Every finding on record at Life Care Center of Morgan County

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, facility policy review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 2 residents (Resident #10, and #53) of 24 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual Version 1.20.1, dated 10/2025, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .Section N .High-Risk Drug Classes .Anticoagulant .Check if an anticoagulant medication was taken .during the 7-day look-back period . Review of the facility's policy titled, Resident Assessment Instrument and Care Plan Development, dated 8/29/2025, revealed .The facility will follow the procedures set forth In the Resident Assessment Instrument (RAI) User's Manual 3.0 when completing the MDS . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Schizoaffective, Depression, Autistic, and Anxiety. Review of a PASRR dated 3/2/2022, revealed Resident #10 had a PASRR Level II Outcome related to a serious mental illness (Schizoaffective, Depression, Autism, and Anxiety). Review of a annual MDS assessment dated [DATE], revealed Resident #10 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had active diagnoses of Schizoaffective, Depression, Autistic, and Anxiety. Continued review revealed the resident was not coded for a PASRR Level II condition. During a medical record review and interview on 7/8/2026 at 8:20 AM, MDS Coordinator reviewed the annual MDS assessment dated [DATE] and the Level II PASRR dated 3/2/2022 for Resident #10. MDS Coordinator confirmed the annual MDS assessment for Resident #10 was inaccurate and did not reflect Resident #10's PASRR level II outcome status. During an interview on 7/8/2026 at 8:13 AM, the Director of Nursing (DON) confirmed it was her expectations for Resident #10 to have an accurate MDS assessment. The DON confirmed Resident #10's annual MDS assessment dated [DATE] was not accurate and did not reflect Resident #10's PASRR Level II condition. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Depression. Review of a baseline care plan for Resident #53 dated 2/28/2024, revealed .on anticoagulant therapy .at risk for adverse bleeding . Review of the Physician's Orders for Resident #53 dated 6/30/2025, revealed .Apixaban .5 MG [milligrams] .one tablet by mouth two times a day .for clot prevention .ATRIAL FIBRILLATION . Review of a quarterly MDS assessment dated [DATE], revealed Resident #53 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident was not coded as receiving an anticoagulant in section N on the MDS. Review of a Medication Administration Record for Resident #53 dated 5/1/2026-5/31/2026, revealed Apixaban was given as ordered twice a day. During an interview on 7/8/2026 at 9:50 AM, the MDS Coordinator stated she was responsible for completing MDS assessments. Further interview with the MDS Coordinator confirmed that the quarterly MDS for Resident #53 was not coded for anticoagulant use.

Based on facility policy review, medical record review, and interview, the facility failed to obtain a Physician's Order for hospice services for 1 resident (Resident #3) of 2 residents reviewed for hospice services. The findings include: Review of the facility policy titled, Physician Orders, dated 2/11/2026, revealed .physician .must provide orders for .ongoing care . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, and Dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 2 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #3 dated 5/1/2026, revealed .receiving hospice services .treatment as ordered .work cooperatively with hospice team . Review of the hospice care plan for Resident #3 dated 7/7/2026, revealed current benefit period 5/27/2026 to 7/25/2026. Review of the current physician's orders for Resident #3 dated 7/8/2026, revealed no documentation of a physician's order for hospice services. During an interview on 7/8/2026 at 8:17 AM, Nurse Supervisor Registered Nurse (RN) A confirmed Resident #3 had received hospice services since admission. During an interview on 7/8/2026 at 9:05 AM, the Director of Nursing (DON) stated all residents with hospice services should have a physician's order. The DON confirmed Resident #3 did not have a physician's order for hospice services.

Based on facility policy review, medical record review, hospital record review, and interview the facility failed to implement care plan interventions related to safe transfers with a mechanical lift for 1 resident (Resident #5) of 10 resident care plans reviewed which resulted in actual Harm for Resident #5. The findings include: Review of the facility policy titled, Comprehensive Care Plans and Revisions, dated 9/11/2024, revealed .The facility will ensure .each resident's person-centered [care plan] .is reviewed and revised .that includes but not limited to .appropriate staff .by resident's needs . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, Bipolar Disorder, and Morbid Obesity. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review revealed the resident was dependent on staff for toileting, shower, and upper and lower body dressing. Review of comprehensive care plan for Resident #5 dated 2/17/2021, revealed Resident #5 was dependent on staff for mobility and required 2 to 4 staff member assistance for transfers related to the resident's morbid obesity. Review of a Dietary Progress Note for Resident #5 dated 3/15/2023, revealed the resident weighed 425 pounds. Review of a Nursing Progress Note for Resident #5 dated 3/15/2023 at 6:11 AM, revealed .CNA [Certified Nursing Assistant] was attempting to put resident [Resident #5] to bed after a shower with the mechanical lift. [The] CNA stated he turned to move the shower chair and heard a scream. When he turned, he seen the resident in the floor and the loop on [the] sling [had] ripped. CNA yelled for nurse. This nurse found the resident in the floor complaining with right ankle and right wrist pain .MD [medical doctor] and DON [director of nursing] notified. EMS [emergency medical services] called for transport to .[hospital] . Review of Emergency Hospital Documentation for Resident #5 dated 3/15/2023, revealed Resident #5 received a distal radial and ulnar fractures to the right wrist. During an interview on 9/17/2024 at 4:12 PM, CNA C stated he was the only staff member in Resident #5's room attempting to put her to bed when he turned and observed Resident #5 in the floor with the lift sling ripped. Continued interview revealed the CNA was aware Resident #5 required the assistance of at least 2 staff members and confirmed he was the only staff member in the room during the transfer at the time of the fall. During an interview and facility documentation review on 9/17/2024 at 4:40 PM, the Director of Nursing (DON) stated Resident #5 required the assistance of 2 to 4 staff members for transfers. The DON confirmed CNA C was the only staff member present when transferring Resident #5 with the mechanical lift. The DON confirmed Resident #5's comprehensive care plan was not followed related to safe transfers, and Resident #5 received an injury as a result of the fall on 3/15/2023.

Based on facility policy review, lift sling manufacture's guidelines review, medical record review, hospital record review, and interview the facility failed to prevent a fall from a mechanical lift for 1 resident (Resident #5) of 3 residents reviewed for falls which resulted in actual Harm for Resident #5. The findings include: Review of the facility policy titled, Fall Management, dated 9/22/202, revealed .Each resident receives adequate supervision and assistance devices to prevent accidents .implement interventions, including adequate supervision .in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident .Adequate supervision is determined by assessing the appropriate level and number of staff required . Review of the manufactures guidelines titled, full body patient sling, dated 2016, revealed .weight capacity 600 pounds .recommends that two (2) assistants be used when positioning the patient sling . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, Bipolar Disorder, and Morbid Obesity. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review revealed the resident was dependent on staff for toileting, shower, and upper and lower body dressing. Review of the comprehensive care plan for Resident #5 dated 2/17/2021, revealed Resident #5 was dependent on staff for mobility and required 2 to 4 staff members for transfers related to the resident's morbid obesity. Review of a Dietary Progress Note for Resident #5 dated 3/15/2023, revealed the resident weighed 425 pounds. Review of a Nursing Progress Note for Resident #5 dated 3/15/2023 at 6:11 AM, revealed .CNA [Certified Nursing Assistant] was attempting to put resident [Resident #5] to bed after a shower with the mechanical lift. CNA stated he turned to move the shower chair and heard a scream. When he turned, he seen the resident in the floor and the loop on sling ripped. CNA yelled for nurse. This nurse found the resident in the floor complaining with right ankle and right wrist pain .MD [medical doctor] and DON [Director of Nursing] notified. EMS [emergency medical services] called for transport to .[name of hospital] . Review of Emergency Hospital Documentation dated 3/15/2023, revealed .patient .presents to the ER [emergency room ] .after a fall .landing on her right side .she braced herself landing on her right outstretched arm .X ray wrist complete 3 plus views .impression .Distal radial and ulnar fractures . Review of a Nursing Progress Note for Resident #5 dated 3/15/2023 at 11:30 PM, revealed .spoke to ED [emergency department] nurse and patient will be transported back to facility as soon as an ambulance is available. X-rays show a broken wrist, the ED is splinting it . Review of a Nursing Progress Note for Resident #5 dated 3/16/2023 at 6:27 PM, revealed .resident returned from .[hospital] .by EMS .at 10:55 AM .right wrist/arm is splinted . During an interview on 9/17/2024 at 11:50 AM, Resident #5 stated she remembered the fall which resulted in a fracture to her wrist .I don't know what happened it [the sling] was within the weight guidelines . During an interview on 9/17/2024 at 4:12 PM, CNA C stated he was the only staff member in Resident #5's room attempting to put her to bed. CNA C stated he turned, then turned back around and saw Resident #5 in the floor and the sling (from the mechanical lift) had ripped. Continued interview revealed the CNA was aware Resident #5 required the assistance of at least 2 staff members for the transfer with the mechanical lift and confirmed he was the only staff member in the room at the time of the fall. During an interview and facility documentation review on 9/17/2024 at 4:40 PM, the Director of Nursing (DON) stated Resident #5 required the assistance of 2 to 4 staff members for transfers. The DON confirmed CNA C was the only staff member present when transferring Resident #5 with the mechanical lift and confirmed Resident #5 received an injury as a result of the fall on 3/15/2023.

Based on observations and interviews the facility failed to maintain cleaniness and sanitary conditions for 2 of 2 microwaves available for patient use in 2 of 2 Nourishment Rooms potentially affecting 76 of 80 residents. The findings include: During an observation and interview on 11/16/2022 at 1:12 PM, of the B Wing Nourishment Room with the Registered Dietician (RD) and the Executive Director (ED) showed splattered and crusty dried debris with a white film covering the whole inside of the microwave. The RD and the ED stated nursing staff were responsible for cleaning the microwaves and the microwave were to be cleaned after each use. The ED confirmed the microwave was dirty and available for patient use. During an observation and interview on 11/16/2022 at 1:30 PM, of the Secure Unit Nourishment Room with the RD and the ED showed splattered and crusty dried debris covering the whole inside of the microwave. The RD and the ED stated nursing staff were responsible for cleaning the microwaves and the microwave were to be cleaned after each use. The ED confirmed the microwave was dirty and available for patient use.

Based on facility policy review, record review, observation and interview, the facility failed to provide privacy of personal care information for 1 resident (Resident #28) of 80 residents reviewed. The findings include: Review of the facility's policy titled, Dignity, dated 9/30/2022, showed .Each resident has the right to be treated with dignity and respect .Facility must treat each resident with respect and dignity .recognizing each resident's individuality .promote the rights of the resident .Staff should not .document .records where others can see a resident's information . Resident #28 was admitted to the facility on [DATE] with diagnoses including, Contracture of Left Knee and Atherosclerosis of Native Arteries of Left L with Ulceration of Lower Leg. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #28 had a Brief Mental Status Score (BIMS) of 15, which indicated the resident was cognitively intact, and required extensive assistance of 2 staff members with bed mobility and transfers. During an observation and interview in the resident's room on 11/14/2022 at 11:30 AM, Resident #28 was lying in the bed with the bed against the wall on the resident's left side, and a hand-written sign was taped to one of the resident's pictures. The sign read, .[Resident #28] .Please reposition Left Lower outer leg to where its [it's] not touching bed or pillow .can place pillow under L [left] hip/thigh. Thanks [Wound Care nurse] . The resident stated the wound care nurse put the sign there, did not ask if she could hang the sign, and the resident did not want the sign there. During an observation and interview in Resident #28's room on 11/15/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #1 confirmed the position of the sign and its contents, the sign displayed resident's personal care information and was visible to anyone entering the room. During an interview on 11/15/2022 at 10:25 AM, the Director of Nursing (DON) confirmed the sign in Resident #28's room was personal care information, was visible to anyone that entered the room, and the sign did not protect her privacy.

Based on facility policy review, medical record review, and interview, the facility failed to protect 1 resident (Resident #16) from verbal abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/2021, showed .Each resident has the right to be free from abuse .It is the policy and practice of this facility that all residents will be protected from all types of abuse .It is the policy of the facility to maintain an environment where residents are free from abuse .Residents must not be subjected to abuse by anyone .includes but is not limited to: staff, other residents . Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Mild Intellectual Disabilities, Cognition Communication Deficit, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. Review of the behavior Monthly Flow Record dated 11/2022, showed Resident #16 had a behavior of arguing with roommate which occurred on 11/1/2022, 11/2/2022, 11/3/2022, 11/6/2022, 11/7/2022, and 11/8/2022 with staff intervention of redirection with 1 on 1 (1:1 - one staff member supervision of resident) on those dates. Resident #73 was admitted to the facility on [DATE] and readmitted [DATE] with Diagnoses including Major Depressive Disorder, Cerebrovascular Disease, Hyperlipidemia, and Adult Failure to Thrive. Review of an admission MDS dated [DATE], showed Resident #73 had a BIMS score of 15 indicating the resident was cognitively intact. Review of the behavior Monthly Flow Record dated 10/2022 and 11/2022, showed Resident #73 had a behavior of arguing with roommate which occurred on 10/7/2022, 10/8/2022, 10/9/2022, and 11/11/2022, with staff intervention of redirection with 1:1 on those dates. Review of a Care Plan for Resident #73 dated 10/21/2022 and revised 10/24/2022, revealed .The resident is/has potential to be physically aggressive and verbally aggressive/threatening with staff and residents. Curses at staff and residents; attempts to hide medication under bed sheet; pulls hand back in motion to hit staff members .Assess and anticipate resident's needs .provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated .Document observed behaviors and attempted interventions in behavior log . Review of a Nursing Progress note dated 10/24/2022 and documented by Licensed Practical Nurse (LPN) #3, showed .Resident [#73] verbally aggressive with staff, and roommate [Resident #16] this shift. Resident stated he was going to 'kick that damn man over there's ass [Resident #16] .that he wasn't nothing but a stupid idiot'. Resident calling CNA's [Certified Nursing Assistant] bitches and demanding to see a DR [Doctor] .resident [#73]stated 'to get these damn bitches and that idiot over there [Resident #16] to leave him alone' .Will report behaviors to oncoming shift nurse . During an interview on 11/15/2022 at 2:23 PM, when Resident #16 was asked if anyone had been mean to him, the resident replied Get me ice cream. During an interview on 11/15/2022 at 3:57 PM, CNA #2 stated Resident #73 and Resident #16 were roommates and did not get along. During interview on 11/16/2022 at 9:13 AM, with CNA #6 stated Resident #73 made comments about Resident #16 liked everything his way and he got annoyed with Resident #16's music. The CNA stated Resident #16 could communicate his needs and concerns. Interview with the MDS Coordinator on 11/16/2022 at 9:38 AM revealed Resident #73 was care planned for the potential to be physically aggressive, had threatened to hit a nurse, and was physically and verbally aggressive. The MDS Coordinator confirmed a nursing note stated Resident #73 was cursing at his roommate, Resident #16. She stated the roommates had conflicts over the TV and radio. The MDS Coordinator stated the incident on 10/24/2022 was the only incident she was aware of where Resident #73 cursed Resident #16. During an interview on 11/15/2022 at 4:07 PM, LPN #3 stated Resident #73 she heard Resident #73 fussing at his roommate, Resident #16, telling him to shut up. LPN #3 stated she did not remember what night it was, but she walked in Resident #73 and #16's room, and Resident #73 said they needed to move dumb retarded roommate. She also stated there was an instance when Resident #16 came out of the room and said he wanted another room because his roommate, Resident #73, was cussing him, but the LPN was unable to recall the date of the occurrence. During an interview on 11/16/2022 at 12:53 PM, the Director of Nursing (DON) stated she was aware of one issue where Resident #73 was calling the nurses names and talking about his roommate, Resident #16. The DON confirmed the nurses note dated 10/24/2022 stated Resident #73 was verbally aggressive to staff and his roommate. The DON confirmed the note stated 'kick that damn man over there's ass [Resident #16's] .that he wasn't nothing but a stupid idiot'. The DON confirmed the resident-to-resident altercation was abuse. The DON stated she was not aware Resident #16 had requested another room due to his roommate's behavior. During an interview on 11/16/2022 at 3:30 PM, Resident #16's Family Member #2 stated if he (Resident #16) said he wanted to be moved, then that would be his wishes. She stated if he (Resident #16) heard someone say get that idiot out of here he would understand that as a derogatory remark.

Based on facility policy review, medical record review, and interview, the facility failed to report allegations of abuse for two residents (Resident #73 and Resident #16) of 24 residents reviewed. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/2021, showed .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency . Resident #73 was admitted to the facility on [DATE] and readmitted [DATE] with Diagnoses including Major Depressive Disorder, Cerebrovascular Disease, Hyperlipidemia, and Adult Failure to Thrive. Review of an admission Minimum Data Set (MDS) dated [DATE], showed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Review of the behavior Monthly Flow Record dated 10/2022 and 11/2022, showed Resident #73 had a behavior of arguing with roommate which occurred on 10/7/2022, 10/8/2022, 10/9/2022, and 11/11/2022, with staff intervention of redirection with 1 on 1 (1:1 - one staff member supervision of resident) on those dates. During an interview on 11/14/2022 at 10:32 AM, Resident #73 stated he has had some problems with staff.Two nights ago my catheter was bothering me and the CNA [Certified Nursing Assistant] said there is nothing wrong with your catheter; go to sleep and shut your mouth . Resident #73 stated he did not recall the CNA's name but he reported the incident to CNA #2. Resident #73 reported he also had an issue with CNA #6 approximately 3 months ago calling him stupid and lazy .they don't let her come in here anymore .she still works here down the hall . During an interview on 11/15/2022 at 2:30 PM, with Licensed Practical Nurse (LPN) #4 stated she had observed behaviors from Resident #73.One night shift a few months ago he was extremely loud with a CNA [CNA #6] . She stated she heard CNA #6 trying to get him up and the resident was rude, yelled and refused to get up. During an interview on 11/15/2022 at 3:57 PM with CNA #2 she stated Resident #73 reported CNA #6 was hateful with him. CNA #2 stated it occurred months ago and CNA #6 was not allowed in Resident #73's room. CNA #2 stated she did not report the incident to anyone after she was told by Resident #73. During an interview on 11/16/2022 at 10:18 AM, with CNA #6 she stated Resident #73 alleged she called him stupid and a dumbass and did not want her in his room. CNA #6 stated Registered Nurse (RN) #1 called her and advised her it was probably not a good idea to go back in Resident #73's room a couple of months ago. CNA #6 stated RN #1 was the only person who ever discussed any issues regarding Resident #73's care with her. CNA #6 had not been assigned to provide care to Resident #73 since that time but did provide care for the roommate. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Mild Intellectual Disabilities, Cognition Communication Deficit, and Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 had a BIMS score of 12 indicating the resident had moderate cognitive impairment. Review of a Nursing Progress note dated 10/24/2022 and documented by Licensed Practical Nurse (LPN) #3, showed .Resident [#73] verbally aggressive with staff, and roommate [Resident #16] this shift. Resident stated he was going to 'kick that damn man over there's ass [Resident #16] .that he wasn't nothing but a stupid idiot'. Resident calling CNA's [Certified Nursing Assistant] bitches and demanding to see a DR [Doctor] .resident [#73]stated 'to get these damn bitches and that idiot over there [Resident #16] to leave him alone' .Will report behaviors to oncoming shift nurse . During an interview on 11/15/2022 at 4:07 PM, LPN #3 stated she heard Resident #73 fussing at his roommate, Resident #16, telling him to shut up. LPN #3 stated she did not remember what night it was, but she walked in Resident #73 and #16's room, and Resident #73 said they needed to move dumb retarded roommate. She also stated there was an instance when Resident #16 came out of the room and said he wanted another room because his roommate, Resident #73, was cussing him, but the LPN was unable to recall the date of the occurrence. LPN #3 stated she notified the DON and charted it in the behavior book. Interview with the MDS Coordinator on 11/16/2022 at 9:38 AM revealed Resident #73 was care planned for the potential to be physically aggressive, had threatened to hit a nurse, and was physically and verbally aggressive. The MDS Coordinator confirmed a nursing note stated Resident #73 was cursing at his roommate, Resident #16. She stated the roommates had conflicts over the TV and radio. The MDS Coordinator stated the incident on 10/24/2022 was the only incident she was aware of where Resident #73 cursed Resident #16. The MDS Coordinator stated the incident on 10/24/2022 was the only incident she was aware of where Resident #73 cursed Resident #16. She stated she updated the care plan after she saw the progress note and the behaviors were discussed in the Interdisciplinary Team (IDT) meeting. The MDS Coordinator stated received verbal abuse training and considered the incident to be verbal abuse that should have been reported immediately. The MDS Coordinator stated the Assistant Director of Nursing (ADON) and Social Services was aware of the allegations. The MDS nurse stated the facility policy stated to report allegations of abuse immediately. During an interview on 11/16/2022 at 12:53 PM, the DON stated she was aware of one issue where Resident #73 was calling the nurses names and talking about his roommate, Resident #16. The DON confirmed the nurses note dated 10/24/2022 stated Resident #73 was verbally aggressive to staff and his roommate. The DON confirmed the note stated 'kick that damn man over there's ass [Resident #16's] .that he wasn't nothing but a stupid idiot' and that was considered abuse. The DON stated she was not aware Resident #16 had requested another room due to his roommate's behavior. The DON confirmed the facility did not report the allegations of abuse to the State Survey Agency within 2 hours. The DON confirmed the resident-to-resident altercation was abuse. She stated the allegation of staff calling Resident #73 names should have been reported to Administration and the State Survey Agency. The DON confirmed the instances of verbal abuse by a staff member for Resident #73 and the allegation of resident-to-resident abuse for Resident #6 was not reported to the State Survey Agency.

Based on facility policy review, medical record review, and interview, the facility failed to investigate allegations of abuse for 2 residents (Resident #73 and Resident #16) of 24 residents reviewed. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/2021, showed .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must .Have evidence that all alleged violations are thoroughly investigated . Resident #73 was admitted to the facility on [DATE] and readmitted [DATE] with Diagnoses including Major Depressive Disorder, Cerebrovascular Disease, Hyperlipidemia, and Adult Failure to Thrive. Review of an admission Minimum Data Set (MDS) dated [DATE], showed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. During an interview on 11/14/2022 at 10:32 AM, Resident #73 stated he has had some problems with staff.Two nights ago my catheter was bothering me and the CNA said there is nothing wrong with your catheter; go to sleep and shut your mouth . Resident #73 stated he did not recall the CNA's name but he reported the incident to another (CNA #2). Resident #73 reported he also had an issue with CNA #6 approximately 3 months ago calling him stupid and lazy .they don't let her come in here anymore .she still works here down the hall . During an interview 11/15/2022 at 3:57 PM CNA #2 stated Resident #73 reported to CNA #2 that CNA #6 was hateful with him. CNA #2 stated it occurred months ago and CNA #6 was not allowed in Resident #73's room. CNA #2 stated she did not report it to anyone. During interview with CNA #6 on 11/16/2022 at 10:18 AM, she stated Resident #73 did not want her in his room. She stated she was told he alleged she called him stupid and a dumbass. CNA #6 stated Registered Nurse (RN) #1 called her and told her it was probably not a good idea to go back in Resident #73's room a couple of months ago. CNA #6 stated RN #1 was the only person who ever discussed any issues regarding Resident #73's care with her. CNA #6 had not been assigned to provide care to Resident #73 since that time but did provide care for the roommate. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Mild Intellectual Disabilities, Cognition Communication Deficit, and Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 had a BIMS score of 12 indicating the resident had moderate cognitive impairment. Review of a Nursing Progress note dated 10/24/2022 and documented by Licensed Practical Nurse (LPN) #3, showed .Resident [#73] verbally aggressive with staff, and roommate [Resident #16] this shift. Resident stated he was going to 'kick that damn man over there's ass [Resident #16] .that he wasn't nothing but a stupid idiot'. Resident calling CNA's [Certified Nursing Assistant] bitches and demanding to see a DR [Doctor] .resident [#73]stated 'to get these damn bitches and that idiot over there [Resident #16] to leave him alone' .Will report behaviors to oncoming shift nurse . During an interview on 11/15/2022 at 4:07 PM, LPN #3 stated she heard Resident #73 fussing at his roommate, Resident #16, telling him to shut up. LPN #3 stated she did not remember what night it was, but she walked in Resident #73 and #16's room, and Resident #73 said they needed to move dumb retarded roommate. She also stated there was an instance when Resident #16 came out of the room and said he wanted another room because his roommate, Resident #73, was cussing him, but the LPN was unable to recall the date of the occurrence. LPN #3 stated she notified the DON and charted it in the behavior book. Interview with the MDS Coordinator on 11/16/2022 at 9:38 AM revealed Resident #73 was care planned for the potential to be physically aggressive, had threatened to hit a nurse, and was physically and verbally aggressive. The MDS Coordinator confirmed a nursing note stated Resident #73 was cursing at his roommate, Resident #16. She stated she updated the care plan after she saw the progress note and the behaviors were discussed in the Interdisciplinary Team (IDT) meeting. The MDS Coordinator stated received verbal abuse training and considered the incident to be verbal abuse that should have been reported immediately. The MDS Coordinator stated the Assistant Director of Nursing (ADON) and Social Services was aware of the allegations. The MDS nurse stated the facility policy states to report allegations of abuse immediately. During an interview on 11/16/2022 at 12:53 PM, the DON stated she was aware of one issue where Resident #73 was calling the nurses names and talking about his roommate, Resident #16. The DON confirmed the nurses note dated 10/24/2022 stated Resident #73 was verbally aggressive to staff and his roommate. The DON confirmed the note stated 'kick that damn man over there's ass [Resident #16's] .that he wasn't nothing but a stupid idiot' and that the incident was considered abuse. The DON stated she was not aware Resident #16 had requested another room due to his roommate's behavior. The DON confirmed the allegation of verbal abuse by a staff member for Resident #73 and the allegation of resident-to-resident abuse for Resident #16 was not investigated by the facility.

Based on facility policy review, record review, observation and interview, the facility failed to provide restorative therapy services for 1 resident (Resident #42) of 12 residents reviewed for limited range of motion (ROM). The findings include: Review of the facility's policy titled, Restorative Nursing, dated 9/19/2022, showed .To promote the resident's optimum function .Restorative programs may be initiated by .therapy .resident is given the appropriate treatment and services to .improve his or her ability to carry out the activities of daily living [ADLs] .Restorative Nursing does not require a physician order . Resident #42 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (paralysis on 1 side of the body) and Hemiparesis (muscle weakness on 1 side of the body) and Left Above the Knee Amputation (AKA). Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #42 required extensive assistance of 2 staff for bed mobility and transfers and extensive assistance of 1 staff for toileting. Review of a PT Discharge Summary dated 10/13/2021, showed Resident #42 was discharged from PT services that were provided from 9/14/2021 to 10/11/2021, and the summary showed Discharge Recommendations .Restorative Range of Motion Program .Balance in sitting .ROM exercises . Review of the quarterly MDS assessment dated [DATE], showed Resident #42 required extensive assistance of 2 staff for bed mobility and transfers and extensive assistance of 1 staff for toileting. During an interview on 11/15/2022 at 1:42 PM, the Rehab Manager revealed Resident #42 was admitted with an amputation below the left knee that was later revised to an amputation above the knee. The resident received Physical Therapy (PT) services from 9/14/2021 to 10/11/2021. At discharge from PT, there was a referral to restorative therapy. The restorative therapy referral was communicated to nursing staff through a Restorative Nursing Communication Tool document. During an interview on 11/15/2022 at 2:20 PM, the RCNA stated she had not provided restorative services to Resident #42 in almost 2 years. During an interview on 11/16/2022 at 12:30 PM, the Rehab manager confirmed that PT #1 discharged Resident #42, and the PT recommended restorative therapy, but therapy was not provided for Resident #30. During an interview on 11/16/2022 at 1:25 PM, the DON stated that it was her expectation restorative therapy would start immediately after a recommendation was made by PT and confirmed Resident #42 did not receive the restorative services.

Based on facility policy review, record review, observation, and interview, the facility failed to implement an intervention after a fall for 1 resident (Resident #9) of 3 residents reviewed for accidents. The findings include: Review of the facility policy titled, Fall Management, undated showed .promote patient safety .reduce .falls by .care planning and monitoring .fall indicators .with any fall event .fall risks .will identify appropriate interventions to minimize the risk of injury related to falls . Resident #9 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses including Right Femur Fracture, Contusion of Eyeball, Osteopenia, Atrial Fibrillation, Congestive Heart Failure, Osteoarthritis, Repeated Falls, and Open-Angle Glaucoma. Review of the of the comprehensive care plan initiated 5/26/2022 and revised 10/28/2022, showed Resident #9 was at risk for falls related to weakness and impaired mobility. Interventions included assistance with activities of daily living and soft touch call light within reach. The resident had an actual fall with injury with an intervention which included a fall mat to bedside on 10/22/2022. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 had moderate cognitive impairment. The resident required limited assistance of 1 staff person with walking in corridor and toileting. Resident #9 required supervision of 1 staff person with walking in room. No falls were documented during the look back period. Review of the facility's Incidents Follow-up & Recommendation Form dated 10/22/2022, showed the nurse entered the room and observed Resident #9 lying on floor by bed (with walker flipped beside her). The intervention put in place after the fall included a fall mat to the bedside. Review of Significant Change MDS assessment dated [DATE], showed Resident #9 required extensive assistance of 1 staff person with toileting and personal hygiene. Resident #9 had several falls since last assessment which included 1 fall with no injury, 1 fall with minor injury, and 1 fall with major injury (right hip fracture-nondisplaced) which did not require surgery. During an observation on 11/16/2022 at 8:32 AM, in Resident #9's room showed no fall mat located at the bedside. During an observation and interview on 11/16/2022 at 9:27 AM, in Resident #9's room with Licensed Practical Nurse #2 and the MDS Coordinator they confirmed there was no fall mat at the bedside. During an interview on 11/16/2022 at 12:51 PM, the Director of Nursing stated interventions on the care plan were to be put in place.

Based on facility policy review, medical record review, observation, and interview, the facility failed to verify a medical justification or diagnosis for the use of an indwelling urinary catheter for 1 resident (Resident #79) of 6 residents reviewed for indwelling urinary catheter. The findings include: Review of the facility policy titled, Indwelling Urinary Catheter (Foley) [type of catheter] Management, reviewed 8/22/2022, showed .The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed .Timely and appropriate assessments related to the indication for use of an indwelling catheter .Identification and documentation of clinical indications for the use of a catheter; as well as criteria for the discontinuance of the catheter when the indication for use is no longer present .A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary .Examples of Appropriate Indications for Indwelling Urethral Catheters .Patient has acute urinary retention or bladder outlet obstruction .Need for accurate measurements of urinary output in critically ill patients .To assist in healing of open sacral or perineal wounds in incontinent patients .To improve comfort for end of life care if needed .Additional care practices related to catheterization .Attempts to remove the catheter as soon as possible when no indications exist for its continuing use . Resident #79 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (paralysis of one side of the body) following a Cerebrovascular Accident, Urinary Tract Infection, Type 2 Diabetes Mellitus, Muscle Weakness, and Chronic Kidney Disease. The medical record did not reflect a diagnosis or medical justification for the use of an indwelling urinary catheter. Review of Discharge Documentation from the hospital dated 10/17/2022 showed .Due to her [Resident #79] grossly bed-bound status, patient will discharge [to the facility] with [indwelling urinary catheter] in place, due to risk of skin breakdown . Review of the comprehensive care plan dated 10/27/2022 showed the resident had an indwelling urinary catheter related to Obstructive Uropathy and Urinary Retention (the medical record did not reflect the diagnosis documented in the care plan). Review of the 5-day Minimum Data Set (MDS) dated [DATE] showed Resident #79 was not able to complete a Brief Interview for Mental Status (BIMS), as the resident was rarely or never understood. The MDS showed the resident had an indwelling urinary catheter. Review of the physician's orders dated 11/1/2022 showed change indwelling urinary catheter to straight drainage 14 French with 10 cubic centimeter (cc) bulb (size of catheter) as needed (a rationale or diagnosis was not provided). During observations on 11/14/2022 at 10:43 AM; 11/15/2022 at 2:00 PM; and on 11/16/2022 at 1:15 PM, Resident #79 was lying in bed with an indwelling urinary catheter in place and was draining urine to a bed side drainage bag. During an interview on 11/15/2022 at 4:15 PM, the Director of Nursing (DON) stated the diagnosis of obstructive uropathy with urinary retention was documented in error on the comprehensive care plan for the resident. The DON confirmed Resident #79 did not have a diagnosis for the continued use of an indwelling urinary catheter.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain an accurate medical record for 2 residents (Resident #23 and Resident #68) of 24 medical records reviewed. The findings include: Review of a facility policy titled, Advance Directives and Advance Care Planning, reviewed [DATE], .it is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical treatment .and to formulate an advanced directive .the resident's choices will be documented in the resident's medical record . Resident #23 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Delusional Disorders, Major Depressive Disorder, and Dementia. Review of an Order Summary Report for Resident #23 showed, .Full code . with a start date of [DATE] and no end date indicated. Review of Resident #23's comprehensive care plan revised [DATE], showed .Full Code . Review of a Tennessee Physician Orders for Scope of Treatment (POST) dated [DATE], showed .Do Not Attempt Resuscitation .DNR .no CPR[cardiopulmonary resuscitation] . 40640 Resident #68 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Sepsis, Chronic Kidney Disease, and Dementia. Review of an Order Summary Report for Resident #68 showed .Full code . with a start date of [DATE] and no end date indicated. Review of the POST form for Resident #68 dated [DATE], showed .DNR .no CPR . Review of Resident #68's comprehensive care plan initiated [DATE], showed Resident #68 was .Full Code . During an interview and observation on [DATE] at 3:35 PM, the Director of Nursing (DON) confirmed the physician order and the comprehensive care plan for Resident #23 and Resident #68's code status was inaccurate.

Based on review of a facility policy, medical record review, facility documents, and interviews, the facility failed to provide showers 2 times per week for 1 Resident (#1) of 6 residents reviewed for Activities of Daily Living. The findings included: Review of a facility policy for showers Standards for Nursing Homes revised 5/2010 showed .Residents shall have baths or showers at least two (2) times each week, or more often if requested by the resident . Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of a facility document ADL (Activities of Daily Living) Look Back Report dated 8/7/2020 - 8/22/2020 showed documentation Resident #1 received a shower on 8/20/2020 with no other documentation regarding showers or bathing. Review of a facility document Occupational Therapy OT Evaluation & Plan of Treatment dated 8/10/2020 showed .Functional Skills Assessment - Activities of Daily Living (ADLs) & Instrumental ADLs .Bathing= Max (A) (Assistance); Bathing Location Assessed = During bathing . Review of Resident #1's 5-day Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact and he required extensive assistance with bed mobility, transfer, dressing, toilet use, and limited assistance with personal hygiene. Review of Resident #1's comprehensive care plan dated 8/17/2020 showed .Resident has an ADL self-care performance deficit .Bathing/Showering: Limited to extensive assist of 1 person . During an interview with Resident #1's family member on 12/28/2020 at 1:20 PM, he stated they wouldn't give him a shower, I don't know if they gave him a bed bath or not. He went 30 days without a shower . During an interview with Certified Nursing Assistant (CNA) #3 on 12/29/2020 at 2:20 PM, she stated showers or bathing is required at least 2 times per week and PRN or if the resident requests bathing more often. During an interview with Licensed Practical Nurse (LPN) #1 on 12/29/2020 at 2:30 PM, he stated showers are to be given at least 2 times per week. During an interview with CNA #4 on 12/29/2020 at 2:40 PM, she stated residents are to receive showers at least 2 times per week and in between if they need one . During an interview with the interim DON on 12/29/2020 at 2:55 PM, she confirmed the facility's policy for showers and bathing was the resident would have a bath or shower at least 2 times per week or more often if requested by the resident. She confirmed Resident #1 had no shower or bath for 9 days during 8/11/2020 - 8/19/2020.

Based on review of facility policy, review of facility protocol, medical record review, observation and interview the facility failed to maintain a medication error rate less than 5 percent as evidenced by 2 medication errors out of 32 medication administration observations resulting in a medication error rate of 6.25 percent. The findings include: Review of the facility policy, Administration of Medications, dated 4/24/19 revealed .All medications are administered safely and appropriately per physician order . Review of a facility protocol revealed, .Common Oral Dosage Forms That Should Not Be Crushed .DR .delayed-release .ER .extended-release .NAME] .Delayed release . Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physicians Recapitulation Order dated 6/7/19 revealed NAME] (medication to treat high levels of stomach acid) 20 milligrams (mg) DR Give 1 tablet by mouth two times a day for ulcer. Medical record review of a Physicians Recapitulation Order dated 8/23/19 revealed Potassium Chloride (medication used to treat low potassium levels) ER Tablet Extended Release 10 milliequivalents per liter (meq)(concentration or strength of pharmaceutical products) Give 1 tablet by mouth two times a day for low potassium level. Observation on 9/3/19 at 9:55 AM, with Licensed Practical Nurse (LPN) #3 on the 200 hallway revealed LPN #3 prepared the following medications for administration: -Potassium 20 meqER on e half tablet -Pantoprazole S 20 mg DR tablet. Further observation revealed LPN #3 crushed the medications and administered the medications with pudding to Resident #63. Interview with the Director of Nursing on 9/4/19 at 9:45 AM, in the conference room confirmed extended release, or delayed release medications are not to be crushed. Interview with the Consultant Pharmacist on 9/4/19 at 10:00 AM, by telephone, confirmed Potassium Chloride ER and Pantoprazole DR are not to be crushed.

Based on review of facility policy, facility of a facility investigation, medical record review, and interviews, the facility failed to report a suspicion of a crime within 24 hours to the State Survey Agency for 1 resident (#1) of 4 residents reviewed for Abuse. The findings included: Review of facility policy Protection of Residents: Reducing the Threat of Abuse & Neglect, last revised 2/2018, revealed .Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made .or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction .TRAINING understanding behavioral symptoms of residents that may increase the risk of abuse and neglect .aggressive and/or catastrophic reactions of residents .outbursts of yelling out . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Continued review revealed the resident exhibited behavioral symptoms towards others (including threatening others, screaming, and cursing) 4 to 6 days per week. Review of a facility investigation dated 6/4/19 revealed a typed summary note dated 6/4/19 from a Nurse Practitioner (NP) to the facility regarding Registered Nurse (RN) #2. Further review revealed .In order to follow the law of our Duty to Warn, we must inform you of homicidal ideation with intent and plan expressed by your employee (RN #2) .to myself this morning toward a current inpatient (Resident #1) .(RN #2) expressed profound feelings of anger toward (Resident #1) and stated to myself and our (behavioral health counselor) .that this past weekend she had considered several ways in which to take the life of (Resident #1) specifically to use critical medications potassium (excessive amounts cause cardiac dysthymias) and insulin (excessive amounts can cause death) (two different plans) to do so. (RN #2) stated she had the potassium in her hand at one point at which (RN #2's sister), also a facility employee) saw her and she (RN #2) stopped and realized it was wrong. She (RN #2) expressed to us (NP) that she needed help because she knows these feelings are wrong and an act of harming a patient is wrong but that she is afraid she will harm the patient if she continues to have to work with her. We did contact inpatient psychiatric services which advised us to have our MD write a letter of non-voluntary committal to a psychiatric facility and to send her to the emergency room via the law enforcement . Continued review of a statement by the Business Office Manager (BOM) dated 6/4/19 revealed RN #2's sister (employed by the facility as a Certified Nursing Assistant) submitted a request for a leave of absence for RN #2 and advised the BOM that RN #2 was going to be admitted to a psychiatric unit. Further review revealed RN #2 had made comments regarding Resident #1. Continued review of a statement by the Director of Nursing (DON) dated 6/4/19 revealed the DON was informed by the BOM that RN #2 made statements regarding Resident #1 and that she wanted to harm the resident and voiced intent with a plan. Medical record review of a Psychiatric Progress Note for Resident #1 dated 6/13/19 revealed Resident #1 was demanding, attention-seeking, was generally unhappy and dissatisfied. Further review revealed the resident calls out on the call light with extreme frequency, often less than a minute of staff leaving the room, yells out frequently, was disruptive, and the resident's continual and near-constant behaviors often interfered with staff's ability to provide care to other residents. Continued review revealed the facility staff and administration explained to resident how her behaviors impacted the unit. Further review revealed .discussed with DON (Director of Nursing) various potential behavioral modifications which might help including parameters set on how often she should expect to call out along with frequent checks by staff. Moving her to a different room and/or having her room with a roommate was another option which may help decrease her need to call out since some of her behaviors may be driven by feelings of loneliness . Interview with the Administrator on 6/4/19 9:30 AM, in the Activities Office, revealed RN #2 had left the Administrator a voice mail .one time about doing something to (Resident #1) . and he went to talk with RN #2 and offered to move her to a different unit, but the RN refused. Interview with the Assistant Director of Nursing (ADON) on 6/20/19 at 12:10 PM, in the Activities Office, revealed on 6/4/19 Registered Nurse (RN) #2 went to her own Physician and reported .some things . which alerted the Physician there was a problem. Continued interview revealed RN #2 worked a 12 hour shift (7:00 PM to 7:00 AM) on 6/3/19. Further interview revealed the facility was told RN #2 stated she was on her way to Resident #1's room to do something and had potassium pills in her hand, but stopped when she saw her sister (CNA#1). Continued interview revealed Resident #1 used her call light often Interview with the Administrator and the ADON on 6/20/19 at 12:35 PM, in the Activities Office, confirmed the facility did not report the incident to the State Survey Agency. Interview with Licensed Practical Nurse (LPN) #1 on 6/27/19 at 10:15 AM, in the Activities Office, revealed Resident #1 would yell at times and had her call light on excessively. Interview with LPN #3 on 6/27/19 at 11:00 AM revealed Resident #1 yelled frequently and was on the call light all the time for things she could do for herself. Telephone interview with LPN #4 on 6/27/19 at 11:15 AM revealed the Resident #1 used the call light frequently and asked for things she could do for herself. Interview with the DON on 6/28/19 at 11:45 AM confirmed Resident #1 was on the called light frequently and the facility was working on getting 2 more nurses to help out with the morning medication pass to help the staff on the floor. Further interview confirmed RN #2 told the DON that Resident #1 was on the call light frequently and stated how much time it took just to go in and move something which was within the resident's reach. Telephone interview CNA #1 (RN #2's sister) on 6/28/19 at 12:05 PM revealed during one night Resident #1 had her call light on over 70 times during the 12 hour shift. In summary, RN #2 had a plan to harm Resident #1 by giving her excessive amounts of insulin or potassium because of the stress caused by the resident's overuse of the call light and demanding nature. The facility failed to report a suspicion of a crime to the State Survey Agency within 24 hours of being made aware by the RN's medical provider.

Based on facility policy, observation, and interview, the facility failed to remove expired food supplies readily available for resident use, potentially affecting 70 of 72 residents. The findings include: Review of facility policy Food Safety last revised [DATE] revealed .Food is stored and maintained in a clean, safe and sanitary manner . Observation and interview with the Dietary Manager on [DATE] at 9:50 AM, at the reach in cooler located in the kitchen, revealed 6 strawberry banana yogurts available for resident use dated [DATE]. Continued interview confirmed the facility failed to discard the expired yogurts.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure routine dental services were provided for 1 resident (#15) of 4 residents reviewed for dental services of 31 sampled residents. The findings include: Review of the facility policy revised 7/2017 revealed .facility is responsible for assisting the patient in obtaining needed dental services, including routine dental services .arrangements will be made promptly for routine .dental services . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the Consent for Dental Treatment, signed by the family, dated 4/10/17. Observation and interview of Resident #15 on 9/17/18 at 10:20 AM, in the resident's room, revealed the resident complained of tooth pain and pointed to the upper teeth. Continued interview revealed the resident had not been seen by dental services since admission. Observation and interview of Resident #15 on 9/18/18 at 9:30 AM, in the resident's room, revealed the resident complained of tooth pain and pointed to the upper teeth. Interview with the Social Service Director on 9/18/18 at 2:30 PM, in the Conference Room, confirmed the dentist visits the facility every 3 months and the resident had not received dental care. Further interview confirmed the facility does not ask residents prior to the dental visit if they needed to see the dentist. Interview with the Director of Nursing on 9/18/18 at 3:20 PM, in the Conference Room, confirmed Resident #15 did not have the opportunity to have her teeth evaluated and cleaned by the dentist since admission to the facility on [DATE].

Based on review of facility policy, observation, and interview, the facility failed to maintain a sanitary kitchen with failure to maintain clean kitchen equipment, and secure, date, and label opened resident foods, in the kitchen affecting 76 of 76 residents. The findings included: Review of the facility policy, Cleaning Schedule, revised 1/1/07 revealed ' .ensure that the Food and Nutrition Services Department .remains clean and sanitary at all times . Review of the facility policy, Food Safety, revised 11/11/16 revealed .food is stored and maintained in a clean, safe and sanitary manner .placed in a leak-proof, pest-proof, non-adsorbent .container with a tight-fitting lid .dated properly .labeled . Observation and interview with Dietary Cook #1 on 8/21/17 at 9:00 AM, in the kitchen revealed a covered deep fryer with brown food debris on the 4 sides, rim, and back splash of the fryer. Continued review revealed, under the covered lid, dark brown oil with floating food debris. Further interview confirmed she did not know when the fryer was used or cleaned. Observation and interview with Dietary Cook #1 on 8/21/17 at 9:05 AM, at the stove and duel oven revealed cooked egg noodles, french fries, and other food debris overflowing in the food trap. Continued review revealed on the stove front, a thick layer of grime and food particles covering the 10 stove knobs. Further interview with the Dietary Cook #1 confirmed the facility had not served egg noodles or french Fries for breakfast on 8/21/17. Observation and interview with Dietary Cook #1 on 8/21/17 at 9:10 AM, at the microwave revealed in the interior of the microwave on all 4 walls, floor, and ceiling, thick dried food debris. Continued interview confirmed the facility had not used the microwave for breakfast service on 8/21/17. Observation with Dietary Cook #1 on 8/21/17 at 9:12 AM, at the low heat dishwasher, revealed food debris on top of the dishwasher. Observation with Dietary Cook #1 on 8/21/17 at 9:15 AM, of the 6-shelf rolling cart, next to the dessert prep table, revealed coffee supplies including cups, lids, coffee, silverware and one coffee pot stored upright with no lid. Further review of the cart, on the top shelf with the coffee mugs, revealed a face mask, a box of opened gloves, and an industrial tube of plastic wrap. Continued review revealed food debris and sticky grime on all 6 shelving rails. Observation with Dietary Cook #1 on 8/21/17 at 9:17 AM, of the ice cream cooler, revealed on top of the cooler, stacked boxes containing nectar juices. Further review revealed the lids of the ice cream cooler covered with thick, dusty, sticky grime. Observation with Dietary Cook #1 on 8/21/17 at 9:20 AM, of the Dry Storage Room, revealed 1 opened, undated, unsecured bag of hamburger buns. Observation with Dietary Cook #1 on 8/21/17 at 9:25 AM, of the walk-in freezer revealed approximately 30 frozen biscuits on the floor. Further review of the freezer revealed a bag of undated, unlabeled, unsecured biscuits. Continued review of the freezer revealed an unlabeled, undated, hand-tied white trash bag containing 10 fish fillets. Observation and interview with the Registered Dietician (RD)/Dietary Manager on 8/21/17 at 11:45 AM, in the kitchen, revealed in the 6 bay steam table, food debris in the water. Further interview confirmed the steam table was to be cleaned daily and had not been cleaned on 8/20/17. Observation with the RD on 8/21/17 at 11:50 AM, at the duel plate rack, revealed beside the clean plates, a wet, gray rag and a glass of tea with ice cubes. Interview with the RD on 8/22/17 at 10:30 AM, in the kitchen confirmed the facility failed to maintain clean kitchen equipment, and to ensure opened foods were secured closed, labeled, and dated, in the kitchen affecting 76 residents.

Based on medical record review, observation, and interview, the facility failed to provide assistance to 1 resident (#83) of 12 residents reviewed who required extensive or total assistance for bed mobility and transfer. The findings included: Resident #83 was readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident required extensive assistance of 2 persons for bed mobility and transfer. Medical record review of the Care Directive provided in the residents' rooms for the Certified Nursing Assistants (CNA's) revealed .Assistance: Transfers Assist 2 .Bed Mobility Assist 1 .When up in w/c (wheelchair) bring resident out closer to the nurses station or near nurse for closer observation . Observation of the resident on 8/21/17 at 8:55 AM, revealed the resident sleeping in a semi-fowlers position and her breakfast tray remained over her on the overbed table. Observation of the resident on 8/21/17 at 11:45 AM and 3:35 PM, revealed she was in the bed. Observation of the resident on 8/22/17 at 8:25 AM, revealed the resident eating her breakfast in a semi-fowlers position in the bed. Observation of the resident on 8/22/17 at 10:45 AM and 2:15 PM, revealed she was in the bed. Interview with CNA #1 on 8/22/17 at 2:20 PM, outside of the resident's room, confirmed Resident #83 had not been out of the bed 8/22/17 and revealed .she was moved out of the secured unit a few weeks ago .not assigned to her today . Interview with the Licensed Practical Nurse (LPN) #1, in charge of the resident's care on 8/22/17, at 2:30 PM, in the A unit nursing station, confirmed the resident had not been out of the bed on 8/21/17 and 8/22/17 during the LPN's dayshift. Interview with CNA #2 on 8/22/17 at 2:45 PM, in the A unit nursing station, revealed she was responsible for Resident 83's care on 8/22/17 and confirmed the resident had not been out of the bed. Interview continued and revealed .she was moved out of the secured unit a few weeks ago .I haven't been told what to do about getting her out of the bed . Interview with the Assistant Director of Nurses (ADON) on 8/22/17 at 2:50 PM, in the A unit nursing station, with CNA #2 included, revealed the facility did not have a formal method of communication in place for the secured unit staff to share knowledge of the resident and the resident's routines with the A unit staff and she stated .they all know each other and share . Interview continued and CNA #2 revealed no such communication had been received. Interview with the Director of Nurses on 8/22/17 at 3:20 PM, in the conference room, confirmed the Care Directive and the facility's licensed nursing staff had failed to provide a plan to ensure Resident #83 was out of the bed.