Every finding on record at Amberwood Health and Rehabilitation

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure staff followed basic competencies and nursing skills when administering medication for 3 (Residents #14, #244, #245) residences observed during medication administration. The findings include: 1. A review of the quarterly Minimum Date Set (MDS) with Assessment Reference Date of [DATE] revealed Resident #14 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact and received scheduled pain medication regimen. a. A plan of care for Resident #14 (revision on [DATE]) revealed Resident #14 had chronic pain related knee pain, back pain, age related decline, muscle wasting and shrinkage of muscle mass, and muscle spasms. b. According to the Medication Administration Record (MAR) Resident #14 had a physician's order for lidocaine External Cream 4% apply to both knees and shoulders. c. On [DATE] at 12:05 PM, the Surveyor observed Licensed Practical Nurse (LPN) #2 apply lidocaine cream to Resident # 14's lower back and knees. 2. Resident #244 was admitted on [DATE] and did not have a completed Admission MDS. a. A plan of care for Resident #244 (date initiated [DATE]) revealed Resident #244 had a nutritional problem or potential nutritional problem related to inflammation of the throat and difficulty swallowing. b. According to Medication Administration Record (MAR) Resident #244 had a physician's order for Sucralfate Suspension 1 gram (GM)/10 milliliter (ML) give 1 gram by mouth before meals and at bedtime for gastric protection. c. On [DATE] at 4:06 PM, the Surveyor observed LPN #3 add 5 ml of diphenhydramine viscous lidocaine added to water and administer to Resident #244. d. On [DATE] at 9:30 AM, the Surveyor reviewed the medication that was administered and noted the medication was expired and there was no physician's order to administer. e. On [DATE] at 9:35 AM, the Assistant Director of Nursing (ADON) stated Resident #244 brought the medication in the facility when admitted and she should have removed it. The ADON stated Resident #244 did not have a physician's order and confirmed the medication was expired. 3. Resident #245 was admitted on [DATE] and did not have a completed Admission MDS. a. A plan of care for Resident #245 (date Initiated: [DATE]) revealed Resident #245 had a nutritional problem or potential nutritional problem related to type II diabetes mellites (T2DM), hypertension (HTN), gastroesophageal reflux disease (GERD), hyperlipidemia (HPLD), gout, chronic kidney disease (CKD) stage 4, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). b. According to Medication Administration Record (MAR) Resident #245 did not have a physician's order for polyethylene glycol 17 grams (g), atorvastatin 5 milligram (mg), or metoclopramide 5 mg. Resident #245 had a physician's order for amlodipine 10 mg daily was taken at 8:00 AM, Carvedilol 12.5 mg twice daily was taken at 8:00 AM, and gabapentin 600 mg three time daily was taken at 8:00 AM and 12:00 PM. c. On [DATE] at 4:15 PM, the Surveyor observed LPN #3 administer Resident #245 atorvastatin 40 mg, amlodipine 5 mg, carvedilol 3.125 mg, polyethylene glycol 17 g added to water, gabapentin 400 mg, and metoclopramide 5 mg. d. On [DATE] at 4:20 PM, after exiting the room the Surveyor asked LPN #3 to see her MAR and noted the name on the MAR was not Resident #245. The Surveyor then stated to LPN #3 the name on the MAR does not match the name on the door. LPN #3 stated That's why I don't like to be watched I knew I was going to make a mistake. LPN #3 locked her cart and walked off. e. On [DATE] at 2:39 PM, the Director of Nursing (DON) stated a nurse should ensure he/she has the right resident, right medication, it is the right time to administer the medication, the dose is correct, and the medication is given the right route prior to administering the medication. The DON stated if these 5 things are not done a resident could get the wrong medication. The DON stated the resident's name and picture are on the MAR to further prevent an adverse outcome. f. A review of policy titled Competency of Nursing Staff noted competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in basis nursing skill.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5%. The medication errors occurred with 3 (Resident #14, #244, #245) sampled residents observed during medication administration. The finding include: 1. A review of the quarterly Minimum Date Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed Resident #14 had a Brief Interview of Mental Status score of 15 indicating cognitively intact, and received a scheduled pain medication regimen. a. A plan of care for Resident #14 (revision on [DATE]) revealed Resident #14 had chronic pain related to r knee pain, back pain, age related decline, muscle wasting or thinning of the muscle mass, and muscle spasms. b. According to Medication Administration Record (MAR) Resident #14 had a physician's order for lidocaine External Cream 4 % apply to both knees and shoulders. c. On [DATE] at 12:05 PM, the Surveyor observed Licensed Practical Nurse (LPN) #2 apply lidocaine cream to Resident # 14's lower back and knees. 2. Resident #244 was admitted on [DATE] and did not have a completed Admission MDS. a. A plan of care for Resident #244 (date initiated [DATE]) revealed Resident #244 had a nutritional problem or potential nutritional problem related to inflammation in the throat and difficulty swallowing. b. According to Medication Administration Record (MAR) Resident #244 had a physician's order for Sucralfate Suspension 1 gram (GM)/10 milliliter (ML) give 1 gram by mouth before meals and at bedtime for gastric protection. On [DATE] at 4:06 PM, the Surveyor observed LPN #3 add 5 ml of diphenhydramine viscous lidocaine added to water and administer to Resident #244. c. On [DATE] at 9:30 AM, the Surveyor reviewed the medication that was administered and noted the medication was expired and there was no physician's order to administer. d. On [DATE] at 9:35 AM, the Assistant Director of Nursing (ADON) stated Resident #244 brought the medication in the facility when admitted and she should have removed it. The ADON stated Resident #244 did not have a physician's order and confirmed the medication was expired. 3. Resident #245 was admitted on [DATE] and did not have a completed Admission MDS. a. A plan of care for Resident #245 (date Initiated: [DATE]) revealed Resident #245 had a nutritional problem or potential nutritional problem related to type II diabetes mellites (T2DM), hypertension (HTN), gastroesophageal reflux disease (GERD), hyperlipidemia (HPLD), gout, chronic kidney disease (CKD) stage 4, chronic obstructive pulmonary disease (COPD) and irritable bowel syndrome (IBS). b. According to Medication Administration Record (MAR) Resident #245 did not have a physician's order for polyethylene glycol 17 grams (g), atorvastatin 5 milligram (mg), or metoclopramide 5 mg. Resident #245 had a physician's order for amlodipine 10 mg daily was taken at 8:00 AM, carvedilol 12.5 mg twice daily was taken at 8:00 AM, and gabapentin 600 mg three time daily was taken at 8 AM and 12 PM. c. On [DATE] at 4:15 PM, the Surveyor observed LPN #3 administer Resident #245 atorvastatin 40 mg, amlodipine 5 mg, Carvedilol 3.125 mg, polyethylene glycol 7 g added to water, Gabapentin 400 mg, and Metoclopramide 5 mg. d. On [DATE] at 4:20 PM, after exiting the room the Surveyor asked LPN #3 to see her MAR and noted the name on the MAR was not Resident #245. The Surveyor then stated to LPN #245 the name on the MAR does not match the name on the door. LPN #3 stated That's why I don't like to be watch I knew I was going to make a mistake. LPN #3 locked her cart and walked off. e. On [DATE] at 6:30 PM, the Surveyor was informed by the Director of Nursing (DON) the Physician was notified that Resident #245 was given the wrong medication. f. On [DATE] at 2:39 PM, the Director of Nursing (DON) stated a nurse should ensure he/she has the right resident, right medication, it is the right time to administer the medication, the dose is correct, and the medication is given the right route prior to administering the medication. The DON stated if these 5 things are not done a resident could get the wrong medication. The DON stated the resident's name and picture are on the MAR to further prevent an adverse outcome. g. A review of the policy titled Administering Medication noted Medication shall be administered in a safe and timely manner, and as prescribed. 6. The individual administering the medication must verify the resident's identity before giving the resident his/her medication. 7. The individual administering the must check the label 3 times to verify the right resident, right medication, right dose, right time and method (route) of administration before giving the medication.

Based on observations, interviews, record reviews, and facility policy review the facility failed to ensure the facility was free from significant medication error for 2 (Resident #244, #245) sampled residents who were administered the wrong medication during observed medication administration. The findings include: 1. Resident #244 was admitted on [DATE] and did not have a completed Admission Minimum Data Set (MDS). a. A plan of care for Resident #244 (date initiated [DATE]) revealed Resident #244 had a nutritional problem or potential nutritional problem related to throat and difficulty swallowing. b. According to Medication Administration Record (MAR) Resident #244 had a physician's order for Sucralfate Suspension 1 gram (GM)/10 milliliter (ML) give 1 gram by mouth before meals and at bedtime for gastric protection. c. On [DATE] at 4:06 PM, the Surveyor observed LPN #3 add 5 ml of diphenhydramine viscous lidocaine added to water and administered to Resident #244. d. On [DATE] at 9:30 AM, the Surveyor reviewed the medication that was administered and noted the medication was expired and there was no physician's order to administer. e. On [DATE] at 9:35 AM, the Assistant Director of Nursing (ADON) stated Resident #244 brought the medication in the facility when admitted and she should have removed it. The ADON stated Resident #244 did not have a physician's order and confirmed the medication was expired. 2. Resident #245 was admitted on [DATE] and did not have a completed Admission MDS. a. A plan of care for Resident #245 (date initiated: [DATE]) revealed Resident #245 had a nutritional problem or potential nutritional problem related to type II diabetes mellites (T2DM), hypertension (HTN), gastroesophageal reflux disease (GERD), hyperlipidemia (HPLD), gout, chronic kidney disease (CKD) stage 4, chronic obstructive pulmonary disease (COPD) and irritable bowel syndrome (IBS). b. According to Medication Administration Record (MAR) Resident #245 did not have a physician's order for polyethylene glycol 17 grams (g), atorvastatin 5 milligram (mg), or metoclopramide 5 mg. Resident #245 had a physician's order for amlodipine 10 mg daily was taken at 8:00 AM, Carvedilol 12.5 mg twice daily was taken at 8:00 AM, and gabapentin 600 mg three time daily was taken at 8 AM and 12 PM. c. On [DATE] at 4:15 PM, the Surveyor observed LPN #3 administer Resident #245 atorvastatin 40 mg, amlodipine 5 mg, Carvedilol 3.125 mg, polyethylene glycol 17 g added to water, Gabapentin 400 mg, and Metoclopramide 5 mg. d. On [DATE] at 4:20 PM, after exiting the room the Surveyor asked LPN #3 to see her MAR and noted the name on the MAR was not Resident #245. The Surveyor then stated to LPN #245 the name on the MAR does not match the name on the door. LPN #3 stated That's why I don't like to be watch I knew I was going to make a mistake. LPN #3 locked her cart and walked off. On [DATE] at 6:30 PM, the Director of Nursing (DON) informed the Surveyor the Physician was notified that Resident #245 was given the wrong medication and LPN #3 was sent home until Monday. e. On [DATE] at 2:39 PM, the Director of Nursing (DON) stated a nurse should ensure he/she has the right resident, right medication, it is the right time to administer the medication, the dose is correct, and the medication is given the right route prior to administering the medication. The DON stated if these 5 things are not done a resident could get the wrong medication. The DON stated the resident's name and picture are on the MAR to further prevent an adverse outcome. f. A review of policy titled Administering Medication noted Medication shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must verify the resident's identity before giving the resident his/her medication. The individual administering the must check the label 3 times to verify the right resident, right medication, right dose, right time and method (route) of administration before giving the medication.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure food items expired food items were promptly removed/discard by the expiration or use by dates as when it was delivered, staff washed their hands, and dietary staff washed their hands and between clean tasks when contaminated. The findings are: 1. On [DATE] at 10:13 AM, the following observations were made in the refrigerator in the activity lounge. a. There was an opened bottle of tomatoes juice on a shelf with no received date on it. b. One turkey sandwich was inside a container on a shelf with an expiration date of [DATE]. 2. On [DATE] at 10:49 AM, Dietary Aide (DA) #1 picked up the water hose with her bare hand, used it to spray off leftover food items from the dishes, contaminating her hands. She placed dishes in the dirty racks and pushed them into the dish washing machine to wash. After the dishes stopped washing, the Dietary Aide #1 turned on the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands. Her hands contaminated and without washing his hands, she picked up clean plates with his fingers inside the plates and placed them on top of the cart to be used in serving food items to the residents for lunch 3. On [DATE] at 10:53 AM, DA #1 picked up the water hose with her bare hand, used it to spray off leftover food items from the dishes, contaminating her hands. She placed dishes in the dirty racks and pushed them into the dish washing machine to wash. After the dishes stopped washing, DA #1 turned on the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands her hands. With her hands contaminated and without washing her hands, she picked up clean plates with her fingers inside the plates and placed them on top of the cart to be used in serving food items to the residents for lunch. DA #1 was asked what she should you have done after touching dirty objects and before handling clean equipment she stated she should have washed her hands. 4. On [DATE] at 12:32 PM, Dietary Aide #1 turned on the hand washing sink and washed her hands, she removed tissue from the tissue dispenser and dried her hands. DA #1 turned off the faucet with the same tissue, contaminated the tissue papers. DA #1 then used the same tissue papers to dry her hands and without re-washing her hands, picked up clean plates and stacked the on a cart to be used in portioning food items to the residents for lunch with fingers inside the plates. 5. On [DATE] at 7:58 AM, DA #1 turned on the hand washing sink and washed her hands, she removed tissue from the tissue dispenser and dried her hands. DA #1 turned off the faucet with the same tissue, contaminated the tissue papers. She then, used the same tissue papers to dry her hands and without re washing her hands, DA #1 picked up clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for breakfast and/or lunch. 6. A review of facility policy titled, Employee Cleanliness and Hand washing Technique, not dated, provided by the Food Service Director on [DATE] indicated hands should be washed before beginning and any other time deemed necessary.

Based on observation, record review and interview, the facility failed to ensure leftover food items were discarded to maintain food quality; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 1 of 2 ice machines and 1 of 2 ice machine holders were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who receive meals from the kitchen (total census: 83) as documented on a list provided by Dietary Supervisor. #1 The findings are: 1. On [DATE] at 09:15 AM, the following observations were during the initial tour of the kitchen with Dietary Employee (DE) #1: a. A container that contained leftover scrambled eggs. b. A container that contained whole sausage, sausage links, resealable plastic bag of ground and resealable plastic bag of pureed meat were on counter by the steam table. The surveyor asked the Dietary Employee (DE) #1 what were in the containers and what they were for. DE #1 stated, They are leftovers from the breakfast meal. The cook saves them and uses them the next day for the pureed. 2. On [DATE] at 09:20 AM, the following observations were made on a shelf in the refrigerator: a. An opened box of cranberry juice was on a shelf. The box was not covered. b. Five gallons of whole milk were on a shelf in the refrigerator with an expiration date of [DATE]. 3. On [DATE] at 09:22 AM, the following observations were made on a shelf above the food preparation counter in the kitchen: a. An opened box of potato pearls. The box was not covered. There was no opened date on the box. b. An opened resealable plastic bag that contained an opened box of cream of wheat was on a shelf. The bag was not sealed, and the box was not covered. There was no date on the box to indicate when it was opened. c. Another opened box of cream wheat was on the counter. The box was not covered. There was no date of when it was opened. d. An opened bag of country style peppered gravy mix. The bag was not sealed. There was no date when the bag was opened. e. The following spices were on a rack above the food preparation counter, there were no dates when the spices were opened: a. Garlic powder. b. Montreal steak seasoning. c. Chili powder. d. Lemon pepper seasoning. e. Ground cinnamon. f. [NAME] leaves. g. Meat tenderizer. h. Poultry seasoning. 4. On [DATE] at 09:23 AM, the following observations were made in the walk-in refrigerator: a. An opened resealable plastic bag that contained a bag of sliced ham was on a shelf. The bags were not sealed. b. An opened resealable plastic bag that contained a bag of sliced turkey was on a shelf. The bags were not sealed. c. An opened resealable plastic bag of shredded mozzarella cheese and an opened resealable plastic bag of shredded cheddar cheese were on a shelf. Both bags of shredded cheese were not sealed. d. A bottle of soy sauce, a bottle of worcestershire sauce, and three opened containers of parmesan cheese had no date as to when opened. 5. On [DATE] at 09:24 AM, an opened box that contained a bag of dinner rolls was on a shelf in the freezer. The box was not covered, and the bag was not sealed. 6. On [DATE] at 09:26 AM, the following spices were made on a shelf in the storage room, there were no dates when the spices were opened: a. Basil. b. Onion powder. c. Lemon pepper seasoning salt. d. Rotisserie chicken seasoning. e. Oregano. f. Ground nutmeg. g. Imitation vanilla flavor. h. Thyme. i. Pure peppermint extract j. Chili powder. 7. On [DATE] at 09:45 AM, an opened metal ice scoop holder on the wall by the ice machine had a buildup of pink residue at the bottom of it and the ice scoop was in direct contact with the buildup. The Surveyor asked DE #2 to wipe the area where the ice scoop holder was resting on. She did so, and stated it was pink residue. The Surveyor asked how often they cleaned the scoop holder. She stated, We clean it every week. The Surveyor asked, Who uses the ice from the ice machine? She stated, We use it to fill the residents' beverages at mealtimes. 8. On [DATE] at 10:14 AM, DE #2 used a scraper to scrape off wet and leftover food items on the dirty side of the dish washing machine. Without washing her hands, she placed gloves on her hands, contaminating the gloves, picked up glasses by the rims and stacked them on the counter. 9. On [DATE] at 10:28 AM, DE #2 picked up the water hose with gloves on her hands, used it to spray leftover food from inside of the dishes, contaminating the gloves. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the utility cart to be used in serving the noon meal to the residents. The Surveyor immediately asked DE #1, What should you have done after touching dirty objects or before handling clean equipment? She stated, Changed gloves and washed my hands. 10. On [DATE] at 11:08 AM, five bags of diabetic source were in a box on a shelf in the clean utility on the 200 Hall, with an expiration date of [DATE]. 11. On [DATE] at 11:10 AM, the ice machine panel had a wet black and pink residue on it. The Surveyor asked Dietary Supervisor #2 to wipe the panel. She did, and the black and pink residue easily transferred to the tissue. She stated, That was black and pink residue on it. The Surveyor asked, Who uses the ice from the ice machine and how often do you clean it? She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. We clean it every week. 12. On [DATE] at 11:50 PM, DE #2 turned off the sink faucet. Without washing her hands, she picked a clean blade attached it to the base of the blender to use in pureeing food items to be served to the residents on pureed diets. The Surveyor immediately asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 13. A facility policy titled, Employee Cleanliness and Handwashing Technique, provided by Dietary Supervisor #1 on [DATE] at 04:07 PM documented, .Dietary department employees are required to wash their hands on the occasions listed below: a. Before beginning shift . g. After handling dirty dishes . j. Any other time deemed necessary .

Based on observation, record review and interview, the facility failed to ensure nailcare was regularly provided or offered, to maintain good personal hygiene, prevent infection and possible skin tears for 2 (Residents #10 and #26) of 12 (Residents #1, 10, 23, 26, 30, 49, 51, 57, 61, 71, 79, and #236) sampled residents who required staff assistance with nail care on Hall 100. This failed practice had the potential to affect 27 residents who required staff assistance for nail care as documented on a list provided by the Administrator on 11/15/23 at 09:14AM. The findings are: 1.On 11/12/23 at 10:15 AM Resident #10 was in bed. His fingernails were long and had a dark black dry substance underneath his nails. a. On 11/13/23 at 08:35 AM, Resident #10 was sitting in bed eating breakfast. His fingernails were long with a dark black substance under them. b. On 11/14/23 at 08:45AM, Resident #10 was lying in the bed with breakfast in front of him. He had some white substance in his right hand eating it. Certified Nursing Assistant (CNA) #6 was asked to observe Resident #10's nails and describe what she saw. CNA #6 stated, He has black dirt under long nails. CNA #6 was asked if the long nails with black dirt under them was an acceptable practice for a resident. CNA# 6 stated, No, It could cause an infection. c. A Care Plan dated 08/10/22 documented, . NAIL CARE PROVIDED BY STAFF. RESIDENT ALSO EDUCATED TO ALERT STAFF FOR NAIL CARE . Keep fingernails short. Date Initiated: 11/18/2019 .with a Revision date on: 05/24/2021 . d. On 11/14/23 at 03:50 PM, the Assistant Director of Nursing (ADON) provided an ADL (Activities of Daily Living) task form for Resident #10 documenting the fingernails were provided care on 11/12/23. 2. On 11/12/23 at 10:09 AM, Resident #26 was in bed. Resident #26 had 1/4 inch long discolored nails cutting into her hand. A foul odor was noted from hand. a. On 11/12/23 at 03:52 PM, Resident #26 was lying in bed with 1/4 inch long discolored nails with a brown substance under them. b. On 11/13/23 at 04:08 PM, Resident #26 was lying on the bed with her hands in a clenched position. Her fingernails were long, discolored and had a brown substance under them. A foul odor was noted. c. On 11/13/23 at 04:21 PM, Resident #26 was sitting in the dining room in a wheelchair with her hands in her lap clenched. Her fingernails were long and had a dark brown dried substance under them. d. A Care Plan dated 09/30/21 with a revision date of 04/30/21 documented, .Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short . e. On 11/13/23 at 4:48 PM, CNA #4 was asked to look at Resident #26's hands and nails. CNA #4 was asked to describe Resident #26's hand and fingernails. CNA #4 stated, They are dirty, and her nails are dirty and cutting into her hand. CNA #4 was asked if the facility used hand rolls or anything to place in the resident's hands. CNA #4 stated, She needs some. f. On 11/13/23 at 4:55 PM, CNA #5 was asked who was responsible for nail care. CNA #5 stated, Everybody. CNA #5 was asked when nail care is normally done. She stated, Anytime it's needed. g. On 11/14/23 at 03:50 PM, the ADON provided an ADL (Activities of Daily Living) task form documenting Resident #26's fingernails were provided care on 11/12/23. 3. On 08/31/23 at 11:04 AM, the Director of Nursing (DON) was asked who was responsible for resident nail care. The DON stated, CNAs unless they are diabetics then nurses do them. The DON was asked how often she expects nail care to be provided. The DON said every week on Sundays and PRN (as needed) The DON was asked what Nail Care on the task form meant. She stated it is to clip and clean the nails. The DON was asked what a possible negative outcome from long dirty nails could be. The DON said they could scratch themselves and get a skin tear and get it infected. 4.On 11/15/23 at 11:27AM, the DON presented a form titled, Fingernails/Toenails, Care of, the form documented, Purpose: The purpose of this procedure are to clean the nail beds, to keep nails trimmed, and to prevent infections .Documentation The following information should be recorded in the resident's medical record: .6. If the resident refused the treatment, the reason(s) why and the intervention taken .Reporting 1. Notify the supervisor if the resident refuses care .

Based on observation, interview, and record review, the facility failed to ensure controlled medications stored in the medication room were kept secured by a lock and that expired medications were removed from the 200 Hall medication cart to prevent use. These failed practices had the potential to affect all 84 residents who reside in the facility. The findings are: On 11/13/23 at 09:24 AM, the Surveyor was inspecting the medication cart on Hall 200 and discovered the following over the counter (OTC) medications which had expired: Docusate Sodium 100 milligrams (mg) stool softener with an expiration date of 9/23 and Ocular Vitamin with an expiration date of 10/23. 46868 On 11/13/23 at 08:40 AM, the centrally located medication room was observed with the Assistant Director of Nursing (ADON) in attendance. Upon inspection of the nonlocked refrigerator, the Hall 100 lock box contained a 30 milliliter bottle of Lorazepam (a schedule IV controlled substance) with 18 milliliters inside the bottle. The Surveyor reached in and opened the lock box without a key. The ADON was asked if the lock box should be locked when there is a controlled substance in the box. The ADON stated, Yes. On 11/13/23 at 08:52 AM, Licensed Practical Nurse (LPN) #1 LPN #1 was asked if the lock box containing a narcotic should be locked. LPN #1 stated, I thought I did, yes, it should be. On 11/15/23 at 11:10 AM, the Director of Nursing (DON) was asked to explain how a refrigerated narcotic should be kept safe. The DON stated, Behind a locked door and in a locked box inside the refrigerator. The DON was asked who all has a key to the locked box and medication room door. The DON stated, All four nurses with a medication cart has a key to the med room door as well as my ADON and myself. Each of the nurses have a key to their own locked medication box. There are four narcotic boxes in the refrigerator. The DON was asked how often the med carts are checked for discontinued medications and expired medications. The DON stated, Weekly, or as discontinued. The DON was asked to explain the purpose of removing expired medications. The DON stated, They are no good after thirty days and they won't be effective. On 11/15/2023 at 9:27 AM, the DON provided a facility policy for Storage of Medications which documented, .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be destroyed . On 11/15/2023 at 10:46 AM, the DON provided a facility policy for Controlled Substances which documented, .3. Controlled Substances are stored in the medication room in a locked container . 4. Access to controlled medication remains locked at all times and accessed is recorded .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold and hot foods at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 20 residents who received meal trays in their rooms on the 100 Hall, 24 residents who received meal trays on the 200 Hall, 7 residents who received meal trays in their room on the 300 Hall, 21 residents who received meal trays in their room on the 400 Hall, as documented on a list provided on 11/13/2023 at 4:07 PM. The findings are: 1. On 11/12/23 at 10:35 AM, the Surveyor asked Resident #79 if his hot food stays hot and cold food stays cold. Resident #79 stated, They serve us cold food. 2. On 11/12/23 at 12:58 PM, an unheated food cart that contained 24 trays for lunch was delivered to the 200 Hall by Certified Nursing Assistant (CNA) #1. At 01:25 PM, immediately after the last resident was served on the 200 Hall, the temperature of the food items on the tray used as a test tray were taken and read by Dietary Supervisor #1 with the following results: Pureed English peas - 110 degrees Fahrenheit. b. Mashed potatoes - 108.1 degrees Fahrenheit. c. Pepper steak - 113 degrees Fahrenheit. d. Pureed pepper steaks with gravy - 111.7 degrees Fahrenheit. 3. On 11/12/23 at 01:25 PM, an unheated food cart that contained 21 trays for lunch was delivered to the 400 Hall by the CNA #2. At 01:37 PM, immediately after the last resident was served in their room on the 200 Hall, the temperature of the food items on the tray used as test tray were taken and read by the Dietary Supervisor #1 with the following results: a. Milk 52.5 - degrees Fahrenheit. b. The ice cream was melted. The Surveyor asked CNA #3 to describe the appearance of the ice cream. CNA #3 stated, It was melted.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 3 residents who received pureed diets, as documented on the list provided Dietary Supervisor #1 on 11/13/2023 at 04:07 PM. The findings are: 1. On 11/12/23 at 11:49 AM, Dietary Employee (DE) #3 placed 4 servings of pepper steaks into a blender, added 2 more pepper steaks, broth and pureed. At 11:57 AM, DE #3 poured the pureed meat into a pan on the steam table. The consistency of the pureed pepper steaks was thick and not smooth. There were pieces of meat still visible in the mixture. 2. On 11/12/23 at 12:20 PM, DE #1 placed 3 servings of bread into a blender, added whole milk and pureed. At 12:23 PM, (DE) #1 poured the pureed bread into 3 bowls. The consistency of the pureed bread was runny. There were intact pieces of breadcrumbs in the mixture. 3. On 11/12/23 at 12:21 PM, DE #3 used a 4- ounce spoon to place 4 servings of english peas into a blender and pureed. At 12:24 PM, DE #3 poured the pureed english peas into a pan on the steam table. The consistency of the peas was lumpy and not smooth. There were pieces of peas in the mixture. 4. On 11/12/23 at 01:33 PM, the following food items: pureed pepper steak, pureed bread and pureed english peas were served to Resident #19 formed in a rounded mound. The consistency of all the pureed food items was lumpy, dried, and not smooth. The Surveyor asked the Certified Nursing Assistant (CNA) #1, who was assisting Resident #19 with her lunch meal in her room, if she could describe the consistency of the pureed food items served to the resident. CNA # 1 stated, This is the way pureed always looks. 5. On 11/13/23 at 02:30 PM, the Surveyor asked Dietary Supervisor #2 to describe the consistency of the pureed food items served to the residents who required pureed diets at the lunch meal on 11/12/23. She stated, They are not smooth like it is supposed to be. I can visibly see a little lump in all the pureed foods.

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This failed practice resulted in Past Immediate Jeopardy which caused or could have caused serious harm, injury, or death to 1 (Resident #1) discharged resident and 4 current residents who were identified at risk for elopement, as documented on a list provided by the Administrator on 2/23/23 at 9:00 a.m. The Administrator was informed of the Past Non-Compliance on 2/23/23 at 12:00 p.m. The findings are: 1. Resident #1 had a diagnosis of Dementia with Agitation and Cerebrovascular Accident. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/7/23 documented a score of 11 on the Brief Interview for Mental Status (BIMS). He required extensive assistance of one staff member for transfers, he did not walk during the lookback period, and he required extensive assistance from one staff member for locomotion. There were no documented wandering behaviors during the lookback period. a. An Elopement Assessment for Resident #1 dated 1/5/23 documented At Risk for Elopement. b. A Care Plan initiated 2/1/23 documented, The resident is an elopement risk/wanderer r/t (related to) mobility status, confusion, wandering around aimlessly. Frequently states he needs to leave and go see wife, easily redirected. short term memory loss noted. Device # Model 007438 {Named c. A Handwritten note provided by the Administrator was written on 2/23/23 at 11:05 AM and signed by the Assistant Director of Nursing (ADON) documented, On 2/16/23 it was reported that resident was asking for help to go outside to wait on his wife. At this time, resident was not able to be redirected and told this nurse, 'I know how to go outside on my own. This was new for resident and [named Electronic Monitoring System] was placed and family called. d. A Physician's Order dated 2/16/23 documented, Check [named Electronic Monitoring System] SERIAL # 007438 Function Q (every) week . every Wed (Wednesday) . e. A Physician's Order dated 2/16/23 documented, [named Electronic Monitoring System] SERIAL NUMBER 007438 to left backside of wheelchair Check placement . every shift. f. A Progress Note dated 2/21/23 at 5:00 a.m., documented, Note Text: Resident noted wandering around in this shift. Resident has not attempted leaving the facility. Resident has asked to contact spouse a few times after already spoken to her on the phone at 2330 [11:30]. After a triggered alarm system. We investigated and found out that resident was missing. ADON was notified at the time. Resident exit through 300 Hall door and local police was notified. Upon investigation resident was reported back to his previous address on file where he resided with his spouse. Spouse was contacted and made aware of incident. She agreed and asked to have him home for a few hours before figuring out how to bring him back. This nurse offered a transportation back to the facility at later time, spouse agreed stating she would like to be informed before arrival. g. An Elopement Assessment for Resident #1 dated 2/21/23 documented, High Risk for Elopement Device # Model 007438 [named Electronic Monitoring System] serial number 007438 to left backside of wheelchair Check placement Q Shift (every shift) Check [named Electronic Monitoring System] SERIAL # 007438 Function Q (every) week Date Initiated: 02/16/2023 . h. A DMS 762 written by Certified Nursing Assistant (CNA) #1 and provided by the Administrator documented, Resident was last seen at 2:15 a.m. At 3:30 a.m. nurse wanted me to check and see if Resident was in his room. He was not. At 3:45 a.m. nurse called a search . Police arrived at 4:15 a.m. Police left and came back at 4:40 a.m. stating Resident relocated outside of facility. i. A Division of Medical Services (DMS) 762 written by LPN #1 and provided by the Administrator documented, . Resident was last seen at 3:00 a.m. This nurse heard an alarm going off around 3:40 a.m. 300 Hall back door . j. A DMS 762 which was written by CNA #2 and provided by the Administrator documented, . Resident was last seen at 3:30 a.m. Nurse called for search at 3:45 a.m. We search until 4:15 a.m. when was notified upon police arrival at 4:40 a.m. that resident was located outside this facility. k. Page 3 of A DMS-7734 provided by the Administrator documented, At approximately 3:52 a.m. on 2/21/23, Licensed Practical Nurse (LPN) #1 heard alarm sounding. Immediately started identifying where alarm was sounding from. Alarm was identified as 300 Hall exit door. LPN #1 informed staff to start rounding on all residents to ensure they were in the facility and LPN #1 immediately went to check on Resident #1 relating to he is the only resident in the facility with a [named Electrical Monitoring System] in place. Resident #1 was immediately noted to be missing . LPN #1 got in his car to canvas the highway and areas close to the facility. LPN #1 stopped at gas station about a block away and gas station clerk stated someone was seen that fits the description of this resident got into a car with his wheelchair and drove off. Police found resident to be with his wife at her home . l. On 2/23/23 at 8:15 a.m., the 100 Hall exit door had a keypad, and a sign that read, Emergency Exit Button Press and Hold for 3 Seconds Alarm Will Sound Door Will Release in 15 seconds and a red button. m. On 2/23/23 at 8:25 a.m., the 200 Hall exit door had a keypad, and a sign that read, Emergency Exit Button Press and Hold for 3 Seconds Alarm Will Sound Door Will Release in 15 seconds and a red button. The Vending area also has an exit door with the same keypad, signage, and red button. n. On 2/23/23 at 8:25 a.m., the Surveyor asked LPN #3, do you usually work this hall? She answered, yes. The Surveyor asked, does anyone on this hall use a [named Electronic Monitoring System]? She answered, no. The Surveyor asked, do any residents on this hall wander or exit seek? She answered, yes. Resident #2 and Resident #3 both wander and look for the exit. The Surveyor asked, how would you document if a resident had a [named Electronic Monitoring System], wandered, or tried to exit the building? She answered, we document behaviors on the MAR, but I don't have anyone on this hall who has a [named Electronic Monitoring System]. o. On 2/23/23 at 8:35 a.m., the 300 Hall exit door had a keypad, and a sign that read, Emergency Exit Button Press and Hold for 3 Seconds Alarm Will Sound Door Will Release in 15 seconds and a red button. There was also a white mesh and red stop sign across the exit door. p. On 2/23/23 at 8:45 a.m., the Activity Room exit door had the same signage, red button, and code pad. q. On 2/23/23 at 8:47 a.m., the Dining Room door had the same keypad, signage, and red button. r. On 2/23/23 at 8:55 a.m., the 400 Hall exit door had a keypad, and a sign that read, Emergency Exit Button Press and Hold for 3 Seconds Alarm Will Sound Door Will Release in 15 seconds and a red button. s. On 2/23/23 at 9:40 a.m., the Surveyor asked the Administrator, what have you done since the incident to prevent it from happening again? She answered, Maintenance Staff checked all the exit doors - alarms and [named Electronic Monitoring Systems]. All were in working order, there is an ongoing in-service. They are doing elopement drills biweekly 2 x [times] week - did one yesterday. It has been QA'd (Quality Assurance). I have reached out to a company for an estimate to turn the sound up on the alarm on the 300 Hall or get a new one due to the shape of the hallway. You can hear it from the nurse's station, but it is not as loud. I watched the camera footage and Resident #1 was seen walking pushing his wheelchair. It took him approximately 5 minutes to get to the street. He went to the gas station on the corner which is open 24 hours. He caught a ride from the gas station. The Surveyor asked, how do the [named Electronic Monitoring Systems] work? She stated, it locks the door but due to the fire code, if you hold down on the bar for 15 seconds the door will unlock. Resident #1 read the signs at the end of the hall. The [named Electronic Monitoring System] also won't let anyone open the door from the outside. The Surveyor asked the Administrator to provide documentation of the exit door alarm and [named Electronic Monitoring System] checks, the ongoing in-service, the elopement drill documentation, and the estimate from the company for the alarm on 300 Hall. t. Page 1 from the [named Electronic Monitoring System] Book, which was provided by the Administrator on 2/23/23 at 9:40 a.m. documented, Step to Finding Sounding Alarms - Review computer at Nurses station - it tells you where alarm is! . u. On 2/23/23 at 9:45 a.m., the Administrator stated, we have a very complex [named Electronic Monitoring System]. If an alarm goes off and it is caused by a [named Electronic Monitoring System], the nurse can look at the computer monitor, and it will tell us the name of the resident and their location. The Surveyor asked, what did the monitor say the night of the incident? She answered, I am not sure about that. Let me find out. v. A Policy titled, Elopements which was provided by the Administrator on 2/23/23 at 10:00 a.m. documented, . When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: Examine the resident for injuries . Document relevant information in the resident's medical record . w. On 2/23/23 at 10:25 a.m., Review of Resident #1's January 2023 and February 2023 Medication Administration Record (MAR) did not document any behavior monitoring. x. On 2/23/23 at 11:00 a.m., the Administrator stated, I asked the nurse about the monitor that night and he said he didn't check it. When he heard the alarm, he went to find where it was coming from. y. On 2/23/23 at 12:00 p.m., the Administrator was notified of the Past Noncompliance.

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen, and dietary staff failed to wash their hands before handling clean equipment. These failed practices had the potential affect 84 residents who received meals from the kitchen (total census: 92) as documented on a list provided by Dietary Supervisor. on 8/30/2022. The findings are: 1. On 8/22/22 at 11:09 AM, The following items on a shelf in the walk-in freezer had no dates indicating when they were received or when they were opened. a. A zip lock bag of breaded chicken. b. Two bags of tater tots. c. Two bags of baby baker. 2. The following items were on the counter in the kitchen: a. An opened box of grits. The box was not covered. b. An opened bag of gravy. The bag was not sealed. 3. On 8/29/22 at 12:20 PM, there was wet black residue on the interior surfaces of the ice machine in the nourishment room on 400 Hall. The Surveyor asked the Dietary Supervisor to wipe off what was on the interior surfaces of the ice machine. She did so, and the black residue easily transferred to the tissue. The Surveyor asked her to describe what was wiped off. She stated, It was black sloughed. The Surveyor asked her how often the ice machine was cleaned and who used the ice from the machine. She stated, The Maintenance Employee cleans once a week. The CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. 4. On 8/29/22 At 3:46 PM, Dietary Employee #1 touched his mask, contaminating his hands. He then pushed a cart that contained clean plates towards the warmer. Without washing his hands, he picked up the clean plates and placed them on the water with his fingers inside the plates. The Surveyor immediately asked the Dietary Employee what should you have done after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. 5. On 8/29/22 At 4:35 PM, Dietary Employee #2 took out a box of breaded squash from the freezer and placed it on the stove. He removed gloves from the glove box and placed them on his hands contaminating the gloves. Without changing the gloves and washing his hands, he removed breaded squash from the box and placed them in the basket that goes into the deep fryer which are to be served to the residents for supper meal. The Surveyor immediately asked Dietary Employee #2 what should you have done after touching dirty objects and before handling clean equipment of food items? He stated, Washed my hands. 6. The facility's policy on hand washing documented, After handling dirty dishes and after other time deemed necessary.

Based on observation, interview, and record review, the facility failed to ensure staff sat with resident and did not stand over them while assisting them with eating, to promote respect and dignity for 3 of 3 sampled residents (R#20, R#392 and R#56 ) This practice had the potential to effect 12 residents who require total assistance during meals as documented on a list of residents dependent on staff for eating, provided by the Assistant Director of Nursing (ADON) on 08/31/2022 at 4:05 PM. The findings are: 1. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/28/2022 documented the resident scored 3 (0 to 7 suggests severe impairment.) on a Brief Interview for Mental Status (BIMS) and Resident requires one-person total assistance eating. A. The care plan initiated on 07/05/2022 documented, .The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Alzheimer's disease, Dementia progression, Weakness, Pain and requires assistance . B. On 08/30/22 at 09:01 AM, Resident #20 was fed breakfast by nurse standing beside bed. C. On 08/31/22 at 03:14 PM, The Resident Rights Document showed, .the right to be treated fairly and with the fullest measure of dignity . 2. Resident #392 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with Assessment Reference Date of 08/20/2022 documented the resident scored 5 (0 to 7 suggests severe impairment) on a Brief Interview for Mental Status (BIMS) and required limited one-person assist with eating. A. The care plan initiated 08/18/2022 showed, The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (Related to) Cerebral Vascular Accident ([CONDITION(S)]) effect, [CONDITION(S)], [CONDITION(S)] with craniotomy, altered mental status, [CONDITION(S)] (Chronic obstructive pulmonary disease) with shortness of breath and requires SUPERVISION WITH SET UP for eating. B. On 08/29/2022 at 12:49 PM, the Certified Nursing Assistant (CNA) at bedside standing to feed Resident #392. 3. Resident #56 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/29/22 documented resident scored 03 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and requires extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. a. On 08/29/22 at 12:39 PM Resident #56 was lying in her bed. CNA #4 standing beside her bed feeding R #56 a pureed meal. b. On 08/30/22 at 8:44 AM, R#56 was sitting in the hall with other residents. CNA #1 walked up to her picking up her spoon and fed the resident while standing beside her. The ADON was on the hall. c. On 8/30/22 at 1:10 PM the surveyor asked CNA #1 How were you helping [R#56] this morning at breakfast. He stated, I was helping her eat .getting the spoon and putting food on it and then I put it up to her mouth for her to eat . The Surveyor asked CNA #1, Where were you when you were feeding her? He stated, She was in the wheelchair, and I was standing in front of her . Surveyor asked CNA #1, Should you have been standing over her when you were feeding her? He stated, No, should be at eye level, so they can see you. 4. On 8/30/22 at 2:42 PM, the Surveyor asked the ADON (Assistant Director of Nursing), Did you observe [CNA#1] feeding [R#56] this morning? She stated, Yes. the Surveyor asked the DON, Where should [the CNA] have been while he was feeding her? She stated, He should have been sitting in a chair beside her. I educated him on that . The Surveyor asked the DON, What is a potential negative outcome of staff standing over the resident's when feeding them? She stated, They are not socializing with them and there is a possibility of them choking? [NAME] West

Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed on the 200 and 400-halls. This failed practice had the potential to affect 26 residents who ate in their room on 200 Hall and 23 residents who ate in their room on 400 Hall, according to a list provided by the Dietary Supervisor dated 8/30/022. The findings are: 1. Resident #8 had diagnoses of CEREBRAL INFARCTION, MUSCLE WASTING AND ATROPHY, UNSTEADINESS ON FEET OTHER ABNORMALITIES OF GAIT AND [CONDITION(S)], UNSPECIFIED AFFECTING RIGHT DOMINANT SIDE [CONDITION(S)] FOLLOWING CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED CAROTID Artery [CONDITION(S)], UNSPECIFIED, NOT INTRACTABLE, WITHOUT [CONDITION(S)] ESSENTIAL (PRIMARY) HYPERTENSION GASTRO-[CONDITION(S)] REFLUX DISEASE WITHOUT ESOPHAGITIS HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, A Quarterly MDS with an ARD of 5/3/2022 documented a BIMS of 05 [00-07 severely impaired]. Section G documented Resident required Supervision with meals and set up assist. b. On 8/29/22 at 12:33 PM, Resident #8 complained food was always cold. 2. Resident #20 had diagnoses of Alzheimer's Disease and Dementia. The admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/28/22 documented the resident scored 03 (0-7 indicates severely impaired), Required extensive assistance with one person assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Total dependence on staff for eating. and received a regular texture diet. a. On 8/29/22 at 8:40 AM, when Registered Nurse #1 (RN) walked into the room to assist resident with eating. Resident was sleeping and her breakfast tray consisting of biscuit with gray, scrambled eggs, sausage link and a bowl of oatmeal was sitting on the bedside table by her bed untouched. Certified Nursing Assistant (CNA) #3 was asked how long the tray had been out. She stated, I don't know. Surveyor requested the temperature of the food items. The temperature of the resident's meal tray was taken and read by the Dietary Supervisor. The temperatures were as follows: a. Biscuit with gravy: 107.5 degrees Fahrenheit b. Scrambled eggs: 111.3 degrees Fahrenheit c. Sausage links: 99.3 degrees Fahrenheit, 3. On 8/30/2022 at 8:30 AM, An unheated cart with breakfast trays was delivered to 400 Hall by the lead Certified Nursing Assistant. At 8:52 AM Immediately after the last tray was served on 400 Hall, the temperatures of the food items on a test tray from the cart were checked and read by read by the Dietary Supervisor with the following results: a. Milk 57.0 degrees Fahrenheit, b. Nectar milk 58.2 degrees Fahrenheit c. Biscuit with gravy 110.3 degrees Fahrenheit d. Scrambled eggs 106.7 degrees Fahrenheit. e. Sink link 104 degrees Fahrenheit. f. Ground sausage 99.5 degrees Fahrenheit, 4. On 8/30/2 at 08:50 AM, the Surveyor asked the Dietary Supervisor what time the food cart was delivered to 400 Hall. She stated, It was 8:30 AM. The lead Certified Nursing Assistant #1 who delivered food cart to 400 Hall stated, It was delivered at 8:30 AM. 5. On 8/30/22 at 9:21 AM, Director of Nursing l stated, Housekeeping Supervisor was the one that delivered breakfast tray to the resident. She did it at 08:16 AM. 6. On 08/30/22 at 9:35 AM, the Surveyor asked the Housekeeping Supervisor, what time did you deliver breakfast tray to the resident room? She stated, I took it there at 8:16 AM. I left to go find someone to go an assist her, but something came up and I forgot.

Based on observation, record review, and interview, the facility failed to ensure treatment and care for management of indwelling urinary catheter was provided in accordance with accepted standards of nursing practice, by failing to ensure the urinary catheter tubing was secured to prevent potential pulling or trauma to the urinary meatus/urethra for 1 (Resident #53) of 5 (Residents R#65, R#69, R#74, and R#390). sample residents with indwelling catheters. The failed practices had the potential to affect 5 residents who had indwelling urinary catheters, according to a list provided by the Assistant Administrator on 8/31/22. The findings are: 1. Resident #53 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/25/22 documented resident scored 5 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and requires supervision with eating and personal hygiene, limited assistance with dressing and extensive assistance with bed mobility, transfer, and toilet use. a. A current 7/21/22 Care Plan documented, .The resident has an indwelling Catheter placed with recent hospitalization . Monitor/document for pain/discomfort due to catheter . The resident will be/remain free from catheter-related trauma . b. The current 7/21/22 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 08/29/22 at 12:12 PM, Resident# 53 was lying in bed with Foley Catheter in privacy bag secured to right side of bed, draining cloudy yellow urine. d. On 8/30/22 at 10:29 AM, Certified Nursing Assistants CNA #2 and CNA #3 provided catheter care to resident. When CNA #2 pulled down R#53's pants and briefs she stated, He needs to be stat locked. Foley Catheter was not secured. CNA #2 stated, We are going to let the nurse know that you need a stat lock. R#53 stated, What is that? She stated, It holds your catheter in place so it won't (will not) flop around. The Surveyor asked CNA #3 What is a potential complication of his catheter not being secured with a stat lock? She stated, It could get pulled out. e. On 08/31/22 at 08:41 AM, the Surveyor asked the ADON, Who is responsible for ensuring residents with Foley Catheters have stat locks in place? She stated, The Treatment Nurse. Surveyor asked the ADON, What is a potential negative outcome of a resident not having their Foley Catheter secured? She stated, It could be ripped out and also a possible infection. f. A policy provided by the Administrator on 8/31/22 documented, .Catheter Care, Urinary ., Purpose ., The purpose of this procedure is to prevent catheter-associated urinary tract infections ., Preparation ., 1. Review the resident's care plan to assess for any special needs of the resident ., Maintaining unobstructed urine flow ., 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks ., changing catheters ., 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site . to replace the catheter .Steps in the procedure ., 18. Secure catheter utilizing a leg band ., 2001 MED-PASS, Inc. (revised September 2014)

Based on observation, record review, and interview the facility failed to ensure a resident who is fed by enteral means received the physician ordered treatment services to potentially prevent complications of enteral feeding including but not limited to dehydration . for 1(R#55) of 6 (Residents #55, R#390, R#65, R#69, R#53 and R#74) sample residents who was fed by enteral means. The failed practice had the potential to affect 6 residents who were fed by enteral means (tube feedings), per list provided by the Assistant Administrator on 8/31/22. The findings are: 1. Resident #55 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/28/22 documented resident was severely impaired according to the Staff Assessment for Mental Status (SAMS) and requires total dependence with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene a. A current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 20mls/hr (milliliters per hour) via peg via kangaroo pump (23hr) (hours) . every shift Enteral Water Flush 35 ml/hour via peg via kangaroo pump . b. A current 8/3/21 Care Plan documented, . The resident requires tube feeding r/t (related to) Dysphagia, Swallowing problem. I am NPO (Nothing by Mouth) status .The resident is dependent with tube feeding and water flushes. See Medical Doctor (MD) orders for current feeding orders . c. On 8/29/22 at 02:00 PM, the resident was resting in bed with Vital 1.5 cal (calories) infusing per pump at 20 cc/hr (cubic centimeter per hour), with 30ml (milliliters) water flush every hour . HOB elevated 30 degrees. d. On 8/30/22 at 1:27P PM, R#55's kangaroo enteral water flush was infusing at 30ccs per hour. e. On 8/30/22 at 1:36 PM the Surveyor asked the ADON (Assistant Directors of Nursing) to accompany them to R55's room. The Surveyor asked the ADON, What is her [R55's] Peg tube water flush infusing at? She stated, It's at 30 milliliters an hour. I will check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] f. On 08/30/22 at 1:44 PM, the ADON stated, Her flush was at 30 cc's /hour when we walked in there. It should be at 35 cc/hr. It was off by 5cc/hr. I talked to the nurse . The Surveyor asked the ADON, What is a potential negative outcome of the water flush not being provided per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? The ADON stated, Her becoming dehydrated . f. A policy provided by the Administrator on 8/31/22 documented, .Enteral Nutrition ., Policy Statement ., Adequate nutritional support through enteral nutrition is provided to residents as ordered ., Policy Interpretation and Implementation ., 1. The interdisciplinary team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feeding. The assessment includes ., c. A review of interventions to maintain oral intake prior to the use of a feeding tube and the resident's response to them ., 3. The Dietitian, with input from the provider and nurse: a. Estimates calorie, protein, nutrient and fluid needs; b. Determines whether the resident's current intake is adequate to meet his or her nutritional needs; c. Recommends special food formulations, and d. Calculates fluids to be provided (beyond free fluids in formula) ., 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary ., 9. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or [CONDITION(S)], and altered electrolytes. The nursing staff and provider also monitor the resident for worsening of conditions that place the resident at risk for the above ., 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include: ., e. Volume and rate of administration; f. The volume/rate goals and recommendations for advancement toward these; and g. Instructions for flushing (solution, volume, frequency, timing and 24-hour volume) ., 2001 MED-PASS, Inc. (revised September 2018)

Based on observation, record review, and interview, the facility failed to ensure a medical symptom that necessitated the use of a reclined Gerichair was identified and failed to ensure less restrictive alternatives were attempted to the extent possible and failed to do a pre-restraint assessment for 1 (Resident #78) of 3 (Residents #78, #82, and #18) sampled residents who had Geri chairs in use. The failed practices had the potential to affect 5 residents who had orders for Geri chairs, according to a list provided by the Administrator on 5/27/21. The findings are: Resident (R) #78 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Plan of Care with a revised date of 9/11/2020 documented, .extensive assist x [times] 1 [for] Geri Chair use (provided by Hospice) . b. A Nsg-I&A [Nursing Incident and Accident] Follow Up Date and I&A Description: 2-28-2021 Resident heard yelling from room. Staff enter room to find resident on the floor with head at the foot of bed. Resident stated she was going over to her friend's house. No injury noted from fall. Resident assisted back to bed by staff. Fall mat and bolster in place at time of fall. Long Term Intervention: low bed added to the Care Plan: Yes . c. A Nsg-I&A Follow up date and I&A Description: 3-1-2021 PT [physical therapy] reported to nurse resident to be on the floor. Nurse enters resident room to find resident sitting on the floor on buttocks. Resident stated that she slid out of her chair and that she does not like that chair. Resident assisted back to bed by staff. Resident with new skin tear to right lower leg. Long Term Intervention: Dycem added to wc . d. On 05/25/21 at 11:55 AM, R #78 was sitting in the hallway of 200 Hall. She was in a geri-chair with the footrest out and the back of the chair leaning back. She had an overbed table over her legs and she was upset. She was speaking in a loud voice, I hate this chair! Someone help me out of this chair! I can't do nothing in this chair! I wet myself 3 times yesterday because I can't even go to the bathroom! A nurse walked over to her and leaned down and said, Are you ready to go back to bed? The resident stated, No, why do I have to go back to bed? I just want out of this chair; I hate this chair! The nurse stated, Well because if you are not in bed, this is your chair. e. On 05/25/21 at 12:15 PM, R #78 was sitting in a geri chair outside of her room on 200-hall with other residents lined on both sides of the hallway eating lunch. Notified by another surveyor that resident was out in the hallway complaining about being in the geri chair and that she couldn't get out and didn't want to be in the chair. Resident stated, I am tired of being put in this dang chair and they put me in this thing every time they get me up and take me out of my room. I hate this darn chair. I peed on myself 3 times yesterday sitting in this chair because I couldn't get anyone to help get me out of this chair. Resident was in the hallway outside of her room being served lunch. R #78 refused to eat her meal. f. On 05/25/21 at 12:19 PM, Licensed Practical Nurse (LPN) #1 came down to where the resident was yelling, Get me out of this chair. in the hallway. The LPN #1 was asked, Can you take the resident to her room and assist her needs? She stated, Sure, she moved the bedside table that had the resident's lunch on it and took the resident via geri chair to her room. Resident continued to yell, Get me out of this chair. LPN #1 was asked, Can you tell me a little bit about what is going and why the resident is in a geri chair tilted back with the lower recliner part raised? She stated, Yes, we were having some issues with the other chairs that the facility had tried using before now to help keep the resident from falling. The resident has had several falls without major injuries. Since we started putting her in the geri chair, the incidences with her falling have decreased. The resident told LPN #1, I peed on myself 3 times yesterday [5/24/21] while sitting in this chair. I asked and asked for help and nobody would help me. Every time someone gets me up to go out of my room they put me in this darn chair and if there was some way for me to start a fire, I would burn this darn chair right here, right now in this room. I don't know why staff will not help me when I ask and every one of you know that I do not like this chair but yet yall's keep on putting me in it. LPN #1 was asked, Would you consider the geri chair a restraint? She stated, No ma'am because I have seen her [the resident] pull herself out of the geri chair before. She was asked, Does the resident have the right to be out of the geri chair if she verbalized that she didn't want to be in the chair? She stated, Yes. g. On 5/25/21 at 2:30 PM, R #78 was lying in bed with her eyes open. There was a Broda chair by her bedside. Resident stated, Look at my new chair, I sure do like it. I hope I can move around in it when I get up from taking a nap. h. On 5/25/21 at 3:00 PM, the Director of Nursing (DON) was asked, Why was [R #78] in a Geri Chair? She stated, She had been in a dine and go chair. Hospice ordered the Geri chair. She was asked, Could the resident get out of the Geri chair if she wanted out? She stated, Yes, if she wanted to, she could. She was asked, Have you ever seen the resident attempt to get out of the Geri chair? She stated, No. She was asked, If the resident wanted out of the Geri chair and couldn't get out of the Geri chair or nobody assisted her to get out of the chair when the resident asked, would that be considered a restraint? She stated, Yes, if we took her mobility away it would be considered a restraint. She was asked, Where is the resident's restraint assessment? She stated, There wasn't one done. She was asked, How long had the Geri chair been used for the resident? She stated, We started putting her in the Geri chair when it arrived after hospice ordered it for her. She was asked, How long has that been? She stated, I would have to go back and look but it has been a while. i. On 05/25/21 at 03:37 PM, Certified Nursing Assistant (CNA) #1 was asked, Have you taken care of the of [Resident #78]? She stated, Yes, and I am familiar with her care. She was asked, Have you ever heard her complain about being placed in the Geri chair with it reclined back? She stated, Yes, she has complained about not liking that Geri chair since it was brought out to her. She was asked, How long has that been? She stated, At least 6 months. She was asked, Have you ever seen the resident get out of the Geri chair? She stated, I have seen her get out of the Geri chair one time but, the Geri chair wasn't reclined, it was in the sitting up position. She was asked, How often does the resident sit up in the Geri chair? She stated, I have only seen her sitting up in it one time and I have been taking care of her for 6 months, the resident has complained about the chair from the day she received it [the Geri chair]. She was asked, Have you been trained on restraints? She stated, Yes ma'am. The resident was reclined in the Geri chair outside of her room in the hallway to eat lunch today, asking to be helped out of the Geri chair and moving around in it asking for someone to help get her out of the chair. She was asked, Would you consider that a restraint? She stated, Yes ma'am and I have been upset several times hearing her yell out that she wanted out of that chair and I would go in there and sit with her to try and calm her, she has never liked that chair and everyone knows this. j. On 5/26/21 at 8:02 AM, R #78 was sitting out in the hallway with other residents getting ready for breakfast sitting in the Broda chair smiling and talking stated, I really like my new chair, I can move myself with my feet now that I am not in that other chair reclined back. k. On 5/26/21 at 01:31 PM, CNA #2 was asked, Have you ever seen the resident propel herself in the Geri chair? She stated, No. She was asked, Did the Geri chair keep the resident from getting up if she wanted out of the chair? She stated, Yes, I feel like the Geri chair was being used for convenience. She was asked, What makes you think the Geri chair was being used for convenience? She stated, I don't know, it's just every time I would come into work, she would always be in the Geri chair if she was up out of bed. She was asked, How long has the resident had the Geri chair? She stated, Ever since I have worked here, and I have worked here for about 5 months. She was asked, Have you ever seen the resident propel herself in any chair? CNA #2 stated, I saw her this morning in her new chair during breakfast in the hallway using both feet. She was asked, Have you been trained on restraints? CNA #2 stated, Yes, I was trained during my orientation after being hired. l. On 5/27/21 at 3:14 PM, a Policy and Procedure received from the Administrator documented .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully; that restricts his/her typical ability to change position or place, that device is considered a restraint .

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 3 (Residents #84, 30 and 64) of 15 (Residents #84, #30, #64, #79, #196, #35, #22, #86, #88, #89, #19, #144, #5, #81, and #18) sampled residents who were dependent on staff for nail care. The failed practice had the potential to affect 33 residents who were dependent on staff for fingernail/toenail care, as documented on a list provided by the Administrator on 5/27/2021 at 2:48 p.m. The findings are: 1. Resident (R) #84 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 5/5/21 documented a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicate cognitively intact), required extensive assist with 2-person physical assist with most Activities of Daily Living (ADL)'s. a. On 1/31/21 a Medical Doctor (MD)'s order documented, .May see podiatrist . b. The Plan of Care with a revised date 2/5/21 documented, . Keep fingernails short [and] Avoid scratching and keep hands and body parts from excessive moisture . c. On 05/24/21 at 10:29 AM, R #84 was in her room, sitting up in a bariatric wheelchair, with fingernails long with jagged edges. Resident was asked, Who trims your nails? She stated, The nurse is supposed to because I am a diabetic controlled with diet. She was asked, Do you like your fingernails that long? She stated, No, and I have a couple that have sharp edges, but I have asked for someone to cut them and so far, nobody has done it. She was asked, How long has it been since you let them know that you wanted your nails trimmed? She stated, Gosh, probably 3 or 4 weeks ago, and I have mentioned it to them several times during that time and I don't know if they just don't have time or they keep forgetting and I have even mentioned my toenails need to be cut. She was asked, Do you remember who you spoke to concerning your nails? She stated, No, not really, I mean I may could tell you if I see them. d. On 5/25/21 at 9:45 AM, Certified Nursing Assistant (CNA) #3 was called to the resident's room and was asked, Who trims the resident's fingernails? She stated, Usually the CNA's if they aren't diabetic, but if they are diabetic, the nurse has to trim them. She was asked, Will you look at the resident's nails and describe to me what you see? She stated, They are long, and some have sharp edges and should be trimmed. e. On 5/25/21 at 9:51 AM, Licensed Practical Nurse (LPN) #2 was asked, Who trims the resident's fingernails? She stated, If they are diabetic the nurses trim them but if they aren't diabetic, the CNA's trim them usually on the residents shower days. She was asked, Will you come and look at R #84's fingernails and tell me what you see? She stated, Sure, I will go right now. LPN #2 stated, Her [the resident] fingernails are long with some sharp edges and definitely needed to be trimmed before she scratched herself possibly causing an abrasion that could lead to an infection. 2. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/23/21 documented a Brief Interview of Mental Status (BIMS) score of 3 (0-7 indicates severe impairment), required extensive assistance with bed mobility, toileting, personal hygiene, and bathing. a. On 05/26/21 at 08:52 PM, the Comprehensive Care Plan initiated on 03/19/21 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Dementia, Arthritis, muscle wasting and atrophy, Dysphagia. PERSONAL HYGIENE: EXTENSIVE X [times] 1 . b. On 05/25/21 at 02:55 PM, Resident #30 had approximately 1/4-inch-long jagged nails. When asked if he liked his nails like that, he replied, I'd rather have them a little shorter. 3. Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/21 documented a Brief Interview of Mental Status (BIMS) score of 3 (0-7 indicates severe impairment), required limited assistance with bed mobility, transfers, toileting, and personal hygiene. a. The Comprehensive Care Plan revised on 4/22/21 documented, .I have an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] right sided weakness, anxiety, depression, [CONDITION(S)], pain, SOB, vascular dementia . PERSONAL HYGIENE: EXTENSIVE X1 . The resident needs their nails kept short to reduce risk of scratching or injury from picking at skin . b. On 05/25/21 at 11:49 AM, Resident #64 had approximately 1/4-inch-long fingernails. Her hands were shaky. She was asked, Do you like your fingernails that long? She replied, They need cut but I can't do it. c. On 05/27/21 at 08:32 AM, Resident #64 had approximately ¼-inch-long fingernails. Her hands were very shaky. 4. On 5/27/21 at 2:48 PM, a Policy and Procedure on Fingernails provided by the Administrator documented, .the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections; do not trim the nails of a diabetic resident or residents with circulatory impairments, do not trim the nails below the skin line or cut the skin; trim fingernails in an oval shape; smooth the nails with a file or emery board .

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician, to minimize the potential for respiratory complications for 2 (Residents #64, and #82) of 13 (Residents #86, #11, #27, #84, #20, #30, #92, #88, #16, #64, #18, #82, and #35) who receive oxygen therapy. This failed practice had the potential to affect 27 residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/21 documented a Brief Interview for Mental Status (BIMS) score of 03 (0-7 indicates severe impairment) and received oxygen while a resident. a. The Physicians orders dated 2/8/21 documented, .OXYGEN @ [at] 2L [liters] PRN [as needed] NC [nasal cannula] for SHORTNESS OF BREATH . b. The Comprehensive Care Plan with a revised date of 2/26/21 documented, .I have an altered respiratory status/difficulty breathing r/t [related to] [CONDITION(S)], SOB, wheezing, allergies and congestion, asthma .OXYGEN VIA NASAL CANNULA PRN PER MD [Physician] ORDERS . c. On 5/24/21 at 12:24 PM, Resident #64 was wearing oxygen via nasal cannula. The concentrator was set on 1.5 LPM. d. On 05/25/21 at 11:52 AM, Resident #64 was wearing oxygen at 1.5 liters per minute per nasal cannula. Resident #64 was short of breath and having to sit straight up in bed to try to catch her breath. Licensed Practical Nurse (LPN) #1 came into the room and saw she was short of breath; she went and got a pulse oximeter and checked oxygen saturation and it was 90-92%. She turned the oxygen setting up to 2 LPM and stated, I think it may have been bumped during care. Once the oxygen was on the ordered rate, Resident #64's oxygen saturation came up to 94%. 2. Resident #82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/4/21 documented a Brief Interview for Mental Status (BIMS) score of 00 (0-7 indicates severe impairment) and received oxygen while a resident. a. The Comprehensive Care Plan revised on 5/6/20 documented, .I have a history of altered respiratory status/difficulty breathing r/t Anxiety, Chronic Respiratory failure, SOB. I get short of breath lying flat and at rest. I use oxygen .OXYGEN 2L VIA NASAL CANNULA OR MASK as needed . b. The May 2021 Physicians orders documented, OXYGEN 2L VIA NASAL CANNULA OR MASK as needed for SOB . c. On 05/25/21 at 11:31 AM, Resident #82 with oxygen in use per nasal cannula. The oxygen concentrator was set at 3LPM. d. On 05/27/21 at 08:28 AM, Resident #82 was wearing oxygen per nasal cannula at a rate of 2.5-3 liters per minute. e. On 05/28/21 at 09:15 AM, LPN #3 was asked to review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, It says 2 liters. She accompanied the surveyor to the room to look at the oxygen concentrator settings and was asked, What is the oxygen set on? She replied, It's on 3 liters. Let me go ahead and bump that down right now. 3. On 05/27/21 at 02:48 PM, the Administrator provided a document titled, Oxygen Administration which documented, .Review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Adjust the oxygen delivery device so that it is comfortable for the resident and that the proper flow of oxygen is being administered .

Based on observation, interview and record review, the facility failed to ensure food items were properly labeled or dated to prevent food borne illnesses. These failed practices had the potential to affect 89 residents who receive a tray from the kitchen as documented on the list of residents with trays provided by the Administrator on 5/27/21 at 3:14 PM. The findings are: 1. On 05/24/21 at 11:04 AM, the initial kitchen rounds were made with Dietary Manager #1 in attendance with the following findings: a. Six packages of 24 counts dinner rolls were on the shelf and were not dated. b. Three cases of white bread were not dated. c. Two cases of wheat bread were not dated. d. One box of whole Idaho potatoes was not dated. 2. On 5/24/21 at 11:08 am, in the walk-in refrigerator the following observations were made: a. Five cartons of 32 ounces liquid eggs were not dated. b. Six cantaloupes in a box were not dated. c. One case with 8 cartons of strawberries was not dated. d. One case of red apples was not dated. e. One case of cabbage was not dated. f. Two cases of shredded lettuce were not dated. g. One case of cream cheese was not dated h. One case pork loin was not dated. 3. On 5/24/21 at 11:29 am, Dietary Manager #1 was asked, Should food items have a date on them? Dietary Manager stated, Oh yes. The Dietary Manager was asked, Do you know why these items identified don't have a date? The Dietary Manager stated, These all came in on Saturday [5/22/2021]. They know they are supposed to put a date on them. 4. On 5/28/21 at 9:04 am, the Administrator was asked, Should food items in the kitchen have a date on them? The Administrator stated, Yes. The Administrator was asked, What can happen if there is not a date on food items? The Administrator stated, They should have a date, so we know when we receive it and know when it expires. 5. On 5/28/21 at 9:15 am, the Dietary Manager #2 was asked, Should food items in the kitchen had a date on them? Dietary Manager #2 stated, Yes, it should have a received date on it and then place an open date on it when it is opened. Dietary Manager #2 was asked, What can happen if there is not a date on food items? Dietary Manager #2 stated, If it don't have a date on it, I will throw it out. It has always been my rule, when in doubt, throw it out. 6. On 5/28/21 at 9:09 am, the facility provided the Food Ordering and Receiving policy. The policy documented, Policy Statement: The dietary department will use guideline when ordering or receiving food for the facility . 11. The date of delivery shall be noted on stock (pursuant facility policy and state regulations) .

Based on observations, record review and interview, the facility failed to ensure proper infections prevention and control practices to prevent the development and transmission of COVID-19 and other communicable diseases and infections by not wearing a face mask and failure to ensure the clean laundry room was free of drinks to prevent potential cross contamination or spread of infection in 1 of 1 facility. The failed practice had the potential to affect 92 resident who resided in the facility according to the census provided by the Administrator on 5/24/21. The findings are: 1. On 05/26/21 at 01:29 pm, the Director of Environmental Services (EVS) accompanied the surveyor to the laundry rooms. Upon entrance into the dirty side of laundry room, a laundry person had on gloves and was sorting dirty laundry in a barrel and placing it into the washer. The laundry person did not have on a face mask, gown or heavy-duty rubber gloves while handling the dirty laundry. 2. On 05/26/21 at 01:31 pm, there was an opened can of energy drink setting on the clean folding table beside folded laundry on the clean side of the laundry room. 3. On 5/26/21 at 1:35 pm, Laundry Worker #1 was asked, Should you have a face mask on while sorting dirty laundry? Laundry Person #1 stated, Yes. Laundry Worker #1 was asked, Why did you not have it on? Laundry Worker #1 stated, I had to wipe my face and get a drink so when I came back in here, I forgot to put it back on. Laundry Worker #1 was asked, Is that an infection control issue? Laundry Worker #1 stated, Yes. Laundry Worker #1 was asked, Should your drink be on the clean folding table with clean laundry? Laundry Worker #1 stated, No. Laundry Worker was asked, Why not? Laundry Worker #1 stated, Because it can spill on the clean laundry and it is not sanitary. Laundry Worker #1 was asked, Is that an infection control issue? Laundry Worker #1 stated, Yes. 4. On 5/26/21 at 1:41 pm, the Director of Environmental Services (EVS) was asked, Should staff wear a face mask while sorting dirty laundry? Director of EVS stated, Yes, at all times. They do not need to be breathing on clean clothes or in dirty laundry. Director of EVS was asked, Would not wearing a face be an infection control issue? Director of EVS stated, Yes it would be a major one actually. Director of EVS was asked, Should personal drinks be on the clean laundry folding table? Director of EVS stated, Absolutely not. There should only be laundry and resident personal clothes on it. Director of EVS was asked, Would a drink on the clean folding table be an infection control issue? Director of EVS stated, Yes it would. 5. On 5/28/21 at 9:04 am, the Administrator was asked, While sorting dirty laundry (Not isolation laundry) in a barrel, what personal protective equipment (PPE) should the laundry person wear? The Administrator stated, Typically wear gloves and a face mask. The face mask is required here at all times for everyone. The Administrator was asked, If a face mask is not worn while sorting dirty laundry in a barrel would that be an infection control issue? The Administrator stated, On the dirty side it should not be an infection control issue because we are washing the dirty linen but on the clean side it would be. The Administrator was asked, Would a personal can drink on the clean folding table beside clean laundry be an infection control issue? The Administrator stated, I would have to see the scenario. We have resolved that and place another table in there for drinks to prevent it from coming in contact with linens. 6. On 5/28/21 at 9:04 am, The Director of Environmental Service was asked, While sorting dirty laundry (Not isolation laundry) in a barrel, what personal protective equipment (PPE) should the laundry person wear? The Director of EVS stated, Gloves, mask and gown so that it doesn't touch the persons' personal clothes. 7. The facility provided Personal Protective Equipment-Using Face Mask policy on 5/27/21 at 2:48 pm. The policy stated, Purpose to guide the use of masks. Objectives 1. To prevent transmission of infectious agents through the air . 8. The facility provided Departmental (Environmental Services) - Laundry and Linen policy on 5/27/21 at 2:48 pm. The policy documented, Purpose: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . Sorting Soiled Linen 1. Employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected. 2. Use heavy-duty rubber gloves for sorting laundry .Washing Linen and other Soiled Items .7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination .

Complaint # (AR 826) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure residents were provided with adequate supervision to prevent accidents/injuries to the extent possible, as evidenced by failure to ensure planned fall-prevention interventions (gait belt, supervised toileting) were consistently implemented to prevent a fall with serious injuries for 1 (Resident #1) of 3 (Residents #1, #2 and #4) case mix residents who had a history of [REDACTED]. The failed practice resulted in past non-compliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who was left unsupervised and sustained fractures to the right lateral 6th through 9th ribs, and had the potential to cause more than minimal harm to 33 residents who had falls in the last three months, as documented on a list provided by the Nurse Consultant on 4/23/19 at 2:25 p.m. The Administrator was informed of the past immediate jeopardy condition on 4/23/19 at 2:00 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. with dressing, extensive assistance of two plus persons with toileting, extensive assistance of one person with personal hygiene, had no functional limitations in range of motion to the upper or lower extremities, was always incontinent of bowel and bladder and had two or more falls since admission/entry or reentry with no injury. a. An MDS Kardex (Closet Care Plan) dated 10/22/18 documented, .Toilet Use: Total Dependence .Two + (plus) persons physical assist .Other .Accidents - Fall Risk .Miscellaneous: pommel cushion: Winged Mattress: Anti rollbacks on w/c: Low bed: Encourage to be in common areas while up in w/c (wheelchair) . b. A Care Plan dated 1/9/18 with a revision date of 3/2/19 documented, . I have a decline in being able to take care of myself concerning my ADLs (activities of daily living) r/t (related to) dementia, impaired mobility .Bathing/Showering: I am totally dependent . Bed Mobility: I require extensive assistance . Dressing; I require extensive . Eating: Limited . Personal Hygiene/Oral Care: I require extensive x 1 . Toilet Use: I require total assistance . A Care Plan dated 12/01/2018 documented, .I had an actual fall. Date . 10-22-2018 staff reeducated on keeping resident in common area while up in wc (wheelchair) . 12-14-2018: .Anti roll backs applied to wc per maintenance . 12/17-2018 anti-tippers placed on wc by maintenance . 2-8-2018 Low PVC ([MEDICATION NAME] chloride) bed (family refused, standard bed in place) . 6-21-18 Staff in-service to place appropriate footwear on resident and to keep resident in common area after breakfast . 6-5-18 Staff re-educated to encourage resident to be in common area when not in bed . 7-30-18 1. Non skid socks placed and provided to resident . Fall mat at bedside . c. A Nursing Morse Fall Scale and Care Plan dated 3/28/19 at 9:30 a.m. documented the resident's fall risk score was 75, with a score of 45 or greater indicating a high risk for falls. d. A Nursing - Incident and Accident (I&A) note dated 3/28/2019 at 10:28 a.m. documented, .Incident Description: CNA (Certified Nursing Assistant) notified nurse at desk that while resident was in bathroom she went to see what his roommate was yelling for while he attempted to get up and walk out of the bathroom by his self and fell in the doorway of the bathroom. Upon entering room resident was sitting in floor of the bathroom door c/o (complained of) pain in right arm and wrist but able to do ROM (range of motion). Multiple skin tears and bruising seen. Area clean and covered, with treatment nurse made aware of new skin issues. Assisted resident up from floor and into Dyn Ergo chair and in the hall in eyesight. Hall CNA educated on not leaving the resident alone in the restroom bc (because) he is a fall risk. Notified son, APN (Advanced Practice Nurse) with order for stat X-ray .DON (Director of Nursing) and treatment nurse aware. Immediate Intervention: Educated CNA on not leaving resident alone in restroom. Treatment orders in place . 1.) A physician's orders [REDACTED].Stat X-ray of right wrist and arm R/T (related to) fall also right rib cage with chest R/T fall with pain . #2 Skin tear to inner right forearm area clean with wound cleaner pat dry apply dry dressing one time only for skin tear for 1 day and every day shift for skin tear. Monitor bruise to inner right wrist area one time only R/T fall for 1 day and every day shift R/T fall . Monitor bruise to right cheek one time only for fall for 1 day and every day shift for fall .Monitor bruise to right inner forearm area surrounding skin tear one time only for R/T fall 1 day and every day shift for R/T fall .Monitor bruise to right outer forearm every day shift for R/T fall .Monitor bruise to right outer wrist x (times) 2 every day shift for R/T fall . 2.) A Radiology Results Report dated 3/28/19 documented, .Procedure: Ribs X-Ray .Exam: Ribs Xray - Unilateral 2-3 views Right .Findings: Rib: Multiple projections of the right ribs. Acute nondisplaced right lateral 6th through 9th rib fractures. Osteopenia. Remaining regional osseous structures without acute finding. [MEDICAL CONDITION] changes spine and shoulder . e. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, documented, .Date and Time of Incident 3/29/2019 .Name of Involved Resident: (Resident #1) . Both CNAs interviewed regarding resident and both admitted to leaving him alone in the restroom. In conclusion this facility does confirm that neglect did occur based (on) resident fell , received a fracture and both CNAs admitted to leaving him alone in the restroom when required extensive/dependent assistance. Resident's medical condition remains unchanged. Resident still required assistance with all ADLs and setup help only with eating. (CNAs #1 and #2) have been terminated from this facility. 1.) An Office of Long Term Care (OLTC) Witness Statement form dated 3/29/19 by CNA #1 documented, .I helped (Resident #1) to the toilet 2-person with another CNA. We went to change his roommate and (Resident #1) came out of the bathroom and fell at the door . 2.) An OLTC Witness Statement form dated 3/29/19 by CNA #2 documented, .Me and (CNA #1) took (Resident #1) to his room from the hall to take him to the bathroom & in the room I ask her was he a 1 or 2 person assist, she said he was easy he would stand to transfer to toilet (1) person so I said then let's go put (other resident) .in bed. After we assisted (other resident) . we went to (Resident #1) & (roommate's) room. We both assisted to toilet, I walked out, started cleaning room and assisting (roommate). I turned around, (Resident #1) is in the floor sitting up position. I was standing in the door way, she (CNA #1) was behind (Resident #1). I said what do we need to do. She (CNA #1) said I'm not sure. I said he has a skin tear on arm & his head/side of face was red, he was holding side. She bent over to lift him up & I said are we getting him up & (CNA #3) walked in and said what happened we told her & she looked at me and said so get (Licensed Practical Nurse (LPN) #1) the nurse. (LPN #1) came in checked his skin tear & bandaged him up. She told me she needed vitals on him & gave me time. He did get a shower before. I checked on him at lunch his wife came and brought him ice cream. We talked about what happen she said it scares her because he has broken his ribs before . f. On 4/23/19 at 10:14 a.m., CNA #3 was asked if she was familiar with Resident #1 and stated, I am familiar with (Resident #1). I was here on the day the resident fell in March. I was on break and I came back and was answering a call light. I went to look for another CNA to assist with a resident in the shower. When I got to (Resident #1's) room, he was lying on the floor outside of the bathroom door. It was approx. 9:30 a.m., right after breakfast. I sent (CNA #2), one of the CNAs in the room, to go get the nurse. (CNA #2) was new; whenever I got to the room, she was asking me what she should do. She went to get the nurse, who came to the room. I then left the room to go assist another resident. (CNA #1) was also in the room with roommate). CNA #1 stayed with (Resident #1) whilst (CNA #2) went to get the nurse. Both CNAs were in the room standing over the resident when I got to the room. I heard (Resident #1) yelling; that is how I found the CNAs. (Resident #1) did not have a gait belt on when I entered the room. (Resident #1) was continent of bowel and incontinent of bladder. Resident's roommate was in bed when I arrived at the room. CNA #2 told me when I asked what happened that they had laid (Resident #1's) roommate down and took (Resident #1) to the bathroom. The roommate was yelling. She (CNA #2) left (CNA #1) in the bathroom with (Resident #1) whilst she took care of his roommate. She had the privacy curtain pulled. She heard something and she went over there and (Resident #1) was on the floor . (Resident #1) was holding his side when I entered the room; he seemed to be in pain. If a resident is a two person assist with toileting, we always leave one person with the resident in the bathroom. g. An IDT (Interdisciplinary Team) - Weekly Fall Note dated 3/31/2019 at 1:51 p.m. documented, .On 3/28/19 resident was found on floor in bathroom. Multiple skin tears noted. X-ray performed and rib fractures noted. Staff inserviced and one on one education provided to not leave resident unattended while in bathroom . h. On 4/23/19 at 1:29 p.m., the Administrator was asked if he was familiar with the resident and the incident that happened on 3/28/19. He stated, (Resident #1) did have a fall coming out of his restroom at the end of March. The next morning, I found out the resident had a fracture. We were in the process of investigating the I&A. I interviewed the aides that were caring for him. One aide told me that the roommate was yelling and needed some help. The one aide left the resident unattended and went to help the roommate. We found that both of the CNAs had exited the bathroom and left the resident unattended, while they helped the roommate. Both aides admitted to this. I placed both aides on administrative leave. I interviewed both aides. Both aides knew that they had to look at the closet care plan prior to transfer. One aide stated that she knew this and just did not do it. The other aide said she just did not take the time to look at the closet care plan . i. On 4/23/19 at 1:42 p.m. the Director of Nursing (DON) was asked if she was familiar with the resident and the incident that happened on 3/28/19 and stated, I am familiar with (Resident #1). It was reported to us that resident had fallen at the end of March. The CNAs heard another resident yelling and they went to check on him and (roommate) had fallen. When we investigated more, we discovered that the CNAs had left the resident unattended in the bathroom and he had fallen. At that time, the aides were suspended. We completed our investigation and provided training to all of the staff on closet care plans and to check what assistance the resident needs, transfers, abuse and neglect. The aides were both terminated. j. The facility removed the Immediate Jeopardy and corrected the failed practices on 4/1/19 prior to the survey, as evidenced by the following: 1.) The DMS form 762 dated 3/29/19 documented, .Findings and Actions Taken .Both CNAs, (CNA #1) and (CNA #2), were placed on administrative leave pending the outcome of this investigation. Police were notified and a report was made . Physician, Administrator and Responsible party notified. All staff in-serviced on recognizing and reporting abuse/neglect. In-serviced/educated all CNAs on toileting residents that require extensive/dependent transfers and verifying closet care plan in regards to the assistance a resident requires. All alert and oriented residents that require extensive/dependent assist for transferring to the toilet interviewed regarding if they are left alone in the restroom. All responded 'no'. 2.) One-on-one check-off sheets dated 3/28/19 and 3/29/19 provided by the Administrator on 4/23/19 documented all CNAs were retrained on gait belt transfers, mechanical lift competency and verification of residents' needs by checking the closet care plans. 3.) A Termination of Employment form dated 4/2/19 for CNA #1 documented, .Involuntary Termination . Violation Of Policies & Procedures . Other specific policy/procedure: Inappropriate R (resident) transfer (not) following P[NAME] (plan of care) . Other Involuntary Termination: Abuse/Neglect . A Termination of Employment form dated 4/2/19 for CNA #2 documented, .Involuntary Termination . Violation Of Policies & Procedures .Other specific policy/procedure: Inappropriate R (resident) transfer o (not) following P[NAME] (plan of care) .Other Involuntary Termination: Abuse/Neglect . 4.) The new Departmental Orientation, provided by the Administrator on 4/23/19 documented, Closet Care Plans and Patient Transfer Assessment as items to be covered with new staff. 5.) A monitoring form titled, Monitor to ensure appropriate toileting of extensive/dependent residents, documented observations were to be made for 2 residents, 3 times weekly for one week; then 2 residents, two times weekly for one week; then 1 resident 1 time weekly. The start date for this monitoring was 4/1/19 and the monitoring sheets indicated no further negative findings had been identified. 6.) On 4/22/19 at 2:05 p.m., Resident #1's Closet Care Plan was reviewed. Included in the interventions was an instruction, Do not leave unattended in bathroom. 7.) On 4/23/19 at 10:14 a.m., CNA #3 stated, .Since the fall, we have had training on transfers, gait belt transfers, lifts and checking the closet care plan . 8.) On 4/23/19 at 1:29 p.m., the Administrator stated, .We immediately started retraining on transfers to include gait belt and lift transfers and to check the closet care plan. Both aides were terminated. We did an action plan and have been monitoring ever since the incident. We also, a week after the incident, implemented a new departmental orientation for new employees. 9.) During the complaint investigation survey conducted from 4/17/19 to 4/23/19, a total of 5 CNAs were interviewed and asked about performing transfers and toileting assistance / supervision. All CNAs were aware to check the care plan for the level of assistance required for transfers and toileting and that a resident requiring assistance with toileting should never be left unsupervised.

Complaint # (AR 540) and # (AR 580) were substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure a thorough pressure ulcer assessment, including the condition of the wound bed and presence or absence of drainage or odor, was conducted and documented and failed to ensure treatment orders were promptly obtained and initiated to promote healing and prevent potential deterioration for 1 (Resident #3) of 6 (Residents #1, # 2, # 3, # 4, # 5, and # 6) case mix residents who had pressure sores. This failed practice resulted in actual harm for Resident #3 who had skin breakdown, which was not thoroughly assessed, documented and immediately reported to the physician, which resulted in a 4-day delay in treatment and deterioration of the wound. The failed practices had the potential to cause more than minimal harm to 6 residents who had pressure ulcers according to a list provided by the Director of Nursing (DON) on 2/15/19. The findings are: 1. Resident #3 was admitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. a. The Nursing Admit/Readmit Assessment and Care Plan dated 2/06/19 at 3:56 p.m. documented a Skin Integrity Assessment which documented the resident's skin was pale, warm, and dry; bruising was present to both arms and legs; skin was occasionally exposed to moisture; resident was chairfast; mobility was very limited; and there was a potential problem of friction and shear. The Braden Scale score was documented as 15, with a score of 15 to 18 indicating a risk for skin breakdown. The Care Plan section of the form had an area designated for documentation of pressure ulcers, which included an area to fill in the blanks for focus and goals. There were 18 possible interventions documented on the form, but none of them were checked as applicable to this resident. No existing wounds were documented. b. A Nsg (Nursing) Skin Observation Daily for Four Days form documented the following skin assessments: 1.) The assessment dated [DATE] at 12:00 a.m. documented, .Description . admission: right heel pressure 0.4 cm (centimeters) x (by) 0.5 cm. Left heel pressure 1.8 cm x 2.5 cm unstageable. No description of the color or condition of the wound bed or the presence or absence of odor or drainage was documented. 2.) The assessment dated [DATE] (not timed) was left blank, except for a note, which documented there were no new skin issues since the previous body audit. The remaining two days (2/9/19 and 2/10/19) of the four-day assessment form were not completed. c. A physician's orders [REDACTED]. The start date was documented as 2/09/19, two days after the pressure ulcer to the left heel was identified and documented on the four-day assessment form; however, the initial treatment documented on the (MONTH) 2019 Treatment Administration Record was dated 2/12/19. d. A Plan of Care (not dated) in the resident's electronic health record (EHR) did not address wound care or other skin integrity issues. e. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status and had 2 pressure ulcers present upon admission which were unstageable, due to coverage of the wound beds by slough and/or eschar. f. A Skin and Wound Evaluation form dated 2/13/19 at 3:05 p.m. for the right heel documented, Pressure deep tissue injury: persistent non blanchable deep red, maroon, or purple discoloration . How long has the wound been present? Unknown length 0.7 cm (centimeters) . width 0.7 cm. Wound bed: eschar 100%. Additional care: Heel suspension/protection device . The measurements from the previous week (on the 4-day assessment form) documented the measurements of the right heel pressure ulcer were 0.4 x 0.5 cm; therefore, the wound had increased by 0.3 cm in length and 0.2 cm in width. A Skin and Wound Evaluation dated 2/13/19 at 3:11 p.m. for the left heel documented, .pressure unstageable (obscured full thickness skin and tissue loss) left heel. Measurements . length 1.0 cm . width 0.8 cm . 70% eschar and slough / eschar present on admission. Additional care: Heel suspension / protection device . Based on these measurements, the left heel pressure ulcer had decreased in size by 0.8 cm in length and 1.7 cm in width since the previous week's assessment on the four-day assessment form. g. On 2/13/19 at 11:05 a.m., Licensed Practical Nurse (LPN) #1 was asked about pressure ulcer assessments for this resident and stated, The only documentation of the left and right heel for (Resident #3) is on the Nursing Skin Observation Daily for 4 Days (form) dated 2/7/19. There are measurements, but no description of the wounds. The Weekly Report will be completed today. The charge nurses are responsible for all body audits, and the body audits on admission and 4-day body audits, and reporting results to the Treatment Nurse. If it happens on a weekend, it is not reported until Monday morning, and the skin and wound evaluation is completed with actual measurements and descriptions of the wound. h. On 2/13/19 at 2:03 p.m., Resident #3 was in bed. The resident had blue foam booties on both feet. They were approximately ¾ inch thick, and her heels rested inside the booties, with a strap across her ankles. The booties were resting directly on the mattress, not offloaded. On the right heel, circling to the bottom of the foot, there was a dark-purple area measuring approximately 1 ½ inches in diameter, with dry, flaky skin surrounding the discolored area. The LPN #1 completed a treatment to the right heel, per the physician orders. The LPN then peeled off the left heel dressing, which was stuck to the wound bed, and soiled with a dark-colored exudate. The LPN cleansed the pressure ulcer with wound cleaner. The open, unstageable area was approximately nickel-sized in width and quarter-sized in length, and the wound bed was dark red. After the treatment was completed, the resident's booties were reapplied to both heels and the heels were not offloaded from the mattress. 2. On 2/15/19 at 10:27 a.m., the Director of Nursing was asked, if a nurse identifies a wound, what are the steps she/he should take initially? She stated, Assess the wound, notify the doctor and family. Receive the treatment order and implement the treatment. She was asked, how often are your nurses required to do wound measurements and descriptions? She stated, Weekly by the Treatment Nurse. She was asked, who is responsible for doing treatments on weekends or holidays? She stated, The floor nurses. She was asked, if a treatment is ordered three times a week, should that treatment be completed and documented on the treatment administration record three times a week? She stated, Yes. She was asked, should a nurse who is admitting a resident complete a full body audit, should she/he document all wounds, and should she/he notify the physician if any wounds are identified? She stated, Yes. She was asked, should a nurse who identifies a wound notify the physician and follow the orders given to treat the wound and complete the treatment during her shift? She stated, Yes or the Treatment Nurse if available. She was asked, if a resident has multiple wound treatments in the same location should those areas have weekly documentation and a means of identification? She stated, Each wound(s) should be identified individually, treated and documented individually. She was asked, if a resident has Deep Tissue Injury or pressure ulcers to the heel(s) what should the interventions be to prevent further pressure injury? She stated, Nutritional Supplements if ordered by the physician, bridge heels, off-loading the heels.