Every finding on record at Specialty Health and Rehabilitation Center

Based on observations, interviews and record review, the facility failed to follow acceptable nationally accepted infection prevention and control standards including proper use of Personal Protective Equipment (PPE) to prevent the spread of infections by staff involved in direct resident care in 1 out 1 resident observed. (Resident #2)The findings include:On 06/22/2026 at approximately 8:53 AM, an observation of Resident #2 was performed. An Enhanced Barrier Precaution (EBP) sign was posted on the outside of his door. (Photographic evidence obtained). The resident's urinary catheter tubing was observed disconnected from the catheter port. A staff member notified Staff B, Licensed Practical Nurse (LPN), who arrived with the catheter drainage bag replacement. The nurse donned gloves; however, she did not don a gown despite an EBP sign posted on the resident's door. After opening the replacement drainage bag package, the nurse cleansed the catheter connection port with an alcohol swab prior to reconnecting the tubing. The nurse completed the task and performed hand hygiene afterwards.On 06/22/2026 at approximately 9:01 AM, an interview was conducted with Staff B. She confirmed that she did not wear the required personal protective equipment (PPE) and did not put on a gown while providing catheter care for Resident #2 on EBP. She stated that she forgot to follow the EBP precaution posted on the residence door. She acknowledged that PPE is used to help prevent the spread of infection.On 06/22/2026 at 9:01 AM, an interview was conducted with Staff A, Advanced Registered Nurse Practitioner (ARNP). She explained that it is her expectation that staff wear the appropriate PPE when providing care to residents on EBP to help prevent the spread of infection. She stated that PPE is required as a precautionary measure, and failure to wear the appropriate PPE could increase the risk of infection transmission to residents.On 06/22/2026 at approximately 1:20 PM, an interview was conducted with the Assistant Director of Nursing (ADON). She explained that infection prevention includes staff compliance with appropriate PPE during high contact resident care, including wounds, catheters, peg tubes (a flexible feeding tube surgically inserted through the abdominal wall directly into the stomach) and intravenous (IV) sites, to reduce the risk of infection transmission.On 06/22/2026 at approximately 1:57 PM, an interview was conducted with the Director of Nursing. She stated that it is her expectation for the staff to wear the appropriate PPE including the gown when providing care to patients on EBP precautions.A review of Resident #2 medical record revealed that EBP precautions were initiated on 06/08/2026 for urinary catheter (a flexible tube inserted into the bladder to drain urine) care and antibiotic therapy was ordered for cystitis (inflammation of the bladder) on 06/16/2026. Further review of the resident care plan revealed that the resident is at risk for Multi Drug Resistant Organisms (MDRO) requiring EBP due to foley catheter with interventions to change PPE after contact with the resident, post notification signs at the door, and provide PPE equipment in room before providing direct high contact care. (Photographic evidence obtained)The facility policy titled Isolation Precautions, Categories of dated June 2025 states, Enhanced Barrier Precautions or to be used with multi drug resistant Organism. EBP Expand the use of PPE beyond situation in which exposure to blood and body fluids is anticipated and referred to the use of gown and gloves during high contact resident care activities to provide opportunities or transfer of multidrug resistant Organisms (MDRO) to staff hands and clothing. All residents with any of the following conditions should use EBP, including wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. During high contact resident care activities that include dressing bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use for central line, urinary catheter, feeding tube, tracheostomy/ventilator, hand hygiene should be performed, gloves and gowns should be worn as the appropriate PPE.

Based on observations, staff interviews, and record reviews, the facility failed to develop and implement a comprehensive-person centered care plan for the safety and use of oxygen therapy for 1 of 1 residents sampled for oxygen use. (Resident #39)The findings include:Resident #39 was observed wearing oxygen via nasal cannula with the flow of 1 liter per minute (lpm) on the following dates and times: 9/29/25 at 12:20 PM, 9/30/25 at 9:40 AM, 9/30/25 at 12:15 AM, 10/01/25 at 9:30 AM, and 10/01/25 at 2:00 PM.An interview was conducted with Nurse C, a Licensed Practical Nurse (LPN), on 9/30/25 at approximately 9:45 on 9/30/25. Nurse C indicated Resident #39 has received oxygen via nasal cannula since she was admitted on [DATE].An interview with Nurse D, another LPN, on 10/1/25 at approximately 11:50 AM. Nurse D confirmed Resident #39 wears oxygen continuously at 2 lpm.A review of Resident #39's medical record revealed an active diagnosis of Dependence on Supplemental Oxygen with an active order for oxygen at 2 lpm every shift for Shortness of Breath. A record review of Resident #39's medication administration record revealed the order for oxygen at 2 LPM every shift with nurse initials each shift since admission of 8/13/25. Record review of Resident #39's care plan dated 8/15/25 revealed no care plan for oxygen.An interview was conducted on 10/2/25 at approximately 10:30 AM with the Minimum Data Set (MDS) Coordinator, who also is the Care Plan Coordinator for short term residents. The MDS/Care Plan Coordinator confirmed oxygen was captured on the MDS report dated 8/20/25, but was not captured on the admission care plan dated 8/15/25. The MDS/Care Plan Coordinator stated if oxygen is captured on the MDS, then it should absolutely be captured on the resident's care plan.The facility's policy on care plan states, The care planning and interdisciplinary team (IDT) shall meet as necessary to assure the residents care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs as defined on the resident's assessment.

Based on observations, interviews, and record review, the facility failed to provide adequate monitoring of labs for 1 of 5 residents sampled for unnecessary drugs. (Resident #3)The findings include:Resident #3's medical record revealed an active diagnosis of cirrhosis of the liver and ascites. The medical record revealed the active medications for diagnosis of cirrhosis of the liver and ascites are the following: 1.Xifaxan Tablet 550 Milligram- Give one tablet by mouth two times a day related to Unspecified Cirrhosis of the liver. 2. Ursodiol Capsule 300 Milligram- Give one capsule by mouth one time a day for Biliary Cirrhosis. 3. Lactulose Oral Solution 20 Grams per 30 Milliliters- Give 45 milliliters by mouth four times a day for Hyperammonemia related to Unspecified Cirrhosis of the Liver and Ascites.Resident #3's care plan initiated on 9/7/22 revealed that the resident has the potential for changes in mental status due to history of an elevated ammonia level. The plan states the laboratory values will be monitored for the resident through the next review. The facility is to obtain labs as ordered by the physician to assess baseline lab values and follow up to determine changes in condition. A review of Resident 3's orders revealed the following order: obtain ammonia level on 3/2/25. At this time, the result was 185 and the resident was sent to the emergency room for altered mental status and elevated ammonia level. The next ammonia level order was to be repeated on 3/3/25. The lab reported no specimen was received from the facility. The next ammonia level order was on 5/22/25 with the lab reporting uncollected specimen with no results. Another ammonia level was ordered on 5/23/25 and to be obtained every six months in January and July. The lab reported the facility cancelled the lab order on 7/11/25. No ammonia level was obtained for the July order. The ammonia level was ordered for 10/1/25 but was rejected by the lab due to the bag the sample being damaged in transit. The physician ordered the next ammonia level on 10/1/25 to be repeated on 10/2/25. The lab reported the result of the ammonia level of 43 to the facility. An interview was conducted with Nurse D, a Licensed Practical Nurse (LPN) on 10/1/25, at approximately 2:15 PM. Nurse D described the process of taking lab orders, scheduling them with the lab, and the process of reporting lab results. The nurses take the verbal telephone order or written order from the physician. The order is then added to the resident's chart and in the lab portal with the date and time to obtain the sample. The lab report comes in by computer and the nurses check the lab portal according to who had samples taken for the day. The results are then called to the physician for any new orders.An interview was conducted with the Director of Nursing (DON) on 10/2/25 at approximately 10:25 AM. The DON indicated that the physician calls with the lab orders and nurses on the floor put orders in the resident chart and into the lab portal for the lab company to be notified of when and which resident to get samples. The samples are obtained Monday through Friday between 3:00 am - 5:00 am by the phlebotomist. If the lab is ordered as stat, then the nurse working at that time obtains the sample and sends the sample. The lab portal is checked multiple times a day for lab results. The lab book at the nurses' station has a list of residents with the lab samples they need and the date the sample needs to be obtained. The phlebotomist signs the lab book by the resident's name after the sample is obtained. The staff views the lab book while working their shift to know which resident to look up results in the lab portal. The nurse manager or floor nurse calls the resident's provider with the lab results and obtains any new orders as needed. The physician will look in the lab portal when they are here and verify lab results also. If the lab is rejected, the portal alerts the nursing staff, who will notify the provider for any new orders. Review of the physician's progress note dated 9/22/25 revealed they will reorder ammonia levels, due to the last collection was rejected. An interview was conducted with the physician on 10/1/25 at approximately 3:30 PM. They reviewed the resident's record and confirmed they had intended to order a repeat the Ammonia Level on 10/1/25 and failed to order it.

Based on observations and staff interviews, the facility failed to ensure that the call system was adequate to allow residents to call for staff assistance through a communication system in 1 of 16 sampled resident rooms (room [ROOM NUMBER]-1) and 2 of 16 sampled resident restrooms (room [ROOM NUMBER] and 347). The findings include: An observation and test of the resident room call system in room [ROOM NUMBER]-1 was conducted on 9/29/25 at 2:48 PM with Employee G (Certified Nursing Assistant). The call system for 302-1 did not appear functional. Employee G acknowledged it was not functional. An observation of the restroom call system cord for room [ROOM NUMBER] was conducted on 9/29/25 at 3:08 PM. The call system cord was observed to be too short to reach the toilet. The cord was only 5 inches long. An observation of the restroom call system cord for room [ROOM NUMBER] was conducted on 9/30/25 at 10:08 AM. The call system cord was wrapped around the toilet seat riser frame and thus did not reach to the toilet. An interview was conducted with Employee A (Certified Nursing Assistant) on 10/2/25 at 8:50 AM. Employee A stated the resident who occupied room [ROOM NUMBER]'s bed 2 usually toileted independently and would at times use the restroom call system. An interview was conducted with Employee B (Certified Nursing Assistant) on 10/2/25 at 9:38 AM. Employee B stated the resident in room [ROOM NUMBER]'s bed 2 toileted himself. The call system cord in room [ROOM NUMBER] restroom was observed in the presence of the Regional Maintenance Director on 10/2/25 at 9:03 AM. He confirmed the call system cord was too short and about 5 inches long. He stated the resident would not be able to reach the call system cord if the resident was in the floor. (Photographic evidence obtained.) The call system cord in room [ROOM NUMBER] restroom was observed on 10/2/25 at 9:32 AM in the presence of the Regional Maintenance Director. He observed the cord and confirmed it was wrapped around the toilet seat riser frame. (Photographic evidence obtained.)

Based on record review, interviews and facility policy review, the facility failed to complete medication administration records (MARs) for 1 of 3 residents sampled for intravenous therapy. (Resident #316) The findings include: A review of Resident #316's medical record was conducted. A physician's order was found for Merrem (meropenem) intravenous solution reconstituted 500 mg (an antibiotic) every 8 hours for prophylaxes with a start date of 2/6/24 and a discontinue date of 2/28/24. Another physician's order stated that Cubicin (daptomycin) solution reconstituted 500 mg (another antibiotic) use 500 mg intravenously every 24 hours for prophylaxis related to right knee revision was to be started on 1/29/24 and discontinued on 2/28/24. A review of the MAR revealed Cubicin 500 mg was not documented on 2/7/24 at 5:00 pm and on 2/21/24 at 5:00 pm. Additionally, Merrem 500 mg was not documented on 2/7/24 at 10:00 pm, 2/16/24 at 2:00 pm, 2/21/24 at 10:00 pm, and on 2/23/24 at 10:00 pm On 7/10/24 at 4:05 pm, an interview was conducted with Staff A, a Licensed Practical Nurse (LPN) and unit manager. Staff A walked the surveyor through the process of documenting the MARs and stated there was a facility policy to fully documented whether the medication is given or not given. On 7/10/24 at 4:19 pm, an interview was conducted with Director of Nursing (DON). She stated it was facility's expectation to fully document on MARs. Facility policy titled Charting errors/omissions dated November 2001 was reviewed. Policy stated accurate medical records shall be maintained by the facility. Bullet 4 stated any hole or omitted documentation is considered an error/omission.

Based on record review and interviews the facility failed to ensure residents were seen by a physician or other delegated licensed health care professional at least every 60 days for 2 of 5 sampled residents (Residents #1 and #2). The findings include: Resident # 1 was admitted on [DATE], with diagnoses of Alzheimer's Disease, late onset, Heart Failure, Congestive Heart Failure, Osteoarthritis, Essential Hypertension, Atrial Fibrillation, and Type 2 Diabetes. Resident #1 has a Brief Interview for Mental Status (BIMS) of 02 indicating severely impaired cognition. Extensive Assistance with one-person physical assist with transfers, dressing, eating, and personal hygiene. The last documented physician assessment was dated 11/10/2022. There was no other documentation to support the physician, physician assistant, nurse practitioner or clinical nurse specialist had assessed the resident since that date. Resident #2 was admitted on [DATE], with diagnoses of Type 2 Diabetes, Hypothyroidism, Hypertensive Heart Disease, Atrial Fibrillation, Osteoarthritis, Gout, Glaucoma, Hyperlipidemia, Major Depressive Disorder, and generalized Anxiety. Resident #2 has a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. She required extensive assistance with a two+ person assist with bed mobility, transferring, dressing, toileting, and personal hygiene. The last documented physician assessment was dated 11/17/2022. There was no other documentation to support the physician, physician assistant, nurse practitioner or clinical nurse specialist had assessed the resident since that date. An interview was conducted on 02/16/2023 at approximately 2:00 PM, with the Regional Facility Consultant. He stated that he was aware that there may be some residents who have not been seen timely. He stated the Medical Director was having some computer problems and may have missed seeing some residents. He stated the facility is trying to adjust and correct any problems for the Medical Director. An interview was conducted on 02/16/2023 at approximately 2:30 PM, with the Medical Director of the facility. The Medical Director stated that there is a glitch in the computer system. He stated the facility had a medical chart upgrade to all of the facilities. He stated, I used to be able to see a list of who I needed to see in the facilities. But now, they all run together, and I cannot tell who I have seen and who I have not seen. When they had the new version upgrade, I was in the middle of a resident assessment and lost that information. The process is broken. I know I have probably missed seeing some patients. A review of the Physician's Visit policy date November 2017 states the resident should be seen by his/her attending physician at least once every sixty days. The policy states the resident's attending physician must review the resident's total program of care, including medications and treatments at least quarterly. The policy states a physician assistant or nurse practitioner may make alternate visits after the initial visit.

Based on observations and interviews the facility failed to maintain a clean, safe, homelike environment for 3 of 3 Wings (A-Wing, B-Wing and C-Wing) of the facility. The findings include: On 10/03/22 at beginning at approximately 11:15 AM, a tour was conducted of the facility during which it was noted that there was an area on the wall in room 222 on C-Wing with torn sheet rock in need of repair, also noted was an area on the wall to the left of the nurses' station that had an area of torn sheet rock and holes that were in need of repair. The tour of A-Wing revealed in room 352 an area noted on the bottom corner of the wall, beside the sink, that was missing a large area of sheet rock. Also observed during the tour was an area of the ceiling in room 351, above the closet, was a brown stain with several half dollar size spots of a black biogrowth. On the ceiling tile just above the fire doors on A-Wing East hall was a brown stain that had black biogrowth in the center. An observation was made in the education room located on the B-Wing, of an area to the ceiling above the north wall there was a brown stain next to the air vent. On 10/03/22 at approximately 12:20 PM, an interview was conducted with the resident in room 351, who stated that she noticed the area to the ceiling in her room and had notified staff. Resident #2 went on to state that maintenance had been in to look at the area. She was told that it was a pipe in the ceiling that had leaked, but the leak had been fixed and they would be back to fix the ceiling, she reported that this was about 3 weeks ago. On 10/03/22 at approximately 12:45 PM, an interview was conducted with the Director of Nursing (DON), the DON was shown the area in room 351 and stated it appeared to be a water stain and needed to be fixed. The DON was shown the area to room 352 and confirmed that the sheet rock had a hole in it and it also needed to be repaired. On 10/03/22 at approximately 12:48 PM, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor when shown the ceiling in room 351, stated there had been a pipe leak that was fixed and that they needed to wait on the ceiling to dry before they could repair it, but that as soon as the resident is moved, they would get the area fixed. The Maintenance Director was shown the area to the ceiling behind the fire doors on A-Wing East hall, he stated they had replaced the tile about a month ago, that the vent above the area sweats in the summer months and causes the issue and the tile has to be changed out. He went on to state that the building was an older building and that his department tries to stay on top of repairs as much as possible. On 10/03/22 at approximately 2:30 PM, an interview was conducted with the Regional Maintenance Director who stated that the facility had an issue with the sprinkler system, not too long ago and had to go on fire watch until it was repaired. The Regional Maintenance Director went on to state that they would do a full building audit and make sure repairs are completed.

Based on staff and Resident representative interview and record review, the facility failed to provide access to a resident's medical record within 24 hours of the request or within 2 working days of the written notice for 1 of 1 Resident (#153) sampled for medical records requests. The findings include: On 11/17/2020 at 10:05 AM, a record review of Resident #153's Authorization Form for the Release of Health Information revealed that Resident #153's representative acting as attorney-in-fact, had signed a written request for medical records on 10/14/2020. On 11/18/2020 at 8:45 AM, an interview with Resident #153's representative was conducted. At that time, the representative stated that the records were ready for release after 14 days on 10/28/2020. The representative stated that the resident was currently at home on hospice care. The representative went on to state that the facility ultimately determined that she had a right to the records and that they have been released to her on 10/28/2020. On 11/19/2020 at 1:10 PM, an interview was conducted with the Director of Nursing (DON). She stated that facility sent the request off to their legal department for review and that was the reason it took 14 days for approval for Resident #153's Representative to get the records. She stated that the facility determined that the representative had a right to the records and they were picked up by the representative at the facility on 11/11/2020.

Based on staff interview and clinical record review the facility failed to accurately assess skin conditions for 1 of 3 residents (#88). The findings include: Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission nursing data collection indicated the only skin condition at the time of admission was a healed surgical site on the right hip. Further review revealed that on 10/5/2020 a wound care note documented a healing right hip incision and bilateral boggy heels. On 11/14/2020 the weekly skin assessment indicated no skin issues. Then 11/17/2020 the record identified deep tissue injury (DTI) both heels red and slow to blanch measuring 3.5 X 5.0. Treatment skin prep and offloading. Wound note indicated she was admitted with the area to the heel on 10/1/2020. A review of the revised care plan dated 10/26/20 identified potential for breakdown due to decrease in mobility, incontinence, anticoagulant therapy, fragile skin, status [REDACTED]. admitted with boggy heels On 11/19/20 at approximately 10:04 AM, an observation of resident #88 was conducted with Employee B, Assistant Director of Nursing (ADON). The ADON observed both heels and stated that they seem to have normal color. At this time she was asked about the deep tissue injury identified in the Wound Care note dated 10/05/20 and on the revised Care Plan, she stated, I do not believe I ever heard that (resident #88) had DTI of the heels. I think that is a mistake. She was told that she had treatment with skin prep to the heels. The ADON said that the facility uses skin prep and skin barrier cream on everyone that is admitted . On 11/19/20 at approximately 10:28 AM, an interview was conducted with the Director of Nursing (DON) regarding the initial skin assessment documentation and the wound note on 10/5/2020. She looked at the initial data collection and said No, I do not see anything about being admitted with heel problem. She then showed the documentation dated 10/5/2020 indicating bilateral boggy heels. She said her goal to have a follow-up skin assessment within 24 hours by the wound care note. Discussed the concern with no documentation on admission notes regarding heels then 4 days later a note showing bilateral boggy heels indicating she was admitted with it. She said she had talked to the wound care nurse about the delay.

Based on staff and resident interview, and clinical record review the facility failed to provide Restorative Nursing Program services (RNP) post discharge from physical therapy for 1 of 1 resident sampled (#95). The findings include: On 11/16/20 at approximately 2:32 PM, an interview with Resident #95 was conducted during which he stated that he was getting therapy for his upper extremities but not his lower extremities and he did not know why. A record review for resident #95 revealed he had orders for occupational and physical therapy. On 11/18/20 at approximately 1:34 PM, an interview was conducted with the Therapy Director during which he stated that Resident #95 did have physical therapy at the facility from 10/21/2020 to 10/27/2020, however he had been discharged to the restorative nursing program (RNP). A copy of the discharge summary for physical therapy was requested. A review of the form indicated that the discharge plan and instructions were: patient is to discharge from skilled therapy services and continue with RNP during length of stay. On 11/18/20 at approximately 2:00 PM, an interview was conducted with Employee E, the Physical Therapist (PT), responsible for discharge summary for Resident #95. She explained that when a resident is discharged from therapy, she usually sends the recommendations to the RNP. On 11/18/20 at approximately 2:05 PM, an interview was conducted with Employee C, the Restorative Nurse. She said she had no recommendations from physical therapy but did have recommendations for occupational therapy. They send us written recommendations. Employee C and this surveyor then went back to Employee E, the PT, to discuss the recommendations. Employee E, stated that she discussed the recommendations with the restorative aide and that she usually writes them out. She then stated if I missed writing it out, I will get to it immediately.

Based on observation, staff interview and policy review the facility failed to maintain clean filters for oxygen concentrators in 2 of 2 rooms (305 and 322), and failed to date humidifier with date of change for 1 of 2 rooms (305) during random observations of oxygen concentrators. The findings include: On 11/16/2020 observations were made in two rooms where residents had oxygen concentrators. room [ROOM NUMBER] had a dusty filter and the humidifier had no date on it. room [ROOM NUMBER] was observed to have a dusty filter in the oxygen concentrator. (Photographic evidence obtained) On 11/17/2020 at approximately 12:43 PM, Employee A, the Unit Manager, and the wound care nurse were asked to observe rooms [ROOM NUMBERS]. room [ROOM NUMBER] after which Employee A stated, referring to the oxygen concentrator yes it looks like the filter needs to be changed. Then proceeded to room [ROOM NUMBER]. She said humidifiers are changed when they are empty. On 11/17/20 at approximately 1:00 PM, the issue with rooms [ROOM NUMBERS] was discussed with the Assistant Director of Nursing (ADON) Employee B. She said that central supply was responsible for changing the humidifier and the filters for the oxygen concentrators. She was not sure how often this was done. On 11/17/20 at approximately 1:30 PM, the DON provided a copy of the policy for Respiratory Therapy Equipment. She pointed out the where in the policy it directed that the humidifier was supposed to be dated and initialed. Respiratory Therapy Equipment policy: from Infection Prevention and Control Program Nursing Services Procedures pages 103 /104 of 115, Dated November 2019. Purpose of this procedure is to provide guidelines to help prevent nosocomial infection associated with respiratory therapy equipment including ventilators and to prevent transmission of infections to residents and staff. Procedure guideline: #2 use sterile distilled water for humidification if indicated, #3 mark bottle with date and initials upon opening, #5 change oxygen cannula's and tubing every 7 days and date; #7 wash filters from oxygen concentrators weekly , rinse and squeeze dry.

Based on record review and interview, the facility failed to provide a refund within 30 days of discharge to the resident's representative for 2 of 3 residents sampled for refund requests (#2 and #4). The findings include: On 12/26/2019, a review was conducted of resident/family refund requests which indicated resident #2 was discharged on [DATE] and a refund was due to the responsible party in the amount of $497.36. The facility administrator signed authorizing the refund on 8/30/2019 and it was approved at 1:48pm, on 9/5/2019. The review also indicated resident #4 discharged on [DATE] and a refund was due to the resident's representative in the amount of $81.01, the facility administrator authorized the refund on 7/4/2019 and it was approved at 3:01pm, on 7/16/2019. On 12/26/2019 at approximately 2:00pm, an interview was conducted with the facility administrator who having been made aware through a phone conversation with the facility's financial consultant that the refunds had not been paid. The administrator was not certain how the oversight occurred and stated an audit would take place beginning immediately to determine the cause and a course of corrective action. Copies of refund checks were provided for review on 12/26/2019 at approximately 2:30pm. Check # in the amount of $497.36, dated 12/26/2019, was made out to the representative of resident #2. Check # in the amount of $81.01, dated 12/26/2019, was made out to the representative of resident #4.

Based on observation, and staff interview, the facility failed to distribute food in a sanitary manner for 2 of 6 wings (300 east and 300 west). The findings included: On 3/25/19 at 11:31, the dietary staff employee E was observed to bring a steam cart from the kitchen to the 300 wing. She was observed to place a towel on the floor in front of the cart on the front hall and stand on the towel. She served meals from the steam cart and when she finished with the front hall she picked up the towel off the floor and put it on a handle on the side of the steam cart. She then moved her cart to 300 East hall where she removed her gloves, replaced with clean gloves without sanitizing her hands, then she removed the towel from the steam cart and placed it in front of the steam cart and stood on it to serve meals. Once the trays were served she then move the steam cart to 300 west and repeated putting the towel down on the floor. She again touched the towel without washing or sanitizing her hands. (Photographic evidence obtained) On 3/25/19 11:35 Employee E was asked why she put the towel on the floor. She said she puts it down for water that gets on the floor from the steam cart. An interview was conducted with the certified dietary manager (CDM) on 3/26/19 at 1:46 pm. He said the staff put the towel down because when the domes are lifted on the steam cart the condensation gets on the floor. He then said the towel should be on the cart not the floor. If they are putting them on the floor they should use 3 clean towels one for each hall. Employee E was interviewed on 3/27/19 at 06:56 am. She said she did put the towel on the floor and then hung it on the cart. She then said she should not have done that.

Based on surveyor observation, review of facility environmental documents and staff/ resident interviews, the facility did not provide ongoing maintenance to 5 of 28 resident rooms ( 229, 247, 250, 254, 258) observed. The findings included: On 3/25/19 at 10:30 AM & 3/26/19 at 8:45 AM, black marks were noted to cover approximately a couple of feet of wall board by the bed closest to the door in room [ROOM NUMBER] .On 03/26/19 9:45 AM it was noted in room [ROOM NUMBER], there were gouges at bottom of bathroom door and multiple black marks on wall near headboard of both beds in the room. 03/26/19 at 10:36 AM in room [ROOM NUMBER], it was observed there was chipped paint on the wall near the sink (approximately four inches in length), chipped paint by bed B (behind the chair), and chipped paint under the bed B light fixture. On 3/25/18 at 2:48 PM, a chip was observed on the corner of a bedside table for the one bed in room [ROOM NUMBER], exposing a rough surface (of the approximate width of a quarter) of pressed board. The resident was asked about it and stated it does hurt if she bumps into the chip. (Photographic evidence was obtained.) An interview was conducted with the facility maintenance director at 3:55 PM on 3/27/19. He stated he believed there had been no preventative maintenance (PM) rounds done in the building since (MONTH) 2019. He said generally four rooms a day would be reviewed for PM. Documentation of the PM program in the computer system was provided by the regional maintenance consultant; it demonstrated the last noted paint touch up in system was (MONTH) 2, 2019. Documentation on the PM log provided by the facility maintenance director then demonstrated PM rounds had not been done since 3/29/18. (Photographic evidence was obtained.) A tour of rooms [ROOM NUMBERS] was completed with the Regional Maintenance Consultant and Administrator on 3/27/19 at approximately 4:20 PM; the regional maintenance consultant confirmed those were areas that needed repair. On 3/25/19 at 2:54pm, an observation of Resident #39 was conducted in room [ROOM NUMBER] which revealed two areas on the popcorn ceiling that were hanging away from the ceiling or missing completely. Over the entry door to the room was an area with a crack approximately two feet in length with a chunk approximately 2 inches by 2 inches hanging down from the ceiling. (photo evidence obtained) The facility Preventative Maintenance Policies and Procedures Manual (dated (MONTH) 2001) was reviewed. The policy indicated maintenance service shall be provided including, maintaining the building in good repair .

Based on observation, record review and staff interviews, the facility failed to ensure the availability of physician ordered medications and failed to ensure pain medications were re-evaluated prior the end of the prescription for 1 of 1 resident's sampled for pain management (#2). Findings include: On 2/26/19 a record review was conducted for resident #2 which revealed she was scheduled to receive [MEDICATION NAME] 10-325 every 6 hours for pain. Review of the Medication Administration Record [REDACTED]. On the (MONTH) 27, 2019 in the boxes marked 0000 and 0600 had a 04 which indicates see Nursing Notes. Review of the Nursing Notes for 0000 and 0600 found the medication was not available waiting for script. Further review of the MAR indicated [REDACTED]. On 2/27/19 at approximately 11:08 AM, an interview was conducted with resident #2 in which she stated that the facility ran out of her pain medicine and they had given her Tylenol but it is not working. She rated her pain at this time as a 10 on a scale of 1-10 in which a 10 indicates the worst pain. On 2/27/19 at approximately 11:25 AM an interview was conducted with the Assistance Director of Nursing /Unit Manager who stated she was aware that the resident was out of her pain medication and was waiting for a prescription. She stated she had received a call last night (2/26/19) regarding the resident being out of pain medication but she did not have the authority to give an order for [REDACTED].>On 2/27/19 at approximately 11:51 AM an interview was conducted with the Omnicare pharmacist during which he stated that he had No requests for yesterday or today regarding [MEDICATION NAME] for resident #2. On 2/27/19 at approximately 12:00 PM a follow up interview was conducted with resident #2 she was observed to be crying, holding tightly to the bed rail and stated that she cannot eat because her pain is too bad. She stated again the facility ran out of her pain medication. On 2/27/19 at approximately 12:39 PM an interview was conducted with nurse B in which she stated she gave the last [MEDICATION NAME] from the resident's punch card yesterday evening (2/26/19 1800). On 2/28/19 at approximately 12:18 PM ADON/Unit Manager in which she stated that medications requiring a written prescription such as [MEDICATION NAME] should be reviewed by the Medical Director on Tuesdays when he makes his rounds. She stated he usually reviews the charts and when he sees someone is getting low he will re-order the medications and the prescriptions are printed at that time. She stated this had not been done in the case of Resident #2. She also stated that it is the nurse's responsibility to ensure residents do not run out of medications. Review of the Policy Administration of Drugs dated (MONTH) 2019 states that Drugs must be administered in accordance with the written orders of the attending physician.

Based on resident and staff interview, facility record review, and facility policy review, the facility failed to follow their policy and failed to file and investigate a grievance concerning missing items presented by 1 of 1 resident (# 36). The findings were: Resident #36 was interviewed on 1/30/2018 at 9:22 am. She stated she had missing money and recounted that she had money go missing in August or September 2017 in the amount of $40.00. In October 2017 she had $18.00 missing, in December 2017 $20.00 went missing, and in January $18.00 went missing. She stated, I told everybody nurses and certified nursing assistants (CNAs). She was not aware if a grievance had been filed. A review of grievances filed since June of 2017 was conducted and there were no grievances regarding money for resident #36. An interview was conducted with licensed practical nurse (LPN) Employee I on 1/31/2018 at approximately 1:40 pm. She stated that when residents have concerns or complaints a grievance form shall be completed by staff or the resident. The forms are then taken to Social Services. When asked if she had any complaints regarding missing money and Employee I stated, No, I have not had any complaints of missing money in a very long time. Employee A, certified nursing assistant (CNA), was interviewed on 1/31/2018 at approximately 1:50 pm. She stated resident #36 had complained about missing money back in the summer somewhere around $20.00. She stated, I told the nurse and the Risk Manager (RM). I do not remember their names they have changed. She continued to say the process was for the resident to put their money in a trust fund first. Resident # 36 has a lock box in her room. When asked if the resident could access the lock box, Employee A stated, No, she cannot access the lock box but she does remember who she gave the key to. A review of the facility's policy revealed two policies one for grievances and one for missing items. The Resident Grievance Program policy: updated 12/2016 stated our Center will assist residents, their representatives, other interested family members, or advocates in filing grievances when such requests are made. Bring grievances to attention of the Center through one of the following means: complete a grievance report or file a written grievance, or file a verbal grievance. In case of a verbal grievance, the person receiving the grievance will document the grievance on the Grievance report. All Grievance reports will be forwarded to the Risk Manager for investigation initiation and follow through. The RM will maintain a log and report to the Quality Assurance Committee all grievances and corrective actions. The Administrator or designee will respond to the grievance within a reasonable time after submission. The Protection of Resident's Personal Property policy: Administrative Services [DATE]: stated in step 1: residents are encouraged to leave valuables and excess cash with family or deposit such items in the trust fund safe. Step 5 stated resident's responsible parties should report missing items promptly. Associates upon discovery of a missing item shall promptly report the loss to Administrator or designee. Step 6 stated the Administrator or his/her designee will log the missing items, complete an investigation on all missing items, and document results of findings. The missing item log will be reviewed periodically for trending analysis. An interview was conducted with the Director of Nursing (DON), RM, Administrator, and consultant nurse on 1/31/2018 at approximately 2:25 pm. The surveyor informed that resident #36 had complaints of missing money, but upon review of the grievance reports and logs there was not any grievances on file for the resident. The DON stated, we may have it located in missing items. At that time the surveyor asked that any additional information or logs be provided for missing items. A review of the facility's missing items report did show other residents with missing money which had all been replaced. Resident #36 was not listed on the log. A follow-up interview was conducted with the DON on 1/31/18 at approximately 3:20 pm and she confirmed there were no allegations of missing money for resident #36 in the grievance or missing items log. She also confirmed they were in the process of interviewing and reporting the allegations of missing money. An interview was conducted with Employee C, an evening shift CNA for Resident #36, on 1/31/2018 at 4:14 pm. Employee C stated, Yes, Resident #36 reported missing money to me back in the summer and again before Christmas. I told my nurse what she said. The Unit Manager, a registered nurse (RN), Employee D, for Resident #36 was interviewed on 2/1/2018 at 8:35 am by another surveyor. She stated the policy for missing items was that residents and family members make a complaint and tell staff. She stated, If the CNA was told the aide would tell the nurse or the RM. If it was money missing, a slip would be completed and turned in to the RM. The DON was interviewed again on 2/1/2018 at approximately 8:40 am. She stated, anyone can complete a grievance including CNA's and they would know whether the grievance was being followed up on because we would talk with them about it. In an attempt to better understand the process for missing items versus grievances the DON was interviewed again on 2/1/2018 at approximately 10:38 am. At that time she stated, When CNA ' s found out about missing money they should call the RM to let them know about the missing money. It is their responsibility to let me, the RM, or the Administrator know about missing money. She indicated that missing items are reported through documenting on a missing item form. After the form is completed, the form should be submitted to the Social Worker by the person who was told. When asked what is defined as a grievance, she replied, any dissatisfaction with our care and services in the building should be reported to the RM. Missing items including money would fall under the missing items policy and should be reported to the Social Worker. When asked how staff were able to determine the difference and know what form to complete or who to report; she replied, staff are in-serviced routinely on the process.

Based on surveyor observations, interview with Resident # 4, interview with LPN F, review of physician orders [REDACTED]. The findings were: A review of Resident #4's care plan was conducted which revealed the following: A plan of care for pain, which was dated as last care plan review completed: 1/27/2018, stated observe type, location, severity and pattern of pain/discomfort. Notify the physician/nurse practitioner of change. Perform comfort measures to promote relaxation and repositioning. Pain medications as ordered: [MEDICATION NAME] three times per day, Tylenol as needed, [MEDICATION NAME] as needed and [MEDICATION NAME] as needed. On 1/29/18 at 10:00am upon entering Resident #4's room she is crouched over and rocking back and forth stating that, it hurts so bad. I need something stronger. When asked if she had told the nurse about her pain she said she could not remember so the surveyor went to let Resident #4's nurse know. On 1/29/18 at 10:20am LPN F entered the room. When she came out she stated that resident #4 had pain medication previously and it was not due for some time. She said she would see what she could do for her. On 1/29/18 at 11:27am the surveyor followed up with the resident. At that time resident #4 stated that she had not received anything more for pain and it still hurt real bad. She stated, If I could have stronger pain pill it may help. No one came in and talked to me. At this time she was still up in her chair holding herself and rocking. On 1/29/18 at 11:31am a quick review of physician orders [REDACTED]. There were no new orders regarding pain. Further review of orders revealed: [MEDICATION NAME] 7.5/325milligrams (mg) by mouth every 6 hours as needed for pain APAP 650mg by mouth every 6 hours as needed for pain [MEDICATION NAME] 440mg by mouth every 12 hours as needed for pain Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] was last given on 1/29/2018 at 9:41am, with follow-up documentation that the pain medication was effective. The next dose of [MEDICATION NAME] was documented as administered about 6 hours later at 3:04pm on 1/29/2018. There is no documentation that other pain management measures were attempted. No non-pharmacological pain management interventions were documented. No Tylenol was documented as given on 1/29/2018. No [MEDICATION NAME] was documented as given on 1/29/2018. On 1/29/18 at 11:34am, when asked what was able to be done regarding the resident's pain, LPN F stated that she just went in the room to check on the resident and she was asleep. On 1/29/2018 at 11:53am a review of nurse's notes and orders regarding pain was conducted which revealed no information regarding the resident's pain. On 1/29/2018 at 4:15pm, the administrator and corporate nurse were informed of the issues that resident #4 had with pain management that day. On 1/31/2018 at 11:45am a follow-up interview regarding pain was conducted with resident #4. Resident #4 she stated, they started giving me pain medication every 4 hours. I think now it is just scheduled. It is working now. A review of physician orders [REDACTED]. 1/29/2018 at 4:30pm - [MEDICATION NAME] 7.5/325mg by mouth every 4 hours as needed for pain for 2 days.

Based on surveyor observations, interview with Resident # 4, interview with LPN F, review of physician orders [REDACTED]. The findings were: On 1/29/18 at 10:00am upon entering Resident #4's room she is crouched over and rocking back and forth stating that, it hurts so bad. I need something stronger. When asked if she had told the nurse about her pain she said she could not remember so the surveyor went to let Resident #4's nurse know. On 1/29/18 at 10:20am LPN F entered the room. When she came out she stated that the resident had pain medication previously and it was not due for some time. She said she would see what she could do for her. On 1/29/18 at 11:27am the surveyor followed up with the resident. At that time resident #4 stated that she had not received anything more for pain and it still hurt real bad. She stated, If I could have stronger pain pill it may help. No one came in and talked to me. At this time she was still up in her chair holding herself and rocking. On 1/29/18 at 11:31am a review of physician orders [REDACTED]. There were no new orders regarding pain. Further review of orders revealed: [MEDICATION NAME] 7.5/325milligrams (mg) by mouth every 6 hours as needed for pain APAP (Tylenol) 650mg by mouth every 6 hours as needed for pain [MEDICATION NAME] 440mg by mouth every 12 hours as needed for pain Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] was last given on 1/29/2018 at 9:41am, with follow-up documentation that the pain medication was effective. The next dose of [MEDICATION NAME] was documented as administered about 6 hours later at 3:04pm on 1/29/2018. There is no documentation that other pain management measures were attempted. No non-pharmacological pain management interventions were documented. No Tylenol was documented as given on 1/29/2018. No [MEDICATION NAME] was documented as given on 1/29/2018. On 1/29/18 at 11:34am, when asked what was able to be done regarding the resident's pain LPN F stated that she just went in the room to check on the resident and she was asleep. On 1/29/2018 at 11:53am, a review of nurse's notes and orders regarding pain was conducted which revealed no information regarding the resident's pain. On 1/29/2018 at 4:15pm, the administrator and corporate nurse were informed of the issues that resident #4 had with pain management that day. On 1/31/2018 at 11:45am a follow-up interview regarding pain was conducted with resident #4. Resident #4 she stated, they started giving me pain medication every 4 hours. I think now it is just scheduled. It is working now. A review of physician orders [REDACTED]. 1/29/2018 at 4:30pm - [MEDICATION NAME] 7.5/325mg by mouth every 4 hours as needed for pain for 2 days.

Based on observations, interviews and resident record reviews, the facility failed to ensure a medication administration error rate of 5% or less for 2 out of 5 sampled residents, #57 and #58. There were 2 medication errors in 25 opportunities, for a medication error rate of 8%. The findings include: Beginning on 01/31/2018 at approximately 08:30am, observations of medication administration were conducted. A total of five different residents, five different staff members and 25 different medication opportunities were observed. At approximately 8:51am, Staff Member H was observed to perform medication pass for Resident #57. Resident #57 was ordered to receive Levetiracetam 750mg, give 1.5 tablets by mouth two times a day for [MEDICAL CONDITION]. Staff Member H administered 1 tablet of Levetiracetam, not 1 and 1/2 tablets. Once completion of medication pass for Resident #57 was completed, the nurse was asked to review the order and medication cards for Resident #57. While retrieving the medication cards, Staff H identified the card with the 1/2 tablets which should have been administered with one whole table. At approximately 08:58am, Staff Member H was observed to perform medication pass for Resident #58. Resident #58 was ordered to receive Tylenol 500mg, 1 by mouth every 12 hours as needed for pain. Staff Member H, administered Tylenol 325mg (2) tablets - equaling 650mg, more than the prescribed amount. Once medication pass was finished for Resident #58, Staff Member H was asked to look at the Tylenol order and was made aware of her error.

Based on observation and staff interview the facility failed to ensure that a medication cart was locked or in direct observation of a person administering medication for 1 of 1 medication carts randomly sampled. Findings Include: On 01/30/18 at approximately 4:11 PM the medication cart on unit 300 was not locked nor were there any staff directly observing the cart. The cart was at the end of a hallway next to an exit door that led to the outside. There were doors to resident rooms open with residents inside their rooms on the hallway. On 01/30/18 at approximately 4:14 PM nurse E came from around a corner back to the medication cart and proceeded to pass medications. On 01/31/18 at approximately 1:40 PM an interview with nurse E was conducted. Nurse E stated that normal protocol for medication storage is to lock a cart before leaving it unattended and agreed that she should have done so.