Every finding on record at Adamsplace, LLC

Based on Infection Control Manual review, employee list review and interview, the facility failed to offer COVID-19 vaccinations to employees hired after 2/2025 which had the potential to affect 37 of 37 residents that were residing in the facility. The findings include: Review of the Infection Control Manual Volume 1, dated 10/2025, revealed .This Infection Prevention and Control program is designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections.Immunizations/vaccinations are offered, as appropriate, to patients and partners to decrease the incidence of preventable infectious diseases. Review of the current employee list revealed 29 employees were hired after 2/2025. During an interview on 12/17/2025 at 10:00 AM, the Infection Control Preventionist (ICP)/Director of Nursing (DON) was asked to explain the process for COVID-19 vaccinations for staff. The ICP/DON stated, We did not offer the COVID vaccination this year.several of the local clinics had it. During an interview on 12/17/2025 at 12:58 PM, the Administrator stated, Covid is a thing of the past, it will be here until we die . During an interview on 12/17/2025 at 2:21 PM, the ICP/DON was asked when the facility last offered the COVID-19 vaccination to staff. The ICP/DON responded the last time it was offered to be given to staff inside the facility was February 2025.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Infection Control Manual review, Infection Tracker review, Infection Control Monthly/Quarterly Report review, observation, and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 1 of 1 nurses (Registered Nurse (RN) C) failed to allow the glucometer machine (a device used to check blood sugar levels with the use of a blood sample) to dry for the manufacturer's suggested time frame after use and when the facility failed to establish and implement an effective infection control program to identify, report, investigate, and control infections and communicable diseases when the facility failed to track and monitor organisms for outbreaks and cross contamination. This had the potential to affect 37 of 37 residents who resided in the facility. The findings include: 1. Review of the CDC Guidelines, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/2024, revealed .Blood glucose meters are portable devices that measure blood glucose levels and aid in diabetes self-management.Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventative measures are not in place. 2. Review of the undated facility policy titled, [Named Glucometer] Blood Glucose Monitor Cleaning and Disinfecting, revealed The meter should be cleaned and disinfected after use on each patient.To clean: Wipe surface of the meter to clean blood and other body fluids.To Disinfect: Wipe entire surface of the meter to remove bloodborne pathogens. Treated surface must remain wet for recommended contact time.[Named Germicidal Disposable Wipe] [Purple Top] .Contact Times.2 minutes. 3. Review of the Infection Control Manual Volume 1, dated 10/2025, revealed .This Infection Prevention and Control program is designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections.The goal of the Infection Preventive and Control Program is to provide a system of preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for patients, partners, volunteers, visitors, and others who provide contracted services.There is ongoing surveillance among patients and partners to identify possible infection or communicable diseases; to report as required by state or federal law; to investigate and control spread.Infection Control Committee.The committee will evaluate the effectiveness of the Infection Control program through review, trending, and reporting the following.Outbreak tracking and trending. 4. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hyperglycemia, and Long-Term use of Insulin. Review of the Physician's Order dated 12/8/2025, revealed .FSBS [Finger Stick Blood Sugar] AC [before meals] and at HS [at bedtime] . During an observation and interview in Resident #16's room on 12/16/2025 at 11:25 AM, RN C entered the Resident's room to obtain Resident #16's blood glucose level. RN C took the glucometer off the dresser and removed the germicidal wipes from a cup and began to cleanse the glucometer machine. RN C wiped the glucometer machine up and down 1 time on the front side and the bottom and immediately placed a test strip in the machine and took the resident's blood glucose level, without allowing the glucometer machine to dry. RN C exited Resident #16's room and returned to the medication cart. RN C stated, I know I didn't clean my machine for 2 minutes . RN C was asked should you have cleaned your machine for at least 2 minutes. RN C stated, Yes. RN C pulled out another germicidal wipe and cleansed the glucometer machine up and down 1 time on the front side and bottom again. RN C failed to disinfect the glucose monitor before or after the blood glucose check for at least 2 full minutes according to the facility's policy. During an interview on 12/16/2025 at 2:36 PM, the Director of Nursing (DON) was asked when staff are cleansing a glucometer machine and use a Sani-cloth how long should the cleansing and drying time be. The DON stated. At least 2 - 3 minutes. The DON was asked should a nurse use the glucometer machine before the full 2 minutes for drying time is completed. The DON stated, No, we need to wait that time.I have already put an in-service in place. 4. Review of the Infection Tracker, dated 9/2025, 10/2025, and 11/2025, revealed no documentation that infections were tracked by organism. Review of the Infection Control Monthly/Quarterly Report, dated 9/2025, 10/2025, and 11/2025, revealed no documentation that infections were tracked by organism. The facility was unable to provide documentation of tracking and trending of infections by organism and location in the facility to monitor for outbreaks, cross contamination, and the need for staff education or reeducation related to Infection Control. During an interview on 12/17/2025 at 12:58 PM, the Infection Control Preventionist (ICP)/DON was asked how the tracking and trending was discussed during the Infection Control meetings. The ICP/DON provided the Infection Control Monthly/Quarterly Report. The ICP/DON was asked to show where the report included what organisms were being monitored. The ICP/DON responded, I can't. The ICP/DON was asked to show where the report included exact room location of infections. The ICP/DON replied, I can't. The ICP/DON was asked to show where the report included if residents with a UTI had the same staff providing care for them. The ICP/DON stated, I can't. The ICP/DON was asked if infections should be monitored by tracking and trending to prevent cross contamination. The ICP/DON stated, Yes.

Based on the Ombudsman Emergency Transfers log, medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 3 of 3 (Resident #41, #42 and #43) sampled residents reviewed for discharges. The findings include: 1. Review of the .Ombudsman Emergency Transfers from Facility form dated August, September, October, and November 2025, revealed .send this form to the Office of the State Ombudsman .each month . 2. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Displaced Bimalleolar (serious break to both the inner and outer parts of the ankle) Fracture of Right Lower Leg, Disruption of External Operation (surgical) Wound, and Osteomyelitis (serious bone infection). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored a 2 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of Progress Notes dated 11/6/2025 at 9:15 AM, revealed .daughter informed of clinical status, as well as MD [Medical Doctor] recommendations for ED [Emergency Department] evaluation .daughter states understanding and verbalized she will meet pt [patient] in ER [Emergency Room] . Review of the .Ombudsman .Emergency Transfers from Facility document, dated 11/2025, revealed there was no documentation Resident #41 was transferred to the hospital. 3. Review of medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Neutropenia (abnormally low neutrophil or key infection fighting white blood cell count) due to Infection, Immunodeficiency (the immune system cannot fight infections), and Multiple Myeloma (rare blood cancer of plasma cells in the bone marrow). Review of the admission MDS assessment dated [DATE], revealed Resident #42 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Review of the Progress Notes dated 9/20/2025 at 2:26 PM, revealed .NURSE FOUND PATIENT TACHYPNEIC [fast heart rate] AND DIAPHORETIC [sweaty] THIS AM [morning] DURING MED PASS .PATIENT WAS HYPOTENSIVE WITH BP [blood pressure] -70/42, LOW O2 [oxygen] SATS [saturations]-81% [percent] WITH O2 AT 8 LITERS VIA [by way of] NASAL CANNULA .GAVE PRN [as needed] NEB [nebulizer] TREATMENT .COUGHED UP A SMALL AMOUNT OF SPUTUM [thick secretions], O2 SATS WENT UP TO 93% .PHYSICIANS NOTIFIED D/T [due to] LOW BP AND RESPIRATORY DISTRESS NEW ORDERS RECEIVED TO SEND PATIENT TO HOSPITAL FOR FURTHER EVAL [evaluation] .EMS [emergency medical service] NOTIFIED .CONTINUED TO DECLINE . Review of the . Ombudsman .Emergency Transfers from Facility document, dated 9/2025, revealed there was no documentation Resident #42 was transferred to the hospital. 4. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation, Peripheral Vascular Disease, Sepsis due to Methicillin Resistant Staphylococcus Aureus (a type of bacteria resistant to many antibiotics), Pseudomonas (infection caused by bacteria found in soil and water), Hypertension, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #43 scored a 12 on the BIMS assessment, which indicated he was moderately cognitively impaired. Review of Progress Notes dated 10/31/2025 at 5:19 PM, revealed .Wife came and let us know that [Named Hospital] had a bed for him and that he would be leaving to go there .NP [Nurse Practitioner] was notified and unit mgr [manager] also notified. Review of the . Ombudsman .Emergency Transfers from Facility document, dated 10/2025, revealed there was no documentation Resident #43 was transferred to the hospital. During an interview on 12/17/2025 at 9:50 AM, the Health Information Manager (HIM) was asked if she was the person responsible for getting the Ombudsman list generated and sent to the Ombudsman. The HIM stated, Yes. The HIM was asked if Residents #41, #42 and #43 should have been on the list. The HIM stated, Yes.

Based on review of the Mayo Clinic website article, medical record review, observation, and interview, the facility failed to provide appropriate diagnoses for the use of antipsychotic medications for 2 of 5 (Resident #6 and #45) reviewed for unnecessary medications. The findings include: 1. Review of the Mayo Clinic.org website article titled, Drugs-Supplements and Quetiapine, Side Effects and Dosages, dated December 1, 2025, revealed Quetiapine [an antipsychotic medication used to treat diagnoses such as bipolar disorder and schizophrenia] is used alone or together with other medicines to treat bipolar disorder (depressive and manic episodes) and schizophrenia. Quetiapine extended-release tablet is also used together with other antidepressants to treat major depressive disorder. This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer disease. Quetiapine is an antipsychotic medicine that works in the brain . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Depression, Diabetes, and Agitation. Review of the Physician's Order dated 11/21/2025, revealed .quetiapine [Seroquel an antipsychotic medication] tablet: 200 mg [milligrams]; amt [amount]; 1 tab [tablet]; oral [by mouth] At Bedtime 8:00 PM. Review of the November 2025 Medication Administration Record (MAR) revealed Resident #6 received quetiapine 200 mg daily at 8:00 PM from 11/22/2025 to 11/30/2025. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating she was cognitively intact. Medications received included Antidepressant, Antianxiety, and Opioid medications. The MDS was not coded to show that Resident #6 received an antipsychotic medication. Review of the Pharmacy Recommendations dated November 2025, revealed the Pharmacist requested a diagnosis for Quetiapine. The Physician entered diagnoses which included Agitation, Insomnia, and Anxiety. Review of the Physician Progress notes revealed no diagnosis for the use of quetiapine. During an interview on 12/16/2025 at 3:00 PM, Resident #6 was asked if she knew why she takes quetiapine 200mg at bedtime. Resident #6 replied, Yes, I take that for anxiety and to help me sleep . During an interview on 12/16/2025 at 4:15 PM, the Director of Nursing (DON) was asked if the physician responded to the pharmacy recommendation from November 2025 regarding a diagnosis for quetiapine. The DON looked Resident #6 up on the computer and stated, The physician replied that it is given for agitation, anxiety, and insomnia. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Pulmonary Embolism, Acute Respiratory Failure, and Atrial Fibrillation. Review of the Physician's Order dated 11/21/2025, revealed .quetiapine tablet: 100 mg; amt; 1 tab; oral At Bedtime 8:00 PM. Review of the Physician's Order dated 12/3/2025, revealed .quetiapine tablet: 100 mg; amt; 1 tab; oral At Bedtime 9:00 PM. Review of the December MAR dated revealed Resident #45 received quetiapine 100 mg at 9:00 PM at bedtime from 12/3/2025 to 12/16/2025. Review of the admission MDS assessment dated [DATE], revealed Resident #45 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Medications received during the assessment period were Insulin, Anticoagulant, Antibiotic, and Antiplatelet medications. The MDS was not coded to show that Resident #45 received an antipsychotic medication. During an interview on 12/16/2025 at 3:25 PM, Resident #45 was asked why she takes Quetiapine. Resident #45 stated, .I take it to sleep . During an interview on 12/17/2025 at 8:42 AM, the Family Nurse Practitioner (FNP) was asked what diagnosis was for the use of quetiapine (Seroquel) for Resident #45. The FNP stated, It is for insomnia. FNP was asked if that was an appropriate for antipsychotic medication. The FNP stated, We interview the resident and asked how long they been on the medication and why are they taking the medication. She had been on the Seroquel for years and at the high 100 mg dose for sleep. The FNP stated, We have borrowed residents for a short time, and we do not want to mess with the long-term medications the residents have been on long term. She had lot of anxiety on her arrival, and she complained she did not sleep at all the first few times. She also has major depression wanting to go home and get out the chest tube. She does not see psych .

Based on policy review, medical record review and interview, the facility failed to ensure residents were accurately assessed for antipsychotic medication use for 2 of 5 (Resident #6 and #45) sampled residents reviewed for unnecessary medication use. The findings include: 1. Review of the facility's policy titled, RAI (Resident Assessment Instrument) -MDS [Minimum Data Set] 3.0 Completion, dated October 2025, revealed .Residents are assessed using a comprehensive assessment process.antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, and Agitation. Review of the Physician's Order dated 11/21/2025, revealed quetiapine (an antipsychotic medication) was ordered at 8:00 PM daily. Review of the November 2025 Medication Administration Record (MAR) revealed Resident #6 received quetiapine 200 mg daily at 8:00 PM from 11/22/2025 to 11/30/2025. Review of the admission MDS assessment dated [DATE], revealed Resident #6 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Further review revealed the use of an antipsychotic medication was not captured. The MDS assessment failed to document Resident #45 received an antipsychotic medication during the assessment period. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Depression and Anxiety. Review of the Physician's Order dated 11/21/2025, revealed quetiapine was ordered at 8:00 PM daily. Review of the Physician Orders dated 12/3/2025, revealed quetiapine tablet was ordered at 9:00 PM daily. Review of the December MAR dated revealed Resident #45 received quetiapine 100 mg at 9:00 PM 12/3/2025 to 12/16/2025. Review of the admission MDS dated [DATE], revealed Resident #45 scored a 15 on the BIMS assessment, indicated she was cognitively intact. Further review revealed her use of an antipsychotic medication was not captured. The MDS assessment failed to document Resident #45 received an antipsychotic medication during the assessment period. During an interview on 12/17/2025 at 8:38 AM, the MDS Coordinator was asked does the admission MDS for Resident #6 and Resident #45 have the Antipsychotic quetiapine documented. The MDS Coordinator stated, It is not and definitely should have been .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when medications were found unattended and unsecured at the bedside for 1 of 37 (Resident # 24) residents.The findings include: 1. Review of the facility policy titled, Medication Storage In The Facility, dated 2/25/2025, revealed .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Glaucoma, Cataract Extraction, and Macular Degeneration. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Review of the Physician Orders dated 11/18/2025, revealed .latanoprost drops [used to treat glaucoma] .0.005% [percent] .Administer: 1drop .ophthalmic (eye).At Bedtime into affected eye(s). Observation in Resident #24's room on 12/15/2025 at 10:41 AM, revealed 1 bottle of latanoprost eye drops laying on Resident #24's bedside table. Review of the medical record revealed Resident #24 did not have a medication self-administration assessment completed. During an interview on 12/15/2025 at 10:47 AM, Licensed Practical Nurse (LPN) I was asked should prescription eye drops be left at the bedside unsecured and unattended in the resident's room. LPN I stated, They should not. During an interview on 12/16/2025 at 2:25 PM, the Director of Nursing (DON) was asked if medications should be left unattended in a resident's room. The DON stated, .If the Resident does not have a self-administration evaluation / assessment, then no there should not be any left at bedside.

Based on facility policy review, medical record review, and interview the facility failed to develop a comprehensive care plan for 2 of 4 residents (Resident #14 and #251) who required indwelling urinary catheters. The findings include: Review of the undated facility policy titled, Updating and revising Care Plans, .New problems are added to the current care plan even if the change is not considered significant enough for a complete revision . Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set (MDS) dated [DATE], revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 5/19/2021, revealed Resident #14 was care planned for Urinary Retention and Urinary Tract Infection. Continued review revealed the resident was not care planned for an indwelling urinary catheter. Observation on 6/14/2021 at 10:53 AM, in Resident #14's room revealed the resident's catheter bag attached to the left side of the footstool. During an interview conducted on 6/15/2021 at 3:37 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #14 was not care planned for an indwelling urinary catheter. During an interview conducted on 6/15/2021 at 4:03 PM, the Quality Assurance (QA) Nurse confirmed she did not see a care plan for an indwelling catheter for Resident #14. She stated, when a resident has an indwelling catheter, it should be on the comprehensive care plan. During an interview conducted on 6/16/2021 at 3:38 PM, the Assistant Director of Nursing (ADON) confirmed Resident #14 should've had the indwelling urinary catheter care planned when the catheter was placed. Review of the medical record, revealed Resident #251 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE], revealed Resident #251 had a BIMS score of 7 indicating severe cognitive impairment. Review of Physican Orders for Resident #251 dated 6/12/2021, revealed .indwelling urinary catheter; catheter care every shift, document output 18Fr [French] 15ml [milliliters] bulb for promotion of wound healing . Review of the Care Plan on 6/15/2021 at 3:30 PM, revealed Resident #251 was not care planned for indwelling urinary catheter. Observation on 6/14/2021 at 11:45 AM, in Resident #251's room revealed a catheter bag attached to the bottom of the wheel chair. During an interview conducted on 6/16/2021 at 9:00 AM, the Director of Nursing (DON) confirmed Resident #251 was not care planned for an indwelling urinary catheter according to the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure 1 of 23 residents (Resident #1) had clean and groomed fingernails. The findings include: Review of the facility's undated policy titled, Fingernails, Cleaning, and Trimming, revealed .Designated partner will care for patients nails with bathing and PRN [as needed] . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 required extensive assistance of staff for personal hygiene. Review of the comprehensive care plan dated 1/14/2021, revealed Resident #1 was care planned for .keep nails trimmed as pt [patient] tolerates . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Ensure fingernails are kept short and filed due to pt scratching .order began on 3/5/2021 . During an Observation and interview on 6/15/2021 at 10:04 AM revealed Resident #1 sitting in his reclining chair in the spa room. Continued observation revealed the resident's nails were long with brown dried debris under his fingernails on both hands. Continued interview the resident stated he had already taken a shower this morning [6/15/2021]. Continued interview when asked if staff cleaned his nails during his bath he stated no. During an Observation and interview on 6/15/2021 at 10:50 AM revealed Resident #1 sitting in his reclining chair in the dining room. Continued observation revealed the resident's nails remained long with brown dried debris under his fingernails on both hands. Continued interview when asked if he liked his nails that long he looked at his nails and said, you can cut them if you want. During an Observation and interview on 6/15/2021 at 10:55 AM in the presence of Certified Nurse Aide (CNA) #1 revealed Resident #1 sitting in his reclining chair in the dining room. Continued interview with CNA #1 confirmed the resident had brown dried debris underneath his fingernails on both of his hands; CNA #1 looked at the resident's hands and said, they are not clean at the moment. During an Observation and interview on 6/15/2021 at 10:56 AM in the presence of the 2nd floor Unit Manager and CNA #1 revealed Resident #1 sitting in his reclining chair in the dining room. Continued interview with the Unit Manager she stated residents' nails are to be cleaned before meals and with baths. Continued interview the Unit Manager confirmed Resident #1's nails were long and had brown dried debris underneath his fingernails on both hands. The Unit Manager looked Resident #1's hands and stated no, they are not clean, we will get them clean and clipped for him.

Based on facility policy review, medical record review, observation and interview the facility failed to provide a sanitary environment for 1 (Resident #16) of 2 residents reviewed for enteral feeding per feeding pumps. The findings include: Review of the facility policy titled, 304 Nursing, dated May 2021, revealed, .Reusable items are used for an individual patient if the product remains intact and sanitary. Items which become broken, chipped or unsanitary are replaced as needed . Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Anorexia, Protein-Calorie Malnutrition, Adult Failure to Thrive, [CONDITION(S)], and Encounter for Attention to Gastrostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status score of 1 which indicated the resident had severe cognitive impairment. During further review revealed the resident required a feeding tube. Review of Physician Order dated 6/8/2021, for Resident #16 revealed, .[MEDICATION(S)] 1.2 Cal [Calorie] (nutritional supplements) liquid; 0.06 gram-1.2 kcal/mL [kilocalorie/milliliter]; amt [amount]: 60ml/hour; gastric tube Every Shift . Observations conducted on 6/14/2021 at 10:45 AM, 11:30 AM, 1:22 PM, 3:18 PM, 4:08 PM, and at 4:25 PM, revealed Resident #16's enteral tube feeding pump pole had a moderate amount of dried tan debris on the pole and the base of the pole. During an interview conducted on 6/14/2021 at 4:25 PM, in Resident #16's room, Licensed Practical Nurse (LPN) #1 confirmed the enteral tube feeding pole had a moderate amount of dried tan debris on the pole and the base of the pole.

Based on medical record review and interview the facility failed to develop and implement a process to inform residents of suspected and confirmed COVID-19 cases in the facility which had the potential to affect 35 cognitively intact residents of 70 residents in the facility including (6) of (6) cognitively intact sampled residents (Residents #1, #2, #3, #4, #5, #6). Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Date Set ((MDS) dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the progress notes showed no documentation Resident #1 was informed of the suspected or confirmed COVID-19 cases in the facility. Review of medical record showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 Day MDS dated [DATE] showed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Review of the progress notes showed no documentation Resident #2 was informed of the suspected or confirmed COVID-19 cases in the facility. Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] showed Resident #3 had a BIMS score of 15 indicating no cognitive impairment. Review of the progress notes showed no documentation Resident #3 was informed of the suspected or confirmed COVID-19 cases in the facility. Review of the medical record showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 Day MDS dated [DATE] showed Resident #4 had a BIMS score of 15 indicating no cognitive impairment. Review of the progress notes showed no documentation Resident #4 was informed of the suspected or confirmed COVID-19 cases in the facility. Review of the medical record showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Interim Payment Assessment MDS dated [DATE] showed Resident #5 had a BIMS score of 15 indicating no cognitive impairment. Review of the progress notes showed no documentation Resident #5 was informed of the suspected or confirmed COVID-19 cases in the facility. Review of the medical record showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] showed Resident #6 had a BIMS score of 14 indicating no cognitive impairment. Review of the progress notes showed no documentation Resident #6 was informed of the suspected or confirmed COVID-19 cases in the facility. During an interview conducted on 1/19/2021 at 4:20 PM with Resident #1 confirmed she was not informed of the suspected or confirmed COVID-19 cases in the facility. During an interview conducted on 1/19/2021 at 4:23 PM with Resident #2 confirmed she was not informed of the suspected or confirmed COVID-19 cases in the facility. During an interview conducted on 1/19/2021 at 1:55 PM with Resident #3 she stated staff provides her with updates regarding new COVID-19 cases only when she asks them. During an interview conducted on 1/19/2021 at 4:37 PM with Resident #4 confirmed she was not informed of the suspected or confirmed COVID-19 cases in the facility. During an interview conducted on 1/19/2021 at 4:48 PM with Resident #5 confirmed she was not informed of the suspected or confirmed COVID-19 cases in the facility. During an interview conducted on 1/19/2021 at 4:58 PM with Resident #6 confirmed she was not informed of the suspected or confirmed COVID-19 cases in the facility. During an interview conducted 1/19/2021 at 2:30 PM with the Administrator confirmed the facility does not inform the residents of suspected or confirmed COVID-19 cases in the facility. He stated the residents and their families are notified by email or they can log onto the website to learn of new cases. He stated he does not have a system for informing the 1/2 Percent of the cognitively intact residents who do not use email or the website.

Based on observation and interview, the facility failed to store biohazard waste in a sanitary manner for one of two biohazard rooms observed. The findings included: Observation of wound care with the Wound Care Nurse on 4/13/16 at 9:27 AM, revealed the Wound Care Nurse completed a dressing change and placed visibly soiled items in a red biohazard bag. Continued observation revealed the Wound Nurse took the bag containing the biohazard items to a room labeled soiled utility, and then placed the biohazard items in a large wheeled plastic container. Further observation of the container revealed there was no red biohazard bag in the container; and there was a visibly soiled towel on the bottom of the container, multiple loose gloves, and a broke plastic fork. Interview with the Wound Care Nurse on 4/13/16 at 9:39 AM, confirmed the facility failed to follow infection control practice by not disposing of the biohazard items in an approved manner.

Based on observation and interview, the facility failed to store food under sanitary conditions and failed to maintain a clean and sanitary kitchen. The findings included: Observation on November 18, 2013, at 7: 20 p.m., in the kitchen revealed on the shelving unit next to the steam table: 1. An unsealed open package of Quick Oats. 2. Two unsealed and opened packages of Creme of Wheat. 3. An unsealed and opened package of Grits. 4. An unsealed and opened box of baking soda. 5. An unsealed and opened package of Creole Seasoning. 6. An unsealed and opened package of White Rice. 7. An unsealed and opened package of Brown Rice. 8. One bottle of Heinz 57 Sauce with the cap opened. Further observation in the kitchen on August 18, 2013, at 7:30 p.m.,revealed: 1. The third bin of the steam table had food debris floating in the water. 2. In the walk-in refrigerator a pan of partially cooked pork tips was not fully covered or sealed with plastic wrap and the meat was exposed. Stored on top of and touching the partially cooked pork tips was a fully cooked pork wrapped in foil. 3. Two convection ovens with dark brown flaky debris on the interior. 4. A deep fryer filled with black oil uncovered with debris floating on the top of the oil. Interview with dietary personnel #1 on November 18, 2013, at 7:40 p.m., in the dietary office confirmed the facility failed to store food properly and maintain a clean and sanitary kitchen.

Based on observation and interview, the facility dietary department failed to maintain a pressure steamer in safe operational condition and created a safety hazard for dietary employees. The findings included: Observation on November 20, 2013, at 7:30 a.m., in the dietary department revealed an approximately four inch wide stream of water from the pressure steamer running on the floor to the trayline in operation. Further observation revealed dietary staff walking in and through the area of the water. Interview on November 20, 2013, at 7:30 a.m., with the dietary chef present during the observation, revealed the pressure steamer had "...been leaking a long time..." Interview on November 20, 2013, at 7:45 a.m., with the Certified Dietary Manager, by the pressure steamer, confirmed the steamer was leaking onto the floor and the water was crossing the floor to the trayline area.

Based on observation, medical record review and interview, the facility failed to maintain a call light within reach for one resident (#223) of twenty residents reviewed. The findings included: Resident #223 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated November 11, 2013, revealed the resident had a potential for falls/injury related to history of falls, decreased mobility, weakness, with the approach to keep the call light within reach. Observation and interview with the resident, on November 19, 2013, at 8:26 a.m. revealed the resident seated in a wheelchair in the resident's room with the breakfast tray on the over bed table in front of the resident. Further observation revealed the call light was on the bed side table directly behind the wheelchair and out of reach of the resident. Interview with the resident revealed the resident was not able to reach the call light. Interview on November 20, 2013, at 8:30 a.m., with the resident's direct care Certified Nurse Aide #1, in the resident's room, confirmed the resident was capable of using the call light. Further interview confirmed the call light was not in reach of the resident.

Based on observation and interview, the facility failed to maintain clean oxygen concentrator filters for one resident (#217) of twenty residents reviewed. The findings included: Resident #217 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED]. Observation on November 19, 2013, at 8:36 a.m., in the resident's room revealed the resident in bed with a nasal cannula in place and the oxygen concentrator in operation. Further observation revealed both filters on the oxygen concentrator were white with debris. Interview, on November 20, 2013, at 8:36 a.m., with Registered Nurse #1, in the resident's room, confirmed both oxygen concentrator filters "were dirty." Further interview confirmed they should have been cleaned.

Based on observation, medical record review, review of the meal intake record, facility policy review, and interview, the facility failed to weigh a resident weekly after admission and failed to reweigh the resident after a weight discrepancy for one resident (#224), of twenty residents reviewed. The findings included: Resident #224 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on November 19, 2013, at 12:30 p.m., and on November 20, 2013, at 8:30 a.m., revealed the resident in the resident's room self feeding the meals. Further observation revealed the resident consumed 75-100 percent of both meals observed. Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident was moderately cognitively impaired and was independent with eating after set-up. Medical record review of the hospital data dated October 28, 2013, revealed the resident's initial weight was "64.5455 kilograms" (142 pounds). Medical record review of the admission nursing assessment dated [DATE], revealed the resident's weight was 161 pounds, had bilateral lower extremity [MEDICAL CONDITION], and had complaints of difficulty/pain with swallowing. Medical record review of the Nursing Progress Notes dated November 2-10, 2013, revealed the resident had bilateral lower extremity [MEDICAL CONDITION], TED hose (compression device) worn, legs elevated on pillow, and/or bilateral heels off loaded. Medical record review of the Weight Record revealed the admission weight was 161 pounds and the usual body weight was 142 pounds at home. Further review of the Weight Record dated November 13, 2013, revealed the resident's weight was 140 pounds, a decrease of 21 pounds in fourteen days. Review of the meal intake record revealed the resident consumed 75-100 percent of every meal after November 11, 2013. Medical record review revealed the resident was ordered a speech therapy evaluation and treatment at admission and therapy remained ongoing with improvement. Review of an undated facility policy entitled "Weighing Procedure" revealed "...The nursing assistant is responsible for weighing all residents...If a resident has a difference in weight of plus or minus five pounds at the time of weighing, the nursing assistant will reweigh the resident within twenty-four hours. The nursing assistant is to notify the charge nurse immediately. The charge nurse will assess the resident and initiate interventions as needed which may include notifying the physician or nurse practitioners the dietitian, family and care plan team. Weights and reweights are to be documented in the patients medical record..." Review of a facility policy entitled "Documentation Guidelines" revealed "...Weights: should be recorded on the appropriate form. 1) Time frames a) Weekly for 4 weeks following admission. b) At least monthly, unless ordered on a more frequent schedule by the physician, nurse, or dietitian...3) Any unusual variation in weights should be verified by re-weighing the patient. a) Document the results. b) If unusual variation still exists, report to licensed nurse, who reports to physician..." Interview on November 20, 2013, at 10:14 a.m., with the resident in the resident's room, revealed the resident was aware of the admission weight of 161 pounds and had told the staff (resident) had not weighed that much in many years and "...didn't believe it (the admission weight) was right..." Further interview revealed the resident clothes fit the same from admission to the current date. Interview on November 20, 2013, at 10:20 a.m., with Certified Nurse Aide (CNA) #1, in the resident's room, confirmed CNA #1 admitted the resident and noticed no difference in the residents weight from admission to the current time. Further interview revealed the CNA noticed no difference in the way the clothes fit the resident. Interview on November 20, 2013, at 10:39 a.m., in the Registered Dietitian (RD) office, with the Director of Nursing and RD, confirmed the facility failed to weigh the resident weekly after admission and failed to reweigh the resident after the weight discrepancy per facility policy.

Based on medical record review and interview, the facility failed to accurately identify pressure ulcers on the Admission Minimum Data Set (MDS) dated [DATE], for one resident (#91) of four residents reviewed for pressure ulcers. The findings included: Resident #91 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the Weekly Wound Assessment Progress Note dated October 7, 2013, revealed "...Lt (left) heel /c (with) 2 (two) sDTIs (Suspected Deep Tissue Injury). Areas are purple, intact blister. Tissue is mushy...Rt (right) heel /c DTI. Area is purple /c mushy, intact blister present...Stage One pressure ulcers present to bilateral ischial tuberosities..." Medical record review of the MDS dated [DATE], revealed no pressure ulcers were documented. Interview with the MDS Coordinator, on November 20, 2013, at 1:35 p.m., in the MDS office, confirmed there no pressure ulcers were documented on the Admission MDS, and the MDS was inaccurate.

Based on observation and interview, the facility failed to secure soiled and biohazardous materials from the resident population. The findings included: Observation during initial tour on October 22, 2012, at 10:00 a.m., revealed a Certified Nurse Assistant (CNA) entered the soiled utility room and discarded soiled linen into containers. Continued observation revealed the door to the soiled utility room did not latch after the CNA entered the room to dispose of soiled linens. Observation on October 22, 2012, at 10:05 a.m., with Licensed Practical Nurse #2 (LPN), revealed LPN #2 attempted to restore the door to the locked position, but was unable to engage the latch. Interview with LPN #2 on October 22, 2012, at 10:05 a.m., confirmed the soiled utility room contained soiled linens and biohazard containers. Continued interview confirmed the door was not working properly, and should have latched and locked automatically when closed.

Based on medical record review, observation, and interview, the facility failed to ensure staff asked permission or knocked on doors before entering resident rooms for two residents (#236, #242) of thirty- six sampled residents. The findings included: Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated October 16, 2012, revealed identified problems areas of impaired vision, balance, and inability to ambulate. Medical record review of the Nurse's Note dated October 21, 2012, revealed alert and oriented. Medical record review of a psychosocial assessment dated [DATE], revealed the resident was cognitively intact. Observation on October 23, 2012, at 7:40 a.m., in the hallway, revealed Registered Nurse (RN) #1 entered the resident's room without knocking or obtaining permission to enter. Interview with RN #1 on October 23, 2012, at 9:45 a.m., in the 1200 hallway, confirmed the nurse failed to respect the resident's private space and failed to knock and request permission to enter the resident's room. Resident # 242 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated October 18, 2012, revealed the resident had impaired functional mobility and was at risk for musculoskeletal discomfort. Medical record review of an Admission note dated October 19, 2012, revealed the resident was alert and oriented. Observation on October 23, 2012, at 7:48 a.m., in the resident's room, revealed Registered Nurse (RN) #1 entered the resident's room without knocking or obtaining permission to enter. Interview with RN #1 on October 23, 2012, at 9:45 a.m., in the 1200 hallway, confirmed the nurse failed to respect the resident's private space and failed to knock and request permission to enter the resident's room.

Based on medical record review and interview, the facility failed to provide accurate information for the Minimum Data Set (MDS) assessment for one resident (#30) of thirty-seven residents reviewed. The findings included: Resident #30 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Dietary Progress Note dated May 28, 2012, revealed the resident had a gastrostomy feeding tube, and received nothing by mouth (NPO). Medical record review of the admission MDS dated [DATE], revealed the resident required extensive assist of one person for eating, and received 51% or more percent intake by artificial route (gastrostomy tube feeding). Medical record review of the 30 day MDS dated [DATE], revealed the resident was dependent on staff for eating. Continued review revealed the resident received 51% or more percent intake by artificial route (gastrostomy feeding tube). Interview with the MDS Coordinator in the private dining room on October 24, 2012, at 9:55 a.m., confirmed the resident had received nothing by mouth, and nutritional support had been provided through the use of the feeding tube. Continued interview confirmed the resident's 5 day/Admission MDS dated [DATE], was inaccurate.