Every finding on record at Somerfield at the Heritage

Based on facility policy review, medical record review, Fire Department Incident report review, facility investigation review, Performance Improvement Plan review, and interviews, the facility failed to ensure the environment was free from accident hazards when staff failed to follow the care plan for 2 person assist for transfers with a mechanical lift (device designed to safely transfer patients with limited mobility) for 1 of 3 (Resident #78) sampled residents reviewed for accidents. On [DATE], Resident #78, a vulnerable and cognitively impaired resident with impaired mobility, was transferred by a Certified Nursing Assistant (CNA) using the mechanical lift (a non-powered or powered mobility device that uses slings to help partially weight bearing individuals to transfer from a sitting position into a supported standing position and sometimes back down) without 2-person assistance. Resident #78 fell from the lift and hit her head on the bed resulting in the Resident being transferred to the hospital where it was determined the Resident had sustained an acute brain bleed and later expired at the hospital. The facility failed to ensure an environment free from accident hazards when staff failed to follow the care plan for 2 person assist for transfers with a sit to stand mechanical lift for 1 of 3 residents requiring transfers with a mechanical lift which resulted in an Immediate Jeopardy (IJ) Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] 2026 at 4:46 PM, in the Conference Room. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ began on [DATE] through [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The facility was cited at F-689 as past non-compliance and is not required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Lifting Machine, Using a Mechanical dated 2001, revealed The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device.One or two nursing staff are needed per manufacture guidelines to safely move a resident with a mechanical lift.may be used for tasks that require: Lifting a resident from the floor, Transferring a resident from bed to chair; Lateral transfers.Toileting or bathing.Types of lifts that may be available in the facility are .Floor-based full body sling lifting.Overhead full body sling lifts.Sit-to stand lifts.Before using a lifting device, assess the resident's current condition, including .Physical .Cognition/Emotional.Measure the resident for proper sling size. 2. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Nonrheumatic Aortic Stenosis (narrowing of the aortic valve not caused by rheumatic fever), Major Depressive Disorder and Interstitial Pulmonary Disease (progressive inflammation and scarring in the lung tissue). Review of the Care Plan dated [DATE] and revised 1/2024, revealed Resident #78 .risk for falls related to mobility, gait and balance deficits .has mobility deficits.Potential for injury related to Mechanical Lift use.2 CNAs to assist resident with transfer using the mechanical lift-full body lift using Large/Green size sling.has impaired cognitive function/dementia or impaired thought processes.moderate deficits, impaired safety awareness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 10, which indicated she was moderately cognitively impaired. Resident #78 was dependent on staff for sit to stand and chair/bed to chair transfer. Review of the Progress Note for a witnessed fall which occurred on [DATE] at 6:30 PM, revealed an (Alert Note) documented by Licensed Practical Nurse (LPN) F on [DATE] at 9:25 PM, .Staff alerted nurse [LPN F] that she [CNA G] used the stand-up lift to transfer resident [Resident #78] to bed. Resident slipped out [of] slang [sling] onto the floor .Nurse [LPN F] observed swelling to back of resident's head. Nurse [LPN F] sent the resident to Named hospital via [by way of] EMS [Emergency Medical Services] . Review of the Incident (fire department report) dated [DATE], revealed: Phone Pickup [DATE] 18:41:56 [6:41:56 PM] 1st Unit assigned [DATE] 18:42:52 [6:42:52 PM] 1st Unit Arrived [DATE] 18:44:41 [6:44:41PM]. Non-Emergency .Transport .Arrived [at Named Hospital] [DATE] 19:17:16 [7:17:16 PM] Fell from her chair/bump on head/no other visible injuries Patient (Resident #78) conscious Alert and Oriented Review of the Incident Witness Statement Form dated [DATE], revealed CNA G's signed handwritten statement stating, When I was pulling [Named Resident #78's] pants down (while she was on the lift), she [Resident #78] slipped through the straps [lift sling] and fell backwards and hit her head behind her. Review of the Incident Witness Statement Form dated [DATE], revealed Named LPN F's signed handwritten statement stating, .I nurse [Named LPN F] observed resident [Resident #78] on the floor with her head against the bottom metal part of her bed. Nurse [LPN F] observed resident [Resident #78] alert and oriented to self.Nurse [LPN F] observed swelling to back of resident's [Resident #78] head. Review of the facility investigation Administrator's typed statement dated [DATE], revealed the Administrator documented, .approximately 6:30pm, CNT [Certified Nurse Technician] [CNA G] was preparing [Resident #78] for bed. CNT placed [Resident #78] in mechanical lift 'sit to stand'. CNT [CNA G] lifted resident [Resident #78] up to pull Resident's [Resident #78's] pants down before placing her on the bed. Resident [#78] while resident's [Resident #78] pants were being pulled down, resident [Resident #78] let go of lift's handle grips and slid through the sling to the floor hitting her head on the bed. CNT [CNA G] obtained nurse [LPN F]. Nurse called 911 and sent resident [Resident #78] out to hospital ER [Emergency Room] because of head hematoma .Per hospital notes resident [Resident #78] was admitted with a brain bleed .it was determined that the care plan for 2 persons assistance was not utilized by CNT [CNA G] on [DATE] . Review of the hospital Discharge Summary revealed Resident #78 was admitted from the emergency room on [DATE] at 1:56 PM and discharged on [DATE] at 9:34 PM. The admitting diagnosis was Traumatic Subarachnoid Hemorrhage (a type of bleeding that occurs in the subarachnoid space of the brain, often due to head trauma) without loss of consciousness. A Commuted Tomography scan ((CT) - a diagnostic imaging procedure that combines x-rays views taken from different areas to create a more detailed view) was performed which showed multifocal areas of bifrontal subarachnoid hemorrhage (multiple small, separate spots of bleeding in the space surrounding the brain that indicates bleeding on the brain's surface) as well as small subdural hemorrhage (a life-threatening emergency that occurs when blood leaks from torn blood vessels and pools in the space between the brain and the outer lining). The head CT conduced on [DATE] revealed intraparenchymal hemorrhage (a life-threatening type of brain bleed that occurs directly within the functional tissues of the brain) with interval worsening. The family did not want to pursue aggressive measures and opted for Resident #78 to transition to comfort care on hospice. Resident #78 discharged to a Hospice Residence with a diagnosis of Traumatic Subarachnoid Hemorrhage. 3. Review of the facility In-service Training dated [DATE], revealed the DON presented training for CNAs and Medication Technicians (Med Techs) regarding residents who required use of mechanical lifts. The Summary of the In-Service was as follows: To assure staff was using the sling that was assigned to the resident requiring the mechanical lift (Measures height and weight to determine proper size). Not using the correct sling can cause serious injury. Slings are to be stored in each resident's room not left on the lift. Review of the mechanical lift policy. 2 people are to be present for each use. An additional In-service for staff to watch a video about using the Mechanical sit to stand lift was conducted. The video was online and demonstrated correct resident handling. All CNAs and Med Techs were required to sign as acknowledgement and understanding. Review of the Performance Improvement Plan (PIP) titled Mechanical Lift Correction Plan authored by the Assistant Director of Nursing (ADON) dated [DATE], revealed a .Problem or Opportunity for Improvement: Mechanical lift usage has been inconsistent among staff which could include improper sling selection, lack of adherence to manufacturer guidelines, and failure to reference the Kardex [nursing cheat sheet-medical documentation system used by nursing to quickly reference patient information] for lift requirements. This creates a risk for resident and staff injury and indicates a need for standardized education and compliance monitoring. Supporting Data: Recent observations and audits identified an opportunity to correct sling sizes, reeducate on manufacturer guidelines and policies and procedures, and review with staff care plan/Kardex information. Not using correct sling size, following policy and procedure and following the care plan/Kardex can increase the risk for falls, skin injury and staff injury. Ensuring proper lift usage is essential to maintain resident safety, regulatory compliance and staff injury prevention.the Root Cause Analysis Inconsistent mechanical lift use is primarily related to gaps in staff education, as well as inconsistent adherence to established processes. Staff have not consistently referenced the KARDEX and care plans for resident-specific transfer requirements. Additionally, there is variability in sling selection and understanding of manufacturer guidelines. Review of Quality Assurance Performance Improvement (QAPI) notes dated [DATE], revealed the facility decided to eliminate all (Name Brand) mechanical Sit to Stand Lifts by attrition which affected 3 residents. 4. During an interview on [DATE] at 3:33 PM, the MDS Coordinator, was asked if Resident #78 died at the hospital. The MDS Coordinator stated, Yes, ma'am. During an interview on [DATE] at 3:45 PM, CNA G was asked to explain the events related to Resident #78. CNA G explained that she was getting Resident #78 ready for bed after dinner and stated, .I remember pulling down her [Resident #78] pants and she [Resident #78] fell through the straps. CNA G was asked how long had she worked at the facility (prior to the transfer of Resident #78). CNA G stated, A little over 1 months. CNA G was asked whether she had been educated about the mechanical lift during orientation. CNA G stated, .I watched videos, and I watched demonstration, and I had to demonstrate [how to use the sit to stand lift] after the incident.no test. CNA G was asked what happened after Resident #78 fell. CNA G stated, After she [Resident #78] fell, I [CNA G] went to get the nurse .I walked to nurse to get her. CNA G was asked who was in the room with you at the time of the accident. CNA G responded, No one at that time. CNA G was asked whether she returned to the room with the nurse [LPN F] and CNA G confirmed that she did. CNA G stated, .the nurse [LPN F] came into the room.assessed everything.the ambulance arrived at the facility almost immediately. CNA G stated, Resident #78 was not bleeding but had hurt her head when she hit it on the bed. CNA G confirmed she gave a written statement related to the incident. CNA G was asked what the facility did following this incident. CNA G stated, .after the incident was when I did the training. CNA G confirmed that Resident #78 was still on the floor when Emergency Medical Services (EMS) arrived. CNA G was asked if she was aware prior to this incident that she should always have 2 people when using a mechanical lift. CNA G stated, I did not. During an interview on [DATE] at 10:57 AM, the DON was asked what the facility plans were to ensure compliance related to mechanical lift use, the DON stated .Either I or the ADON [Assistant Director [f Nursing] will monitor the monthly [quality improvement audits monitoring the random compliance checks of staff's mechanical lift use] for compliance, and all CNAs were educated and were tested for recall. There were also electronic education, video review and demonstration conducted. This was also discussed in QAPI meeting to monitor any events .during the Interdisciplinary meeting the residents that require lift were reviewed and the care plan were updated . During an interview on [DATE] at 4:30 PM, the Administrator was asked how often QAPI meetings were conducted and he responded .QAPI meetings are usually conducted monthly although they are only required quarterly . The Administrator stated, .We have had at least 3 QAPI meetings since the incident involving [Named Resident #78] . The regular QAPI meeting was scheduled for the day after the event involving Resident #78 (on [DATE]) and the Medical Director (MD) was consulted at that time. An attempt was made to contact the Medical Director by telephone on [DATE] at 3:45 PM. The Medical Director was unavailable during the survey period. A message was left with the Medical Director's office, and an urgent message was sent by the Office Manager for him to return a call to the surveyor on [DATE], when he was back in the office. During an interview on [DATE] at 5:30 PM, Nurse Practitioner (NP) Q was made aware of the IJ citation. NP Q worked at the facility part-time and did not participate in QAPI meetings. During a telephone interview on [DATE] at 2:25 PM, the Medical Director returned the call and said he had been made aware of the circumstances involved in this event and was involved in the discussion about the prevention of this reoccurring. The MD said he attended QAPI meetings monthly and has had no concerns with being notified about adverse events. The IJ Plan of Correction was validated by surveyors on [DATE] through [DATE] by review of in-services started on [DATE], review of Care Plans for all residents requiring mechanical lifts completed by the facility on [DATE], the PIP dated [DATE], Quality Improvement Audits dated [DATE] and [DATE], review of QAPI notes, Course Completion History (Named Mechanical Lift), and staff interviews. The facility's implemented the following Plan of Correction: Deficient Practice The facility failed to ensure staff followed the care plan requiring a two-person assist resulting in a resident fall, serious injury on [DATE], and subsequent death. Immediate Actions Taken to Remove Immediate Jeopardy Upon identification of Immediate Jeopardy on [DATE], the facility immediately implemented review of corrective actions to eliminate the risk: On [DATE] responsible parties and Health Care provider were notified as appropriate. The Director of Nursing or designee in-serviced facility nursing assistants after this incident from [DATE] through [DATE] on the proper use of Sit-to-Stand mechanical lifts including the facilities policy of two-person Sit-to-Stand mechanical lift procedure. The director of nursing or designee reassessed residents utilizing a Sit-to-Stand mechanical lift safe usage and IDT reviewed Sit-to-Stand Mechanical Lift assistance care plans on or before [DATE]. On [DATE] through [DATE] return demonstration of proper use of a Sit -to -Stand mechanical lift was initiated for Sit-to-Stand mechanical lift transfers Licensed nurse verified care plan requirements and CNA assignments on or before [DATE]. Outcome: All residents requiring Sit-to-Stand mechanical lift transfers were safely transferred using appropriate staffing and supervision. No ongoing risk remained. Identification of Residents Affected and At Risk The facility completed a house-wide review to identify any residents affected or at risk. Actions completed: 100% audit of residents requiring: Sit-to -Stand Mechanical lift transfers Review of care plans and Kardex Direct observation of transfer techniques Findings: All residents requiring Sit-to-Stand mechanical lift transfers were confirmed to have appropriate care plans in place Community follows facility policy for Sit-to-Stand mechanical lift transfers including the use of two-person assist for transfers. Any discrepancies identified were corrected immediately prior to IJ removal

Based on facility policy review, job description review, medical record review, and interview, the facility failed to report allegations of Abuse for 5 of 6 (Resident #7, #21, #78, #83, and #84) sampled residents reviewed for Abuse. The findings include: 1. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2022, revealed .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of the facility's undated policy titled ABUSE PREVENTION POLICY, revealed .It is the goal of this facility to establish a resident sensitive and secure environment to assure proper and respectful treatment of all residents. The facility is obligated to insure [ensure] that residents have the right to be free from verbal, mental, physical and sexual abuse, corporal punishment, and involuntary seclusion and neglect.The facility will not tolerate any abuse and will promptly and thoroughly investigate any allegation of abuse, neglect, and misappropriation of resident property.Reporting Allegations of Abuse.all covered individuals (operator, employee, manager, agent, contractor, volunteer) are required to report to a law enforcement agency if there is a reasonable suspicion of a crime against a resident. If a resident sustains a serious bodily injury the law enforcement agency.TN [Tennessee] Department of Health [State Survey Agency].TN Department of Human Services must be contacted within two (2) hours of forming the suspicion. If the resident's injury is not serious, the law enforcement agency.must be contacted within twenty-four (24) hours after forming the suspicion.The results of the investigation will be reported to the State Department of Health [State Survey Agency] within five (5) working days of the initial report of alleged abuse. 2. Review of the facility's .Licensed Practical Nurse [LPN] job description dated 12/28/2023, revealed .Reports suspicions of abuse, neglect, exploitation, or abandonment of a resident to supervisor, director, or abuse coordinator in accordance with state and federal regulations. Review of the facilities .Director of Nursing job description dated 2/27/2024, revealed .The Director of Nursing (DON) is responsible for the overall supervision, provision, and quality of nursing care and services provided in the skilled nursing facility.This position is responsible for ensuring compliance with state, federal and CMS [Centers for Medicare and Medicaid Services] laws and regulations for skilled nursing facilities.Reports suspicions of abuse, neglect, exploitation, or abandonment of a resident to supervisor, director, or abuse coordinator in accordance with state and federal regulations. 3. Review of the medical record revealed Resident #7 was admitted to this facility on 9/1/2017, with diagnoses including Hypertensive Heart Disease with Heart Failure, Anxiety Disorder and Major Depressive Disorder. Review of the Care Plan dated 5/9/2023, revealed .risk for alteration of activity pursuits r/t [related to] Behaviors, mental status.has increased risk for discomfort related to osteoarthritis and osteoporosis.has increased risk for pressure related skin breakdown.has requested hospice services.resident is at risk for falls related to cognitive impairment, vascular dementia, arthritis. Review of annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had short and long-term memory problems and was not able to recognize current season, location of own room or staff names and faces which indicated Resident #7 was severely cognitively impaired. Review of an undated facility investigation revealed the facility received a report of suspected misappropriation of narcotics on 6/12/2025. The facility failed to report the allegation to the State Survey Agency in accordance with state and federal guidelines. 4. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Senile Degeneration of Brain, Depression, Encounter for Palliative Care and Dementia Review of Comprehensive Care Plan for Resident #83 dated 2/1/2025, revealed, Resident #83 was .at risk for experiencing pain due to end-of-life discomfort.diagnosed with terminal condition and is at risk for loss of dignity during dying process end stage dementia bed bound.at risk for falls.here on hospice care and is here for rest and comfort.on Pain medication Therapy r/t disease process end of life. Review of the quarterly MDS assessment dated [DATE], revealed Resident #83 had no Brief Interview for Mental Status (BIMS) score. Resident #83 could not recall season, own room, staff names and faces therefore was severely cognitively impaired. Review of an undated facility investigation revealed the facility received a report of suspected misappropriation of narcotics on 6/12/2025. The facility failed to report the allegation to the State Survey Agency in accordance with state and federal guidelines. 5. Review of the medical record revealed Resident #84 was admitted to this facility on 9/22/2022, with diagnoses including Aphasia, Hemiplegia and Hemiparesis and Shortness of Breath. Review of Care Plan dated 5/2/2023, revealed .has increased risk for pressure related skin breakdown .risk for falls .at risk for experiencing pain/discomfort related to mobility deficits, chronic kidney disease, muscle spasm, osteoarthritis.has a terminal prognosis condition and is followed by [named] Hospice.Potential for injury related to Mechanical Lift use. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 00 which indicated Resident #84 was severely cognitively impaired. Review of an undated facility investigation revealed the facility received a report on 6/12/2025 of discrepancies in narcotics signed out by Registered Nurse (RN) J and illegible dates on the Controlled Drug Receipt/Record/Disposition Form. RN J was suspended pending the results of a drug screening and when it was negative she was allowed to return to work. The facility-initiated weekly narcotic spot checks related to the allegation which identified additional discrepancies. On 7/21/2025, it was discovered that on 7/6/2025 and 7/7/2025, RN J signed out a narcotic 2 more times than it was ordered, on 7/14/2025 RN J had signed out a narcotic medication as being administered to the same resident twice within a 30 minute period, on 7/16/2025 RN J documented that RN J administered a narcotic at 8:00 PM (during a time when she was not working). RN J self-terminated when she was questioned about the discrepancies. The facility failed to report the allegations of misappropriation of narcotics to the State Agency according to state and federal guidelines. During an interview on 6/10/2026 at 10:57 AM, the Director of Nursing (DON) was asked why the allegations of narcotic misappropriation related to Residents #7, #83 and #84 were not reported to the State Survey Agency per state and federal guidelines. The DON explained that (RN J) claimed there was an error in documentation. The facility did random documentation audits and performed a drug test on (RN J) which was negative. The facility was unable to verify the allegations and therefore did not report them to the SA. During a phone interview on 6/17/2026 at 2:25 PM, the Medical Director (MD) was asked whether he had been made aware of an allegation of narcotic misappropriation and the MD said he had been alerted to some pharmacy concerns in 2025, but he could not recall specifics. 6. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety, and Hypertension. Review of the Progress Note for Resident #21 written by LPN D dated 1/25/2026 at 11:51 AM, revealed .Behavior Note .resident [Resident #21] hit another resident [Resident #78] on the back of the head after saying sshh! . The facility failed to report the incident to the state agency. Review of the facility's soft file (word document) dated 1/25/2026, revealed only 4 sentences. Resident #21 was the only named resident mentioned, no staff was mentioned, no witness statements were included, and no location or time of the alleged incident was documented. The facility failed to report the incident according to state and federal regulations. Review of the annual MDS assessment dated [DATE], revealed the BIMS assessment was not completed, due to Resident #21 was rarely or never understood. Resident #21 had short- and long-term memory problems, was unable to recall the current season, location of room, staff names or faces, or that she was in a nursing home, and had severely impaired decision-making skills which indicated severe cognitive impairment. During an interview on 6/10/2026 at 7:48 AM, the DON was asked if there were any facility reportable incidents involving Resident #21. The DON stated, No. During an interview on 6/11/2026 at 10:51 AM, Certified Nursing Assistant (CNA) E was asked if she recalled an incident in January (1/2026) involving Resident #21 hitting another resident. CNA E stated, I don't really, but I do know she has hit several residents several times. During an interview on 6/11/2026 at 10:57 AM, the DON was asked if she was aware of an incident in January (1/2026) where Resident #21 hit another resident. The DON stated, I do, I actually have a soft file.we viewed the video footage. The DON was asked if they still had the video footage. The DON stated, No. The DON confirmed the other resident in the video with Resident #21 was not Resident #78. The DON was unable to recall an altercation between Resident #21 and #78. 7. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Depression, Heart Failure, and Dementia. Review of the annual MDS assessment dated [DATE], revealed Resident #78 scored an 8 on the BIMS assessment, which indicated moderate cognitive impairment. During an interview on 6/11/2026 at 11:25 AM, LPN D was asked if she recalled the incident in January (1/2026) that involved Resident #21 hitting another resident. LPN D stated, I do remember. LPN D was asked who the other resident involved in the incident was. LPN D named Resident #78. LPN D was asked if she reported it to anyone. LPN D stated, No. The facility failed to report any allegations of abuse related to Resident #21 and #78.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and unattended in 1 of 60 (Resident #42) resident occupied rooms and when controlled medications were stored unsecured in 1 of 6 (Monarch Hall medication refrigerator) medication storage areas. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, dated 2001, revealed .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Controlled substances.and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and missing dose can be readily detected. Review of the facility policy titled, Controlled Substances, dated November 2022, revealed .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.All keys to controlled substance containers are on a single key ring that is different from any other keys. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including Dementia, Dry Eye Syndrome, and Glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #42 was moderately cognitively impaired. Review of the Physician Order dated 5/1/2023, revealed Latanoprost Ophthalmic [related to or near the eye] Solution 0.005 % [percent] (Latanoprost).Instill 1 drop in both eyes in the evening related to UNSPECIFIED GLAUCOMA. Review of the Physician Order dated 7/31/2024, revealed Please ensure patient medications are being dispersed by nursing staff only; patient keeps medications in bathroom, top right drawer.every shift. Review of the Physician order dated 6/20/2025, revealed Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium (Ophth [ophthalmic]).Instill 2 drop in both eyes as needed for Dry Eyes as needed. Review of the revised Care Plan dated 6/4/2026, revealed Resident #42 was not Care Planned for self-administration of eye drops. Observation in Resident #42's room on 6/8/2026 at 10:00 AM and 12:25 PM, revealed a bottle of Latanoprost eye drops and a bottle of Carboxymethylcellulose 0.5 % eye drops sitting on the resident's nightstand, unsecured and unattended. The facility failed to ensure medications were properly stored and secured. During an observation and interview in Resident #42's room on 6/8/2026 at 12:28 PM, revealed Registered Nurse (RN) A was asked if the bottle of Latanoprost eye drops and the bottle of Carboxymethylcellulose eye drops on the nightstand were prescription. RN A stated, I don't know, I didn't give her eye drops this morning. RN A was asked if medications should be left unsecured and unattended in a resident's room. RN A stated, No sir. RN A was asked if having medications unsecured and unattended in a resident's room could create a potential risk for residents with altered cognition. RN A stated, Yes, it could. During an interview on 6/10/2026 at 3:21 PM, the Director of Nursing (DON) was asked if eye drops should be left unattended and unsecured in a resident's room. The DON stated, No. The DON was asked if having unattended and unsecured medications in a resident's room could create a potential risk for residents who may have a cognitive deficient or wanderers. The DON stated, Of course. 3. During an observation and interview in the Monarch Medication Room on 6/10/2026 at 9:10 AM, revealed an unlocked and unsecured controlled medication box, inside a medication refrigerator without a lock, containing 1 unopened 30ml (milliliter) bottle of Ativan (a medication used to treat anxiety) 2mg (milligram)/ml and 2 unopened 1ml vials of lorazepam (Ativan) 2mg/ml. The Assistant Director of Nursing (ADON) was asked if the controlled medication box inside of the refrigerator should be locked. The ADON stated, I think so. The ADON was asked if the controlled medication box should be permanently affixed to the refrigerator. The ADON stated, I don't think it has to be permanently affixed. The ADON was asked if all controlled substances should be stored behind 2 locks. The ADON stated, Yes. During an observation and interview in the Monarch Medication Room on 6/10/2026 at 10:13 AM, revealed the controlled medication box remained unlocked and unsecured, in the medication refrigerator without a lock. The DON was asked if the controlled medication box should be locked. The DON stated,Yes. The DON was asked if it was locked. The DON stated, No. The DON was asked if the box should be permanently affixed inside the refrigerator. The DON stated, I'm assuming it should be, I'm not sure what to affix it to. The DON was asked if someone could easily remove and walk away with the box due to it not being secured to the refrigerator. The DON stated, Yes, easier than I would like. The facility failed to ensure controlled substances were stored behind 2 locks in a permanently affixed compartment when the controlled substance box was left unlocked and unsecured inside the medication refrigerator.

Based on facility policy review, facility job description review, medical record review, and interview, the facility failed to follow Physician Orders for 1 of 4 (Resident #9) residents reviewed for nutrition. The findings include: 1. Review of the facility's policy titled Administering Medications, dated 4/2019, revealed .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders.The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication. 2. Review of the facility's Certified Medication Aide (CMA) job description dated 7/2015, revealed .Gives treatment .Records administration of the medication on resident's medication administration record. Discards medication refused or otherwise not given and records on medication administration record [MAR]. Review of the facility's .Licensed Practical Nurse [LPN] job description dated 12/28/2023, revealed .Provides treatment, performs testing, collects specimens, and carries out procedures as ordered by physicians .Administers medications as prescribed by physicians and documents accordingly. Review of the facility's .Registered Nurse [RN] job description dated 12/28/2023, revealed . Provides treatment, performs testing, collects specimens, and carries out procedures as ordered by physicians . Administers medications as prescribed by physicians and documents accordingly. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety, Depression, and Hypertension. Orders Review of the Physician's Orders revealed an order with a start date of 10/31/2023 to provide and encourage Ensure (a nutritional supplement used to provide extra calories and nutrients) 3 times a day, an order with a start date of 11/7/2025 for a Fortified shake (a nutrient-dense beverage designed to boost calorie and protein intake) at all meals, and an order with a start date of 1/31/2026 to give 30 ml [milliliters] of Pro-Stat Oral Liquid (a protein supplement) by mouth two times a day. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not performed due to Resident #9 was rarely/never understood, which indicated she was severely cognitively impaired. Review of the Care Plan dated 4/16/2026, revealed .Resident is at risk for altered nutrition.Provide nutritional supplementation OR fortified foods, as MD [Medical Doctor] ordered for additional calories/protein . Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) dated 3/2026, revealed the facility failed to provide and document the following nutritional supplements as being administered at 2 PM on the following dates: Ensure a. 3/3/2026 b. 3/7/2026 c. 3/19/2026 Pro-stat oral liquid a. 3/3/2026 b. 3/10/2026 c. 3/11/2026 d. 3/12/2026 e. 3/16/2026 f. 3/31/2026 Review of the MAR/TAR dated 4/2026, revealed the facility failed to provide and document the following nutritional supplements as being administered at 2 PM on the following dates: Pro-Stat oral liquid a. 4/2/2026 b. 4/9/2026 c. 4/23/2026 Review of the MAR/TAR dated 5/2026, revealed the facility failed to provide and document the following nutritional supplements as being administered on the following dates and times: Supplement/fortified shake at 8:00 AM a. 5/12/2026 Ensure at 10:00 AM a. 5/12/2026 b. 5/30/2026 Supplement/fortified shake at 12:00 PM a. 5/12/2026 b. 5/25/2026 c. 5/30/2026 Ensure at 2:00 PM a. 5/12/2026 b. 5/25/2026 c. 5/30/2026 Pro-Stat oral liquid at 2:00 PM a. 5/4/2026 b. 5/6/2026 c. 5/11/2026 d. 5/20/2026 Supplement/fortified shake at 5:00 PM a. 5/22/2026. Ensure at 6:00 PM a. 5/22/2026 During an interview on 6/11/2026 at 10:57 AM, the Director of Nursing (DON) was asked how she would know if staff were following Physician's orders. The DON stated, .we spot check.we go through various MARs and TARs and look at documentation on different days. The DON was asked if she was looking at the MARs and TARs to make sure there were no blank spaces (no documentation). The DON stated, Yes. The DON was asked if staff should provide nutritional supplements as ordered by the physician. The DON stated, .yes.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Registered Nurse (RN) B and Certified Nursing Assistant (CNA) C) failed to follow proper infection control practices for 4 of 7 (Resident #11, #42, #49, #54) residents reviewed for Medication Administration, Enhanced Barrier Precautions (EBP), and Indwelling Urinary Catheter care. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated March 2024, revealed .Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.EBPs are indicated.for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.Wounds generally include chronic wounds.Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies.EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.Signs are posted in the door or wall outside the resident's room indicating the type of precautions and PPE [personal protective equipment] required.PPE is available outside of the residents rooms. Review of the facility policy titled, Administering Medications, dated April 2019, revealed .Staff follows established facility infection control procedures.for the administration of medications, as applicable. Review of the facility policy titled, Handwashing/Hand Hygiene, dated December 2025, revealed .Hand hygiene is the primary means for preventing healthcare-associated infections (HAIs) and the transmission of multidrug-resistant organisms (MDROs). This facility requires strict adherence to evidence-based hand hygiene practices . for all personnel .Hand hygiene is indicated .after glove removal . 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection, Mild Cognitive Impairment, Hypertension, Folate Deficiency Anemia, Anxiety, Depression, and Hallucinations. A comprehensive MDS assessment not completed due to recent admission. Review of the Physician Order dated 6/3/2026, revealed Carvedilol Oral Tablet 3.125 MG [milligram] (Carvedilol) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) give with food. Hold for SSBP [systolic blood pressure] < [less than] 100 HR [heart rate] 60 Review of the Physician Order dated 6/4/2026, revealed Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 tablet by mouth one time a day related to ANEMIA, UNSPECIFIED. Review of the Physician Order dated 6/4/2026, revealed Aspirin EC [enteric coated] [a coating designed to pass through the stomach to prevent stomach upset] Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to CORONARY ATHEROSCLEROSIS [heart disease] DUE TO LIPID RICH PLAQUE. Review of the Physician Order dated 6/4/2026, revealed DULoxetine HCl [hydrochloric acid] Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to ANXIETY DISORDER. Review of the Physician Order dated 6/4/2026, revealed Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold for SBP less than 110 Review of the Physician Order dated 6/4/2026, revealed ZyPREXA [used for psychosis] Oral Tablet 5 MG (Olanzapine) Give 1 tablet by mouth one time a day related to OTHER HALLUCINATIONS. Review of the Physician Order dated 6/7/2026, revealed Acetaminophen [given for generalized pain] Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day related to SPINAL STENOSIS. Observation during medication administration on the Harpeth/Radnor Medication Cart on 6/10/2026 at 8:08 AM, revealed, Registered Nurse (RN) B sanitized her hands, and pulled the following medications for medication administration for Resident #11: a. Aspirin chew 81mg 1 tablet b. Folic acid 1 mg 1 tablet c. Losartan Potassium 50mg 1 tablet d. Zyprexa 5mg 1 tablet e. acetaminophen 500mg 2 tablets f. carvedilol 3.125 mg 1 tablet g. duloxetine 60mg 1 capsule When pulling the medications the Folic acid 1mg tablet, Losartan Potassium 50mg tablet, and the Zyprexa 5mg tablets fell out of the bottom of the packaging and landed on top of the medication cart, there was no clean barrier in use on top of cart. RN B picked the 3 tablets up with a bare hands and placed them in a medication cup with the other prepared medications, knocked on Resident #11's door, and administered the medications to Resident #11. During an interview on 6/10/2026 at 8:27 AM, RN B was asked if the medications that had fallen onto the medication cart and handled using bare hands should have been administered. RN B stated, Yes our hands are clean, we scrub in and out. This Surveyor stated to RN B that throughout observation, including prior to pulling the medications and following the administration of the medications, the top of the medication cart had not been cleaned. RN B stated, We wipe the top of the med cart each shift with sani-wipes [germicidal sanitizing wipes]. During an interview 6/10/2026 at 3:21 PM, the DON was asked if staff should administer a medication that was dropped on top a medication cart during medication preparation. The DON, stated, No. The DON was asked if staff should pick up medications using bare hands and administer them. The DON stated, No. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Dementia, Cellulitis, and Dermatitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #42 was moderately cognitively impaired. No ulcers, wounds and skin problems noted. Review of the Physician Order dated 4/29/2026, revealed, Open lesion on outer right ankle. Cleanse with gauze and wound cleanser. Pat dry Cover with Xeroform petrolatum dressing [a non-adherent wound dressing]. Apply 2x [by] 2 Comfort foam dressing. Until healed one time a day every 7 day (s) AND as needed for For [duplicate wording] soiled or missing dressing. Review of the Physician Order dated 5/26/2026, revealed, Left lower leg weeping edema. 1. Cleanse with wound cleanser, dry completely 2. Apply lotion 3. Wrap with non stick pads 4. Apply compression stocking one time a day for weeping edema AND as needed for for [duplicate wording] saturated dresswing [dressing]. The Physician Orders did not reflect EBP. Review of the Progress Notes dated 4/29/2026 at 8:07 AM, revealed .Skin Check .Skin Issues.Skin Issue: #001: Skin issue has not been evaluated.Location: Right lateral malleolus.Issue type: Other skin issue.Other skin issue description: open lesion.Wound acquired in-house.Wound is greater than 3 months.Skin Issues Note: Order added for treatment.Skin issue education: Treatment of skin issue. Skin issue notification: Manager. Review of the revised Care Plan dated 6/4/2026, revealed, .The resident has potential/actual impairment to skin integrity. contact dermatitis, fragile skin.10/30/2025. The Care Plan did not reflect EBP. Review of the Progress Note dated 6/8/2026 at 6:41 PM, revealed .Skin Check. Skin Issu.Skin Issue: #002.Location: Right lateral malleolus.Issue type: Other skin issue.Other skin issue description: open lesion .Wound acquired in-house. Wound is greater than 3 months. Observations in Resident #42's room on 6/8/2026 at 10:00 AM, 12:18 PM, 12:28 PM, 4:32 PM, and 6/9/2026 at 7:48 AM, revealed no EBP signage noted on Resident #42's door or on the wall outside of the resident's room and no PPE noted. 4. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease, and Neurogenic Bladder. Review of the Physician Orders dated 3/30/2026, revealed Change [Indwelling Urinary] catheter 1x [time]/month FR [French] 18 bulb 10 .one time a day every 1 month(s) starting on the 15th for 1 day(s) . Review of the Physician Orders dated 3/30/2026, revealed Change [Indwelling Urinary] Catheter Bag as needed for Nonfunctioning Review of the Physician Orders dated 3/30/2026, revealed [Indwelling Urinary] Catheter care every shift, clean peri-area [area between the genitals and the rectum] and obtain output. Document output in mL [milliliters]. The Physician Orders did not reflect EBP. Review of the significant change MDS dated [DATE], revealed Resident #49 scored a 10 on the BIMS assessment, which indicated he was moderately cognitively impaired. He had an indwelling urinary catheter. Review of the Care Plan dated 5/11/2026, revealed, The resident has Indwelling Catheter R/T [Related To]: Neurogenic bladder. Change catheter as ordered per MD orders. Check tubing for kinks. Clean peri-area front to back. Monitor and document intake and output as ordered and report abnormalities to Physician.Privacy bags at all times. Secure catheter to reduce friction. Observations in Resident #49's room on 6/8/2026 at 10:10 AM, 3:44 PM and 6/9/2026 at 7:30 AM. revealed no EBP signage or PPE on door. Observation in Resident #49's room on 6/10/2026 at 9:39 AM, revealed Certified Nursing Assistant (CNA) C failed to perform hand hygiene between glove changes while performing catheter care. During an interview outside Resident #49's room on 6/10/2026 at 9:55 AM, CNA C was asked if she should have performed hand hygiene between glove changes. CNA C replied, Yes . During an interview on 6/11/2026 at 11:24 AM, the DON (Director of Nursing) was asked if a resident with an indwelling urinary catheter should have EBP signage and PPE outside their door. The DON stated, Yes, they should. The DON was asked how often her staff is in serviced on hand hygiene. The DON replied, They are in-serviced several times a year. The DON was asked if hand hygiene should be performed after glove changes. The DON replied, .yes .absolutely . 4. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], with diagnoses including Dementia, Venous Insufficiency, Cellulitis of Right Lower Limb, Localized Swelling, Mass and Lump, Right Lower Limb. Review of the quarterly MDS assessment dated [DATE], revealed Resident #54 scored a 5 on the BIMS assessment, which indicated Resident #54 was severely cognitively impaired, and noted for open lesions on the foot. Review of the Care Plan dated 4/15/2026, revealed .The resident has actual for impairment to skin integrity. The Care Plan did not reflect EBP. Review of the Physician Order dated 5/25/2026, revealed Please change resident's sheets as needed. They get wet and stained from weeping edema. as needed for For [duplicate wording] wet and stains r/t [related to] weeping legs. Review of the Physician Order dated 5/26/2026, revealed Please place chucks pads [absorbent pads] on patient's lower bed to absorb weeping legs and protect sheets.at bedtime for weeping legs. Review of the Physician Order dated 5/26/2026, revealed BLE weeping edema. 1. cleanse with wound cleanser 2, dry completely 3. Apply Unna boot [a compression dressing]. Wrap with cast padding 5. Top wrap [named elastic bandage] bandage one time a day for Weeping edema AND as needed for for [duplicate wording] soiled or missing dressing. The Physician Orders did not reflect EBP. Observations in Resident #54's room on 6/8/2026 at 10:37 AM, revealed bilateral lower extremities wrapped from toe to below knees with bandage gauze. Resident voiced he has areas on both legs that are aggravating. No EBP signage noted on Resident #54's door or on the wall outside of the resident's room and no PPE noted. Observation in Resident #54's room on 6/08/2026 at 3:18 PM, revealed Resident on side of bed, bilateral legs dependent with edema, wrapped from toes to below knees with bandage gauze. Dressings loose on both legs revealing redness below the knees to the front of both legs and a pale yellow tinge to wrap. No EBP signage noted on Resident #54's door or on the wall outside of the resident's room and no PPE noted. Observation in Resident #54's room on 6/09/2026 at 7:56 AM, revealed no EBP signage noted on Resident #54's door or on the wall outside of the resident's room and no PPE noted. During an interview on 6/9/2026 at 12:58 PM, the Director of Nursing (DON) was asked if residents with weeping ulcers or weeping edema should have EBP. The DON stated, Yes they should. During an interview on 6/10/2026 at 3:21 PM, the DON was asked what conditions would require the implementation of EBP. The DON stated, Anything not contained, open weeping wounds, urinary catheter. The DON was asked if residents with wounds would require EBP. The DON stated, Not unless it is draining or weeping. The DON was asked what the EBP policy is for chronic wounds. The DON stated, I will have to review it. The DON was asked if EBP precautions were in place for Resident #42 and #54 prior to the interview on 6/9/2026. The DON stated, They were not. The DON was asked if not utilizing EBP for residents with chronic wounds or weeping ulcers/edema create an increased risk of infection or transmission to or from those residents and others. The DON stated, Yes. During an interview on 6/11/2026 at 11:01 AM, revealed the DON confirmed chronic wounds would require EBP.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide indwelling urinary catheter care as ordered by the physician for 2 of 2 (Resident #23 and #49) sampled residents reviewed for indwelling urinary catheter. The findings include: 1. Review of the facility policy titled, Catheter Care, Urinary, dated August 2022, revealed .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.the following information should be recorded in the resident's medical record.the date and time that catheter care was given.the name and title of the individual giving the catheter care. 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Insomnia, Neuromuscular Dysfunction of Bladder, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Resident #23 had an indwelling urinary catheter. Review of the Care Plan dated 3/22/2026, revealed .Catheter Care per policy . Review of the Treatment Administration Record (TAR) dated 4/2026, 5/2026, and 6/2026, revealed .[Indwelling Urinary] Catheter care every shift,[day, evening, and night shift] document output in mL [milliliters] .clean peri-area and obtain output .start date 11/14/2024. Review of the TAR dated 4/2026, revealed that catheter care was not documented as being provided on the following dates: a. 4/1/2026 day shift b. 4/2/2026 day shift, evening shift, and night shift c. 4/3/2026 day shift and evening shift d. 4/4/2026 night shift e. 4/5/2026 day shift f. 4/6/2026 evening shift and night shift g. 4/9/2026 night shift h. 4/10/2026 evening shift and night shift i. 4/11/2026 day shift j. 4/14/2026 day shift, evening shift, and night shift k. 4/15/2026 day shift l. 4/16/2026 evening shift m. 4/18/2026 day shift and evening shift n. 4/19/2026 day shift and evening shift o. 4/20/2026 evening shift p. 4/21/2026 day shift and evening shift q. 4/22/2026 evening shift r. 4/23/2026 evening shift s. 4/24/2026 evening shift and night shift t. 4/26/2026 day shift, evening shift, and night shift u. 4/27/2026 day shift and night shift v. 4/28/2026 evening shift and night shift w. 4/29/2026 day shift and evening shift Review of the TAR dated 5/2026, revealed that catheter care was not documented as being provided on the following dates: a. 5/1/2026 day shift and night shift b. 5/2/2026 day shift and evening shift c. 5/3/2026 evening shift and night shift d. 5/5/2026 night shift e. 5/7/2026 day shift f. 5/8/2026 evening shift g. 5/10/2026 day shift, evening shift, and night shift h. 5/12/2026 evening shift i. 5/13/2026 evening shift j. 5/14/2026 evening shift k. 5/16/2026 day shift l. 5/19/2026 night shift m. 5/24/2026 evening shift and night shift n. 5/26/2026 evening shift o. 5/27/2026 day shift p. 5/28/2026 day shift Review of the TAR dated 6/2026, revealed that catheter care was not documented as being provided on the following dates: a. 6/2/2026 day shift b. 6/6/2026 night shift c. 6/7/2026 day shift and evening shift d. 6/9/2026 day shift and night shift Observation in Resident #23's room on 6/10/2026 at 8:34, revealed an indwelling urinary catheter bag with amber colored urine hanging at bedside. 3. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Neurogenic Bladder, and Chronic Kidney Disease. Review of the Physician Order dated 3/30/2026, revealed .[Indwelling Urinary] Catheter care every shift, clean peri-area . Review of the significant change MDS dated [DATE], revealed Resident #49 scored a 10 on the BIMS assessment, which indicated he was moderately cognitively impaired. Resident #49 had an indwelling urinary catheter. Review of the TAR dated 4/2026, revealed that catheter care was not documented as being provided on the following dates: a. 4/1/2026 - night shift b. 4/2/2026 - night shift c. 4/4/2026 - day shift and night shift d. 4/5/2026 - day shift and evening shift e. 4/6/2026 - night shift f. 4/9/2026 - night shift g. 4/10/2026 - day shift and night shift h. 4/12/2026 - day shift and night shift i. 4/14/2026 - night shift j. 4/15/2026 - night shift k. 4/18/2026 - night shift l. 4/19/2026 - day shift and night shift m. 4/21/2026 - night shift n. 4/23/2026 - evening shift o. 4/24/2026 - night shift p. 4/26/2026 - day shift q. 4/27/2026 - evening shift and night shift Review of the TAR dated 5/2026, revealed that catheter care was not documented as being provided on the following dates: a. 5/1/2026 - night shift b. 5/2/2026 - day shift and night shift c. 5/3/2026 - day shift d. 5/5/2026 - night shift e. 5/6/2026 - day shift and evening shift f. 5/8/2026 - day shift and night shift g. 5/9/2026 - night shift h. 5/10/2026 - day shift and night shift i. 5/15/2026 - night shift j. 5/18/2026 - evening shift k. 5/19/2026 - evening shift l. 5/20/2026 - evening shift m. 5/23/2026 - night shift n. 5/28/2026 - day shift o. 5/29/2026 - day shift Review of the TAR dated 6/2026, revealed that catheter care was not documented as being provided on the following dates: a. 6/4/2026 - evening shift b. 6/5/2026 - night shift c. 6/7/2026 - night shift Observation in Resident #49's room on 6/8/2026 at 10:55 AM, 3:54 PM and 6/9/2026 at 7:33 AM, revealed an indwelling urinary catheter draining clear, yellow urine to bedside bag with dignity cover. During an interview on 6/11/2026 at 11:24 AM, the Director of Nursing (DON) was asked if she expected her Nurses and Certified Nursing Assistants (CNA) to follow physician orders. She replied, Yes. The DON was asked if there should be blanks on the TAR where catheter care should be documented as provided. She replied, .No, there should not be any blanks. The DON was asked if staff were expected to provide catheter care. The DON stated, Absolutely. The DON was asked if failure to provide catheter care could result in a resident developing a Urinary Tract Infection. The DON stated, Yes it could.

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 2 of 11 sampled residents (Resident #49 and #302) reviewed for Advance Directives. The findings include: Review of the facility's policy titled, Advance Directives, dated 12/2016, revealed .Advance directives will be respected in accordance with state law and facility policy .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment to formulate an advance directive if he or she chooses to do so . Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set (MDS) dated [DATE], revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Review of Resident #49's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission. Review of the medical record, revealed Resident #302 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission MDS dated [DATE], revealed Resident #302 had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #302's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission. During an interview on 4/19/2022 at 3:28 PM, the Assistant Director of Nursing (ADON) confirmed that Resident #49 and #302 did not have Advance Directives and there was no documentation the residents or legal representatives were informed or provided written information regarding their right to develop an Advance Directive upon admission.

Based on policy review, medical record review, and interview, the facility failed to accurately assess a pressure injury for 1 of 1 sampled resident (Resident #205) reviewed for pressure ulcers. The findings include: Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 4/2018, revealed .the nurse shall describe and document/report the following .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate . Review of the closed medical record, revealed Resident #205 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Note Entry dated 3/3/2022, revealed Resident #205 had a Stage 2 pressure injury on the coccyx that was present on admission to the facility. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #205 had a Stage 2 pressure injury that was present on admission to the facility. Review of the Clinical Notes Report dated 3/15/2022, revealed .PI [Pressure Injury] to coccyx, stage II [2] .7cm [centimeter] x [by] 7.2cm x 0.2cm, 80% [percent] tan slough [necrotic tissue] to wound bed . Review of the Clinical Notes Report dated 3/22/2022, revealed .PI [Pressure Injury] to coccyx, stage II [2] .8cm x 9.5cm x UTD [unable to determine] [depth], 100% dark brown to yellow, firm adherent tissue to wound bed . During an interview on 4/20/2022 at 1:50 PM, the Director of Nursing (DON), confirmed that Resident #205 had a stage 2 pressure injury to the coccyx that was present on admission to the facility. The DON confirmed that Resident #205's coccyx pressure injury should have been re-classified as a stage 3 on 3/15/2022, when there was 80% slough present, and as an unstageable on 3/22/2022, when the wound depth was unable to be determined due to being 100% covered with a firm adherent tissue.

Based on policy review, medical record review, and interview, the facility failed to report an injury of unknown origin to the State Survey Agency within 2 hours for 1 of 4 (Resident #1) sampled residents reviewed for potential abuse. The findings include: Review of the facility's Abuse Prevention Policy documented, .Required to report to a law enforcement agency if there is a reasonable suspicion of a crime against a resident .The TN Department of Health .must be contacted within two (2) hours of forming the suspicion . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set Assessment (MDS) revealed Resident #1 scored a 3 on the Brief Interview of Mental Status (BIMS), which indicated the resident was severely impaired for decision making. Review of the Event Report dated 6/28/19 at 12:00 PM documented, .Reported to DON (Director of Nursing) by Senior Helpers Supervisor that resident had a bruise to right wrist .deep purple discoloration circular to top of right wrist .area 4 x 4 x 0 (centimeters) . The DON completed her assessment and reported the injury of unknown origin/potential abuse to the Assistant Administrator at 12:30 PM. Medical record review of a Nurses' Note dated 6/28/19 at 3:33 PM documented, .Reported by private sitter (Resident #1) had a bruise to his top right wrist . resident noted with a 4 x 4 x 0 (centimeter) dark purple area of discoloration to the top of his right wrist .Son (named person) called and message left for him requesting a return call. (named person) notified . Review of the Facility Reported Incident (FRI) reported to the State Agency revealed the incident was reported to the State Agency on 7/1/19 at 9:07 AM, 3 days after the injury of unknown origin was identified. Interview on 7/11/19 at 10:30 AM in the conference room, the DON stated, .(Named person) came to me at approximately 12 noon (6/28/19) and informed me that (Resident #1) had a reddened area to his upper right wrist .I saw (Resident #1) at 12:15 PM and noted on top of his right wrist was a 4 x 4 x 0 cm (centimeter) dark purple bruise .After leaving them, at 12:30 PM (6/28/19) I alerted (named person) (Assistant Administrator) of potential abuse . Interview with the Administrator on 7/11/19 at 2:00 PM in the conference room, the Administrator confirmed the abuse allegation was reported to the State on 7/1/19. He stated, .I thought I had five days to report it to the State. I got confused and read it wrong .

Based on policy review, observation, and interview, the facility failed to ensure medications were securely locked and inaccessible to residents, unauthorized staff and visitors in 1 of 4 medication (Sunflower Medication Cart) storage areas. The findings include: Review of the facility's undated Storage of Medications policy revealed, .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use or out of sight, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . Observations in the Sunflower Hall on 1/29/19 at 8:10 AM, revealed a medication cart unlocked and unattended. The medication cart contained numerous containers of physician prescribed medications. Interview with Registered Nurse (RN) #2 on 1/29/19 at 8:15 AM, at the Sunflower Medication Cart, RN #2 was asked if the medication cart should be unlocked and unattended. RN #2 stated, No. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked if a medication cart should be locked when unattended. The Interim DON stated, Yes, if it is out of sight, it should be locked.

Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH EDITION provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of a significant medication error when 1 of 4 (Registered Nurse (RN) #1) nurses failed to administer food promptly after a rapid-acting insulin injection. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS .[MEDICATION NAME] .Insulin [MEDICATION NAME] .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION .5-10 minutes prior to meals . 2. The facility's Insulin Administration policy revised on 9/2014, documented, .1. The three key characteristics of insulin are: a. Onset of action-how quickly the insulin reaches the bloodstream and begins to lower blood glucose .Rapid-acting .Onset .10-15 min (minutes) . 3. Medical record review revealed Resident #169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] U (Unit) .100 unit/mL (milliliter) subcutaneous (SSI) (Sliding Scale Insulin) INSULIN PEN .Therapeutic Range Sliding Scale Insulin .Blood sugar is 141.00-200.00 8 Units . Observations in Resident #169's room on 1/28/19 at 4:45 PM, revealed RN #1 obtained a blood glucose test from Resident #169 with a reading of 172. Observations in Resident #169's room on 1/28/19 at 4:57 PM, revealed RN #1 administered [MEDICATION NAME] 8 units to Resident #169. Observations in Resident #169's room on 1/28/19 at 5:45 PM, revealed Resident #169 was delivered a meal tray. Staff failed to provide a meal or substantial snack for 48 minutes after [MEDICATION NAME] a rapid-acting insulin was administered. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked how soon should a resident eat after receiving a [MEDICATION NAME] injection. The Interim DON stated, With short acting, 15-30 minutes.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were available for administration for 1 of 4 (Resident #269) residents observed during medication pass. The findings include: The facility's Medication Administration Schedule policy revised (MONTH) 2007documented, .Medications shall be administered according to established procedures . Medical record review revealed Resident #269 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] (vitamin D2) 2,000 unit tablet .every one day starting 1/19/2019 . Observations on 1/29/19 at 8:50 AM, at the med cart on Sunflower Hall, revealed Registered Nurse (RN) #2 was unable to administer [MEDICATION NAME] to Resident #269 because the medication was not available. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked if it was acceptable not to give a medication for 2-3 days because it is not available. The DON stated, No ma'am.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain privacy and confidentiality of medical records for 1 of 5 (Resident #119) sampled residents. The findings include: The facility's undated HIPAA (Health Insurance Portability and Accountability Act)/PRIVACY SAFEGUARDING AND STORING PROTECTED HEALTH INFORMATION policy documented, .The policy of this Community is to ensure, to the extent possible, that PHI (Private Health Information) is not intentionally or unintentionally .disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulation governing confidentiality and privacy of health information .Access to computer-based PHI shall be limited to staff members who need the information for treatment, payment, or health care operations .Community staff members shall log off their workstation when leaving the work area .Computer monitors shall be positioned so that unauthorized persons cannot easily view information on the screen . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in the Sunflower Hall on 1/29/19 at 8:10 AM, revealed Resident #119's personal health information opened and visible on the computer monitor on the unattended medication cart. Interview with RN #2 on 1/29/19 at 8:15 AM, at the medication cart in the Sunflower Hall, RN #2 was asked if a resident's personal health information should be visible on the computer monitor when the medication cart was unattended. RN #2 stated, No. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked if a resident's personal health information should be visible on the computer monitor when the medication cart was unattended. The DON stated, No ma'am.

Based on policy review, review of kitchen sanitation logs, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when open employee drinks were stored in the kitchen refrigerator, the 3 compartment sink sanitizer was not tested per policy, utensils were stored in the utensil drawer which contained pooled water and unknown dried substances, brooms were stored in the kitchen, plates, bowls and pans in the immediate trayline area were soiled with an unknown debris, a holding well with various empty food containers in it had debris in it, pans were stored with thick black build-up on them, a cleaning cloth was on top of the clean plates in the spring-loaded plate holder by the tray line, cleaning supplies were stored by the plates, a stove top and oven were soiled with debris, improper storage of tongs, and fuzzy white substances stuck on the ventilation hoods over the stove top. The facility had a census of 5 skilled residents with all 5 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's .FOOD BROUGHT IN BY FAMILY/VISITORS policy documented, .No foods brought in by visitors may be stored in the Dietary Departments' refrigeration units . Observations in the kitchen on 3/4/18 at 10:40 AM, revealed 2 (named coffee brand) drinks with straws inserted, in the refrigerator. Interview with Supervisor #1 on 3/4/18 at 10:40 AM, in the kitchen, Supervisor #1 was asked if those were employee drinks. The supervisor confirmed that they were employee drinks. Supervisor #1 was asked if they should be stored in the kitchen refrigerator. Supervisor #1 stated, No. 2. The facility's .DISH WASHING & (and) DISH WARE STORAGE policy documented, .3 compartment dispensed sanitizer will be tested prior needed use to ensure product adequately dispensing . The facility's .SANITATION policy documented, .Utility workers will be trained in the proper use of the dish machine and three-compartment sink . The facility was unable to provide documentation that the 3 compartment sink sanitizer was tested on the morning of 3/4/18. Review of the facility's DISH MACHINE TEMPERATURE LOG revealed the San (Sanitizer) 1 and San 2 were not marked as done on 3/2/18 or 3/3/18, and the San 1 was not marked as done on 3/4/18. Interview with Supervisor #1 on 3/4/18 at 10:48 AM, in the kitchen, Supervisor #1 was asked to test the 3 compartment sanitizer. Supervisor #1 was unable to find any test strips. Supervisor #1 was asked how often the sanitizer was tested . Supervisor #1 stated, Once a week . 3. The facility's .DISH WASHING & DISH WARE STORAGE policy documented, .It is the policy of the community to maintain safety and sanitation methods of dish washing methods .Dishes and utensils must be air dried before being stored or must be stored in non-obstructed, self-draining position . Observations in the kitchen on 3/4/18 at 10:53 AM, revealed a utensil drawer with spoons and scoops with water pooled in them and a scoop with a dried white substance in it. Interview with Sous Chef #1 on 3/4/18 at 10:53 AM, Sous Chef #1 was asked what the dried white substance was on the scoop. Sous Chef #1 stated, I'm not sure. Interview with Sous Chef #2 on 3/5/18 at 8:35 AM, in the kitchen, Sous Chef #2 was asked if it was acceptable for spoons and scoops to be stored wet. Sous Chef #2 stated, It is unacceptable. 4. The facility's .STORING OF CHEMICALS AND CLEANING SUPPLIES policy documented, .It is the policy of the community that .cleaning supplies be stored in such a way that they are not in contact with food service and preparation areas .Storage of cleaning supplies in designated storage area off of food production or prep line Observations in the kitchen on 3/4/18 at 10:53 AM, revealed brooms and dust pans openly hanging on the wall near the preparation and trayline area. Interview with the Food Manager on 3/4/18 at 11:06 AM, in the kitchen, the Food Manager was asked if the brooms and dust pans were kept openly in the kitchen all the time. The Food Manager stated, Yes ma'am. 5. The facility's DISH WASHING & DISH WARE STORAGE policy documented, .Maintain separation of defined areas of handling soiled and clean dishes and utensils .Pots, pans, dishes, and utensils must be free of build-up on food contact surfaces and additional deep clean completed, when needed . Observations in the kitchen on 3/4/18 at 10:53 AM, revealed particles of debris in the bowls, plates, and pans by the tray line serving area, a covered storage well with empty food containers that had debris in the containers and in the storage well directly beside the tray line area, and frying pans covered with a thick black substance. Interview with Sous Chef #1 on 3/4/18 at 10:53 AM, Sous Chef #1 was asked if the bowls, plates and pans in the serving area by the trayline had particles of debris in them. Sous Chef #1 confirmed there were particles of debris in them. Sous Chef #1 was asked if the storage well with empty food containers should be clean. Sous Chef #1 stated, Yes, it should . Sous Chef #1 was asked what the thick black substance was on the frying pans. Sous Chef #1 stated, I don't know .carbon. Interview with Sous Chef #2 on 3/5/18 at 8:35 AM, in the kitchen, Sous Chef #2 was asked if the bowls, plates and pans by the tray line should have particles of debris in them. Sous Chef #2 stated, No ma'am. Sous Chef #2 was asked if the frying pans should have carbon build-up on them. Sous Chef #2 stated, No ma'am, it should not. 6. The facility's .STORING OF CHEMICALS AND CLEANING SUPPLIES policy documented, .It is the policy of the community that .cleaning supplies be stored in such a way that they are not in contact with food service and preparation areas .Storage of cleaning supplies in designated storage area off of food production or prep line Observations in the kitchen on 3/4/18 at 10:53 AM, revealed a cleaning cloth on the top plate in the spring-loaded plate holder by the tray line and a container of bleach wipes in the immediate area of the plates. Interview with Sous Chef #1 on 3/4/18 at 10:53 AM, in the kitchen, Sous Chef #1 was asked why there was a cleaning cloth on the cleaned top plate of the stack of serving plates. Sous Chef #1 stated, It shouldn't be there. Interview with the Food Manager on 3/4/18 at 5:23 PM, in his office, the Food Manager was asked if bleach wipes should be kept by the tray line. The Food Manager stated, No, in the chemical closet. 7. The facility's .EQUIPMENT MAINTENANCE policy documented, .Food service staff will maintain cleanliness of equipment . Observations in the kitchen on 3/4/18 at 10:53 AM, revealed multiple areas of crusty black material on the stove top and in the oven. Interview with the Sous Chef #1 on 3/4/18 at 10:53 AM, Sous Chef #1 was asked if the stove and oven were clean. Sous Chef #1 stated, No. 8. Observations in the kitchen on 3/4/18 at 10:53 AM, revealed 3 sets of tongs hanging on the handle of the stove. Interview with the Food Manager on 3/4/18 at 11:06 AM, in his office, the Food Manager was asked if the tongs should be hanging on the stove. The Food Manager stated, That's where they have always kept them. Interview with Sous Chef #2 on 3/5/18 at 3:00 PM, in the Food Manager's office, Sous Chef #2 was asked if the tongs were always left on the stove. Sous Chef #2 stated, No. Sous Chef #2 was asked if it was appropriate to store them there. Sous Chef #2 stated, No, the utensils need to be in a safe and sanitary place. 9. The facility's .EQUIPMENT MAINTENANCE policy documented, .Food service staff will maintain cleanliness of equipment . Observations in the kitchen on 3/4/18 at 10:53 AM, revealed a fuzzy white substance on the ventilation hoods over the stove. Interview with the Sous Chef #1 on 3/4/18 at 10:53 AM, in the kitchen, Sous Chef #1 was asked what the substance was. Sous Chef #1 stated, Grease on top of dust. Interview with Supervisor #1 on 3/4/18 at 11:16 AM, in the kitchen, Supervisor #1 was asked where the cleaning schedules were kept. Supervisor #1 stated, We don't have a cleaning schedule.

Based on policy review, observation, and interview, the facility failed to ensure 2 of 3 (Licensed Practical Nurse (LPN) #1 and 2) medication nurses followed practices to prevent the potential spread of infection. The findings included: The facility's Handwashing/Hand Hygiene policy documented, .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .m. After removing gloves .Washing Hands .3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . Observations in front of Resident #53's room on 1/24/17 beginning at 9:52 AM, revealed LPN #1 was preparing medications at the medication cart. LPN #1 dropped the [MEDICATION NAME] as she was punching the pill out of the card, one half went into the cup, the other half fell on to the floor. LPN #1 applied a glove to her left hand, picked the medication off of the floor, and disposed of the pill in the sharps container. LPN #1 removed the glove, applied gloves to both hands without performing hand hygiene, and removed the other half of the [MEDICATION NAME] from the pill cup. LPN #1 punched out another [MEDICATION NAME] into the medication cup, removed her gloves without performing hand hygiene, and continued preparing the medications. The Potassium popped out onto the floor, and LPN #1 applied gloves, and as she tried to punch another Potassium out, it also popped out onto the floor. LPN #1 picked these two medications off of the floor, removed her gloves without performing hand hygiene. LPN #1 applied new gloves, punched out the Potassium into the medication cup, and continued preparing the pills with the same gloves. LPN #1 removed her gloves, used hand gel, entered Resident #53's room, and administered eyedrops and oral medications to this resident. LPN #1 removed her gloves, washed her hands, and turned off the faucet with her bare hands. Observations in front of Resident #58's room at the medication cart on 1/25/17 beginning at 9:10 AM, revealed LPN #2 applied gloves and broke 2 pills in half. LPN #2 removed her gloves without performing hand hygiene, entered Resident #58's room, and administered medications to this resident. When LPN #2 completed administering medications to this resident, she washed her hands and turned off the faucet with her bare hands. Interview with the Director of Nursing (DON) on 1/25/17 at 9:43 AM, in the Astor Lounge, the DON was asked what should be done after removing gloves. The DON stated, They should wash their hands or use hand gel. The DON was asked if the faucet should be touched with bare hands after washing hands. The DON stated, No, they should use a paper towel.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 6 (monarch hall medication cart and front hall medication room) medication storage areas. The findings included: 1. The facility's Administering Medications policy documented, .When opening a multi-dose container, the date opened shall be recorded on the container . 2. Observations in the monarch hall medication cart on 1/24/17 at 9:55 AM, revealed 1 open and undated bottle of Lantanoprost 0.0005% Ophthalmic Solution. Interview with Licensed Practical Nurse (LPN) #3 on 1/24/17 at 9:56 AM, at the monarch nurse's station, LPN #3 was asked how long the Lantanoprost solution could be used after it had been opened. LPN #3 stated, 28 days. LPN #3 was asked if she could find an opened date on the medication. LPN #3 stated, No . LPN #3 was asked if she would expect to see a date opened on the medication. LPN #3 stated, I would. 3. Observations in the front hall medication room refrigerator on 1/24/17 at 10:02 AM, revealed 1 open and undated multi-dose vial of Lantus insulin. Interview with LPN #3 on 1/24/17 at 10:03 AM, in the front hall medication room, LPN #3 was asked if she could find an opened date on the Lantus insulin vial. LPN #3 stated, Nope, I don't see one. Interview with the Director of Nursing (DON) on 1/24/17 at 2:44 PM, in the the Astor Lounge, the DON was asked what she expected nursing staff to do when they opened a multi-dose vial of medication. The DON stated, Date it with an open date .

Based on policy review, observation, and interview, the facility failed to determine if it was clinically appropriate for 1 of 6 (Resident #47) sampled residents reviewed to self-administer medications. The findings included: The facility's Self-Administration of Medications policy documented, Policy Statement Residents in our facility who wish to self-administer medications may do so, if it is determined they are capable of doing so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications .13. The staff and practitioner will periodically .reevaluate a resident's ability to continue to self-administer medications . Observations in the independent dining room on 1/13/17 at 12:20 PM, revealed Resident #47 was seated in a chair, eating. Resident #47 placed a pill cup with several medications in it on the table. Resident #47 would take 2 medications, eat several bites, then take 2 more pills, and eat several bites. Resident #47 continued this until she had taken all of the medications in the cup. Interview with the Director of Nursing (DON) on 1/24/17 at 4:30 PM, in the Astor Lounge, the DON was asked if there were any residents that self administer medications. The DON stated, Yes. The DON was asked what is the process when a resident self-administers medications. The DON stated, .should be an order and a self-administration assessment . The DON confirmed there was no self-administration assessment or order for this resident, and stated, .I was not aware that was her preference to take her medications with her meals .went and talked to her and she has a preference to take medications with her meals .I will do that now (obtain an order and do an assessment) .

Based on policy review, observation and interview, it was determined the facility failed to ensure medications were not stored past their expiration dates in 2 of 7 (Cumberland/Harpeth treatment cart and Monarch medication room) medication storage areas. The findings included: 1. Review of the facility's medication storage policy documented, "...The facility shall not use... outdated... biologicals..." 2. Observations of the Cumberland/Harpeth treatment cart on 9/10/14 at 2:00 PM, revealed 6 Solosite conformable wound gel dressings stored past the expiration date of 1/2014. 3. Observations in the Monarch medication room on 9/10/14 at 2:10 PM, revealed 6 Solosite conformable wound gel dressings stored past the expiration date of 1/2014. 4. During an interview at the receptionist desk on 9/10/14 at 2:00 PM, The Medical Records Clerk was asked if she restocked the treatment carts. The Medical Records Clerk stated, "Yes." The Medical Records Clerk was then asked if it was appropriate for Solosite conformable wound gel dressings with expiration dates of January, 2014, to be in the treatment carts to be used used for treatments. The Medical Records Clerk stated, "No." During an interview at the receptionist desk on 9/10/14 at 2:10 PM, the Director of Nursing (DON) was asked if it was appropriate for Solosite conformable wound gel dressings with expiration dates of January, 2014, to be on the treatment carts to be used for treatments. The DON stated, "No."

Based on medical record review and interview, it was determined the facility failed to accurately assess a resident for falls for 1 of 15 (Resident #36) sampled residents of the 25 residents included in the stage 2 review. The findings included: Medical record review for Resident #36 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Sets ((MDS) dated [DATE] and 12/31/12 revealed Section J1800 were coded as "0", indicating no falls since prior assessment. Review of the "Clinical Note Entry" documented Resident #36 had falls with no injuries on 8/29/12, 9/6/12, and 11/15/12. During an interview in the conference room on 6/12/13 at 9:55 AM, the Director of Nursing (DON) was questioned concerning the 8/29/12, 9/6/12, and 11/15/12 falls not reflected on the MDS. The DON confirmed the 10/1/12 and 12/31/12 MDSs were inaccurate and stated, "...will have to check with her (MDS Coordinator) why this is not reflected on these MDSs..."

Based on policy review, medical record review and interview, it was determined the facility failed to revise the care plan to reflect a left heel pressure ulcer for 1 of 15 (Resident #40) sampled residents of the 25 residents included in the stage 2 review. The findings included: Review of the facility's "Prevention of Pressure Ulcers" policy documented, "...The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate..." Review of the facility's "Care Plans - Comprehensive" policy documented, "...An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident..." Medical record review for Resident #40 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. cover with ALLEVYN 3 x (by) 3. apply ALLYVYN HEEL. secure with KERLIX..." Review of the weekly pressure ulcer assessment dated [DATE] documented a left heel stage 2 fluid filled blister 2 x 1.5 x 0.2. Review of the care plan dated 3/5/13-3/28/13 documented "...at risk for impaired skin integrity..." The care plan was not individualized and did not reflect Resident #40's stage 2 pressure ulcer to her left heel. During an interview in the conference room on 6/12/13 at 9:30 AM, the Director of Nursing (DON) was asked if the left heel pressure ulcer should be on the care plan. The DON stated, "...I would expect so..." The DON verified the care plan did not include the pressure ulcer on the left heel.