Every finding on record at 15 Craigside

Based on interviews and record review, the facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of services covered by Medicare for one of three residents (Resident (R)22) sampled. As a result of this deficient practice, the responsible party is unable to file an immediate, independent medical review (appeal). Findings include: On 06/20/25 at 10:00 AM, conducted a review of three NOMNCs provided by Social Worker (SW)33. Review of R22's NOMNC documented Medicare Coverage of the resident's skilled nursing services will end on 01/16/2025. However, the form was signed on 01/17/2025 after coverage ended. On 06/20/25 at 10:22 AM, conducted an interview with SW33 regarding R22's NOMNC. SW33 reported the NOMNC was signed a day later because that is when the resident representative came in to sign the form. Requested for any additional documentation that R22's resident representative was notified of the appeal rights prior to 01/17/25. At 10:53 AM, SW33 confirmed R22's NOMNC form was not provided within the required timeframe (two days) to allot the resident representative right to appeal.

Based on interviews and record review, the facility failed to ensure one resident (Resident (R) 15) received adequate assistance to prevent an avoidable fall. R15 does not have the functional ability to support her trunk while sitting at the side of the bed. One staff attempted to dress R15's upper body while the resident was sitting on the side of the bed. Staff was unable to maintain the resident's body position, the resident hit her head on the bedrail and fell to the ground on her left side. As a result, of this deficient practice, the resident sustained a laceration to the forehead which required stitches and a displaced fracture of the first cervical vertebra. Prior to the start of this recertification survey, facility had corrected this deficient practice resulting in past non-compliance. Findings include: On 06/18/25 at 02:18 PM, conducted an interview with R15's Family Member (FM) 4. FM4 was informed by staff that R15 fell while staff was assisting the resident with changing her clothes. The resident leaned to one side, then hit her head on the bedrail and fell to the ground. FM4 reported R15 requires two staff for assistance because the resident is dependent on staff and cannot do things for herself. As a result of the fall, R15 needed stitches to the forehead, fractured some bones in her neck, and was not quite the same after the fall. Asked FM4 for an example of how the resident was not the same after the fall. FM4 stated, prior to the fall R15 would speak and have conversations with FM4 during visitations, but since the fall the resident is unable to hold a conversation and when she does answer it's with minimal responses. Conducted a review of R15's Electronic Health Record (EHR) on 06/23/25 at 09:15 AM. Review of Registered Nurse (RN) 3 Statement written on 05/06/25 documented, Per CNA (Certified Nurse Aide (CNA) 9), she assisted resident to sit on the side of bed and tried to put on resident's sweater when resident suddenly tilted on her right side and bump her head on the bed's side rail. CNA lost her grip on the resident and slowly slide her from bed to the floor where resident landed on her left side. CNA yelled for help and other CNA came, and assisted resident to sit up. Other CNA called this writer to assess. Review of the resident's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/25 Section GG, Functional Abilities, GG0130, Self-Care documented the resident is dependent (helper does ALL the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for oral hygiene, toileting, shower/bathe, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Review of a progress note, post fall evaluation, written on 05/06/25 at 11:03 AM, Certified Nurse Aide (CNA) was trying to put on R15's sweater while the resident was sitting on the side of the bed, sustained a laceration measuring 2.5 centimeters (cm) with bleeding and a bump with redness measuring 3.5 cm x 4.0 cm. and the resident was sent to the emergency room (ER). Upon returning to the facility (on 05/09/25) from the ER, the resident was diagnosed with a traumatic subdural hemorrhage without loss of consciousness and displaced fracture of the first cervical vertebra. On 06/23/25 at 09:44 AM, conducted an interview with CNA9 regarding R15's fall. CNA9 confirmed R15 is unable to support her trunk while sitting on the side of the bed with both feet on the ground. CNA9 stated in that position, R15 will sway and requires support to stabilize the resident as she will sway from side to side. Inquired if in CNA9's opinion, R15's upper body can safely be dressed by one staff while sitting on the side of the bed with both feet on the ground. CNA9 confirmed in that position, R15 requires two staff to assist her, one to put on the upper body clothing and another staff to ensure the resident does not fall. Conducted an interview and record review with the Administrator regarding R15's fall on 06/23/25 at 10:59 PM. Administrator confirmed the investigation process was started as soon as he became aware of the incident and only one CNA was in the room assisting R15 with putting on a sweater while the resident was sitting on the side of the bed with both feet on the ground. On 06/23/25 at 11:23 AM, conducted an interview with CNA8 regarding R15's functional abilities. Asked CNA8 if one staff can put a sweater on R15 without a second staff, safely. CNA8 confirmed while the resident is sitting on the side of the bed, even with both feet on the ground, R15 will sway back and forth. Asked if R15 has the trunk strength to support herself. CNA8 confirmed R15 has poor trunk strength and little to no control of her trunk and needs two staff to safely dress the resident and R15 needs two staff to be able to sit up in bed. On 06/23/25 at 12:10 PM, conducted an interview with CNA Manager (CNAM) 14 regarding R15's fall. During the interview, CNA14 confirmed two staff should have been with the resident while R15 was seated at the side of the bed, putting the resident's sweater on, one staff to support the resident in the seated position and another staff to provide support to the resident. CNA14 pointed out that if R15 was lying in bed, then one staff would be able to safely dress the resident. CNA14 confirmed R15's fall on 05/06/25 was avoidable and the resident sustained physical injuries. While on survey it was determined that the facility corrected this deficient practice. A complete and thorough investigation was conducted by the Administrator in a timely fashion. R15's care plan interventions were updated to ensure the resident was in a stable position prior to staff dressing her upper body. All residents were reviewed and identified for the potential of needing a two-person assist at all times. Staff were re-trained on safe completion of the resident's Activities of Daily Living (ADLs) and training on which residents require two-person assistance. The facility also devised a color-coded system for staff to easily identify which resident required two-person assistance. For example, residents who require two-person assistance have a green name plate outside their room and resident who do not need a two-person assist has a white name plate. The use of the color-coded system for identifying residents in need of two-person assistance was observed on the unit. Interviews with staff documented the color-coded system was a practical and effective intervention. In addition to addressing and reviewing all the current residents, the facility implemented monitoring newly admitted residents for one week, then review their ADLS to determine if the resident is a two-person assist at all times. These corrective actions were implemented into the facility's Performance Improvement program. Monitoring and evaluation of the newly implemented interventions are on-going.

Based on observation, interview and record review, the facility failed to communicate food preferences to all staff involved in the preparation and service of resident meals for one resident (Resident (R) 42) sampled for accommodation of food preferences. This deficient practice did not ensure that the resident's food choices were honored. Findings include: On 06/18/25 at 02:23 PM, R42 was interviewed in her room and stated that she does not like and will not drink milk or eat butter and cheese. On 06/19/25 at 02:03 PM, a review of R42's nutrition care plan did not include the resident's preferences of no milk, butter, and cheese. A 05/07/25 Initial Care Plan Meeting note for R42, found in the progress notes of the Electronic Health Record (EHR), stated to allow whole finger food, banana, dessert with no mention of R42's preferences. On 06/19/25 at 04:05 PM, R42 a second interview with R42 was conducted. The resident reiterated that she does not like to eat milk, butter, and cheese. She stated when first admitted to the facility, she was asked about her food preferences and shared her likes and dislikes. On 6/19/25 at 04:13 PM, the top of the dinner meal ticket stated no butter and milk. It did not include, no cheese. On 06/20/25 at 07:05 AM, the breakfast meal ticket also did not include no cheese. On 06/20/25 at 09:48 AM, conducted a concurrent interview with Chef and observation of the lunch meal tray line. Chef confirmed that meal preparation for each resident is based on what is listed on the meal ticket obtained from the Dietician and Dietary Clerk. Therefore, if a resident's preferences are not listed, it will be prepared, plated, and served to the resident. On 06/20/25 at 10:38 AM, the Registered Dietician (RD) 23 was interviewed at her desk with a concurrent review of R42's initial nutritional assessment, dated 05/01/25, located in the EHR. The nutritional assessment stated under 14b. Dislikes a notation of no butter, no cheese, hot drinks. RD23 confirmed that only no butter and milk was listed on the top of the meal ticket for R42. RD23 stated that no cheese was not listed because only a certain number of characters could by typed on the ticket and there was not enough space to put all the information. RD23 then stated that additional dietary information is put in a binder that staff can refer to, the care plan can be checked for resident dietary preferences, and the Health Services Assistant (HSA) 2, who checks the meal trays before it is served, was aware of R42's preferences. When asked how the kitchen staff are aware of a resident's preference when preparing the food, RD23 stated that it is not the kitchen staff's responsibility and if a resident is served something they dislike, the kitchen is called for a substitution. On 06/20/25 at 11:05 AM, HSA2 was interviewed at the meal tray preparation area on the resident unit with RD23 present. HSA2 identified the preference of no milk and butter on RD23's meal ticket but was unaware R42's preference of no cheese. On 06/20/25 at 11:45 AM, RD23 provided the reference binder that contained additional dietary information. RD23 verbalized that resident food preferences were not listed in this binder.

Based on observation and interview the facility placed oral care supplies (used for mouth hygiene and kept as clean as possible) with incontinent care supplies (used for managing bodily waste) and instant food and beverage thickener packets with adult briefs in the resident bedside storage drawers for two of two residents (Resident (R) 13 and R15) sampled. This deficient practice increases the risk of cross-contamination (potential for microorganisms to transfer from one supply to another) and transfer of microorganisms from the perineal and buttock area to the mouth. Findings include: On 06/20/25 at 08:51 AM, Certified Nurse Aide (CNA) 8 and CNA14 was observed providing bladder and bowel incontinence care for R13. Incontinence care supplies (tube of moisture barrier cream and disposable incontinence wipes) were removed from R13's bedside drawer by CNA14. Bladder and bowel incontinence care was provided to R13 using those supplies. Once completed, the used supplies were returned to the drawer by CNA14. Inspection of R13's drawer with CNA14 observed both incontinence care supplies, including the incontinent care supplies just used by CNA14, and an open package of oral swab sticks were stored in the same drawer with an opportunity for the transfer of microorganisms from the perineal and buttock area to the supplies used in the resident's mouth. CNA14 stated the open package of oral swab sticks (which were not individually wrapped in the package) should not be stored in that drawer because bladder and bowel should not be mixed with oral, and proceeded to remove the package of oral swab sticks. On 06/23/25 at 10:32 AM, the Infection Preventionist (IP) was interviewed. The IP stated best practice is to separate clean and dirty items, however, oral and incontinence care products can be stored together if they are not touching. On 06/23/25 at 10:50 AM, observation of R15's bedside drawer was done with the IP and Certified Nurse Aide Manager (CNAM) 2. Disposable briefs and three packets of instant food and beverage thickener, partially tucked under a brief, were observed stored together. CNAM2 confirmed that the briefs and oral thickener packets should not be stored in the same drawer together and proceeded to remove the thickener packets and disposed of them in the trash receptacle.

Based on observations, interview, and record review, the facility failed to ensure one resident (R)38 in the sample was free from accident hazards. Despite having a history of falls and an unsteady gait, the resident was ambulated without the use of a gait belt, placing her at risk for an avoidable fall and/or injury. This deficient practice has the potential to affect all residents at the facility who require assistance to ambulate. Findings include: Resident (R)38 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her current diagnoses include repeated falls, muscle weakness, age-related osteoporosis, and dementia. During a review of her electronic health record (EHR) it was noted that R38's last documented fall was on 06/17/23. On 08/22/23 at 10:09 AM, an observation was made of R38 being assisted back to her chair in the dining room from her room where she had gone to use the restroom. R38 was using a front-wheel walker (FWW) and was bent over slightly with a steady but awkward gait. R38 ambulated back to her chair in the dining room with a certified nurse aide (CNA) providing stand-by assistance. On 08/22/23 at 03:29 PM, on observation was done of CNA1 assisting R38 ambulate back to her chair in the dining room. R38 was bent forward at the waist, more so than the previous observation, and her gait was unsteady and a bit stumbly. Aware of her unsteadiness, CNA1 had grabbed and was guiding R38 by the back center of the elastic waistband on her loose polyester pants. Each chair that they passed, R38 asked to sit. CNA1 led her past at least two chairs, maintaining a firm grip on the back of her pants. When R38 finally made it to her seat, she plopped down and stated, my pants are too tight, it hurts! An interview with CNA1 was done at this time. When asked about the unsteadiness of R38's gait as opposed to earlier in the day, CNA1 stated it's because she is tired. When asked about using a gait belt with R38, especially when she is tired with an unsteady gait, CNA1 admitted that she should have used a gait belt. On 08/24/23 at 08:00 AM, an interview was done with the CNA Manager (CNAM) in the conference room. When asked about using gait belts for safe transfers and ambulation, CNAM stated that the physical and occupational therapists determine who needs to have a gait belt, otherwise gait belts are recommended for the safety of residents and staff, as well as comfort of the residents, and are used at the CNA's discretion. CNAM reported that her expectation is that gait belts are used for anyone determined to need extensive assistance (unless the residents refuse it), and if the CNA feels it is unsafe. CNAM agreed that using a gait belt is preferable to grabbing the resident by the back of the pants. CNAM stated that R38 requires limited to extensive assistance and is known to be more tired and unsteady on her feet in the afternoon. CNAM agreed that given R38's history of falls, she would expect to see a gait belt used when R38 has an unsteady gait. On 08/24/23 at 12:30 PM, a review of the facility's Gait Belts Nursing Protocol, last updated 09/18/22, revealed the following: Staff will use the Gait Belt as an assistive tool when transferring and ambulating residents. Not all residents require the use [sic] a Gait Belt, but to reduce possible injury, a Gait Belt is recommended during all transfers and ambulation. 22063 2) On 08/22/23 at 11:24 AM observed R18 in the dining room. R18 was seated in a recliner and was asked if she wanted to sit in her chair. R18 was agreeable. CNA2 and CNA3 grabbed R18's pant waistband, pulled the resident up to stand, and pivoted resident to sit on a chair. There was no gait belt and the resident's pant were hiked up in the crotch area. Record review noted R18 was admitted to the facility on [DATE]. Diagnoses include but not limited to paroxysmal atrial fibrillation; age-related osteoporosis without current pathological fracture; other abnormalities of gait; and other lack of coordination. A review of the admission Minimum Data Set (MDS) with assessment reference date of 06/28/23 notes R18 requires extensive assist with one-person physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). R18 also noted to be not steady and only able to stabilize with staff assistance for moving from seated to standing position, surface-to-surface transfer (transfer between bed and chair or wheelchair). Review of R18's care plan notes she is at high risk for falls related to weakness, history of orthostatic hypotension (condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), syncope (fainting or passing out caused by a temporary drop in the amount of blood that flows to the brain), and fall score of 19. R18 is also diagnoses with osteoporosis which placed her at risk for significant injury related to fall. Interventions for transfer include to instruct and remind resident to slowly transfer and give simple cues and instruction during transfer; provide limited to extensive assist with transfer; and one-man support. On the afternoon of 08/22/23, interviewed Physical Therapist (PT)1 regarding the use of gait belts when transferring residents. PT1 reported it is recommended to use a gait belt during transfers. PT1 further reported staff will determine whether a gait belt is needed. On 08/24/23 at 08:00 AM an interview was conducted with CNAM in the conference room. CNAM reported a gait belt is used for residents that require extensive assistance for transferring. Inquired which residents require the use of a gait belt, CNAM included R18 in the list. CNAM further reported gait belts are used for the safety of the residents.

Based on observation and interview the facility failed to store and label food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. Findings include: On 09/20/22 at 08:17 AM, the state agency (SA) did an initial tour of the kitchen with the Food Service Supervisor (FSS). SA observed several cartons of egg whites in the walk-in refrigerator with no manufacturer expiration dates. When asked, the FSM was unable to verbalize how long the egg whites are good for. On 09/23/22 at 09:55 AM, the SA conducted a follow-up tour of the kitchen with the FSM. In the outside walk-in refrigerator, the SA observed two (2) large metal trays with approximately 9 to 12 cartons of egg whites per tray. The cartons read frozen egg product. Most cartons were labeled with a handwritten date of 09/12/22, with one carton labeled 09/19/22. The FSS stated staff write the date of receipt on the cartons. Confirmed cartons were received on 09/12/22 and 09/19/22. When asked again about the expiration dates for the egg whites, the FSS was unable to verbalize an answer, stating I'm not sure .we keep them frozen in here. The SA picked up a carton and indicated that it was fully thawed. The FSS was surprised they were not frozen. The SA turned the carton to the side and observed storage instructions that read: STORAGE KEEP FROZEN Use within 3 days after thawing Keep unused portion refrigerated Do not re-freeze. Upon reading this, the FSS stated I didn't know about that suggestion. SA informed the FSS that storage instructions are not suggestions, and it is a deficient practice to not be following them. The FSS agreed and stated he would discard all the thawed cartons. On 09/23/22 at 10:15 AM, a food service worker informed the SA that the usual process of receipt for the frozen egg whites is to receive them frozen and to label each carton with the date of receipt, then place them in the freezer. Because they go through so many egg whites, they will pull whole trays and place them in the refrigerator to thaw, but unfortunately it is not their current practice to label when they are being pulled for thawing. The food service worker and the FSS both acknowledged that without labeling when they were pulled for thawing, there is no way to ensure the egg whites are being used within 3 days as per the storage instructions.

Based on observations, record review and interview with facility staff, the facility failed to identify an accident risk to avoid an accident while wheeling/pushing a resident in the wheelchair without foot rests for one (Resident 14) of one residents sampled for accident hazards Findings include: Resident (R)14 was admitted to the facility on [DATE] from an acute facility. R14's [DIAGNOSES REDACTED]. On 10/09/19 during lunch observation, R14 was found to self-propel in a wheelchair (utilizing his/her feet) away from the table and had to be redirected by staff back to the table for lunch, three times before the resident's meal arrived. On 10/09/19 at 01:30 PM observed the resident in the hallway with Certified Nurse Aide(CNA)1. There were no foot rests on the resident's wheelchair, the CNA began to push the resident, then stopped and stated he/she would get R14's foot rests. The foot rests were retrieved from the resident's room, applied and R14 was wheeled (pushed) from the hall to the dining room. On 10/09/19 at 01:54 PM observed Staff Member (SM)1 wheeling R14 back to his/her room. There were no foot rests applied to the wheelchair, R14 had to lift his/her feet to prevent it from dragging on the ground. The resident's feet were barely off the ground. On 10/10/19 at 11:45 AM observed CNA2 pushing R14 from the resident's room to the dining area. The foot rests were not applied and the resident had to hold up his/her feet for the duration of the ride. CNA2 was asked whether R14 has foot rests, the CNA replied the foot rests are not applied as the resident wants to propel himself/herself about the unit. A record review found a quarterly Minimum Data Set with an assessment reference date of 08/05/19. R14 yielded a score of zero (severe cognitive impairment) upon administration of the Brief Interview for Mental Status. The resident was coded with signs and symptoms of [MEDICAL CONDITION] (fluctuating behavior, inattention, disorganized thinking and altered level of consciousness). R14 was also noted to have range of motion impairment of both lower extremities. A review of the care plan provided by the facility on the morning of 10/11/19 notes R14 is at risk for fall and injuries due to impaired safety judgment and generalized weakness (extensive to total assist with mobility). Also noted, R14 uses the wheelchair as the main mode of locomotion, he/she is able to wheel in the hallway with general supervision. R14 is documented to receive routine antipsychotic medication ([MEDICATION NAME]). Further review found a Care Plan Update Sheet which notes an additional entry dated 10/09/19 with the following intervention: If staff is wheeling resident from resident's room to around dining area, foot rest is not needed as resident is able to propel but resident may need assistance in direction. If resident uses his/her feet as a brake to stop the wheelchair, staff will stop wheeling and ask resident what he/she would like to do. The update was recorded by the Director of Nursing (DON) on 10/11/19 at 08:24 AM after initial observations and interviews were done. On 10/11/19 at 09:52 AM an interview was conducted with the Physical Therapist (PT). The PT confirmed he/she is familiar with R14 and concurrent observation of the resident's wheelchair found the foot rests were not affixed to the chair. The PT reported the foot rests are not placed on the wheelchair to allow R14 to be mobile. The PT demonstrated that with the foot rest applied, the foot rests can snap back and hit the resident's feet/legs while he/she is self-propelling. The PT was asked about staff members pushing the resident in the wheelchair without placing his/her feet on the foot rests. The PT reported R14 has a tendency to drop his/her feet down and for safety purposes foot rests are indicated.

Based on observation and interview with staff members, the facility failed to control and account for controlled drugs while awaiting disposal, as evidenced by accurate documentation of medications placed in the locked drawer for disposal; multiple nurses having access to controlled drugs stored in a locked drawer; and a system to account for controlled medication disposal in sufficient detail to enable accurate reconciliation to prevent drug diversion. Findings include: On 10/10/19 at 12:05 PM, inspected the medication storage room with Registered Nurse (RN)1. Observation of the locked controlled drugs found a discrepancy between the list of medications and the actual medications. There were five medications in the drawer; however, only four were listed. An open bottle of [MEDICATION NAME] HCL 100 mg/ 5 ml for Resident (R)13 was not documented on the Medication to be Discarded log. RN1 confirmed that the [MEDICATION NAME] was not documented on the log. Although RN1 did not place the [MEDICATION NAME] in the locker drawer, upon discovery of the undocumented medication, RN1 made an entry dated 10/10/19 with R13's name, type of medication, number of units remaining (11.4 ml) and initialed the entry. RN1 did not measure the [MEDICATION NAME] prior to documenting the units remaining. Inquired about the process of discarding medication. RN1 responded medications that are removed from the medication cart, are then listed on the Medications to be Discarded log. Medications are stored for a week in the locked drawer, with disposal scheduled every Friday. The responsibility for discarding medications are rotated between the three shifts. The RN1 was asked who has access to the locked drawer, RN1 responded multiple staff have access to the drawer. During a day, there are up to five nursing staff that have access to the drawer (two medication nurses during the day shift; two medication nurses during the evening shift; and one mediation nurse during the night shift). The Director of Nursing confirmed that there are multiple staff that have access to the locked drawer. Further review of the Medication to be Discarded log for controlled drugs found there is no documentation of the time the drug was placed in the locked drawer. Also, there is no initial verification by another nurse to attest how many units/tablets remain when it is placed in the locked drawer for disposal purposes. Additionally, there is no way to identify who and when staff accessed the drawer.

Based on observation, inquiry with staff, and policy review, the facility failed to follow their protocol/procedure; where a kitchen staff member, (KSM)1, failed to wear a hair restraint while in the kitchen. As a result of this deficient practice, the facility put the residents at risk for food contamination. Findings include: During a walk through of the kitchen on 10/09/19 at 08:35 AM, KSM1 was observed not wearing any hair restraint (such as a hat, or hair net) while being in the kitchen. When asked the reason why a hair restraint was not being used, KSM1 stated that he/she just came in recently from outside. The Kitchen Manager (KMgr), who accompanied the walk through, was queried about the above finding. KMgr acknowledged that KSM1 should have been wearing a hair restraint while being in the kitchen. KMgr also stated that it was in their Dining Protocols to wear hair restraints (such as a hat, or hair net). A review of facility's policy on Dining Protocols stated the following: Personal Hygiene; Dining Services personnel are to wear appropriate clothing including hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens, and unwrapped single-service and single-use articles.

Based on observations, staff interviews, review of facility policy, and review of manufacturer recommendations, the facility failed to properly store three of five Soft-Fall Bedside Mats (mats) reviewed. As a result of this deficient practice, the facility put the safety and well-being of not only the residents, but the public and the staff at risk for accidents/tripping/falls. Findings Include: During an observation of 16 resident rooms (201A to 208B) on 10/25/18 at 10:30 AM, there were a total of 5 mats being used in these rooms. Two mats were properly placed along both sides of the bed in room [ROOM NUMBER]B, as per manufacturer's instructions. However, a total of 3 mats, 1 mat for each room; 205B, 206B, and 207A, were not properly stored away, as per manufacturer's instruction. These mats were stored away either by leaning up against the wall or leaning up against a cabinet. These mats had the potential to end up on the floor, and thus, creating a risk for accidents/tripping/falls, etc. During staff interview with Registered Nurse (RN) 1, on 10/25/18 at 01:30 PM, RN1 acknowledged that all mats assigned to residents were being stored away, when not in use, by leaning up against the wall. RN1 was not aware of the manufacturer's recommendation for properly storing these mats. During discussion with the Administrator (Admin) on 10/25/18 at 1:50 PM, Admin reviewed the manufacturer instructions which stated The one-piece mat is sized to fit under the bed for storage. Admin acknowledged that storing the mats by leaning it against the wall or cabinet had the potential for it to end up on the floor and creating a risk for accidents/tripping/falls.

Based on interview and policy review the facility failed to establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply. Finding includes: On 9/09/16 at 9:26 a.m., the facility Emergency Water Supply Plan was reviewed with the Environmental Service Manager (ESM). The policy stated The Water storage tank in the Lower Level Main Mechanical Room holds a total of _____ gallons of potable water. 55 gallon containers and smaller containers to be used for toilet flushing. The ESM stated there would be one gallon per person. When asked about ratio of gallons to resident; ratio of gallons for staff, and length of days the supply would last, the ESM was not able to find the information documented in the plan. The ESM acknowledged that availability of emergency water for resident and staff should be documented for emergency preparedness.

The facility failed to ensure that residents' possessions, regardless of their apparent value to others, were treated with respect, for what they were and for what they may have represented to the resident, failed to follow their policy on documentation, and failed to notify the family of the missing items status for 1 of 26 residents in the Stage II survey sample. Findings include: In an initial interview with Resident (R) #37's family member, she stated that they had reported several missing personal items including: a watch; an expensive Japanese vase, and a Topaz ring. She stated that she wasn't aware that staff were looking for the items as she asked several times if they had been located. In an interview on 9/09/16 at 8:26 a.m., with the Social Worker (SW) regarding missing items, she verified that they had procedure to follow, usually they fill out a form for lost items then do a search and let me know and I do another search. I usually get a report, but no form was completed in this instance. The SW verified that she wasn't sure if she had notified that family member that none of these items had been located. When asked if there is a company policy regarding missing items she stated we do have a policy for staff to follow regarding missing items. I do the residents admissions and they are given a handbook which states we are not responsible. I go over this with residents and/or family members. I recommend that they do not keep any expensive personal items here but we would provide a locked drawer if they want to keep expensive items. We are not always aware that they have these items as family members will bring in items, and no log is kept for personal items. We ask families to tell us when they bring something in but we usually find out after the fact if something is missing or broken. In an interview with the Director of Nursing (DON) on 9/09/16 at 9:15 a.m., she verified that she was aware there were missing items as the family member brought it up in a meeting. She validated that during the time when the items were missing she was sent to the hospital and the family member was not sure if she had the items while at the hospital. She further stated that we cannot determine where it was lost. We tried to find it. We also moved her to a different room during this time. She stated if they cannot find the item, we will tell the family and ask if they want us to pay them. So far we haven't because the family member wasn't sure where it was lost. When asked if they have a policy on bringing personal items to the facility, she stated we let the family know that if they want their relative to carry this item we can lock it in our safety box. If they want to wear it we tell them if it gets lost we will try to help them search for it. We will make every effort. When asked if they keep track of personal items she stated we do not itemize personal items. If it's clothing we have the family label them. When asked if they set limits on the value of items residents bring in she stated we don't set limits but we tell the family that we aren't responsible. In a review of the facility policy Residents' Rights - personal Property (Missing or Damaged) Policy on 9/09/16 at 10:32 a.m., under the heading Missing or Damaged Property of Residents it reads: Claims of missing money and other property belonging to residents are reported to the charge nurse who completes a missing property form. the completed form is given to the Social Worker for follow-up with resident or family, no longer than 48 hours after the initial report is made. Information concerning the missing property, circumstances surrounding its loss, the outcome of the search and the manner in which the matter was resolved is documented in a report and entered into the Missing Property Log by the Social Worker once the report is complete. The Social Worker follows up with the resident and/or family to share the results of the investigation.

The facility, in accordance with State and Federal laws, failed to store all drugs and biological's at the proper temperature to preserve the integrity. Findings include: On 9/09/16 at 8:43 a.m., in an observation of the medication storage room, Latanoprost 0.005% (eye drops) were found in a drawer. Directions on the package read that the eye drops must be kept in the refrigerator until opened. LN #1 confirmed that these drops should be stored in the refrigerator. In an interview with the Director of Nursing (DON) she validated that the policy stated to follow directions on insert. The DON verified that medications labeled to store in the refrigerator should not have been stored in the drawer.

Based on observation, interview, and policy review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection. Findings include: 1) On 9/07/16 in the midmorning, observed an aide wheeling an uncovered cart filled with folded white linen down the hall and entering room [ROOM NUMBER]. When asked if the cart needed to be covered the aide stated I forgot to cover, the aide verified the cart held clean linen. The facility policy titled Laundry and Bedding stated under Storage: Clean linen should be placed in a covered cart when transported. 2) On 9/08/16 at 8:51 a.m., AM during a medication pass observation, observed Licensed Nurse (LN) #2 place medications, a tissue box, and gloves for Resident #11 (R #11) into a small black plastic tray; carry the tray into R #11's room; and placed the tray onto the overbed table. After administering the medication, LN #11 then returned to the medication cart and without sanitizing the tray placed the tray on top of the medication cart. LN #2 then proceeded to administer medication to R #37. When asked about sanitizing the tray after resident use, LN #2 stated that the tray should be sanitized after resident use for infection control. The facility Medication Administration Guidelines stated under Additional Guidelines, Follow infection control standards.

Based on staff interviews and record review, the facility failed to accurately reflect the status for 1 of 5 residents in the Stage II sample weights. Findings include: In a record review of the Minimum Data Set (MDS) 14-day scheduled assessment with an ARD (Assessment Reference Date) of 6/21/15, the data showed an admitted for resident #26 on 5/21/15, and a re-admission date of [DATE] from an Acute Care Hospital. Under Section K of the MDS - Swallowing/Nutritional Status the resident's weight was recorded as 99 pounds. In a record review of the weight log book, weights were recorded for this resident on 5/25/15 (104 pounds) and 6/29/15 (96 pounds). No weight of 99 pounds was documented in the weight log book. In an interview with the Registered Dietician (RD) on 7/02/15 when asked about the inaccuracy of the resident's weight on the MDS, she verified that she was uncertain as to where the weight was obtained. When asked if the resident had a significant weight loss within the assessment period the RD verified that the resident did indeed have a 5% weight loss. The significant weight loss of 5% was not caputured on the MDS.

Based on observation, resident and staff interviews, the facility failed to post results of the most recent survey (The Statement of Deficiencies, HCFA-2567) in an area readily accessible to residents. Findings include: During an interview with Resident #27, the President of the Resident Council, she stated that yes they were posted on the bulletin board but I never asked to look at them. During an observation of the bulletin board, the State inspection results were available on the board for residents to read but it was located high up towards the top right hand side of the board, making it difficult for residents who were unable to reach the top of the board (those in wheel chairs or short in stature) to obtain the information. A Certified Nurses Aide, CNA, verfied her inability to easily access the survey results on the bulletin board due to the height of the forms.

Based on observation and staff interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions for several residents in the second floor dining area on June 30, 2015. Findings include: In an observation on 6/30/15 at 11:39 A.M., CNA # 1 was serving soup from a large kettle into bowls for several residents. CNA #1 was not wearing a hair net nor any form of hair covering. In an interview with CNA #1 on 6/30/2015 at 11:42 A.M., he stated that he didn't know if he had to wear a hair net. He stated that he didn't usually do this task and in fact this was the first time he had dished soup into bowls for residents. He turned to a co-worker and asked about wearing a hair net. His co-worker validated that he needed to wear a hat or hair net. In an interview 7/02/2015 at 9:21 A.M. with the Head Chef, he stated that all staff who prepare food need to wear a hair net or head covering. He was speaking on behalf of the main kitchen's staff. The nursing floor had different staff who portioned out the soup and served the food trays to residents. The Head Chef indicated that he wasn't sure whether the nursing floor staff were required to wear hair restraints. In a documentation review on 7/02/2015 (Dietary Protocols) provided by the Head Chef, under meal coordination (MC) responsibilities was listed: Ensures hairnets/hats are being worn by all staff members assisting with meal service outside of the kitchen

Based on observation, record review and staff interview, the facility failed to monitor and ensure the dishwashing machine temperatures were documented on a daily basis and reviewed for accuracy. Finding includes: During the tour of the kitchen on 11/14/13 (Stage 2 of the survey), it was found the dishwashing machine temperature log for September 2013 had incomplete documentation. There were a total of 5 days in which the "AM" temperatures were not recorded from 9/26 - 9/30/13. There also were a total of 22 days in which the "PM" temperatures were not recorded from 9/2 - 9/22/13 and 9/30/13. For the month of October 2013, the dishwashing machine temperatures were recorded on the "Pots and Pans Sanitizer Chart" instead of the Dishwasher Temperature Chart. A review of this log also found on 10/25/13 and 10/31/13, there were missing PM temperatures, respectively. During an interview with the head Chef of the kitchen on 11/15/13 at 7:30 A.M., he verified the staff were not accurately recording the temperatures on the logs for the dishwashing machine for the month of September. He also confirmed they were using the wrong log sheet to record the October temperatures. He verified this process was not being monitored for accuracy and completeness and an inservice would be provided to the kitchen staff.

Based on resident interview, record review, staff interviews and facility policy review, the facility failed to maintain the nutritional status for 1 of 3 residents sampled for nutrition of the 13 residents in the Stage 2 sample. Findings include: Interview of Resident #30 (R #30) on the morning of 11/13/13 found the resident reporting weakness and loss of appetite. The R #30 stated her taste buds must have diminished because the food was not tasty and appetizing. She reported decreased food intake. Observation of R #30 on the afternoon of 11/13/13 found the resident speaking in a soft voice and sitting up in bed. She spoke slowly and refrained from extra body movements. During record review on the afternoon of 11/14/13, it was found that R #30 experienced significant weight loss. The resident weighed 85 pounds on admission (10/30/13), 83 pounds on 10/31/13, and 79 pounds on 11/4/13. The Registered Dietitian (RD) performed her initial nutritional assessment of the resident on 11/4/13 and documented the resident had experienced significant weight loss of 6% since admission. The RD interviewed the resident for her food preferences and noted the resident herself suggested that she take Ensure because she previously tried it and liked it. There was no documentation showing communication with the physician. After the resident experienced the 6% weight loss, there were no physician orders for Ensure. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/5/13, Section K (Swallowing/Nutritional Status), Item K0300 (Weight Loss), noted no significant weight loss (5% or more in the last month). The RD stated she didn't note the significant weight loss because of the resident's reported usual body weight (UBW) of 83 pounds. There was a noted disparity between item K0300 on the MDS from the resident' initial nutritional assessment. According to the RD, the R #30 experienced a 4% weight loss when compared to the resident's reported UBW. Review of R #30's care plan (effective 10/30/13) noted she was at risk for inadequate nutrition. The care plan further noted she experienced a 6.3% weight loss over the course of 6 days (10/30/13 - 11/4/13). Outcomes included maintaining the resident's weight within 5% of her current weight (75-83 pounds) with desired gradual weight gain. Interventions included providing Ensure Plus between meals as requested by resident. Further interventions were to take weights as directed and report significant changes in weight to the PMD. Review of physician's orders included a prescription for [MEDICATION NAME] 7.5 mg orally daily, which was indicated for situational depression. The order for Ensure Plus 120 mL orally twice per day between meals was ordered on [DATE], and was indicated as a supplement. There was no physician's order for Ensure Plus prior to 11/12/13. Review of R #30's intake record on the morning of 11/15/13, found documentation for Ensure from 11/13/13. There was no other documentation of R #30 receiving Ensure prior to 11/13/13, as it was noted in the RD's initial assessment. On-going record review revealed no further documentation of communication with the physician. There was no indication that the physician was notified of R #30's weight loss. Interview of the MDS Coordinators #1 & #2 found the facility's protocol for weights was to have the Certified Nurses Aides (CNAs) take daily weights for 3 days after admission. After 3 days, weekly weights were indicated. The CNAs took R #30's weight for the first 2 days then again on 11/5/13. The CNAs were expected to notify the nursing staff when residents experienced weight loss, and the nursing staff then notifying the RD and physician. Interview of the RD on the morning of 11/15/13 revealed that the resident told her that her usual body weight (UBW) was 83 pounds. The RD used the resident's reported UBW as a baseline to calculate the resident's weight loss, which indicated a 4.4% loss. The RD stated that she didn't consider the resident's weight loss as significant, since it was less than 5% (4.4%) when compared to her reported UBW. However, the RD's initial assessment noted a 6% weight loss. The RD stated that she performed her initial nutrition assessment on 11/5/13, when she noted a trial of Ensure Plus to be given between meals per the resident's preference. The RD stated that she needed an actual weight to compare to. Therefore, she asked R #30 for her UBW, which was noted as 83 pounds. The RD further stated that the Dietary Manager (DM) was responsible to update her of residents' status because she was a part time employee. Interview of the DM on the afternoon of 11/15/13 revealed an understanding that the resident was experiencing weight loss. She stated they had been providing the resident with Ensure Plus between meals. Review of the facility policy found that all residents were administered an Admission Care Plan to carry them through the initial assessments. The Admission Care Plan noted weights were to be monitored daily for 3 days then weekly for 4 weeks. The facility failed to get R #30's weight on the 3rd day following admission and waited until 11/4/13 to obtain the next weight, which then showed the significant weight loss.