Every finding on record at Miller's at Oak Pointe

Based on observation, interview, and record review, the facility failed to ensure food and kitchen was maintained to prevent food borne illnesses. 48 of 48 residents residing in the facility ate food prepared in the facility kitchen.Findings include:During a kitchen observation on 12/16/2025 9:16 AM, a bag of diced celery in the walk in freezer did not have an opened label or date. A bag of sweet potatoes in the freezer did not have an opened label or date. 3 loose hashbrown wedges were observed lying on the bottom of a cardboard box not enclosed in a plastic bag or any other packaging. In the walk-in refrigerator, 2 covered containers holding a whitish, lumpy substance did not have labels or dates. 4 lidded opaque containers did not have a labels or dates. A container labeled mixed vegetables was dated 12/10/25. A container labeled puree was dated 12/4/25. A block of light yellow substance was on a shelf, partially covered with a piece of wax paper, with parts open to air. There was no label or date on the substance or the paper. A cart holding containers of cereals was observed in the kitchen. On the bottom shelf of the cart, a container of puffed rice cereal was observed unlidded and open to air. The cart was positioned about 5 feet away from the dirty breakfast dishes adjacent to the dishwasher. In an interview, on 12/6/25 at 9:21 AM, the Dietary Manager (DM) indicated the mixed vegetables should have been discarded after 3 days. He indicated the unlabeled containers were filled with potato salad and tomato slices, and the unlabeled yellow block was margarine. He indicated all food items should be labeled and dated. He indicated he was unable to identify the pureed item in the refrigerator, and indicated it should have been discarded. He indicated the hash browns and block of margarine should have been in a sealed bag or container, labeled and dated. He indicated the container of puffed rice should have been tightly sealed with a lid. On 12/16/2025 at 9:34 AM, a dishwasher cycle was observed. The wash cycle reached 160 degrees. The final rinse temperature reached 171. In an interview, on 12/16/2025 9:36 AM, the DM indicated he would restart the dishwasher and retest the temperature of the rinse cycle. If it did not reach 180 degrees during the final rinse cycle, he would call the maintenance man and then call out a service technician if maintenance was unable to fix it. In a record review, on 12/16/2025 9:51 AM, a document titled Dishwasher Temperature Worksheet, provided by the DM on 12/16/25 at 9:50 AM indicated the dishwasher's final rinse temperatures were as follows:12/13/25 Breakfast 17212/14/25 Breakfast 17512/15/25 Breakfast 17612/16/25 Breakfast 177. In an interview, on 12/16/2025 11:03 AM, the DM indicated he had reset the dishwasher and re-checked the temperature readings. He indicated the auxiliary water temperature booster had not been turned on. He indicated staff should have called him immediately when low rinse cycle temperatures were discovered. In an interview, on 12/16/2025 11:18 AM, the DM indicated he did not believe staff understood labeling and dating adequately. He indicated he was relatively new to the position and had not had opportunity to educate staff adequately on labelling and dating. A current policy titled Food Protection and Storage, dated 10/6/2015, provided by the Administrator on 12/16/25 at 2:40 PM indicated open boxes and containers of food should be securely enclosed, labeled and dated. A current policy, titled Dishwasher Temperatures, dated 3/4/2019, provided by the Administrator on 12/16/25 at 2:40 PM, indicated any temperature below minimum should be reported to the dietary manager and corrected prior to washing any dishes. The policy indicated the final rinse temperatures for the dishwasher should reach 180 to 190 degrees. A current policy, titled Safe Food Storage Guidelines, dated 4/2025, provided by the Administrator on 12/16/25 at 2:40 PM, indicated cooked meat and poultry leftovers and casserole leftovers should be discarded after 3-4 days. The policy did not specify a time frame for discarding leftover cooked vegetables. 3-1-21(i)(3)

Based on interview and record review, the facility failed to ensure quality assurance policies were followed to prevent recurrent deficiencies. 48 of 48 residents lived in the facility.Findings include:The facility annual survey, completed on 11/14/24 identified noncompliance regarding kitchen sanitation. The facility indicated the noncompliance would be corrected by 12/4/24. Please refer to F 812 for additional information related to current kitchen sanitation findings.On 12/16/25 at 11:15 AM, a Quality Assurance Performance Improvement (QAPI) committee list was provided by the facility Administrator. The QAPI committee members included the Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, MDS Coordinator, Activity Director, Social Service Director, Pharmacy Consultant, Dietary Manager, Housekeeping Supervisor, Maintenance Supervisor and Business Office Manager.In an interview, on 12/22/25 at 10:10 AM, the Administrator indicated there was a Performance Improvement Plan (PIP) in place for the kitchen. The Administrator indicated the Registered Dietician (RD) performed monthly kitchen audits. The Administrator indicated they were not aware of the RD sharing the audit findings with the Dietary Manager. The Administrator reviewed the QAPI binder and was unable to locate any follow up education, in-service records, or monitoring related to the RD audit findings.The Administrator provided the following documents from the QAPI binder:1. RD focused onsite visit worksheet, dated 7/19/25, indicated the kitchen staff had displayed noncompliance in the following:-handwashing-temperature logs-all food items covered, labeled and dated-cleanliness-raw food separate from prepared food-all food stored 6 off floor and 18 from ceiling2. RD focused onsite visit worksheet, dated 9/24/25, indicated the kitchen staff had displayed noncompliance in the following:-handwashing-thermometers (refrigerator and freezer)-temperature logs (refrigerator and freezer)-all food items covered, labeled and dated-cleanliness-raw food separate from prepared food- all food stored 6 off floor and 18 from ceilingIn an interview, on 12/22/25 at 10:55 AM, the Administrator indicated kitchen staff education had been provided by hanging signs in the kitchen. The Administrator provided 3 signs, undated, titled Helpful Reminders About Covering, Labeling and Dating Food, Helpful Reminders About Glove Use and Food Handling, and Helpful Reminders About Handwashing.A current facility policy, dated 11/8/22, indicated Performance Improvement Plans (PIP) would be documented. The PIP documentation would include a timeline for planning actions and follow-up.3.1-52

Based on interview, record review and observation, the facility failed to ensure a physical restraint position changing alarm device was ordered and monitored for 1 of 1 resident reviewed (Resident B).Findings include:During an observation on 7/16/25 at 10:35 AM, Resident B was observed in her bed asleep with a position changing alarm under her body and in her wheelchair.During an interview on 7/16/25 at 10:42 AM, Certified Nurse Aide (CNA) 2 indicated Resident B's alarm was active and used as a fall prevention. CNA 2 indicated when Resident B attempted to get up the alarm would sound to alert staff for assistance.During an interview on 7/16/25 at 10:54 AM, the Director of Nursing (DON) indicated a position changing alarm was placed on Resident B's bed and wheelchair for fall prevention after Resident B had an unwitnessed fall on 6/26/25.During an interview on 7/16/25 at 1:38 PM, Unit Manager (UM) 3 indicated Resident B was at risk for falls. UM 3 indicated after Resident B's fall on 6/26/25 a position changing alarm was placed on resident's chair and bed to prevent falls. UM 3 indicated an order should be placed in the resident's chart and in the care plan.During an interview on 7/16/25 at 2:24 PM, the DON and Administrator indicated they were unaware an order was needed for a position changing device. The DON indicated on 6/26/25 a position changing device was placed on Resident B's bed and chair to prevent falls. The DON indicated the resident was sneaky in getting up on her own. The DON also indicated the device should be monitored.During an interview on 7/16/25 at 2:24 PM, Nurse Practitioner (NP) 4 indicated she was aware of the position changing device prior to implementation. NP 4 indicated she was unaware of documentation, or an order was needed for a position changing device.An interview was attempted with Resident B on 7/16/25 at 10:35 AM, 1:29 PM and 3:12 PM. Resident B was asleep during each attempt.Resident B's record was reviewed on 7/16/25 at 11 AM. Diagnoses included traumatic subarachnoid hemorrhage without loss of consciousness, secondary malignant neoplasm of bone and vascular dementia.A re-admission Minimum Data Set (MDS) assessment, dated 7/6/25, indicated Resident B had a Brief Interview of Mental Status (BIMS) of 10/15 (moderately impaired).A care plan, last revised 7/9/2025, indicated Resident B was at risk for falls. Interventions included monitoring changes in gait/positioning.A fall report, dated 6/26/25, indicated Resident B was at risk for falls. Interventions included to place bed and chair position changing alarm and monitor for functionality.Resident B's orders dated 6/26/25 - 7/16/25, did not include an order for a position changing alarm device nor an order for monitoring the device.Nursing notes dated 6/26/25 - 7/16/25, did not include any documentation of the position changing alarm device discussion or an order with the physician or nurse practitioner. The nursing notes did not include any documentation regarding monitoring of the device.A nursing note, dated 7/11/25, indicated Resident B was observed turning off the position changing alarm multiple times.A policy, dated 1/14/2008, titled Alarm Use and Maintenance, was provided by the Administrator on 7/16/25 at 2:24 PM. The policy indicated alarms are used in prevention of residents transferring self-unassisted. The policy indicated an order was needed. The policy also indicated that the device was monitored for effectiveness and functionality.3.1-26 (b)This finding relates to Complaint 1586111.

Based on observation, interview, and record review, the facility failed to ensure left overs were labeled, equipment was cleaned, gloving, and hand hygiene was observed during tray pass. 52 of 52 residents ate food prepared in the kitchen and were served ice from the ice machine. Findings include: 1. During a tour of the kitchen, on 11/12/24 at 09:23 AM, Dietary Manager (DM) 3 indicated the left over chicken patties should be kept 3-7 days. The date on the bag was unreadable. In an interview, on 11/12/24 at 09:23 AM, DM 3 indicated the date on the patties in the gallon zip lock was unreadable. She indicated staff should ensure dates are readable on leftover items. A policy, titled Food Protection and Storage, dated 10/06/2015 indicated X. Food not in original containers are clearly labeled for contents, dated, and stored in food related containers with tight fitting lids. 2. During a tour of the clean utility, on 11/12/24 at 10:39 AM , a black residue was observed on the inside white shield of the ice machine. During an interview, on 11/12/24 at 10:39 AM , Licensed Practical Nurse (LPN) 1 indicated she was not sure what the black residue was on the inside white shield of the ice machine, but she would ask maintenance. During an interview, on 11/12/24 at 10:47 AM, Maintenance 2 indicated the ice machine was cleaned in December and June, according to policy. During an observation, on 11/12/24 at 10:47 AM, Maintenance 2 rubbed off the black residue from the white shield inside the ice machine. Maintenance 2 indicated the ice machine served all residents currently residing in the facility. A policy, titled Ice Machine Monthly Maintenance, provided by Maintenance 2 on 11/12/24 at 10:52 AM, indicated to complete maintenance on the machine monthly. 3. During an observation, on 11/12/24 at 10:59 AM, Dietary Aide (DA) 4 was observed, during pureed meat preparation, to don a glove on his right hand. No hand hygiene had been performed prior to donning the glove. Dietary Aide 4 then touched a bread sack with the gloved hand, put his gloved hand on the menu, handled the beef stock canister, and opened the oven. Without changing the glove, DA 4 completed the pureed meat preparation utilizing the food processor, then placed the pureed meat on the steam table. DA 4 had not changed the glove nor performed hand hygiene. DA 4 then prepared to plate foods for the lunch meal. He did not perform hand hygiene, nor change the glove. DA 4 touched a cart with the gloved hand, then touched serving tongs, then touched the utensil drawer. DA 4 obtained measuring spoons, but had not performed hand hygiene or changed his glove. DA 4 handled measuring spoons with his gloved hand, touched his ungloved left hand, handled a coffee cup with his gloved hand, and stirred the meat puree with a spoon. Dietary Aide 4 removed his glove. With his bare right hand, DA 4 obtained some leftover puree in the food processor by touching the inside of the processor with his ungloved right index finger, then licked his finger. Dietary Aide 4 did not wash his hands prior to regloving for food plating. In an interview, on 11/12/24 at 11:25 AM, DM 3 indicated she knew there were problems with gloving and hand hygiene she would need to correct. A policy, titled Handwashing, dated 10/6/2015 indicated Hand hygiene should be performed G. during food preparation as often as necessary .to prevent cross contamination while changing tasks A policy, titled Glove policy, dated 9/9/2015 indicated when using gloves, they should be used for one task then changed. 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, interview, and record review the facility failed to ensure medications and treatment supplies were secured, insulin was dated upon opening and discarded upon expiration for 4 of 11 reviewed (Resident 15, Resident 27, Resident 45, and Resident 1). Findings include: 1) During an observation on [DATE] at 9:20 AM, Resident 15 was seated in a recliner in her room with a cup containing 11 round pills of various colors in her hand, and an additional cup with a large oblong pill was observed on her bedside table within her reach. No staff member was in the room or in the hall in the line of vision of Resident 15. Resident 15 indicated she took some of her pills and was going to let the rest of them sit for a little while before she took them. She indicated nurses would normally leave her pills with her to take when she was ready. During an interview, on [DATE] at 9:29 AM, Licensed Practical Nurse (LPN) 6 indicated she left the pills with Resident 15 and intended to come back to make sure she had taken them. Resident 15's record was reviewed on [DATE] at 10:36 AM. Diagnoses included dissociative and conversion disorder, diabetes mellitus type 2, and dementia, unspecified severity with anxiety. Resident 15's current quarterly, Minimum Data Set (MDS), dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). Resident 15's current care plan titled behavior . indicated the resident had a problem of excessive nervousness, worrying about things she could not control, with a goal date of [DATE]. Interventions included administering medications as ordered. Resident 15's current care plan titled hyperthyroidism . indicated the resident had a problem of a risk for complications, with a goal date of [DATE]. Interventions included administering medications as ordered. During an interview, on [DATE] at 2:04 PM, The Director of Nursing (DON) indicated nurses should watch residents swallow their medications and should not leave pills at the bedside. A current policy, titled Medication Administration Procedure, dated [DATE], provided by the Administrator on [DATE] at 1:55 PM, indicated staff should remain with the resident until each medication is swallowed. Staff should never leave medication with the resident. 2) During an observation, on [DATE] at 9:18 AM, a labeled bottle of rubbing alcohol, about ,d+[DATE] full of clear liquid, was observed at Resident 27's bedside table, visible from the hallway. During an interview, on [DATE] at 9:30 AM, LPN 6 indicated she was not aware the bottle of rubbing alcohol was at her bedside before this encounter. She indicated there was not a current physician's order regarding Resident 27's use of the alochol. She indicated the Nurse Practitioner should evaluate the appropriateness of the use of rubbing alcohol and provide an order with guidelines for use. She indicated the label indicated the liquid was rubbing alcohol and the amount on the label was 32 ounces. She indicated about ,d+[DATE] of the bottle was empty. During an interview, on [DATE] at 9:29 AM, Resident 15 indicated her family brought the bottle of rubbing alcohol and she used it to cleanse her chin. She indicated she always kept the bottle on her table. Resident 27's record was reviewed on [DATE] at 10:49 AM. Diagnoses included cerebral infarction, chronic kidney disease stage 3, and dysphagia, oral phase. Resident 27's current quarterly Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). No physician orders for the use of rubbing alcohol for Resident 27 were available for review. In an interview, on [DATE] at 2:04 PM, the DON indicated the bottle of rubbing alcohol should not have been at the bedside due to risk of accidental consumption. A current policy dated [DATE], titled Storage of Medications provided by DON on [DATE] at 9:54 AM indicated potentially harmful substances should be clearly identified and stored in a locked area separately from medications. 3) During an observation, on [DATE] at 10:51 AM, LPN 5 removed a bottle of lispro insulin from the 100-hall medication cart labeled for Resident 45. The bottle's seal was removed and the top of the rubber stopper had pinprick sized puncture marks. No open date was indicated on the bottle. During an interview, on [DATE] at 10:52 AM, LPN 5 indicated staff should discard the insulin by the expiration date printed on the bottle, or 28 days after opening. She indicated the open date could not be determined because no date was written on the bottle. Resident 45's record was reviewed on [DATE] at 9:20 AM. Diagnoses included type 2 diabetes mellitus with hyperglycemia, hyperlipidemia, and acute on chronic congestive heart failure. Resident 45's current quarterly MDS indicated his BIMS score was 13 (cognitively intact). The MDS indicated Resident 45 used insulin 7 days a week. Current physician orders dated [DATE] indicated Resident 45 should receive Insulin Lispro solution as per a sliding scale. A review of Resident 45's medication administration record, dated [DATE], indicated Resident 45 was administered Lispro insulin each day from [DATE] through [DATE]. During an interview, on [DATE] at 9:54 AM, the DON indicated insulin bottles should be labeled with an open date and discarded 28 days after opening. A current, undated policy, titled Refrigerated Preparations-Injectables and Liquids, provided by the DON on [DATE] at 9:54 AM, indicated insulin vials should be marked with an open date on the label. 4) During an observation on [DATE] at 8:58 AM, a bottle of Lantus insulin labeled for Resident 1 was labeled with an open date of [DATE]. During an interview on [DATE] at 8:59 AM, Registered Nurse (RN) 7 indicated insulin can be used for 28 days after opening. He indicated the insulin should have been discarded the previous day. He indicated the expired insulin had been administered to Resident 1 earlier that morning. Resident 1's record was reviewed on [DATE] at 2:21 PM. Diagnoses included diabetes mellitus without complications, hyperlipidemia and hypertension. A current admission MDS dated [DATE] indicated Resident 1's BIMS score was 9 (cognitively impaired). The MDS indicated Resident 1 used insulin 7 days a week. Current physician's orders dated [DATE] indicated Resident 1 should receive 13 units of Lantus Insulin twice daily for diabetes mellitus. Resident 1's medication administration record, dated [DATE], indicated Resident 1 was administered 13 units of Lantus insulin on [DATE]. During an interview, on [DATE] at 9:54 AM, the DON indicated insulin bottles should be labeled with an open date and discarded 28 days after opening. A current policy, undated, titled Refrigerated Preparations-Injectables and Liquids, provided by the DON on [DATE] at 9:54 AM, indicated Lantus insulin vials should be marked with an open date on the label and discarded 28 days after opening. 3XXX,d+[DATE](j)(o)

Based on observation, interview, and record review the facility failed to ensure cleanliness of the kitchen, sanitary storage of cookware, sanitary storage of outside food and other opened food items. 39 residents resided in the facility. During a tour of the kitchen with the Dietary Manager (DM) on 1/11/23 at 9:46 am, an open gallon of milk approximately 1/4 full was observed. The open gallon of milk was not labeled with an open date. Another open gallon of milk approximately 3/4 full was observed with an open date of 1/11/23. The DM indicated all items should be labeled with an open date. The DM indicated all residents residing in the facility ate food prepared in the kitchen. An unopened dented soup can dated 12/7/22 was observed on a shelf. The DM indicated the can must have been damaged by kitchen staff. The DM indicated dented cans should be removed and returned for credit. She indicated she would remove the can. Moisture was observed between 5 stacked steam table pans. The CDM indicated the moisture was probably from putting the pans away this morning. She indicated the pan should have been placed on a cart to air dry. She indicated the pans had probably been put away wet by new staff. She removed the pans and indicated she would allow them to air dry. The CDM agreed the pans should probably be washed again. The floor was observed to be covered with a dull film. The CDM indicated the film was probably grease. The CDM indicated the floor was mopped every day and as needed. She indicated the floor was deep cleaned every month. She indicated the cleaning log for this week was not completed yet. A white substance was observed on the floor underneath the sinks and the dishwasher. The CDM indicated she was unaware of what the substance is. She indicated she had not notified maintenance of the white substance. The DM indicated the cleaning log was not completed for this week due to the DM manager having the previous day off (Tuesday). During an interview on 1/11/23 at 10:44 am the Administrator indicated she was unaware of the white substance on the floor under the dishwasher and sinks. She indicated cleaning schedules were not available. She indicated the kitchen had previously been short staffed for a long period of time. She indicated new staff had been hired and were being trained. A Consultant Dietician report dated 10/21/22 provided by the Administrator on 1/13/23 at 8:40 am indicated the DM had worked 92 hours in 1 week. The Consultant Dietician indicated the kitchen floor was not clean. She indicated some refrigerated food items were not labeled with an end date. A Consultant Dietician report dated 11/16/22 provided by the Administrator on 1/13/23 at 8:40 am indicated the kitchen staff worked numerous double shifts. She indicated some refrigerated food items were not labeled with an end date. A Consultant Dietician report dated 1/3/23 provided by the Administrator on 1/13/23 at 8:40 am indicated some refrigerated food items were not labeled with an end date. The Consultant Dietician indicated dishes and utensils were not cleaned and stored properly. She indicated the kitchen floor had a white build up. She indicated there was no cleaning log posted. A current policy titled Food Protection and Storage provided by RN 9 on 1/12/23 at 11:02 am indicated kitchen walls and floors were to be clean. The policy indicated vendor recommendations were to be followed for dented cans. The policy indicated all opened food items must be labeled with the open date. 3.1-21(i)(1) and (3)

Based on observation, record review and interview, the facility failed to ensure care plans were developed and implemented for 2 of 5 residents reviewed for respiratory care. (Resident 6 and Resident 16). Finding include: 1) During an observation on 1/11/23 at 10:39 AM, Resident 6 was observed in her room sitting in her recliner with oxygen administered by a nasal cannula (NC) (tubing used to deliver oxygen through the nostrils). The oxygen had humidity to her oxygen concentrator (a machine used to produce oxygen) at the bedside. The oxygen concentrator gauge indicated the oxygen was being delivered at 2 liters per minute (LPM). On 01/13/23 at 10:40 AM, Resident 6's record was reviewed. Diagnoses included chronic respiratory failure with hypoxia, pulmonary fibrosis, acute on chronic diastolic, congestive heart failure, hypothyroidism, essential hypertension, paroxysmal atrial fibrillation, generalized edema and a history of Covid19. Resident 6's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 15, she was alert, oriented and interviewable. The MDS assessment indicated she had shortness of breath/trouble breathing with exertion such as walking, bathing, transferring and while laying flat. The MDS indicated she was on a diuretic 7 days a week and started using oxygen while a resident of the facility. A physician order, dated 12/29/21, indicated oxygen was ordered for Resident 6 to be administered at 2 LPM via NC continuously every shift; may remove the oxygen for showers and beauty/barber shop as needed. Other physician orders related to the oxygen maintenance included: take oxygen saturations every shift, place no smoking magnets on inside and outside of door, check oxygen flow rate, tank level, tube patency, portable/concentrator function, humidifier level every 4 hour every shift and clean concentrator filter weekly every night shift every Sunday. A physician order, dated 1/2/22, indicated to change oxygen tubing, humidifier and clean concentrator filter weekly every night shift every Sunday. A review of Resident 6's Treatment Administration Record (TAR), dated 12/1/22 to 1/12/23, indicated all physician orders related to oxygen administration and maintenance were completed as ordered. Resident 6's comprehensive care plan, last revised 12/29/22, was reviewed. A care plan guiding care and related to oxygen administration and maintenance was not located. 2) During an observation on 1/11/23 at 11:30 AM, Resident 16 was observed in his bed with oxygen administered by a NC. There was humidity added his oxygen concentrator at the bedside. The oxygen concentrator gauge indicated the oxygen was being delivered at 3 LPM. On 01/13/23 at 4:58 PM, Resident 16's record was reviewed. Diagnoses included chronic obstructive pulmonary disease, acute respiratory infection with hypoxia, acute on chronic systolic congestive and diastolic congestive heart failure, simple chronic bronchitis, essential hypertension, sleep apnea, edema, and a history of Covid 19. Resident 16's quarterly MDS, dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 13, he was alert, oriented and interviewable. The MDS assessment indicated he had shortness of breath while laying flat. The MDS indicated he was on a diuretic 7 days a week and started using oxygen while a resident of the facility. A physician order, dated 8/2/22, indicated oxygen was ordered for Resident 16 to be administered at 3 LPM via NC continuously every shift; may remove the oxygen for showers and beauty/barber shop as needed. Other physician orders related to the oxygen maintenance included: take oxygen saturations every shift, place no smoking magnets on inside and outside of door and change the oxygen tubing, humidifier, and clean concentrator filter weekly every night shift every Sunday. A review of Resident 16's TAR, dated 12/1/22 to 1/12/23, indicated all physician orders related to oxygen administration and maintenance were completed as ordered. Resident 16's comprehensive care plan, last revised 9/5/22, was reviewed. A care plan guiding care and related to oxygen administration and maintenance was not located. In an interview on 1/17/23 at 9:15 AM, the Director of Nursing (DON) indicated there were no care plans for oxygen administration and there should have been. On 1/17/22 at 12:34 PM, a current policy titled Care Plan Development & Review, dated 1/24/20, provided by the DON, indicated a comprehension care for each resident should include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment process. Care plan development included addressing needs, identifying the professional services that are responsible for each element of care, and showing evidence the treatment or service provided were to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Care plans should be revised daily and pro re nata (PRN) as changes in the resident's condition dictates and included changes in Physician orders, therapy changes, , behavior changes, etc. 3.1-47(a)(4)

Based on observation, and record reviews the facility failed to ensure care plans were personal centered and goals measureable for 3 of 12 resident reviewed (Resident 24, Resident 23, and Resident 28). Findings include: 1) During a record review, completed on 12/10/21, Resident 24 had care plan for the problem of constipation. The goal indicated resident would have regular bowel movements every 1 to 3 days. The interventions listed were to administer medication as ordered, monitor bowel sounds as needed, monitor for sign and symptoms of constipation and to record bowel movement size. During a record review, completed on 12/10/21, Resident 23 had a care plan for the problem of constipation. The goal indicated resident would have regular bowel movements every 1 to 3 days. The interventions listed were to administer medication as ordered, moniter bowel sounds as needed, moitor for sign and symptoms of constipation and to record bowel movement size. The care plans for Resident 24 and Resident 23 were the same. The care plans lacked person centered interventions. 2) On 12/9/21 at 9:45 A.M., Resident 28's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan dated 12/05/21 indicated the problem of nutritional risk. The goal was for the resident to consume meals that she selected, to have no significant weight loss, and the diet be served as ordered. All goals had a target date of 2/25/22. The most recent intervention was dated 4/8/21 which was oral pharmaceutical supplements as ordered. The care plan goals did not include measurable objectives. An observation of Resident 28 at lunch on 12/8/21 at 12:04PM indicate resident showed no intention of eating meal. Resident answered all question with one-word answers. Resident 28 received two verbal redirections and encouragement to eat. Resident 28 did not eat. The facility policy and procedure titled Care Plan Development & Review stated .a comprehensive care plan for each resident includes measurable objectives .Reflect goals and objectives in measurable outcomes. Corroborate information regarding the resident's goals and wishes for treatment in the plan by interviewing residents, especially those identified as refusing treatment. 3.1-35(b)(1)

Based on record review and interview the facility failed to ensure normal bowel function for 1 of 2 residents reviewed. (Resident 24) Findings include: A record review, completed on 12/10/21 at 12:34PM, indicated Resident 24's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan with the problem of constipation included. the goal of comfortable and regular bowel movements every 1-3 days. The interventions were all dated 8/28/20. No updates to the care plan for constioation had been made for 15 months. The care plan interventions listed were to administer medications, encourage fluids, monitor bowel sounds, monitor for signs and symptoms of constipation and to record bowel movements size.The medications ordered for Resident 24 were listed: suppository as needed for constipation daily if no results from milk of mag dated 7/24/21; milk of magnesia 30ml by mouth as needed for constipation daily dated 12/12/20 and [MEDICATION(S)] powder as needed for constipation every day if no bowel movement for 3 days dated 12/2/21. A BM (bowel movement) report indicated Resident 24 had no bowel movement for 5 or more days three times in the last 60 days. the report indicated: Resident 24 did not have any bowel movement for 6 days through 10/7/21 up to 10/13/21. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 24 went 6 days without a bowel movement from 11/2/21 through 11/8/21. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 24 went 5 days without any bowel movement recorded from 11/16/21 to 11/20/21. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The last 60 days of weekly nursing assessment provided by DON on 12/10/21 at 9:00AM indicated that the gastrointestinal system was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with LPN 2 on 12/9/21 at 9:23AM indicated resident bowel movements were tracked daily. After 2 days of no bowel movement the facility encouraged prune juice. LPN 2 indicated the 3rd shift nurse kept track of bowel movement patterns then indicated who needed medication after 3 days of no bowel movement. LPN 2 indicated a resident can also request medication when feeling constipated. LPN 2 indicated tracking was difficult when a resident was ambulatory and did not require assistance with toileting. LPN 2 indicated Resident 24 did require assistance with toileting. An interview with the DON (Director of Nursing) on 12/10/21 at 10:16AM indicated residents were monitored for constipation in weekly nursing assessments and tasks list for certified nursing assistants. The DON indicated the weekly nursing assessment should indicate when the resident had issues with constipation or diarrhea. The facility policy and procedure, subject Bowel Elimination indicated Purpose: to ensure that each resident maintains a safe and healthy bowel elimination pattern .3rd day with no bowel movement, an ordered bowel aide or stool softner will be administered if within 8 hours of administering the bowel aide or softner, the resident has not had a bowel movement, another bowel aide will be administered. If within another 8 hours the resident had not had a bowel movement, the nurse will do an abdominal assesssmentkk and notify the Physcian

Based on record review and interview the facility failed to ensure the resident received adequate supervision and devices to prevent accidents for 1 of 2 resident reviewed (Resident 24). Findigns include: 1) A record review, completed on 12/10/21 at 10:45AM, indicated Resident 24's diagnosis included but were not limited to: history of falling, reduced mobility, muscle weakness and abnormal gait and mobility. Resident 24's care plan indicated he had the problem of fall risk started on 8/30/20. The goal on the care plan was fall risk factors will be reduced in an attempt to avoid significant injury related to falls. Interventions were added on 9/6/20, 9/7/20, 12/21/20, 1/4/21, 5/24/21, 7/11/21, 9/16/21 and 11/23/21. The initial assessment for a fall on 7/11/21 at 4:30PM indicated the resident had a fall with injury, a small cut on his left eye was presumed to be from his glasses. The resident was not sent to ER, neuro checks were started on 7/16/21. The new intervention was to monitor the resident more closely when at the desk. The post fall assessment indicated Resident 24 was toileted just prior to fall and was wearing non slip socks. The initial assessment for a fall on 8/23/21 at 3:40PM indicated the resident had a fall with injury (a cut to left knee). Resident 24 attempted to take himself to the bathroom, was found with pants around his ankles and was found with his walker and tv from night stand on top of himself. The description of details further indicated that Resident 24 and his roommate both stated Resident 24 did not hit his head. The assessment indicated neuro checks were started. The record had a neuro checklist dated 8/23/21 filled out. The intervention included on the assessment wasv the resident was brought to nurses station to be monitored. The post occurrence assessment indicated staff are to stay with Resident 24 while in the bathroom. The initial fall assessment from a fall on 9/16/21 at 7:15AM indicated the residnt had fall with injury- a skin tear. A description of the incident was when staff heard a loud noise, they found Resident 24's on his right side with his head resting on the door. Resident 24 was not sent to emergency room , but neuro checks were started. On the assessment the new intervention was the resident was to be at the nurses station while up. The post fall assessment indicated interdisciplinary team recommendations were to bring the resident to the nurses station after showers in the morning while awake. The initial fall assessment from a fall reported on 11/13/21 at 2:05PM indicated the residnet had a fall with injury (a skin tear to left hand). The description indicated Resident 24 was in a wheelchair then attempted to walk into bathroom unattended, lost balance and fell to left side. The intervention was the resident was brought to nurse station to be monitored by staff. The post fall assessment indicated interdicplinary team recommendations was to have Resident 24 in a recliner at the nursing station or to lay down in bed between lunch and supper. The facility failed to implement interdisciplinary recommendations. An interview with LPN (licensed practical nurse) 2 on 12/9/21 at 12:03PM, indicated the facility did neuro checks after falls and attempts at elopement. LPN 2 indicated any fall not witnessed by staff was to have neuro checks done due to the possibility of head injury. LPN 2 indicated Resident 24 was difficult to keep safe due to trying to go to the bathroom on his own. 3.1-45(a)

Based on interviews and record review the facility failed to evaluate pain and manage pain for 1 of 1 resident reviewed (Resident 23). Findings include: An interview with Resident 23, on 12/7/21 at 1:40PM , indicated the resident had pain in left shoulder, neck and arm. Resident 23 indicated the pain get up to a 7 at times. She had used biofreeze in the past yet it was no longer effective for her. She indicated the facility staff do not use massage, heat or any other means to assist with the pain. She indicated that her knee which she had on a brace does not hurt as long as the brace is on correctly. Resident 23 indicated she came to facility due to tearing all the ligaments in her knee; but the injury was not currently her source of pain. Resident 23 denied any recent falls to contribute to the pain in her neck, arm and shoulder. Resident 23 indicated staff were aware of where her pain was located and that she had taken Tylenol when unable to function due to pain. A record review completed on 12/10/21 at 1:45PM indicated Resident 23's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A copy of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A copy of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 23 was documented as receiving Tylenol three times in the month of October on 10/5/21, 10/10/21 and 10/24/21. There are no documented doses of biofreeze given during the month of October. Resident 23 had documented rated pain above a zero 21 times ( 10/2/21, 10/3/21 twice, 10/4/21 twice, 10/5/21, 10/6/21, 10/7/21, 10/11/21, 10/14/21, 10/15/21, 10/20/21, 10/23/21 three times, 10/24/21, 10/26/21, 10/27/21 and 10/28/21). Weekly nursing assessments indicated Resident 24's level of pain was a zero. A blank list of pain medications or other interventions used and the effectiveness were on the notes dated 10/7/21, 10/18/21 and 10/21/21. The facility weekly nursing assessment rated pain a 4 with medication, other interventions and effectiveness was documented as needed Tylenol and [MEDICATION(S)] at bedtime. A copy of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 23 was documented as receiving Tylenol once in the month of November on 11/5/21. There are no documented doses of biofreeze given during the month of November. Resident 23 had documented rated pain above a zero 36 times ( 11/1 twice, 11/4 twice, 11/5 three times, 11/6 three times, 11/7, 11/8 twice, 11/9, 11/10, 11/12 twice, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18 twice,11/19, 11/22 three times, 11/23, 11/24 twice, 11/25, 11/26 three times and 11/27). Weekly nursing assessments indicated the resident had a level of pain at zero. A blank list of pain medications or other interventions used and the effectiveness were on the notes dated 11/11 and 11/18/21. There was no weekly nursing assessment for the date of 11/25/21. A copy of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 23 was documented as not receiving Tylenol nor Biofreeze through 12/9/21. Resident 23 had documented rated pain above a zero on 6 times in 9 days ( 12/2, 12/3, 12/4 twice, 12/7 and 12/8). Weekly nursing assessments indicated the resident had a level of pain at zero. A blank list of pain medications or other interventions used and the effectiveness were on the notes dated 12/2/21. An interview with DON on 12/9/21 at 1:45PM indicated that she was frustrated with pain managment and documentation. She indicated she was having her nurses do weekly assessments, they should document pain level when giving medication and monitor for signs and symptoms of pain. The DON indicated they document what a resident states their pain level was at time of medication administration. The DON was unable to supply any documentation for non-pharmacological interventions nor follow up on pain medication effectiveness. The DON indicated Resident 23 only receives Tylenol as needed in addition to routine pain medication. On 12/10/21 9:15AM a facility policy was provided as requested by administrator titled, Pain management program which indicated .goal of this facility to assist residents in achieving their optimal level of care by providing an effective pain management program 3.1-37(a)

Based on observation, interview and record review the facility failed to ensure individual behavior needs were met for 1 of 1 resident reviwed. (Resident 28) Findings include: In an observation of lunch, on 12/8/21 at 12:04PM, Resident 28 was observed not eating meal. Staff attempted 2 verbal interventions to encourage the resident to eat without success. Resident 28's record was reviewed began on 12/8/21 at 1:15PM. Diagnosis included but not limited to depression and dementia without behavioral disturbances. Physician orders include but not limited to: house shakes twice daily ordered 6/4/20 as well as Ensure daily ordered 11/5/21 ( a meal supplement). Social Services assessment dated [DATE] indicated the resident feels down and having poor appetite. The Social Services assessment dated [DATE] indicated the resident expresses she feels down and having poor appetite. A physciatry progress note dated 9/27/21 indicated the resident was seen for delusions and hallucinations. The report did not indicate the Nurse Practioner was made aware of Resident 28's poor appetitie. A care plan dated 12/5/21 indicated resident's mood will not innterfere with eating. A review of Resident 28's food and fluid intake monitoring indicated during the month of September indicated 16 meals of 84 meals had little to no intake. The record did not indicate a snack was offered. During the month of October the record indicated 22 of 90 meals had little to no intake. Snack were offered for only 5 meals. The month of November the record indicated 44 of 90 meals had little to no intake. Snacks were offered for only 1 meal. The month of December the record indicated. 8 of 21 meals had little to no intake. Snacks were offered for only 3 meals. The nursing weekly assessmet dated 10/1/21, 10/8/21, 10/15/21, 10/22/21, 10/29/21, 11/5/21, 11/18/21, 11/19/21, and 11/26/21 did not indicate any psychosocial concerns. In an interview on 12/10/21 at 10:06AM the Social Services Director indicated Resident 28 was not being followed by psych services for any specific behavior and the residents behaviors are not being tracked. The Social Services director indicated Resident 28 is on [MEDICATION(S)] for pain but not depression. A current facility policy titled Behavior Assessment and Management provided by DON (director of nursing) indicated . to identify specific behaviors that may impact the residents quality of life and to gather evidence for other possible reasons for the distress or behavior. 3.1-34(a)

Based on observation, interview and record review, the facility failed to provide care and services for a non-pressure related wound and skin impairment for 1 of 1 residents reviewed for non-pressure related skin issues (Resident 11). Findings include: On 12/9/21 at 9:45 A.M., Resident 11's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (Minimum Data Set) assessment, dated 9/23/21, indicated the resident had a BIMS (Brief Interview Mental Status) score of 6-severely impaired cognition. The resident required extensive assistance from 1 staff member for his activities of daily living. He had no rejection of care or other behaviors and had no wounds or skin issues. A care plan, dated 12/15/20, indicated the resident was at risk for skin breakdown and would be provided preventative measures to avoid skin breakdown. Interventions included, but were not limited to, monitor skin daily during care and perform a skin assessment at least weekly by the nurse. The care plan didn't indicate the resident had any current skin issues. On 12/8/21 at 2:02 P.M., the resident was observed to have uncovered bruises and cuts on his left arm. On 12/9/21 at 9:38 A.M., Resident 11 was observed with uncovered cuts/wounds on his left forearm and open to air. He had a fading red skin discoloration from his elbow down to his wrist on his outer left forearm. There were 4 wounds observed on the top of his forearm approximately 1/2 to 1 inch in length and were closed with a thin line of dried blood covering the top of each wound. His forehead and top front of his scalp were observed to have thick, greasy/waxy appearing scales that were flaking off onto his face. On 12/10/21 at 9:57 A.M., Resident 11 was observed in his room visiting with his guardian. The wounds and red skin discoloration remained uncovered and open to air. The guardian indicated the red skin discoloration on the resident's left forearm had been present for years, would come and go, and had never been treated. He indicated he hadn't seen the areas that appeared like cuts before and wasn't sure where those had come from. The guardian was aware the resident had thick, greasy/waxy appearing scales on his forehead and scalp. He indicated he had assumed that the facility was using a special shampoo to treat it. A Nursing-Weekly Assessment form, dated 12/6/21 at 5:38 p.m., indicated Resident 11's skin had been assessed and he had no new skin issues. Nurse progress notes had not indicated the resident had wounds to his left forearm, red skin discoloration, nor scaling to his forehead and scalp. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/9/21 at 2:27 P.M., CNA 5 (Certified Nurse Assistant) was interviewed. They indicated they had cared for Resident 11 and had not seen any bruising/discoloration or wounds to the resident's left arm although they had applied lotion to his arms. On 12/9/21 at 2:33 P.M., the Director of Nursing (DON) was interviewed as she observed the resident's wounds and discolored area of redness on his forearm and thick scales on his forehead and scalp. She indicated she hadn't been aware of the residents wounds. The resident indicated he hadn't known where the wounds came from but that they were itchy. On 12/10/21 at 8:42 A.M., the DON indicated, upon further investigation, it was believed the discoloration on the resident's forearm had always been present due to his many years working in the sun as a farmer however, it was unknown how the wounds had occurred on his forearm. She indicated a treatment order has been obtained from the physician to treat the wounds and itchiness. The DON did not know why the care plan hadn't indicated the discoloration on his forearms but the care plan had been updated with the current treatments. On 12/10/21 at 9:45 A.M., CNA 3 was interviewed. He indicated the resident usually received showers with his hair washed, 2 times per week, and the resident never refused. CNA 3 was not aware of any special shampoo that was to be used on the residents forehead and scalp but that if there had been one, it would be ordered by the physician and provided by the nurse. A current facility policy, titled Wound and Non-wound Assessment and Documentation was provided by the DON on 12/10/21 at 10:55 A.M., which stated the following: 3. Non-wound skin alterations: A. All non-wound skin alterations will be managed by the licensed staff nurses. Initial assessment and documentation will be completed on the .'nursing daily assessment' .The non-wound area will be .monitored at least daily until healed 3.1-37(a)

Based on interview and record review, the facility failed to provide shower opportunities for 1 of 1 residents reviewed for choices (Resident13). Findings include; On 3/1/19 at 2:10 P.M., an interview was conducted with Resident 13. Resident 13 indicated he only gets bed baths and he would like to get showers. Resident 13's care plan dated 11/30/17 indicated it was important for Resident 13 to choose what type of bathing he received. Resident preference for bathing was to shower 2 times per week and get cleaned up daily. Resident 13 had a BIMS (brief interview of mental status) score of 12 which indicated moderately impaired cognition. Resident 13's [DIAGNOSES REDACTED]. On 3/4/19, at 11:05 A.M., an interview was conducted with CNA 3. CNA 3 indicated Resident 13 received bed baths only as he was hard to get in a shower chair. CNA 3 noted Resident 13 was on hospice and they give him bed baths also. On 3/4/19, at 11:10 A.M., an interview was conducted with LPN 2. LPN 2 indicated according to Resident 13's care plan, he should have been receiving 2 showers per week. On 3/4/19, at 11:27 A.M., an interview was conducted with the DNS (director of nursing services). The DNS indicated hospice gives Resident 13 full sponge baths. The DNS indicated Resident 13 is not stable in a shower chair and could slide out. The DNS indicated Resident 13's care plan should have been followed for 2 showers per week or the care plan changed. The DNS indicated Resident 13's care plan had been updated to indicated he was to get a bedbath 2 times per week and cleaned up daily. 3.1-3(u)(1)

Based on observation, record review and interview, the facility failed to address pain in 2 of 2 residents reviewed for pain. (Resident 39 and Resident10). Findings include: 1. Resident 39's clinical record was reviewed on 3/5/19 at 1:06 P.M Resident 39's [DIAGNOSES REDACTED]. Resident 39's physician's orders [REDACTED]. Resident 39 had a care plan for potential pain/discomfort related to [DIAGNOSES REDACTED]. Resident 39's weekly nursing assessments were reviewed from 11/8/19 through 3/7/19. On 6 occasions (11/8/18; 11/14/18; 12/5/18; 1/2/19; 1/16/19; 3/4/19) the weekly nursing assessments indicated Resident 39 had mild pain (1-3 on the 0-10 pain scale). On 11/14/18, the weekly nursing assessment indicated Resident 39 refused an as needed pain reliever for pain. On the other 5 occasions, Resident 39 was not offered as needed pain medication for mild pain. An interview was conducted with the DNS (director of nursing services) on 03/07/19, at 11:38 AM. The DNS indicated routine pain monitoring is done during weekly nursing assessments. The DNS indicated on the 5 occasions during the weekly nursing assessments where Resident 39 indicated mild pain without treatment of [REDACTED]. The DNS indicated the nurse's doing the weekly assessments for Resident 39 should have documented why they chose to not treat the mild pain with [MEDICATION NAME] after the pain was identified. 2. The clinical record for Resident 10 was reviewed on 3/4/19 at 1:53 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment from 12/9/18, indicated Resident 10 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive impairment). During an observation on 3/1/19 at 10:56 A.M., Resident 10 was humming lowly and had facial grimacing During and observation on at 3/6/19 at 8:32 A.M., Resident 10 was sitting in a chair humming lowly and had facial grimacing. During an observation on 3/7/19 at 11:07 A.M., Resident 10 was sitting in chair humming lowly and had facial grimacing. A physician's orders [REDACTED].M., mid-day, and at bedtime) for chronic pain. A physician's orders [REDACTED]. A care plan problem initiated on 3/23/16, indicated Resident 10 had the potential for pain/discomfort related to decreased mobility. Interventions included, but were not limited to, assessment of pain using a 0-10 scale; monitoring for adverse reactions such as constipation, drowsiness, etc.; monitoring the effectiveness of pain medications; administering pain medications per physician's orders [REDACTED]. During an observatin on 3/6/19 at 11:16 AM , Licensed Pratical Nurse (LPN) 4 administered 1 tablet of [MEDICATION NAME] 7.5- 325 milligrams to Resident 10. LPN 4 did not assess Resident 10's pain level prior to administering the medication. During an interview LPN 4 indicated she should have asssessed Resident 10's pain level before administering the pain medicaion and she had not. LPN 4 was interviewed on 3/6/19 at 11:43 A.M. During the interview LPN 4 indicated Resident 10 hums lowly, has for a long time and it is her baseline. She also indicated Resident 10 is able to tell her if she has pain when asked at times, but also displays pain by facial grimacing. LPN 4 indicated Resident 10's pain should be assessed and recorded each time she received pain medication. She also indicated Resident 10's pain had not been assessed and recorded each time she had received pain medication from (MONTH) 1 to (MONTH) 5, 2019. An assessment of Resident 10's pain had been documented 9 times from 1/1/19 to 3/7/19 as part of weekly nursing assessments. There was no documentation in January, (MONTH) or (MONTH) 1-5, 2019 that indicated Resident 10's pain had been assessed daily,each time pain medication was administered, or any time other than the 9 times during the weekly nursing assessments. A policy dated 4/11/17, was provided by the DNS on 3/6/19 at 3:25 P.M., titled Pain Management Program and she indicated it was the policy currently used by the facility. The policy indicated 1. PURPOSE: It is the goal of this facility to assist residents in achieving their optimal level of comfort by providing an effective pain management program. 2. PR[NAME]EDURE: A. Assessment of pain will be completed with all assessments. This includes: I. admission assessment II. nursing daily assessments III. MDS completion IV. wound assessments V. each time vital signs are taken. 3.1-37(a)

Based on record review and interview, the facility failed to adequately monitor side effects on an anticoagulant for 1 of 5 residents reviewed for unnecessary medications (Resident 39). Findings include Resident 39's clinical record was reviewed on 3/5/19 at 1:06 P.M The record indicated Resident 39 had [DIAGNOSES REDACTED]. Resident 39's physician's orders [REDACTED]. Resident 39 had a care plan dated 11/8/18 for anticoagulant therapy. One of the interventions indicated on the care plan were to monitor for signs symptoms of bleeding: tarry stool; bruising; blood in urine; headaches; nose bleeds; gums bleeding, and report to the physician. On 3/6/19, at 11:07 A.M., an interview was conducted with LPN 4. LPN 4 indicated anticoagulant monitoring is done on resident's MARs (Medication Administration Records). LPN 4 indicated Resident 39's MAR indicated [REDACTED] On 3/6/19, at 11:10 A.M., an interview was conducted with the ADNS (Assistant Director of Nursing). The ADNS indicated anticoagulant monitoring is supposed to be on physician's orders [REDACTED]. 3.1-43(a)(3)

Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5%. This deficiency affected 2 of 2 residents observed for insulin administration (Resident 24 and Resident 190). Findings include: During an observation on 3/6/19 at 10:55 A.M., Licensed Practical Nurse (LPN) 11 prepared 4 units of insulin in an insulin pen for Resident 24. LPN 11 then administered 4 units of insulin in Resident 24's right lower abdomen. The insulin pen was not primed before use. During an observation on 3/6/19 at 11:31 A.M., LPN 11 prepared 12 units of insulin in an insulin pen for Resident 190. LPN 11 then administered 12 units of insulin in Resident 190's right upper arm. The insulin pen was not primed before use. The Director of Nursing Services (DNS) was interviewed on 3/7/19 at 9:14 A.M. During the interview the DNS indicated insulin pens should be used acording the the facility's policy and should be primed before use. A policy dated 5/18/17, was provided by the DNS on 3/6/19 at 3:25 P.M., titled Use of Insulin Flex Pen and she indicated it was the policy currently used by the facility. The policy indicated .5. Remove needle cap and dial the pen to 2 units. 6. Hold insulin pen upright and press the push button all the way. A drop of insulin should appear at the end of the needle or shot out of the needle. If a drop doesn't appear repeat process up to six (6) times. If after six attempts no insulin appears, do not use the insulin pen and contact pharmacy. 7. Check that the dose indicator is at zero, check the Medication Administration Record [REDACTED] 3.1-48(c)(1)

Based on interview and record review, the facility failed to ensure 1 of 1 residents (Resident 29), reviewed for hearing aids, received services in a timely manner. Findings include. On 3/1/9, at 10:52 A.M., an interview was conducted with Resident 29. Resident 29 indicated a company came to check her hearing in (MONTH) and were supposed to come back to adjust her hearing aids but no one had come back to fix her hearing aids. Resident 29 had a BIMS (brief interview of mental status) score of 15, which indicated intact cognition. On 3/4/19, at 11:52 A.M., an interview was conducted with the SSD (social service director). The SSD indicated Resident 29 received an audiology exam on 12/19/18. The SSD indicated the audiology exam indicated the company that sold Resident 29 her hearing aids needed to come back to program and make them louder. On 3/4/19, at 12:05 P.M., an interview with the SSD indicated Resident 29 had not been scheduled for a follow-up exam to get her hearing aids turned up but she should have been after the audiology exam on 12/19/18. 3.1-39(a)(1)

Based on observation, interview and record review, the facility failed to ensure vents were maintained in the kitchen area. This had the potential to affect 27 of 27 residents residing in the facility. Findings include: During a tour of the kitchen on 03/01/19 at 09:38 AM, the vent over the trash can at the west end of three compartment sink was observed to have grey feathery substance that was moving with the air currents. The vents over the dry storage and dish washing area were also observed to have grey feathery substance with grey feathers onto ceiling. In an interview on 03/01/19 at 09:57 AM, the CDM indicated the vents needed cleaned and maintenance usually cleaned the vents. In an interview on 03/01/19 at 03:01 PM, Maintenance Employee 1 indicated they had been with the facility about 6 months, had not cleaned any vents in the kitchen, and were not sure when the vents were to be cleaned. Maintenance Employee 1 was not sure where the documentation would be found about cleaning kitchen vents. A review of the kitchen vent cleaning schedule dated 1/29/2019 provided by the Administrator on 3/4/2019 indicated the kitchen ceiling vents had been cleaned on 1/2/2019. There was no other documentation provided to indicate the ceiling vents had been cleaned after that date. 3.1-21(i)(1)and (3)

Based on observation, record review and interview, the facility failed to ensure 2 shower rooms located on the 300 hall were free from a potential hazard. This deficiency had the potential to affect 13 of 43 residents residing in the facility. Findings include: On 4/10/18 at 1:01 P.M., during an interview with Resident 8 indicated he had a concern in regard to the shower room located on the 300 hall. The resident indicated in the 300 hall shower room was a metal shelf that had what looked like hooks that protruded from the metal shelf and under the metal shelf was a grab bar. Resident 8 indicated after he had showered a staff member had assisted him to stand up the resident had faced the wall and with both hands had held onto the grab bar and when he had stood up the hook attached to the metal shelf came to the level of the resident's forehead. Resident 8 indicated he had never hit his head on the hook that protruded from the shelf located in the 300 hall shower room. On 4/10/18 at 2:47 P.M., during an observation with RN Supervisor in the east 300 hall shower room wall just outside of the shower room stall hung on the wall was a metal shelf with 9 protrusions shaped like hooks that were flat on the end of hook shaped protrusions. Also observed on the shower room wall located under the metal shelf with hook like protrusions was a metal handicapped bar attached to the wall. On 4/10/18 at 2:51 P.M., during an observation in the west 300 hall shower room wall just outside the shower room stall was a handicapped metal rail attached to the wall and located above the handicapped bar on the wall was a metal shelf with 9 protrusions shaped like hooks that were flat on the end of each hook shaped protrusion. Also observed on top of the metal shelf with the hook shaped protrusions were 4 rolls toilet paper and 2 rolls of disposable plastic bags and hung on 1 of the hooks were 4 clothing hangers and a gait belt. On 4/10/18 at 3:12 P.M., during an observation, the Maintenance Director was in the east 300 hall shower room. He had removed the metal shelf with the hook shaped protrusions from the wall that had been above the handicapped bar. During an interview on 4/10/18 at 3:12 P.M., the Maintence Director indicated the protrusions were shaped like a hook and the residents would hang their towel on and after the resident had showered would use the handicap rail to assist a resident to a standing potion. On 4/11/18 at 03:20 P.M., during an observation, the Maintenance Director was in the west 300 hall shower room. He had measured the height of the metal shelf from the shower room floor to the hook shaped protrusion was 61 and 1/2 inches. On 04/11/18 at 3:30 P.M., during an interview, the Health Facility Administrator (HFA) indicated none of the residents had ever been injured by the protrusions on the metal shelf that were in both shower rooms located on the 300 hall. On 4/11/18 at 10:50 A.M., during an interview the Director Nursing Service (DNS) indicated she and the HFA were not aware the shelf in both of the 300 hall shower rooms were a concern because no one had ever reported to either of them a concern or potential concern. The DNS indicated the shelf in both shower rooms located on the 300 hall had been present since she started employment at the facility in (MONTH) (YEAR). On 4/11/18 at 12:50 P.M., during an interview the HFA indicated the metal shelf that had hung on the wall in both shower rooms located on the 300 hall were removed yesterday because of the potential for injury to a resident was present. The HFA indicated none of the residents or staff had ever voiced any concerns in regard to the shelf located in both of the shower rooms located on the 300 hall. On 4/12/18 at 10:21 A.M., during an interview the Certified Nursing Assistant (CNA) 4 indicated before Resident 8's shower the resident had faced the shower room wall and had placed both hands on the grab bar which had allowed the resident to stand up from his wheel chair. CNA 4 indicated Resident 8 had said at the time of the shower if he had been taller he might had hit head on the hook that protruded for the shelf located in the west 300 hall shower room. She indicated there were 13 residents who used the two shower areas on the 300 hall. Resident 8's clinical record was reviewed on 4/13/18 at 10:34 A.M. The [DIAGNOSES REDACTED]. The 30 day MDS (Minimum Data Set) assessment, dated, 4/5/18, indicated Resident 8 was interviewable. 3.1-19(c)

Based on record review and interview, the facility failed to ensure constipation was addressed timely to prevent fecal impaction complications including increased pain, had been given enemas twice with no results, and had been transferred to the hospital for resident # 94. This deficient practice affected 2 of 10 residents who met the criteria for constipation. (Residents #94 and 64) Findings include: 1. The clinical record for Resident #94 was reviewed on 06/28/12 at 9:00 A.M. Resident #94 was admitted to the facility on [DATE] with diagnoses, including but not limited to, status [REDACTED]. The resident's current physician's orders [REDACTED]. The resident also received [MEDICATION NAME] 325 mg once a day, ordered on [DATE]. There were also orders for Milk of Magnesia, dated 04/28/12, 30 ml once daily as needed for constipation and [MEDICATION NAME] powder, dated 04/28/12, 17 grams once daily as needed for constipation. The resident was also on routine medications to address constipation, including Senna conc/[MEDICATION NAME], ordered on [DATE], two tablets twice a day, and [MEDICATION NAME], ordered on [DATE], 24 mcg one capsule twice a day. Interview with RN (Registered Nurse) #31, on 06/28/12 at 7:55 A.M., indicated the resident had complained of increased pain, had been given enemas twice with no results, and had been transferred to the hospital last night around 5:00 P.M. Nursing notes, from 06/19/12 - 06/21/12 did not mention any s/s (signs and/or symptoms) of constipation or any bowel assessment Nursing notes, dated 06/22/12 at 11:00 am indicated the resident had complained of flank pain and difficulty voiding, had stated she " feels different," the physician was notified and a urinalysis was ordered. Subsequent nursing notes, dated 06/22/12 indicated an order was received for an antibiotic and an order was received to discharge the resident to home. The note also indicated the resident was also medicated with pain meds twice during the second shift for complaints of flank pain. Nursing notes at 06/23/12 at 3 am indicated the resident was medicated with Tylenol pm due to lower back pain. Nursing notes on 06/23/12 at 10:00 A.M. indicated the resident complained of severe lower back pain and was medicated with [MEDICATION NAME] twice and the physician was notified. The resident's discharge was postponed until the "abt" (antibiotic) had time to work. There was no bowel assessment done and no mention of any problems with bowel movements. On 06/24/12 8:35 A.M. the resident complained of severe back pain, was medicated with Tylenol Pm, and the resident stated "There is something wrong, I have never felt pain like this before." The resident's bowel sounds were assessed as hypoactive abdomen slightly firm but non-tender. The resident requested xray's be done. The physician was notified and an order given to send to the emergency room . On 06/24/12 at 10:30 A.M. a nurses note indicated the resident had returned from the emergency room , refused breakfast, and had complained of pain. The note indicated the resident had returned with orders for oxygen to keep saturation levels above 90 percent and skelatia (a muscle relaxant) and [MEDICATION NAME] (a narcotic pain medication) for pain. Nursing notes from 06/24/12 at 7:00 A.M. through 06/25/12 at 13:15 (1:15 p.m.) indicated no bowel assessments were documented as having been completed. Nursing notes on 06/25/12 at 1315 (1:15 P.M.) indicated a new order was obtain for [MEDICATION NAME] to be given daily until results. The note indicated a dose was given on the day shift with no results. Nursing notes, dated 06/25/12 at 2130 (9:30 p.m.) indicated the following: "got report from day shift resident need have bowel move to be able to d/c (discharged ) home per doctor order. encouraged resident have more fluids promo and BM. offered prune juice received new order for liver function panel. hepatic ABC panel." (Sic). There was no bowel assessment done. Nursing notes, dated 06/26/12 at 12:05 a.m. indicated the following: "No BM noted... boso (bowel sounds) active x4 quads.(quadrants) abdomen soft and round..." Nursing notes, dated 06/26/12 at 12:15 P.M. indicated: "abdomen round et distended. slightly firm to touch. Boso present x4 quads, but hypoactive et sluggish. no c/o pain when abdomen palpated. (physician name) notified. Awaiting response." Nursing notes, dated 06/26/12 at 18:05 (6:05 p.m.) indicated the following: "new orders received from (physician's name) fleet enema daily until results for constipation...abdomen round et distended with hypoactive bowel sounds...." Nursing notes, dated 06/27/12 at 12:11 A.M. indicated the following: "...abdomen soft et round...boso present x4 quads..." Nursing notes, dated 06/27/12 at 9:20 a.m. indicated the following: "Soap suds enema given per rectum. stool was noted to be hard. ...750 cc warm water with [MEDICATION NAME] soap administered rectally (sic)..." Nursing notes, dated 06/27/12 at 13:35 (1:35 p.m.) indicated the following: "... no results from soap suds enema. Abdomen round et distended, but non tender to touch....MD notified...Ate bites of breakfast et lunch, but refused alternatives. water encourage prn [MEDICATION NAME] given..." Nursing notes, dated 06/27/12 at 16:45 (4:45 p.m.) indicated the writer phoned had phoned the physician regarding continued pain without any bowel movements after the soap suds enema. A physician's orders [REDACTED]. A nurses noted, written on 06/28/12 at 6 am indicated a late entry for 06/27/12 at 1335 of a bowel assessment indicated the resident had boso (bowel sounds) x4 hypoactive et (and) sluggish..." Review of bowel records for June 2012 indicated no bowel movement recorded from the 19th to the 27th of June. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In addition, PRN orders for Milk of Magnesia and [MEDICATION NAME] Powder for constipation, both ordered on [DATE] . The June MAR indicated [REDACTED]. The Fleets enema daily until results ordered on [DATE] given on 06/27/12 one time and the Soap suds enema ordered on [DATE] was given once on 06/26/12. Review of the current health care plans for Resident #94, initiated on 04/28/12, and current as of June 28, 2012, included a plan to address the potential for constipation related to decreased mobility and narcotic pain medication use. Interventions included: "uses Senna/[MEDICATION NAME] routinely and MOM, [MEDICATION NAME] as needed." The goal was for " (resident's name) will have a regular soft-formed bowel movement at least 3 times per week." Interventions included: "encourage fluid intake, position (resident's name) upright on a toilet or a bedside commode, Administer medications per MD order. Monitor effectiveness and side effects, Document frequency and character of bowel movements. Hospital emergency room notes, from 06/24/12, indicated the abdominal xray's ordered originally upon admission to the emergency room were later canceled and the resident was diagnosed with [REDACTED]. Hospital emergency notes, from 06/27/12 indicated the abd x-rays done showed "grossly non obstructive bowel gas pattern, with air and stool seen in the colon..." In addition, the resident was found to have 999 ml of [MEDICAL CONDITION] and was given [MEDICATION NAME] (a laxative) in the emergency room . The History documentation for the emergency room indicated the time frames documented for previous admissions was not accurate even though the resident had been seen in the same emergency room . In addition, the note indicated a CT scan done (on 06/24/12)showed constipation when the CT scan ordered on [DATE] was canceled before it was completed. The note indicated the resident was admitted to hospital on [DATE] to a medical floor. Interview, on 06/28/12 at 3:00 P.M., with the DON indicated the facility had no bowel monitoring protocol or policy. It was unclear how licensed nursing staff were informed of those residents who had not been having routine bowel movements unless the residents themselves complained to the licensed nurse. In addition, there was no policy or protocol to ensure interventions were initiated timely to ensure fecal impaction complications did not occur. 2. The clinical record for Resident #64 was reviewed on 06/29/12 at 9:00 a.m. Resident #64's [DIAGNOSES REDACTED]. Resident #64 also had medications ordered as needed (prn), on 06/29/12 for: [MEDICATION NAME] 10 mg suppository rectally once daily as needed for constipation; Fleets enema rectally once a day as needed for constipation; senna concentrate/[MEDICATION NAME] sodium 8.6/50, 2 tabs as needed for constipation. An interview with CNA (Certified Nursing Assistant) #12 on 6/28/12 at 9:50 A.M. indicated the resident care record was where CNA's documented bowel movements for the residents. Review of the resident care record for June 2012, under bowel action, indicated: no documented bowel movement from 2nd shift on 6/5/12 until 6/13/12, 2nd shift, when resident #64 was noted to have had a large bowel movement; Resident #64 was noted to have a large bowel movement on 3rd shift on 6/13/12 and did not have another bowel movement until 6/17/12 on second shift; Resident #64 did not have bowel movements between 2nd shift on 6/20/12 until 6/24/12 on 1st shift, a small bowel movement. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. the resident received PRN senna concentrate/[MEDICATION NAME] sodium 8.6/50, 2 tabs by mouth for constipation. No results were documented in the MAR, nurse's notes or the resident care record. Review of nurse's notes indicated on 6/12/12 at 9:40 A.M. resident received PRN (as needed) [MEDICATION NAME] suppository for constipation. On 6/12/12 at 11:00 p.m., resident was incontinent of a large BM (bowel movement) after receiving a fleets enema on 2nd shift. Review of June 2012 MAR indicated [REDACTED]. the [MEDICATION NAME] suppository and fleets enema given on 6/12/12. No additional PRN meds for constipation given this month. Review of the resident's current health care plans, on 06/29/12 at 9:00 AM., indicated no care plan for constipation. An interview with LPN (Licensed practical nurse) #13, 6/29/12 at 10:45 A.M. indicated when residents go 3 days without a bowel movement the night shift starts a list of who has not had a bowel movement for the day shift nurse's. LPN #13 indicated resident #64 should have been given PRN Milk of Magnesia or senna/[MEDICATION NAME] after 3 days without a bowel movement. LPN #13 indicated after 3 days without a bowel movement nurse's should be assessing bowel sounds and checking for abdominal distention. LPN #13 indicated sometimes residents may have bowel movements and CNA don't document the results. LPN #13 did not know why resident #64 was not assessed for bowel sounds or abdominal distention, nor given PRN medications until 5 days after it was noted he had not had a bowel movement. 3.1-37(a)