Every finding on record at Rainelle Healthcare Center

Reference complaint# 2667227 Based on Record review and staff interview, the facility failed to ensure the safety and security of resident property; specifically medication. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Resident Identifiers #1, 15, 39, 56, 64, 65. Census 55.Based on Record review and staff interview, the facility failed to ensure the safety and security of resident property; specifically, medication. This was discovered during the normal Long Term Survey Process and had the ability to affect more than a limited number of residents. This citation was issued at past noncompliance. Resident identifier: #64. Facility census: 55. Findings included: a) Resident #64 On 10/21/25 it was discovered that LPN #100 was not giving out as needed (PRN) medications to the residents assigned to them. There were multiple accounts of the medications being marked as given on the Medication administration Record (MAR), but when residents were asked about their PRN medication need or use, they stated they did not request those medications. This triggered an investigation to ensure no diversion was present. On 10/24/25 the facility went to Resident #64 and asked about the increase in PRN pain medication use, to ensure they were treated appropriately. During that time, it was discovered that LPN #100 was marking off PRN medications for this resident and others as given, but the residents were not needing nor getting those PRN medications. The PRN medications were controlled substances and as such monitored closely for use. The facility looked at both Resident #64's MAR and her overall pain assessments as well as performed a blood draw (with the resident permission) to test for medication levels in their system. The daily assessment of Resident #64 showed pain on average around Zero to One out of Ten for her daily pain. However, on the days LPN #100 the PRN pain scale that is needed to be submitted with the administration of a PRN pain med, showed Five to Seven out of Ten prior to the pain meds being administered. The follow up pain score reflected a Zero out of Ten after a one hour time period. The lab work also showed only trace amounts of pain medication in Resident #100's blood. This was not consistent with expected levels based upon the administration record. The facility performed a thorough investigation into this matter and found that there was sufficient evidence to support a diversion concern and took the necessary steps to protect the residents and their property. No harm was found to have come to any resident because of the LPN's actions. The residents did not miss any necessary medications, only had their PRN misappropriated by the nurse. Timeline of events Incident 10/21/25 Labs drawn and sent out 10/21/25 Facility filed reports and informed all necessary parties 10/24/25 LPN #100 placed on a temp suspension, pending investigation 10/24/25 Diversion forms filed and sent to appropriate offices 10/24 OIG informed 10/24/25 - Initial report APS informed 10/24/25 - Initial report Local police 10/24/25 - Initial report Audits performed 10/24 - 10/29 Investigations 10/24-10/29Labs in file all show trace levels only of the residents PRN pain medsInconsistent administration of PRN med versus pain assessments and resident requests. Other residents noted with similar concerns/missing PRN medication Resident's #1, #15, #39, #56, #64,#65. OIG 5 day follow up - 10/29/25 APS 5 day follow up - 10/29/25Staff education completed - 10/29/25LPN was terminated .- 10/29/25 Plan of correction The facility completed its investigation and put into place a Plan of Correction (POC) that was fully completed by 10/29/25. This POC included assessments of all residents, labs drawn and levels checked, PRN medications replaced, education of all staff about medication administration and storage. LPN #100's employment was terminated 10/29/25. The facility took all necessary steps in the investigation and correction of this issue prior to them having their yearly Long Term Survey Recertification completed.

Based on observation, record review, and staff interview the facility failed to provide an environment free from accident hazards including, provide bed side floor mat for a resident that was in a care plan and ordered by physician and non-locking doors to general shower room and linen room. This was true for Resident #23 and has the potential affect a larger number of residents. Resident identifier: #23. Facility census: 55. Findings included: a) Resident #23 Review of Resident #23's physician orders on 05/19/26 revealed the following: Fall mat to patient's left side. Order date: 04/23/26. Review of the care plan on pages 19 and 20 revealed: Focus -Resident is at risk for falls related to, but not limited to history of falls, Parkinson's, Tremor etc Interventions- include fall mat to patients left side of bed when in bed. Date initiated 02/02/26 On 05/20/26 at 4:02 PM Resident #23 was observed lying in bed with eyes closed, call light within reach, bilateral bed bolsters but the fall mat was absent from the left side. On 05/20/26 at 4:04 PM the administrator was interviewed regarding the observation of Resident #23. The administrator acknowledged the mat was not in place. At 4:10 PM, the Administrator returned and reported the floor mat was behind the bed and had since been put into place. b) A hallway On 05/19/26 at approximately 11:30 AM during a routine walkthrough of the facility, two (2) doors in the A Hall of the residents' area were found unlocked. The General shower room and Clean utility room doors were unlocked and did not lock on three (3) attempts to allow the door to open and close under its own. Upon further inspection the doors were found to not function properly and would not lock even with assistance from a person to push them closed. These rooms contain multiple accident hazards and are to be secured at all times when not in use. On 05/19/26 at approximately 11:45 AM the Administrator (Admin) and Maintenance #11 were shown the two doors, both confirmed they were not locking. The Admin stated, I will have those looked at and fixed immediately. Maintenance #11 stated, Ill look into those right away and get them working for ya.

Based on record review and staff interviews the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission by not ensuring Pre-admission screening and resident review (PASSR) reflected the medical diagnosis prior to admission to facility and updated the PASSR. This was found true for one (1) of four (4) reviewed during the Long Term Care Survey process. Resident identifier: #17. Facility census: 55. Findings Include: a) Resident #17 During record review completed on 05/20/26 at 11:00 Am found resident # 17 has a diagnoses of Major Depressive Disorder Recurrent unspecified on 11/17/23 resident was admitted to the facility on [DATE]. Further record review revealed the most recent Pre-admission screening and Resident Review (PASSR) created on 04/20/26 did not have the diagnosis of Major Depressive Disorder Recurrent unspecified. An interview with the facility's administrator was completed on 05/20/26 at 1:00 PM and confirmed the PASSR did not have the diagnosis when completed for admission. and no other updated PASSR was completed after admission.

Based on observation, staff interview and and record review, the Facility failed to implement a resident's care plan by failing to use a floor mat for Resident #23 with a a history of falls. Resident identifier: #23. Facility Census 55. a) Resident #23 A review of Resident #23's physician orders on 05/19/26 revealed the following: Fall mat to patients left side. Order date 04/23/26. A review of the care plan on pages 19 and 20 revealed: Focus -Resident is at risk for falls related but not limited to history of falls, Parkinson's, Tremor etc Interventions- include fall mat to patients left side of bed when in bed. Date initiated 02/02/26. On 05/20/26 at 4:02 PM Resident #23 was observed lying in bed with eyes closed, bulb call light in reach, bilateral bed bolsters but absence of fall mat to left side. On 05/20/26 at 4:04 PM interview with administrator who observed Resident #23, and acknowledged the mat was not in place. At 4:10 PM the Administrator returned and reported the floor mat was behind the bed but had since been put into place.

Based on interview, record review and observation the facility failed to ensure resident #10 was provided sunscreen prior to an outside activity. Resident identifier #10. Facility Census: 55. Findings Include: a) Resident #10 After observation of Resident #10 it was evident that the resident had a sunburn. Resident #10 stated that she had been outside for an activity and was not offered sunscreen prior to going outside, therefore Resident #10 suffered a sunburn. Resident #10 sunburn resulted in an order for aloe vera to be applied to affected areas. This deficient practice was verified by the Administrator on 5/20/26 at 2:39 PM.

Based on resident interview, staff interview and record review the facility failed to protect the resident's rights to communicate with individuals confidentially by opening Resident #15's package before giving it to her. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #15. Facility Census 52. Findings include: a) Resident #15 During an interview, on 12/11/24 at 9:40 AM, Resident #15 stated, Yesterday I got a package Resident #15 then showed me the package. It was a box that she had received through mail delivery services. Resident #15 further stated, I don't like them opening my stuff without me. A record review on 12/11/24 at 10:02 AM, of Resident #15's Brief Interview for Mental Status (BIMS) assessment revealed that Resident #15, had a BIMS score of (9) nine. During an interview on 12/11/24 at 10:13 AM, The Activity Director (AD) stated, I opened it and put it in there, because she is on a special diet, and she sometimes gets hard candy so I wanted to make sure she didn't get that.

Based on record review and staff interview, the facility failed to implement the comprehensive care plan in the area of falls. This deficient practice had the potential to affect one (1) of six (6) residents investigated for the care area of falls. Resident identifier: #12. Facility census: 52. Findings included: a) Resident #12 Review of Resident #12's comprehensive care plan showed a focus relating to potential injury from falls was initiated on 04/05/17. The following intervention was initiated on 04/07/23, Staff to ensure clothes fit properly when dressing resident. If elastic is worn out in pants notify nurse and use a different pair. Review of Resident #12's medical records showed the resident experienced a fall on 11/30/24. A nursing note written on 11/30/2024 at 7:47 PM stated, Resident was observed to have hipsters in place, only one shoe was in place (right shoe.) Resident did not have properly fitting pajama pants as they were observed to have no elastic in the waistband. Pants were observed to be around her ankles and possibly the cause of this fall. New fall intervention: staff to ensure resident's clothing fits properly. On 12/11/24 at 9:48 AM, the Director of Nursing confirmed Resident #12's care plan was not implemented in the area of properly fitting pants to prevent potential falls. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Neurological checks were not performed according to professional standards of practice after an unwitnessed fall. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of falls. Resident identifier: #12. Facility census: 52. Findings included: a) Resident #12 The facility's policy and standard procedure titled Neurological Checks, no implementation date given, stated neurological checks would be performed for falls with unknown head injury as follows: - Every 15 minutes for four (4) times - Every 60 minutes for four (4) times - Every four (4) hours for four (4) times - Daily for four (4) times Review of Resident #12's medical records showed the resident had an unwitnessed fall with a head laceration on 11/13/24. The resident was evaluated in the emergency room where the head laceration was sutured. A computed tomography showed no abnormalities. Neurological evaluations were initiated when the resident returned from the emergency room to the facility. On 11/17/24, the resident had another unwitnessed fall. A nurse's note written on 11/17/2024 at 6:50 AM stated, Resident found sitting in floor on buttocks with legs outstretched in front of her behind room door. Able to get door open enough to enter room. Resident assessed for injuries, no visible injuries, no c/o [complaint] or s/s [signs or symptoms] pain/discomfort with palpation of hips. Legs equal in length. ROM [range of motion] intact. Resident assisted to seated position in wheelchair and assisted to nurses station per her request. Resident immediately requested to return to room and get back in bed. Resident assisted back to bed and resting with eyes closed, bed low position, call light in reach. Resident #12's medical records contained no documentation that neurological evaluations were initiated after the resident's unwitnessed fall on 11/17/24. However, on-going neurological evaluations related to the resident's fall on 11/13/24 continued and were now being done daily for four (4) days. The neurological evaluations last been done on 11/16/24 at 2:00 PM. The daily neurological evaluations continued on 11/17/24 at 2:00 PM and 11/18/24 at 6:00 PM. On 12/11/24 at 10:13 AM, the Director of Nursing confirmed evaluations were not initiated after the resident's unwitnessed fall on 11/17/24. She stated this was because the resident was already receiving change in condition monitoring due to the fall on 11/13/24. However, she confirmed the neurological evaluations were only being done daily after the fall on 11/17/24. No further information was provided through the completion of the survey.

Based on record review and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This deficient practice affected one (1) of six (6) residents investigated for the care area of falls. Resident #12 experienced actual harm from the fall because she experienced pain after the fall and required evaluation in the emergency room . X-ray examination showed an abnormality of the hip and further evaluation was recommended. However, the resident experienced another fall before further imaging could be obtained. After the second fall, the resident was found to have a hip fracture, requiring surgical intervention. Resident identifier: #12. Facility census: 52. Findings included: a) Resident #12 Review of Resident #12's comprehensive care plan showed a focus relating to potential for injury from falls was initiated on 04/05/2017. The focus stated, Potential for injury from falls r/t [related to] weakness, difficulty walking, hx [history] falls, Dementia with sundowning, poor safety awareness, Afib [atrial fibrillation], HTN [hypertension], CHF [congestive heart failure], Hx closed head injury, Depression, Anxiety, Behaviors, OA [osteoarthritis], allergic rhinitis, glaucoma/bilateral cataracts, Emphysema/COPD [chronic obstructive pulmonary disease], Lumbago with Sciatica, Herniated Disc, noncompliant using walker for ambulation, Cardiomegaly, Pulmonary fibrosis and nodules, Kyphosis, Hallux Valgus L/R [left and right] foot, Hammer toe L/R foot, Tinea Unguium, urinary retention, spinal stenosis lumbar, scoliosis lumbar, intervertebral disc displacement thoracic, interveterbral disc degeneration lumbar, L (left) kidney cyst, L abd (abdominal) hernia, muscle spasms to back, possible medication s/e [side-effects], CAD [coronary artery disease], incontinence, hx dislocation/fx [fracture] L humerus, ventral hernia without obstruction or gangrene. The following intervention was initiated on 04/07/23, Staff to ensure clothes fit properly when dressing resident. If elastic is worn out in pants notify nurse and use a different pair. Other interventions were as follows: - Administer Vitamin D (Ergocalciferol) per physician order. (Initiated on 07/08/2021.) - Anti-rollbacks, Anti-tippers, Dycem and extended Brakes to wheelchair. (Initiated on 10/18/2019.) - Assure that lighting is adequate and keep room and hallways free of clutter. (Initiated on 04/05/2017.) - Bed buddies while in bed as tolerated. (Initiated on 08/17/2022.) - Bed in mid to low position as tolerated (Initiated on 04/03/2018.) - Bedside commode placed next to bed per preference for resident to use, instead of attempting to walk to the bathroom. (Initiated on 03/17/2022.) - Bulb Light for ease of use, keep within reach. Check on resident frequently as she may not remember to use it. (Initiated on 04/05/2017.) - Cushion to outside of foot board of bed. (Initiated on 12/05/2024.) - Dim light on at HS [night] as resident will allow. (Initiated on 02/21/2018.) - Encourage patient to go to dining room for all meals as tolerated. (Initiated on 06/17/2021.) - Encourage patient to sleep in middle of the bed, and reposition if laying to close to edge as tolerated. (Initiated on 12/11/2021.) - Encourage resident if she allows to have door half open so staff can visibly see her when they pass by her room to check on her. (Initiated on 09/14/2019.) - Encourage resident to have rails in bathroom down so resident can use to help with stability. (Initiated on 12/08/2018.) - Encourage resident to pull up pants prior to trying to ambulate/transfer. (Initiated on 10/28/2019.) - Ensure empty isolation cart outside of room, resident uses as landmark to find room. (Initiated on 05/06/2024.) - Ensure resident is wearing double sided non-skid socks when ambulating or transferring as tolerated (resident likes to remove socks when in room) or non skid slippers. (Initiated on 04/05/2017.) - Ensure resident's cord to call light is not in the way of her walking path to transfer to her bedside commode. (Initiated on 08/09/2024.) - Ensure residents bedside table and wheelchair are within easy reach. (Initiated on 07/11/2024.) - Grab bar to wall between bathroom and sink for resident to use for steadiness while ambulating/transferring. (Initiated on 06/27/2022.) - Hand sanitizer on wall in bathroom (Initiated on 04/19/2022.) - If resident is in a carpeted areas, she must be supervised at all times as she cannot roll her wheelchair on carpet. (Initiated on 03/27/2023.) - Motion Sensor Night light in bathroom. (Initiated on12/17/2021.) - Observe for and remind resident as indicated to not place blankets in seat of the wheelchair. (Initiated on 01/15/2020.) - Observe for side effects from medication, such as dizziness or over-sedation, that may increase fall risk. (Initiated on 04/05/2017.) - Offer regular distractions that the resident enjoys (such as coloring or music) to prevent boredom. (Initiated on 10/10/2020.) - Offer to assist resident up to wheelchair and to nurses' station after last rounds in the morning. (Initiated on 11/18/2024.) - Provide AM (morning) care before breakfast ensuring all resident needs are met. (Initiated on 05/31/2024.) - Regular pressure relieving mattress with parameters to bed. (Initiated on 11/23/2021.) - Remind resident not to use bed side table for ambulation. (Initiated on 09/07/2022.) - Staff to assist resident in to wheelchair before lunch and encourage her to eat in the dining room. (Initiated on 08/19/2024.) - Staff to assist resident to call family members on handheld phone when she is having increased anxiety. (Initiated on 11/26/2024.) - Staff to bring pt to nurses station in times of increased confusion and anxiousness as res [resident] will allow. (Initiated on 10/30/2020.] - Staff to check on resident make sure her non skid socks are pulled up while in bed. (Initiated on 06/22/2020.) - Staff to check resident when up in chair to ensure proper positioning. (Initiated on 11/11/2020.) - Staff to encourage patient to use call light when in need of assistance. (Initiated on 06/18/2022.) - Staff to ensure both slippers are in place when resident is ambulating. (Initiated on 02/23/2023.) - Staff to ensure extra blanket is in her reach when she is in bed. (Initiated on 10/10/2022.) - Staff to make sure temperature in room is to residents liking before exiting room. (Initiated on 06/14/2019.) - Staff to observe resident while dining in her room in order to pick up her tray promptly when done. (Initiated on 03/23/2024.) - Staff to offer assistance with toileting prior to meals, after meals, upon rising in the morning and at bedtime. (Initiated on 07/25/2020.) - Staff to offer laying down to rest after lunch If refuses place in common area as tolerated. (Initiated on 11/25/2022.) - Staff to put long sleeve sweater on resident during AM care as requested. (Initiated on 08/15/2022.) Revision on: 07/11/2024 - Staff to stay with resident when she is observed on bedside toilet as resident tolerates. (Initiated on 09/21/2023.) - Turn heat on prior to taking resident for shower to ensure room is warm when she comes out. (Initiated on 06/11/2020.) - When staff sees resident is wheeling self down hall towards her room offer to assist her to bathroom/bed. (Initiated on 09/24/2022.) Upon observations during the investigation 12/10/24 through 12/11/24, Resident #12's fall interventions were in place. Resident #12's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 11/20/24 showed the resident's Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment. The resident had a diagnosis of vascular dementia. Review of Resident #12's medical records showed the resident experienced a fall on 11/30/24. A nursing note written on 11/30/2024 at 7:23 PM stated, At approximately 1845 resident observed sitting in floor on her buttocks in her doorway, tearful. Resident was stating, help me honey, help I'm hurt bad. Resident's left leg was observed to be slightly rotated outwards. Pillows were placed behind resident's back, and she was assisted to lay flat on her back on the floor. Resident continued to call out in pain and was not able to move her left lower extremity. L (left) hip observed to have a palpable knot which was tender to touch. V/S [vital signs] obtained: T [temperature]: 98.2 P [pulse]: 94 RR [respiratory rate]: 18 B/P [blood pressure]: 168/90 manual in L arm, O2 [oxygen saturation]: 96% on RA [room air]. Using nursing judgement this nurse called 911 at 1849 for emergency transfer to ER [emergency room ] for evaluation of L hip/LLE [left lower extremity]. While awaiting ambulance resident was observed to begin to move LLE but continued with s/s [signs and symptoms] of pain i.e. facial grimacing. MPOA [medical power of attorney], Dr [doctor] and DON [director of nursing] made aware of situation. Resident left facility at 1904 via [ambulance service]. Called and gave report to [nurse's name] RN [Registered Nurse] at [hospital name] at 1920. A nursing note written on 11/30/2024 at 7:47 PM stated, Resident was observed to have hipsters in place, only one shoe was in place (right shoe.) Resident did not have properly fitting pajama pants as they were observed to have no elastic in the waistband. Pants were observed to be around her ankles and possibly the cause of this fall. New fall intervention: staff to ensure resident's clothing fits properly. The emergency room documentation reported the resident's hip pain had resolved prior to evaluation in the emergency room . X-ray of the left hip and leg showed a very small clinically irrelevant stress fracture. An incidental viewing of the right hip showed a potential abnormality, potentially a right femoral neck fracture but more likely a positional abnormality due to the fact that the resident had no pain in the right hip or symptoms of fracture. However, this x-ray abnormality was not discovered until the resident had left the emergency room . The emergency room contacted the facility on 12/01/24 to advise them to order an x-ray of the right hip. A nursing note written on 12/1/2024 at 6:45 AM, ER physician called and stated that when radiologist read image of left hip x-ray he saw a right Fem [femoral] neck abnormality from a small part of right side that [was] visible on image. Suggested a portable x-ray on Monday for follow up. PCP [primary care physician] notified. No new orders at this time. A nursing note written on 12/1/2024 at 8:11 AM stated, POA [power of attorney] aware of this, POA stated she would like resident to stay in facility and have portable x-ray done as resident is not having pain at this time, she does not feel it is necessary to have resident sent to ER. Dr. gave orders to obtain x-ray of right hip, R knee. A nursing note written on 12/1/2024 at 2:23 PM stated, Resident is alert and oriented to baseline this shift, observed to be in a pleasant mood. Resident has allowed staff to assist her with oral care x1 [once] this shift. No issues noted in relation to this. No s/s of pain or distress noted at this time. Resident did complain of pain to R knee earlier this shift but topical biofreeze was effective for pain management. R knee is currently elevated on pillows. All fall interventions are in place. Call light is within reach. A nursing note written on 12/01/24 at 8:05 PM stated, Called to room by CNA's [certified nursing assistants]. Observed resident to be laying on floor between bed and table on left side with head toward head of bed and legs stretched out and arms to chest. Resident alert and talking with staff. Blood noted on left cheek and ear. Lacerations to left cheek noted and partial detachment of left ear lobe observed with moderate bleeding noted. Lacerations x 2 [two] noted on left forearm with minimal bleeding. Resident c/o [complained of] pain from lacerations but no other complaints of pain voiced. PCP notified. 911 called for EMS [emergency medical services] transfer due to lacerations and bleeding. POA also notified of fall and injuries and states she will meet EMS at hospital. A computed tomography (CT) scan performed at the hospital showed a right femoral neck fracture, requiring surgical intervention. The resident returned to the facility on [DATE] at 4:00 PM. On 12/11/24 at 9:48 AM, the Director of Nursing (DON) confirmed the nursing note stated Resident #12's fall on 11/30/24 was potentially caused by improperly fitting pajama pants that did not have a waist band and were down around the resident's ankles. The DON also stated it could not be determined which fall caused the resident's hip fracture. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure medical records were complete and accurate regarding fall risk evaluations for one (1) of six (6) residents reviewed for the care area of falls. Resident identifier: #54. Facility census: 52. Findings included: a) Resident #54 Review of Resident #54's medical records showed the resident had been admitted to the facility after a falling at home and fracturing her hip. A Fall Risk Observation Tool assessment was performed on 07/19/24 and documented the resident required minimum transfer assistance with gait belt. The assessment also documented the resident had a balance problem while walking and was unable to lift her head. The assessment also documented the resident had a fall history, currently took one (1) or two (2) medications that could contribute to a fall, and had one (1) or two (2) medical conditions that could contribute to falls. A Fall Risk Observation Tool assessment was repeated on 07/31/24 and documented the resident required minimum transfer assistance with gait belt. The assessment also documented the resident had a balance problem while standing. The assessment also documented the resident had a fall history, currently took one (1) or two (2) medications that could contribute to a fall, and had one (1) or two (2) medical conditions that could contribute to falls. Section E of both Fall Risk Observation Tools stated, Based on this assessment, the resident has been identified as a potential risk for falls. Proceed to care plan. Section F of both Fall Risk Observation Tools answered No to the question, After completing this assessment, is there a statement displayed in section 'E' above that identifies the resident as a potential risk for falls? Review of Resident #54's comprehensive care plan showed the resident was care planned for a risk for falls. On 12/10/24 at 3:55 PM, the Director of Nursing (DON) stated Section F of the Fall Risk Observation Tools incorrectly answered No because Section E correctly indicated Resident #54 had a potential risk for falls. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to thoroughly investigate an allegation of verbal abuse. This failed practice was found true for (1) one of (3) three residents reviewed for abuse during the survey process. Resident identifier: #53. Facility census: 49. Findings included: a) Resident #53 A review of the facilities reportables on 11/04/24 at 12:15 PM, revealed a reportable dated 01/25/24 made by Resident #53 that reads as follows: Resident reported to social worker that the day prior, he had finished using the restroom. He then states he asked the Certified Nursing Assistant (CNA) to assist him with getting cleaned up and the CNA told him, Do it yourself. Further review revealed that the alleged perpetrator was Nursing Assistant (NA) #8, and that the allegation was unsubstantiated. There was only one employee statement in the reportable. That statement was made by NA #8 and read as follows: I gave (Resident #53 name) a shower on Monday the 22nd. I changed his pullup for him on Tuesday the 23rd. I asked him if he could do it himself and he said, No, so I did it for him. He never asked for me to wipe him. He usually does that himself. A record review on 11/04/24 at 1:00 PM of Resident #53's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/24, Section C, revealed that Resident #53's Brief Interview for Mental Status (BIMS) score at the time of the incident was 15. During an interview, on 11/04/24 at 1:22 PM, the Licensed Social Worker (LSW) stated, The only staff interviewed are the ones in the reportable file.LSW confirmed that more staff should have been interviewed to unsubstantiate the allegation.

Based on staff interview and record review the facility failed to follow physician's orders. The facility failed to administer medication as ordered, failed to complete the Neuro checks after a fall, and failed to follow physician's orders for low Blood Sugars. Resident identifiers: # 41, #19, #34, #23, #9, and #44. Facility census 53. Findings included: a) Resident #41 Resident #41 is alert and has capacity. Resident #41 has a medical history (HX) of pertinent diagnosis: Parkinson's disease, Artificial knee joint bilateral, type 2 diabetes mellitus (DM), Hypokalemia, dysphagia following cerebral infarction, Hypothyroidism, Cornea transplant, bipolar II disorder, Congestive heart failure, Major depression, Anxiety, and Atrial Fibrillation. During a review of the medical records for Resident #41 the admission medications dated 09/16/23 at 5:30 PM, found the list of admission medications are as follows: 1. Acetaminophen- Codeine oral tablet 300/30 mg continue taking as at home, for pain (fracture right foot). Ordered on 09/16/23. 2. Albuterol Sulfate HFA inhalation Aerosol continue taking as at home for shortness of breath. Ordered on 09/16/23. 3. Aspirin Adult low dose oral tablet delayed release 81 mg daily at 8 AM, for HX of cerebral infarction and Atrial Fibrillation. Ordered on 09/16/23. 4. Atorvastatin Calcium oral 80 mg tablet daily at 5 PM, for hyperlipidemia. Ordered on 09/16/23. 5. Basaglar Kwik pen Subcutaneous (insulin) give 16 units subcutaneous at bedtime for DM. Ordered on 09/16/23. 6. Buspirone HCL one tablet oral 10 mg three (3) times a day, for anxiety. Ordered on 09/16/23. 7. Carbidopa-levodopa 25-100 mg tablet three times a day, for Parkinson's disease. Ordered on 09/16/23. 8. Clonazepam oral 1 mg twice a day for Seizures. Ordered on 09/16/23. 9. Eliquis 5 mg oral twice a day for HX of cerebral infarction and Atrial Fibrillation. Ordered on 09/16/23. 10. Fenofibrate 160 mg by mouth one time a day for hyperlipidemia. Ordered on 09/16/23. 11. Trimethoprim one 100 mg tablet at bedtime for prophylaxis, ordered on 09/16/23. 12. Levothyroxine 25 mcg one time a day for hypothyroidism. Ordered on 09/16/23. 13. Potassium Chloride ER 10 mEq by mouth twice a day for hypokalemia ordered on 09/16/23. 14. Acidophilus/Pectin 100 mg by mouth three times a day for prophylaxis. 15. Omeprazole 20 mg one time a day for GERD, ordered on 09/16/23. 16. Nystatin 4 ml by mouth four times a day ordered on 09/16/23. 17. Oxybutynin 15 mg by mouth one time a day for overactive bladder. Ordered on 09/16/23. 18. Venlafaxine 150 mg by mouth one time a day for depression ordered on 09/16/23. 19. Isosorbide 30 mg by mouth one time a day for hypertension. Ordered on 09/16/23. 20. Metoprolol 25 mg by mouth one time a day for hypertension. Ordered on 09/16/23. 21. Losartan Potassium 25 mg by mouth one time a day for hypertension. Ordered on 09/16/23. 22. Fluorometholone Ophthalmic 0.1 percent 1 drop in the right eye for cornea transplant. Ordered on 09/16/23. On 09/25/23 at 2:39 PM, the Director of Nursing (DON) provided the list of medications for Resident #41 and noted the medications were not given for three (3) days after admission. On 09/25/23 at 3:02 PM, the DON said the facility got a new pharmacy and she did not know why it took so long to get the medications for Resident #41. On 09/25/23 at 2:54 PM, Resident #41 and her daughter were interviewed in her room. They were asked about not receiving medications for three (3) days when admitted on [DATE]. Resident #41 said she asked the nurses about her medication and was told they were waiting on pharmacy to bring them. The pharmacy sent DON an email with a list of medication that was packaged and delivered on 09/18/23 at 5:00 PM and to start on 09/19/23. Along with this email were pictures of the medications packaged together. The packages had the date and time to administer and the names of the medications, residents name and room number. Packet #1 to be dispensed on Tuesday 09/19/23 at 8:30 AM and contained: Eliquis, Famotidine, Buspirone, Furosemide, Fenofibrate, Packet #2 to be dispensed on Tuesday 09/19/23 at 8:30 AM and contained: Isosorbide, Levothyroxine, Losartan, Metoprolol, Omeprazole. Packet #3 to be dispensed on Tuesday 09/19/23 at 8:30 AM and contained: Potassium, Oxybutynin, Venlafaxine Packet #4 to be dispensed on Tuesday 09/19/23 at 3:30 PM and contained: Buspirone. Packet #5 to be dispensed on Tuesday 09/19/23 at 4:30 PM and contained: Furosemide. Packet #6 to be dispensed on Tuesday 09/19/23 at 9:30 PM and contained: Eliquis, Potassium, Buspirone, Trimethoprim, Atorvastatin. An additional packing slip dated 09/19/23 showed the following medications that were delivered on this day were, Basaglar Kwik pen, Nystatin, Furosemide. On 09/26/23 at 3:30 PM, the DON agreed Resident #41 should have not gone three days without her medications. b) Resident #19 A review of the medical record for Resident #19 found on 08/07/23 at 10:52 AM she had a blood sugar of 53 (a normal range is 60-119). A review of the orders reveals that if a blood sugar was less than 60. Typed as written: There was not a step one (1) in the order set. Step 2: Wait 15 minutes. Recheck BS (Blood Sugar). If still below Target, give another 15g of Glucose or Carbohydrate. Once BS in normal range for resident to have meal/snack which includes a protein, Carbohydrate, and fat (i.e sandwich) Step 3: If BS <60 and resident unable to chew/swallow-give 1mg Glucagon IM (intramuscular). Repeat BS q15 minutes until BS is in normal range x 2 readings. DO NOT repeat Glucagon. Glucose gel may be repeated every 15 minutes until resident able to chew/swallow. Arrange for resident to have a snack as needed related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE (E11.22) The nursing note written on 08/07/23 reads: Finger stick blood sugar is 53, Resident alert and eating her own candy bar. On 09/25/23 at 12:23 PM, the Director of Nursing (DON) could not find any information the attending Physician was notified of the blood sugar being 53. The DON agreed the nurse did not follow protocol on 09/26/23 at 1:53 PM. c) Resident #34 A review of the medical records found Resident #34 had a blood sugar (BS) (this is a test to check the level of glucose in the blood system by collecting a small amount of blood normally from a finger) was 402. The orders state contacts the physician if BS is above 400. The only nursing note found by this surveyor was, BS was above 400. On 09/25/23 at 12:04 PM, the Director of Nursing (DON) was informed of the above. At 1:32 PM on 09/25/23, the DON stated she corrected the nursing note and added the information the facility physician was made aware. The DON provided a piece of paper with the name of Resident #34 on it. The paper appeared to be a screen shot of Text messaging. The DON said this was a method the nurses use to notify the physician and called it a Secure Conversations in Point Click Care (PCC). DON was asked if these conversations were a part on the medical record and if the surveyors have access to it. DON stated no but she could print it out if needed. On 09/25/23 at 2:33 PM, the nursing note that previously the BS was 402 was changed to the following. On 09/23/23 at 11:23 AM, glucose reading 402 currently has not eaten lunch yet. The next two notes were edited by the DON. On 09/23/23 at 2:34 PM, Glucose is now 235. Residents ate 25 percent of the lunch tray. Is asymptomatic. On 09/23/23 at 5:27 PM, (named the facility physician): Discussed. d) Resident #23 A review of the medical record for Resident #23, found this resident had many falls. A review of the facility forms called the Neurocheck Eval V 4.0-V5. were not completed on the following dates: For a fall that occurred on 08/23/23 at 1 AM. Number 14. On 08/25/23 Daily-2nd was blank. Number 15. On 08/26/23 Daily-3rd was blank. Number 16, On 08/27/23 Daily-4th was blank. For a fall that happened on 08/11/23 at midnight. Number 12. On the 4 hour-4th was blank. Number 13. Daily-1st day was blank. Number 14. Daily-2nd day was blank. Number 15. Daily-3rd day was blank, Number 16. Daily -4th day was blank. For a fall that occurred on 08/01/at 9:15 PM. The following lines were left blank. Number 6, 10, 11, 12, 14, 15, and 16. During a brief interview on 09/26/23 at 1:35 PM the Director of Nursing (DON) stated she was aware of the many unanswered questions on the forms used by the facility. At the conclusion of the survey no additional information was provided. e) Resident #9 A review of the medical record for Resident #9 found this resident had many falls. A review of the facility forms called the Neurocheck Eval V 4.0-V5. were not completed on the following dates: For a fall that occurred on 09/04/23 at 3:40 AM revealed the following numbered lines were left blank and unanswered. Number 14, 15, and 16. For a fall that happened on 09/09/23 at 11:35 AM, found the following numbered lines were left blank: Number 14. During a brief interview on 09/26/23 at 1:35 PM, the Director of Nursing (DON) stated she was aware of the many unanswered questions on the forms used by the facility. At the conclusion of the survey no additional information was provided f) Resident #44 A review of the medical record for Resident #44, found this resident had many falls. A review of the facility forms called the Neurocheck Eval V 4.0-V5. were not completed on the following dates: For a fall documented as happening on 09/04/23 at 8:15 AM questions number 1 to number 16 were left blank. On 09/26/23 at 10:39 AM, the DON agreed the form was never started and completed. For a fall that occurred on 09/05/23 at 3:45 AM, the first 15-minute checks number's 1 to 6 were left blank. For the fall that happened on 09/09/23 at 4:15 PM, the numbered lines left blank were: Number's 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16. During a brief interview on 09/26/23 at 1:35 PM the Director of Nursing (DON) stated she was aware of the many unanswered questions on the forms used by the facility. At the conclusion of the survey no additional information was provided

Based on record review, resident and family interview, and staff interview the facility failed to obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals, and quality of life that are consistent with current standards of practice. This was true for one (1) out of four (4) reviewed for receiving medications from the pharmacy in a timely manner. Resident identifier: Resident #41. Facility census 54. Findings included: a) Resident #41 Resident #41 is alert and has capacity. Resident #41 has a medical history (HX) of pertinent diagnosis: Parkinson's disease, Artificial knee joint bilateral, type 2 diabetes mellitus (DM), Hypokalemia, dysphagia following cerebral infarction, Hypothyroidism, Cornea transplant, bipolar II disorder, Congestive heart failure, Major depression, Anxiety, and Atrial Fibrillation. A review of the medical records for Resident #41 found the resident was admitted to the facility on [DATE] at 5:30 PM. The list of admission medications were as follows: 1. Acetaminophen- Codeine oral tablet 300/30 mg continue taking as at home, for pain (fracture right foot). Ordered on 09/16/23. 2. Albuterol Sulfate HFA inhalation Aerosol continue taking as at home for shortness of breath. Ordered on 09/16/23. 3. Aspirin Adult low dose oral tablet delayed release 81 mg daily at 8 AM, for HX of cerebral infarction and Atrial Fibrillation. Ordered on 09/16/23. 4. Atorvastatin Calcium oral 80 mg tablet daily at 5 PM, for hyperlipidemia. Ordered on 09/16/23. 5. Basaglar Kwik pen Subcutaneous (insulin) give 16 units subcutaneous at bedtime for DM. Ordered on 09/16/23. 6. Buspirone HCL one tablet oral 10 mg three (3) times a day, for anxiety. Ordered on 09/16/23. 7. Carbidopa-levodopa 25-100 mg tablet three times a day, for Parkinson's disease. Ordered on 09/16/23. 8. Clonazepam oral 1 mg twice a day for Seizures. Ordered on 09/16/23. 9. Eliquis 5 mg oral twice a day for HX of cerebral infarction and Atrial Fibrillation. Ordered on 09/16/23. 10. Fenofibrate 160 mg by mouth one time a day for hyperlipidemia. Ordered on 09/16/23. 11. Trimethoprim one 100 mg tablet at bedtime for prophylaxis, ordered on 09/16/23. 12. Levothyroxine 25 mcg one time a day for hypothyroidism. Ordered on 09/16/23. 13. Potassium Chloride ER 10 mEq by mouth twice a day for hypokalemia ordered on 09/16/23. 14. Acidophilus/Pectin 100 mg by mouth three times a day for prophylaxis. 15. Omeprazole 20 mg one time a day for GERD, ordered on 09/16/23. 16. Nystatin 4 ml by mouth four times a day ordered on 09/16/23. 17. Oxybutynin 15 mg by mouth one time a day for overactive bladder. Ordered on 09/16/23. 18. Venlafaxine 150 mg by mouth one time a day for depression ordered on 09/16/23. 19. Isosorbide 30 mg by mouth one time a day for hypertension. Ordered on 09/16/23. 20. Metoprolol 25 mg by mouth one time a day for hypertension. Ordered on 09/16/23. 21. Losartan Potassium 25 mg by mouth one time a day for hypertension. Ordered on 09/16/23. 22. Fluorometholone Ophthalmic 0.1 percent 1 drop in the right eye for cornea transplant. Ordered on 09/16/23. At 2:39 PM on 09/25/23, the Director of Nursing (DON) provided a list of medications for Resident #41 that were not given for three (3) days after admission. On 09/25/23 at 3:02 PM, the DON said the facility has a new pharmacy and she did not know why it took so long to get the medications for Resident #41. On 09/25/23 at 2:54 PM, the Resident and her daughter were interviewed in her room. They were asked about not receiving medications for three (3) days after being admitted on [DATE]. Resident #41 said she asked the nurses about her medication and was told they were waiting on pharmacy to bring them. The pharmacy sent the DON an email with a list of medication that was packaged and delivered on 09/18/23 at 5:00 PM and to start on 09/19/23. Along with this email were pictures of the medications packaged together. The packages had the date and time to administer and the names of the medications, residents name and room number. Packet #1 to be dispensed on Tuesday 09/19/23 at 8:30 AM and contained: Eliquis, Famotidine, Buspirone, Furosemide, Fenofibrate, Packet #2 to be dispensed on Tuesday 09/19/23 at 8:30 AM and contained: Isosorbide, Levothyroxine, Losartan, Metoprolol, Omeprazole. Packet #3 to be dispensed on Tuesday 09/19/23 at 8:30 AM and contained: Potassium, Oxybutynin, Venlafaxine Packet #4 to be dispensed on Tuesday 09/19/23 at 3:30 PM and contained: Buspirone. Packet #5 to be dispensed on Tuesday 09/19/23 at 4:30 PM and contained: Furosemide. Packet #6 to be dispensed on Tuesday 09/19/23 at 9:30 PM and contained: Eliquis, Potassium, Buspirone, Trimethoprim, Atorvastatin. An additional packing slip dated 09/19/23 showed the following medications that were delivered on this day: Basaglar Kwik pen, Nystatin, Furosemide. On 09/26/23 at 3:30 PM, the DON agreed Resident #41 should have not gone for three days without her medications.

Based on record review and staff interview, the facility failed to notify the physician when the Resident's oxygen saturation dropped outside of the specified physician's order for notification. This was a random opportunity for discovery. Resident identifier: #54. Facility census: 53. Findings included: a) Resident #54 Record review revealed Resident #54 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included: End Stage Renal Disease, Congestive Heart Failure, Type II Diabetes, Anemia, and Dependence Renal Dialysis. Review of the medication administration record for September 2023, found an order for: Oxygen at 2L/min via nasal cannula as needed for shortness of breath or oxygen less than 88% Documentation review of Weights and Vitals Summary revealed the following information: An oxygen saturation was recorded at 5:33 AM of 82% on 09/06/23. There was no documentation available to reflect the physician had been notified of decreased oxygen saturation. The medication administration record did not reflect that oxygen had been administered to the resident at the time of the 82% oxygen saturation.) An oxygen saturation was recorded at 9:08 PM of 87% on 08/20/23. There was no documentation available to reflect the physician had been notified of decreased oxygen saturation. The medication administration record did not reflect that oxygen had been administered to the resident at the time of the 87% oxygen saturation. During an interview on 09/26/23 at approximately 10:40 AM, the Director of Nursing reviewed the surveyors findings. No further information was provided to verify the physician was made aware the Resident's oxygen Saturation was below 88% on 09/06/23 and 08/20/23. 39571

Based on record review and staff interview, the facility failed to ensure a resident was provided a safe and orderly discharge from the facility. This was found for one (1) of two (2) residents reviewed for the care area of discharges. Resident identifier #54. Facility census: 53. Findings included: a) Resident #54 Record review revealed Resident #54 was admitted to the facility on [DATE] and was discharged home on 09/08/23. Diagnoses included: End Stage Renal Disease, Congestive Heart Failure, Type II Diabetes, Anemia, and Dependence Renal Dialysis. (Resident had been at the facility prior to 04/19/23, but had a hospital admission and was readmitted to the facility on [DATE].) Review of a Physician Progress Note, dated 09/05/23, found the Resident was planning to go home on peritoneal dialysis and patient feels she needs her oxygen and will have to qualify. Review of a social worker note dated 09/07/23 at 11:04 AM, revealed a referral for Home Health for evaluation. A follow-up appointment was made for Friday 09/22/23 at 3:00 PM at a medical center nearby. All medication prescriptions were being sent to the pharmacy. Review of nursing note dated 09/08/23 at 3:15 PM, revealed the resident received discharge training including, but not limited to, diabetic care, renal diet, medications, and safety awareness. All upcoming appointments were explained to the resident. Copies of, but not limited to, included all physician orders, labs, progress notes, etc, given to the resident, for discharge. The Resident voiced understanding, and questions answered to resident satisfaction. The Resident was being discharged with her daughter. Review of nursing note dated 09/08/23 at 3:57 PM, revealed the resident was leaving facility to discharge home. Resident had all of her belongings and medications were present with her. Left with daughter via car. Review of nursing note dated 09/08/23 at 4:49 PM, revealed resident was being discharged home today. Resident had occasional back pain, reported shortness of breath at rest, but had shortness of breath lying flat and on exertion. Oxygen had been discontinued after trial of oxygen weaning and oxygen saturations being completed. The Surveyor was unable to locate a physician order to discontinue PRN (as needed) oxygen prior to discharge from the facility on 09/08/23. A list of oxygen saturations were obtained, some on room air, some on oxygen, but surveyor was unable to determine what steps had been taken to ensure resident's oxygen levels did not decline with movement or ambulation. Review of a nursing assessment dated [DATE] at 11:04 AM revealed an oxygen saturation of 93% on room air. A cardiology appointment was made for 12/05/23 at 1:00 PM. Documentation review of Order Summary Report (active orders prior to discharge from facility) revealed the following information: Oxygen at 2L/min (2 liters per minute) via nasal cannula as needed for shortness of breath or oxygen saturation less than 88%. Check oxygen saturation and notify physician if less than 88%. Review of the medication administration record for September 2023, found an order for: Oxygen at 2L/min via nasal cannula as needed for shortness of breath or oxygen less than 88% Documentation review of Weights and Vitals Summary revealed the following information: An oxygen saturation was recorded at 5:30 AM of 82% on 09/06/23. There was no documentation available to reflect the physician had been notified of decreased oxygen saturation. The medication administration record did not reflect that oxygen had been administered to the resident at the time of the 82% oxygen saturation.) An oxygen saturation was recorded at 9:08 PM of 87% on 08/20/23. There was no documentation available to reflect the physician had been notified of decreased oxygen saturation. The medication administration record did not reflect that oxygen had been administered to the resident at the time of the 87% oxygen saturation. During an interview on 09/26/23 at approximately 10:40 AM, the Director of Nursing stated she believed the social worker had spoken to a customer representative at a durable medical equipment company who had informed the social worker a resident had to have consecutive oxygen saturations below 88% to qualify for oxygen. She also stated when they received a copy of the oxygen requirements guidelines, it revealed a patient may qualify on a resting room air saturation that is documented at 88% or below. She stated they had been given incorrect information, but did not specify why they did not have the guidelines available for their facility to utilize. She stated it was a new night shift nurse who had recorded the oxygen saturation of 82% at 5:30 AM on room air, and this nurse had not notified the physician of the result. In addition, it had not been recorded on the medication administration record that oxygen had been placed on the resident at the time of the 82% saturation. Per the Director of Nursing, the night shift nurse placed the oxygen back on the resident when the oxygen saturation was at 82%. During an interview on 09/26/23 at approximately 11:30 AM, the attending physician stated this resident used oxygen (as needed) only. Sometimes she would use it and sometimes she would not. Upon discharge, resident had a referral for Home Health for evaluation. Per physician, the resident had to have a low pulse oximeter for forty-eight (48) hours prior to discharge and resident did not meet that qualification. There was no documentation provided to this surveyor by the physician to verify the regulation for a low pulse oximeter forty-eight hours prior to discharge. A copy of guidelines sent by the durable medical equipment company revealed: Testing is required to be completed within two days prior to discharge. The low oxygen saturation was taken at 82% on 09/06/23 and resident was discharged on [DATE]. During an interview on 09/26/23 at approximately 1:50 PM, the facility's social worker stated he had spoken to a representative at a durable medical equipment company that the facility used concerning the guidelines for someone to qualify to receive oxygen and he thought the resident would not qualify for oxygen. It was brought to his attention after the resident was discharged that she might have needed oxygen. He had contacted the home health agency to possibly re-evaluate the resident for the need for oxygen, but they did not have a referral for nursing services, they only had an order for physical therapy at that time.

Based on record review and staff interview the facility failed to ensure the medical record was complete and accurately documented. This failed practice was true for one (1) out of four (4) residents reviewed for insulin. Resident identifiers: #34. Facility census 54 Finding included: a) Resident #34 A medical record review found Resident #34 had a blood sugar (BS) (this is a test to check the level of glucose in the blood system by collecting a small amount of blood normally from a finger) of 402 on 09/23/23. The order reads contact the physician if BS is above 400. The only nursing note found by this surveyor was, BS was above 400. There was no mention of any new orders. On 09/25/23 at 12:04 PM, the Director of Nursing (DON) was informed of the above. At 1:32 PM DON stated she corrected the nursing note and added information the facility physician was made aware of the BS. The DON provided a piece of paper with the name of Resident #34 on it. The paper appeared to be a screenshot of Text messaging. The DON said this was a method the nurses use to notify the physician and called it a Secure Conversations in Point Click Care (PCC). The DON was asked if these conversations were a part of the medical record and if the surveyors have access to it. The DON stated no, but she could print it out when needed. On 09/25/23 at 2:33 PM, it was noted the nursing note that previously said the BS was 402 was changed to the following: On 09/23/23 at 11:23 AM, glucose reading 402 currently has not eaten lunch yet. On 09/26/23 at 1:23 PM, the DON stated she edited the next two (2) notes in the Residents medical record: On 09/23/23 at 2:34 PM, Glucose is now 235. Residents ate 25 percent of the lunch tray. Is asymptomatic. On 09/23/23 at 5:27 PM, (named the facility physician): Discussed.

Based on observation, record review, and staff interview the facility failed to ensure the nutritional needs of the residents were met. Portion sizes were not provided according to the menus. In addition, the facility failed to provide menu items according to resident preference and residents were not notified of a deviation from the planned menus. This had the potential to affect more than a limited number of residents. Facility Census: 55 Findings Included: a) Inconsistent Portions A tour of the kitchen on 07/03/23 at 11:23 AM, with the Culinary Director(CD), found Culinary Aide(CA) #4 and Culinary Aide # 73 were preparing the lunch meal trays for the serving line. Observations of the serving line began at 11:23 AM on 07/03/23. CA #4 was serving broccoli which according to the menu should be served with a four (4) ounce scoop for the correct nutritional value. CA #4 was using a four (4) ounce gray handled slotted spoon. CA #4 was not measuring out a level portion of broccoli; sometimes it would be half of a spoon and then CA #4 would get a little more broccoli to fill the bowl. The portions were not consistent. CA #4 was serving scalloped potatoes which according to the menu should have been served with a four (4) ounce scoop for the correct nutritional value. CA #4 was using a 4 ounce scoop, but the serving size was not level with the scoop causing the portions to be inconsistent. The CD acknowledged the portion sizes were inconsistent. The CD and this Surveyor looked at the menu and confirmed the residents should be getting four (4) ounces of broccoli and 4 ounces of scalloped potatoes. The CD then instructed CA #73 to begin serving the correct amount of the food. At the time of this change Residents on A Hall and B Hall had already been served the broccoli and scalloped potatoes. Observation of the serving line beginning at 07/04/23 at 8:05 AM, found CA #4 was serving sausage gravy which according to the menu should have been served with a four (4) ounce scoop for the correct nutritional value. CA #4 was using a four (4) ounce gray handled slotted spoon, but CA #4 was not measuring out a level spoon,sometimes it would be half a spoon and she would get a little more to cover the biscuit. The portions were not consistent. The CD acknowledged the portion sizes were not consistent and it would not be known if the resident is receiving the appropriate nutrients needed. b) Menus During a tour of the kitchen on 07/03/23 at 11:23 AM with the CD, CA #4 and CA # 73 were preparing the lunch meal trays from the serving line. CA #73 stated the menu for today is: Pork loin Scalloped Potatoes Broccoli a slice of bread Black forest cake The residents were supposed to have rolls, but we do not have rolls. They never came on the truck, the residents are getting a slice of bread instead. An observation of the resident's lunch meal tray tickets stated the food to be served was: Country Fried steak with gravy Seasoned greens Herbed mashed potatoes Cornbread s/more pudding parfait CA #4 and the CD stated yesterday's staff used today's meal tray tickets, so we are using Sunday's meal tickets today. This surveyor asked how do you know who gets what or if they have dislikes to today's meal. CA #4 stated, I know the residents pretty well. The CD acknowledged meal tray tickets should have been re-made prior to lunch being served. During a tour of the facility on 07/03/23 at 2:35 PM, observations revealed weekly menus were posted in the Resident's room on their bulletin boards. The posted menus did not include any meal changes. During an observation on 07/04/23 at 7:50 AM, Resident #43's breakfast meal tray ticket reads as follows: Biscuit 1 (one) Rice Crunchies Cereal 1 (one)Serving Hash brown 1/2 cup Milk Hot Coffee Orange Juice Resident #43 breakfast tray was as follows: Biscuit with Sausage Gravy Hash browns a bowl of Rice Crunchies a cup of coffee a glass of orange juice Nurse Aide (NA) #25 acknowledged Resident #43 breakfast meal did not match what was on the meal tray ticket. During an interview on 07/04/23 at 8:10 AM, the CD stated Resident #43 name does not like gravy that is why the ticket says 1 biscuit. This surveyor stated he received a biscuit with sausage gravy for breakfast. The CD stated I will go speak with him and see what I can get him to replace the biscuit and gravy.

Based on observation, staff interviews, and facility documents, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The failed practices were found in the areas of monitoring and prevention of Legionella, and no hand hygiene provided for the residents prior to meals being served. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census 55. Findings included: a) Water management A review of the facility documents found the facility failed to take measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings' water systems that is based on nationally accepted standards. Which should include, description of the building water systems using text and flow diagrams) where Legionella and other opportunistic waterborne pathogens can grow and spread. Measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards (e.g., American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Centers for Disease Control (CDC), U.S. Environmental Protection Agency .) For example, control measures can include visible inspections, disinfectant, temperature control. During an interview on 07/04/23 at 9:00 AM, the Director of Plant Maintenance #32 stated he was not aware that he needed to be monitoring the cold-water temperatures and was unaware he needed a diagram and text, to show how the water flows. b) Hand hygiene During an observation of lunch being served in the dining room on 07/03/23 from 11:20 AM until 12:34 PM, it was noted there were 23 residents in the dining room, and no one was offered hand hygiene. During an interview with Nurse Aide (NA) #49 on 07/03/23 at 12:36 PM, NA #49 confirmed residents were not offered hand hygiene because, I did not know where the hand wipes were at. 45174 c) Hand Hygiene on B Hall During a dining observation on B Hall on 07/03/23 at 11:42 am, hand hygiene was not provided to the Residents prior to the lunch meal being served. During a interview on 07/03/23 at 11:45 AM, Nurses Aide (NA) #69 stated no hand hygiene was provided to the Residents prior to meals being served. During a interview on 07/03/23 at 11:45 AM, NA #42 stated, I am not going to lie to you, I did not clean their hands before lunch. The Director of Nursing was informed of the above incident during the afternoon of 07/03/23. No further information was provided.

Based on observation and staff interview the facility failed to ensure a dignified dining experience, This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside at the facility. Resident Identifier: Resident #43, #10, #15, and #16. Facility census 55. Findings included: a) Table number one (1). During an observation on 07/03/23 at 11:42 AM, Nurse Aide #53 served a lunch tray to Resident #43 seated at Table #1. Resident #10 was sharing the table with Resident #43 and did not receive a tray until six (6) minutes later. b) Table number two (2). During an observation on 07/03/23 at 11:42 AM, Nurse Aide #23 served a lunch tray to Resident #15 seated at Table #2. Resident #16 was sharing the table with Resident #15. Resident #16 did not receive a lunch tray for eight (8) minutes after her table companion. c) Interview On 07/03/23 at approximately 11:44 AM, Nurse Aide (NA) #49 was asked why Resident #10 did not receive his tray after resident #43? NA #49 said that the kitchen got the order of the trays mixed up, but agrees all residents seated at the same table should be served together.

Based on record review and staff interview the facility failed to implement a care plan for two (2) of nine (9) residents reviewed. Resident #43 and #48 did not have physician ordered equipment/utensils for meals. This was a random opportunity for discovery and affected a limited number of residents. Resident Identifiers: #43, and #48. Facility census 55. Findings included: a) Resident #43 Resident #43 had a physician's order to use a scoop bowl with meals. During an observation on 07/03/23 at 11:42 AM, Resident #43 was served chocolate cake on a dessert plate. An interview with Nurse Aide (NA) #49 on 07/03/23 at 12:10 PM, confirmed Resident #43 should have received the cake in a scoop bowl. Review of the current care plan found Resident #43 is to have meals served in scoop bowls. On the morning of 07/04/23 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the care plan was not followed. 45174 b) Resident #48 During a record review on 07/03/23 at 10:15 AM Resident #48 medical records revealed a Physician order dated 07/25/23 for a Regular diet, Dysphagia pureed texture, nectar consistency, liquids in nosey cup, yellow scoop plate with meals. During a dining room observation on 07/03/23 11:50 AM, Resident #48 was served thickened consistency coffee in a coffee mug, not a nosey cup. During an interview on 07/03/23 at 12:35 PM, the Director of Nursing acknowledged the use of the coffee mug, not a nosey cup being used. During a dining room observation on 07/04/23 at 7:50 AM, Resident #48 received regular 2% milk in a paper carton. Resident #48 was drinking the milk. During an interview on 07/04/23 at 7:52 AM the DON, acknowledged Resident #48 was not drinking thickened milk from a nosey cup per physician orders. Further record review on 07/04/23 at 9:30 AM, found Resident #48's medical record revealed a care plan with an initiated date 02/24/22 and a revision date 05/04/23. The care plan contained the following: Focus: (Resident's Name) is at risk of altered nutrition/hydration status related to diagnosis of congestive heart failure (CHF,) Vitamin D Deficiency, Anorexia, Anxiety, Depression, Dysphagia, Hypertension (HTN,) and gastroesophageal reflux disease (GERD,) elevated body mass index (BMI,) receives a mechanically altered diet with thickened liquids, order for no weights to be obtained. The goal associated with the focus: Will maintain comfort and dignity through progression of disease processes through the next review period. (Resident's name) will remain free of signs/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Inventions: Included: Provide diet as ordered; Thickened liquids in Nosey Cup: yellow scoop plate: Resident's name prefers meals in dining room. During an interview 07/04/23 at 10:23 AM, the Speech therapist #80 stated Resident #48's has severe swallowing problems, has had aspiration pneumonia, and is on thickened liquids. She has significant oral dysphagia. I re-evaluated her in December and she was still not improved enough to discontinue the thickened liquids or the pureed foods. On the morning of 07/04/23 at approximately 11:00 AM, the DON confirmed the care plan was not implemented for the residents thickened liquids to be served in a nosey cup.

Based on medical record review, resident interview, staff interview, family interview, and observation, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for five (5) of ten (10) sampled residents. The facility failed to assess, monitor, and administer pain medications to ensure effective pain management for these residents. Resident identifiers: #32, #3, #24, #42, and #64. Facility census: 56. Findings include: a) Resident #32. Resident #32 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A resident interview and family interview were conducted on the afternoon of 08/14/12. Resident #32 stated she had fallen and showed the black bruises on her buttocks, legs, and arms. She stated, "Oh, it hurts." Her son-in-law, the resident's medical power of attorney (MPOA), also stated on the afternoon of 08/14/12, "She always says she hurts in her back." Review of the incident / accident reports, on 08/16/12, revealed the resident had fallen on 06/20/12, 07/20/12, and 07/23/12. She had been sent to the emergency roiagnom on [DATE] for evaluation of the fall which occurred on that date. She was complaining of low back pain and pain in her buttock. Review of the hospital record identified Resident #32 complained of pain in multiple areas: left shoulder, left arm, left buttock, hip, and lower back. The hospital records revealed the resident had stated the pain was constant. The resident returned to the facility, on 07/23/12, with no new orders. Further review of the medical record found the skin alteration record for Resident #32 identified the facility nursing staff had documented this resident was complaining of pain on 07/23/12, 07/24/12, 07/31/12, 08/07/12, and 08/14/12. No evidence could be found the facility reassessed this resident's pain after it was documented on the "skin alteration record." The physician's progress note, dated 07/30/12, noted the resident said, "My butt hurts - I fell ." This progress note was written seven (7) days after the fall. Further review of the medical record found no new orders written for pain on this day. The resident was again interviewed, on 08/16/12, at approximately 11:45 a.m. She again complained of pain in her back and stated, "It hurts worse when I stand up." During an interview with Employee #42 (director of nursing) and Employee #78 (administrator), on 08/16/12, at approximately 4:02 p.m., it was identified that Resident #32 and her family had complained of this resident having pain during several interviews with the surveyor. The resident's medical record was reviewed, on 08/16/12. It revealed Resident #32 was to receive [MEDICATION NAME] 7.5/325 mg every 6 (six) hours for pain. Review of the medical record, on 08/20/12, found the physician had increased the resident's pain medication to [MEDICATION NAME] 10/325 mg every 6 (six) hours on 08/17/12, after surveyor intervention on 08/16/12. Review of the medical record, on 08/20/12, found no evidence of a nursing evaluation of the resident's pain. Interview with Employee #42, on 08/20/12, confirmed the facility should have completed a pain assessment on 08/17/12, when the pain medication was increased. Resident #32 was also observed during the morning medication administration pass on 08/21/12. Employee #28, a licensed practical nurse, administered medications to Resident #32, but failed to assess her for pain during the administration. Review of the Medication Administration Record, 0" for the pain assessment. Employee #28 confirmed, at approximately 3:00 p.m., on 08/21/12, she had not assessed this resident for pain. Further review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"0" pain level for the entire month of August. . b) Resident #3 Review of Resident #3's medical records, on 08/15/12 at 12:30 p.m., revealed a psychiatrist's consultation report dated 07/15/12. The consultation report stated in part "c/o (complains of) back pain." The resident's history and physical, dated 03/23/12, revealed [DIAGNOSES REDACTED]. Resident #3's comprehensive care plan, dated 07/12/12, included a problem statement for "Potential for pain evidenced by complaint of and/or signs or symptoms pain related to [MEDICAL CONDITION], urinary tract infection, history of fracture right tibia/fibula and limited mobility." The goal associated with this problem was, "Will express or present that pain management is within acceptable limits of 2/10 pain scale or show no signs or symptoms of distress." The interventions associated with this goal were, "a) Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying or thrashing out or a change in breathing, etc. b) Administer pain medication per physician orders. c) Encourage/assist to reposition frequently to position for comfort. d) Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective." A review of Resident #3's physician orders [REDACTED]. Interview with Employee #42, the director of nursing (DON), on 08/21/12 at 11:00 a.m., verified no [MEDICATION NAME] had been ordered for Resident #3 since her admission on 03/23/12. ==== c) Resident #42 During a conversation with Resident #42, on 08/22/12 at 8:45 a.m., the resident state "I am having severe pain in my neck and shoulders." The resident was holding his neck to the left side and facial grimacing was noted during the conversation with the resident. When asked if he had informed a member of nursing staff of his pain, he stated "Yes, I told them and the nurse said something about ointment and heat and would see if I could have a pain pill." Review of Resident #42's history and physical, on 08/22/12 at 8:55 a.m., revealed he had [DIAGNOSES REDACTED]. In an interview with Employee #17 (LPN supervisor), on 08/22/12 at 9:00 a.m., she stated she had notified the doctor he was having pain due to this being a new complaint of pain. On 08/22/12 at 9:20 a.m., a conversation was overheard at the nurses' station between Resident #42 and Employee #20, the activities director (AD). The resident voiced he was having severe neck and shoulder pain and had been experiencing this pain since last night. The resident's complaint of pain was verified with Employee #17, a licensed practical nurse (LPN). She added, "We are waiting to hear from doctor. " Review of Resident #17's physician orders, on 08/22/12 at 9:45 a.m., revealed on 07/30/12, the order for [MEDICATION NAME] 7.5 mg by mouth daily for treatment of [REDACTED]. (Note: [MEDICATION NAME] is use to relieve pain, tenderness, swelling, and stiffness caused by some types of arthritis.) On 08/03/12, an order was written for [MEDICATION NAME] with Tylenol 10/500mg ([MEDICATION NAME]), give one (1) tablet by mouth every four (4) hours as needed for pain. Review of Resident #17's Medication Administration Record, [REDACTED]. [MEDICATION NAME] 10/500mg had been given on the 7:00 a.m. to 3:00 p.m. shift on 08/15/12, 08/20/12, 08/21/12 and on 08/17/12 on the 11:00 p.m. to 7:00 a.m. shift. No further documentation could be found since 08/21/12 on the 7:00 a.m. to 3:00 p.m. shift to indicate the resident had received any pain medication. An interview with Employee #42, the director of nursing (DON), was conducted on 08/22/12 at 11:30 a.m. She confirmed the resident's orders for pain medication and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ==== d) Resident #24 Interview with the resident during the Stage I interview process revealed he had just returned from therapy and was having pain. Later, during Stage II of the survey process, this resident was asked again on 08/25/12 about his pain and how staff were addressing this issue for him. He said he could get pain medication when asked and he would ask sometimes 3-4 times per week. The staff had not addressed whether there was a need to administer medication prior to therapy which might help lessen the pain during and after therapy. On 08/22/12 at 9:50 a.m. the resident described his pain level to the surveyor as being as high as 7-9 on a scale of 1-10 with 10 being the worst. After medication, he said the pain would lessen to a level of 1-2. Review of the resident's medical record found documentation of pain scale intervention was in error as it showed all 0s, as if the resident had been asked or been given any pain medication. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 06/20/12, indicated the resident had had pain in the past 5 days. Also, it indicated the resident was having pain frequently. It further indicated that pain made it hard for him to sleep at night. Additionally, the assessment was coded to reflect he received scheduled pain medication and non-medication intervention. However, documentation of pain administration did not show that pain medication was given on regular basis. The current care plan, dated 03/28/12, and effective until 10/13/12, did identify pain and addressed interventions. It stated there was a risk for pain related [MEDICAL CONDITION], history of back pain and impaired mobility. The goal was for the resident to express that the pain management was within acceptable limits of 5-10 on pain scale. However, since 10 is the worst pain, this would not be a realistic goal for pain management. Interventions were listed as: administer pain medications as physician ordered, report non-verbal expression of pain such as moaning, striking out and grimacing and notify the physician if pain frequency/intensity is worsening or current regimen becomes ineffective. The resident has no pain medications ordered on a routine basis. Current medication orders on the medical record showed the resident was ordered Neuron 300 mg 1 tablet my mouth at bedtime on 08/15/12. ([MEDICATION NAME] is used to treat [MEDICAL CONDITION], postherpetic neuralgia, restless leg syndrome - it is classified as an anticonvulsant.) [MEDICATION NAME] was ordered for chest pain. He was to also receive Aspirin 1 tablet by mouth every day to [MEDICAL CONDITION](cardiovascular accident). Staff were to use a pain score scale every shift, which upon review of the documentation had all 0's listed. This was discussed with the administrator, Employee #78, the director of nursing, Employee #42, and physician on the late afternoon of 08/25/12. e) Resident #64 This resident had a [DIAGNOSES REDACTED]. A review of the medical record, specifically the physician orders, with Employee #41 (the Director of Delivery Care), on the morning of 08/23/12, revealed there had been no pain medications ordered since the resident's admission in April 2012. Review of the current care plan, of 04/19/11 that was effective until 10/20/12, revealed that pain related to vertebrae was identified as a problem. She was to receive pain medications as ordered by the physician and the nurses were to note the effectiveness. However, there was no pain medication ordered. The quarterly MDS, dated [DATE], indicated non-medication measures had been tried for pain relief. The resident's records were reviewed with Employee #41, the director of delivery care, on the morning of 08/22/12. Review of the resident's pain assessment scale documentation found they were listed as 0s. Employee #41 stated they do not want her pain level to be higher than a 4 on the scale of 1-10 with 10 being the highest level. If the resident did need pain medications they would have to contact the doctor and get a PRN (as needed) order. Staff should ask on medication pass about the resident's level of pain and document. Progress notes and assessments showed she did not complain of pain. The resident was interviewed at 1:45 p.m. on 08/22/12. She stated she has arthritis pain and knee pain at times, but does not take anything for it. She said it had not been that bad yet, and she did not feel that it was a kind of pain that needed routine pain med. When asked whether the staff checked with her about her pain level, she said they did today. (This was after surveyors had brought to the nursing staffs' attention that they had not routinely been documenting that they were asking residents about their pain level during medication pass.) .