Every finding on record at NHC Healthcare, Cookeville

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure a care plan intervention was in place after a fall for 1 resident (Resident #11) of 3 residents reviewed for accidents. The findings include:Review of the facility policy titled, .[FACILITY NAME] FALLS PROGRAM . undated, revealed .Initiate a falls care plan .Implement appropriate interventions .Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Difficulty in Walking, and History of Falling. Review of a Fall Scene Investigation Report dated 2/17/2026, revealed Resident #11 .Found on the floor .Attempting self-transfer .initial root cause(s) of the fall .confused .generalized weakness .Sent to ER [Emergency Room] .Upon return from hospital on 2/19 .fall intervention added .Ghost bed alarm .Review of a comprehensive care plan for Resident #11 dated 2/19/2026, revealed .At risk for falls .Ghost Bed/chair alarms .Every Shift .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of a Progress Note dated 6/13/2026, revealed .found on floor after a loud crash .laying on back with minor bleeding .three small open tears on the left occipital [back of head] .physician notified .bed alarm was removed from bed onto side shelf at time of fall .Review of a Fall Scene Investigation Report dated 6/13/2026, revealed Resident #11 .Lost strength/appeared to get weak .Self transferring from bed .Found on the floor .root cause(s) of the fall .needed to go to bathroom .interventions to prevent future falls .Educate CNA's on importance of making sure alarms are on . Review of ROOT CAUSE/ANALYSIS, undated, revealed .Educate CNAs on importance of making sure alarms are in place +[and] functioning appropriately .Review of a comprehensive care plan for Resident #11 revised 6/13/2026, revealed .Education provided to CNAs on importance of making sure alarms are in place and are functioning appropriately .During an interview on 6/16/2026 at 4:00 PM, Licensed Practical Nurse (LPN) A stated he had just started his shift when the CNA reported Resident #11 had fallen. LPN A stated alarm checkoff sheets had been signed, but at some time during the day the alarm was removed from the bed and .was on the right side on the shelf . when LPN A entered the room. During an interview on 6/17/2026 at 11:38 AM, with the Administrator and Director of Nursing (DON), the Administrator stated Resident #11's bed alarm should have been in place prior to Resident #11's fall but was not. The Administrator stated the housekeeper had removed the alarm to clean it, left it off to dry, and had not placed it back on the bed. The Administrator and DON confirmed the bed alarm was not in place on Resident #11's bed prior to her fall. The Administrator stated the facility identified it was a problem and educated all staff. During a telephone interview on 6/17/2026 at 12:02 PM, CNA B stated at the time of Resident #11's fall, she was at the nurse's station and heard a loud noise. She stated she went to the room and saw Resident #11 on the floor. CNA B further stated the bed alarm was on a table, not on the bed. CNA B confirmed she had been educated on making sure alarms are in place and working properly.

Based on medical record review, observations, and interviews, the facility failed to properly store refrigerated food items for 1 Resident (Resident #5) of 19 residents observed for a homelike environment related to food storage. The findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Stroke, Difficulty Swallowing, Kidney Disease, and Falls. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. Further review of the annual MDS assessment revealed Resident #5 was able to feed herself with staff set up and staff clean up assistance. During an observation on [DATE] at 11:20 AM, revealed Resident #5 was resting in her bed with her eyes closed. Further observation revealed two 4-ounce yogurts which were room temperature and unopened and located on the overbed table. During an interview on [DATE] at 2:37 PM, Certified Nursing Assistant A stated Resident #5 was able to feed herself and open tray items independently which included yogurt containers. During an observation on [DATE] at 7:30 AM, revealed Resident #5 was resting in her bed with her eyes open. Further observation revealed two 4-ounce yogurts which were room temperature and unopened and located on the overbed table. During an interview on [DATE] at 7:35 AM, Resident #5 stated the two 4-ounce yogurts were safe to consume. During an observation and interview on [DATE] at 7:40 AM, in Resident #5's room, Registered Nurse (RN) Supervisor confirmed the two 4-ounce yogurts were .expired . and available for resident use. During an interview on [DATE] at 7:50 AM, the Certified Dietary Manager (CDM) stated the 2 room temperature yogurts would not have hurt the resident if they were consumed. The CDM further stated the yogurt if left unrefrigerated may have a bad taste but would not have likely caused an upset stomach.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a person-centered comprehensive care plan related to hospice services for 1 resident (Resident #75) and for dental issues for 1 resident (Resident #85) of 19 residents reviewed for care plans. The findings include: Review of the facility's policy titled, SECTION VII: PATIENT CARE PLANS, dated 11/2023, revealed .services outlined in the comprehensive care plan meet .standards of quality .Problems are patient conditions .Care plans are updated as needed .New problems are handled as they arise .are to be added to the current care plan . Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Atrial Fibrillation, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #75 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the comprehensive care plan for Resident #75 initiated 1/1/2025, revealed the resident did not have a care plan for hospice services. Review of the Physician's Order Summary Report for Resident #75 dated 2/7/2025, revealed .HOSPICE TO EVAL AND TREAT . Review of a facility document titled, Hospice Plan of Care, for Resident #75 dated 2/8/2025, revealed .HOSPICE .CERTIFY THAT THE PATIENT HAS A TERMINAL DIAGNOSIS .PROGNOSIS IS SIX MONTHS OR LESS . Review of a Nurse's Note for Resident #75 dated 2/10/2025, revealed .Sig [significant] change MDS [assessment] set up for admit to hospice services . Review of the medical record revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Diabetes. Review of the comprehensive care plan for Resident #85 initiated on 8/30/2024, revealed the resident did not have a care plan for dental issues related to broken and missing teeth. Review of a quarterly MDS assessment dated [DATE], revealed Resident #85 scored a 13 on the BIMS assessment which indicated that the resident was cognitively intact. Review of the Physician's Order Summary Report for Resident #85 dated 2/10/2025, revealed .Penicillin [antibiotic medication] 500 mg [milligram] r/t [related to] broken tooth .Four Times A Day .Tramadol [pain relieving medication] .50 mg .Three Times A Day .PRN [as needed] . During an interview on 2/10/2025 at 11:16 AM, Resident #85 stated .I was eating breakfast this morning and tooth broke off and came out . Resident #85 stated .do not have any pain at present . During an interview on 2/11/2025 at 7:45 AM, Resident #85 stated .they are giving her some antibiotics and she has Tramadol for pain and is not in pain at this time . During an interview on 2/12/2025 at 7:30 AM, the Director of Nursing revealed the dentist was coming to the facility to evaluate Resident #85 on 2/13/2025. During an interview on 2/12/2025 at 9:25 AM, the Assistant Director of Nursing (ADON) revealed she was responsible for updating the residents' care plans. The ADON confirmed the care plan had not been developed to include hospice services for Resident #75 and dental issues to include broken with missing teeth for Resident #85.

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 3 residents (Residents #43, #47, and #69) of 11 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR), revised on 11/2016, revealed .Center should refer any patient for Level II resident review upon a significant change in status/ condition such as newly evident or possible serious mental disorder, intellectual disability or a related condition . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Dementia, Right Leg Fracture, and Insomnia. Review of a PASARR Level 1 screen outcome for Resident #43 dated 7/14/2023, revealed the resident had 1 mental health diagnosis which included Adjustment Disorder. Review of the medical record revealed Resident #43 was diagnosed with a new mental health condition of Delusional Disorder on 4/16/2024. Review of a quarterly Minimum Data Set (MDS) assessment for dated 9/3/2024, revealed Resident #43 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review of the quarterly MDS assessment revealed Resident #43 had psychiatric and mood conditions which included Anxiety Disorder, Depression, and Psychotic Disorder. Review of the medical record revealed Resident #43 was diagnosed with a new mental health condition of Major Depressive Disorder on 12/3/2024. Review of the medical record revealed Resident #43 was diagnosed with a new mental health condition of General Anxiety Disorder on 1/24/2025. Review of a Psychiatric Nurse Practitioner note for Resident #43 dated 1/24/2025, revealed the resident was seen for management of mental health conditions which included Anxiety, Depression, and Delusional Disorder. Review of the medical record revealed a new PASARR for Resident #43 was not submitted after the mental health diagnosses of Delusional Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, or Psychotic Disorder was added. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Dementia, Rib Fractures, Falls, and Heart Disease. Review of a PASARR Level 1 screen outcome for Resident #47 dated 3/24/2023, revealed the resident did not have a substance related abuse or dependency disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review of the quarterly MDS assessment revealed the resident received medications of high-risk drug classes which included Antipsychotic, Antidepressant, and Opioid. Review of the medical record revealed Resident #47 was diagnosed with 2 new mental health conditions of Psychoactive Substance Dependency and Opioid Dependency on 1/7/2025. Review of a Nurse Practitioner Note for Resident #47 dated 1/7/2025, revealed the resident was seen for management of mental health conditions which included Psychoactive Substance Dependency and Opioid Dependency. Review of the medical record revealed a new PASARR for Resident #47 was not submitted after the new mental health conditions of Psychoactive Substance Dependency and Opiod Dependency was added. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including Dementia, Senile Degeneration, Adult Failure to Thrive, and Kidney Disease. Review of a PASARR Level 1 screen outcome for Resident #69 dated 11/4/2022, revealed the resident did not have a mental health condition. Further review of the PASARR Level 1 screen outcome revealed the resident did not have a substance related abuse or dependency disorder. Review of the medical record revealed Resident #69 was diagnosed with a new mental health condition of Adjustment Disorder on 1/16/2023. Review of the medical record revealed Resident #69 was diagnosed with a new mental health condition of Delusional Disorder on 10/5/2023. Review of the medical record revealed Resident #69 was diagnosed with 2 new mental health conditions of Psychoactive Substance Dependency and Opioid Dependency on 8/6/2024. Review of a significant change MDS assessment dated [DATE], revealed Resident #69 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review of the significant change MDS revealed the resident had psychiatric and mood disorders which included Anxiety Disorder and Psychotic Disorder. The significant change MDS also revealed the resident received medications of high-risk drug classes which included Antianxiety and Opioid medications. Review of the medical record revealed Resident #69 was diagnosed with a new mental health condition of General Anxiety Disorder on 1/21/2025. Review of the medical record revealed a new PASARR for Resident #69 was not submitted after the new mental health diagnoses of Generalized Anxiety Disorder, Delusional Disorder, Psychoactive Substance Dependency, and Opiod Dependency was added. Review of a Nurse Practitioner Note for Resident #69 dated 1/25/2025, revealed the resident was seen for management of mental health conditions which included Adjustment Disorder, Delusional Disorder, Psychoactive Substance Dependency, Opioid Dependency, and General Anxiety Disorder. During a record review and interview on 2/11/2025 at 2:40 PM the Assistant Director of Nursing (ADON) stated the Level 1 screen outcomes which included Resident #43 dated 7/14/2023, Resident #47 dated 3/24/2023, and Resident #69 dated 11/14/2023 were the most recent referrals to the state designated PASARR agency. During further interview the ADON confirmed the facility failed to refer Resident #43, Resident #47, and Resident #69 to the state designated agency for PASARRS after identifying new mental health conditions.

Based on interview and observation, the facility failed to ensure refrigerated food was not expired. The facility failed to discard one bag of mild cheddar cheese. The facility census was 102. Findings include: During the initial tour of the kitchen on [DATE] at 10:55 AM, one bag, labeled mild cheddar cheese, revealed an opened date of [DATE] and an expiration date of [DATE]. During interview on [DATE] at 10:59 AM, the Dietary Director (DD) #1 confirmed the cheddar cheese had expired on [DATE] and should have been removed from the refrigerator and discarded. The DD #1 removed the cheddar cheese from the refrigerator and placed it into a kitchen trash can. During interview on [DATE] at 11:10 AM, the Administrator was informed of the expired mild cheddar cheese located in the kitchen refrigerator and confirmed the expired mild cheddar cheese should have been discarded and removed from the refrigerator.

Based on facility policy review, medical record review and interview, the facility failed to treat 1 resident (Resident #1) of 5 residents reviewed, with dignity and respect when a LPN (Licensed Practical Nurse) #2 compared Resident #1 to a baby on 4/25/2021. The findings include: Review of the facility policy titled PATIENT'S RIGHTS R (Revised) 2/2021, revealed .At [named facility] we support the patient/resident's right's right to live in an environment which is individualized for them. We strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services, by honoring and supporting each patient/resident's preferences, choices, values and beliefs .We will strive to create a health promotion environment supporting the adoption of attitudes that contribute to positive well-being . Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored 99 on the Brief Interview for Mental Status (BIMS) indicating the resident was unable to complete the interview. Continued review revealed Resident #1 was severely impaired related to Cognitive Skills for Daily Decision Making. Further review showed Resident #1 required extensive assistance with a 2-person physical assist for the following: bed mobility, transfers, walk in room, walk in corridor, and toilet use. Further review revealed Resident #1 required extensive assistance with a 1-person physical assistance for the following: locomotion on unit, dressing and personal hygiene. Continued review revealed Resident #1 required total assistance for locomotion of unit and bathing. Review of Resident #1's care plan revealed Resident #1 was assessed for .Nutrition/Hydration/Dental . with interventions which included .KEEP BEDSIDE TABLE AT THE BEDSIDE OR CHAIRSIDE AT ALL TIMES WITH BOTTLED WATER WITHIN REACH OF PATIENT .Family brings bottled water, provide 2 bottles of water on bedside table (BST) open and reclose to make easier for resident to manage. When notice one is empty, please replace . Continued review revealed Resident #1 was also assessed for .Mood State, [CONDITION(S)] Drug Use, Cognitive/Loss Dementia, Diabetes, Constipation/GI (gastrointestinal) complications r/t (related to) hx (history) of constipation, cardiac complications, bowel and bladder/toileting/incontinence, At risk for infection r/t hx of utis (urinary tract infection), ADL (activity of daily living) Functional/Rehabilitation Potential, Falls, Communication/vision/hearing, skin integrity, pain, Advanced Directive, Physician Orders, PASRR (Preadmission Screening and Resident Review) and Patient Data . Further review revealed Resident #1 had appropriate interventions in place. During an interview on 6/7/2021 at 11:08 AM with the Director of Social Services, she stated the family reported they (family) did not want [named LPN] LPN #3 and [named LPN] LPN #2 taking care of their mother. During continued interview the Director of Social Services stated the family didn't like the term babies used on patients. It is personal to the family. During an interview on 6/7/2021 at 4:15 PM, LPN #2 stated I never had but one interaction with them, that is when I went with [named housekeeping supervisor] from housekeeping, to [named resident] Resident #1's room when they (family) brought in their own cleaning products. During continued interview LPN #2 confirmed her statement to the family this is what I tried to say to her (Resident #1's daughter), they (the residents) are like great big babies. During an interview on 4/25/2021 at 6:35 PM, the housekeeping supervisor stated there was some agitation in that room, that was for sure. During continued interview the housekeeping supervisor stated whatever was going on, I don't know the full scope, they were upset with nursing. During further interview the housekeeping supervisor stated he did not think [named resident] Resident #1's room smelled like urine, I thought there was a bleach smell. During continued interview the housekeeping supervisor stated LPN #2 was not rude, I think it was a poor choice of words. During further interview he stated LPN #2 said I'm here to take care of the babies and your mom is one of my babies. During continued interview he stated [named lpn] LPN #2 didn't say it in an aggressive way. During an interview on 6/7/2021 at 6:56 PM, the Administrator stated, [named Resident #1's daughter] told him [named lpn] LPN #2 had referred to the residents as her babies. During continued interview the Administrator confirmed it is a dignity issue. Labels rarely work out well.

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure devices utilized to prevent falls were implemented for 1 resident (Resident #1) of 3 residents reviewed for falls. The findings include: Review of the facility policy, Falls Program dated 11/25/2019, showed .Identify residents at risk for falling .implement .appropriate interventions .reduce .resident's risk of falling . Review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 8/18/2020, showed a plan of care developed to address falls which included chair and seat belt alarm. Review of Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 utilized chair alarm. Review of the facility's Safety Events-Fall report dated 9/13/2020, showed .slid from wheelchair to the floor . The fall was unwitnessed. Resident #1 stated .I slid out of my chair onto the floor . No injury noted. Adaptive equipment not in use at the time of the fall. During an interview with Nurse #2 on 10/27/2020 at 10:39 AM, showed Resident #1 had a fall on 9/13/2020. Alarm was not used at the time of the fall. The Resident was care planned for chair alarm. During an interview with Nurse #1 on 10/27/2020 at 1:50 PM, showed during the investigation of the fall on 9/13/2020, the Certified Nursing Assistant's (CNA's) had switched chairs for more comfort the alarm was left off by accident. During an interview with the Director of Nursing (DON) on 10/27/2020 at 2:37 PM, confirmed the CNA's changed chairs for resident comfort and failed to replace the alarm when they changed chairs. She confirmed the nursing staff did not utilize the chair alarm when Resident #1 fell on [DATE].

Based on facility policy review, record review, observation, and interview the facility failed to follow infection control practices for 2 residents (#34 and #125) of 3 residents in isolation precautions of 18 sampled residents. The findings include: Review of the facility policy Transmission-Based Procedures revised date 11-2019 showed .Enhanced Barrier Precautions .In addition to Standard Precautions, use Enhanced Barrier Precautions (EBP) during high-contact patient care activities .EBP expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated .Equipment .Appropriate Contact Precautions sign on door . Record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident plan of care dated 1/31/2020 showed .enhanced barrier percation (precaution) in place . Review of the physician's order dated 2/1/2020 showed .enhanced barrier precautions r/t (related to) ESBL (Extended Spectrum Beta-Lactamase) in the urine . Observation on 2/3/2020 at 11:40 AM, on the 400 hall, showed no isolation sign on Resident #34's door to indicate the resident was in isolation. Interview with Licensed Practical Nurse (LPN) #2 on 2/3/2020 at 11:40 AM, on the 400 hall, confirmed that Resident #34 was on enhanced barrier precautions for ESBL in the urine and an isolation sign had not been posted on the resident's door. Record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident plan of care revised date 2/3/2020 showed .pt (patient) on enhanced barrier precautions related to lice on scalp . Observation on 2/3/2020 at 9:30 AM, on the 100 hall, showed no isolation sign on Resident #125's door to indicate the resident was in isolation. This surveyor entered the resident's room and was thereafter verbally informed by a staff member that an isolation room had been entered. Interview with LPN #1 on 2/3/2020 at 11:35 AM, on the 100 hall, confirmed the resident was on isolation for head lice and an isolation sign had not been posted on Resident #125's door. Interview with the Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room, confirmed the facility had not posted isolation signs for Residents #34 and #125.

Based on review of facility policy, observation, and interview the facility failed to maintain a sanitary kitchen evidenced by improperly storing the flour scoop, undated food items in dry food storage, and open to air items in 1 of 1 walk in freezers, potentially affecting 85 residents. The findings include: Review of the facility policy Dry Storage, revised 11/2017, revealed .Scoops should be stored in a sanitary method with handles of scoops not contacting food . Review of the facility policy Refrigerator and Freezer Storage, revised 11/2017, revealed .Refrigerated and frozen foods will be stored properly for optimal product safety . Observation and interview with the Director of Dietary Services (DDS) on 2/4/19 at 10:05 AM, of the flour bin, in the kitchen, revealed the flour scoop improperly stored with the scoop placed inside the bin and resting on top of the flour. Continued interview confirmed .it was touching the flour . Further interview confirmed the facility failed to properly store the flour scoop. Observation and interview with the DDS on 2/4/19 at 11:20 AM, of the dry storage, in the kitchen, revealed an undated 21lb. (pound) bag of corn flakes, half used, an undated 21 lb. bag of bran flakes, half used, an undated 21 lb. bag of fruit wheels, a quarter used, an undated 21 lb. bag of frosted flakes, three-quarters used, and an undated 32 ounce bag of flake coconut, half used. Continued interview confirmed the facility failed to properly store dry food items available for resident consumption. Observation and interview with the DDS on 2/4/19 at 11:31 AM, of the walk in freezer, outside the kitchen, revealed an undated 30 lb. bag of winter vegetables, in a large plastic bag inside a cardboard box, open to air. Further observation revealed an undated 30 lb. bag of vegetable stew, in a large plastic bag inside a cardboard box, open to air. Continued interview confirmed the facility failed to properly store frozen food items available for resident use.

Based on facility policy review, medical record review, and interview, the facility failed to provide a rationale in response to pharmacy recommendations for 1 resident (#53) of 5 residents reviewed for unnecessary medications, of 36 sampled residents. The findings include: Review of the facility policy Consultant Pharmacist Reports, dated 6/2016, revealed .Recommendations are acted upon and documented by .the prescriber. 1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Medical record review revealed Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's quarterly Minimum (MDS) data set [DATE] revealed Resident #53 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 7/23/18 revealed .Patient has continued on current dose of [MEDICATION NAME] (a medication used to treat anxiety) since 4/2018. Please evaluate risks vs (versus) benefits of current dose and consider reduction. If a reduction is not indicated, please document reasoning below .Recommend: Discontinue [MEDICATION NAME] 7.5 mg (milligrams) bid (twice daily). Start [MEDICATION NAME] 3.75 mg po (by mouth) qam (every morning) and 7.5 mg po qpm (every evening) . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale read .DO NOT D/C (discontinue) . Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 8/17/18 revealed .Consider drawling labs to evaluate benefits vs risks of [MEDICATION NAME] (a medication used to treat high cholestral) in this patient .Recommend: Order lipid panel and liver function tests . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale was left blank. Interview with Assistant Director of Nursing on 2/06/19 at 7:35 AM, in the conference room, confirmed .They don't always fill out the form . Continued interview confirmed the facility failed to obtain a Physician's rationale in response to the Pharmacist's recommendations dated 7/23/18 and 8/17/18.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide activities based on the resident's preferences for 2 residents (#88, #85) of 5 residents reviewed for activities, of 25 residents reviewed. The findings included: Review of the facility policy Group Activities revised 9/1/14 revealed .activities should be suited to the needs, abilities, and interests of patients . Medical record review revealed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Staff Assessment of Daily Activity Preferences dated 10/23/16 revealed .Listening to music yes-all music .Keeping up with the news yes on TV .Spending time outdoors yes, sometimes when weather is nice . Medical record review of the Recreation Assessment Report dated 10/24/16 revealed Plan for involvement . individual 1 on 1 . staff will try talking to her, doing her nails, and grooming her .while here she enjoys watching out her window listening to music, visiting with her daughter, listening to tv and sometimes getting her nails done. staff will offer 1 on 1 visits and offer to help groom and do her nails . Medical record review of the Recreation Notes dated 1/26/17 revealed .Quarterly Note .Pt (Patient) enjoys snacks, listening to music, one-on-one visits, and family visits . Medical record review of the October 2016 Activity Calendar revealed the resident was provided 2 activities (Visitors) out of 31 days. Medical record review of the November 2016 Activity Calendar revealed the resident was provided 3 activities (talking/reminiscing, TV, Visitors) out of 28 days. Medical record review of the December 2016 Activity Calendar revealed the resident was provided 2 activities (singing, visitors) out of 31 days. Medical record review of the January 2017 Activity Calendar revealed the resident was provided 2 activities (visitors) out of 31 days. Medical record review of the February 2017 Activity Calendar revealed no documentation the resident was provided any activities. Observation on 3/14/17 at 1:45 PM and 3:30 PM revealed the resident lying in bed. Continued observation revealed the TV was not on and there was no music playing. Observation on 3/15/17 at 7:25 AM revealed the resident seated in a reclining back wc (wheelchair) in the resident's room. Continued observation revealed no TV or music on, and fingernails not painted. Observation on 3/15/17 at 1:00 PM revealed the resident seated in a reclining back wc in the resident's room with the TV on a soap opera program. Interview with the Recreation Director on 3/15/17 at 8:30 AM in the conference room confirmed the facility had not provided Resident #88 activities based on the resident's preferences. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 99 (resident unable to complete interview, indicating severe cognitive impairment), behaviors included physical (occurred 1 to 3 times), other behavioral symptoms not directed at others (occurred 4 to 6 days but less than daily), and required extensive assistance for completion of Activities of Daily Living. Medical record review of the Recreation Plan of Care dated 4/22/16 and Updated/Reviewed on 1/16/17 through 4/16/17 revealed .Pt (patient) may need one-on-one .or materials to support independent recreation or to provide social stimulation and opportunity for recreation participation .one-on-one visits 2 times per week . volunteers with similar interests/hobbies . Medical record review of the monthly 1:1 Independent Activity Participation Log revealed the following documentation: 11/2016: 5 activities 12/2016: 5 activities 1/2017: 1 activity 2/2017: 3 activities 3/2017: 2 activities Further review revealed the activities included talking/reminiscing, pet visits, TV, newspapers/delivered/read, and 1 attendance of a singing group. Observation of Resident #85 on 3/15/17 at various times of the day in the resident's room revealed the resident in the bed, the TV on with the remote not in reach of the resident. Interview with the Recreation Director on 3/15/17 at 9:50 AM, in the Conference Room confirmed personalized preferences for 1 on 1 activities had not been done for Resident #85 .haven't had time .I'm weak on documenting 1 on 1 activities . Continued interview confirmed Resident #85 did not receive the newspaper but she said hello to him when she delivered the newspaper to his roommate. Further interview confirmed it is her responsibility to plan, coordinate, and document individual activities for the residents. Interview with the Administrator on 3/15/17 at 12:35 PM, in the Conference Room confirmed the facility failed to provide personalized 1 on 1 activities twice a week for Resident #85.

Based on facility policy review, observation, and interview, the facility failed to ensure pans used to serve food for the residents were dry when stored, ensure the mixer and food preparation areas used to prepare food for the residents were clean, ensure scoops in food bins were not stored in the food, and failed to ensure 1 of 3 ice machines in use for the residents was clean and sanitary. The findings included: Review of facility policy Safety & Sanitation Best Practice Guidelines revised 1/2011 revealed, .Air-dry all items. Make sure all items are completely dry before stacking to prevent wet-nesting . Observation on 3/7/16, at 8:45 AM, of the facility kitchen area with the Nutritionist revealed: 4 of 4 6 inch pans stored wet; 2 of 3 1/2 pans stored wet; debris on the mixer/beater and cage; the drawer in the food preparation table had food crumbs with the spoons and ladles used to serve food for the residents; the shelf below the food preparation table was wet and had whitish debris; and the cornmeal and sugar bins had scoops lying in the food. Interview with the Nutritionist on 3/7/16 at 9:10 AM, in the kitchen confirmed the facility failed to ensure equipment and utensils used to prepare and serve food for the residents was sanitary. Observation and interview with Registered Nurse #1, of the ice machine in the 100 hallway Hydration room on 3/7/16, at 9:30 AM, confirmed the ice machine had brown/black debris on the inside right side wall. Observation and interview with Licensed Practical Nurse #2 of the ice machine in the 100 hallway Hydration room on 3/9/16, at 11:15 AM, confirmed the ice machine had brown/black debris on the inside right side wall. Interview with the Administrator on 3/9/16, at 11:25 AM, outside of the conference room, revealed the ice machines are .cleaned semi-annually due to they grow algae maybe we need to do it more often .

Based on observation, facility policy review, review of manufacturer's recommendations, and interview, the facility failed to ensure dishes and utensils were cleaned under sanitary conditions in the dietary department. The findings included: Observation on March 10, 2015, at 8:41 a.m., in the kitchen, revealed dietary employee #1 washed kitchen utensils using the three compartment sink. Continued observation revealed the dietary employee washed a large skillet, food scoop, and two quarter pans by dipping the kitchen items in the chemical sanitizer and then immediately placing them on a rack. Review of the facility policy Chemical Sanitizing, revised January 2011, revealed "...4. Chemical sanitizing may be accomplished...by immersing a clean object in a specific concentration of sanitizing solution for a required period of contact time..." Review of the chemical product manufacturer's recommendations and interview with the dietary manager on March 10, 2015, at 3:56 p.m., in the dietary office, confirmed a 1 minute contact time was needed for chemical sanitizing, and the facility policy and manufacturer's recommendations were not followed for chemical sanitizing.

Based on medical record review and interview, the facility failed to revise a care plan for one resident (#134) of thirty sampled residents. The findings included: Resident #134 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory report dated March 8, 2015, revealed, "Specimen: Stool...Report Final: 03/08/2015 (7:29 p.m.)...C. diff ([MEDICAL CONDITION])...positive." Medical record review of a physician's orders [REDACTED]." Medical record review of a physician's orders [REDACTED]." Medical record review of the resident's current care plan, effective through March 19, 2015, revealed no documentation regarding infectious disease and/or isolation. Interview with the Assistant Director of Nursing (ADON) on March 10, 2015, at 3:12 p.m, at the 400 wing nurse's station, revealed the ADON was responsible for revising the resident's care plan. Continued interview confirmed the facility failed to revise the care plan to address the resident's infectious disease and isolation.

Based on medical record review, review of facility investigation, observation, and interview, the facility failed to ensure staff transferred a resident in a manner to prevent accidents for one resident (#11) of three residents reviewed for accidents. The facility's failure to transfer the resident according to the resident's assessment resulted in harm to resident #11. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the ADL 31 Day Look-back dated August 30 through September 30, 2013, revealed the resident required one to two persons for transfers. Medical record review of the Monthly Nursing Summary Report dated September 3, 2013, revealed, "...Current Modes of Transfer: Lifted manually Lifted mechanically..." Medical record review of the Minimum Data Set (MDS) Significant Change dated September 23, 2013, revealed the resident required extensive assistance of two persons for transfers. Medical record review of the nurse's notes for September 2013, revealed, "9/4/13 1:55 p (p.m.) (up) dly (daily) in rock-n-go w/c (wheelchair). Requires ext (extensive) assist (assistance) (with) locomotion. Non-amb (non-ambulatory), 0 (no) walking occurred in room/corridor. Requires ext. assist (with) ADLs (Activities of Daily Living)...Requires ext assist (with) meals...9/18/13 @ (at) 6:48 p (p.m.)...Assist x 2 (two people) for transfers...9/25/13 11:15 A (up) dly in rock-n-go w.c. Requires ext assist (with) locomotion. Non-amb. Ext assist (with) ADL's...Requires ext assist (with) meals..." Review of an Investigation of Incident dated September 28, 2013, revealed, at 7:25 p.m., the resident received a cut to the left lower leg during a transfer in the resident's room. Further review of the investigation revealed the Certified Nursing Assistant (CNA) was transferring the resident from the chair to the bed. Continued review of the investigation revealed the question, "...How much assistance does the patient require in transfer?..." with the response, "...2 person or mechanical lift..." Further review of the investigation revealed one CNA was transferring the resident. Review of a statement written by CNA #3 dated September 28, 2013, revealed, "...When I transferred...(named resident #11) from...wheelchair to...bed...became combative with me while holding...When I laid...down I noticed blood on my gloves and arm. That is when I realized the skin tear on...left leg. It had gotten caught on the bottom of...bed rail..." Review of a statement written by CNA #4 dated September 28, 2013, revealed, "...When I was getting my resident ready for bed I heard my coworker, (named CNA #3), saying that...has blood on...gloves and arm. I came around the corner to see if I could help. That's when I noticed the skin tear on...left leg. I asked...how...did...get that skin tear...said it had gotten caught on the bottom part of the rail. After that we went and got the nurse..." Review of the Emergency Department (ED) report dated September 28, 2013, revealed the resident presented to the ED by ambulance with complaints of leg injury. Continued review of the ED record revealed, "...EMS (Emergency Medical Services) state resident was being moved...skin became caught on a foreign object, and was subsequently torn. The resident presents with a laceration 9 cm (centimeters), clean, irregular L shaped tear on anterolateral leg...Positive for laceration, pain, of the lateral aspect of the left calf, 10 cm laceration in L shape on lateral leg..." Continued review of the ED record Physician Documentation revealed, "...noted in the lateral aspect of left calf: laceration 8 cm laceration in "L" pattern, L (left) anterolateral leg..." Further review of the ED record revealed, wound repair of "...8 cm full thickness laceration to lateral aspect of calf, irregularly shaped. Wound cleansed, irrigated, and explored. Subcutaneous tissue closed with 7 sutures and skin closed with 8 sutures..." Review of a staff in-service Transfers and Mechanical Lifts dated October 1, 2013, revealed, "Every Resident under your care must be transferred as care planned no exceptions. If your resident is a two person transfer you must have two people to transfer this resident every time. All Manual Transfers require the use of a gait belt, no exceptions. If your resident requires the use of a lift for transfers you must use the appropriate lift to transfer this resident every time...Improper transferring of the resident can and does cause serious injury to our residents..." Observation of the resident on January 23, 2014, at 8:30 a.m., in the resident's room, revealed the resident seated in a chair with the lower bars padded. Continued observation revealed the resident did not respond to questions. Observation of the resident on January 23, 2014, at 11:10 a.m., revealed the CNA taking the resident to the bathroom, cleaning the resident, and taking the resident to lunch. Interview with CNA #1 on January 24, 2013, at 1:30 p.m., at the 300/400 hall nursing station, revealed staff used a stand-up lift or two people to transfer the resident. Continued interview with CNA #1 revealed two people were usually present even if the lift was used. Interview with CNA #2 on January 23, 2014, at 4:15 p.m., at the 300/400 hall nursing station, revealed the resident was transferred with two people or using a lift. Continued interview with CNA #2 revealed staff used the lift more often since the resident can become combative with transfers. Interview with the Director of Nursing (DON) on January 23, 2014, at 9:40 a.m., in the conference room, revealed in-services were begun the day of the incident on September 28, 2013, for all staff regarding Transfers and Mechanical Lifts. Further interview confirmed when the resident sustained [REDACTED]. c/o #

Based on observation and interview, the facility dietary department failed to prevent cross contamination while processing the dishes in the dish room. The findings included: Observation and interview with the morning cook on January 21, 2014, at 9:35 a.m., in the dietary department dish room, revealed the dish machine was in operation. Further observation revealed the dietary staff member operating the dish machine pushed a rack containing dirty dishes into the rack of clean dishes inside the dish machine in two consecutive operations of the dish machine, thereby cross contaminating the cleaned dishes. Further interview with the cook confirmed the dietary staff member failed to properly process the dishes by having the dirty dishes come in contact with the clean dishes.

Based on medical record review and interview, the facility failed to maintain a complete medical record for one resident (#78) of thirty residents reviewed. The findings included: Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed the last monthly recapitulation orders signed by the physician were dated October 2 and 3, 2013. Interview with the Assistant Director of Nursing on January 21, 2014, at 2:10 p.m., at the 300/400 hall nursing station, confirmed the record for resident #78 did not contain current monthly recapitulation orders signed by the physician. Interview with the Director of Nursing, on January 21, 2014, at 2:50 p.m., in the conference room, confirmed the facility failed to have current physician orders [REDACTED].

Based on observation and interview, the facility failed to ensure expired items were discarded and food items were correctly labeled in two of two medication rooms observed. The findings included: Observation of the medication room for the ,[DATE] hall on [DATE], at 1:50 p.m., revealed a 1000 ml (milliliter) container of Glucerna 1.5 calories (used for tube feedings) sitting on the shelf next to other containers of tube feeding. Continued observation revealed the container had 600 ml remaining in it but there was no resident name on it nor was there a date when the container was opened. Interview with LPN (Licensed Practical Nurse) #1 on [DATE], at 2:00 p.m., in the medication room, confirmed the container of tube feeding was undated, unlabeled, and available for resident use. Observation of the medication room for the ,[DATE] hall on [DATE], at 2:15 p.m., revealed a partial bottle of wine in the refrigerator used for resident nutrition. Continued observation of the refrigerator revealed there was no name on the bottle nor was there a date when it was opened. Interview with LPN #2 on [DATE], at 2:40 p.m., in the medication room, confirmed the wine bottle belonged to one of the residents but it was not labeled with the resident's name or the date of opening.

Based on medical record review, review of facility investigation reports, observation, and interview, the facility failed to revise the care plan following a resident incident for one resident (#11) and for current medication interventions for one resident (#19) of thirty residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) Significant Change dated September 23, 2013, revealed the resident required extensive assistance of two persons for transfers, bathing, dressing, grooming, and toileting; required extensive assistance of one person for eating; was always continent of bowel and frequently incontinent of bladder. Review of the facility's investigation dated September 28, 2013, revealed at 7:25 p.m., the resident received a "cut" to the left lower leg during a transfer in the resident's room. Further review of the facility's investigation documentation revealed the Certified Nursing Assistant (CNA) was transferring the resident from the chair to the bed. Continued review of the facility's investigation documentation revealed the question, "...How much assistance does the patient require in transfer?..." with the response, "...2 person or mechanical lift..." Medical record review of the Quarterly MDS dated [DATE], revealed the resident required extensive assistance of two people for bathing, dressing, grooming, transfers, and toileting; extensive assistance of one person for eating; was always incontinent of bowel and frequently incontinent of bladder. Medical record review of the care plan dated October 3, 2013, and revised on December 31, 2013, revealed no documentation of the amount and type of assistance the resident required with transfers and Activities of Daily Living. Continued medical record review of the care plan revealed no documentation the front lower bars on the wheelchair were to be padded and wrapped with ace wraps. Further medical record review of the care plan revealed no documentation the side rails were removed from the bed and were not to be reapplied. Observation of the resident on January 23, 2014, at 1:25 p.m., in the resident's room, revealed the resident was sitting in a rock-n-go chair with an alarm in place, support bars on the bilateral from wheelchair bars were wrapped with cotton batting and covered with wraps. Observation of the resident's bed revealed the bed rails had been removed from the bed. Interview with CNA #1 on January 23, 2014, at 2:10 p.m., at the 400 hall nursing station, confirmed the resident required use of a stand-up lift or two people for transfers, the side rails were removed from the bed after the accident, and the wheelchair front bars were padded to prevent skin injuries. Interview with the Director of Nursing (DON) on January 23, 2014, at 9:40 a.m., in the conference room, confirmed the care plan did not address the assistance required for transfers nor the fact the wheelchair bars were to remain padded. Resident #19 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Clinical Pharmacy Review dated September 3, 2013, revealed the resident had been readmitted with physician's orders [REDACTED]. Review of the Physicians Recapitulation Orders dated January 2014, revealed, the resident received [MEDICATION NAME] and [MEDICATION NAME] daily. Review of the Care Plan dated November 5, 2013, revealed care plan interventions for [MEDICATION NAME] (antidepressant) and no interventions for [MEDICATION NAME] or [MEDICATION NAME]. Interview with the Assistant Director of Nursing on January 23, 2014, at 9:40 a.m., at the 100/200 hall nurse's station, confirmed the care plan had not been revised to reflect the resident's current medication regimen. COMPLAINT #

Based on review of the CFR Title 42, Volumn 3, PART 483 Requirements for States and Long Term Care Facilities (Nurse Aide Training Programs) and interview, the facility failed to ensure no nurse aide was charged for any portion of the program. The findings included: Review of the Requirements for States and Long Term Care (LTC) Nurse Aide Training Requirements revealed, "...Sec.483.152(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program..." Interviews with three Nurse Aide Trainees (NAT) currently enrolled in the NAT class provided by the facility on January 23, 2014, from 10:05 a.m., to 10:10 a.m., in the conference room, revealed each trainee had been required to pay $225.00 for class materials and training. Interview with the Staff Education Coordinator on January 23, 2014, at 10:10 a.m., in the Staff Education Coordinator's office, confirmed the NAT students were not employed during the training, and the charge for the class was $225.00 for the training and materials. Continued interview confirmed the Staff Education Coordinator had no knowledge of persons who had been hired by the facility after completing the class being reimbursed for the cost of the class. Interview with NAT #1 on January 23, 2014, at 10:40 a.m., in the conference room, confirmed the nurse aide had been enrolled in the class that started October 7, 2013, and was hired by the facility on October 30, 2013. Continued interview confirmed NAT #1 had not been reimbursed by the facility for the NAT class. Interview with the Administrator in the Administrator's office on January 23, 2014, at 10:45 a.m., confirmed the facility had not reimbursed nurse aides for the cost of the class after the nurse aides completed the class and were employed by the facility.