Every finding on record at Shawnee Care Center

Based on observation, record review, and interview, the facility failed to ensure: a. sanitizer solution was dispensed and tested in the dishwasher during 1 of 2 observations made in the kitchen, b. a clean and sanitary kitchen during 1 of 2 observations made in the kitchen, and c. all items were labeled and dated in 2 of 2 refrigerators sampled for labeling and dating of food items. The administrator identified 38 residents received nutrition from the kitchen. Findings: On 05/12/26 at 6:57 a.m., dietary aide #1 was observed using the dish machine. The sanitizer solution was observed under the machine and empty. The sanitizer was observed to not be dispensing during the wash and rinse cycle. There was no sanitizer and temperature testing log observed on the wall clip board designated to log the daily dish machine testing. On at 05/12/26 at 7:00 a.m., the following observations were made in the kitchen: a. grease and food debris was on the wall above the microwave and fire suppression system, b. grease and food debris was on the right side of the oven, c. grease and food debris was on the pipes and table legs to the right of stove, d. food debris, sediment, and dust were above the grill on the on the hood vent lip, e. turkey lunch meat in a container with a green lid had no date or label, f. fruit salad in a plastic container with a green lid in the refrigerator was not labeled with a date, g. four cups of fruit salad covered in plastic wrap in the refrigerator was not labeled with the date, and h. a dish machine testing log designated to track safe temperature and proper sanitization levels was not being utilized. On 05/18/26 at 12:09 p.m., the dishwasher specification tag was observed on the dish machine. The tag showed the dish machine was a low temperature machine with a minimum temperature of 120 degrees Fahrenheit and a minimum amount of sanitizer to be used as 50 parts per million. A facility policy titled Dishwasher Policy, undated, read in part, The facility shall use commercial dishwashing equipment, according to manufactures instructions, local health department, regulations, and infection prevention standards. All dietary staff must follow, approved dishwashing, and sanitizing procedures at all times.The commercial dishwasher must: Be maintained in proper working order, Reach required wash and rinse temperatures, dispense sanitizer at approved concentrations when applicable, be clean daily.The following must be checked and documented each shift: Wash temperature, Final rinse temperature, Sanitizer concentration.Sample Dishwasher Log Date time wash Temp Rinse temp Sanitizer ppm Employee Initials. A facility policy titled Kitchen, Sanitation, and Cleaning Policy, undated, read in part, To ensure a clean, sanitary, and safe kitchen environment that protects residents from foodborne illness and complies with federal, state, and local health regulations for long-term care facilities.1. General kitchen cleaning .Walls, ceilings, vents, and light fixtures shall be clean routinely to prevent grease, dust, and debris buildup. On 05/12/26 at 6:57 a.m., dietary staff # 1 stated they could not locate the testing strips to test the sanitizer and had not tested the dish machine prior to using it that morning. On 05/12/2026 at 7:19 a.m., the administrator stated everything in the refrigerators should have had a date and all leftovers should have been used in 24 hours. On 05/12/26 at 7:30 a.m., cook #1 stated the fruit salad and turkey lunch meat were not labeled and should have been labeled with the date. On 05/12/2026 at 7:48 a.m., the administrator stated the sanitizer on the dishwasher was empty and they could not locate the testing strips to test the sanitizer. They stated the kitchen should have been clean and sanitary.

Based on observation, record review, and interview, the facility failed to ensure the care plan was revised to include catheter care for 1 (#2) of 13 sampled residents reviewed for care plans. The administrator identified 39 residents resided in the facility and three residents had catheters.On 05/13/26 at 10:35 a.m., Resident #2 was observed sitting in their wheelchair at a table waiting for activities to start. Resident #2 was observed to have a catheter bag hanging from the bottom of their wheelchair.An undated face sheet showed Resident #2 admitted to the facility on [DATE] with diagnoses which included urinary tract infection and neuromuscular dysfunction of the bladder.A physician order, dated 03/03/26, showed to place an indwelling catheter due to recurrent urinary tract infections related to poor bladder emptying. The order showed to change the catheter monthly and as needed.There was no documentation in Resident #2's care plan to show a catheter was present or what care was required for the catheter.On 05/15/26 at 11:34 a.m., the DON stated catheter care should have been added to the care plan.

Based on record review and interview, the facility failed to ensure physician orders were followed for 1 (#2) of 13 sampled residents reviewed for quality of care. The administrator identified 39 residents resided in the facility. An undated face sheet showed Resident #2 admitted to the facility on [DATE] with diagnoses which included acute kidney failure and congestive heart failure.A physician order, dated 10/21/24, showed to document fluid intake three times a day. An ADL (activities of daily living) administration history, dated 3/15/26 through 4/13/26, showed fluids consumed with meals were not documented for:a. 03/15/26 (Sunday) lunch,b. 03/16/26 (Monday) dinner,c. 03/17/26 (Tuesday) breakfast and lunch,d. 03/18/26 (Wednesday) lunch and dinner,e. 03/19/26 (Thursday) lunch,f. 03/20/26 (Friday) lunch,g. 03/21/26 (Saturday) lunch,h. 03/22/26 (Sunday) lunch and dinner,i. 03/23/26 (Monday) lunch and dinner,j 03/24/26 (Tuesday) lunch and dinner,k. 03/25/26 (Wednesday) lunch,l. 03/26/26 (Thursday) lunch,m. 03/27/26 (Friday) lunch,n. 03/28/26 (Saturday) lunch and dinner,o. 03/29/26 (Sunday) breakfast, lunch, and dinner,p. 03/30/26 (Monday) lunch,q. 03/31/26 (Tuesday) lunch,r. 04/01/26 (Wednesday) lunch,s. 04/02/26 (Thursday) lunch, t. 04/03/26 (Friday) lunch,u. 04/04/26 (Saturday) lunch,v. 04/05/26 (Sunday) lunch,w. 04/06/26 (Monday) lunch,x. 04/07/26 (Tuesday) lunch,y. 04/08/26 (Wednesday) lunch,z. 04/09/26 (Thursday) lunch and dinner,aa. 04/10/26 (Friday) breakfast, lunch, and dinner, bb. 04/11/26 (Saturday) breakfast and lunch,cc. 04/12/26 (Sunday) lunch, anddd. 04/13/26 (Sunday) lunch.On 05/15/26 at 11:34 a.m., the DON stated the 1400 mililiter fluid restriction was not documented appropriately. The DON stated they would add the order for the nurses to complete.

Based on observation, record review, and interview, the facility failed to ensure medication carts were secured for 2 (#1 and #2) of 4 medication carts observed for medication storage.The DON identified four medication carts. On 05/12/26 at 5:45 a.m., LPN #2 was observed sitting at the nurse's station where the medication carts were in direct sight. The medication carts were observed to be unlocked. LPN #2 was observed to have walked down the hallway, leaving the medication carts unsecured while out of direct line of vision. The Medication and Treatment Cart Policy, undated, read in part, medication and treatment carts shall remain locked at all times when not under direct supervision of authorized staff . Staff must maintain visual control of unlocked carts during medication and treatment pass. Carts shall not be left unattended in hallways or resident rooms. On 05/12/26 at 5:48 a.m., LPN #2 stated they had just passed meds. LPN #2 stated medication carts were to be locked when out of direct line of vision of responsible staff members. On 05/12/26 at 6:14 a.m., the administrator stated LPN #2 had admitted to them they had walked away from the unsecured medication cart upon the surveyors' arrival.

Based on observation, record review, and interview, the facility failed to ensure proper infection control for 1 (#1) of 2 sampled residents reviewed for appropriate use of enhanced barrier precautions.The administrator identified 10 residents required enhanced barrier precautions. On 05/13/26 at 2:14 p.m., LPN #1 and the DON were observed to don PPE which included gown and gloves prior to providing wound care to Resident #1. LPN #1 removed the dressing from Resident #1's right hip and cleansed with normal saline soaked gauze. LPN #1 applied medication on Resident #1's right hip and secured with a new dressing. The DON and LPN #1 were observed to have repositioned Resident #1 for wound care on Resident #1's left above the knee amputation.On 05/13/26 at 2:19 p.m., LPN #1 was observed to have removed the old dressing from the left above knee wound. LPN #1 was then observed to have cleansed the wound and applied a new dressing to the wound. LPN #1 was not observed to have changed their gloves or perform hand hygiene throughout the wound care on the two different wounds on Resident #1. On 05/13/2026 at 2:27 p.m., CNA #2 and CNA #4 were observed wearing gown and gloves to clean Resident #1 of bowel movement and change linen. CNA #4 cleansed the catheter tubing at the insertion site with a washcloth and wiped bowel movement from the buttocks with the same washcloth. CNA #4 then replaced dirty linen with clean linen. CNA #4 was observed to not change their gloves between cleaning Resident #1 of bowel movement and positioning the clean linen beneath the resident.On 05/13/26 at 2:42 pm., LPN #1 was observed to remove their gown and gloves and remove the wound supplies from the room. CNA #2 and CNA #4 gathered dirty supplies, placed them into appropriate bins, removed their gown and gloves, and left the room. LPN #1, CNA #2, and CNA #4 were not observed to wash their hands before exiting the room. An admission assessment, dated 04/13/26, for Resident #1 showed the resident was admitted on [DATE] with diagnoses which included sepsis, surgical amputation, necrosis of amputation stump left lower extremity, dehiscence (broke open along the suture line) of amputation stump, and open wound of right hip. The admission assessment showed Resident #1 was moderately cognitively impaired with a BIMS (brief interview for mental status) score of 11. The assessment showed Resident #1 required substantial to maximum assistance from staff for all activities of daily living including bed mobility and toileting hygiene. An undated Infection Control Policy, showed all employees shall be instructed in proper hand-washing techniques. Protective clothing-gowns, gloves, masks-shall be provided to employees required for protection of the resident or the employee. The policy showed gloves were to be removed and hand hygiene performed before donning clean gloves and continuing care after cleaning up blood or body fluid contamination.A Handwashing/Hand Hygiene policy, revised 08/2019, read in part, The facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after direct contact with residents; .Before and after handling an invasive device (e.g. urinary catheter); .Before handling clean or soiled dressings, gauze pads, etc,; Before moving from a contaminated body site to a clean body site during resident care; .After handling used dressings, contaminated equipment, etc,; .After removing gloves; . Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.On 05/13/2026 at 2:50 p.m., LPN #1 stated they should have changed their gloves after cleaning the wounds and between providing care for different wounds. LPN #1 stated hands should be washed before and after providing wound care and gloves should be changed between dirty and clean aspects of providing wound care to help prevent the spread of infection. On 05/13/2026 at 2:52 p.m., the DON stated they would have to check the policy for when gloves needed to be changed and hands needed to be washed.On 05/13/26 at 2:59 p.m., CNA #4 stated they wished they would have brought more gloves into the room with them. CNA #4 acknowledged they did not change their gloves after cleaning bowel movement off Resident #1 and before preparing and positioning clean linen to be used beneath Resident #1. CNA #4 stated they were supposed to wash their hands before and after providing care and before exiting the room. CNA #2 nodded in agreement. On 05/18/26 at 4:13 p.m., the IP stated all the rooms that require enhanced barrier precautions have the PPE outside of the door and signs hanging up to inform staff of what PPE is necessary to wear for what type of interactions. The IP stated the observed staff members were new and were not used to being watched by surveyors.

Based on observation, record review, and interview, the facility failed to ensure a gradual dose reduction for a psychotropic medication was initiated when ordered by the physician for 1 (#1) of 3 sampled residents whose medications were reviewed.The MDS coordinator identified 39 residents who received psychotropic medications.Findings:On 08/11/25 at 4:20 p.m., Res #1's medications were reviewed with CMA #1. A pill medication blister card, dated 07/07/25, showed a 30-day supply of olanzapine 15 mg tablets. The card showed the first dose of olanzapine 15 mg (an antipsychotic medication) had been popped on 07/19/25 and six tablets currently remined in the blister card.An undated face sheet showed Res #1 had diagnoses which included bipolar disorder and recurrent depressive disorders.A physician order, dated 12/16/24, showed to administer olanzapine 20 mg daily.A pharmacist monthly medication review, dated 07/01/25, showed a request for a gradual dose reduction of olanzapine 20 mg daily. The review showed the physician had agreed to decrease the dosage to 15 mg daily.A quarterly assessment, dated 07/07/25, showed Res #1 had a BIMS score of 11 and was moderately cognitively impaired. The assessment showed Res #1 had no symptoms of depression, no behaviors, and had received antipsychotic and antidepressant medication.A physician order, dated 07/07/25, showed to discontinue olanzapine 20 mg daily.A physician order, dated 07/07/25, showed to administer olanzapine 15 mg daily.A medication error report, dated 07/19/25, showed the dosage of olanzapine was changed from 20 mg daily to 15 mg daily on 07/07/25. The report showed CMA #1 was unaware the dosage had changed and continued to administer 20 mg daily until the error was noticed on 07/19/25. The report showed no apparent effects as an outcome for Res #1.On 08/11/25 at 4:20 p.m., CMA #1 stated the first dose of olanzapine 15 mg had been administered out of the pill medication blister card on 07/19/25. On 08/11/25 at 4:23 p.m., CMA #1 was asked what dosage of olanzapine Res #1 had received from 07/08/25 through 07/18/25. CMA #1 stated they had not realized the physician order had changed from 20 mg daily to 15 mg daily on 07/07/25 and continued to give the 20 mg pill until the error was noticed on 07/19/25. CMA #1 stated they should have verified the dosage shown on the physician order in the medical record with the dosage on the pill card prior to administration. On 08/12/25 at 12:15 p.m., the DON stated they completed an investigation after they were informed of a possible medication error for Res #1 on 07/19/25. They stated the physician order for olanzapine had changed from 20 mg to 15 mg daily on 07/07/25. The DON stated Res #1 continued to receive olanzapine 20 mg daily until the medication error was verified on 07/19/25. They stated CMA #1 should have verified the correct dosage on the pill card with the physician order prior to administration. The DON stated Res #1 received the wrong dosage of olanzapine for 11 days.

Based on observation, record review, and interview, the facility failed to ensure residents narcotic pain medications were able to be refilled and arrange for a pain specialist for 1 (#1) of 3 sampled residents reviewed for pain management. Resident #1 ran out of morphine and went six days without the medication which caused increased pain levels. Findings: On 05/14/25 at 10:00 a.m., Resident #1's bubble pack of morphine tablets were observed with CMA #1. The fill date on the morphine showed it was filled on 05/09/25. Resident #1's admission orders, dated 04/28/25, showed they had the following orders: Schedule II morphine extended release; 30 milligrams, one tablet by mouth twice a day for chronic pain. Schedule two oxycodone 10 milligrams one tablet by mouth every four hours as needed for chronic pain. Resident #1 admission morphine count sheet, dated 04/28/25, showed they were admitted with eleven tablets. Resident #1's base line care plan, dated 04/30/25, showed Resident #1 received opioid's of morphine and oxycodone for chronic pain. The medication administration record, dated 04/28/25 through 05/13/25, showed Resident #1 received 11 doses of morphine after admission with the last dose being received on 05/04/25 at 10:14 a.m. The medication administration record also showed the resident did not receive the next 12 doses of morphine from 05/04/25 until 05/10/25 during the 4:00 p.m. to 8:00 p.m. medication pass. Resident #1 went without 12 doses (six days) of their routine morphine. Resident #1's nurses progress note, dated 05/05/25 at 9:20 a.m., showed they went to the emergency room due to being out of morphine and the script was pending. Resident #1's nurses progress note, dated 05/06/25 at 6:00 p.m., read in part, Call from [Name deleted doctor] r/t [Resident #1] coming to ER for Rx. He advised that he had discussed with [Resident #1] his need to come to the ER. He advised [Resident #1] he would not prescribe PRN meds in ER. There was no documentation Resident #1 pain level was assessed prior to going to the emergency room. Resident #1 nurses progress note, dated 05/07/25 at 6:07 a.m., read in part, At 0210, 0422, and 0630, [2:10 a.m., 4:22 a.m., and 6:30 a.m.] the charge nurse and CNA entered room together to inform resident that it was time to turn and reposition d/t skin breakdown. Each time the resident very politely told staff that he will not turn until he gets his demands. Staff asked what he was referring to and he stated #1 I want a bariatric bed and #2 I want to see the pain doctor. The note was entered by RN #1. Resident #1's face sheet, dated 05/13/25, showed they were admitted to the facility on [DATE] and had diagnoses of anxiety, depression, paraplegia, and chronic pain. The face sheet showed Physician #1 was the attending physician for the resident. On 05/13/25 at 11:55 a.m., Resident #1 stated they had been at the facility three weeks and did not have a doctor. Resident #1 stated they ran out of their morphine and could not get it refilled and they went six days without their pain medication. Resident #1 stated they could live with a pain level of five ,but their pain went up to a seven without their morphine twice a day. Resident #1 stated they took other pain medication but it was not as effective without the morphine and the highest the pain got was a seven out of ten. On 05/14/25 at 10:17 a.m., CMA #1 stated the MDS coordinator was responsible for ordering all narcotic medications when it was needed. CMA #1 stated Resident #1 usually complained of pain in the neck and shoulder. CMA #1 stated Resident #1 came with some morphine and it ran out. CMA #1 stated there was a discrepancy on who Resident #1 physician was, and who was filling the morphine when it ran out. CMA #1 stated Resident #1 went to the emergency room to get the morphine, but they would not fill the script. CMA #1 stated they were not aware of Resident #1 being referred to a pain specialist and they went six days without the morphine. CMA #1 stated Resident #1 would complain of pain at a level of seven without the morphine. CMA #1 stated they did not document the level of pain, just where the pain was located when they provided as needed medication and/or routine pain medication. On 05/14/25 at 10:39 a.m., the corporate nurse consultant stated the facility had not been monitoring pain levels properly because it was not added to the medication administration record. The corporate nurse consultant stated the messages on the medication administration record were when medications were not provided as ordered. They reviewed the medication administration record and stated Resident #1 did not have morphine to take for six days. On 05/14/25 at 10:57 a.m., LPN #1 stated Resident #1 did not have a physician after April 30th and went to the emergency room to try and get their morphine. LPN #1 stated they thought there would be a new physician by now, but there continued to be no physician for Resident #1. LPN #1 stated physician #1 was contacted by the hospital emergency room and agreed to fill the morphine at the request of the emergency room. LPN #1 stated physician #1 worked at the hospital. On 05/14/25 at 11:36 a.m., the social service director stated they were responsible for making arrangements for outside services like pain management specialist. The social service director stated they were not aware of Resident #1's request for a pain management specialist. On 05/14/25 at 12:00 p.m., RN #1 stated they worked nights from 11:00 p.m. through 7:00 a.m. RN #1 stated Resident #1 had requested to see a pain specialist and they talked to RN #2 about it, but nothing more was done. RN #1 stated Resident #1 stated they were in more pain without the morphine and rated the pain between seven and eight. RN #1 stated Resident #1 went without their morphine for more then two days. RN #1 stated they could not get a prescription for the medication because the facility was transitioning to a new physician. RN #1 stated physician #1's last day was in April and the facility was attempting to get a new physician. RN #1 stated Resident #1 went to the emergency room to get their morphine two or three times. RN #1 stated Resident #1's normal pain level was a five and it was consistently at a seven to eight without the pain medication. On 05/14/25 at 12:33 p.m., RN #2 stated Resident #1 wanted to see a pain management doctor and spoke with the former administrator about it and no referrals were made. RN #2 stated they went to the administrator because the facility had no director of nursing and the resident did not have an attending physician. RN #2 stated Resident #1 went to the emergency room to attempt to get the morphine because there was no doctor to sign the script. RN #2 stated the emergency room would not write a script for Resident #1. RN #2 stated the hold up with getting the morphine prescription was Resident #1 did not have an attending physician. RN #2 stated they did not tell the social service director about the need for a pain specialist. RN #2 stated Resident #1's pain was back down with the morphine back in stock. On 05/14/25 at 2:13 p.m., the corporate nurse consultant, stated physician #1 was to fill prescriptions until a new physician was found. The corporate nurse consultant stated Resident #1 was without the pain medications for six days. The corporate nurse consultant stated there was no physician after 04/30/25, and that delayed the morphine prescription being written and filled. On 05/14/25, at 3:22 p.m., Physician #1 stated they sent an email in February to provide plenty of notice for a replacement for a medical director and physician for the residents. They stated it was very clear April 30th was going to be the last day. Physician #1 stated they were no longer filling prescriptions or providing care to residents after April 30th. Physician #1 stated the emergency room contacted them because they worked at the hospital and as a courtesy signed a prescription for morphine to be filled. Physician #1 stated Resident #1 came to the emergency room because the facility did not have a physician to fill the prescription.

Based on record review and interview, the facilty failed to have a supervising physician for 6 (#1, 2, 4, 5, 6, and #7) of 6 sampled residents reviewed for physician services. Physician #1 no longer provided services to the residents after 04/30/25. The corporate nurse consultant identifed 39 residents who resided in the facility and had physician services from physician #1 and was without the supervision of a physician. Findings: The facility policy, Physician Services, last revised February 2021, read in part, The medical care of each resident is supervised by a licensed physician.Supervising the medical care of residents includes (but is not limited to) prescribing medications and therapy. An email, dated 02/26/25, read in part, Please accept this as my letter of resignation as the medical director of Shawnee Care Center. I will provide services through April 30, 2025. If you choose to replace me prior to that date, I would understand. The email was sent from physician #1. On 05/13/25 at 10:34 a.m., Resident #2's family stated Physician #1 was no longer the physician and they did not know who replaced them. On 05/13/25 at 10:55 a.m. Resident #5 stated they did not have a physician after Physician #1 left. On 05/13/25 at 11:08 a.m., Resident #7 stated Physician #1 use to come see them and they did not know who was going to come now. On 05/13/25 at 11:25 a.m., Resident #4 stated Physician #1 was their doctor and they had to get a new one. Resident #4 stated they did not know who the new doctor was going to be. On 05/13/25 at 11:50 a.m., Resident #6 stated Physician #1 came monthly but quit the end of April. On 05/13/25 at 11:55 a.m., Resident #1 stated they had been at the facility three weeks and did not have a doctor. Resident #1 stated they ran out of their morphine and could not get it filled and they went six days without their pain medication. Resident #1 stated they can live with a pain a level of five but their pain went up to seven without their morphine twice a day. Resident #1 stated they took other pain medication but it was not as effective without the morphine and the highest the pain got was seven out of ten. On 05/14/25 at 2:13 p.m., the corporate nurse consultant, stated there was no physician, after 04/30/25, for 39 residents, and they did not know why it took so long for a replacement. The corporate nurse consultant stated on 05/01/25 there was no physician for Resident #1 and that delayed the morphine prescription from being written and filled. On 05/14/25 at 3:22 p.m., Physician #1 stated they sent an email in February to provide plenty of notice for a replacement for a medical director and physician for the residents. They stated it was very clear April 30th was going to be the last day. Physician #1 stated they were no longer filling prescriptions or providing care to residents after April 30, 2025.

Based on observation, record review, and interview, the facilty failed to have a registered nurse as the director of nursing. The corporate nurse consultant identified 49 residents who resided in the facility. Findings: On 05/12/25 at 1:48 p.m., the posted nurse staffing was observed without a name listed as the director of nursing. The undated facility employee list did not have a name of a registered nurse listed as the director of nursing. The undated list of facility key staff, provided by the corporate nurse consultant, did not contain a name listed as the director of nursing. A review of time cards for RN #3, the former director of nursing showed the last day of employment was April 1, 2025. On 05/13/25 at 2:34 p.m., the corporate nurse consultant stated the requirements were for the facility to have a full time registered nurse as the director of nursing. The corporate nurse consultant stated they did not have anyone designated as the director of nursing since the last one quit. The corporate nurse consultant stated they would need to look at the time cards to see when the last day RN #3 worked. They left and returned and stated April 1, 2025 was the last day of employment for RN #3.

Based on record review, and interview, the facility failed to have a medical director after 04/30/25. The corporate nurse consultant identifed 49 residents who resided in the facility. Findings: The facility policy Medical Director, last revised July 2016, read in part, Physician services shall be under the supervision of the medical director.Medical director functions also include, but are not limited to helping assure that the residents receive adequate services appropriate to meet their needs. An email, dated 02/26/25, read in part, Please accept this as my letter of resignation as the medical director of Shawnee Care Center. I will provide services through April 30, 2025. If you choose to replace me prior to that date, I would understand. The email was sent from physician #1, who was also the medical director. A review of the facilty medical directors contracts showed the only contract for services was with physician #1. No new contracts were located that showed a new physician replaced physician #1. On 05/14/25 at 2:13 p.m., the corporate nurse consultant, stated there was no medical director after 04/30/25, and they did not know why it took so long for a replacement. The corporate nurse consultant stated on 05/01/25, there was no active medical director or signed contract for an active medical director. On 05/14/25 at 3:22 p.m., physician #1, the former medical director, stated they were the medical director until April 30th. Physician #1 stated they sent an email in February to provide plenty of notice for a replacement. They stated it was very clear April 30, 2025 was going to be the last day.

Based on record review and interview the facility failed to provide notices to Medicaid recipients trust account holder when balances was within $200 of the resource limit for a medicaid recipient resident for one (#1) of three sampled residents reviewed for active trust account balances. The Business office manger identified 24 residents that have money in the trust account, were current residents and had Medicaid as their payer source. Findings: A review of the current trust account ledger dated 07/08/24, documented Resident # 1 had a current balance in their trust account of $2,874.59. Resident #1 face sheet documented they were a Medicaid recipient. There was no documentation to indicate the facility had notified the resident when they were within $200 of the $2,000 resource limit. On 07/09/24 at 10:48 a.m., the business office manager stated the resource limit for medicaid recipient residents was $2,000. They were asked to provide the notification provided to Resident #1 when they were within the $200 of the resource limit. They stated they had not provided and had no documentation a notice was provided.

Based on observation, record review, and interview, the facility failed to provide meals in the assisted dining room in a dignified manner for two (#28 and #47 ) of three sampled residents reviewed for assisted dining. The Administrator identified ten residents who required asssistance with their meals and had their meals in the assisted dining room. Findings: 1. Resident #28 had diagnosis to include dementia, schizoaffective disorder, depression, and cerebral infarction. A care plan, last updated 05/31/2024, documented Resident #28 required one person extensive assistance with eating. An annual assessment dated /31/2024, documented Resident #28 cognition was severely impaired and required moderate assistance with eating. 2. Resident # 47 had diagnosis to include Malignant neoplasm of prostate, Shortness of breath, erythema conditions, Xerosis cutis, primary thrombocytopenia, Need for assistance with personal care, Cognitive communication deficit, and contracture of knee. A significant change assessment, dated 06/21/2024, documented Resident #47 cognition was severely impaired, and required substantial assistance with eating. On 07/07/24 at 8:25 a.m., Resident #28 and #47 were observed in the assisted dining area waiting for their morning meal. Resident #28 was yelling he needed help and was cold. Resident #28 said he wanted a jacket. Three additional residents were heard complaining about it being cold in the assisted dining room. No staff were present in the assisted dining room to assist the resident and addresses the complaints of being cold. On 07/07/24 from 8:25 a.m., through 8:43 a.m., Resident #28 and three additional three additional residents continued complaining it was cold and no staff was present in the room to assist the residents. On 07/07/24 at 8:43 a.m. a certified nurse aide was observed brining a Resident to the dining room, Resident #28 and three additional residents continued to say it was cold. Resident #28 continued to ask for a jacket, and the aide left the dining room without assisting the residents who were complaining it was cold in the dining room. On 07/07/24 from 8:43 a.m., through 8:48 a.m., Resident #28 and three additional residents continued to complain it was cold in the room with Resident #28 asking for a jacket. On 07/07/24 at 8:48 a.m., the infection preventionist was observed coming into the assisted dining room with drinks and lutenists. The infection preventionist places a plate guard in front of Resident #28 who continued to yell for help they were cold and wanted a jacket, and three additional residents also continued to complain it was cold in the assisted dining room. The infection preventionist continued passing drinks and placing utensils in front of the residents without assessing any of the residents who were complaining it was cold. On 07/07/24 at 8:51 a.m., the infection preventionist acknowledged the complaints from Resident #28 and stated they would go and see if they could get something for them. The infection preventionist then continued to pass drinks and utensils to the residents in the assisted dining room. On 07/07/24 from 8:51 a.m. through 9:00 a.m. Resident #28 and three additional residents continued complaining it was cold and no asssistance was provided to address the concerns. On 07/07/24 at 9:00 a.m., the infection preventionist went to get an aide and requested blankets be brought into the residents that were complaining about being cold and adjusted the temperature in the assisted dining room. Resident #28 and three additional residents were observed from 8:25 a.m. until 9:00 a.m., (35 minutes) complaining of being cold without anyone assisting them. On 07/07/24 at 9:05 a.m., the infection preventionist was observed providing the first meal tray to Resident #28 and at 9:15 a.m., to Resident #47. The meal was served over one and half hours past the scheduled meal service time in the assisted dining room. On 07/09/24 at 9:30 a.m., the infection preventionist stated they started with drinks and silverware first, and then assisted the residents who were cold. When asked why they did not assist residents who were cold sooner, the infection preventionist stated they were waiting for more staff to come into the room and assist with the meal. They then stated it was not right for residents to wait that long and be cold and it was a dignity issue. On 07/09/24 at 9:59 a.m., the administrator and Corporate Nurse Consultant #1 were made aware of the issues with meal service and residents being cold in the assisted dining room. Both the administrator and Corporate Nurse Consultant #1 stated that was a dignity issue with residents waiting that long and being cold.

Based on record review and interview, the facility failed to ensure residents were bathed according to standards of care for two (#31 and #35) of three sampled residents reviewed for bathing. The corporate nurse reported 49 residents resided in the facility. Findings: 1. Res #31 admitted to the faiclity with diagnoses of cerebral infarction, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle wasting and atrophy. On 07/07/24 at 9:25 a.m., the resident reported there isn't enough CNAs on her showers nights so she is going to take them during the day. A care plan last revised on 05/09/24 documented the resident requires extensive assist of 1 person with bathing. A Point of Care ADL category report documented the resident had a partial bath on 06/09/24, the report contained no other documentation of bathing from 06/09/24 to 07/08/24. On 07/10/24 at 9:02 a.m., the corporate nurse reported the residenrt did not received showers according to standards of care. 2. Res #35 dmitted with metabolic encephalopathy, acute kidney failure, unspecified, morbid (severe) obesity due to excess calories, and generalized anxiety disorder. A care plan, revised on 05/31/24, contained no documentaion of activities of daily living. On 07/08/24 at 9:01 a.m., resident #35 was observed sitting in her wheelchair in her room. The resident reported she did not get showers as scheduled. On 07/09/24 at 11:09 a.m., the resident's ADL documentation reviewed including shower/bath logs. The log documented the resident received a partial bath on 06/09/24 and no other showers were documented until 07/01/24. Point of Care ADL category report documented the resident requires limited assist of 1 with showers/bath. On 07/10/24 at 9:05 a.m., the corporate nurse reported the resident did not receive showers per standards of care nad the resident's activities of daily living was not care planned.

Based on observation, record review, and interview the facility failed to update the care plan related to pressure ulcers for one (#32) of one resident reviewed for pressure ulcers. The infection preventionist identified two residents with pressure ulcers. Findings: Res #32 had diagnoses which included stage III sacral pressure ulcer, dementia, and fracture of right femur. A quarterly assessment, dated 02/21/24, documented the resident was cognitively intact, required partial to moderate assistance with mobility, and did not have a pressure ulcer. A care plan, revised 05/07/24, documented the resident was at risk for pressure ulcers due to the inability to walk far, malnutrition, and a bony appearance. The care plan documented a goal of intact skin without evidence of redness, irritation, maceration, or open areas. A quarterly assessment, dated 05/21/24, documented the resident was cognitively intact, required partial to moderated assistance with mobility, and had one stage II pressure ulcer not present upon admission. There was no documentation related to the presence of a pressure ulcer or treatment documented on the care plan. On 07/07/24 at 9:01 a.m., Res #32 was observed sitting in a wheelchair. Res #32 stated they had wounds on their tailbone that developed while in the facility. Res #32 stated they received wound care from the staff. On 07/08/24 at 11:25 a.m., LPN #1 was observed performing wound care on Res #32. LPN #1 stated the resident received wound care every other day of the week per physician orders. LPN #1 stated the wound care and interventions should be documented on the care plan. On 07/08/24 at 1:37 p.m., the corporate RN stated the care plan should have been updated to reflect the pressure ulcer and treatment.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed and/or implemented to address the residents' needs related to a urinary catheter for one (#32) and activities of daily living, and anticoagluant therapy for one (#35) of residents whose care plans were reviewed. The corporate RN identified 49 residents who resided in the facility. The corporate RN identified five residents with a urinary catheter. Findings: A Comprehensive Person-Centered Care Plan policy, revised December 2016, read in part, .The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 1. Res #32 had diagnoses which included stage III sacral pressure ulcer, dementia, and fracture of right femur. A care plan, revised 05/07/24, documented the resident was occasionally incontinent of bladder due to inability to move fast. The care plan documented the resident wore adult undergarments while out of bed for dignity. A quarterly assessment, dated 05/21/24, documented the resident was cognitively intact, required partial to moderate assistance with toileting, was frequently incontinent of bladder, and did not have an indwelling catheter. A nurse note, dated 06/04/24, documented Res #32 had an indwelling urinary catheter placed. A 5-day assessment, dated 06/05/24, documented the resident was cognitively intact, dependent with toileting, and had an indwelling catheter. There was no documentation related to an indwelling urinary catheter, catheter maintenance, or infection prevention interventions documented on the care plan. On 07/07/24 at 9:02 a.m., Res #32 was observed sitting in a wheelchair. An indwelling catheter was observed attached to the bottom of the wheelchair. Res #32 stated they had the catheter for a while but did not know why it was placed. On 07/08/24 at 1:22 p.m., the corporate RN stated the catheter was placed due to wounds on Res #32's coccyx. They stated a comprehensive care plan should have been developed to reflect the catheter, catheter maintenance, and infection prevention interventions. 43023 2. Res #35 dmitted to the faciit with diagnoses of metabolic encephalopathy, acute kidney failure, unspecified, morbid (severe) obesity due to excess calories, and generalized anxiety disorder. A physican order, dated 08/11/23, documented Eliquis 5mg every 12 hours. A physician's order, dated 01/02/24, documented Toresemide 20mg once a day. A Point of Care ADL category report, dated July 2024, documented the resident requires limited assist of 1 with showers/baths. A care plan, dated 05/31/24, was reviewed and contained no documentation for activies of daily living, diuretic therapy or anticoagulant therapy. On 07/10/24 at 9:05 a.m., the corporate nurse wasasked to review the care plan for ADL's, diuretic therapy and anticoagulant therapy. They reported neither was care planned and should have been.

Based on record review and interview it was determined the facility failed to notify a family of falls for one (#29) of three sampled residents reviewed for notification of a change in condition. The corporate nurse reported 49 residents resided in the facility. Findings: An undated policy, Change in a Resident's Condition or Status, read in part, .in addition to notifying the resident and/or their representative .of a change . Resident #29 had diagnosis to include abnormalities of gait, history of falling, and cognitive communication deficit. An incident report dated 05/17/24 documented the resident had a fall while in the shower. A nursing progress note, dated 05/17/24 at 2:25 p.m., read in part, .While getting a shower this morning, upon standing to transfer to shower chair . There was no documentation on the incident report or in the clinical record the family had been notified of the fall. An incident report dated 05/27/24 documented the resident had a fall while in the shower. A nursing progress note, dated 05/28/24 at 12:14 p.m., read in part, .On 5/27, while in the shower and being transferred to shower chair, [NAME] stated I'm going down, my foot turned! CNA eased him to the floor .Family has been notified of event . There was no documentation on the incident report or in the clinical record the family had been notified of the fall until 24 hours after the fall had occurred. On 07/10/24 at 11:19 a.m., the corporate nurse consultant #1 stated families should be notified right away after a fall once the resident was stabilized. The corporate nurse consultant #1, then stated the notification of a fall should be documented in the progress notes and occur the same day as the fall. They then stated the family did not get notified of the fall in the shower on 05/17/24 and was not notified timely when they fell on [DATE].

Based on record review and interview the facility failed to ensure residents: a. were offered the choice to formulate an advanced directive for one (#21) of two sampled resident for advanced directives, b. DNR (Do Not Resuscitate) forms were filled out correctly. The corporate nurse reported 49 residents resided in the facility. Findings: 1. Res #21 admitted to the facility with diagnoses of vascular dementia, and malignant neoplasm of uterine adnexa. A review of the resident's record did not contain an advance directive acknowledgement. On 07/09/24 at 9:00 a.m., the administrator was asked to provide the resident's advanced directive acknowledgment. On 07/09/24 at 9:32 a.m., the Administrator reported the resident does not have an advanced directive acknowledgment. 2. Res #33 admitted to the facility with diagnoses of dementia, hypertension, and anemia. On 07/07/24 at 2:04 p.m., a DNR was located in the resident's chart. The form does not have a resident name on it. On 07/08/24 10:35 AM DNR is not located in the resident's paper chart 07/08/24 at 10:41 a.m., the corporate nurse was asked to look at the resident's DNR and asked if it was valid, she reported it is not valid without the resident's name. The corporate nurse reported the form was not filled out correctly.

Based on record review and interview the facility failed to secure a surety bond with sufficient coverage for the account balance. The Business office manger identified 24 residents that have money in the trust account and were current residents. Findings: A review of the current surety bond for the resident trust account documented the surety bond had coverage of $20,000 The resident trust account monthly bank statement, 04/30/24, documented the account balance was $26,681.86. The resident trust account monthly bank statement, dated 05/31/24, documented the account balance was $32, 329.75. On 07/09/24 at 10:48 a.m., the business office manager confirmed the surety bond was only for $20,000. They then stated they had noticed the account balance had gone up and there was no system in place to ensure the surety bond was sufficient for the account balance.

Based on record review and interview the facility failed to ensure resident trust accounts were closed out with funds conveyed within 30 days for three (#106. #107 and #108 ) of three residents who expired and were no longer in the facility over 30 days. The business office manager identified five residents who have been gone from the facility over 30 days and had open trust accounts. Findings: An undated Nursing Home Resident Trust Fund policy, read in part, If the resident leaves the home for any reason or passes away, funds must be returned to the resident or the resident's estate within 30 days . discharged residents with accounts still open: 1. A review of Resident #106 face sheet documented they expired on [DATE]. A review of the recipient trust account balance, dated [DATE], indicated Resident #106 had a current balance of $6,890.62. Resident #106 trust account remained open 131 days after they had expired. 2. A review of Resident #107 face sheet documented they were discharged from the facility on [DATE]. A review of the recipient trust account balance, dated [DATE], indicated Resident #107 had a current balance of $682.44. Resident #107 trust account remained open 228 days after they had expired. 3. A review of Resident #108 face sheet documented they were discharged from the facility on [DATE]. A review of the recipient trust account balance, dated [DATE], indicated Resident #108 had a current balance of of $205.15. Resident #108 trust account remained open 243 days after they had expired. On [DATE] at 10:48 a.m., the business office manager stated cooperate trained them to wait 90 days to close out trust account and then convey the funds to the family.

Based on observation, record review, and interview, the facility failed to ensure residents had access to their trust account money on nights and weekends for three (#1, #12 and #50 ) of three residents reviewed for access to their trust account money. The Business office manger identified 24 residents that have money in the trust account and were current residents. Findings: A review of the Resdient trust policy did not address residents access to their funds from their trust account. On 07/07/24 during the initial tour of the facility and sign was observed posted on the business office indicating banking hours for obtaining money from the trust account was Monday through Friday 1:00 p.m. through 3:00 p.m. There were no documented times funds were available at any times in the evening or on the weekends. On 07/07/24 at 9:25 a.m. Resident #50 stated the business office manager was here Monday through Friday from 8:00 a.m. through 5:00 p.m., and that was when they could get their money. Resident #50 then stated they had no way of getting money on the weekends. On 07/08/24 at 1:30 p.m., Resident #12 stated they can only get money when the business office manager was working. They stated they could not get any money on the weekends or in the evenings. On 07/09/24 at 10:48 a.m., the business office manager was asked about residents access to their funds. The business office manager stated the residents could get their money Monday through Friday between 1:00 p.m. through 3:00 p.m. The business office manager than stated they were the only one to access the funds for the residents and they only worked Monday through Friday.

Based on clinical record review and staff interview, it was determined the facility failed to assess, monitor and intervene for one (#1) of three sampled residents whose clinical records were reviewed. All three residents had experienced a decline in condition. This had the potential to affect all 60 residents residing in the facility. Findings: Resident #1 was admitted with [DIAGNOSES REDACTED]. An admission assessment documented the resident could usually make herself understood and could usually understand others. She had severely impaired cognitive skills for daily decision making. She required extensive assistance for transfers, toileting, and personal hygiene. She frequently had pain rated as severe. The resident was receiving physical therapy status [REDACTED]. On 09/10/13, the resident experienced a fall and was sent to the emergency room for evaluation. The radiology report, dated 09/10/13, documented, "...Impression: Internal fixation of proximal left femur with intramedullary rod and screw. The femoral head is within the acetabulum..." A MAR indicated [REDACTED]. The record documented the resident did not require pain medication on a daily basis during the month of September 2013. The record documented the resident started requiring more pain medication beginning 09/27/13, and took the pain medication daily and sometimes twice a day. Weekly Physical Therapy notes from 09/22/13 through 09/28/13 documented the resident was ambulating distances of up to 70 feet without pause and requiring only stand-by assistance. Weekly Physical Therapy notes from 09/29/13 through 10/2/13 documented the resident was ambulating with moderate assistance and could only ambulate 5 to 30 feet. The note documented, "...pt. given pain meds prior to P.T.--pain medications seems to be ineffective 10-01-13...". The note also documented, "...pain medications seem to be ineffective; pains seems to be getting worse 10-2-13...Nursing staff notified of pts. significant (arrow up) pain & (illegible) levels & decline in function related to increased pain 10-2-13..." A nursing note, dated 10/01/13; documented the resident had a temperature of 99.0 degrees Fahrenheit. A nursing note, dated 10/02/13, documented the resident had a temperature of 99.4 degrees Fahrenheit. A nursing note, dated 10/03/13, documented the resident had a temperature of 100 degrees Fahrenheit. On 10/03/13 the resident was admitted to (name deleted) hospital following a visit to her orthopedic physician. A radiology report dated 10/04/13 documented, "...Comparison: September 10, 2013 Findings: A compression nail is in place in the left femur. The nail is now extending through the femoral head and into the pelvic area. This is a new finding since the previous exam....Impression: There has been interval impaction of the compression nail an intramedullary rod in the left femur. The compression nail now extends beyond the femoral head..." An operative report dated 10/4/13 documented, "...(name deleted) is an [AGE] year old female who is six weeks status [REDACTED]. Patient was in a nursing home and was complaining of increasing pain in the left hip. She had had several falls. Patient was seen in the clinic and was noted to have failure of her hardware with acetabular penetration of the LAG screw with fragmentation of her greater trochanter..." On 11/5/13, at 1:50 p.m., Physical Therapy Assistant #1 was asked to describe the resident's progress's and abilities since beginning therapy. She stated the resident was progressing well until about 09/30/13. She stated prior to this date the resident was walking up to 100 feet with contact assist and a walker. She stated during the therapy visit on 09/30/13, she noticed a big change in resident's function. She stated the resident could only ambulate 30 feet and was having more pain. She stated the resident continued to decline in function and she notified the charge nurse on north hall on both 10/01/13 and 10/02/13 that the resident's pain medication was not effective. On 1l/06/13, at 8:30 a.m., a call was placed to the resident's orthopedic surgeon. He was asked what could have caused the resident's compression nail to have migrated into the pelvic cavity. He stated that in his opinion the only thing that would have caused the nail to protrude into the pelvis was pressure on the back side of the nail such as a fall. He was asked if an improper transfer could have caused the hip to re-fracture and the compression nail to pierce the pelvic cavity. He stated no. He further stated that he could imagine no other scenario which would cause the nail to be driven into the pelvic cavity other than a fall. He was asked if he had been notified of any significant changes in the resident's pain level, functional ability, or that she had been febrile prior to her physician's visit on 10/03/13. He stated he had not been notified of any changes in the resident's condition. On 11/06/13, at 9:00 a.m., LPN #1 was asked if she noticed the resident having an increase in pain during the time period of 09/27/13 through 10/03/13. She stated that on 10/02/13, Physical Therapy Assistant #1 called and asked for the resident to have pain medication before therapy. She said the PTA stated the pain medications weren't working. She stated she told the DON during report and the DON stated she was aware and had made the resident an appointment with her physician. At 9:20 a.m., CMA #1 was asked if during late September and early October 2013 the resident had complained of more pain than usual. She stated yes, the resident had complained of more frequent pain, especially during transfers. She stated the charge nurse was aware of the resident needing pain meds more frequently. At 10:00 a.m., a telephone call was placed to LPN #2. She was asked if she had completed nursing notes on 10/01/13, 10/02/13, and 10/03/13. She stated she had. She was read the nursing notes which documented the resident had a temperature on those dates. She was asked if she notified the physician of the resident's temperature. She stated she would have notified the on-coming nurse because normally the day shift calls the doctors. She was asked if the physician had been notified. She stated as far as she knew it had been reported. She was told the physician had not been notified of the change in resident's condition. She stated, "Sounds like they didn't do anything about it." At 11:30 a.m., the DON was asked when she became aware of the resident having increased pain. She stated on 09/27/13, she overheard a nurse and the therapist talking about giving pain medication before therapy. She stated she told the therapist to stop the therapy until the resident could see a physician. She was asked if she called the physician regarding the increased pain the resident was having. She stated she told Social Services to call and make an appointment with the physician. She stated an appointment was made on 10/01/13 or 10/2/13 for the resident to be seen by her orthopedic surgeon. The DON was notified by the surveyor the resident was seen on 10/03/13. The appointment had been made on 09/03/13, was a routine follow-up appointment, and had not been made by facility staff. She was asked if she was aware the resident had been running a temperature during the night shift since 10/01/13. She stated this was not communicated to her. She was asked if anyone had called the physician regarding the resident's increased pain, decline in functional abilities and temperature. She stated she had not called the physician and to her knowledge none of her staff had called.