three residents sampled. The findings included: Review of the facility policy, Charting and Documentation, dated 6/14 revealed .Telephone/verbal orders may be accepted from a licensed physician or dentist. Such orders must be counter signed by the issuing physician/dentist in accordance with state and federal regulations: Tennessee - within ten (10) days. Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a History and Physical dated 1/3/14 revealed .now on hospice secondary to [MEDICAL CONDITION] . Medical record review of a physician's recapitulation order dated 9/1/15 through 9/30/15 revealed an order for [REDACTED].>Interview with Licensed Practical Nurse (LPN) #1 on 10/13/15 at 12:52 PM, at nurses' station #1, confirmed there should have been an order for [REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the physician's recapitulation orders for 10/1/15 through 10/31/15 were not signed by the physician. Interview with the Director of Nursing (DON) on 10/13/15 at 1:20 PM, at nurses' station #1, confirmed the Physicians Orders should be on the chart for the month of October .but they are at the doctor's office waiting to be signed . Interview with the Administrator on 10/14/15 at 1:03 PM, in the Administrator's office, confirmed physician's recapitulation orders should be signed and on the resident's medical record within the first 10 days of the current month. Medical record review revealed Resident #46 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a physician's telephone order dated 8/12/14 revealed .PT (physical therapy) .eval (evaluate) .bedbound .contractures .bracing . Medical record review of a physical therapy annual screen dated 4/10/15 revealed .resident is on restorative program for B (bilateral) LE (lower extremity) braces . Medical record review of a restorative documentation tool dated 9/2015 revealed .knee braces applied & (and) worn (greater to or equal) .5 hours .daily ongoing . Medical record review of a signed physician's recapitulation order dated 9/1/15 through 9/30/15 revealed the order for the braces was not reflected on the orders. Further review revealed the physician's recapitulation orders dated 10/1/15 through 10/31/15 had not been signed by the physician. Interview with Restorative Aide #1 on 10/13/15 at 1:33 PM, in the resident's room, revealed .she gets leg splints 5 hours per day I write in the restorative notebook what time I put them on and then what time I take them off . Interview with the Nurse Consultant on 10/13/15 at 2:25 PM, in the Administrator's office, confirmed the order for splints was not on the physician's recapitulation order and the medical record was incomplete. Interview with the Administrator on 10/14/15 at 1:03 PM, in the Administrator's office, confirmed physician's recapitulation orders should be signed and on the resident's medical record within the first 10 days of the current month. Medical record review revealed Resident #25 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a physician's telephone order dated 8/20/15 revealed .change time .[MEDICATION NAME] (anxiety medication) to 8am, 4pm, and 12am . Medical record review of a physician's telephone order dated 9/24/15 revealed .d/c (discontinue) [MEDICATION NAME] (medication for excess stomach acid) . Medical record review of a medication administrator record (MAR) for Resident #25 revealed the scheduled time for [MEDICATION NAME] administration was changed to 8AM, 4PM, and 12AM. Continued review revealed the [MEDICATION NAME] had been discontinued. Medical record review of a physician's recapitulation order for 10/1/15 through 10/31/15 revealed the recapitulation orders did not have any orders for [MEDICATION NAME] or discontinuation of the [MEDICATION NAME]. Interview with the Assistant Director of Nursing (ADON) on 10/13/15 at 8:20 AM, at nurses' station #1, confirmed the physician's recapitulation orders were incorrect. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the physician's recapitulation orders for 10/1/15 through 10/31/15 were not signed by the physician. Interview with the ADON on 10/13/15 at 2:27 PM, in the conference room, confirmed the Physicians Orders should be on the chart for the month of October but they had not been signed by the physician. Interview with the Administrator on 10/14/15 at 1:03 PM, in the Administrator's office, confirmed physician's recapitulation orders should be signed and on the resident's medical record within the first 10 days of the current month.

Based on review of resident personal funds and interview, the facility failed to refund account balances within 30 days of discharge for three residents (#86, #33, and #76) of six discharged residents reviewed. The findings included: Review of resident personal funds revealed Resident #86 was discharged from the facility on 9/5/15 and had a balance of $50.02 in his personal funds account. Continued review revealed the resident's balance was refunded on 10/13/15 (38 days after discharge). Review of resident personal funds revealed Resident #33 was discharged from the facility on 8/25/15 and had a balance of $40.02 in her personal funds account. Continued review revealed the resident's balance was refunded on 10/13/15 (49 days after discharge). Review of resident personal funds revealed Resident #76 was discharged from the facility on 8/21/15 and had a balance of $20.02 in his personal funds account. Continued review revealed the resident's balance was refunded on 10/13/15 (53 days after discharge). Interview with the Business Office Manager on 10/13/15 at 11:15 AM, in the Business Manager's office, confirmed the facility did not refund the residents' personal funds balance within 30 days.

Based on medical record review, observation, review of Nursing 2015 Drug Handbook, and interview, the facility failed to follow a physician's order for one Resident (#16) of five residents observed during medication administration of thirty-three residents sampled. The findings included: Medical record review revealed Resident #16 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a physician recapitulation order dated 10/1/15 through 10/31/15 revealed .[MEDICATION NAME] (steroid) .0.5MG (milligrams) / (per) 2ml (milliliters) .aerosol .(at) 8PM . Observation on 10/13/15 at 8:14 PM with Licensed Practical Nurse (LPN) #2, during a medication administration, revealed the LPN administered [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) 15 micrograms (MCG)/2ml aerosol treatment to Resident #16. Review of Nursing 2015 Drug Handbook 35th edition revealed [MEDICATION NAME] is a long-acting selective beta 2 agonist [MEDICATION NAME][MEDICATION NAME] used for treatment of [REDACTED]. Interview with LPN #2 on 10/13/15 at 8:25 PM, outside the resident's room, revealed the LPN was not sure if [MEDICATION NAME] and [MEDICATION NAME] were the same medication or if [MEDICATION NAME] was a pharmacy substitution for [MEDICATION NAME]. Interview with the Assistant Director of Nursing (ADON) on 10/13/15 at 8:26 PM, at nurses' station #2, revealed the ADON was not aware if [MEDICATION NAME] was a pharmacy substitution but would call the pharmacy and verify. Continued interview with the ADON at 8:28 PM, revealed the [MEDICATION NAME] was not a substitution and [MEDICATION NAME] and [MEDICATION NAME] were not the same medication class. Further interview confirmed the facility failed to follow the physician's orders.

Based on medical record review, observation, review of meal service tray card, and interview the facility failed to ensure straws were not provided during a meal service in accordance with the physician's orders [REDACTED].#2) of five residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Significant Change Minimum Data Set Significant (MDS) Assessment and Care Area Assessment (CAA) Documentation Notes, both dated 1/28/2015 revealed she was able to feed self with tray set-up and supervision. Continued review revealed Resident #2's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15. Medical record review of the August 2015 Physician's Recapitulation orders revealed, .Thin liquids .No straws . Observation of Resident #2 in the dining room on 8/19/2015 at 12:35 confirmed she was seated at a table eating lunch with two other residents. Observation and review confirmed her meal service tray card was lying at the head of her plate and revealed, .NO STRAWS . Continued observation confirmed Resident #2 had two straws with one in her glass of punch and the other in her cup of coffee. Further observation confirmed she was actively drinking the punch through a straw with most of the punch drank; and the coffee cup was empty. Interview with Licensed Practical Nurse (LPN) #1 on 8/19/2015 at 12:40 P.M., in the dining room, confirmed LPN #1 was assigned supervision of the residents' meal service. Continued interview confirmed Resident #2 was drinking liquids through straws, was not to use straws, and stated, .I did not notice her (Resident #2) using straws to drink . During the interview, the surveyor observed LPN #1 walk over to Resident #2's dining table, talked with her, and removed her straws. Further interview with LPN #1 confirmed Resident #2 was served 240 milliliters (ml) of punch and 240 ml of coffee; and she used straws to drink 180 ml of the punch and 240 ml of the coffee. Interview with the Speech Language Pathologist (SLP) on 8/19/2015 at 12:50 P.M., in the Rehabilitation Department, confirmed residents with Dysphagia have less control using a straw. The SLP stated, .When using a straw there is less control over the bolus (mass of food or liquid). When a straw is used, the bolus goes to the back of the mouth making it more difficult to manage with Dysphagia versus sipping from a glass or cup. Pulling the liquid through the straw can cause fatigue, also . Interview with the Director of Nursing (DON) on 8/19/2015 at 1:00 P.M., in the dining room confirmed Resident #2 was not to use straws due to Dysphagia. Continued interview with the DON confirmed the facility failed to ensure straws were not provided during Resident#2's meal service to maintain her highest well-being.

Based on medical record review, observation, review of meal service tray card, and interview the facility failed to develop an individualized plan of care for one resident (#2) of five residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Significant Change Minimum Data Set Significant (MDS) Assessment and Care Area Assessment (CAA) Documentation Notes, both dated 1/28/2015 revealed she was able to feed self with tray set-up and supervision. Medical record review of the August 2015 Physician's Recapitulation orders revealed, .Thin liquids .No straws . Medical record review of Resident #2's Care Plan dated 2/10/2015 through 8/13/2015 did not reveal the development of a plan or interventions for no straws. Observation of Resident #2 in the dining room on 8/19/2015 at 12:35 confirmed she was seated at a table eating lunch with two other residents. Observation and review confirmed her meal service tray card was lying at the head of her plate and revealed, .NO STRAWS . Interview with Licensed Practical Nurse (LPN) #1 on 8/19/2015 at 12:40 P.M., in the dining room, confirmed Resident #2 was drinking liquids through straws and stated, .I did not notice her using straws to drink . Interview with the Administrator on 8/19/2015 at 7:00 P.M., in the Administrator's Office confirmed the facility failed to develop an individualized Care Plan to ensure no straws for Resident #2.

Based on medical record review, observation, and interview, the facility failed to ensure the correct safety device was in place for one (#31) resident of three residents reviewed for accidents of thirty-one residents reviewed. The findings included: Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Interdisciplinary Progress Note dated July 28, 2014, revealed "...resident observed in floor of restroom sitting upright in front of w/c (wheelchair)...stated...was trying to use the restroom...resident was wearing proper footwear at time of fall (with) PSA (personal safety alarm) alarming as well. New interventions to include d/c (discontinue) of PSA and pad alarm to be on at all times..." Medical record review of a physician's orders [REDACTED]. Observation on July 29, 2014, at 2:45 p.m., revealed the resident seated in a wheelchair in front of the nursing station with a personal safety alarm attached to the resident's shirt. Observation on July 29, 2014, at 3:30 p.m. with Licensed Practical Nurse (LPN) #1, revealed the resident seated in a wheelchair in front of the nursing station with a personal safety alarm attached to the resident's shirt. Interview with LPN #1 confirmed the pad alarm was not in place. Interview on July 30, 2014, at 12:45 p.m., with the Assistant Director of Nursing, in the conference room, confirmed the resident removed the clip alarm at the time of the fall on July 28, 2014.