Every finding on record at United Transitional Care Center

Based on interview and record review, the facility failed to provide ongoing resident-centered group activity programming that met the expressed interests of residents, including a variety of facility-sponsored activities and weekend group activities. This failed practice had the potential to affect more than an isloated number of residents in the facility. Resident identifier: #84. Facility Census: 28.Findings included:a) A review of the admission Minimum Data Set (MDS) for Residents #84, #24, #76, #25, #83, #82, #86, #85, #78, #75, #74, #4, and #72 completed on 08/05/25 at approximately 10:00 AM, revealed each had marked it was very important for them to do things with groups of people. A review of the facility's posted activity calendars for April, May, June, July, and August 2025 revealed the only scheduled group activity was Activities in the Dayroom on Thursdays at 2:00 PM. No group activities were scheduled on weekends during this review period. On 08/05/25 at 8:20 AM, Resident #84 stated the facility handed out puzzles and she watched TV, but she did not think group activities were offered. When asked if she would attend if they were offered, she replied, Yeah, if I felt like it. Residents #76, #25, #78, #75, #74, #4, and #72 stated there was an activity room/dayroom but they did not think it was used for group activities. They reported most activities offered to them occurred in their rooms (crosswords, puzzles, church on TV). During an interview on 08/05/25 at 12:00 PM, the Activity Director (AD) stated she provided activities of the residents' choice in the dayroom on Thursdays and went room-to-room during the week offering snacks and word search puzzles. She confirmed there was no activity staff coverage on weekends. When asked how many activity staff the facility employed, the AD stated, Just me.

Based on observations, record review and staff interviews, the facility failed to ensure residents were given the choice to eat their meals in a communal setting rather than in their room all the time. This was a random opportunity for discovery during the Long-Term Care Survey. This deficiency can affect more than an isolated number of residents. Resident identifier: #24, #25, #72, #76, #86, and #24. Facility Census: 28 a) Findings included: Observations made during lunch on 08/05/25 revealed the residents were all eating their meal in their room. Further observations revealed an area on the unit marked as an activity room. On the blueprint (facility layout) that was submitted during construction of the unit this room was marked dining/activities. However, observation on 08/05/25 of the sign outside the door to this room revealed the sign said Activities. On 08/06/25 a review of a policy titled Meal Passage and Nutritional Intake revised on 02/2025 revealed the following statement, In order to encourage a homelike atmosphere and to promote a social interaction between our Residents, we will offer to assist them to the day room for meals if desired. During an interview on 08/05/25 the administrator stated this space was for dual purposes and could be used if needed. Interviews on 08/05/25 with Resident #25 revealed this resident did not know they had a dining area. Resident #75 said no dining options had been explained except eating in their room. Resident #76 said they had no idea there was an option to eat in a dining room. Resident #72 said they had no idea there was anywhere to eat except in their room. Resident #24 said they had never been given the option to eat anywhere except in their room. Resident #86 did not know there was a dining or activity room on the unit. On 08/06/25 an interview with Licensed Practical Nurse (LPN) #7 revealed the facility staff did not offer the option to the residents to eat in a dining room but if the resident would ask, they would accommodate them. LPN #8 also stated they do not offer this as an option but would accommodate the resident's if they asked. Clinical Supervisor (CS) #54 said residents were given the option to use the dining room if they ask, or if their family asks but this was not something that was offered to them upfront.

Based on observation, interview, and record review, the facility failed to ensure food items were stored and discarded in accordance with facility policy to prevent the potential for foodborne illness. This deficient practice was observed for one of the food items in the kitchen and had the potential to affect all residents who consume food prepared by the facility. Facility Census: 28Findings include:On 08/04/2025 at 12:27 PM, during the initial tour of the kitchen, a tray of biscuits was observed on a rack with a discard date of 08/03/2025.Review of the facility policy titled Food Dating (Effective Date 4/08; Revised 09/24) revealed, in part: Date items for the last day to be used. Disposal should be that night after dinner or early the next morning before breakfast.During an interview on 08/04/2025 at 12:30 PM with the Dietary Manager (DM) the DM stated, Yes, they should have been thrown out this morning or last night.

Based on record review and staff interview, the facility failed to manage pain in accordance with current professional standards of practice. Pain assessments were not consistently performed before and after as needed (PRN) pain medication was given. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of pain. Resident identifier: #16. Facility census: 26. Findings include: a) Resident #16 Review of Resident #16's medical records showed a physician's order written on 06/17/24 for oxycodone (Roxicodone) 5 mg, every six (6) hours as needed for pain. Further medical record review showed three (3) occasions when oxycodone was administered for pain, but no premedication pain assessment was performed. Additionally, the resident was not assessed for effectiveness of the pain medication. These three (3) occasions were as follows: - 06/26/24 at 12:54 PM - 06/29/24 at 10:37 PM - 07/30/24 at 9:59 PM Additionally, on 06/29/24 at 3:31 AM, pain effectiveness was assessed after medication administration, but premedication pain assessment was not performed. On 07/03/24 at 9:00 AM, the Director of Nursing (DON) confirmed no premedication or postmedication pain assessments were performed on 06/26/24 at 12:54 PM, 06/29/24 at 10:37 PM, and 07/30/24 at 9:59 PM. Additionally, the DON confirmed no premedication pain assessment was performed on 06/29/24 at 3:31 AM. No further information was provided through the completion of the survey process.

Based on staff interview and record review, the facility failed to provide the required beneficiary notification for Resident #189. This was true from one (1) of three (3) residents reviewed for beneficiary notcies during the long term care survey. Finding include: On 07/02/24 the required Notice of Medicare Non Coverage was requested from the facility for Resident #189 when her most recent medicare stay was ending. On 07/02/24 at 1:30 PM an interview was completed with the Administrator who acknowledged, he could not find a copy of the Beneficiary Notification for Resident #189.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was discovered for one (1) of two (2) residents reviewed for the care area of position and mobility. The physician's order for Resident #67 was not followed for the application of heel lift boots. Resident identifier: #67. Facility census: 27. Findings included: a) Resident #67 A medical record review for Resident #67 on 10/04/22, revealed a physician's order for heel lift boots to be worn continuously with a start date of 09/22/22. During an observation on 10/04/22 at 8:15 AM, it was discovered Resident #67 was not wearing the bilateral heel lift boots. An interview with the Director of Nursing (DON) on 0/04/22 at 8:20 AM, verified Resident #67 was not wearing the bilateral heel lift boots.

Based on medical record review and staff interview the facility failed to revise an interim care plan for an indwelling Foley catheter. This was discovered for one (1) of one (1) residents reviewed for the care area of urinary catheter. The interim care plan for Resident #67 was not revised for placement and care of a urinary Foley catheter. Resident identifier: #67. Facility census: 27. Findings included: a) Resident #67 A medical record review for Resident #67 on 10/04/22, revealed the interim care plan was not revised to include an order for insertion and maintenance of an indwelling Foley catheter for Resident #67. In an interview with the Director of Nursing (DON) on 10/04/22 at 3:18 PM, reported the Foley catheter was placed on 09/29/22 for Resident #67. The DON also verified the interim care plan was not revised to show placement and care of the indwelling Foley catheter for Resident #67.

Based on record review and staff interview the facility failed to complete a discharge assessment for Resident #1. This was true for one (1) of three (3) residents reviewed for discharges. This failed practice had the opportunity to affect only a limited number of residents. Resident identifier: #1. Facility census: 27. Findings included: a) Resident #1 Record review showed a discharge summary dated 04/27/22 indicating Resident #1 was to be discharged to home effective 04/28/22. A progress note dated 04/28/22 indicated that the Resident was taken off the unit and discharged home via personal vehicle at 12:17 PM. Review of Resident #1's Minimum Data Set (MDS) assessment indicated only an admission assessment was completed. The five-day scheduled assessment in section A0310 was completed on 04/28/22 for the resident's admission on 04/22/22. No additional MDS assessment was completed for the discharge. Section A2000, discharge date , was blank on the MDS assessment. On 10/04/22 at 2:00 PM Registered Nurse (RN) #27 stated, You got me, I didn't do it. I'll go do it now. The RN further clarified she had missed completing the discharge assessment for Resident #1.

Based on medical record review and staff interview the facility failed to provide the State Ombudsman with notification of a hospitalization . This was discovered for one (1) of three (3) residents reviewed for hospitalization s during the Long Term Care Survey Process. Resident #13 was hospitalized and the State Ombudsman was not notified of the hospital discharge. Resident identifier: #13. Facility census: 27. Findings included: a) Resident #13 A medical record review on 10/04/22, revealed Resident #13 was discharged to the hospital on 08/30/22 and there was no hospitalization notice sent to the State Ombudsman. During an interview with the Director of Nursing on 10/04/22 at 10:45 AM, the DON confirmed the State Ombudsman had not been notified of the hospitalization for Resident #13 on 08/30/22. She also reported it was their procedure to send the State Ombudsman notice of hospital transfers.

Based on observation and interview the facility failed to properly store and maintain equipment in accordance with professional standards for food service safety. The facility failed to properly remove ice build-up from a freezer, date food items for storage, and discard food items when expired. The failed practice had the potential to effect more than unlimited number of residents. Facility census: 24. Finding included: a) Meat Freezer An observation during the initial tour, on [DATE] at 10:45 AM, revealed ice build up that formed a frozen waterfall from the roof of freezer down to the storage shelves. The shelves had a thick layer of solid ice on them where the frozen waterfall formation ended. An immediate interview with Director of Food Services (DFS), on [DATE] at 10:45 AM, stated, sometimes that happens when the freezer defrosts but usually the hospital maintenance will clear it. DFS stated, I will put a work order in for it today. b) Bakers Freezer An observation during the initial tour, on [DATE] at 10:50 AM, revealed, two (2) frozen bags of strawberries both out of the original manufactures box with no dates. One (1) package of the frozen strawberries were open but not dated. The second bag of strawberries was full but had no date on the package. An immediate interview with DFS, on [DATE] at 10:50 AM, stated, staff had been educated to date food items before storing and they know better. c) Produce Cooler An observation during the initial tour, on [DATE] at 11:00 AM, revealed two (2)16 ounce (oz) bags of peeled and ready to eat baby carrots with expiration dates of [DATE]. An additional observation during the initial tour, on [DATE] at 11:00 AM, revealed two (2) five (5) pound (lb) bags of lettuce with an expiration date of [DATE]. An immediate interview with DFS, on [DATE] at 11:00 AM, confirmed vegetables were expired and stated the items should be discarded.

Based on observation and interview the facility failed to secure and keep confidential residents personal and medical information. The facility failed to safe guard private information that was written on white boards in residents rooms. This was a random opportunity for discovery. The failed practice was true for six (6) of 13 sampled residents. Resident identifiers: #30, #5, #11, #33, #36 and #25. Facility census: 24. Findings included: a) Resident #30 An observation, on 07/06/21 at 12:35 PM, revealed a sheet of paper taped to the white board in Resident # 30's room that stated, Fluid Restrictions- 7a 250 cc and 7p 250 cc. b) Resident #5 During a random opportunity for discovery on 07/06/21 at 11:47 AM, the following clinical/personal care instructions were written on the whiteboard in Resident #5's room: - FWW (front wheeled walker) Min A (minimum assist) to Bed, Chair, Potty Chair - STEDY (Sara Stedy walker) for longer mobility - Can amb (ambulate) to bathroom with FWW (front wheeled walker) A x 1 (assist of one) There was also a white 8 1/2 x 11 sheet of paper attached to the whiteboard noting: -FLUID RESTRICTIONS -7a 250 cc -7p 250 cc c) Resident #11 During a random opportunity for discovery on 07/06/21 at 1:02 PM, the following clinical/personal care instructions were written on the whiteboard in Resident #11's room: -L LE WBAT (left lower extremity weight bearing as tolerated) -FWW (front wheeled walker) Min A x 1 (minimum assist of one) d) Resident #33 During a random opportunity for discovery on 07/06/21 at 12:31 PM, the following clinical/personal care instructions were written on the whiteboard in Resident #33's room: - Hoyer lift - Care to L UE (left upper extremity) - flaccid/CVA (cerebral vascular accident) - Honey thickened liquids e) Resident #36 During a random opportunity for discovery on 07/06/21 at 12:13 PM, the following clinical/personal care instructions were written on the whiteboard in Resident #36's room: - FWW (front wheeled walker) Min A x 1 (Minimum assist of one) - Binder on at all times - STEDY (Sara Stedy walker) as needed - Able to amb (ambulate) to bathroom with FWW A x 1 (front wheeled walker assist of one) f.) Resident #25 During a random opportunity for discovery, on 07/06/21, at 11:55 AM, medical information was observed in plain view, on a white board, on the resident's wall. The information written noted Resident #25's weight bearing status which included direction of non-weight bearing of right upper extremity and right lower extremity. g.) Staff Interview An Interview with the facility Administrator, on 07/07/21 at 01:45 PM, confirmed private health information should not be written on the whiteboard in resident's rooms, and the therapies may be continuing to do so.

Based on observation and staff interview, the facility failed to respect resident dignity. This was true for eight (8) of thirteen (13) residents reviewed during the long-term care survey process. The facility practice required residents to wear wristbands prominently denoting confidential information (for example, code status, allergies, and fall risk). This practice was not inconspicuous and could readily be seen by any visitor. A Resident was also not treated with dignity during personal care. Resident Identifies: #11, #33, #35, #36, #123, #124, #7 and #30. Facility Census: 24 Findings included: a) Resident #11 Based on observation on 07/06/21 at 1:02 PM, Resident #11 was wearing a bright yellow wristband with the wording FALL RISK. b) Resident #33 Based on observation on 07/06/21 at 12:31 PM, Resident #33 was wearing a purple wristband with the wording DNR (do not resuscitate). c) Resident #35 Based on observation on 07/06/21 at 12:33 PM, Resident #35 was wearing a bright yellow wristband with the wording FALL RISK as well as a red wristband with the wording: ALLERGY. d) Resident #36 Based on observation on 07/06/21 at 12:13 PM, Resident #36 was wearing a red wristband with the wording ALLERGY. On 07/07/21 at 7:40 AM, a random opportunity for discovery revealed Resident #36's door was open, no curtain was pulled, and Certified Nursing Assistant (CNA) #49 was providing care to resident. Resident #36 was on the side of bed with her gown up above part of her chest. This was visible from hallway. CNA #49 made eye contact with Surveyor and then immediately crossed the room to shut the door. CNA #49 opened Resident #36's door at 8:00 AM after personal care had been completed. The Director of Nursing (DON) asked CNA #49 if she was aware of what she had done. CNA #49 stated she had Resident #49's breakfast tray and was about to go in when she saw resident at the edge of her bed. She reported she immediately entered the room out of concern for resident safety. CNA #49 acknowledged the door was not shut and care was being provided to resident without any privacy. CNA #49 reported once she realized that error, the door was immediately shut prior to finishing the care. e) Resident #30 An observation, on 07/06/21 at 12:35 PM, revealed Resident # 30 wore bright yellow wristband that stated, Fall Risk. f) Resident #7 An observation, on 07/07/21 at 1:03 PM, revealed Resident #7 wore three (3) color wristbands. The wristbands were yellow stated fall risk, red for allergies and purple stated, do not resuscitate DNR. g.) Resident #123 During a random observation on 07/06/21 at 11:42 AM , Resident #123 was observed to have a bright yellow wrist band in place noting the resident was a FALL RISK. h.) Resident # 124 During a random observation, on 07/06/21 at 12:42 PM, Resident #124 was observed with a red wrist band in place noting ALLERGY on the wrist band. i.) Staff Interview An interview with the Administrator on 07/07/21 confirmed wrist bands are being used that are color coded with special needs identified for the resident. The Administrator further stated, they are placed on the resident during the hospital stay and are kept on the resident when they are admitted to their unit in order to identify needs of the residents to others.

Based on observation and staff interview, the facility failed to ensure transmission-based precautions were maintained during resident care. This was a random opportunity for discovery. Resident Identifier #36. Facility Census: 24. a) Resident #36 Based on observation on 07/06/21 at 12:05 PM, there was a sign posted outside of Resident #36's room noting that resident was under CONTACT II precautions. On the inside door of the supply cupboard, just outside of Resident #36's room, the facility had posted guidance on what CONTACT II precautions meant as well as what personal protective equipment (PPE) should be worn. The guidance noted CONTACT II precautions were due to a C-Diff (Clostridium difficile) diagnosis. It also listed the following expectations: gloves, gown, and wash hands with soap and water only - do not use alcohol foam. On 07/07/21 at 7:40 AM, a random opportunity for discovery revealed Resident #36's door was open and Certified Nursing Assistant (CNA) #49 was providing care to resident. CNA #49 was wearing a mask and face shield. CNA #49 was NOT wearing a gown or gloves. CNA #49 made eye contact with Surveyor and then immediately crossed the room to shut the door. The Director of Nursing (DON) opened Resident #36's door, at 7:50 AM, to visually confirm CNA #49 was not wearing the appropriate PPE. The DON spoke to CNA #49 long enough to encourage her to finish what she was doing before shutting the door again. After personal care had been completed, CNA #49 opened Resident #36's door at 8:00 AM. The Director of Nursing (DON) questioned CNA #49 if she was aware of what she had done. CNA #49 stated she had Resident #36's breakfast tray and was about to go in when she saw resident at the edge of her bed. She reported she immediately entered the room out of concern for resident safety. CNA #49 acknowledged the door was not shut and care was being provided to resident without any privacy. CNA #49 reported once she realized that error, the door was immediately shut prior to finishing the care. The DON asked if there was anything CNA #49 had overlooked prior to grabbing Resident #36's breakfast tray and getting ready to enter the room. CNA #49 looked at the DON somewhat confused. The DON then pointed to the contact precautions sign posted to the side of Resident #36's door. CNA #49 replied, I didn't even see that!

Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice upon transfer. This had the potential to affect all residents being transferred or discharged . Resident identifier: #23. Facility census: 24. Findings included: a) Resident #23 A medical record review was completed on 07/07/21 at 11:02 AM. The record review revealed Resident #23 was transferred to the hospital on 04/12/21. The record did not reflect the resident/resident's representative was provided a written Bed Hold Notice upon transfer. During an interview with the Director of Nursing (DON) on 07/07/21 at 11:59 AM, the DON reported a written Bed Hold Notice was not provided to Resident #23.

Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This had the potential to affect all residents being transferred or discharged . Resident identifier: #23. Facility census: 24. Findings included: a) Resident #23 A medical record review was completed on 07/07/21 at 11:02 AM. The record review revealed Resident #23 was transferred to the hospital on 04/12/21. The record did not reflect the resident/resident's representative was provided a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred and a statement of the resident's appeal rights. During an interview with the Director of Nursing (DON) on 07/07/21 at 11:55 AM, the DON reported a written Notice of Transfer was not provided to Resident #23.

Based on a random opportunity for discovery, through record review, observation and interview, the facility failed to ensure a safe environment for two (2) of twenty-four (24) residents, by failing to properly store medications in a secure location and not kept at the bedside. Resident Identifiers: Resident # 25 and Resident # 123. Census: 24 Findings included: a.) Resident #25 An observation on 07/06/21 at 11:55 AM, revealed a box labeled muscle rub at bedside. A review of the medical record did not show any physician's order for Resident #25 to keep any medication at the bedside. An Interview, on 07/06/21 at 12:43 PM, with Registered Nurse #36 (RN #36), confirmed there was no order for Resident #25 to keep muscle rub at the bedside and removed the medication from the bedside table in the resident's room. b.) Resident # 123 An observation on 07/06/21 at 11:42 AM, revealed a box of [MEDICATION(S)] .025 percent cream laying on the bedside table in Resident #123's room on the bedside table. An interview with Resident #123, on 07/06/21 at 11:42 AM, revealed the medication had been brought in by the nurse and was left on the table. A record review noted an order written for [MEDICATION(S)] .025 % to be applied topically to affected area four times daily but no order for the medication to be kept at the bedside. On 07/06/21 at 12:43 PM, an interview with RN# 36 , verified the Zosterix was at the bedside and there was no order for the medication to be at the bedside. RN #36 removed the medication from the room.

Based upon record review, staff interview, and policy review, the facility quality assurance committee failed to identify and correct quality deficiencies issues of which they had knowledge or should have had knowledge. The facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The Registered Pharmacist failed to identity and report an irregularity in a resident's MRR. In addition, the facility failed to ensure physician orders [REDACTED]. This practice has the potential to affect all residents. Resident identifier: #10. Facility census: 25. Findings included: a) Cross reference findings at F756 b) Cross reference findings at F758

Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the monthly medication regimen review (MRR) process. In addition, the Registered Pharmacist failed to identity and report an irregularity in a residnet's MRR. Resident identifier: #10. Facility census: 25. Findings include: a) MRR policy On 03/09/20 at 2:45 PM, review of the facility policy titled Medication Regimen Review with a reviewed date of 09/18 states (typed as written): The Medication Regimen Review (MRR) of each resident must be reviewed at least once a month by a licensed pharmacist . --Paragraph 4. The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing and the reports must be acted upon . This statement is followed by the different steps in the process taken by the pharmacist. --Paragraph 7. Upon completion of the MRR, the facility designee and/or physician will respond to the recommendations within 10 days of the recommendation. --Paragraph 8. If the pharmacist should identify an irregularity and communicates to the facility that it requires urgent action to protect a resident, it will be acted upon immediately, preferably by paging the physician at the time it is discovered . **Except for the identified urgent irregularities, the policy lacks specific time frames for the various steps in the process. After review of the facility MRR policy on 03/09/20 at 03:20 PM, the Administrator verified specific time frames and steps the pharmacist must take if an urgent irregularity is identified is lacking in the policy. He reported, Agree there is nothing in there if the physician does not answer the immediate page. b) Resident (R) #10 1) [MEDICAL CONDITION] medication Review of the medical record on 03/09/20, revealed Resident (R) #10 has received the antidepressant [MEDICATION NAME] twice a day since admission. The physician orders written and electronically signed by Medical Doctor (MD) #84 on 02/04/20 includes [MEDICATION NAME] ([MEDICATION NAME] SR) sustained release tablet 150 milligrams (mg) twice a day. The associated [DIAGNOSES REDACTED].#10 but is silent for the [DIAGNOSES REDACTED]. On 02/18/20, Family Nurse Practitioner #85 prescribed [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 mg nightly. The associated [DIAGNOSES REDACTED].#10's medical record but is silent for the [DIAGNOSES REDACTED]. Pharmacy reviews completed on 02/04/20 and 02/08/20 failed to identify any irregularities in the physician orders. The Director of Nursing (DON) and Registered Pharmacist (RPh) #83 reviewed R #10's medical record during an interview on 03/09/20 at 4:00 PM, and confirmed the MEDICATION ORDERS FOR [REDACTED]. RPh #83 reported MD #84 copies and pastes all of the resident's [DIAGNOSES REDACTED]. The DON and RPh #83 confirmed the [DIAGNOSES REDACTED]. RPh #83 reported the concern with MD #84 not writing the appropriate [DIAGNOSES REDACTED]. RPh #83 acknowledged he was aware MD #84's medication orders lack appropriate [DIAGNOSES REDACTED]. RPh #83 stated he attends the quarterly QAPI meetings and noted he has not brought this concern to the meeting and/or reported it to the Medical Director or facility Administrator. 2) Pain medication Review of the medical record on 03/09/20, revealed Resident (R) #10 was admitted to the facility on [DATE] with osteo[DIAGNOSES REDACTED] (an infection in the bone). Admission medication orders dated 02/04/20 include the following pain medications: [REDACTED] [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5-325 milligrams (mg) one (1) tablet every four (4) hours as needed for moderate pain (pain scale 4-6). [MEDICATION NAME] ([MEDICATION NAME]) 50 mg every six (6) hours as needed for moderate pain (pain scale 4-6). *The orders lack directions for which pain medication to administer. During an interview on 03/09/20 at 3:25 PM, the Director of Nursing (DON) reviewed R #10's medical record and agreed the pain scale parameters for both the [MEDICATION NAME] and the [MEDICATION NAME] are the same. The DON acknowledged there are no directions for staff to utilize in determining which pain medication to administer. At 4:00 PM on 03/09/20, Registered Pharmacist (RPh) #83, agreed the pain scale references were the same for both pain medications and the physician orders lack directions for nursing to utilize when administering the pain medications. In addition, RPh #83, acknowledged he completed medication regimen reviews on R #10 on 02/04/20 and 02/08/20 and did not identify this concern.

Based on medical record review and staff interview, the facility failed to develop a comprehensive person centered care plan with nonpharmacological interventions for a resident receiving [MEDICAL CONDITION] medications. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #10. Facility census: 25. Findings included: a) Resident #10 Review of the medical record on 03/09/20, revealed Resident (R) #10 was receiving [MEDICATION NAME] an antidepressant and [MEDICATION NAME] an anti-anxiety medication daily. The current care plan, with a revision date of 02/25/20, identifies R #10's problem/focus of psychosocial needs, but lacks person centered nonpharmacological interventions. In addition, the care plan fails to identify the use of an antidepressant and/or anti-anxiety medication. Skilled Care Coordinator/Registered Nurse (RN) #60 reviewed R #10's care plan during an interview on 03/10/20 at 8:45 AM. RN #60 confirmed the care plan lacks nonpharmacological interventions and does not identify the use of an antidepressant and anti-anxiety medication.

Based on medical record review and staff interview, the facility failed to ensure physician orders [REDACTED]. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #10. Facility census: 25. Findings included: a) Resident #10 Review of the medical record on 03/09/20, revealed Resident (R) #10 has received the antidepressant [MEDICATION NAME] twice a day since admission. The physician orders [REDACTED].#84 on 02/04/20 includes [MEDICATION NAME] ([MEDICATION NAME] SR) sustained release tablet 150 milligrams (mg) twice a day. The associated [DIAGNOSES REDACTED].#10 but is silent for the [DIAGNOSES REDACTED]. On 02/18/20, Family Nurse Practitioner #85 prescribed [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 mg nightly. The associated [DIAGNOSES REDACTED].#10's medical record but is silent for the [DIAGNOSES REDACTED]. The Director of Nursing (DON) and Registered Pharmacist (RPh) #83 reviewed R #10's medical record during an interview on 03/09/20 at 4:00 PM, and confirmed the MEDICATION ORDERS FOR [REDACTED]. RPh #83 reported MD #84 copies and pastes all of the resident's [DIAGNOSES REDACTED]. The DON and RPh #83 confirmed the [DIAGNOSES REDACTED].

Based upon record review, staff interview, resident interview, and observation, the facility did not demonstrate a consistent process to track, monitor, or consult and communicate with the physician for the management and treatment of [REDACTED].#226'S left heel ulcer worsened from her admission on 9/15/17 and resulted in harm to the resident. This was found for two (2) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #226, #217. Facility census: 28. Findings include: a) Resident #217 Resident #217 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review found she was admitted with three pressure areas. The acute care hospital assessed left and right buttocks wounds as stage two wounds, and a coccyx wound as a deep tissue injury. There were documented assessments for 9/13/17, 9/17/17, and 9/20/17 for all three wounds. There was a physician's order dated 9/12/17 for the Stage two wounds to left and right buttocks for mild soap and water and a sacral foam border dressing every other day. There was no order for the care of the coccyx wound. Treatments were documented to all three wounds as ordered by the physician for the left and right buttocks wounds only. The interim care plan had interventions for the coccyx wound including treatment as ordered, encourage to turn every two hours or turn schedule, encourage food and fluids, initiate prevention protocol. There was no care plan for the left and right buttocks wounds. A request was made to Director of Nursing, #37 on 9/20/17 at 2:35 p.m. for a physician's order for the treatment to the coccyx wound. On 9/20/17 at 3:45 p.m., the Director of Nursing advised there was no physician's order for the coccyx wound treatments. She said the dressing utilized for the wounds to the left and right buttocks was one large dressing that covered all three wounds. She was asked if she would consider the left buttock wound, the right buttock wound and the coccyx wound three separate pressure ulcers. She said she would consider them as three separate wounds. She said that due to their proximity, the dressing just covers all three. It was pointed out that according to the assessment completed today, the coccyx wound has now opened, and she was asked if this might indicate a different treatment for [REDACTED]. She acknowledged that was possible. The wounds were observed by Nurse Surveyor # on 9/21/17 at 9:42 a.m. The observation confirmed the assessment and accompanying photograph of the wounds completed on 9/20/17. At the completion of the investigation, the final determination was there was no physician's order for the treatments being administered to the coccyx wound, which has now opened. b) Resident #226 Resident #226 is was most recently admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was on contact isolation related to [MEDICAL CONDITION]-resistant staphylococcus [MEDICAL CONDITION] in her foot wound and [MEDICAL CONDITIONS]. Review found she was admitted with an unstageable pressure ulcer to her left heel. There was a document dated 9/15/17 that included the following fields: 1. Wound Characteristics. This field had the entry of Pressure 2. Wound odor. This field was blank. 3. Dressing type. This field had the entry of Foam [MEDICATION NAME] 4. Dressing status. This field had the entry of Clean, Dry, and Intact 5. Dressing Drainage. This field was blank. There was a document dated 9/20/17 that was an order to change the dressing that included Wound dressing: gauze pad and cleanse: [MEDICATION NAME]. There was no other documentation found in the record related to the identified pressure ulcer. There was no care plan for the pressure ulcer. There was no record of any measurement of the area. Information was requested from the Director of Nursing, #37 on 9/20/17 at 9:29 a.m. for the initial assessment, tracking documentation showing size/measurements, ongoing status, progression, changes in treatment, current measurements, the care plan for the pressure ulcer, physician's order for treatment, and the treatment administration record (TAR) to document the provision of treatments. The response to the request did not come until 9/20/17 at 12:25 p.m. There were documents provided from the acute care hospital prior to admission. There was an assessment done by the hospital for 9/14/17. The facility provided a photograph of the wound taken in the acute care facility on 9/14/17, the day prior to her admission in the long-term care facility. This document indicated the ulcer was 1.5cm in width and 1.2cm in length. The facility provided a photograph of the wound taken today, 9/20/17 that indicated the ulcer was now 3.0cm wide by 1cm long. The interim care plan provided did not address the pressure ulcer. Director of Nursing, #37 was then interviewed on 9/20/17 at 12:25 p.m. She agreed there was no assessment completed when resident #226 was admitted to the facility. She agreed only two assessments had been done, one on 9/15/17 and one on 9/17/17. These two assessments did not include any measurements, no indication of status of the area surrounding the ulcer, whether pain, if present, is being adequately controlled. She acknowledged the wound was not mentioned in the interim plan of care. She agreed the wound has increased in size since resident #226's admission on 9/15/17. She was asked again on 9/20/17 at 1:05 p.m. for documentation of the physician's order for treatments to show when they were ordered and how often they were to be done, and for Nursing documentation to show what treatments have been done for resident #226 since her admission. She provided some documents at 1:14 p.m. that contained an order released on 9/20/17. It gave the dressing location as left heel. The wound dressing was gauze pad with Kling. Included was cleanse: [MEDICATION NAME]. There were no instructions as to how frequently the treatments should be done. There was an order for [REDACTED]. At 3:02 p.m., the Director of Nursing returned with a physician's order dated 9/17/17 for treatments to be done daily. Upon review, the physician's order was noted to be for the right foot, while the ulcer being investigated is on the left foot. The Director of Nursing said she must have printed the wrong order and would bring back the correct one. She returned at 3:45 p.m. and said there was actually no physician's order for the treatment to the left heel until today, 9/20/17. She provided the order that included the treatment was to be done every day. She also provided an order for [REDACTED]. An interview was conducted with Clinical Supervisor, Registered Nurse #7, on 9/20/17 at 3:38 p.m. She has been assuming the role of wound nurse. She said she did not do any treatments to resident #226's pressure ulcer on her left heel until today, 9/20/17. The wound was observed by Nurse Surveyor # on 9/20/17 at 2:00 p.m. during a dressing change. The observation confirmed the assessment and accompanying photograph of the wounds completed on 9/20/17. Resident #226 stated this was an old wound site five (5) years ago with [MEDICAL CONDITION]-resistant staphylococcus aureus infection (MRSA). She said was more dependent on this heel after problems with her other foot from podiatrist procedures, and that caused the wound to open. Resident #226 pointed out she received new boots today (they were sitting on the couch). At the completion of the investigation, the final determination was there was no assessment of resident #226's pressure ulcer completed upon admission. An assessment completed by the acute care hospital on [DATE] documented the presence of a pressure ulcer 1.5cm wide by 1.2cm long. The only intervention implemented by the facility was to keep heels off bed/utilize heel relief function on bed. Treatments were ordered by the physician today, 9/20/17. The acting wound nurse, #7, did the first dressing today and documented the wound to resident #226's left heel as an unstageable wound 3cm by 1cm. The wound has worsened. The facility had no consistent process to track, monitor, or consult and communicate with the physician for the management and treatment of [REDACTED].

Based on observation, resident interview, staff interview, and record review, the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well being, in accordance with the comprehensive assessment. On 05/28/14, one (1) of five (5) residents with food allergies (Resident #249) was served food to which he was allergic. This situation was determined an immediate jeopardy (IJ), requiring an immediate plan of correction (POC) by the facility. The facility implemented an appropriate POC at 7:36 p.m. on 05/28/14; however, the POC was not implemented the following day, 05/29/14, resulting in continuing non-compliance at an IJ level. The continuing non-compliance affected one (1) of four (4) residents with allergies, who remained in the facility (Resident #264). The continued non-compliance as a result of the IJ was abated at 3:36 p.m. on 05/29/14. The scope and severity was then reduced to a "D". Resident identifiers: #249 and #264. Facility census:23. Findings include: a) Resident #249 During a conversation with Resident #249, on 05/28/14 at 9:15 a.m., he asked, "Can you do me a favor?" The resident said he received grape jelly on his tray, and said he was very allergic to it. He requested it be disposed of and requested strawberry jelly. Review of the tray ticket, found it identified he was allergic to "grape." He had one (1) packet of reduced sugar grape spread on his tray. The resident added, "It is on my record, I am not allowed to have it. My lips would swell turn inside out, my eyelids would swell shut, and my tongue would swell." The case manager, Employee #22 , a registered nurse (RN), reviewed the tray ticket at 9:25 a.m. on 05/28/14. The RN confirmed the resident had an allergy to grapes, and disposed of the grape jelly. On 05/28/14 at 9:50 a.m., three (3) nursing assistants (NAs), Employees #69, #70, and #31 (NA) said nursing assistants' responsibilities included reviewing the tray ticket to ensure residents received the items ordered and received the correct diet. They indicated diet restrictions were noted at the bottom of the tray ticket, and included any restrictions and allergies. Employee #69 said the NAs compared the tray tickets when the trays were passed to the residents. Upon request, at 10:15 a.m. on 05/28/14, the director of nursing (DON) arranged an interview with the dietary manager, referred to in the facility as the food service supervisor (FSS). Review of the medical record, at 10:30 a.m. on 05/28/14, revealed an order summary which noted Resident #249 had an allergy " to grapes, and anything with grapes in it ...such as juices. Pt states he has a severe reaction to them. " It was dated 05/20/14, the date of admission to the facility. Another entry noted the reaction was "throat swelling." Additionally the resident's face sheet noted "ALLERGIES: GRAPES." An interview with Employee #10, the FSS, on 05/28/14 at 10:45 a.m., revealed the dietary department obtained resident information via the electronic system. She indicated allergies were entered into the system by the nurse. The FSS related the galley technician obtained any other food preferences (and allergies if information was obtained) and made a note of that. She said this information was entered into the dietary system. The FSS said whomever was working in dietary had access to the information. She said allergies and preferences were entered into the system in separate places and only allergies were printed on the tray ticket. The FSS related, before assembling the trays, staff ". . . matched the ticket with the diet sheet to make sure it was kosher." She said a second check was completed on the tray line before meal assembly. Employee #10 said tray tickets were printed in the morning and staff were kept updated on any changes throughout the day. During a second interview, at 11:00 a.m. on 05/28/14, the FSS provided a census report which noted: " Allergy: NO GRAPE. " She confirmed the facility was aware the resident had an allergy "to grape," and the resident should not have received the grape jelly. Another interview was conducted with the FSS in the kitchen, at 12:15 p.m. on 05/28/14. She related, "The girl picked up the wrong one. . . " because they were obtained from a box containing a variety of flavors. The FSS presented a box of jelly with a mixture of blackberry, grape, and strawberry flavored spreads. The content label on the grape spread (jelly), reviewed with Employee #10, revealed it contained "Concord grape juice concentrate and concord grape puree concentrate." A meeting was requested with the administrator (ADM) and director of nursing (DON) at 12:55 p.m. The ADM and DON were notified , on 05/28/14 at 1:15 p.m., of an immediate jeopardy related to Resident #249's receipt of grape jelly. They indicated they were "aware of the concern", and the FSS had ". . . already begun to put together a plan of correction." The POC of correction was accepted and the immediate jeopardy was abated at 7:36 p.m. on 05/28/14. b) Resident #264 (Continued Non-Compliance) Follow up food delivery observations, related to the immediate jeopardy identified on 05/28/14, were completed on 05/29/14. A lunch observation revealed the POC was not implemented. According to the POC, the facility would highlight the food tray ticket to alert staff of a food allergy. Observation of Resident #264's tray ticket revealed the resident's food allergy to [MEDICATION NAME] was not highlighted on the tray ticket. The tray ticket was immediately presented to the administrator. He reviewed the tray ticket, confirmed staff did not highlight the allergy, and confirmed a failure to implement the POC. A status of continued non-compliance was instituted at that time. According to the POC, the tray line ticket review would "include highlighting allergies with a highlighter marker and carefully reviewing the ticket for not allowed items." This portion of the plan to abate the IJ was not implemented, as Resident #264's food allergy was not highlighted. As part of the POC, nurses, nursing assistants, and housekeepers were educated, on 05/28/14, to check resident tray tickets for allergies that would be highlighted. The FSS had also educated dietary staff on the procedures. The in-service provided to dietary staff indicated, "Beginning 05/28/14 . . . at each meal, all tray tickets are checked to assure food allergies are printed on each tray ticket. The allergy is highlighted with a highlighter pen . . . The employee that checks the tray ticket will initial the ticket that it has been checked for food allergy compliance. All tray line workers will check each ticket for the highlighted food allergy . . . the tray line checker will check the tray for the highlighted food allergy. . . ." During a follow up interview on 05/29/14 at 1:00 p.m., the administrator confirmed the facility had not implemented the procedure. Observation revealed the continued non-compliance was abated on 05/29/14 at 3:36 p.m., when the facility implemented the plan of correction as indicated. Subsequent observations also revealed the POC was effectively implemented, and compliance was maintained. .