Every finding on record at Pine Ridge Skilled Nursing and Rehab

Based on observation, interview and policy review, the facility failed to ensure essential kitchen equipment was operating and maintained in good condition. This had the potential to affect 47 of 47 residents who received food from the kitchen. The facility identified two (Resident #2 and #3) who did not receive food from the kitchen. The facility census was 49.Findings Include:1. Observation during the initial kitchen tour on 06/28/26 at 8:35 A.M. and on 06/30/26 at 12:15 P.M., of the large three-door refrigerator, revealed there was one quarter to one half inch of standing water on the bottom of the refrigerator shelf and dripping from the top of the refrigerator. Bags of food were wet from the dripping water. Observation on 06/28/26 at 1:20 P.M. of a resident refrigerator on the 200 unit revealed the freezer section had a heavy one half inch build-up of white ice on the top and side surfaces. The gasket around the freezer was splintered and did not attach well to the freezer compartment. Interview on 06/28/26 at 1:20 P.M., the Assistant Director of Nursing (ADON) #354 verified the freezer gasket was in disrepair and did not attach well to the freezer compartment.Interview on 06/30/26 at 12:15 P.M. with Maintenance Director (MD) #375 verified the three-door refrigerator in the kitchen had standing water in the bottom and water was dripping from inside the top onto covered food. The MD #375 verified the refrigerator was not working properly and needed repaired.Review of facility policy titled Maintenance Repairs and Requests, undated revealed maintenance will attempt to make repairs, and if unable will use outside contractors. This deficiency represents non-compliance investigated under Complaint Number 3053748.

Based on observation, interview and policy review, the facility failed to ensure a clean and safe homelike environment in resident living areas. This had the potential to affect all 49 residents residing in the facility. The facility census was 49.Findings Include:Observations on 06/28/26 at 8:15 A.M. through 06/30/26 at 2:45 P.M. the front lobby carpet had a heavily soiled pathway into the entrances to the resident unit 200 hallway, and unit 100 unit and the sitting area. There were six 4.0 inch by 6.0 inch heavy grayed areas scattered in the carpet. One of the areas was not adhered and raised from the floor with loose carpet string. In resident occupied room [ROOM NUMBER], there was a missing drawer front of the facility provided wardrobe. In resident room [ROOM NUMBER] there was a three foot long section of a cover base piece missing in the bathroom exposing a six inch area of missing plaster.Observation on 06/28/26 from 8:45 A.M. through 9:30 A.M with Certified Nursing Assistant (CNA) #236 revealed single occupied resident room bathrooms in room [ROOM NUMBER], 102, 114 and double occupied rooms [ROOM NUMBERS], 104 and 110, 113 and 115, 102 and 104 revealed all bathroom vents had a heavy build up of gray debris hanging from the ceiling vents. Observation on 06/28/26 at 9:45 A.M. the unit 100 ceiling vents had heavy gray debris buildup.Interview on 06/28/26 at 9:30 A.M., CNA #236 verified all the resident room bathrooms ceiling vents had a heavy build up of debris and needed cleaned. The CNA #236 verified the missing drawer front in room [ROOM NUMBER] and the missing cover base in room [ROOM NUMBER].Interview on 06/28/26 at 9:45 A.M., the Housekeeper #320 stated she had attempted to clean the hallway vent and was not able to clean the inside of the vent.Interview on 06/30/26 at 12:15 P.M., Maintenance Director (MD) #375 verified the entrance and lobby carpet was heavily soiled and needed cleaned and repaired. The MD #375 stated he had attempted to clean one of the gray areas and the adhesive was loosened and had pulled the carpet string. Review of a facility policy titled Maintenance Repairs and Requests, undated revealed maintenance will attempt to make repairs, and if unable will use outside contractor.

Based on observation, interview and policy review, the facility failed to ensure the kitchen garbage was sealed.This had the potential to affect 47 of 47 residents who received food from the kitchen. The facility identified two (Resident #2 and #3) who did not receive food from the kitchen. The facility census was 49.Findings Include:Observation during initial kitchen tour on 06/28/26 at 8:35 A.M. revealed three garbage cans, not actively in use, were not covered.Interview on 06/28/26 at 8:35 A.M. the Administrator verified the three kitchen garbage cans were not actively in use and should have been covered.Observation on 06/29/26 at 12:15 P.M. with [NAME] #358 verified three garbage cans, which were not actively in use, were not covered.Observation on 06/30/26 at 8:45 A.M. [NAME] #318 verified three garbage cans, which were not actively in use, were not covered.Review of facility policy titled Garbage and Rubbish Disposal, undated revealed all garbage containers shall be provided with tight fitting lids and must be kept covered when stored or not in continuous use. This deficiency represents non-compliance investigated under Complaint Number 3053748.

Based on record review, observation, interview, and policy review, the facility failed to ensure the menu and menu spreadsheets as planned by the Registered Dietitian were followed. This affected 47 of 47 residents who received food from the kitchen. The facility identified two (Resident #2 and #3) who did not receive food from the kitchen. The facility census was 49.Findings Include:1.Review of the lunch meal spreadsheet of 06/28/26 revealed all residents were to receive Italian chicken, noodles, peas, a roll and gelatin. Review of the substitution log revealed the 06/28/26 substitution log had listed ham, black eyed peas, collard greens and a cookie had been substituted.Observation of the lunch menu of 06/28/26 posted outside of the main dining room and in the lobby areas of units 100, 200 and 300 revealed the lunch menu was to consist of Italian chicken, noodles, peas, a roll and gelatin. Observation of the lunch meal of 06/28/26 at 11:45 A.M. consisted of ham, black eyed peas, collard greens and a cookie.Interview on 06/28/26 at 11:50 the [NAME] #318 stated she had been provided a spreadsheet which listed the menu of ham, black eyed peas, collard greens and a cookie and verified she had not prepared the menu of Italian chicken, noodles, peas, a roll and gelatin. [NAME] #318 stated she had no knowledge until 06/28/26 of the substitution process and had not completed a substitution log. 2.Review of physician orders revealed Residents #6, #26, #42 and #49 had diet orders for diet consistency of puree.Review of the lunch meal spreadsheet of 06/29/26 revealed puree consistency diets were to receive eight ounces, ( 2 times of a #8 scoop) of chicken and dumplings. The green bean portion was two ounces, (#16 scoop) and the two slices of puree bread, (noted 4 ounces or #8 scoop, on the recipe card). The dessert was a cake of a #12, ( 2.6 ounces ) scoop size.Review of the substitute log dated 06/28/26, further entries, revealed no puree substitution entry for the chocolate pudding from the brownie.Observation on 06/29/26 at 12:05 P.M. revealed the residents receiving puree diets, #6, #26, #42, and #49, received two servings from a 2 ounce scoop of the main entree (total of 4 ounces), 4 ounces of green beans and #10 scoop or 3 ounces of puree bread. The residents received 4 ounces of chocolate pudding instead of the puree chocolate brownie.Interview on 06/29/26 at 12:15 P.M. with [NAME] #358 verified the residents receiving puree consistency received the incorrect amount of chicken and dumpling, green beans, and bread. [NAME] #358 verified the residents received pudding instead of the brownies, as listed on the spreadsheet and the same for regular diets. [NAME] #358 stated the residents received the pudding because the residents liked it better. The [NAME] #358 stated he was not aware of a document to record food substitution for the pudding instead of brownie. The [NAME] #358 stated he had not used the menu spreadsheet for meal service since he knew the portions from his memory.Review of a facility policy titled Menu Substitutions, undated revealed appropriate substitute foods are utilized when a menu change is necessary. The dietitian should initial the substitution log. Review of a facility policy titled Portion Control, undated revealed menus are built with specific portions to meet resident's needs. Portions must be followed during all phases of food production and service.3.Review of the breakfast meal spreadsheet of 06/30/26 revealed the Residents #6, #26, #42 , and #49, with physician orders for a puree consistency, were to receive a #16 scoop portion of scrambled eggs, a #8 scoop for puree bread and a #8 scoop of hot cereal.Observation on 06/30/26 at 8:45 A.M revealed the puree consistency diet for Residents #6, #26, #42 and #49, received a #10 scoop portion of eggs, a #16 scoop portion of a muffin and not bread, and a #6 scoop portion of cereal. Interview on 06/30/26 at 8:45 A.M the [NAME] #318 verified the scoop sizes were incorrect for the puree consistency of the egg, bread and cereal. The [NAME] #318 had not realized the puree consistency diet was to receive bread instead of a muffin and the scoop size was not listed on the spreadsheet. [NAME] #318 stated she did not have the spreadsheet and did the best she could in remembering the scoop sizes and preparation for the specified puree foods. 4.Review of the lunch spread sheet of 06/30/26 revealed Residents #6, #26, #42 and #49 ordered on a puree consistency, were to receive a #8 scoop of tuna noodle casserole, a #10 scoop of puree cornbread, and 4 ounces of orange sherbet. Observation on 06/30/26 at 2:45 P.M. the puree meal consisted of a #12 scoop of tuna casserole, a #16 scoop of cornbread and a #16 scoop of puree gelatin.Interview 06/30/26 at 8:45 A.M., the [NAME] #318 verified the scoop sizes were incorrect for the puree consistency of the tuna casserole and cornbread. The [NAME] #318 stated she pureed gelatin because she did not have the spreadsheet to know to serve the orange sherbet. [NAME] #318 stated she did not have the correct dated spreadsheet, and did the best she could in remembering the scoop sizes. The [NAME] #318 stated she did not know of a substitution log or had been instructed of its use.Review of facility policy titled Menu Substitution, undated revealed appropriate substitute foods are utilized when a menu change is necessary. The dietitian should initial then substitution log. Review of facility policy titled Portion Control, undated revealed menus are built with specific portions to meet resident's needs. Portions must be followed during all phases of food production and service.

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen sanitation was maintained and provide meals in a sanitary manner. This had the potential to affect 47 of 47 residents who received food from the kitchen. The facility identified two (Resident #2 and #3) who did not receive food from the kitchen. The facility census was 49.Findings Include:Observation during initial kitchen tour on 06/28/26 at 8:35 A.M. the following was observed:1. In the reach in refrigerator there was an opened undated package of donuts. There was a plate of food unwrapped with no date or label. There were two large pans of gelatin dessert, undated and unlabeled. The reach in refrigerator had no thermometer inside.The deep freezer had no thermometer inside. There were six wrapped sandwiches dated 06/22/25.There was a plate of sliced tomatoes undated.The upright freezer had a heavy build up of approximately a quarter inch of white frost on top, bottom and on the shelves.2.The refrigerator temperature logs, for three different refrigerators and freezers, had no temperature entries for the dates of 06/05/26, 06/06/26, 06/07/26, 06/08/26, 06/09/26, 06/10/26, 06/11/26, 06/12/26, 06/13/26, 06/14/26, 06/15/26, 06/16/26, 06/17/26, 06/18/26, 06/19/26, 06/21/26,06/23/26, 06/24/26, 06/25/26, 06/26/26 and 6/27/26.The three compartment sink sanitation logs had no sanitation documentation for the dates of 06/05/26 through 06/29/26.Testing of the three compartment sink on 06/30/26 at 10:45 A.M. with the Administrator and [NAME] #318 revealed the testing strip registered no sanitizing indication. The Administrator verified the three compartment sink was not registering any sanitizer solution and that the three compartment sink had no documentation it had been tested since 06/04/26.Review of the dishwasher temperature and sanitation log for June 2026 revealed from 06/01/26 through 06/04/26 had temperature and sanitizer documenting initials, identified by the facility of the Former Dietary Manger (FDM)#700. Dates of 06/05/26 through 06/17/26 had temperatures and sanitizer documentation that matched exactly 120 degrees and 50 parts per million (PPM) and initialed by [NAME] #318. There was no documentation of the dishwasher temperatures and sanitizer levels from dates of 06/18/26 through 06/30/26.Observation on 06/30/26 at 10:30 A.M. of the dishwater directions posting near the dishwasher, revealed the dishwasher was a low temperature dishwasher and should have a rinse cycle temperature of 120 degrees Fahrenheit and reach a sanitizer solution of chlorine level of 50 to 100 PPM.Interview on 06/30/26 at 12:45 P.M. [NAME] #318 stated she did not know where the dishwasher sanitation testing strips were located and had never used the testing strips. The [NAME] #318 verified she had documented dishwasher temperatures and sanitizer levels on the dishwasher log form from 06/05/26 through 06/17/26 and did not complete the log from 06/18/26 through 06/30/26 because she ran out of time to fill out the form. The [NAME] #318 stated she was asked by the Administrator on 06/28/26 to complete the log form 06/28/26 of date 06/05/26 through 06/28/26. The [NAME] #318 verified the dishwasher log was not accurate and the dishwasher had not been monitored for temperature and sanitizer level from o6/05/26 through 06/29/26.3.Observation on 06/29/26 at 12:15 P.M. revealed [NAME] #358 preparing pure foods for the lunch meal. [NAME] #358 placed the soiled blender bowl and blade in the dishwasher and reassembled the blade into blender bowl with bare hands. The [NAME] #358 then pureed the next food item in the reassembled blender bowl. The [NAME] #358 repeated the same process reassembling the blade in the bowl with bare hands and then blended more food in the bowl.Interview on 06/29/26 with the [NAME] #358 verified he reassembled the blade with his bare hands and continued to puree the next food item, and stated he should not touch the clean blade with his bare hands to reassemble the bowl.Observation on 06/30/26 at 10:30 A.M. the Dishwasher Aide (DA) #312 loaded the dirty pans into the dishwasher and removed clean pans from the dishwasher without sanitizing or using different gloves to unload the dishwasher.Interview on 06/30/26 at 10:30 A.M. the DA #312 stated he washed off the gloves used during loading the dishwasher before he unloads the clean dishes. The DA #312 stated he did not change gloves or sanitize hands between loading and unloading the dishwasher.4. Observation on 06/30/26 at 12:15 P.M. revealed the eight ceiling vents in the kitchen had heavy buildup of gray debris in the louvers of the vents. The vents were located over food preparation areas.Interview 06/30/26 at 12:15 P.M. with Maintenance Director (MD) #375 verified the eight kitchen ceiling vents had a heavy buildup of debris and needed cleaned.5. Observation on 06/28/26 at 1:10 P.M. of a resident refrigerator on the 100 unit revealed one container of thickened juice dated 06/15/26. There was a two-inch-wide brown substance extending 12 inches on the back side of refrigerator cavity and pooling into the bottom drawers of the refrigerator. Interview on 06/28/26 at 1:10 P.M. with the Assistant Director of Nursing (ADON) #354 verified the refrigerator should be cleaned of the brown substance.Interview on 06/28/26 at 2:15 P.M the Clinical Region Nurse (CRN) #800 said the thickened juice should have been discarded after seven days on 06/22/26. Observation on 06/28/26 at 1:20 P.M. of a resident refrigerator on the 200 unit revealed in the refrigerator section, there were three unlabeled insulated bags, identified by the ADON #354 as staff lunch bags. There were two containers of uncovered food with no label and no date. There were 10 clear bags containing protein sandwiches dated 06/24/26. The temperature log was missing temperatures for dates of 06/24/26, 6/25/26, 6/26/26 and 6/27/26.Interview on 06/28/2026 at 1:20 P.M. the ADON #354 verified the unlabeled staff lunch bag should not be stored in the refrigerator and the foods should be labeled, dated and foods discarded in three days.Review of a facility policy titled Dish machine Temperatures, undated revealed cold (low) temperature machines prior to use run a test strip through the dishwasher. Document all action on the dish machine temperature record form. Review of a facility policy titled Pot Sink, undated revealed test the chemical sanitizer using the appropriate strip and maintain a temperature of 170 degrees Fahrenheit in the rinse compartment.Review of a facility policy titled Food Brought in By Family Members, undated revealed foods are to kept in containers with lids and perishable foods destroyed daily.Review of a facility policy titled Storage Temperatures, undated revealed refrigeration temperatures are to be recorded daily of each storage unit.This deficiency represents non-compliance investigated under Complaint Number 3053748.

Based on record review, observation, interview, and policy review, the facility failed to ensure residents were treated with dignity during meals. This affected two (Resident #37 and #49) of 18 residents observed for dining. The facility census was 49.Findings include:1.Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, contracture of the left hand, chronic pain, and degeneration of nervous system. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #37 had severely impaired cognition and required partial to moderate assistance when eating.2.Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, dementia, and Parkinson's Disease. Review of the MDS comprehensive assessment dated [DATE] revealed Resident #49 had severely impaired cognition and required partial assistance for eating.Observation on 06/28/26 at 11:30 A.M. in the facility's main dining room revealed nine residents sitting at tables awaiting meals, one certified nursing assistant (CNA) #202 and one Licensed Practical Nurse (LPN) #110 assisting residents with positioning at the tables and awaiting meal trays. CNA #202 distributed meals to residents, removing the plates, cups, utensils, and placing the trays back on the counter and retrieved the next tray. Resident #49 was served her tray by placing the tray in front of her and LPN #110 sat down next to her, opened her drink, inserted a straw and began to feed Resident #49. CNA# 202 continued to serve meals to residents then placed a tray in front of Resident #37, and while standing next to him, began feeding him. CNA #202 served meals to two additional residents, removing the plates, cups, utensils, etc., and returned to Resident #37, sat down and continued to feed him.Interview on 06/28/26 at 12:02 P.M. with LPN #110 revealed she was there to assist and since the tray was in front of Resident #49 she started feeding her, LPN #110 was unsure if all residents who required assistance with feeding were served meals on trays.Interview on 06/28/26 at 12:05 P.M. with CNA #202 she was only standing to watch for trays and normally sits when assisting a resident with eating, confirmed its normal for her to leave plates, cups, napkins and flatware on the trays for residents' who required feeding assistance.Interview on 06/30/26 at 12:10 P.M. with the Executive Director (ED) confirmed the staff was to serve all the residents in the same fashion by removing all items from the tray and placing the empty tray on the cart in the corner of the dining room.Review of the facility policy titled Dignity Policy, dated December 2020, revealed the facility staff will promote residents' independence and dignity in dining.This deficiency represents non-compliance investigated under Complaint Number 3053748.

Based on record review, observation, resident and staff interview, policy review, and review of online clinical resources per Medline Plus, the facility failed to ensure the medication error rate was less than 5.0 percent (%). There were 36 opportunities for error with two medications errors for a calculated error rate of 5.56 %. This affected two (Resident #4 and #9) out of two residents observed for medication administration. The facility census 49.Findings include: 1. Medical record review for Resident #4 revealed admission on [DATE]. Diagnoses included post traumatic stress disorder, unspecified psychosis and diabetes mellitus. Review of the physician orders dated 10/18/25 revealed Resident #4 was to receive Synthroid 175 microgram (mcg) tablet by mouth in the morning for thyroid.Review of the quarterly minimum data set 04/30/26 revealed Resident #4 was cognitively intact and required setup or clean-up assistance with eating.Observation on 06/29/26 at 8:26 A.M. revealed Resident #4 was administered Synthroid 175 mcg by Licensed Practical Nurse (LPN) #104 at the same time her breakfast tray was brought to her.Interview on 06/29/26 at 8:27 A.M. with Resident #4 revealed she regularly gets her Synthroid at the same time as her breakfast. Resident #4 reported she thought she should get her Synthroid earlier, before breakfast.Interview on 06/29/26 at 8:33 A.M. with LPN #104 confirmed she gave Synthroid 175 mcg to Resident #4. LPN #104 stated she usually gave the morning medications including Synthroid 175 mcg to Resident #4 as she was getting her breakfast.2. Medical record review for Resident #9 revealed admission on [DATE]. Diagnoses included vascular dementia, encephalopathy, and chronic obstructive pulmonary disease. Review of the physician orders dated 09/02/25 revealed Resident #9 was to receive Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 micrograms/actuation. Review of the quarterly minimum data set assessment completed on 06/14/26 revealed Resident #9 was cognitively intact and utilized a walker for mobility.Observation on 06/29/26 at 7:54 A.M. revealed LPN #104 administered Trelegy Ellipta breath activated aerosol powder 100-62.5-25 micrograms/actuation to Resident #9. LPN #104 had not advised Resident #9 to rinse mouth and spit after receiving Trelegy Ellipta. Resident #9 walked away after receiving her medication.Interview on 06/29/26 at 7:54 A.M. with LPN #104 confirmed she was finished with giving Resident #9 her medication. LPN #104 then confirmed that she had not asked Resident #9 to rinse and spit after receiving Trelegy Ellipta and she should have. LPN #104 reported it was important for residents receiving Trelegy Ellipta to rinse and spit after medication in order to minimize the risk of oral infection. Review of facility policy titled Medication Administration-General Guideline, revised 11/18 revealed medications are administered as prescribed in accordance with good nursing principles and practices.Review of online clinical resource titled Fluticason, Umeclidinium, and Vilanterol Oral Inhalation (brand name Trelegy Ellipta) last revised 11/15/2020 at https://medlineplus.gov/druginfo/meds/a618017.html revealed After inhalation, rinse your mouth with water and spit the water out; do not swallow the water.Continued review of online clinical resource titled Levothyroxine (brand name Synthroid) last revised 02/15/2019 at https://medlineplus.gov/druginfo/meds/a682461.html revealed Synthroid should be taken once a day on an empty stomach 30 minutes to 1 hour before breakfast.

Based on record review, observation, interview and policy review, the facility failed to ensure staff used hand hygiene followed infection control practices. The affected two (Resident #29 and #37) of nine residents reviewed for infection control. The facility census was 49.Findings include:1. Record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included vascular dementia and hypertension. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed the resident had severely impaired cognition and required set-up or touch assistance for eating.2. Record review revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, contracture of the left hand, chronic pain, and degeneration of nervous system. Review of the MDS quarterly assessment dated [DATE] revealed Resident #37 had severely impaired cognition and required partial to moderate assistance when eating.Observation on 06/28/26 at 12:08 P.M. in the facility's main dining room revealed nine residents sitting at tables finishing meals or awaiting assistance to exit the dining room. Certified Nursing Assistant (CNA) #202 wore gloves while clearing dirty plates, cups, drinks, utensils, and napkins from each of the tables. CNA #202 approached Resident 29 and touched his arm with her soiled gloves while bending down to ask him a question. CNA #202 continued clearing dirty dishes and moved on to Resident #37, reached behind him and removed the clothing protector he was wearing then placed it on his lap with the same gloves on.Interview on 06/28/26 at 12:13 P.M. with CNA #202 revealed she always wore gloves when she was clearing tables and confirmed she was wearing the gloves she used to clear dirty dishes from tables when she touched Resident #29 and #37. She confirmed she should have removed the gloves and followed proper hand hygiene prior to touching Resident #29 and #37.Interview on 06/30/26 at 11:30 A.M. with the facility Infection Control Coordinator, Assistant Director of Nursing, Licensed Practical Nurse (LPN) #354 revealed she would not recommend her care staff to wear gloves soiled with food from clearing plates while touching residents including removing clothing protectors following eating a meal.Review of the facility policy titled Handwashing/Hand Hygiene Policy and Procedure, dated August 2022 revealed the facility staff must wash their hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water under after handling soiled equipment or utensils, the use of gloves does not replace hand hygiene and hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on record review, staff interview, and policy review, the facility failed to develop a comprehensive care plan. This affected one (Resident #20) out of one resident reviewed with a hearing deficit and one (Resident #37) of three residents reviewed for limited mobility. The facility census was 49.Findings include: 1.Review of the medical record for Resident #20 revealed an admission date of 02/27/25. Diagnoses included unspecified hearing loss and vascular dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had severely impaired cognition.Review of the care plan for Resident #20 dated 06/28/26 revealed no plan for the resident's hearing deficit.2.Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, contracture of left hand, chronic pain, and degeneration of nervous system. Review of the MDS quarterly assessment dated [DATE] revealed the resident had severely impaired cognition and required partial to moderate assistance when eating.Review of the care plan for Resident #37 dated 04/30/26 revealed no plan for the resident's left hand contracture.Interview on 06/30/26 at 9:30 A.M. with Director of Nursing (DON) confirmed the care plan for Resident #20 had not included a hearing deficit and the care plan for Resident #37 had not included his left hand contracture.Review of the facility policy titled Comprehensive Care Planning, dated 03/02/21 revealed the facility would establish a care plan for every resident that included the resident's medical, nursing, mental, and psychosocial needs.

Based on medical record review, hospital record review, staff interview, and review of the facility, the facility failed to implement resident tube feeding orders upon admission. This affected one (Resident #19) of three residents reviewed for hospitalization. The facility identified one (Resident #19) with orders for tube feeding. The facility census was 46 residents.Findings include: Review of the medical record for Resident #19 revealed an admission date of 05/14/25 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, and mild protein-calorie malnutrition. Resident #19 transferred to the hospital on [DATE], was readmitted to the facility on [DATE], was transferred again to the hospital on [DATE], and was readmitted to the facility on [DATE] Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 09/06/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the hospital continuity of care record for Resident #19 dated 08/22/25 revealed an order for Nutren 2.0 tube feeding 10 milliliters (ml) per hour with goal rate of 35 ml per hour. Review of the physician's orders for Resident #19 revealed no order for tube feeding initiated on 08/22/25 for the resident. Review of the Medication Administration Record (MAR) for Resident #19 dated 08/22/25 to 08/25/25 revealed it did not include documentation of tube feeding administration for the resident. Review of the care plan for Resident #19 dated 08/28/25 revealed the resident was at a moderate nutritional risk related to the need for enteral feedings. Interventions included to provide enteral feedings per the order. Interview on 09/19/25 at 10:52 A.M. with the Director of Nursing (DON) verified the tube feeding orders were not entered into Resident #19's medical record upon her return from the hospital. The DON stated the facility did not provide the tube feeding for Resident #19 from 08/22/25 to 08/25/25 because they did not have the formula that was ordered available in the facility. Review of the facility policy titled Enteral Nutrition dated November 2018 revealed nutritional support through enteral nutrition should be provided to residents as ordered. The staff could use products from a basic formulary until specialized products can be delivered. This deficiency represents noncompliance investigated under Complaint Number 2601904.

Based on observation, interview and record review, the facility failed to ensure food items, a kitchen dehumidifier, and the kitchen flooring were maintained in a manner to prevent foodborne illness. This affected 47 out of 47 residents that resided in the facility. The facility census was 47. Findings include: Observation of the kitchen on 11/12/24 at 8:31 A.M. revealed there was a black substance and a gray fuzzy substance on the dehumidifier in the kitchen. There was also black substance built up on the kitchen floor and a frozen pack of raw original bratwurst on a Styrofoam tray that was covered with plastic wrap in the freezer that was next to a bag of frozen asparagus. Interview with Dietary Supervisor #72 on 11/12/24 at 8:31 A.M. verified there was a black substance and a gray fuzzy substance on the dehumidifier in the kitchen. Dietary Supervisor #72 also verified there was also a black substance built up on the kitchen floor and a frozen pack of raw original bratwurst on a Styrofoam tray that was covered with plastic wrap in the freezer that was next to a bag of frozen asparagus. Observation of the room tray food cart on 11/12/24 at 11:44 A.M. revealed residents were served a piece of cake, chicken fettuccine Alfredo, vegetables, and a roll. The chicken fettuccine Alfredo, vegetables, and roll were covered but the cake was open to air on the food cart. Further observation of the food cart revealed a fly was sitting on a piece of cake in the food cart. Interview with Licensed Practical Nurse (LPN) #88 on 11/12/24 at 11:44 A.M. verified the cakes were uncovered in the food cart. LPN #88 also verified there was a fly on a piece of cake in the food cart. Review of the facility's undated dietary policy revealed food shall be prepared and served in a manner that meets the individual needs of each resident.

Based on observation, interview, and record review, the facility failed to ensure a resident was provided with an adequate privacy curtain. This affected one (Resident #20) of one resident reviewed for privacy. The facility census was 47. Findings include: Review of Resident #20's chart revealed Resident #20 admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, congestive heart failure, hypothyroidism, hypertension, major depressive disorder, anxiety disorder, chronic kidney disease, insomnia, rheumatoid arthritis, cellulitis of right lower limb, acute respiratory failure with hypoxia, and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Observation of Resident #20's room on 11/12/24 at 9:30 A.M. revealed the privacy curtain between Resident #20 and Resident #20's roommate's bed did not cover the whole track and there was a gap that was approximately two feet wide that was not covered on the privacy curtain track. Interview with Resident #20 on 11/12/24 at 9:30 A.M. revealed Resident #20's privacy curtain between her bed and her roommate's bed did not shut all the way. Resident #20 stated that she did not like that her privacy curtain did not shut all the way because she was always partially viewable to her roommate. Interview with the Director of Nursing (DON) on 11/13/24 at 12:30 P.M. verified the privacy curtain between Resident #20 and Resident #20's roommate's bed did not cover the whole track and there was a gap that was approximately two feet wide that was not covered on the privacy curtain track. Review of the facility's dignity policy dated August 2009 revealed staff shall promote, maintain and protect resident privacy including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview, medical record review, and policy review, the facility failed to ensure residents had comprehensive care plans. This affected two (Residents #42 and #20) of eight residents reviewed for care plans. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #42 was admitted tot he facility on 08/06/24. Diagnoses included acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the care plan dated 08/08/24 revealed no care plans for diabetes, congestive heart failure, and chronic kidney failure. During an interview on 11/14/24 at 10:40 A.M. the Director of Nursing (DON) verified Resident #42's care plan was incomplete and did not address the resident's known medical conditions. 39967 2. Review of Resident #20's chart revealed Resident #20 admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, congestive heart failure, hypothyroidism, hypertension, major depressive disorder, anxiety disorder, chronic kidney disease, insomnia, rheumatoid arthritis, cellulitis of right lower limb, acute respiratory failure with hypoxia, and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #20's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required supervision with eating and oral hygiene. Resident #20 required maximal assistance with toileting, showering, lower body dressing, putting on and taking off footwear, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, and tub transfers, and moderate assistance with upper body dressing and personal hygiene. Resident #20 had minimal difficulty with hearing with no hearing aids. Review of Resident #20's ear care visit dated 06/29/24 revealed Resident #20 had hearing loss in both ears, but it was worse in the left ear. Resident #20 had a whisper test completed. Resident #20 could not hear the whisper test. Review of Resident #20's ear care visit dated 08/06/24 revealed Resident #20 had a perforated ear drum on the left side and a diagnosis of Eustachian tube dysfunction. Review of Resident #20's care plan on 11/13/24 revealed Resident #20 did not have a care plan for hearing impairment. Interview with Resident #20 on 11/12/24 at 9:35 A.M. revealed Resident #20 had difficulty hearing and needed hearing aids. Interview with the DON on 11/14/24 at 11:16 A.M. verified Resident #20 did not have a care plan for hearing impairment. The DON verified Resident #20 was listed as having hearing impairment on the 10/04/24 MDS. Review of policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016 revealed the facility developed and implemented a comprehensive care plan for each resident which incorporated identified problem areas and risk factors associated with identified problems.

Based on observation, interview, medical record review and policy review, the facility failed to ensure appropriate signage was posted for residents in transmission-based and enhanced barrier precautions. This affected two (Residents #201 and #6) of two residents reviewed for infection control signage. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #201 was admitted to the facility on [DATE]. Diagnoses included chronic combined congestive heart failure, unspecified chronic obstructive pulmonary disease, unspecified pulmonary disease, and type two diabetes. Review of the medical record revealed on 11/05/24 revealed Resident #201 was assessed for mental status and was cognitively intact. Review of the medical record revealed Resident #201 had physician orders dated 11/06/24 for isolation precautions two times a day for c-diff toxin. Observation on 11/12/24 at 9:47 A.M. revealed Resident #201 was in his room with the door closed. There was a bin located outside of the room which contained Personal Protective Equipment (PPE), but there was no sign posted on door or any walls adjacent to the door to indicate transmission-based precautions. During an interview on 11/12/24 at 2:13 P.M. the Director of Nursing (DON) stated Resident #201 was a new admission with no wounds or medical devices and had no orders for transmission-based precautions. The DON checked the medical record, verified Resident #201 had order for isolation precautions for C-diff, and verified there was no sign for precautions posted on or near the resident's door. Review of policy titled, Isolation Precautions, dated August 2019 revealed when transmission-based isolation was implemented, a sign was placed on the door or doorframe directing visitors to see a nurse before entering the room. 25908 2. Resident #6 was readmitted to the facility on [DATE]. Diagnoses included insomnia, bipolar, and diabetes. Observations on 11/12/24 at 10:00 A.M. and 2:00 P.M. revealed a infection control cart outside Resident #6's room. No signage was noted on the door or on the cart. Interview with the DON on 11/12/24 at 2:13 P.M. revealed the resident was on Enhanced Barrier Precautions (EBP) due to a recent surgery with a JP (Jackson Pratt) tube in place. Review of the physician's orders for 11/12/24 revealed the resident should be in enhanced barrier precautions. Review of the Enhanced Barrier Precautions policy dated 04/01/24 revealed the facility will implement a strategy to identify residents with EBP such as signage placed outside the room.

Based on interviews, medical record review, and policy review, the facility failed to ensure medications were available and administered as ordered. This affected two (Residents #20 and #42) of five residents sampled for medications administration. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #42 was admitted tot he facility on 08/06/24. Diagnoses included acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #42 had physician orders dated 08/12/24 for Ozempic (0.25 or 0.5 milligram (mg)/dose) Subcutaneous Solution Pen-injector 2 mg/3 milliliters (ml) (Semaglutide) Inject 0.5 mg subcutaneously once weekly every Monday for Diabetes. Review of the Medication Administration Record (MAR) dated November 2024 revealed Resident #42 did not receive weekly Ozempic administrations on 11/04/24 and 11/11/24. Review of the MAR dated October 2024 revealed Resident #42 did not receive weekly Ozempic Administrations scheduled on 10/07/24, 10/14/24, 10/21/24, and 10/28/24. Review of the MAR dated September 2024 revealed Resident #42 did not receive Ozempic Administration as ordered on 09/30/24. Review of progress notes dated 11/11/24, 11/04/24, 10/28/24, 10/21/24, 10/14/24, 10/07/24, and 09/30/24 revealed Resident #42 did not receive Ozempic medication because the medications was not available form the pharmacy. During an interview on 11/12/24 at 9:36 A.M. Resident #42 and her daughter each stated Resident #42 had been giving herself a weekly shot at home for diabetes management and the facility had not been administering the medication. Both were unsure if the order was still active or had been discontinued. During an interview on 11/14/24 8:28 A.M. Assistant Director of Nursing (ADON) #92 verified Resident #42 had not received weekly Ozempic shots as ordered since September 2024 due to an error in the the electronic ordering process. The ADON stated nurses were expected to phone the pharmacy when medications were unavailable and stated no nurse had called the pharmacy to inquire why the medication was not available until the ADON called last week, date unspecified. Review of policy titled, Medication Administration - General Guidelines, dated 11/2018 revealed medications were administered in accordance with written orders of the prescriber. When medications with an active, current order were not available, the facility contacted the pharmacy and documented an explanatory note in the electronic health record.

Based on interviews, medical record review, and policy review, the facility failed to ensure the provider and family were notified when medications were unavailable for administration as ordered. The affected two (Residents #42 and #20) of eight residents reviewed for notification. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed progress notes dated 11/11/24, 11/04/24, 10/28/24, 10/21/24, 10/14/24, 10/07/24, and 09/30/24 revealed no documentation of family or provider notification that Ozempic medication was not available and was not given. During an interview on 11/12/24 at 9:36 A.M. Resident #42 and her daughter each stated they were unsure if Resident #42 had a current order for Ozempic medication because the resident was not receiving shots and they had not received any notification that the medication was discontinued. During an interview on 11/14/24 at 10:55 A.M. Assistant Director of Nursing (ADON) #92 verified Resident #42's medical record had no documentation regarding provider or family notification when Ozempic medications were not administered 11/11/24, 11/04/24, 10/28/24, 10/21/24, 10/14/24, 10/07/24, and 09/30/24. 39967 2. Review of Resident #20's chart revealed Resident #20 admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, congestive heart failure, hypothyroidism, hypertension, major depressive disorder, anxiety disorder, chronic kidney disease, insomnia, rheumatoid arthritis, cellulitis of right lower limb, acute respiratory failure with hypoxia, and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #20's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required supervision with eating and oral hygiene. Resident #20 required maximal assistance with toileting, showering, lower body dressing, putting on and taking off footwear, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, and tub transfers, and moderate assistance with upper body dressing, and personal hygiene. Review of Resident #20's Medication Administration Record (MAR) from 09/01/24 to 11/13/24 revealed Resident #20 was ordered Trulicity subcutaneous solution pen injector 4.5 milligrams (mg) inject 4.5 mg in the morning every Thursday related to type two diabetes mellitus without complications on 05/02/24. Further review of Resident #20's MAR revealed Resident #20 did not receive her Trulicity 4.5 mg on 09/12/24, 10/24/24, and 10/31/24. Review of Resident #20's progress notes from 09/01/24 to 11/13/24 revealed no documentation related to Resident #20's Trulicity 4.5 mg not being given on 09/12/24, 10/24/24, and 10/31/24. There was also no documentation that Resident #20's physician was notified that Resident #20's Trulicity 4.5 mg was not given on 09/12/24, 10/24/24, and 10/31/24. Interview with Resident #20 on 11/12/24 at 9:30 A.M. revealed Resident #20 had not received her Trulicity. Interview with Director of Nursing (DON) on 11/13/24 at 2:13 P.M. verified Resident #20's Trulicity 4.5 mg was not given per the physician order on 09/12/24, 10/24/24, and 10/31/24 because it was not available at the facility. The DON also verified there was no documentation Resident #20's physician was notified Resident #20 did not receive her Trulicity 4.5 mg on 09/12/24, 10/24/24, and 10/31/24. Review of policy titled, Change in Condition & Physician Notification Policy, dated 09/2020 revealed the nurse notified the physician and the resident/resident representative when there was a medication omission or a need to alter medications.

Based on review of the resident council minutes, observation and resident and staff interviews the facility failed to ensure they had a grievance policy and procedure, posted information on how to file grievances and designate a Grievance Official. This directly affected five residents (#03, #09, #20, #30, and #40) of 11 interviewed and had the potential to affect all 39 residents residing in the facility. Findings include: Review of the resident council meeting minutes dated from 09/23/21 through 01/25/22 revealed no information was provided to residents on how to file a grievance, no information about how confidentially would be maintained if a grievance was filed. Interview on 02/23/22 03:46 P.M., revealed residents (#03, #09, #20, #30, and #40) complained they were unaware of how to file a grievance. The residents attending the council meeting reported they were not sure who to go to when and if they wanted to file a grievance. Interview on 02/23/22 at 4:51 P.M., the Activities Director (AD) #21 stated she facilitated the resident council meetings held once a month. The AD #21 reported she goes over every department to see if residents have any comments or concerns. The AD #21 denied informing residents during resident council meetings on how to file a grievance. The AD #21 revealed the facility had no designee at this time for residents to go to if they needed to file a grievance. AD #21 reported if a resident had an issue pertaining to a grievance, she thought they would go to the social services department. Interview on 02/23/22 at 5:00 P.M., the Social Services Designee (SSD) #03 denied assisting residents with grievances. The SSD #03 stated she was new in the position and was not informed of this duty but would be happy to assist with residents' grievances. The SSD #03 reported no one told her she was solely the designee for grievances and denied receiving any grievance issues form the previous designee. The SSD #03 stated the old management took all the documents therefore, she had no information on grievances at that time. Observation on 02/23/22 at 5:15 P.M., revealed there were no postings pertaining to how to file a grievance on the 300 hall. The AD #21 verified there were no postings. Interview on 02/23/22 5:56 P.M., the Administrator reported the social services department handled grievances. The facility was unable to provide a grievance policy.

Based on resident and staff interviews and review of the local post office business hours the facility failed to ensure residents received mail on Saturdays, delivered to the facility by the post office. This directly affected five residents (#03, #09, #20, #30, and #40) of 11 interviewed and had the potential to affect all 39 residents residing in the facility. Findings include: Interview, during the resident council meeting, on 02/23/22 03:46 PM., revealed residents (#03, #09, #20, #30, and #40) stated no mail was delivered on Saturdays due to no business office staff in the building on Saturdays. The residents reported they received their mail from the activities department. Interview on 02/23/22 at 4:51 P.M., revealed the Activities Director (AD) #21 reported mail was delivered every other Saturday due to the Activity Aide (AA) #22's schedule. AA #22 delivers mail on the Saturdays she worked. AD #21 reported she works Monday through Friday and was not scheduled on Saturdays. Interview on 02/23/22 5:56 P.M., revealed the Administrator reported she was hiring a manager to work every weekend who would be responsible for delivering the residents mail every Saturday. Review of the local post office business hours revealed on Saturdays the post office was open from 9:00 A.M. through 12:00 P.M.

Based on medical record review, staff and resident interview, observations and policy review the facility failed to ensure prescribed medications were not left at the bedside for self-administration without assessment or physician's orders. This affected one resident (#22) of 16 reviewed for medication storage. In addition, expired medications were observed on two of two medications carts and one medication room. This had the potential to affect 13 residents (#05, #09, #16, #19, #20, #22, #29, #32, #33, #36, #39, #40 and #42) who had orders for the expired stock medications. The facility census was 39. Findings include: Medical record review for resident #22 revealed an admission on 06/02/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had intact cognition. Resident #22 required extensive assistance for bed mobility, transfers, and toilet use. Resident #22 required supervision for eating. Review of the plan of care for Resident #22 had no plan for self-administration of medication. Review of the active physician orders for Resident #22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic health record assessment tab revealed no assessments were completed for Resident #22 to self-administer medications. Observation on 02/21/22 at 11:07 A.M. Resident #22's bedside stand revealed an inhaler labeled [MEDICATION(S)] Aerosol Powder Breath Activated 62.5-25 mcg/inhalation, and a nasal spray labeled [MEDICATION(S)] Suspension 50 mcg unsecured. Interview on 02/21/22 at 11:15 A.M., with Resident #22 stated he was allowed to keep the medication at the bedside. He said he took the medication daily and has been since he arrived at the facility. Interview on 02/21/22 at 1:30 P.M., with the Director of Nursing (DON) verified the resident should not have medications at bedside. The DON advised the nurse working the unit to remove the medications from Resident #22's room. Review of the facility policy titled Medication Administration, dated 2017 revealed if the resident desires to self-administer mediations an assessment is conducted by the interdisciplinary team of the residents cognitive, physical, and visual ability to care out the responsibility during the care planning process. 2. Observation on 02/23/22 at 8:45 A.M. with Licensed Practical Nurse (LPN) #32 of the 200/300 hallway medication room revealed four unopened bottles of milk of magnesia with an expiration date of 12/2021, two unopened bottles of Loperamide liquid with an expiration date of 09/2021, one box of hemorrhoid suppositories with an expiration date of 05/2021, and two unopened bottles of Dairy Aide with an expiration date of 09/2021. Interview on 02/23/22 at 8:45 A.M. during the observation LPN #32 verified all outdated items located in the 200/300 hallway medication room. Observation on 02/23/22 at 8:50 A.M. with LPN #32 of the 300-hallway medication cart revealed one opened bottle of fish oil with an expiration date of 12/2021, and one opened bottle of Loperamide liquid with an expiration date of 09/2021. Interview on 02/23/22 at 8:50 A.M. during observation LPN #32 verified all outdated items located on the 300-hallway medication cart. Observation on 02/23/22 at 9:20 A.M. with LPN #20 of the 100-hallway medication cart revealed one opened bottle of milk of magnesia with an expiration date of 01/2022. Interview on 02/23/22 at 9:20 A.M. during the observation LPN #20 verified the opened bottle of milk of magnesia was outdated. Review of the facility policy titled Storage of Medication, dated 09/2018 revealed outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.

Based on medical record review, observation and staff interview the facility failed to ensure a resident urine collection bag was covered. This affected one resident (#02) of two residents reviewed for dignity. The facility census was 39. Findings include: Medical record review for Resident #02 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #02 had impaired cognition and required extensive assistance for bed mobility and transfers. Resident #02 required the use of an indwelling urinary catheter due to obstruction. Review of the plan of care dated 02/04/22 revealed resident #02 was at risk for bladder infections, and urinary obstruction. Observations of the resident on 02/22/22 at 12:30 P.M. revealed Resident #02 was in bed. The residents' door to the hall was open and from the hall the resident's catheter urine collection bag could be seen. Observations on 02/23/22 at 11:16 A.M. and 2:30 P.M. revealed the resident's door was open and the catheter urine collection bag could be seen from the hall way. Interview with State tested Nursing Assistant (STNA #14) on 02/23/22 at 2:35 P.M., revealed the facility had dignity bags someplace but she was not sure where and the resident did not have one in his room and did not have one covering his on his urine collection container. Interview with the Director of Nursing (DON) on 02/23/23 at 3:00 P.M., revealed the resident should have the urinary collection bag covered.

Based on clinical record review, observation, staff interview, policy review, and review of hospital records, the facility failed to administer the correct ordered dose of a long acting antipsychotic injectable medication. This resulted in harm for one (#18) resident of three reviewed, when Resident #18 was hospitalized for [REDACTED]. The facility census was 47. Findings include: Clinical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] documented SR #1 had some cognitive impairment, unclear speech and was taking antipsychotic medications. Review of the physicians order (PO) dated January 2017 documented Resident #18 was to receive [MEDICATION NAME] (a long acting antipsychotic medication) 25 mg/ml intramuscularly every 14 days. Review of the nursing note dated 01/28/17 at 8:15 P.M., revealed Licensed Practical Nurse (LPN) #50 documented Resident #18 was more lethargic and she noted a medication error that had taken place from the previous shift. LPN #50 called the Medical Director (MD) #51 and he stated to monitor Resident #18 and to call the previous nurse (LPN #54) to get the actual dose that was given. The actual dose was called to MD #51 and he stated to closely monitor Resident #18. LPN #50 went back in to monitor Resident #18 and noted decreased blood pressure and he was more lethargic, which was a change of condition per her first assessment. LPN #50 called MD #51 back and an order was received to send Resident #18 to the local emergency room . (The note did not contain the name or dose of the medication given, just that it was incorrect). Review of the local hospital record dated 01/28/17 documented Resident #18 was being admitted due to an accidental overdose of [MEDICATION NAME]. The record further noted Resident #18 had received 125 mg of the long acting antipsychotic medication instead of the ordered 25 mg. He had resting high amplitude tremors and lip smacking. He was at risk for [DIAGNOSES REDACTED] (NMS) (A life threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs). The first symptoms of NMS are usually muscle cramps and tremors, fever, symptoms of autonomic nervous system instability such as unstable blood pressure and alterations in mental status. Unfortunately the medication was long acting and Resident #18 was at risk to develop possible side effects from neuroleptics. The hospital's recommendation was to watch Resident #18 closely for possible NMS. Resident #18 had been diaphoretic and was having extreme tremors of all extremities and unable to get accurate heart monitoring. The local hospital Licensed Social Worker (LSW) #52 documented she confirmed with the facilities pharmacy services the [MEDICATION NAME] was a 125 mg vial. Review of the faxed local hospital discharge paperwork dated 02/02/17 documented Resident #18 was monitored for fever, and AIMS test was negative. He showed no significant adverse effects, however he would remain off the [MEDICATION NAME] for the time being. During a telephone interview on 02/02/17 at 12:15 P.M., Registered Pharmacist (RPH) #53 confirmed they had dispensed a 125 mg/5 ml a multidose vial of the [MEDICATION NAME]. She stated there was a long list of side effects, however would want to watch for NMS, cardio vascular and central nervous system concerns. She stated the medication was long acting and he would need to be monitored closely for awhile. During a telephone interview on 02/02/17 at 1:12 P.M., LPN #50 stated she worked on 01/28/17 on the night shift and Resident #18's empty box of [MEDICATION NAME] was sitting on top of the medication cart and she knew it was a multi dose vial and she could not find the actual vial. LPN #50 then stated she wondered if LPN #54 had given the whole vial. She then called MD #51 and reported to him she thought Resident #18 had been given the whole vial of [MEDICATION NAME]. MD #51 told her to contact LPN #54 and stated to monitor him. LPN #50 contacted LPN #54 who reported to her she had administered the entire vial of [MEDICATION NAME]. LPN #50 then called MD #51 back who stated to monitor him closely. LPN #50 stated Resident #18 had a change in blood pressure ([MEDICAL CONDITION]) and she sent him out per MD #51. LPN #50 stated she called the hospital to give report. The hospital called the facility back and stated they had admitted Resident #18 for an accidental overdose of [MEDICATION NAME]. During an interview on 02/02/17 at 1:41 P.M., the Director of Nursing (DON) stated she had not looked into the error of the [MEDICATION NAME], which was given on 01/28/17, until she came back to work on 01/30/17. The DON further stated LPN #54 worked 01/29/17, however she had not been educated her about the medication error of Resident #18's [MEDICATION NAME]. She further stated LPN #54 filled out an incident report regarding the medication error on 01/29/17, however it was very vague. The incident report revealed LPN #54 had given the wrong dose of medication to Resident #18. The DON also confirmed LPN #54 did not even know she committed a medication error. The DON also confirmed the order was clear and concise about how much of the [MEDICATION NAME] to give to Resident #18. During an interview on 02/02/17 at 2:37 P.M., the DON and the Administrator stated they received a phone call from LPN #50 that she had called MD #51 who told her to monitor Resident #18. The DON and Administrator stated they reported the medication error to the Corporate Quality Assurance coordinator (CQAC) #55 who contacted pharmacy to confirm. The CQAC then reviewed the order to see if it was clear and agreed it was. She further stated she was conducting medication administration reviews and had only conducted one, however she could not find the monitoring tool. She further confirmed LPN #54 worked on 01/29/17 and no education had been completed. LPN #54 was asked to come to the facility on [DATE] to discuss the medication error and she was a no call, no show, so she was terminated. Review of the facility incident log for medication errors from November 2016 to January 2017 documented there were two reported medication errors both committed by LPN #54. The facility would not allow access to the actual incident report or investigations into the medication errors. These were just gone over verbally with the Administrator and the DON. They did produce education for the nurses which was conducted on 01/31/17, however not all nurses had been educated on this date. Review of the two residents (#20 and #46) who had observed or reported medication errors revealed they were not significant errors at this time. Review of the policy titled Medication Error Reporting dated 02/24/14 revealed the following should be documented in the residents medical record, name/dose of medication that was given or omitted. Review of the policy titled Medication Administration revised April 2002 revealed to read medication label three times, follow procedure for giving specific medications. This deficiency substantiates allegations contained in complaint number OH 357.

Based on record review and staff interview, the facility failed to ensure a resident received a physician ordered antibiotic timely to treat a urinary tract infection. The resident's condition subsequently worsen and she was hospitalized [MEDICAL CONDITION]. This affected one (#24) of three sampled residents. Findings include: Review of the medical record of Resident #24 revealed [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had difficulty with recall, was moderately cognitively impaired and required limited to extensive assistance for all activities of daily living. Review of nursing progress notes dated 07/01/12 at 2:11 A.M., indicated as a late entry, revealed Resident #24 complained of nausea and dry heaving with reports of body aching and feeling dehydrated. The resident did not show any signs or symptoms of dehydration at that time and temperature was 98.6 degrees Fahrenheit. The physician was called and ordered a urinalysis. Review of laboratory results dated [DATE], reported to the facility at 7:55 A.M., revealed the resident's urine had bacteria too numerous to count with [MEDICATION NAME], leukocytes and white blood cells. Nursing progress notes dated 07/02/12 indicated the physician was not notified until that evening at 7:53 P.M. At that time a physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., on 07/03/12 at 9:00 A.M., 1:00 P.M., 9:00 PM or on 07/04/12 at 9:00 A.M., 1:00 P.M. and 9:00 P.M. Further review of the MAR indicated [REDACTED]. Nurses notes dated 07/05/12 at 6:50 P.M. noted the resident was not feeling well and had a urinary tact infection. The notes stated the resident's temperature had increase throughout the day and was currently 99.8 degrees Fahrenheit. Nurses notes dated 07/06/12 at 12:05 A.M. noted the resident's temperature was 99.4 with an increased pulse of 102, respirations of 24 and oxygen saturation level of 86 percent. The resident's daughter advised the resident was prone to getting septic with urinary tract infections. The resident complained of nausea with signs and symptoms of emesis. The notes stated the resident asked to go to the hospital. Nurses notes dated 07/06/12 at 7:40 A.M. stated the resident was admitted to the hospital with [REDACTED]. Review of hospital laboratory results of the resident's blood count dated 07/05/12, revealed the white blood cell count was 19.5 thou/mcl (normal white blood count 3.6 to 10.5). The laboratory results indicated the resident had [DIAGNOSES REDACTED]. Review of the hospital therapy evaluation dated 07/11/12 noted the resident was admitted to the hospital due [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 08/21/12 at 2:30 P.M. revealed the three nurses working at the time of the resident's change in condition did not call the physician or the pharmacist regarding the antibiotic not being available, and they did not look in the facility's emergency medication box (E-box) to see if the antibiotic was available in the box. The DON confirmed the antibiotic was available in the E-box at that time. The DON stated she did an investigation and the pharmacist stated they didn't receive an order for [REDACTED]. This is an incidental certification deficiency found during the investigation of Complaint Control Number OH 850.