Every finding on record at Thomas Hospitals Skilled Nursing Unit

Based on observation, and staff interviews, the facility failed to date and safely store open and prepared food items in multiple refrigeration units; maintain cleanliness of kitchen equipment and surfaces; and implement effective systems to prevent contamination or spoilage of food, including food that may be consumed by residents. These practices created a risk of foodborne illness. Facility Census: 16.On 07/30/2025 at 11:48 AM, the following was observed in the kitchen areas:Walk-In Cooler:A canister of chopped garlic was observed with no open or discard date.Walk-In Freezer:A bag of chicken tenders was stored outside of the original box, open and without a date.An open box of fish filets was observed without an open date and not sealed, exposing contents to possible contamination.Reach-In Cooler:The following perishable food items were observed undated and unsealed:OnionsCheeseLettuceSliced tomatoesSalad mixDishwashing Area:The floor under the dishwasher was visibly soiled with build-up.Racks and surrounding walls were observed to be unclean, indicating a lack of proper sanitation in an area critical to cleaning and storing eating utensils.Kitchen Equipment:Deep fryers were found to have grease accumulation behind the vats. The oil appeared dark and foamed at the edges, indicating potential overuse or contamination.The front of the fryer was coated in dried grease.Exhaust hoods above cooking equipment were visibly covered in grease.All ovens, reach-in coolers, and prep stations had build-up on the metal surfaces and visible debris and grease under the units.Reach-In Freezer:The following frozen food items were found open and without dates:Five (5) bags of French friesPre-made frozen omeletsFrozen biscuitsFrozen carrots, which were brown and discolored, indicating possible spoilageDuring the tour of the Kitchen the Dietary Manager (DM) was present and confirmed all findings as we completed the tour of the kitchen.

Based on record review, interviews, and observations, the facility failed to provide an ongoing activities program that met the individual needs, interests, and abilities of residents in accordance with their comprehensive assessments and care plans. Specifically, the facility failed to offer room-based or sensory stimulation activities for residents who did not leave their rooms, failed to develop individualized care plans for activities for most sampled residents, and did not offer weekend activities. These systemic failures had the potential to negatively impact the residents' quality of life and psychosocial well-being. Facility census: 16.a) During the survey on 07/30/25, the following concerns were identified:Facility staff reported that there were no community outings or external engagement opportunities offered to residents.Staff stated they did not provide one-on-one or sensory stimulation activities for residents who are room-bound or chose not to leave their rooms.14 of 16 resident care plans reviewed showed no individualized activities interventions for residents, especially those with low BIMS (Brief Interview for Mental Status) scores or cognitive decline.The interview with the Activities Director (AD) revealed she did not know how to create or update activity care plans in the current system. She stated: I don't have an option to create care plans in this system that I know of. If there is, I haven't been shown yet. I've been out due to health issues.The interview with the Director of Nursing (DON) revealed she was unaware of the absence of activity care plans. She acknowledged all residents should be care planned for activities.Review of the facility's activity calendars for May, June, and July showed no weekend activities were provided during those months.Observation and record review confirmed that residents with low BIMS scores who remained in their rooms had no documented individualized activity interventions, and staff were unable to describe any in-person, sensory, or alternate engagement methods being used.

Based on interviews, observations, and record reviews, the facility failed to ensure residents maintained the highest practicable mental and psychosocial well-being. The facility did not provide individualized activities and meaningful engagement for residents who remain in their rooms, failing to implement sensory stimulation or one-on-one interventions. In addiiton they failed to offer weekend activity programming for all residents. Facility Census: 16. a) On 07/30/25 The facility reported that it does not provide outings or opportunities for community involvement.On 07/31/25 The facility was unable to provide specific programming for one-on-one or sensory stimulation residents who are either unable or unwilling to leave their rooms.During record review on 07/30/25 at 12:00 PM a review of 16 resident care plans for activities revealed nine (9)lacked individualized activity care plans/interventions, particularly for residents who remain in their rooms or have low BIMS scores.An Interview on 07/30/25 with the Activities Director (AD) revealed that she was unaware of how to create or update activity care plans in the current new system. She stated, I don't have an option to create care plans in this system that I know of. If there is, I have not been shown yet. I have been out due to health issues.On 07/30/25 at 3:00 PM an Interview with the Director of Nursing (DON) revealed that she was unaware of the lack of activity care plans and stated, All residents should be care planned for activities, I will get with the AD now. Further Record review on 07/30/25 Review of facility activity calendars for May, June, and July showed no weekend activities were offered during those months.Various observations during the survey process revealed residents with a low Brief Interview for Mental Status (BIMS) score were noted to remain in their room without any documented one-on-one engagement or sensory-based activity plan.

Based on record review, staff interviews, and observation, the facility failed to develop and implement person-centered, comprehensive care plans that included individualized activities for 9 of 16 residents reviewed (Residents #30, #29, #6, #1, #32, #27, #37, #38, and #23). This failure resulted in residents, including those with low BIMS scores and those who remained in their rooms, lacking documented activity interventions tailored to their needs and preferences. Resident Identifier: #30, #29, #6, #1, #32, #27, #38, and #23 Facility Census: 16a) On 07/30/2025 at 12:00 PM, a review of 16 resident records revealed that nine (9) lacked individualized activity care plans or interventions, despite cognitive or physical limitations requiring modified or room-based activities.Resident #30 had a low BIMS score and remained in their room and had no documented activity plan or evidence of room-based engagement effort.On 07/30/25 at 12:30 PM, during an interview with the Activities Director (AD) revealed she was unaware of how to create or update activity care plans in the facility's current electronic medical records system. She stated: I don't have an option to create care plans in this system that I know of. If there is, I have not been shown yet. I have been out due to health issues.On 07/30/25 at 3:00 PM, the Director of Nursing (DON) acknowledged she was not aware that residents were not care planned for activities, stating: All residents should be care planned for activities. I will get with the AD now.

Based on staff interviews and review of time card, the facility failed to have an Infection Control Preventionist (IP) at least part time. This failed practice had the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Facility census: 17. Findings included: a) Infection Control Preventionist On 10/12/22 at 10:00 AM in an interview with the IP regarding the hours the IP worked in the facility, the IP stated that she worked at the facility approximately 4-6 hours per month. She further stated that she was shared with a sister hospital as well as with the Skilled Care Unit and the rest of the hospital. In addition, she stated she depends on the unit management to complete infection control audits and monitor infection control practices. An attempt was made to obtain the IP's time card to review the hours worked on the Skilled Care Unit. During the interview on 10/12/22 at 10:00 AM, the IP stated she was salaried and therefore did not clock in and/or out so there were no records of the hours she worked in any facility.

Based on observation and staff interview, the facility failed to ensure food items were stored, prepared, distributed and served in accordance with professional standards for food service safety. Meats were stored above vegetables and fruit in kitchen refrigeration's. The cook in the kitchen did not have a hair restraint. In addition, the facility failed to ensure residents personal snacks in the pantry refrigerator on the unit were labeled and dated as to when they were prepared and when to discard. This had the potential to affect more than a limited number of residents. Resident identifier: #66. Facility census: 17. Findings included: a) Tour of the kitchen The initial tour of the kitchen with the Dietary Operations Manager (DOM) #6 began at 11:25 AM on 10/10/22 and ended at 11:40 AM on 10/10/22 found the following: --Observation of 1 refrigerator found an unsliced section of roast beef which had not been prepared stored above an open box containing watermelon. --Observation of a second refrigerator found sliced ham and a unsliced section of ham stored above an open box containing bags of lettuce. --The floor of the walk-in freezer was littered with tape, pieces of boxes, crushed food items, crumbs and debris. --The kitchen cook, employee #31, was observed to be preparing/handling food was not wearing a hair restraint. DOM #6 confirmed the following: meat should not be stored above fruit and vegetables; the floor of the walk-in freezer needed cleaned; and the cook was not wearing a hair restraint. b) Unit Resident pantry At 2:08 PM on 10/12/22, observation of the unit's food pantry with Unit Manager, Registered Nurse (RN) #15 found food items belonging to Resident #66 in the refrigerator. RN #15 identified a container of tomato sauce and meatballs with no date to indicated when prepared and placed in the refrigerator and no date to indicate when to discard. In addition, a plastic glass containing a partially consumed frozen drink from a fast - food restaurant for Resident #66 was stored in the freezer of the refrigerator. RN #15 removed the items from the refrigerator. At approximately 2:45 PM on 10/12/22, RN #15 provided a copy of a policy entitled, Home Food, effective 04/2019: .The facility will refrigerate label and dated prepared or perishable food items in the patient specific nourishment refrigerator .

Based on observation, resident interview, and staff interview, the facility failed to have an ongoing activity program that included group activities. This was true for six (6) of six (6) anonymous residents reviewed for the care area of activities during the long - term care survey process. This had the potential to affect more than a limited number of residents. Facility census: 17. Findings included: a) Resident interviews Anonymous interviews with residents during the initial phase of the survey on 10/10/22 found the unit has no group activities scheduled. One resident said, If they ever had any bingo, I would probably go. At 12:20 PM on 10/11/22, the activities coordinator (AC) #14 said, We have not had any group activities since COVID started, we have not been released to have group activities. Review of the August, September, and October activities calendar with AC #14 confirmed the unit has no group activities listed on the calendar. The AC was asked if residents who were not in isolation and did not have COVID could attend group activities with masks and social distancing? The AC again replied, We have not been cleared to have any group activities. Review of five (5) care plans for various Residents found the following activity intervention listed for all five (5) Residents: (Typed as written) Due to COVID - 19 the skilled nursing unit is restricted and is in effect until further notice. All residents are to stay in there rooms no group activities. On 10/11/22 at approximately 12:30 PM, the Registered Nurse (RN) unit manager #15 confirmed the unit has not had any group activities since COVID-19 started approximately 3 years ago. Observation of the activity room at 7:20 AM on 10/12/22 with the Minimum Data Set Coordinator (MDSC) #2 found a large activity room measuring at least 34 feet by 18 feet. Observations on 10/10/22, 10/11/22, and 10/12/22, found no group activities were occurring. At approximately 3:00 PM on 10/12/22, RN #15 was advised the above memo is available for guidance for facility group activities. RN #15 confirmed none of the 17 residents at the facility have COVID-19. Only two (2) of the 17 in the unit are in contact isolation for infections unrelated to COVID - 19. 47119

Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of accidents during the long - term care survey process received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Neurological checks were not started after the resident had a fall, hit her head, resulting in a hematoma. Resident identifier: #55. Facility census: 17. Finding included: a) Resident #55 Review of the medical record revealed the resident fell at 4:30 AM on 10/05/22. At 0430 Nursing Assistant entered patient's room. Patient was found on the floor. Notified nursing supervisor and (name of physician.) (Name of physician was apprised of patient hitting her head and the presence of a hematoma. Doctor's order was to continue to monitor patient Patient complained of hitting her head and shoulder on the right side. Placed patient back in bed; applied ice pack to forehead; noted bruise to left arm. Will continue to follow. At 8:12 AM on 10/05/22 the physician documented the resident had a traumatic hematoma of the forehead. On 10/05/22 at 1:20 PM, an x-ray report noted the resident had a minimally displaced fracture of the right humerus. At 11:14 AM, on 10/11/22 the Director of Nursing (DON) confirmed the nurse did not start neurological checks after the fall as the facility policy directs. The DON provided a copy of the policy entitled: Fall prevention/entrapment plan, revised on August, 2020. H. Patient fall in spite of precautions: Reassess the patient, including the patient's vital signs, patient complaint of pain and obvious injury. If there is a change in LOC, loss of consciousness or head injury, the RN is to add neurological checks to plan of care and document results. At 11:30 AM on 10/11/22, the unit manager (UM) #15 said the nurse in charge received a disciplinary action because the nurse did not complete a nursing assessment following the fall and did not follow through with obtaining the orders from the physician for neurological checks after the fall. The nurse on duty did not complete her assessment until 10/10/22.

Based on observation and staff interview, the facility failed to ensure medications were properly stored for Resident #57. This was a random opportunity for discovery. Resident identifier: #57. Facility census: 17. Findings included: a) Resident #57 On 10/12/22 at 10:34 AM during medication pass, observed Registered Nurse (RN) #1 remove a cup of medications from the back pocket of her uniform. When asked why the prepoured medications were stored in her uniform, RN #1 explained the medications were poured and found Resident #57 was not available to take the medications. An interview with the Unit Manager (UM) #15 on 10/12/22 at 10:34 AM regarding RN #1 putting poured medications in uniform pocket stated that the medications should have been placed in the locked box outside Resident #57's room and not in RN #1's uniform.

Based on record review and staff interview, the facility failed to update the resident's care plan after the resident experienced a fall. This was true for one (1) of one (1) resident reviewed for the care area of accidents during the long - term care survey process. Resident identifier: #55. Facility census: 17. Finding included: a) Resident #55 Review of the medical record revealed the resident fell at 4:30 AM on 10/05/22. At 0430 Nursing Assistant entered patient's room. Patient was found on the floor. Notified nursing supervisor and (name of physician.) (Name of physician was apprised of patient hitting her head and the presence of a hematoma. Doctor's order was to continue to monitor patient Patient complained of hitting her head and shoulder on the right side. Placed patient back in bed; applied ice pack to forehead; noted bruise to left arm. Will continue to follow. At 8:12 AM on 10/05/22 the physician documented the resident had a traumatic hematoma of the forehead. On 10/05/22 at 1:20 PM, an x-ray report noted the resident had a minimally displaced fracture of the right humerus. At 11:14 AM, on 10/11/22 the Director of Nursing (DON) confirmed the nurse did not start neurological checks after the fall as the facility policy directs. The DON provided a copy of the policy entitled: Fall prevention/entrapment plan, revised on August, 2020. H. Patient fall in spite of precautions: Reassess the patient, including the patient's vital signs, patient complaint of pain and obvious injury. If there is a change in LOC, loss of consciousness or head injury, the RN is to add neurological checks to plan of care and document results. At 11:30 AM on 10/11/22, the unit manager (UM) #15 said the nurse in charge received a disciplinary action because the nurse did not complete a nursing assessment following the fall and did not follow through with obtaining the orders from the physician for neurological checks and did not place the intervention for neurological checks on the care plan.

Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of nine (9) residents reviewed during the long - term care survey process had a chair in the room to accommodate her needs and personal preferences. This was a random opportunity for discovery. Resident identifier: #62. Facility census: 17. Findings included: a) Resident #62 On 10/10/22 at 12:18 PM, the resident said she needs a chair so she can get up out of bed. She said, it needs to be a chair that would allow me to prop up my right leg. The residents' husband was visiting in the room and occupying the only chair in the room which was a hard back chair with arms. The residents' husband added, it could even be a wheelchair with an extension because she has a fractured leg. When asked if she had asked staff for a chair, the resident replied, I did but they told me all the reclining chairs are in use. Observation revealed no other chairs or wheelchairs were present in the residents' room. Review of the medical record found the resident was admitted to the facility on [DATE] with a right lateral plateau fracture. At approximately 11:00 AM on 10/11/22, the resident was observed to be up in a wheelchair with her right leg resting on a trash can turned upside down on the floor with a pillow on top of the can. At 1:24 PM on 10/11/22, the unit manager, Registered Nurse (RN) #15 observed the resident in her room with her right leg propped up on a trash can. She said, that's not good, I will get her a reclining chair, we have plenty of those.

Based on review of record review and interview, the facility failed to ensure the employee, who was designated as the Infection Preventionist for the unit, had completed specialized training in infection prevention and control. Additionally, the facility failed to ensure the Infection Preventionist was a member of the Skilled Nursing Unit Quality Assessment and Assurance Committee and reported on the infection control program, to the committee, on a regular basis . This practice had the potential to affect all residents in the facility. Facility census: 11. Findings included: a) Infection Preventionist training An interview, with the Infection Preventionist, on 07/13/21 at 3:05 PM, revealed the employee had not completed a specialized training in infection prevention and control. A review of the information provided for review, dated 2019, provided no evidence of a specialized training. Training included reporting and data collection with no specified length of event, and educational activity for continuing education. An interview with the DON, on 07/13/21 at 07:50 AM, revealed the facility had not ensured the Infection Preventionist had completed a specialized training for infection prevention and control because they were unaware of the requirement to do so. b) Quality Assessment and Assurance Committee Role A facility document titled Health Facility Key Personnel was reviewed, on 07/13/21 at 10:46 AM. The document was provided by the Director of Nursing (DON) and listed the Skilled Nursing Unit (SNU) Quality Assessment and Assurance (QAA) Committee members. The Health Facility Key Personnel form excluded the Infection Preventionist (IP). The SNU QAA Committee members were as followed: Director of Nursing DON Minimum Data Set MDS Coordinator Social Worker Activities Director Lead Physical Therapist Occupational Therapist Medical Director Dietician A facility document titled, SNU Quality Care Conference Council Meeting was reviewed on 07/13/21 at 11:00 AM. The documentation contained three (3) sign in sheets for the SNU QAA Committee meetings. The dates included 01/06/21, 04/07/21 and 05/26/21. The SNU QAA sign in sheets revealed no attendance or participation by the Infection Preventionist. A facility document titled, [NAME] Health Infection Preventionist Job Description reviewed on 07/14/21 at 8:30 AM, revealed job duties as assigned for the Infection Preventionist position. The documentation revealed, the Infection Preventionist's role was to compile and interpret surveillance reports to Quality Council or appropriate committees or speciality areas on a regular basis. An interview with DON, on 07/14/21 at 9:00 AM, revealed everyone who attended the SNU quarterly QAA meetings are required to sign in. DON confirmed the sign in sheets for the SNU QAA committee meetings were correct. DON confirmed the list of quarterly QAA meeting members were correct on the Health Facility Key Personnel form.

Based on facility documentation review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that consisted of the minimum required members. The facility failed to ensure the Administrator, Owner or a Board member participated and was included as a member of the Skilled Nursing Unit (SNU) quarterly QAA committee. The failed practice had the potential to affect more than unlimited number of residents on the SNU. Facility census: 11. Findings included: a) Skilled Nursing Unit QAA Committee A facility document titled Health Facility Key Personnel was reviewed, on 07/13/21 at 10:46 AM. The document was provided by the Director of Nursing DON and listed the SNU QAA Committee members. The Health Facility Key Personnel form excluded the Administrator as a member of the SNU QAA Committee. The SNU QAA Committee members were as followed: Director of Nursing DON Minimum Data Set MDS Coordinator Social Worker Activities Director Lead Physical Therapist Occupational Therapist Medical Director Dietician An additional facility document titled, SNU Quality Care Conference Council Meeting was reviewed on 07/13/21 at 11:00 AM. The documentation contained three (3) sign in sheets for the SNU QAA Committee meetings. The dates included 01/06/21, 04/07/21 and 05/26/21. The SNU QAA sign in sheets revealed no attendance or participation by the Administrator, Owner or a Board member. An interview with DON, on 07/14/21 at 9:00 AM, revealed everyone who attended the SNU quarterly QAA meetings are required to sign in. DON confirmed the sign in sheets for the SNU QAA committee meetings were correct. DON confirmed the list of quarterly QAA meeting members were correct on the Health Facility Key Personnel form.

Based on observation, record review and interview, the facility failed to accurately ensure a resident's advance directive was correct on the information board at the nurses' desk. The facility failed to ensure the advance directive was completed and documented in the resident's electronic medical record (EMR). This was true for one (1) of 11 residents reviewed for advance directives. Resident identifier: #7. Facility census: 11. Findings included: a) Resident #7 A record review, on 07/13/21 at 8:15 AM, revealed a Skilled Nursing Unit Admission Communication form in the medical record that stated, Do Not Resuscitate DNR. An interview with Registered Nurse (RN) #1, on 07/13/21 at 8:25 AM, revealed the Information board located at the Nurses' desk was color coded as to a resident's current resuscitation status. RN #1 stated, if the Resident is a full code their name would be written in black on the information board and if the resident is a DNR their name would be written in red on the board. An observation of the information board, on 07/13/21 at 8:30 AM, revealed Resident #7's name was written in black on the information board. An interview with the Director of Nursing (DON), on 07/13/21 at 9:20 AM, revealed the information board was wrong for Resident #7's advance directives and stated the issue would be fixed. The DON revealed the information board was used for a quick glance to help staff when working on the floor. DON stated the advance directives section in Resident #7's Electronic Medical Record (EMR) was not completed but the advanced directive information of DNR was added immediately.

Based on daily staffing review and staff interviews, the facility failed to provide an accurate accounting of available daily staff. The facility failed to list the accurate number of nurses and certified nursing aides (CNA) on the unit. The deficient practice had the potential to affect more than a limited number of residents. Facility census: 15 Findings included: a) Daily Staff Posting An interview with Registered Nurse (RN) #6, on 01/15/20 at 8:34 AM, revealed both CNA's called off today and four (4) nurses were doing complete patient care and assignments. A review of the daily posted staffing form, on 01/15/20 at 2:01 PM, revealed, one (1) RN, one (1) Licensed Practical Nurse (LPN) and two (2) CNAs available on the skilled nursing unit (SNU) on 01/15/20 for the 7:00 AM-7:00 PM shift. An interview with the Director of Nursing (DON), on 01/15/20 at 2:55 PM, confirmed the daily posted staffing form was inaccurate related to available daily staff. DON confirmed the SNU consisted of two (2) RN's and two (2) LPN's with no CNAs available on 01/15/20 for the 7:00 AM-7:00 PM shift.

Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items in the freezer and failed to maintain items in a sanitary manner. The deficient practice had the potential to affect more than a limited number of residents. Facility census: 15 Findings included: a) Freezer An observation during the initial tour, on 01/14/20 at 8:10 AM, revealed a bag of five (5) frozen breadsticks that were not labeled or dated. The bag of five (5) breadsticks was laying on the freezer shelf and had chunks of ice in the bag with the breadsticks. An additional observation during the initial tour, on 01/14/20 at 8:10 AM, revealed two (2) unopened bags of Brussels spouts that were not labeled or dated. The two (2) bags of Brussels sprouts was laying on the freezer shelf and was not in original manufactured box to indicate date of expiration. An interview with Kitchen Supervisor (KS) #65, on 01/14/20 at 8:15 AM, confirmed all food in the freezer, when not stored in original box, should be labeled and dated. KS #65 confirmed neither the bag of breadsticks nor the two (2) bags of Brussels spouts were labeled or dated. b) Dry storage area An observation, on 01/14/20 at 8:20 AM, revealed three (3) one (1) gallon containers of [NAME]slaw dressing. The three (3) containers had [NAME]slaw dressing residue dried to the outside of each container. An immediate interview with KS #65, on 01/14/20 at 8:20 PM, confirmed the containers had [NAME]slaw dressing residue dried to the outside of each container. KS #65 stated, residue on the outside of the containers was not the regular practice of storing food items. KS #65 stated food items should be free from residue and all three (3) containers would be discarded for resident safety.

Based on resident interview, record review and staff interview, the facility failed to revise a care plan to indicate the use of a bed and chair alarm for Resident #108. The failed practice affected one (1) of nine (9) care plans reviewed. Resident identifier: #108. Facility census: 15. Findings included: a) Resident #108 An interview with Resident #108, on 01/14/20 at 9:50 AM, revealed the use of a bed and chair alarm. A record review, on 01/15/20 at 10:45 AM, revealed a care plan with no interventions related to the use of a bed or chair alarm. An interview with the Director of Nursing (DON), on 01/15/20 at 11:20 AM, confirmed no bed or chair alarm interventions were noted on the care plan. DON confirmed the care plan should have been revised with the interventions of bed and chair alarms added under the fall prevention focus.

Based on observations and staff interview, the facility failed to ensure foods and equipment were maintained in a sanitary condition. Foods were stored undated it indicate when it was opened and some equipment was in need of cleaning. This has the potential to affect more than a limited number of residents who consume food served from this central location. Facility census: 12. Findings included: a) Observations During the tour of the dietary department on 03/18/19 at 10:00 a.m. with the assistance of the dietary manager, the following issues were noted: --Can of vegetable beef soup had dents around the rim of the can but located on the shelf to still be in use. --A container of cooked spaghetti and a container of butter was in the refrigerator, and was undated to indicated the date opened or placed in refrigerator. --A bag of shredded cheese was unlabeled and undated in the walk in refrigerator. --Serving utensils were found in a storage drawer all jumbled together with the serving portions touching the handles of others. This could lead to the possibility of cross contamination. --Drip pan under the range top was found to be heavily soiled with food debris and in need of cleaning. The dietary manager was present and verified the above issues.

Based on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of five (5) residents reviewed for the care area of unnecessary medications. The physician was not notified when Resident #159's medication was held. Additionally, blood glucose monitoring was performed for Resident #159 without a physician's orders [REDACTED]. Resident identifier: #159. Facility census: 12. Findings included: a) Resident #159 1. Physician notification of held medication Review of Resident #159's medication administration record (MAR) revealed the resident's blood pressure medications, [MEDICATION NAME] and [MEDICATION NAME], were not given on 03/15/19 at 8:53 AM. The reason documented in the MAR for not giving the medication was hold for parameters. Resident #159's [MEDICATION NAME] and [MEDICATION NAME], were also not given on 03/16/19 at 9:09 AM. The reason documented in the MAR for not giving the medication was low bp (blood pressure). Resident #159's [MEDICATION NAME], was also not given on 03/19/19 at 7:59 AM. The reason documented in the MAR for not giving the medication was hold for parameters. A note written by the nurse on 03/19/19 at 8:00 AM stated, [MEDICATION NAME] 20 mg po (oral) held this am per orders (physician's name) d/t (due to) BP 100/64. The medical records contained no indication the physician was notified when Resident #159's blood pressure medications were held on 03/15/19 and 03/16/19. During an interview on 03/19/19 at 1:57 PM, the Registered Nurse (RN) Clinical Coordinator stated Resident #159 did not have physician's orders [REDACTED]. The RN Clinical Coordinator stated there was no evidence in the medical records that Resident #159's physician was notified when the nurse held her blood pressure medication on 03/15/19 and 03/16/19. No further information was provided through the completion of the survey. 2. Blood glucose monitoring Review of Resident #159's medical records revealed the following nursing notes: - 03/15/19 at 9:00 PM Accucheck 185. Given hs (bedtime) snack. - 03/16/19 at 6:19 AM Accucheck 165. Given [MEDICATION NAME]. [MEDICATION NAME] is a medication for type II diabetes. - 03/16/19 at 9:40 AM Accucheck 208. Eating hs snack. - 03/17/19 at 6:23 AM Accucheck 137. Given [MEDICATION NAME]. No needs at present. Accucheck testing, also called fingerstick blood glucose testing, is a method of measuring a resident's blood glucose level at their beside using a drop of the resident's blood, usually obtained from the fingertip. Review of Resident #159's medical records did not reveal an order for [REDACTED]. During an interview of 03/19/19 at 12:00 PM, the Registered Nurse (RN) Clinical Coordinator stated Resident #159 did not have an order for [REDACTED]. She stated Resident #159's physician wrote an order today. On 03/19/19 at 11:52 AM, Resident #159's physician wrote an order for [REDACTED]. For blood glucose levels above 121, Resident #159 was to receive insulin. The amount of insulin to be administered was based on the blood glucose level. Per the physician's orders [REDACTED]. No further information was provided through the completion of the survey.

Based on review of staffing documentation and by staff interview, the facility failed to ensure the complete staffing numbers for each shift is posted daily. There were days noted where the staff available for only one shift was recorded on the form and the other two shifts were blank. This was for three days out of months of (MONTH) and March. This practice has the potential to affect more than a limited number of residents and family who are to have access to this informaiton. Findings included: a) 03/19/19 at 1:20 p.m. discussion with the director of nursing (DON) verified the staff postings had not been completely filled out for the evening and night shifts This was found during a review of the staff posting sheets on file for (MONTH) and so far for the month of March. The documentation was incomplete for (MONTH) 14 and 17. Also for (MONTH) 9, 2019. This informaiton is to be posted for all the public to have access to the information.

Based on record review, observation, and staff interview, the facility failed, for one (1) of eighteen (18) Stage II sample residents, to provide care and services to prevent the development of pressure ulcers for a resident who entered the facility without pressure ulcers and/or to promptly identify and treat pressure sores after they developed, in order to promote healing. Resident #100, who was assessed as having no skin impairment upon admission to the nursing unit on 02/02/11, was identified by the occupational therapist as having skin breakdown on the buttocks and lower extremities on 02/03/11. However, there was no evidence of nursing documentation acknowledging the presence of any skin breakdown until 02/06/11, when Wound #1 (a Stage II pressure sore) was identified and first treated. Wound #2 (also a Stage II pressure ulcer) was identified and first treated on 02/07/11. When the resident's skin was observed in the presence of a facility nurse on 02/10/11, Wound #1 was dressed, Wound #2 had no dressing on it, and a third wound (also a Stage II) was found which had not previously been identified or treated by facility staff. Resident identifier: #100. Facility census: 19. Findings include: a) Resident #100 Record review revealed Resident #100 was admitted to the facility on [DATE]. Upon admission to the facility, a registered nurse (RN - Employee #12) completed an admission report which stated Resident #100 had no skin problems, recording "no impairment" on the skin risk assessment. On 02/03/11, the occupational therapist gave Resident #100 a bath. The occupational therapist subsequently documented the following: "SKIN: Some breakdown on buttocks and LE's (abbreviation for lower extremities). Nursing is treating." Prior to 02/06/11, no documentation could be found to support that nursing was treating the pressure areas. No evidence was found for further assessment of Resident #100's skin integrity until 02/06/11, when an employee documented the following: Location of Wound #1 Right / Left Buttocks Type: Blister / Excoriation Stage: II - Break In Skin - Blister Margins: Pink Wound Bed: Pink Drainage: None Allevyn adhesive dressing was applied. A Stage II pressure area is described by the National Pressure Ulcer Advisory Panel (www.npuap.org <http://www.npuap.org>) as a "partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open / ruptured serum filled blister." Record review found no evidence that nursing was treating any pressure ulcers prior to 02/06/11. On 02/07/11, another RN (Employee #21) documented the following: Wound Location: RT (right) BUTTOCK Type: PRESSURE ULCER Stage: II - BREAK IN SKIN - BLISTER Margins: RED Wound Bed: RED Drainage: Y Description / Odor: SANGUINOUS Employee #21 measured Wound #1 to be 1 cm x 0.7 cm x 0.1 cm. Wound #2 was measured to be 2.0 cm x 0.5 cm x 01. cm and was identified as a Stage II pressure ulcer. Allevyn dressing was applied to Wound #1, and Sensicare was applied to Wound #2. On 02/10/11 at 9:35 a.m., after reviewing the occupational therapy notes dated 02/03/11, the clinical coordinator (Employee #34) was asked why there was no nursing documentation related to the findings. She stated she was not sure Resident #100 had any pressure ulcers. She said, "It may just be excoriation. I need to go look." Employee #34 and this nurse surveyor went to look at Resident #100. Upon observation, Resident #100 had three (3) Stage II pressure ulcers to the buttocks and coccyx, one (1) which had not previously been identified. He had only one (1) Allevyn dressing to one (1) of the pressure ulcers. The second pressure ulcer (identified on 02/07/11) did not have a dressing on it. According to Employee #34, if a Stage II pressure ulcer is identified, the treatment would require a dressing. On 02/10/11 at 11:15 a.m., Employee #34 reported she asked the occupational therapist why she wrote, "Nursing is treating." According to Employee #34, the occupational therapist replied, "I just assumed that nursing was treating."