Every finding on record at Western Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure raw eggs were not stored above raw tomatoes and lettuce in the refrigerator to prevent food borne illness. The DON identified 22 residents in the facility received food from the kitchen.Findings: On 07/28/26 at 11:20 a.m., a tray of raw pasteurized eggs was stored on the top shelf of one of the facility's refrigerators used to store food for residents. The tray of eggs was observed to be stored directly above raw tomatoes and lettuce that were uncovered. A policy titled Food Storage, dated 04/30/09, read in part, Food items will be stored, thawed, and prepared in accordance with approved sanitary practices. On 07/28/26 at 11:21 a.m., the dietary manager stated they had just put the eggs on the top shelf because that was all they had left. The dietary manager stated the eggs should not be stored above the lettuce and tomatoes.

Based on record review and interview, the facility failed to ensure a resident's significant change assessment accurately reflected the resident received an antipsychotic medication for 1 (#5) of 5 sampled residents reviewed for unnecessary medications. The DON identified fiver residents received antipsychotic medications resided in the facility.Findings: A physician's order for Resident #5, dated 07/02/26, showed Seroquel (antipsychotic medication) 50 milligrams one tablet at bedtime for delusional disorders. A significant change assessment for Resident # 5, dated 07/09/26, showed the resident's cognition was moderately impaired with a BIMS score of 09. The assessment showed the resident had diagnoses which included psychotic disorder, depression, and anxiety. The assessment showed Resident #5 was not on an antipsychotic medication. On 07/30/26 at 10:57 a.m., the minimum data set coordinator stated the resident was on an antipsychotic medication at the time of the significant change assessment, and the antipsychotic medication should have been reflected.

Based on observation, record review, and interview, the facility failed to staff were able to accurately identify a resident's code status for 1 (#6) of 3 sampled residents reviewed for advance directives. The DON identified 13 residents with a DNR code status resided in the facility.Findings: On 07/28/26 at 2:10 p.m., a red colored name plate was observed outside the door of Resident #6's room. An Oklahoma Do-Not-Resuscitate consent form for Resident #6, dated 11/11/25, showed the DNR consent form was signed by the resident. A care plan for Resident #6, dated 05/11/26, showed the resident's code status was a full code. The care plan showed to ensure Resident #6's name plate outside their door was labeled green to indicate code status. The care plan showed if Resident #6 was found in cardiac arrest, start cardiopulmonary resuscitation immediately. A quarterly assessment for Resident #6, dated 07/17/26, showed the resident's cognition was intact with a BIMS score of 15. The assessment showed Resident #6 had a diagnosis of coronary artery disease. On 07/29/26 at 10:15 a.m., Certified Nursing Assistant #1 stated the red colored name plate outside the door indicated the resident was a DNR. On 07/29/26 at 10:16 a.m., LPN #1 stated to identify a resident's code status they would look in the EMR or on the resident's wheelchair. On 07/29/26 at 10:20 a.m., Resident #6 stated their code status was a DNR. On 07/29/26 at 10:40 a.m., LPN #1 stated Resident #6's EMR showed the resident was a full code and that was where they would look to find the code status. LPN #1 stated they were not aware the resident had a signed DNR on file. LPN #1 stated that was a problem for the EMR to show the resident was a full code since the resident had a signed DNR. On 07/29/26 at 10:43 a.m., the DON stated Resident 6#'s EMR and care plan showed the resident was a full code. The DON stated they were not aware the resident had a signed DNR on file. The DON stated the EMR and care plan needed to be changed to reflect the resident's DNR code status.

Based on observation, record review and interview, the facility failed to maintain a homelike environment for one (#21) of 16 sampled residents. Findings: A Maintenance Policy, dated 06/27/06, read in parts .The facility shall provide a safe, functional .and comfortable environment for residents, staff and public .In the event that an item is in need of repair, the defect should be reported to the maintenance department on form ., and the maintenance department will repair them promptly. If the skill to repair is beyond the ability of the facility staff, an outside vendor will be called in the case of emergency, or [company name] will be called for repair . 1. Resident #21 had diagnoses which included unspecified visual loss, history of falling, and Epilepsy. On 12/05/23 at 8:58 a.m., multiple broken/cracked tiles were observed on Resident #21's floor in their room. On 12/06/23 at 1:01 p.m., the regional consultant was asked to observe the tiles in Resident #21's room. They were asked how long the tiles had been that way. They were unsure. On 12/06/23 at 1:03 p.m., CNA #2 was asked how long had the tiles been broken. They stated A long time. On 12/06/23 at 1:09 p.m., the assistant administrator was asked to observe the tiles. They stated there had been a leak in the floor, it was repaired and they had to wait on the concrete to settle. The assistant administrator asked maintenance why the tiles had not been replaced. They stated that corporate office needed to come out and level the concrete before they could lay more tiles. On 12/07/23 at 10:03 a.m., maintenance #1 was asked how long the request had been made to corporate office. They stated the request was made about a year ago and they were instructed by corporate their staff plumbers would make the repair. On 12/07/23 at 10:09 a.m., the administrator was asked when corporate had been notified regarding the floor. They stated, maintenance should have a copy of an email. No documentation was provided for correspondence from the facility to corporate regarding the repair of the tiles.

Based on record review, observations, and interview, the facility failed to ensure an assessment had been completed monthly to ensure the continued need for a lap belt restraint for one (#14) of two sampled residents with lap belt restraints. The Resident Census and Conditions of Residents form, dated 01/04/23, documented two residents had restraints. Findings: A Restraint and Non-Restraint devices policy, dated 05/15/01, read in parts: .provide an environment .discourages the use of restraints, or when required, the least restrictive device in the least restrictive manner .A Monthly Restraint .Assessment .will be completed .determine the continued need for the use of the restraint .document recommendations for changes . Resident #14 had diagnoses to include dementia with Lewy bodies, paranoid personality, and a history of falling. A Physician Order, dated 08/05/21, read in parts, .Waist Restraint/Non-Self Releasing Belt, while up in w/c . The resident's clinical record did not contain a monthly restraint assessment for the Months of July through December 2022, to ensure the continued need for a non-self releasing lab belt. A Quarterly Assessment, dated 10/29/22, documented Resident #14 had moderate impaired cognition, and required extensive assistance for transfers. The assessment documented a trunk restraint was used daily while in the chair and out of the bed. A Care Plan, dated 11/20/22, read in parts, .potential risk for falls .NSRB while up in wheelchair .needs opportunities for restraint-free time and physical activity .Evaluate/record continuing risks/benefits .alternatives to restraint, need for ongoing use and reason for restraint use .Monitor/document/report to PCP .changes regarding effectiveness of restraint, less restrictive device . On 01/04/23 at 10:38 a.m., Resident #14 was seated in a wheelchair in the common area. A non-releasing lap belt was across her lap, criss-crossed behind the wheelchair and secured on the lower bars of the wheel chair. The ends of the lap belt were out of the resident's reach. On 01/06/23 at 9:23 a.m., CNA #1 was asked if Resident #14 tries to get up if the restraint is not in place. The CNA stated Resident #14 does not usually try to get up but reaches for things out of reach, and leans too far. CNA #1 stated Resident #14 will try to stand up if it is a day she has a lot of energy. CNA #1 stated Resident #14 required staff to assist to a stand position. On 01/06/23 at 9:29 a.m., the DON was asked if a monthly assessment had been completed to evaluate the need for a lap belt restraint, after 06/06/22, for Resident #14. The DON reviewed the record and stated, There is not, but should be. The DON was asked if the facility followed their policy regarding the assessment and evaluation that a lap belt restraint continued to be appropriate, was the least restrictive choice, and utilized in the least amount of time. The DON stated, If there is nothing since June, then we haven't.

Based on record review, and interview, the facility failed to ensure RN coverage for eight consecutive hours for seven days in October, November and December 2022. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 29 residents resided in the facility. Findings: The October 2022 staff schedule did not have any RN coverage scheduled for 10/22 and 10/23. A Time and Attendance Archived Detail report, dated 10/22 and 10/23 had no documentation an RN had clocked in for these days. A Time and Attendance Detail report, dated 11/19/22, documented the RN clocked in at 7:03 a.m., and clocked out at 11:35 a.m., then the RN clocked in at 1:00 p.m., and clocked out at 6:00 p.m. A Time and Attendance Detail report, dated 11/26/22, documented: a. the RN clocked in at 8:25 a.m., and clocked out at 10:47 a.m., b. the RN clocked in at 11:00 a.m., and clocked out at 3:00 p.m., and c. the RN clocked in at 5:56 P.M., and clocked out at 8:25 p.m. The December 2022 staff schedule, documented RN coverage on 12/04/22 and 12/11/22 no other weekends had an RN scheduled. On 01/06/23 at 10:46 a.m., the DON was shown the December 2022 staff schedule and was asked who had worked on the weekends. The DON identified the facility employed an RN/DON (themself) and one other RN staff nurse in the month of December 2022. The DON confirmed the other staff RN had worked on 12/04/22 and 12/11/22. The DON reviewed their personal calendar and confirmed they had worked the other weekend days in question with the exception of 12/17/22, 12/18/22 and 12/25/22. On 01/06/23 at 10:51 a.m., the Administrator was asked if the RN had clocked in on the days in December when there was no RN coverage. The Administrator stated, the assistant administrator was printing the time (time and attendance details) on these days. On 01/06/23 at 1:28 p.m., the DON was shown the Time and Attendance Detail reports dated, 12/17, 12/18 and 12/25 that had been provided by the DON. The DON was asked if they had told the surveyor they had not worked those days in December. The DON stated, I worked days in December, new information was already there, I know I didn't work those days. The DON was shown the October 2022 schedule and the Time and Attendance Archived Detail report and asked if there was eight consecutive hours RN coverage on 10/22 and 10/23. The DON stated No. On 01/06/23 at 1:44 p.m., the DON was shown the Time and Attendance Detail report , dated 11/19/22, that documented the DON clocked in at 7:03 a.m., and clocked out at 11:35 a.m., (salary pay) then returned at 1:00 p.m., and clocked out at 6:00 p.m. (coverage) and asked if there was five hours of coverage but had 1.5 hours in between was there eight consecutive RN hours. The DON stated, No. The DON was shown the Time and Attendance Detail report, dated 11/26/22 and asked where does staffing get these hours. The DON stated, I don't enter anything on these reports, something is wrong with this, I passed meds 8:30 [a.m.] to 11:00 [a.m.], then I worked this [5:56 p.m., to 8:25 p.m.] on the floor as an aide. The DON acknowledged there was not eight consecutive hours of RN coverage.

Based on record review, and interview, the facility failed to track and trend infections for six months from July 2022 through December 2022. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 29 residents resided in the facility. Findings: An Antibiotic Stewardship Policy and Procedure, effective 12/20/17, read in parts, .The Antibiotic Stewardship program will be incorporated in the overall infection control and isolation program .The clinical team will track antibiotic use .A facility floor plan will be highlighted to show tracking and trending of antibiotic use and or side effects . The Facility Infection Analysis reports, dated July 2022 through December 2022 did not document infections and antibiotic use had been tracked using the facility floor plan. On 01/05/23 at 11:34 a.m., the IP was asked to review the Antibiotic Stewardship Book (Facility Infection Analysis forms), and asked if there had been tracking and trending of infections since June 2022. They stated, No. On 01/05/22 at 12:51 p.m., the DON was asked to review the Facility Infection Analysis reports for July 2022 through December 2022. The DON was asked if there had been tracking and trending completed since June. They stated, No. There was no facility floor plan that documented tracking and trending for July 2022 through December 2022.

Based on record review and interview, the facility failed to follow the care plan to monitor for side effects from the use of an anticoagulant (Xarelto) medication for one (#28) of six residents reviewed for unnecessary medications. The DON identified four residents had physician orders to be administered an anticoagulant medication. The Resident Census and Conditions of Residents report, dated 01/04/23, documented the census to be 29 residents Resident #28 had diagnoses to include hypertension and hyperlipidemia. A Physician Order, dated 08/04/22, documented Resident #28 was to be administered Xarelto 10 mg daily for hypertension. A Quarterly Assessment, dated 12/15/22, documented Resident #28 was cognitively intact for decision making, and had been administered an anticoagulant seven of seven days during the assessment. A Care Plan, dated 12/27/22, read in parts, .skin .During daily ADL care, observe skin for .bruises .is on Anticoagulant therapy .administer Xarelto .Monitor/document/report to MD .anticoagulant complications: blood tinged or [NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s . The clinical record contained no documentation Resident #28 had been monitored for side effects from the use of an anticoagulant medication. On 01/04/23 at 10:24 a.m., Resident #28 was asked if they had experienced any skin changes or concerns. Resident #28 stated, I did have a big bruise on my leg, but I don't remember what happened. On 01/05/23 at 4:20 p.m., the DON was asked if the facility had monitored Resident #28 for side effects from the use of an anticoagulant medication. The DON stated the facility does not monitor for side effects of all anticoagulants. The DON was shown Resident #28's care plan and was asked if the facility followed the resident's care plan to monitor for side effects of an anticoagulant medication. The DON stated they had not.

On 01/04/22 at 7:06 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy related to a third degree burn resulting from a hot pack treatment. The facility had no policy and procedure in place to ensure safe treatment with a hot pack. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/02/21 a CNA applied a hot pack which resulted in blisters to the resident's left chest/shoulder area. The resident was later diagnosed with third degree [CONDITION(S)]. At 7:18 p.m., the administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On 01/05/22 at 11:07 a.m., the plan of removal was accepted by the Oklahoma State Department of Health. The plan of removal was as follows: .I. The facility will ensure the resident environment remains as free of accident hazards as is possible and residents receive adequate supervision and assistance devices to prevent accident; and residents are free from abuse, neglect, and misappropriation of resident property and exploitation. 1) All residents will be assessed for any areas of skin breakdown, skin issues, [CONDITION(S)], injuries and/or pressure ulcers by midnight on 1-4-2022. The physicians will be notified and appropriate treatment orders will be obtained for any new skin issues identified during the skin assessments. 2) All nursing staff will be in-serviced on the warm compress protocols and ensure residents receive adequate supervision to prevent accidents by midnight on 1-4-2022. Any nursing staff not currently in the facility will be in-serviced before returning to work. 3) All resident records will be reviewed to ensure physicians orders are obtained for the use of warm compress treatment, if appropriate by midnight on 1-4-2022. 4) New nursing staff members will be in-serviced prior to beginning their work on the floor. 5) The facility has updated its policies and procedures to include a warm compress protocol and a warm compress skills checklist. 6) All nursing staff will be in-serviced on the abuse, neglect, and misappropriation by midnight on 1-4-2022. Any nursing staff not currently in the facility will be in-serviced before returning to work. On 01/06/22 at 8:07 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 01/05/22 at 4:52 p.m. The deficiency remained at an isolated event at a level of actual harm. On 01/06/22, interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on observation, interview, and record review the facility failed to ensure a resident was assessed/monitored before, during, and after a hot pack treatment for two (#1 and #4) of three sampled residents reviewed for neglect. This resulted in resident #1 sustaining third degree [CONDITION(S)]. The DON identified 25 residents resided in the facility. Findings: An Abuse Neglect, policy, revised 09/06/16, read in part, .Neglect is defined as failure to provide goods and services necessary to avoid physical harm .Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas . 1. Resident (Res) #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's discharge assessment, dated 12/02/21, documented Res #1 was independent with daily decision making. An Incident Note, dated 12/02/21 at 10:00 a.m., documented, .Note text: Called to East end shower room by [RN #1] wound nurse. Resident noted to have a fluid filled blister to posterior neck and two on left neck. Resident is unable to tell this nurse what happened. Reported by [LPN #1] passing meds that resident had complained of a sore neck this AM and that she advised South Hall aide [CNA#1] to place a warm pack on his neck. It was noted later the residents skin had blistered in that area . A Skin Wound Note, dated 12/02/21 at 4:32 p.m., read in part, .This nurse was in bathroom with resident and nurse aid to administer routine treatments to resident this am. It is noted that resident reports pain to neck area and when assessed this nurse finds blister to posterior neck and 2 blisters to left neck. Blisters are surrounded by reddened skin. Blisters are clear and fluid filled .Posterior blister measures 0.6 cm x 0.6 cm, Left neck blister at 12 o'clock measures 1.3 cm x 1 cm and left neck blister at 6 o'clock measures 0.5 cm x 0.5 cm . A Nurses Progress note, dated 12/02/21 at 7:30 p.m., documented Res #1 was sent to the hospital for a change of condition, and was diagnosed with uro-[CONDITION(S)] (severe urine infection.) A hospital History and Physical Note, dated 12/02/21 at 10:11 p.m., read in part, .Physical Exam .Skin .Blisters are seen to the left side of clavicle where hot pack was left on accident at nursing home . Res #1 readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/04/22 at 10:40 a.m., the ADON was asked if Res #1 had any wounds. She stated yes, from a hot pack that was on too long, and he wasn't able to remove it. She stated Res #1 had a wound care treatment. At 3:05 p.m., CNA #2 was asked if she used hot packs on any residents. She replied, only one. CNA #2 was asked if she had been trained on how to use the hot packs. She stated, I believe if it's hot on myself it's too hot for the residents. CNA #2 was asked to describe how she prepared a hot pack. She stated, I put it in the microwave and heat it for 30 seconds or when warm enough. Then take it to the resident. CNA #2 was asked if she tests the hot pack on herself. She replied, yes. CNA #2 was asked if any resident had been harmed during the use of a hot pack treatment. She replied, Res #1. CNA #2 was asked if there was any training for staff. She stated, Not that I know. At 3:11 p.m., CNA #3 was asked if she used hot packs on residents. She replied, we heat rice bags. CNA #3 was asked to describe how she prepared the rice bag. She replied, I heat it up for a minute then bring it back to the resident's room. She was asked how she knew it was the right temperature. She stated by feeling it on her hand for a while. She stated if it was too hot she would put a towel between the resident's skin and the hot pack. CNA #3 was asked if she had any training on hot packs. She replied, No. At 4:10 p.m., LPN #1 stated some residents used hot packs. She stated staff would microwave it to warm it up. She stated it was left on the resident until it cooled, usually 15-20 minutes. She stated the staff would check the temperature of the hot pack on themselves. She stated the resident would be monitored every 15-20 minutes while the hot pack was on. She was asked if the resident was assessed before and after the use of the hot pack. She stated the nurse, or herself, would tell the CNA if the resident could have the hot pack or not. She was asked about the incident with Res #1. She stated he had a hot pack on his neck. She didn't know when it was put on, when it was removed, if he was assessed before it was placed, or if he was monitored during the use. She stated she saw the area after and it was red. At 4:24 p.m., the DON was asked to describe the incident with Res #1. She replied, it was at shift change from night to day shift, and Res #1 was complaining of his neck hurting. A hot pack was placed, and caused a blister. She was asked who applied the hot pack. She replied, [CNA #1]. She was asked who normally applied hot packs. She replied, the aides. The DON was asked who monitored when a hot pack was placed. She stated, the charge nurse. She was asked if the resident was assessed before and after the treatment. She replied, It should be by the nurse. She was asked at what time the hot pack had been applied. She replied, Around 6:00 a.m., according to the staff reports. She stated between 7:00 a.m., and 7:30 a.m., the hot pack was off. At 9:00 p.m., CNA #1 was asked if he was aware of any resident who utilized hot packs. He stated was aware Res #1 had an event with a hot pack that created a rash. CNA stated the charge nurse instructed him to place a hot pack on the resident. CNA was asked how long the hot packs was to be heated. CNA stated the hot packs were heated 1-2 minutes. CNA was asked how it was determined which residents could be provided a hot pack. He stated he thought any of the residents could have a hot pack. CNA was asked how what time and how long the hot pack was on the resident. He stated the hot pack was placed around 5:50 a.m. and he notified the oncoming shift before he left at 6:00 a.m. CNA was asked if he had received any education or inservice regarding the hot packs. He stated he had not. CNA was asked how the temperature of the hot pack was checked to ensure safety. He stated he used the palm of his hands. On 01/05/22 at 2:41 p.m., Res #1's wound to upper left anterior chest was observed during a dressing change. There was an unhealed wound that measured 1.2 cm x 0.4 cm with yellow slough in the center and two smaller pink healed areas (were not measured) just below the larger one. 2. Res #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's quarterly assessment, dated 10/12/21, documented the resident's cognition was intact. On 01/04/22, at 3:55 p.m., Res stated she used a hot pack. She stated CNA #1 would heat the pack too hot, and she would have to lay it to the side before applying it. She stated she wasn't assessed before or after using the hot pack.

On 01/04/22 at 7:06 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy related to a third degree burn resulting from a hot pack treatment. The facility had no policy and procedure in place to ensure safe treatment with a hot pack. There was no physician order for a hot pack treatment, and the facility failed to assess and monitor a resident during treatment. On 12/02/21 a CNA applied a hot pack which resulted in blisters to the resident's left chest/shoulder area. The resident was later diagnosed with third degree [CONDITION(S)]. At 7:18 p.m., the administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove of the immediacy. On 01/05/22 at 11:07 a.m., the plan of removal was accepted by the Oklahoma State Department of Health. The plan of removal was as follows: .I. The facility will ensure the resident environment remains as free of accident hazards as is possible and residents receive adequate supervision and assistance devices to prevent accident; and residents are free from abuse, neglect, and misappropriation of resident property and exploitation. 1) All residents will be assessed for any areas of skin breakdown, skin issues, [CONDITION(S)], injuries and/or pressure ulcers by midnight on 1-4-2022. The physicians will be notified and appropriate treatment orders will be obtained for any new skin issues identified during the skin assessments. 2) All nursing staff will be in-serviced on the warm compress protocols and ensure residents receive adequate supervision to prevent accidents by midnight on 1-4-2022. Any nursing staff not currently in the facility will be in-serviced before returning to work. 3) All resident records will be reviewed to ensure physicians orders are obtained for the use of warm compress treatment, if appropriate by midnight on 1-4-2022. 4) New nursing staff members will be in-serviced prior to beginning their work on the floor. 5) The facility has updated its policies and procedures to include a warm compress protocol and a warm compress skills checklist. 6) All nursing staff will be in-serviced on the abuse, neglect, and misappropriation by midnight on 1-4-2022. Any nursing staff not currently in the facility will be in-serviced before returning to work. On 01/06/22 at 8:07 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of 01/05/22 at 4:52 p.m. The deficiency remained at an isolated event at a level of actual harm. On 01/06/22, interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on observation, interview, and record review the facility failed to have a policy and procedure in place, and obtain a physician's order for the safe use of hot pack treatments for two (#1 and #4) of three sampled residents reviewed for accident hazards. This resulted in resident #1 sustaining third degree [CONDITION(S)]. The DON identified 25 residents resided in the facility. Findings: 1. Resident (Res) #1 had diagnoses which included intellectual functioning disability, dementia, and [CONDITION(S)] of third degree to the left shoulder. The resident's discharge assessment, dated 12/02/21, documented Res #1 was independent with daily decision making. An Incident Note, dated 12/02/21 at 10:00 a.m., documented, .Note text: Called to East end shower room by [RN #1] wound nurse. Resident noted to have a fluid filled blister to posterior neck and two on left neck. Resident is unable to tell this nurse what happened. Reported by [LPN #1] passing meds that resident had complained of a sore neck this AM and that she advised South Hall aide [CNA#1] to place a warm pack on his neck. It was noted later the residents skin had blistered in that area . A Skin Wound Note, dated 12/02/21 at 4:32 p.m., read in part, .This nurse was in bathroom with resident and nurse aid to administer routine treatments to resident this am. It is noted that resident reports pain to neck area and when assessed this nurse finds blister to posterior neck and 2 blisters to left neck. Blisters are surrounded by reddened skin. Blisters are clear and fluid filled .Posterior blister measures 0.6 cm x 0.6 cm, Left neck blister at 12 o'clock measures 1.3 cm x 1 cm and left neck blister at 6 o'clock measures 0.5 cm x 0.5 cm . There was no physician order for the use of a hot pack. A Nurses Progress note, dated 12/02/21 at 7:30 p.m., documented Res #1 was sent to the hospital for a change of condition, and was diagnosed with uro-[CONDITION(S)] (severe urine infection.) A hospital History and Physical Note, dated 12/02/21 at 10:11 p.m., read in part, .Physical Exam .Skin .Blisters are seen to the left side of clavicle where hot pack was left on accident at nursing home . Res #1 readmitted to the facility on [DATE] with a diagnosis that included, burn of third degree of left shoulder. On 01/04/22 at 10:40 a.m., the ADON was asked if Res #1 had any wounds. She stated yes, from a hot pack that was on too long, and he wasn't able to remove it. She stated Res #1 had a wound care treatment. At 3:05 p.m., CNA #2 was asked if she used hot packs on any residents. She replied, only one. CNA #2 was asked if she had been trained on how to use the hot packs. She stated, I believe if it's hot on myself it's too hot for the residents. CNA #2 was asked to describe how she prepared a hot pack. She stated, I put it in the microwave and heat it for 30 seconds or when warm enough. Then take it to the resident. CNA #2 was asked if she tests the hot pack on herself. She replied, yes. CNA #2 was asked if any resident had been harmed during the use of a hot pack treatment. She replied, Res #1. CNA #2 was asked if there was any training for staff. She stated, Not that I know. At 3:11 p.m., CNA #3 was asked if she used hot packs on residents. She replied, we heat rice bags. CNA #3 was asked to describe how she prepared the rice bag. She replied, I heat it up for a minute then bring it back to the resident's room. She was asked how she knew it was the right temperature. She stated by feeling it on her hand for a while. She stated if it was too hot she would put a towel between the resident's skin and the hot pack. CNA #3 was asked if she had any training on hot packs. She replied, No. At 4:10 p.m., LPN #1 stated some residents used hot packs. She stated staff would microwave it to warm it up. She stated it was left on the resident until it cooled, usually 15-20 minutes. She stated the staff would check the temperature of the hot pack on themselves. She stated the resident would be monitored every 15-20 minutes while the hot pack was on. She was asked if the resident was assessed before and after the use of the hot pack. She stated the nurse, or herself, would tell the CNA if the resident could have the hot pack or not. She was asked about the incident with Res #1. She stated he had a hot pack on his neck. She didn't know when it was put on, when it was removed, if he was assessed before it was placed, or if he was monitored during the use. She stated she saw the area after and it was red. At 4:24 p.m., the DON was asked to describe the incident with Res #1. She replied, it was at shift change from night to day shift, and Res #1 was complaining of his neck hurting. A hot pack was placed, and caused a blister. She was asked who applied the hot pack. She replied, [CNA #1]. She was asked who normally applied hot packs. She replied, the aides. The DON was asked who monitored when a hot pack was placed. She stated, the charge nurse. She was asked if the resident was assessed before and after the treatment. She replied, It should be by the nurse. She was asked at what time the hot pack had been applied. She replied, Around 6:00 a.m., according to the staff reports. She stated between 7:00 a.m., and 7:30 a.m., the hot pack was off. DON was asked if staff had been inserviced or was provided education prior to the incident. She stated not that she was aware of. At 9:00 p.m., CNA #1 was asked if he was aware of any resident who utilized hot packs. He stated was aware Res #1 had an event with a hot pack that created a rash. CNA stated the charge nurse instructed him to place a hot pack on the resident. CNA was asked how long the hot packs was to be heated. CNA stated the hot packs were heated 1-2 minutes. CNA was asked how it was determined which residents could be provided a hot pack. He stated he thought any of the residents could have a hot pack. CNA was asked how what time and how long the hot pack was on the resident. He stated the hot pack was placed around 5:50 a.m. and he notified the oncoming shift before he left at 6:00 a.m. CNA was asked if he had received any education or inservice regarding the hot packs. He stated he had not. CNA was asked how the temperature of the hot pack was checked to ensure safety. He stated he used the palm of his hands. The facility did not have a policy or procedure in place for the safe use of hot packs. On 01/05/22 at 11:29 a.m., the administrator assistant brought an undated policy titled Warm Compress Application. She stated this policy was created last night. At 2:41 p.m., Res #1's wound to upper left anterior chest was observed during a dressing change. There was an unhealed wound that measured 1.2 cm x 0.4 cm with yellow slough in the center and two smaller pink healed areas (were not measured) just below the larger one. 2. Res #4 was admitted with diagnoses which included chronic pain. The resident's quarterly assessment, dated 10/12/21, documented the resident's cognition was intact. On 01/04/22, at 3:55 p.m., Res stated she used a hot pack. She stated CNA #1 would heat the pack too hot, and she would have to lay it to the side before applying it. She stated she wasn't assessed before or after using the hot pack.

Based on observation, record review, and interview, it was determined the facility failed to ensure assessments were completed accurately for 3 (#17, 19, and #29) of 12 sampled residents whose assessments were reviewed for accuracy. The facility census was 33. Findings: 1. Resident #19 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The SCSA (significant change in status assessment) dated 01/01/18 documented the resident was moderately impaired in cognition and was on hospice. The assessment did not identify [MEDICAL CONDITION] as an active diagnosis. The care plan last reviewed 01/01/18 documented the resident had a terminal [DIAGNOSES REDACTED]. The resident was observed as she rested in a recliner in her room. Oxygen was in use. On 03/20/18 at 2:26 PM, the DON (director of nurses) was asked if the hospice [DIAGNOSES REDACTED]. She was asked to review the SCSA dated 01/01/18. She was asked if the [DIAGNOSES REDACTED]. After review of the assessment she stated, No. 2. Resident #29 had [DIAGNOSES REDACTED]. A progress note dated 01/29/18 documented the resident was admitted with a stage 2 pressure ulcer to the sacrum. The SCSA dated 02/05/18 documented the resident was moderately impaired in cognition and required extensive assistance with activities of daily living. The assessment did not document a stage 2 pressure ulcer. A wound note dated 02/07/18 documented a pressure ulcer to the sacrum with onset on admission from the hospital. The care plan dated 2/12/18 documented the resident exhibited a stage 2 pressure ulcer to her sacrum on re-admission. The resident was observed numerous times during the survey seated in her wheelchair as she attended multiple activities. The resident answered simple questions appropriately. On 03/20/18 at 2:30 PM, the DON was shown the wound note, the progress note, and the SCSA regarding the pressure ulcer. She was asked if the resident had a pressure ulcer when the information for the SCSA was recorded. She reviewed the information and stated the resident did have a pressure ulcer. She was asked if the documentation on the SCSA was accurate for the pressure ulcer. She stated, No. 3. Resident #17 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognition for daily decision making. The assessment documented the resident had been administered an antianxiety medication 7 of the 7 days prior to the assessment. The assessment did not indicate the resident had an active [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The care plan last reviewed/updated on 01/25/18 documented the resident used anti-anxiety medications related to anxiety due to dementia. The resident was observed throughout the survey. He was pleasant in conversation and able to make his needs known. On 03/22/18 at 1:30 PM the DON was asked to review the current physician's orders [REDACTED]. After review, she was asked if the resident was administered an antianxiety medication. She stated, Yes. She was asked if anxiety was on the active [DIAGNOSES REDACTED]. She was asked if the quarterly assessment was accurate. She stated, No.

Based on observation and interview, it was determined the facility failed to ensure kitchen sanitation was maintained as evidenced by a Formica counter top with raw edges exposed, unlabeled/undated food in the refrigerator, and lint on the stove hood. This had the potential to affect 33 of 34 residents who received food from the kitchen. One resident received nutrition via a feeding tube. Findings: On 02/06/17 at 10:05 a.m., a tour of the kitchen was conducted. A plastic container of a thick white substance was stored in the refrigerator of the preparation room. The container did not have an identifying label. The container was not dated. The hood of the cook stove was observed to have lint hanging from the sprinkler heads and on the metal pipe along the front of the hood. At 10:20 a.m., the dietary manager (DM) was shown the above findings. She stated the white substance was dressing that had been poured from a larger container. She stated the plastic container should have been labeled and dated when the dressing was placed inside. She stated the lint on the stove hood needed to be removed as it could fall into food being prepared. On 02/08/17 at 2:40 p.m., the food preparation surface in the back room was observed. A dietary aide was preparing lettuce and tomatoes on the surface. The front edge of the Formica surface was noted to be worn, with a porous, unfinished surface exposed. At 2:45 p.m., the DM was asked how the workers ensured the raw edges of the counter top were clean. She stated they could not ensure the edge of the counter top was cleaned of all stains/food substances.

Based on observation, record review, and interview, it was determined the facility failed to ensure the physician was notified of a change in condition regarding blood pressure (B/P). This affected 1 (#9) of 9 sampled residents whose clinical record was reviewed for a change in condition. The facility census was 34. Findings: Resident #9 had [DIAGNOSES REDACTED]. The annual assessment dated [DATE] documented the resident was cognitively intact. The care plan dated 01/11/17 documented a problem of hypertension. Interventions included the following: ~ the administration of anti-hypertensive medications, ~ taking B/Ps on Thursday and notification of the primary care physician if the systolic B/P is greater than 200 or the diastolic B/P is greater than 100. Current physician's orders [REDACTED]. ~ [MEDICATION NAME] 25 milligrams (mg) daily for hypertension. ~ [MEDICATION NAME] 20 mg daily for hypertension. ~ [MEDICATION NAME] 25 mg daily for hypertension. ~ [MEDICATION NAME] 2 mg, 2 tablets, 2 times per day for hypertension. The medication administration records (MARs) dated 01/2017 and 02/2017 documented the resident's B/P was to be taken every shift. A B/P flow sheet was provided by the facility. The flow sheet documented 12 times the resident's diastolic B/P was greater than 100 between 01/2017 and 02/2017. There was no documentation to indicate the physician had been notified of the resident's B/P when the diastolic reading was greater than 100. The resident was observed as he rested in his room and as he was seated in the common area with other residents. He was pleasant during conversation and was able to make his needs known. On 02/08/17 at 1:55 p.m., licensed practical nurse #1 was asked when she would report a B/P reading. She stated if less than 100/60 or greater than 130/70 she would report. At 2:00 p.m., the director of nurses was shown the B/P flow sheet for the documentation of diastolic B/P greater than 100. She was asked if a diastolic B/P greater than 100 would be considered abnormal. She stated, Yes. She was asked if she would notify the physician. She stated she would. She was asked to review the nurses' notes for documentation the physician was notified when the diastolic B/P was greater than 100. After review, she stated she did not see indications the B/P was reported to the physician. At 2:40 p.m., the physician was interviewed. He was asked at what point he would like to be notified of a resident's B/P reading. He stated systolic above 160 or diastolic above 100. He stated it would not be an emergency, but probably he would need an e-mail about the B/P.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents were free from unnecessary medication. This affected 2 (#1 and #3) of 9 sampled residents whose clinical records were reviewed for unnecessary medications. The unnecessary medication was in regard to an anti-emetic. The facility census was 34. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The significant change in status assessment dated [DATE] documented the resident was moderately impaired in cognition and required extensive assistance with most activities of daily living. The care plan reviewed 01/11/17 documented the resident had episodes of nausea/vomiting. The care plan documented the resident would be monitored and the amount, color, consistency, odor of emesis, frequency, duration, and aggravating or alleviating factors would be documented. Current physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The physician's orders [REDACTED]. However, there was no documentation to indicate the resident's voiced complaint/symptom when the medication was administered. The resident was observed seated in her recliner and lying in her bed. The resident opened her eyes to the surveyors voice, but did not respond. 2. Resident #3 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was cognitively intact. The care plan dated 12/14/16 documented the resident was administered [MEDICATION NAME] PRN for nausea/vomiting. Current physician's orders [REDACTED]. The MARs dated 01/2017 and 02/2017 documented the resident was administered 23 doses of PRN [MEDICATION NAME] between 01/21/17 and 02/06/17. The physician's orders [REDACTED]. However, there was no documentation to indicate the resident's voiced complaint/symptom when the medication was administered. The resident was observed multiple times as she rested in her room and as she self propelled in the hallway. She was pleasant during conversation and stated she was nauseated and vomited at times. The resident was observed with a container for emesis in her lap when in her room, as well as when she was in her wheelchair. The facility's policy for medication administration documented, .When PRN medications are administered, the following documentation is provided .Complaints or symptoms for which the medication was given . On 02/08/17 at 10:50 a.m., the director of nurses was shown the nurses' notes, MARS, and the facility's policy regarding the administration of the PRN [MEDICATION NAME]. She was asked if the policy was followed for the documentation of complaints/symptoms for which the medication was administered. She did not give a definitive answer.

Based on observation and interview, it was determined the facility failed to ensure the inside environment was maintained in a sanitary and orderly manner as evidenced by discolored floor tile/linoleum, debris in light fixtures, scratched/worn furniture, missing cove base, uncovered commode plungers stored on the floor, broken/missing drawer pulls on a dresser, and lint around an air conditioning/fan unit. This had the potential to affect 35 of 35 residents who resided in the facility. Findings: An environmental tour was conducted on 01/27/15 at 2:30 p.m. The following was observed: 1. On the 100, 200, and 300 halls, the floor tile was discolored in the resident room door entries. 2. In room 210: a. The floor tile was cracked/discolored in multiple areas. b. The television stand was scratched in multiple areas. c. The dresser was scratched on the side next to the hall door and a piece of trim was missing on the top corner. d. The brown bed frame had a white dried substance on the lower rail facing the inside of the room. e. The bathroom linoleum was yellowed/worn. f. A hole had been cut in the wall for a pipe to connect to the commode. The hole around the pipe had not been sealed. 3. In the 300 hall dining room/siting area: a. Debris was in 10 ceiling light fixtures. b. The floor tile was discolored in multiple areas. c. The support arm and base of an overbed table was scratched and had missing paint in multiple places. 4. On the 300 hall along the north wall was a bathing room, then 2 resident bathrooms, then another bathing room. a. In the first bathing room, above the sink, dried debris was in the metal bar soap holder. b. In the first resident bathroom, an uncovered commode plunger was stored on the floor. The commode seat was worn/missing the top layer in places. c. In the next resident bathroom, an uncovered commode plunger was stored on the floor. The white floor tiles were discolored between the sink and the commode. The floor was wet between the sink and the commode. The base of the red pipe under the sink was corroded. d. In the second bathing room, an area on the blue wall, approximately 10 inches by 4 inches was unpainted. In the shower stall, the handheld shower head was laying in the floor. The metal hand bar and a metal bar soap holder on the wall were white with hard water deposits. Above the sink, dried debris was in the metal bar soap holder. The base of the sink faucet was corroded. Lint was on the ceiling exhaust fan cover. 5. In room 301, a. The west wall was scratched and paint was missing. b. The cove base was loose on the west wall. c. Black marks and dents were in the floor tile of the room entry. 6. In room 303, a. Two dresser drawer handles were broken and 2 handles were missing. b. The night stand was scratched in multiple places. c. Dust/lint was on the ceiling around the air vent. d. Cove base was missing by the closet door. 7. In room 305, the night stand was scratched/worn. 8. In room 308, a. The night stand and refrigerator stand were scratched/worn. b. The inside of the refrigerator had dried food spills. c. The floor tile was discolored under the wheels of the foot of the bed and under the night stand. 9. In room 311, black marks were on the floor tile of the room entry. 10. In the front lobby, a. The side table, by the dietary manager's office, was scratched in multiple places. b. The brown couch by the television, had a loose piece of trim on the right arm rest and the left arm rest had the top layer of fabric worn off. 11. By the nurses' station door the wall above the water fountain was unpainted and multiple holes were visible. On 01/28/15 at 9:55 a.m., the administrator and the director of nurses were shown the above findings. They acknowledged the findings and had no questions.

Based on observation and interview, it was determined the facility failed to store food and maintain the kitchen in a clean and sanitary manner as evidenced by an open container of food, unlabeled/undated foods, debris on surfaces, and a white substance on the ice scoops/holders and ice machine surface. This had the potential to affect 41 of 41 residents who received meals from the kitchen. Findings: On 12/09/13 at 1:45 p.m., a tour of the kitchen was conducted. The following was observed: ~ A plastic container of cheese was open and exposed to the air in the refrigerator in the west preparation room. ~ Food debris and dried liquid stains were on the two plate holders containing clean plates which were stored under the preparation table and the serving line table. ~ Three bowls of a creamy substance were unlabeled/undated in the milk refrigerator located in the dining room. ~ A white substance was on the ice scoops and the storage holders. ~ A build up of a white substance was on the outside surface of the ice machine. At 2:15 p.m., the above findings were reviewed with the dietary manager. She acknowledged the above findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the medication error rate was 5% or less. The facility medication error rate was 10% which resulted from three errors in 29 opportunities. This affected 2 (#2 and #13) of 5 residents who were observed during the administration of medication. The facility census was 41. Findings: On 12/10/13 at 7:55 a.m., the medication pass was observed. 1. Resident #13 had current physician's orders [REDACTED]. The medication was to be administered on an empty stomach. At 8:10 a.m., certified medication aide (CMA) #1 administered [MEDICATION NAME] 0.25 mg to the resident. The resident had finished eating his breakfast. 2. Resident #2 had current physician's orders [REDACTED]. At 8:15 a.m., CMA #1 administered [MEDICATION NAME] 100 mcg to the resident. The resident had finished eating her breakfast. Resident #2 was assisted to her room and administered the inhaler. The CMA did not encourage the resident to rinse her mouth. The resident was not observed to rinse her mouth. The [MEDICATION NAME] package insert documented, "...After each dose, rinse your mouth with water and spit the water out..." At 8:20 a.m., the CMA was informed of the surveyor's observations. She stated she would watch administering the [MEDICATION NAME] and be sure to give before breakfast. She stated she was not aware the resident needed to rinse her mouth out with water after using the [MEDICATION NAME].

Based on observation, record review, and interview, it was determined the facility failed to ensure care plans were fully developed to reflect the residents' condition for 4 (#2, 3, 6, and #9) of 9 sampled residents whose care plans were reviewed. This had the potential to affect 41 residents who resided in the facility. Findings: 1. Resident #3 had [DIAGNOSES REDACTED]. The significant change assessment dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident had stated she had pain in the 5 days prior to the assessment, the pain had been frequent, and the intensity of the pain had been rated 8 on a scale of 1 to 10, with 10 being severe pain. The clinical records contained physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The care plan for pain dated 11/15/13 documented the resident had a problem with pain and took pain medications. The plan of approach was to allow the resident to do what she could for herself, have the resident report pain to the staff, and take her medications as ordered by the physician. The plan of care did not address indicators of pain, non-pharmocologic interventions to be attempted when the resident appeared to be in pain, or potential adverse effects with the usage of a naracotic. On 12/09/13 at 9:20 a.m., certified nurse aide (CNA) #1 stated the resident was often able to verbalize pain. She stated the resident would wring her hands and say that her hands hurt. The CNA stated the resident did not always verbalize pain and if the resident was wringing her hands, the staff would need to ask if she was in pain. On 12/10/13 at 2:30 p.m. the Minimum Data Set (MDS) coordinator, who was responsible for developing care plans, was asked how the resident demonstrated pain. She stated the resident would rub her hands together. The coordinator stated when she observed the resident rubbing her hands, she would ask the resident if she could rub them with lotion to make them feel better. The coordinator was asked if the care plan included non-pharmacological interventions for alleviating the resident's pain. She stated the interventions had not been care planned. The coordinator was asked if the care plan included adverse effects such as constipation with the use of narcotics for the treatment of [REDACTED]." On 12/10/13 at 3:00 p.m., the resident was observed as she sat calmly in her recliner. She was noted to be rubbing her hands together, but did not verbalize that she was in pain. After approximately 30 seconds the resident became restless, swinging her legs from side to side. The MDS coordinator entered the room and asked the resident if her hands hurt. The resident responded, "Yes." 2. Resident #6 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognition, had experienced no behaviors in the 7 days prior to the assessment, and had been administered an antianxiety medication 7 of the 7 days prior to the assessment. The care plan last reviewed 11/14/13 documented the resident was administered [MEDICATION NAME] 1 milligram (mg) at bedtime. The following approaches were documented, "...I am redirected by Staff as needed...I have one on one with Staff as needed...Food/Fluids offered...I will take my (medications) per (Doctor) orders." The care plan did not document signs/symptoms (s/s) of anxiety exhibited by the resident. Current physician's orders [REDACTED]. The resident was observed multiple times during the survey as she rested in bed, was in the common area with other residents, and as she was supervised during meals. On 12/09/13 at 2:40 p.m., the MDS coordinator was shown the care plan and asked if the s/s of anxiety exhibited by the resident were care planned. She reviewed the care plan and stated, "No." 3. Resident #9 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was moderately impaired in cognition and required supervision for most activities of daily living (ADLs). The assessment documented the resident had exhibited behaviors daily, not directed toward others, in the 7 days prior to the assessment and had been administered an antipsychotic medication 7 of the 7 days prior to the assessment. The behavior monitoring psychoactive flow record dated 11/2013 documented the resident was monitored for behaviors to include angry outbursts. The care plan last reviewed 11/06/13 documented the resident was administered [MEDICATION NAME] and [MEDICATION NAME] at bedtime. The following approaches were documented, "...I am redirected by Staff as needed...I have one on one by Staff as needed...Food/Fluids offered...I will take my (medications) per (Doctors) orders." The care plan did not include the resident's behavior of angry outbursts. Current physician's orders [REDACTED]. The resident was observed multiple times during the survey as he ambulated with a walker and participated in activities in the common area. On 12/11/13 at 11:10 a.m., the director of nurses was shown the care plan and asked if the resident's angry outbursts were care planned. She stated, "No." 4. Resident #2 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was cognitively intact, required assistance with ADLs, and had frequent pain at an 8 on a pain scale of 1-10 with 10 being severe pain. The care plan reviewed/revised 09/19/13 documented, "Problem (:) pain. Goal (:) will have fewer episodes of pain in next 90 days. Plan of approach (:)...I am encouraged to do what I can and am assisted as needed...I will report any complaints of pain to charge nurse...I will take my (medications) per (doctors) orders." The current physician's orders [REDACTED]. The plan of care did not address indicators of pain, non-pharmocologic interventions to be attempted when the resident appeared to be in pain, or potential adverse effects with the usage of narcotics. The resident was observed several times during the survey in her wheelchair in the dining room, in her room, and in bed. On 12/10/13 at 10:40 a.m., the MDS coordinator was shown the resident's care plan and asked if the care plan was individualized for the resident. She stated, "No."

Based on observation, record review, and interview, it was determined the facility failed to identify and prevent potential accident hazards related to hot water for 2 (north and south) halls of 3 halls. Thirty-two residents resided on the 2 halls. Of the rooms checked for water temperatures, 3 residents were identified by the facility as being cognitively impaired and independently mobile. The facility identified no residents who wandered into other residents' rooms. The facility census was 41. Findings: On 12/09/13 from 2:10 p.m. through 2:30 p.m., water temperatures were checked in resident rooms on the north and south halls. The water temperatures were as follows: ~ Room 105 - 132.9 degrees Fahrenheit (F), and ~ Room 205 - 132.2 degrees F. The resident who resided in room 105 stated she used the sink occasionally and the water was never too hot. The residents who resided in room 205 did not mobilize independently. At 2:30 p.m., the maintenance man was asked for the water temperature log. The log showed the facility water had been checked weekly at the nurses' station, the baths/showers, the laundry, and the kitchen. The maintenance man was asked what the temperature was supposed to be. He stated it should be no higher than 115 degrees F. At 3:00 p.m., the surveyor's thermometer was re-calculated. At 3:05 p.m., the maintenance man checked the water temperatures. The water temperature in room 105 was 110 degrees F. and the water temperature in room 205 was 124 degrees F. The surveyor re-checked the water temperatures. The water in room 105 was 128.6 degrees F. and the water in room 205 was 130.6 degrees F. At 3:15 p.m., the maintenance man was asked if he checked the water temperatures in the residents' rooms. He stated, "I used to check room 101 as it's at the beginning of the line for the hot water. Lately I checked the nurses' station, the baths/shower, the laundry, and the kitchen. I check them weekly and they usually run in the 101 to 103 range." At 3:20 p.m., the director of nurses was asked about residents who were cognitively impaired and wandered into other resident's rooms. She stated there were 3 cognitively impaired, independently ambulatory residents. She stated the residents had never wandered into other resident rooms. On 12/10/13 at 3:35 p.m., the water temperatures were re-checked by the surveyor. The water temperature in room 105 was 102.1 degrees F. and in room 205 the temperature was 101.4 degrees F. The facility domestic hot water monitoring policy documented, "...Water temperatures shall be taken and recorded on a weekly basis. These temperatures shall be taken from at least two resident rooms per wing, typically rooms on opposite ends and sides of the corridor...The acceptable temperature range in resident areas is 100 to 115 degrees Fahrenheit..."

Based on observation, record review, and interview, it was determined the facility failed to ensure residents were free from unnecessary antianxiety medication for 1 (#6) of 4 sampled residents whose clinical records were reviewed for antianxiety medication. The resident census and conditions of residents documented 11 residents were administered antianxiety medication. Findings: Resident #6 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognition, had experienced no behaviors in the 7 days prior to the assessment, and had been administered an antianxiety medication 7 of the 7 days prior to the assessment. The care plan last reviewed 11/14/13 documented the resident was administered [MEDICATION NAME] at bedtime. The following approaches were documented, "...I am redirected by Staff as needed...I have one on one with Staff as needed...Food/Fluids offered...I will take my (medications) per (Doctor) orders." The care plan did not document signs/symptoms (s/s) of anxiety exhibited by the resident. The behavior monitoring psychoactive flow records dated 10/2013 and 11/2013 documented the resident was monitored for behaviors of hitting, hallucinations, and [MEDICAL CONDITION]. The behavior monitoring psychoactive flow records did not document the s/s of anxiety exhibited by the resident for which she was monitored. Current physician's orders [REDACTED]. The resident was observed multiple times during the survey as she rested in bed, was in the common area with other residents, and as she was supervised during meals. On 12/09/13 at 3:30 p.m., the director of nurses was shown the behavior monitoring psychoactive flow records and asked if the resident's s/s of anxiety were identified for monitoring. She reviewed the flow records and stated, "No."