Every finding on record at NHC Healthcare, Oak Ridge

Based on facility policy review, facility document review, medical record review, observation, and interview, the facility failed to follow the facility's policy related to fluid restrictions for 3 residents (Resident#2, Resident#7, and Resident#23) of 5 residents reviewed for fluid restrictions.The findings include: Review of the facility's policy titled, FNS [Food Nutrition Services] Fluid Restriction Distribution Best Practice, undated, revealed .distribute fluid when a resident has an order for the fluid to be restricted .fluid restrictions order is entered .nursing should go to the Diet Order and to see if there is a Special Instruction note related to the fluid restriction . Review of the facility's document titled, FNS [food nutrition services] Fluid Restriction Distribution Best Practice, undated, revealed .The purpose of this guideline is to recommend how to best distribute fluid when a resident has an order for the fluid to be restricted .Fluid Restriction Orders .Fluid Restrictions are written as .Total volume in ml's (milliliters); fluid to be used by nursing shift for med [medication] passes; fluid to be provided by FNS .The Recommended Baseline Fluid Restriction Distribution is .[fluid restriction of] 1000 [ml] .Nursing Total .280 [ml per 24 hours] .140 [ml per 12 hour shift] .[fluid restriction of] 1500 [ml] .Nursing Total .300 [ml per 24 hours] .150 [ml per 12 hour shift] .[fluid restriction of] 1800 [ml] .Nursing Total .360 [ml per 24 hours] .180 ml [per 12 hour shift] . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Chronic Stage 5 Kidney Disease and Chronic Congestive Heart Failure. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 99 on the Brief Interview for Mental Status (BIMS) assessment which indicated the interview was unable to be completed. Review of the Comprehensive Care Plan dated 2/10/2026, revealed .end stage renal disease requiring dialysis .report s/s [signs and symptoms] of fluid deficits . Review of the Physician's Order for Resident #2 dated 1/27/2026, revealed .1000 fluid restriction (280 ml [milliliter] from nsg [Nursing] .720 ml from FNS [food and nutrition services]) daily .no bedside water pitcher . Review of the electronic Medication Administration Record (e-MAR) for Resident #2 dated 2/1/2026 – 2/19/2026, revealed .1000 fluid restriction every day . Further review revealed no documentation which indicated how much fluid nursing staff was to administer each shift (7:00 AM-7:00 PM and 7:00 PM-7:00 AM) or how much fluid had been administered to the resident. During an interview on 2/19/2026, at 2:10 PM, Licensed Practical Nurse (LPN) B stated Resident #2 had a fluid restriction of 1000 ml daily and nursing administered 300 ml each shift. LPN B confirmed she administered 300 ml when she worked (7:00 AM-7:00 PM). Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Kidney Disease, and Congestive Heart Failure. Review of the Comprehensive Care Plan dated 12/01/2025, revealed .Nutritional Status .Diet . 1800 fluid restriction: FNS 1440 ml, Nursing 360 ml, No bedside pitcher . Review of the 5-day admission MDS assessment dated [DATE], revealed Resident #7 scored a 15 on the Brief Interview for BIMS assessment which indicated the resident was cognitively intact. Review of e-MAR dated 2/2026, revealed Resident #7 had no documentation of how much fluid the resident had received in a 24-hour period. Review of the Physician's Order for Resident #7 dated 2/19/2026, revealed Resident #7, .Dietary .2/19/2026-Special Instructions .1800 Fluid Restriction .no bedside water pitcher . Review of a Nursing Progress notes for Resident #7 dated 1/17/2026- 2/17/2026, revealed no documentation of fluid overload or hospitalization. During a medical record review and interview on 2/19/2026 at 9:24 AM, Registered Nurse (RN) A stated if a resident was on fluid restriction, a physician order was obtained and the order was reflected on the e-MAR. RN A reviewed the e-MAR for Resident #7 and stated the resident was not on fluid restrictions (was not reflected on the e-MAR). During an interview on 2/19/2026 at 9:30 AM, LPN C confirmed Resident #7's fluid restriction was not reflected on the e-MAR. During an interview on 2/19/2026 at 10:02 AM, the Regional Dietician (RD) stated when a resident had a Physician's Order for a fluid restriction, dietary provided a certain amount of fluids and nursing provided a certain amount of fluids. The dietary department followed the recommended Baseline Fluid Restriction Distribution form. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease with Heart Failure, Chronic Diastolic (Congestive) Heart Failure, Stage 3 Chronic Kidney Disease, and Type 2 Diabetes Mellitus. Review of a Scheduled 5 Day MDS assessment dated [DATE], revealed Resident #23 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment and was dependent with eating. Review of the Comprehensive Care Plan dated 2/18/2026, revealed .1500ml Fluid restriction (300ml NSG [nursing], 1200ml FNS); no bedside water pitcher due to fluid restriction . Review of the Physician's Order for Resident #23 dated 2/18/2026, revealed .Fluid .1500ml daily of fluid provided to patient .(300ml NSG, 1200ml FNS) . Review of the e-MAR for Resident #23 dated 2/4/2026-2/18/2026, revealed the resident's fluid intake was documented as follows: 2/4/2026 7:00 AM-7:00 PM-800 ml 2/4/2026 7:00 PM-7:00 AM-800 ml 2/5/2026 7:00 AM-7:00 PM-300 ml 2/5/2026 7:00 PM-7:00 AM-800 ml 2/6/2026 7:00 AM-7:00 PM-300 ml 2/6/2026 7:00 PM-7:00 AM-200 ml 2/7/2026 7:00 AM-7:00 PM-300 ml 2/7/2026 7:00 PM-7:00 AM-200 ml 2/8/2026 7:00 AM-7:00 PM-300 ml 2/8/2026 7:00 PM-7:00 AM-200 ml 2/9/2026 7:00 AM-7:00 PM-300 ml 2/9/2026 7:00 PM-7:00 AM-200 ml 2/10/2026 7:00 AM-7:00 PM-300 ml 2/10/2026 7:00 PM-7:00 AM-300 ml 2/11/2026 7:00 AM-7:00 PM-300 ml 2/11/2026 7:00 PM-7:00 AM-240 ml 2/12/2026 7:00 AM-7:00 PM-300 ml 2/12/2026 7:00 PM-7:00 AM-200 ml 2/13/2026 7:00 AM-7:00 PM-300 ml 2/13/2026 7:00 PM-7:00 AM-500 ml 2/14/2026 7:00 AM-7:00 PM-300 ml 2/14/2026 7:00 PM-7:00 AM-300 ml 2/15/2026 7:00 AM-7:00 PM-300 ml 2/15/2026 7:00 PM-7:00 AM-240 ml 2/16/2026 7:00 AM-7:00 PM-240 ml 2/16/2026 7:00 PM-7:00 AM-300 ml 2/17/2026 7:00 AM-7:00 PM-300 ml 2/17/2026 7:00 PM-7:00 AM-300 ml 2/18/2026 7:00 AM-7:00 PM-300 ml 2/18/2026 7:00 PM-7:00 AM-350 ml During an interview on 2/19/2026 at 10:10 AM, LPN C stated Resident #23 returned from the hospital on 2/2/2026, and fluid restrictions were ordered on 2/4/2026. Review of Nursing Progress Notes for Resident #23 dated 2/2/2026-2/19/2026, revealed Resident #23 had not been hospitalized since return on 2/2/2026. During an interview on 2/19/2026 at 2:33 PM, the Director of Nursing confirmed the facility did not follow the fluid restriction policy. During an interview on 2/19/2026 at 2:45 PM, the Medical Director (MD) stated if a resident had a Physician's Order for fluid restrictions, he expected the orders to be followed. The MD also stated Residents #2, #7, and #23 were not harmed due to the facility not following Physician Orders for fluid restrictions.

Based on facility policy review, observation and interview, the facility failed to ensure proper infection control practices during the medication administration for 2 residents (Resident #33 and Resident #34) of 4 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Medication Administration, dated 2/25/2025, revealed .medications are administered as prescribed in accordance with good nursing principles and practices .the person administering medications adheres to good hand hygiene .gloves must be worn to prevent touching tablets . Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Hypertensive Heart Disease, Dementia, and Generalized Anxiety Disorder. Review of the current physician's recapitulation orders for Resident #32 revealed, .Eliquis [medication to thin blood] 5 mg [milligram] .twice a day .Risperidone [antipsychotic medication] 0.5 mg .once a day .Lexapro [medication for depression]10mg .once a day .Benazepril [medication for high blood pressure] 20mg .once a day .Carvedilol [medication for high blood pressure]12.5mg .twice a day .Acetaminophen [medication for pain] 325mg .twice a day .Buspirone [medication for anxiety] 5mg .twice a day . Review of a discontinued prescription order change for Resident #32 dated 2/17/2026, revealed .buspirone [medication for anxiety] 7.5 mg discontinue order. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Anxiety Disorder, and Major Depressive Disorder. Review of the current physician's recapitulation orders for Resident #34 revealed .Aspirin [medication to reduce pain] 81mg .once a day .Clopidogrel [medication to prevent blood clots] 75 mg .once a day .Loratadine [medication for allergies] 10 mg .once a day .Senna [laxative] 8.6 mg .twice a day .Flouxetine [medication for depression] .60 mg .once a day .Lisinopril [medication to treat high blood pressure] 10mg .Bupropion [medication for depression] .150 mg once a day .Abilify [medication for depression] .5 mg .once a day .Lyrica [medication for pain] .150 mg twice a day . During observation of a medication administration on 2/18/2026 at 8:22 AM, Licensed Practical Nurse (LPN) A prepared medications for Resident #33, failed to wash hands or don gloves, and removed the discontinued Buspirone 7.5 mg from Resident #33's medication packet coming in contact with the resident's additional medications. Continued observation revealed the LPN administered the medications to Resident #33. During observation of a medication administration on 2/18/2026 at 8:30 AM, LPN A prepared medications for Resident #34, dropped the resident's medications on the unclean medication cart, picked up the medications with an ungloved hand, and put into a medication cup and administered the medications to Resident #34. During an interview on 2/18/2026 at 8:40 AM, LPN A stated gloves should be donned before touching medications and medications should be discarded when come in contact with the unclean medication cart. During an interview on 2/18/2026 at 2:35 PM, the Director of Nursing (DON) confirmed it was her expectation for medications dropped on the medication cart to be discarded, hands washed, and gloves donned prior to touching medications to be administered.

Based on facility policy review, observations, and interviews, the facility failed to ensure food items were sealed properly, failed to ensure kitchen cooking/ serving equipment was maintained in a sanitary manner, and failed to ensure expired foods were discarded, which had the potential to affect 96 of 96 residents. The findings include: Review of the facility's policy titled, Safe Food Storage, dated ,d+[DATE], showed .properly store food items in a safe manner .Discard food items that have passed the expiration date .Securely wrap or cover all food items . Review of the facility's policy titled, Machine Warewashing, dated ,d+[DATE], showed .Check each rack for soiled items as it comes out of the machine. Run dirty items through again until they are clean . Observation of the preparation room with the Dietary Manager (DM) on [DATE] at 9:15 AM, showed the following items was not sealed and open to air: One 21-ounce (oz) container of Garlic Powder Seasoning One 21-oz container of Nutmeg Seasoning One 21-oz container of [NAME] Pepper Seasoning One 19-oz container of Paprika One 5-pound container of Seasoning Salt Observation of the dry storage room with the DM on [DATE] at 9:20 AM, showed the following items: Two 12-quart storage containers of dry cereal, ,d+[DATE] full, was not sealed and open to air Two 106-oz cans of Sauerkraut had expired on [DATE] Observation of the clean dish storage area with the DM on [DATE] at 9:25 AM, showed the following: One divided, serving plate with dried, yellow food debris One 4-inch hotel pan with dried, yellowish-brown food debris During an interview on [DATE] at 9:30 AM, the DM stated dry cereals and dried seasoning are to be fully sealed in the storage containers, plates/pans are to be free of food debris after sanitization, and expired food should be discarded. The DM confirmed the food items had not been stored properly, expired food had not been discarded, and pans/plates had not been maintained in a sanitary condition.

Based on facility policy review, medical record review, and interview, the facility failed to follow a physician's order related to blood glucose monitoring for 1 resident (Resident #58) of 3 residents reviewed for routine blood glucose monitoring. The findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Type 2 Diabetes Mellitus, and Anemia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 scored 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment and received insulin. Review of Resident #58's comprehensive care plan revised 10/3/2023, showed .Potential alteration in gastrointestinal issues r/t [related to]: Diabetes Mellitus type II with hyperglycemia, long term use of insulin .Administer insulin as ordered . Review of the physician recapitulation orders dated 11/28/2023, showed .Insulin lispro .insulin pen Per Sliding Scale .Twice A Day .If Blood Sugar is greater than 400, give 12 Units and recheck in 1 hour. If continued greater than 400, call [provider] for additional orders . Review of the Medication Administration Record (MAR) dated 11/1/2023-11/28/2023, showed on 5 days (11/1/2023, 11/4/2023, 11/10/2023, 11/12/2023, and 11/22/2023) of 28 days reviewed, blood sugar readings were over 400 and the blood sugar had not been rechecked. During an interview on 11/29/2023 at 9:38 AM, the Director of Nursing (DON) stated it was her expectation the physician orders are followed. The DON confirmed Resident #58's blood sugar was not rechecked per physician orders on 11/1/2023, 11/4/2023, 11/10/2023, 11/12/2023, and 11/22/2023. During an interview on 11/29/2023 at 9:33 AM, the Nurse Practitioner (NP) confirmed Resident #58's blood glucose had not been rechecked as ordered. The NP stated there had not been any adverse outcome to the resident from this deficient practice.

Based on facility policy review, observation, and interview the facility failed to properly secure medications for 1 resident (Resident #3) of 96 residents reviewed. The findings include: Review of the facility policy titled Self -Administration of Medications, revised 1/1/2019, showed .If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility .If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted .medications of resident .are stored in central medication cart or medication room . Resident #3 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Dysphagia (difficulty swallowing), Hypertension, and Peripheral Vascular Disease. Review of the Physician Orders showed .Start Date .01/25/2023 .Flonase Allergy Relief (medication used to treat allergies) .spray .50 mcg [microgram] .1 spray in each nostril Twice A Day . Review of a quartlery Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resdient was cognitively intact. During an observation on 11/27/2023 at 10:00AM, in the resident's room, showed a bottle of Flonase nasal spray on the resident's overbed table within the resident's reach. During an observation on 11/27/2023 at 3:00PM, in the resident's room, showed a bottle of Flonase nasal spray on the resident's overbed table within the resident's reach. During an interview on 11/27/2023 at 3:30PM, Registered Nurse (RN) #1 stated she had administered Flonase to Resident #3 this morning and .I must have left it in the room . RN #1 stated the resident had not been assessed to self-administer medications. RN #1 confirmed medication was left within Resident #3's reach. During an interview on 11/29/2023 at 1:15PM, the Director of Nursing (DON) confirmed Resident #3 had not been assessed for self-administration of medications and the Flonase should have not been left within the resident's reach.

Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (Resident #11) received dental services of 24 residents reviewed. The findings include: Review of the facility policy titled, Dental Services, undated, showed .The center will refer patients .for dental services within three days . Resident #11 was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Congestive Heart Failure, and Diabetes Mellitus. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact, and had no pain with chewing. Review of a Dental Note dated 7/6/2023, showed .teeth #7, 9 and 20 are broken to gum line .Pt [Patient] referred out to oral surgeon due to root tips needing surgical repaired . Review of the care plan dated 10/4/2023 revealed .risk of altered nutrition status .Dental services as warranted . Review of the annual MDS assessment dated [DATE], showed Resident #11 had a BIMS score of 11, which indicated the resident had moderate cognitive impariment, had no pain with chewing, and no weight loss. During an observation and interview with Resident #11 on 11/27/2023 at 9:38 AM, showed multiple upper teeth were broken and missing. Resident #11 stated she had been seen by the dentist a few months ago but had not gone back to have her broken teeth removed, and denied mouth pain. Review of the medication administration record (MAR) dated 11/1/2023-11/28/2023, showed no presence of mouth/dental pain. During an interview on 11/29/2023 at 9:05 AM, the Social Services Director confirmed the facility failed to schedule a follow up appointment with an oral surgeon for Resident #11. During an interview on 11/29/2023 at 9:53 AM, the Director of Nursing (DON) confirmed Resident #11 had not received a follow-up appointment with the oral surgeon after a referral had been made on 7/6/2023, by the dentist.

Based on facility policy review, medical record review, and interview, the facility failed to revise the comprehensive care plan after an anti-anxiety medication was added for 1 resident (Resident #78) of 24 residents reviewed for care plans. The findings include: Review of the facility policy titled, Patient Care Plans, dated 11/2023, showed .New problems are handled as they arise and are to be added to the current care plan . Resident #78 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Anxiety, and Depression. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], showed Resident #78 scored 99 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had been unable to complete the interview, and received anti-depressant and anti-psychotic medications. Review of Resident #78's comprehensive care plan revised 9/28/2023, showed .Mood state: potential alteration in related to: Bipolar .depression .Administer medications as ordered-Vraylar [anti-psychotic medication] .Administer Fluoxetine [anti-depressant medication] per orders . Review of a Psychiatric Provider Note dated 10/27/2023, showed .Resident [Resident #78] was seen for medication management of: unspecified depression .reported that she [Resident #78] feels anxious all the time .resident requested something for anxiety .start trial of Buspirone for anxiety . Review of the current physician recapitulation orders dated 11/29/2023, showed Fluoxetine 40 milligram (mg) daily, Vraylar 3mg at bedtime and Buspirone (anti-anxiety medication) 5mg twice daily (11/3/2023). Review of the Medication Administration Record (MAR) dated 11/1/2023-11/29/2023, showed Resident #78 had received Buspirone 29 of 29 days. During an interview on 11/28/2023 at 2:38 PM, the Lead MDS Coordinator stated after new psychotropic medications are added, the care plan should be updated at the time the new order is confirmed. The Lead MDS Coordinator confirmed the comprehensive care plan had not been updated for Resident #78 after an anti-anxiety medication was added on 11/3/2023.

Based on facility policy review, medical record review, observation, and interview the facility failed to protect the resident's rights for 1 resident (Resident #20) of 53 residents reviewed. The findings include: Review of the facility policy titled, Resident Rights, revised 11/2017, showed .We strive to cultivate and sustain an excellent quality of life for each individual .by honoring and supporting each patient/resident's preferences, choices, values, and beliefs. Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Diabetes Mellitus. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact and a bed and chair alarm was used. Review of the comprehensive care plan dated 10/24/2023, showed .Falls .At risk for falls and injury related to falls as evidenced by: Hx [history] of fall, impaired hearing & [and] vision, requires extensive assist w [with]/transfers and ADLs [activities of daily living] . difficulty in walking, muscle weakness, unsteadiness on feet .Sensor Alarm to chair/bed .Educated resident on using chair sensor alarm and not turning alarm off for safety. Resident states I will continue to turn alarm off . During an observation and interview on 11/27/2023 at 10:30AM, in Resident #20's room showed the resident lying in bed with a bed alarm in place. The resident stated she did not like the bed alarm. During an observation and interview on 11/27/2023 at 2:00PM, in the resident's room showed the resident sitting in a wheelchair with a chair alarm in place. The resident stated .I hate this bed and chair alarm .they are annoying .I just turn them off .I don't want them . During an interview on 11/28/2023 at 3:15 PM, Licensed Practical Nurse (LPN) #2 stated she was familiar with Resident #20 and cared for the resident routinely. She also stated the resident removed the bed and chair alarms frequently and the resident had expressed she did not want the alarms in place. During an interview on 11/28/2023 at 3:20 PM, Certified Nursing Assistant (CNA) #1 stated she was familiar with Resident #20 and cared for the resident routinely. She also stated the resident turned the bed and chair alarms off. CNA #1 stated the resident did not want the alarms in place and she informed the resident .it was for her safety . During an observation on 11/29/2023 at 7:50AM, in the resident's room showed the chair alarm was activated and the resident was able to deactivate the alarm. During an interview on 11/29/2023 at 8:00AM, CNA #2 stated she was familiar with Resident #20 and cared for the resident routinely. She also stated the resident had a bed and chair alarm, the resident did not like the alarms, and the resident was able to remove and/or deactivate the alarms. During an interview on 11/29/2023 at 8:05AM, LPN #3 stated she was familiar with Resident #20 and the resident had a bed and chair alarm in place. She also stated the resident hated the sound of the alarms and removed the alarms frequently. During an interview on 11/29/2023 at 1:15PM, LPN #1 stated Resident #20 was weak and unsteady, had a bed and chair alarm in place, and the alarms were placed to prevent falls. LPN #1 confirmed the resident was alert/orientated, was able to voice her wants/needs, and it was a violation of Resident #20's rights to have the alarms in place if the resident had expressed, she did not want the alarms. During an interview on 11/29/2023 at 1:15PM, the Director of Nursing (DON) stated she was not aware Resident #20 did not want the bed and chair alarm in place. The DON confirmed the resident had the right to refuse the bed and chair alarm and the facility violated the resident's rights.

Based on medical record review, observation, and interview, the facility failed to revise the care plan for 1 resident (#2) with a newly developed pressure ulcer of 3 residents reviewed for pressure ulcers. The findings include: Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #2's baseline care plan dated 12/13/2021 showed .Pressure Ulcer at risk for as evidenced by: Needs assistance with ADL's [Activities of Daily Living], incontinent of B&B [bowel and bladder] hx [history of] falling, limited mobility, difficulty walking .Apply moisture to lower extremities as needed .assess skin for redness, swelling, bruising, or open areas .assist with repositioning and use pillows to aid in positioning as needed .Avoid tight fitting sock/shoes .Offload pressure to bony prominences and heels as resident tolerates .Pressure reduction device in wheelchair and pressure reduction mattress on bed .Apply moisture to lower extremities as needed . Continued review showed the care plan was revised on 12/21/2021 to include .Paint 3rd toe with [MEDICATION(S)] q 6 [every six] hours . Further review showed the care plan was revised on 1/11/2022 to include .Pt [Patient] to wear post op [operative] reducing pressure black shoe/boot to L [left] foot when out of bed .Pt to wear reducing pressure boots to bilateral feet while in bed to reduce pressure and friction . Further review showed the care plan was revised on 1/12/2022 to include .Paint L heel with [MEDICATION(S)], twice a day . Continued review showed there was no updated documentation on 1/5/2022 indicating the resident's newly acquired unstageable wound to the left heel or the treatment interventions put into place. Medical record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident had moderate cognitively impairment. The resident required extensive assistance of 2 or more persons physical assistance with bed mobility, transfer, and toilet use, and required limited assistance with locomotion, dressing, and personal hygiene. The resident was identified with being at risk for developing pressure ulcers. Observation and interview on 1/13/2022 at 9:45 AM with Licensed Practical Nurse (LPN) #2 (Wound Care Nurse), in Resident #2's room, showed the resident had a wound to his left heel measuring 4 centimeters (cm) by 5 cm and had a dry eschar (dead tissue) cap and a thin line of pink skin bordered the wound. No drainage or odors were observed. LPN/Wound Care Nurse #2 confirmed the wound was unstageable. During an interview on 1/13/2022 at 3:40 PM, LPN #2/Wound Care Nurse stated .He [Resident #2] had not complained with pain, but with history of having an unstageable wound on his left heel in June it likely happened very quickly .when the nurse notified me of the wound [on 1/5/2022] I was not on the floor so I gave a verbal order .for skin prep two times daily and to continue to offload pressure . Further interview confirmed Resident #2's care plan had not been revised on 1/5/2022 to include the resident's wound or the interventions.

Based on review of a facility policy, medical record review, review of an electronic message, and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#2) of 4 residents reviewed for complete medical records. The findings include: Review of the facility's policy titled Order Entry Policy dated 10/27/2021 showed .Telephone and verbal orders should be entered into the EHR [electronic health record] . Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident had moderate cognitively impairment. The resident required extensive assistance of 2 or more persons physical assistance with bed mobility, transfer, and toilet use, and required limited assistance with locomotion, dressing, and personal hygiene. The resident was identified with being at risk for developing pressure ulcers. Review of an electronic message dated 1/5/2022 from Licensed Practical Nurse (LPN) #2/Wound Care Nurse to LPN #3 showed .[Resident #2's] heel, I will look at it when I get up there however in the meantime .you'll need to put skin prep on it and be sure his heel protectors are on . Further review showed LPN #3's reply to LPN #2/Wound Care Nurse was .I went ahead and skin prepped and put a foam patch and protectors on . Medical record review of Resident #2's Medication Administration Record (MAR) dated 1/1/2022-1/31/2022 showed no documentation of the treatment orders given by LPN #2/Wound Care Nurse on 1/5/2022. During an interview on 1/13/2022 at 11:10 AM, LPN #3 stated .before the wound developed, we were floating his [Resident #2's] heels when he was in bed. When an area is identified we notify the wound care nurse and do an intervention, then we wait for her course of treatment, on the weekend we notify her by text or call to notify her .when .[LPN #2/Wound Care Nurse] sent me a message .I did not realize she was giving me a verbal order and I did not enter it into the computer . During an interview on 1/13/2022 at 3:40 PM, LPN #2/Wound Care Nurse stated .He [Resident #2] had not complained with pain, but with history of having an unstageable wound on his left heel in June it likely happened very quickly. On admission we were applying moisturizer as need and offloading the pressure on his heels. He has a tendency to move his legs back and forth rubbing his heels on the linen .when the nurse notified me of the wound, I was not on the floor, so I gave a verbal order .for skin prep two times daily and to continue to offload pressure .the verbal order did not get to the resident's Medication Administration Record . During an interview on 1/18/2022 at 1:10 PM, the Director of Nursing stated .on admission we implement approaches to help prevent skin break down . the wound care nurse was notified on 1/5/2022 of a skin issue on his [Resident #2's] left heel by the floor nurse. She [wound care nurse] instructed the floor nurse to apply skin prep and to offload his heels as a verbal nurse's order. The floor nurse did not realize that it was an actual verbal order that needed to be transposed to the MAR however the wound care instructions were followed .the wound care nurse and I confirmed treatments had been done through interviews with the floor nurses who provided treatment 1/5/2022-1/10/2022 when the wound care nurse identified the order had not been transposed to the MAR. At that point the wound care nurse placed the order on the MAR. My expectation would have been the floor nurse would process the order by placing it on the MAR and that was not done.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure 1 resident (Resident #2) was free from abuse of 7 residents reviewed for abuse. Resident #2 was punched in the face by Resident #1 and received a bruised eye (black eye), resulting in actual harm. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 12/11/2017, showed .Abuse .will not be tolerated by anyone, including .patients .The patient has the right to be free from abuse .The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse .holds the highest priority .Abuse: the willful infliction of injury .with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse: includes hitting, slapping, pinching and kicking .The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors . Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan dated 12/31/2018, showed .Mood State .Hx [history] of [CONDITION(S)] [[CONDITION(S)]], Irritability & [and] Anger .Dementia .AFTT [Adult Failure to Thrive], [CONDITION(S)] . Interventions included .provide emotional support .visit as needed . Review of Resident #1's Care Plan dated 1/3/2019, showed .Maintain quiet, comfortable environment in room. Limit night-time interruptions. Monitor for mood/behavior changes, assess cause, reassure resident, maintain calm demeanor . Review of Resident #1's Care Plan dated 1/31/2020, showed .Use Anger Management to help contain negative emotional reactions and techniques .identify and implement more productive problem solving efforts . Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had moderate cognitive impairment and exhibited no behavioral symptoms. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Care Plan dated 12/9/2019, showed .Mood state: potential fluctuation r/t: [related to] Anxiety Disorder and Unspecified dementia without behavioral disturbances. Dizziness & [and] Giddiness Dx [diagnosis] .Hx [history] Delusions. [CONDITION(S)] . Interventions included .Maintain quiet, comfortable environment in room. Limit night time interruptions .Monitor for mood/behavior changes, assess cause, reassure resident, maintain calm demeanor . Review of Resident #2's quarterly MDS assessment dated [DATE], showed Resident #2 had moderate cognitive impairment and exhibited no behavioral symptoms. Review of Resident #1's Progress Note dated 7/18/2021, showed Resident #1 walked to the nurse's station angry and yelling. Resident #1 stated, My roommate [Resident #2] is destroying my things. He has done this multiple times and I'm sick of it. Licensed Practical Nurse (LPN) #1 and LPN #2 walked into Resident #1's room and observed his overbed table covered with spilled liquid. Resident #1 continued to curse and yell at staff and Resident #2 and stated, I'm gonna kick the[OBSCENITY]out of him. I'm tired of this! Resident #2 was removed from the room and brought to the nurse's station for observation. Resident #1 had new redness to his left lateral hand. Review of Resident #2's Progress Note dated 7/18/2021 at 11:45 AM, showed [Resident #1] walked to nurse's station angry and yelling .states 'My roommate [Resident #2] is destroying my things. He has done this multiple times and I'm sick of it.' [LPN #1] and [LPN #2] walked into [Resident #1 and Resident #2's room] and observed [Resident #1]'s overbed table was covered with spilled liquid. [Resident #1] continued to curse and yell at staff and [Resident #2]. [Resident #1] states, 'I'm gonna knock the[OBSCENITY]out of him! I'm tired of this!' . [Resident #1] has new redness to L [left] lateral [referring to the side] hand. [Resident #2] has new bruising .to R [right] lateral orbit [the bony cavity in which the eyeball sits] . Review of Resident #1's Care Plan dated 7/18/2021, showed .Resident was the aggressor in a recent altercation with his former room-mate. This outburst was in opposition to his normal role of watching over the room-mate. Resident admits 'he lost it' while explaining his over-reaction toward his former room-mate . Interventions included .Visit with the Psych NP [Nurse Practitioner] .Tuesday July 20, 2021 .no visits in rooms .sent to .ER [emergency room ] for evaluation after striking his room mate .Reported Physical abuse/hitting his room mate . Review of Resident #2's Care Plan updated on 7/18/2021, showed .Monitor for reported physical abuse/hitting by room mate .Ongoing investigation continues with changes made as needed .Psych nurse practitioner visit scheduled for Tuesday July 20th .Sent to ER for evaluation due to being struck by room mate .Staff will monitor for increased anxiety and depression due to reported physical abuse/hitting by room mate . Review of facility investigation documentation dated 7/18/2021, showed a resident-to-resident altercation with Resident #1 and Resident #2 occurred on 7/18/2021 at approximately 11:45 AM. Resident #2 had a bruised right eye and reported his roommate [Resident #1] hit him. Resident #2 denied hitting Resident #1. On 7/18/2021 at 12:10 PM, the Director of Nursing (DON) spoke with Resident #1 and the resident stated, I am tired of him taking all my things. The DON asked Resident #1 if he hit Resident #2 and he stated, I do not think so, I pushed my table at him so may be this hit him. On 7/18/2021 at 12:15 PM, the DON spoke with Resident #2 at the nurse's station about what happened, and Resident #2 stated, he [Resident #1] hit me, I do not know what I did to him, we use to be the best of friends and he turned on me. On 7/18/2021 at 12:55 PM, the police officer and the Administrator interviewed Resident #1. Resident #1 stated he was coming out of the bathroom and Resident #2 had his food out and spilled his coke bottle. Resident #1 also stated Resident #2 tampers with his belongings, and it has happened 5 or 6 times in the past. Resident #1 stated he had not reported this to facility staff. Resident #1 denied hitting Resident #2 and said he pushed his bedside table towards Resident #2 to get him away. Resident #1 had some redness and bruising on his left hand, but Resident #1 could not recall how it occurred. The officer asked Resident #1 if he hit Resident #2 and he stated that he did not hit him but wished he could have. On 7/18/2021 at 1:04 PM, the Administrator and the officer interviewed Resident #2. Resident #2 stated, We have been friends for [AGE] years. I would have never thought he would have hit me .he [Resident #1] swung at me twice and he brushed me on the left cheek, but he hit me on the right eye with his second punch. Resident #2 stated he was sitting in his wheelchair during the altercation. Review of Resident #1's Emergency Department (ED) Note dated 7/18/2021, showed .from [nursing home], 'mental status change related to anger' hx [history] of R [right] [CONDITION(S)] [[CONDITION(S)] on one side of the body] from previous [CONDITION(S)], [nursing home] wants geri-psych [geriatric psychiatric] eval [evaluation] for increased anger/outbursts .patient says he walked into his room at [nursing home] where he has a roommate, and his roommate was trying to take his belongings. He grabbed the belongings back, and the roommate swung at him. He then swung back .roommate is wheelchair-bound and denied provoking the patient in this anger outburst .facility was concerned and wanted him evaluated for increased anger outbursts .Patient states he does not like other people touching his stuff .denies any new injuries himself and said he is feeling fine. He states he likes the facility he is at and has no problems with them . Review of Resident #2's ED Note dated 7/18/2021, showed .Pt [patient] punched at nursing home and c/o [complains of] right eye swelling and bruising. [Nursing home] requesting facial bone CT [Computerized Tomography] .denies loc [loss of consciousness], head injury, fall. pt is on [MEDICATION(S)] [blood thinner] .assaulted by another resident .punched in the face near his right eye. Does have some bruising around the orbit. Denies headache .Denies lightheadedness or dizziness .Source of the history is provided by the patient. Source is a good historian .No acute distress, cooperative, conversant .bruising on lateral aspect of the right orbit .awake, alert, orientated . Further review showed .CT of the head and facial bones negative. Has no focal neurologic deficits. Was in a seated position when he was hit so there is no additional head injury. Will discharge with follow-up to primary care .Stable/nontoxic upon discharge . Review of the police report for the 7/18/2021 altercation showed .On Sunday July 18, 2021, at approximately 12:32 P.M. I, [named officer], responded to [nursing home] .in reference to a report of a physical altercation between two patients .Upon arrival .met with complainant and Director of Nursing .also met with .an administrator for the facility .[DON] and [Administrator] stated they had been notified by staff just after 12:00 P.M. about a physical altercation that took place between two patients that share a room together .both individuals had been separated .alleged aggressor in the altercation was [Resident #1] .[Resident #1] and [Resident #2] have been roommates together in the room for nearly a year, since August of 2020, without prior incident .I spoke to [Resident #1] .[Resident #1] was calm and laying in bed watching television .He stated that he walked into the room and observed [Resident #2] touching and moving his personal effects and that he did not like it .[Resident #2] often touches items that belong to him and that he has told [Resident #2] not to do it but that he has never told the staff about it. This has allegedly happened at least five or six times before. [Resident #1] admitted that he confronted [Resident #2] about him moving/touching his items and that a verbal altercation ensued. He stated that he did not strike [Resident #2] but admitted that he pushed a cart (wheeled tray) in the room in anger. [Resident #1] stated that he observed that [Resident #2] was injured but said that he was not sure how he became injured. I then spoke to [Resident #2]. [Resident #2] was sitting in a wheelchair down the hallway from the room and had a black eye that looked to have been caused recently. [Resident #2] had great difficulty articulating his side of the incident due to his medical condition(s) but I was able to understand that [Resident #2] thought the altercation was unprovoked and had taken him by surprise. He did not know why [Resident #1] had struck him. It was unclear if [Resident #2]'s injury had been caused by [Resident #1] striking him or by an object that had been thrown at him by [Resident #1]. I then spoke to [LPN #1] and [LPN #2], both of whom .work at the facility. Both stated that they heard a verbal altercation coming from [Resident #1 and Resident #2]'s room and heard [Resident #1] make a statement implying that he was going to beat up [Resident #2]. They stated they immediately responded and separated the two men and that [Resident #2] was still sitting in his wheelchair but had an injury to his face (the black eye). They stated that [Resident #1] was swearing uncontrollably and was very angry with [Resident #2] . Further review showed the Administrator was present with the police officer during all interviews. Review of Resident #2's Care Plan updated on 7/22/2021, showed .Resident on the receiving end of a recent altercation with former room-mate . During an interview on 7/28/2021 at 9:05 AM, Resident #2 stated somebody hit me when asked about the resident-to-resident altercation. During an interview on 7/28/2021 at 9:22 AM, Resident #1 stated Resident #2 would take his things (food/candy) and go through his stuff. Resident #1 had never notified the facility staff of his problems with Resident #2. Resident #1 stated after the 7th or 8th time of Resident #2 taking his stuff, .I had enough . Resident #1 stated Resident #2 was going through his belongings on his bedside table and .I pushed this thing [pointing to his bedside table] back and it pushed him back onto his side of the room . Resident #1 stated that he did not think the bedside table hit Resident #2 and denied hitting Resident #2 with his hand. During an interview on 7/28/2021 at 2:48 PM, LPN #1 stated she was the nurse responsible for care of Resident #1 and Resident #2 at the time of the resident-to-resident altercation. On 7/18/2021 at about 11:45 AM, Resident #1 came to the nurse's station. Resident #1 was angry and stated that he was tired of Resident #2 destroying his stuff. Resident #1 was cursing. LPN #1 went to the room and observed spilled liquid on the bedside table. Resident #2 was seated in his wheelchair on his side of the room. Resident #1 stated he would knock the[OBSCENITY]out of him because he was tired of his room being destroyed. Resident #2 was taken to the nurse's station and bruising was noticed on the right side of his face around the orbital bone (eye socket). Resident #2 stated, that man hit me. LPN #2 noticed redness on Resident #1's left hand. LPN #1 and LPN #2 interviewed Resident #1 about the incident, and he denied hitting Resident #2. During an interview on 7/28/2021 at 3:22 PM, LPN #2 stated she had been sitting at the nurse's station on 7/18/2021 around lunchtime when Resident #1 approached the nurse's station. Resident #1 was physically agitated and stated that his roommate was stealing things and destroying the place. Resident #1 asked her to come to his room and look. LPN #2 and LPN #1 accompanied Resident #1 to the room and observed a spilled coke on his overbed table. Resident #2 was in the room and denied spilling the coke on the overbed table. Resident #1 became upset and stated Resident #2 was a liar and that he was going to beat the[OBSCENITY]out of him. LPN #1 stayed in the room with Resident #1 and LPN #2 took Resident #2 into the hallway to separate the residents. LPN #1 noticed bruising and swelling to Resident #2's right eye that was new. Resident #2 stated, that man hit me. LPN #2 asked a CNA to stay with Resident #2 and obtain vital signs. LPN #2 went back into the room with LPN #1 and Resident #1 and noticed Resident #1's left hand was reddened with bruised knuckles. Resident #1 denied hitting Resident #2. Resident #1 stated they shoved each other but the bedside table was in the way so they couldn't get to each other. Resident #1 never admitted to hitting Resident #2. During an interview on 7/29/2021 at 12:36 PM, the DON and the Administrator confirmed there had been a resident-to-resident altercation between Resident #1 and Resident #2 on 7/18/2021 and based on their investigative findings they substantiated the abuse allegation. The DON stated, The abuse wasn't witnessed but based on our investigative findings, we believe [Resident #1] abused [Resident #2].

Based on review of facility policy, observation, and interview, the facility failed to maintain a sanitary kitchen with undated, unlabeled food items available for resident use in 2 of 2 coolers. The facility failed to maintain a sanitary kitchen with undated, unlabeled and open to air food items available for resident use in 1 of 1 walk in freezers. The facility failed to maintain a sanitary kitchen with undated and unlabeled food items in 1 of 1 walk in refrigerators potentially affecting 106 of 109 residents. The findings include: Review of the facility's policy titled, Safety and Sanitation Practice Guidelines, with a revised date of 11/2017, showed .Refrigerated and frozen foods will be stored properly for optimal product safety .Foods will be stored in their original container or .approved container or wrapped tightly in a moisture-proof film, foil .Clearly labeled with the contents and the use by date .Once food is cooked, such perishable items must be labeled with the use by date before properly storing in the refrigerator . Observation of cooler #2, in the kitchen, on 3/09/2020 at 9:46 AM, with the Dietary Manager (DM) showed the following: *Five 8 ounce (oz) plastic glasses of tea undated and available for resident use. *Three 8 oz plastic clear cups of nectar thick unsweet tea undated and available for resident use. *Three 8 oz plastic clear cups of nectar thick orange juice undated and available for resident use. *Three 8 oz plastic clear cups of nectar thick apple juice undated and available for resident use. *Twelve 8 oz plastic clear cups of nectar thick tea undated and available for resident use. *Six 8 oz plastic clear cups of nectar thick cranberry juice undated and available for resident use. *Five 4 oz plastic clear cups of cranberry juice undated and available for resident use. *Two 4 oz plastic clear cups of apple juice undated and available for resident use. Observation of cooler #1, in the kitchen, on 3/09/2020 at 9:56 AM, with the DM showed the following: *Six 4 oz plastic clear cups of apple juice undated and available for resident use. *Fourteen 4 oz plastic clear cups of cranberry juice undated and available for resident use. *Six 4 oz plastic clear cups of tomato juice undated and available for resident use. *One 8 oz plastic clear cup of tomato juice undated and available for resident use. *Nine 4 oz plastic clear cups of prune juice undated and available for resident use. *Fifteen 4 oz plastic clear cups of grape juice undated and available for resident use. *Thirty-five 8 oz plastic clear cups of unsweet tea undated and available for resident use. *Forty-nine 8 oz plastic clear cups of a clear liquid substance (identified by the DM as water) unlabeled, undated, and available for resident use. *Thirty-four 8 oz plastic clear cups of a brown substance undated, unlabeled, and available for resident use. During an interview conducted on 3/09/2020 at 10:04 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with undated and unlabeled food items available for resident use. The DM also confirmed the facility failed to label and date food items in the coolers. Observation of the walk in freezer, in the kitchen on 3/09/2020 at 10:10 AM, with the DM showed the following: *One half a loaf of gluten free soft white bread open to air, undated, and available for resident use. *One clear plastic bag of approximately 9 frozen waffles, open to air, undated, unlabeled, and available for resident use. *Twelve rolls (identified by the DM as sweet rolls) in a plastic bag undated, unlabeled, open to air, and available for resident use. *Three breaded pork chops in a plastic bag undated, unlabeled, and open to air. *Approximately ten farm raised parmesan crusted tilapia fillets frozen solid in a bag undated, open to air, and available for resident use. During an interview conducted on 3/09/2020 at 10:18 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with undated, unlabeled, open to air food items available for resident use in the walk in freezer. Observation of the walk in refrigerator, in the kitchen, on 3/11/2020 at 3:33 PM, with the DM showed the following: *One blue and beige colored muffin and one beige colored muffin in a plastic zip lock bag undated, unlabeled, and available for resident use. *One 48 ounce bag of fully cooked grilled chicken breast fajita strips wrapped in plastic wrap approximately 1/3 full undated and available for resident use. *One gallon sized zip lock bag of cooked bacon approximately 3/4 full undated, unlabeled, and available for resident use. During an interview conducted at 3/11/2020 at 3:52 PM, the DM confirmed the facility failed to maintain a sanitary kitchen with undated and unlabeled food items available for resident use in the walk in refrigerator.

Based on review of facility policy, medical record review, observation, and interview the facility failed to provide a call light within reach of 1 resident (#53) of 36 residents observed. The findings include: Review of the facility policy Answering Call Lights, dated 3/2018, revealed .when the resident is confined to the bed or confined to a chair be sure the call light is within easy reach of the resident . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status of 15 indicating intact cognition. Further review revealed functional status required total dependence for toileting needs. Medical record review of the ADL (Activities of Daily Living) Functional/Rehabilitation Care Plan dated 2/5/19 revealed .set up necessary equipment and place within patient's reach .assist with toileting needs . Observation and interview with Resident #53 on 2/25/19 at 10:00 AM, in the resident's room, revealed the resident in her recliner yelling out .I'm wet . Further observation and interview revealed the call light wrapped around the assist railing attached to the bed located behind the resident's recliner .I can't reach it (call light) . Observation and interview with the Assistant Director of Nursing on 2/25/19 at 10:08 AM, in the resident's room, confirmed the facility failed to ensure the resident's call light was within the resident's reach.

Based on review of the facility Center Statement, review of the Antibiotic Stewardship Notebook and Infection Control Records, and interview, the facility failed to implement an Antibiotic Stewardship program for 98 of 98 residents in the facility. The findings included: Review of the facility Center Statement: Antibiotic Stewardship undated revealed .( Name of facility) is committed to establish and implement practices to maximize treatment of [REDACTED]. Review of the Antibiotic Stewardship Notebook and Infection Control Records with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the Assistant Director of Nursing office, revealed no system was in place to monitor antibiotic usage in the facility for residents with infections. Interview with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the ADON's office, confirmed .I don't surveillance antibiotics .There is no written antibiotic protocol .I review labs and cultures at the end of the month .We have no antibiotic policy just a mission statement . Continued interview confirmed she was not aware of the specific infections and the antibiotic medications prescribed in the facility. Further interview confirmed the facility had not developed, promoted or implemented a system to monitor use of antibiotics in the facility.

Based on review of facility policy, review of the Antibiotic Stewardship Notebook, review of Infection Control Records, and interview, the facility failed to track and trend infections for 15 of 98 residents reviewed for infections. The findings included: Review of the facility policy, Fundamental elements needed to prevent transmission of infectious agents in healthcare settings undated revealed .Surveillance is an essential tool for case-finding of single patients or clusters of patients who are infected or colonized with epidemiologically important organisms .for which transmission-based precautions may be required .Surveillance is defined as the ongoing, systematic collection, analysis, interpretation and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health . Review of the Antibiotic Stewardship Notebook and Infection Control Records with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the Assistant Director of Nursing (ADON) Office, revealed the facility failed to surveillance (track and trend) patients infected with prevalent organisms. Continued interview revealed the Infection Control Nurse was notified of infections but did not Interview with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the ADON's office, confirmed .I do not track organisms of residents just whether it's like a UTI, not actual organism .We are not computerized .I review labs and cultures at the end of the month .I have not track and trended for Feb (February) . Continued interview confirmed the Infection Control Nurse failed to track or trend infections/organisms until the end of each month to present the information for the facility quality monthly meeting. Continued interview confirmed the facility failed to track and trend infections.

Based on medical record review and interview, the facility failed to ensure ongoing communication between the facility and the [MEDICAL TREATMENT] clinic for 1 resident (#21) of 1 resident reviewed for [MEDICAL TREATMENT] of 31 sampled residents. The findings included: Medical record review revealed Resident #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].RESIDENT TO RECEIVE [MEDICAL TREATMENT] ON MONDAY, WEDNESDAY, and FRIDAY . Interview with the Director of Nursing (DON) on 2/28/18 at 11:20 AM, in the conference room, revealed a Post [MEDICAL TREATMENT] Report which included: date of service; pre/post [MEDICAL TREATMENT] weights; pre/post [MEDICAL TREATMENT] vital signs; lab work ordered or preformed during [MEDICAL TREATMENT]; problems that occured pre/post treatment or with shunt or catheter; and a line for the nurse to sign and date. The form was to be sent with the resident to [MEDICAL TREATMENT] and returned to the facility with the resident. Continued interview revealed the Post [MEDICAL TREATMENT] Report should be located in the resident's medical record. Medical record review from 1/18/17 to 2/28/18 revealed no Post [MEDICAL TREATMENT] Reports were present in Resident #21's medical record. Interview with the DON in the DON's office on 2/28/18 at 2:40 PM confirmed no Post [MEDICAL TREATMENT] Reports had been completed for Resident #21 from 1/18/17 to 2/28/18.

Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility staff failed to report an allegation of abuse timely for 1 resident (#1) of 3 residents reviewed for abuse. Review of the facility policy Patient Protection and Response to Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, dated 11/28/16, revealed .Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, or misappropriation of patient property must report the event immediately . Review of a facility investigation revealed a witness statement completed by Certified Nursing Assistant (CNA) #3 dated 8/10/17. Further review revealed CNA #3 alleged she witnessed CNA #4 stuff a wash cloth in the mouth of Resident #1 on 8/6/17 (4 days prior) and .(CNA #4) told her (Resident #1) that she better shut up because she had[***]all over her and we were cleaning her up . Continued review revealed CNA #3 reported the allegation to CNA #2 and Registered Nurse (RN) #1 on 8/10/17. Further review revealed CNA #2 and CNA #3 reported the allegation to Licensed Practical Nurse (LPN) #2 on 8/10/17 before the start of the evening shift (7:00 PM) and LPN #2 immediately called the Director of Nursing. Medical record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview Mental Status score of 8 (moderate cognitive impairment). Continued review revealed the resident was resistant with care 1-3 days during the 7 day look back period. Further review revealed the resident required maximum assist with transfers, dressing, and personal hygiene with 2 person assist. Interview with the Director of Nursing (DON) on 9/5/17 at 11:35 AM, in the conference room, confirmed she was notified by LPN #2 on 8/10/17 at approximately 7:00PM of the allegation of abuse (4 days after the alleged incident). Interview with CNA #2 on 9/6/17 at 7:00 AM, in the conference room, revealed .was working with (CNA #3) on Sunday (8/10/17) .she (CNA 3#) told me would not believe what (CNA #4) had done to (Resident #1) .ask if she reported it .she said no . Interview with RN #1 on 9/6/17 at 7:15 AM, in the conference room, revealed . was leaving work (8/10/17) that morning .had clocked out . (CNA #2) called me over to the table and made (CNA #3) tell me what (CNA #4) had done on Wednesday (8/6/17) .DON was not there that morning so I planned to catch her the next morning . Telephone interview with LPN #2 on 9/6/17 at 11:55 AM revealed .was on break (8/10/17) when 2 night shift CNA's were getting ready to start their shift told me what had happened (on 8/6/17) .immediately called the DON . Interview with the DON on 9/6/17 at 9:00 AM, in the conference room, confirmed she would have expected to have been notified immediately of the allegation of abuse and the facility failed to do so. Interview with the Administrator on 9/6/17 at 9:05 AM, in the conference room, revealed facility staff .should have followed the policy as they were trained . Continued interview confirmed the facility failed to follow facility policy.

Based on review of manufacturer's instructions, observation, and interview the facility failed to ensure laboratory supplies had not expired for 1 of 2 medication rooms and failed to ensure blood glucose control solutions had not expired for 1 of 3 medication carts reviewed. The findings included: Review of the manufacturer's instructions for blood glucose control solution revealed .Use the control solution within 90 days .of first opening .write the date of opening on the control solution bottle label as a reminder to dispose of the opened solution after 90 days . Observation with Licensed Practical Nurse (LPN) #2 on [DATE] at 11:00 AM, in the Wing 2 medication storage room revealed 3 pediatric purple top specimen collection tubes with expiration date of ,[DATE]. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:11 AM, in the Wing 2 medication storage room confirmed the facility failed to monitor expired laboratory supplies. Observation with LPN #3, of the medication cart B on [DATE] at 11:30 AM, in the Wing 1 medication storage room revealed 2 bottles of the test solution for testing the accuracy of the blood glucose machine had an opened date of [DATE]. Continued observation revealed 2 bottles of test solution was open and undated. Interview with the ADON on [DATE] at 2:53 PM, in the Wing 1 medication storage room confirmed the facility failed to ensure blood glucose control solutions had not expired.

Based on medical record review and interview the facility failed to follow a physician's order for medication administration for 1 resident (#58) of 21 sampled residents. The findings included: Medical record review revealed Resident #58 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED].[MEDICATION NAME] (medication used to control phosphorus levels in people with [MEDICAL CONDITION] who are on [MEDICAL TREATMENT]) 0.8 GM (Gram) Powder Pac Give 1 Packet 3 times daily with meals . Continued review revealed the medication was signed by the Licensed Practical Nurse (LPN) #1 for 8:00 AM. Observation of Resident #58 on 2/1/17 at 10:30 AM, sitting in a geri-chair in the dining room. Continued observation revealed the Assistant Director of Nursing assisted Resident #58 with breakfast and the resident ate 75% of her meal. Interview with LPN #1 on 2/1/17 at 4:15 PM, at the 200 nurse's station confirmed the LPN failed to follow the physician's order and gave the medication without food.

Based on facility records review and interview, the facility failed to provide a Surety Bond to cover the residents' personal funds account. The findings included: Review of the daily ledger balance summary for the residents' personal funds dated 12/1/16 through 12/31/16 revealed the following balances: 1) 12/2/16 with a balance of $42,126.24 2) 12/5/16 with a balance of $41,265.53 3) 12/6/16 with a balance of $41,665.53 4) 12/7/16 with a balance of $19,884.93 5) 12/8/16 with a balance of $19,849.93 Review of a facility letter from the insurance company dated 12/5/16 revealed a bond amount of $18,000.00. Interview with the Administrator on 2/1/17 at 7:45 AM in the conference room, confirmed the Surety Bond amount was $18,000.00 and the resident trust balance had been more than $18,000.00 on 5 occasions in December 2016.