Every finding on record at Amie Holt Care Center

Based on observation, resident and staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented during meal delivery during 2 of 3 meal observations in the main dining room. The census was 32. The findings were: 1. Observation on 4/22/25 from 4:48 PM showed dietary aide #1 was taking orders for the evening meal using a pen and pad of paper. After obtaining the orders the dietary aide returned to the kitchen and obtained milk, coffee, and hot water, and served the beverages to residents with her fingers touching the rims of the cups. Further observation showed the dietary aide continued to serve beverages to residents in the same manner without performing hand hygiene. 2. Interview on 4/22/25 at 10:55 AM during resident council with resident # 20 revealed staff handled the cups at the top when they served beverages at meals. 3. Observation on 4/23/25 at 12:33 PM showed CNA #1 carried a beverage cup to a resident with her palm covering the top of the cup and fingers wrapped around the sides of the cup. Further observation at 12:37 PM showed CNA #2 carried another resident's beverage cup in the same manner. 4. Observation on 4/23/25 at 12:36 PM showed dietary aide #2 carried hot plates to residents with her shirt sleeves wrapped over her hands. The sleeves made full contact with the eating surface of the plate. 5. Interview on 4/24/25 at 8:50 AM with the dietary manager revealed her expectation was for staff to hold cups at the bottom when beverages were served to residents. 6. Review of the facility policy titled Hand Hygiene, last revised 11/2022 showed Hand hygiene (using either alcohol-based hand rubs or soap and water) should be performed before and after each resident contact and after contact with a resident's belongings, environmental surfaces, and resident care equipment . 2. Hands must be thoroughly washed with soap and water: (20 sec. minimum scrub time) .b. Prior to handling food (preparation or assistance with meals) .

Based on payroll-based journal (PBJ) staffing data report review, facility time clock records review, staff interview, and policy and procedure review, the facility failed to submit to CMS complete and accurate direct staffing information for 28 days out of a 10-month period (March 1, 2024 through December 31, 2024). The findings were: 1. Review of PBJ staffing data report for quarter 4 of fiscal year 2024 and quarter 1 of fiscal year 2025 showed the facility failed to ensure eight consecutive RN hours for 10 days, 8/18, 8/25, 9/1, 9/25, 9/28, 9/29, 10/5, 10/12, 10/20 and 10/26. Further review of the PBJ staffing data report showed the facility failed to have licensed nursing coverage 24 hours per day on 8/18, 8/24, 8/25, 8/31, 9/1, 9/2, 9/7, 9/8, 9/14, 9/15, 9/21, 9/22, 9/23, 9/24, 9/25, 9/27, 9/28, 9/29, 9/30, 10/1, 10/2, 10/5, 10/6, 10/12, 10/13, 10/19, 10/20 and 10/26. 2. Review of facility time clock records showed the facility did have at least eight consecutive RN hours and did have licensed nursing coverage 24 hours per day on the above-referenced dates; however, they were not reported. 3. Interview with financial controller #1 on 4/24/25 at 10:24 AM revealed salaried staff members including the DON and team leaders did not clock in on the facility time clocks. She revealed the shifts where a salaried RN was the only RN on duty were not being reported in the PBJ data. 4. Review of facility policy titled Nurse Staffing provided by the DON on 4/24/25 showed, There will always be eight consecutive hours covered by an RN each day. The DON, PCC, or Team Leader may serve as the RN for these eight hours . Night shift will have one licensed nurse who is responsible for medication pass, treatments and supervisor/charge nurse . The [previous] is used as a guidance for minimum staffing. More staff may be scheduled leading to lower resident-to-staff rations as schedule and staffing allow.

Based on observation, staff interview, review of the dishwasher and refrigerator/freezer temperature log sheets, manufacturer's instructions, hot and cold food temperature logs, policy and procedures, and the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen and failed to ensure temperatures were monitored for 5 of 5 refrigerator/freezers which stored food for resident use outside of the kitchen (downstairs pantry, upstairs pantry, 100 hallway, 200 hallway, and 400 hallway). The census was 28. The findings were: Related to temperature monitoring of food storage units: 1. Review of the December 2023, the January 2024, and February 2024 temperature monitoring log sheets for food storage areas outside of the kitchen showed the following concerns: a. Review of the downstairs pantry refrigerator/freezer log sheets showed the temperature of the refrigerator/freezer was to be checked by the evening shift CNA daily. The facility was unable to locate the December log sheet. The January log sheet showed 6 out of 31 days and the February log sheet showed 7 out of 27 days that failed to include documentation of the temperature of the refrigerator/freezer. In addition, the January log sheet showed 22 days and the February log sheet showed 7 days where the temperature of the freezer was not documented. b. Review of the upstairs pantry refrigerator/freezer log sheets showed the temperature of the refrigerator/freezer was to be checked by the evening shift CNA daily. The facility was unable to locate the December log sheet. The January log sheet showed 6 out of 31 days and the February log sheet showed 4 out of 27 days that failed to include documentation of the temperature of the refrigerator/freezer. In addition, the January log sheet showed 5 days and the February log sheet showed 1 day where the temperature of the freezer was not documented. c. Observation on 2/28/24 at 4:19 PM showed a small Midea refrigerator was located in the 200 hallway which contained drinks and snacks for resident consumption. There was no evidence the facility monitored the temperature of the refrigerator. d. Observation on 2/28/24 at 4:21 PM showed a small GE refrigerator was located in the 100 hallway which contained drinks and snacks for resident consumption. There was no evidence the facility monitored the temperature of the refrigerator. e. Observation on 2/28/24 at 4:25 PM showed a small Hanai refrigerator was located in the 400 hallway which contained drinks and snacks for resident consumption. There was no evidence the facility monitored the temperature of the refrigerator. f. Interview on 2/28/24 at 12:10 PM with team leader #2 revealed she was unable to locate the December 2023 log sheets for the downstairs and upstairs pantry refrigerator/freezers. g. Interview on 2/28/24 at 4:17 PM with the RAC revealed a system had not been developed to monitor the small refrigerators in the resident common rooms. In addition, the RAC confirmed the temperature log sheets were incomplete. 2. Review of the December 2023, the January 2024, and February 2024 CC Cooling Unit Temp Log sheets showed columns to record the temperature of the Cook's Fridge, the A la Carte Top & Bottom, the Office Fridge & Freezer, the Double Fridge, the Single Fridge, the Single Freezer, the Double Freezer, and the [NAME] Freezer used for food storage equipment inside the kitchen. The following concerns were identified: a. Review of the December 2023 temperature log sheet showed 10 days when the temperature of the food storage equipment was not recorded. b. Review of the January 2024 temperature log sheet showed 5 days when the temperature of the food storage equipment was not recorded. c. Review of the February 2024 temperature log sheet showed 4 out of 27 days where the temperature of the food storage equipment was not recorded. d. Interview with the dietitian on 2/28/24 at 4:30 PM revealed it was her expectation the temperature of the food storage equipment be monitored daily. 3. Review of the policy and procedure titled PREPARING AND HOLDING FOOD last reviewed in 2019, showed POLICY: The use of proper techniques for preparation and holding of foods. Adherence to established sanitation practices in food service and holding, to protect foods from contamination and reduce the potential for food borne illness outbreak. PROCEDURE: .9. Cold food items are refrigerated at 41 degrees or below . 4. According to the 2022 FDA Food Code 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that .(J) FOOD EMPLOYEES are properly maintaining the temperature of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS during thawing through daily oversight of the FOOD EMPLOYEE'S routine monitoring of FOOD temperatures . Related to the sanitary environment of the kitchen: 1. Observation on 2/27/24 at 8 AM showed cook #1 was preparing made to order breakfast for residents in the facility kitchen. The cook was not wearing a beard restraint over his facial hair. Interview with the cook on 2/27/24 at 8:18 AM revealed he had not received any education related to wearing a beard restraint while preparing or serving food. Interview on 2/28/24 at 4:30 PM with the dietitian revealed it was her expectation kitchen staff with facial hair wear a beard restraint while preparing and serving food. 2. Observation on 2/27/24 at 8:07 AM showed cook #1 removed a glove from his left hand and used hand sanitizer before donning a new glove. Interview with the cook at 8:18 AM revealed he used hand sanitizer after removing his gloves unless his hands were visibly soiled and then he would wash them with soap and water. The hand sanitizer used was 3M Avagard and was labeled as healthcare personnel hand sanitizer. Interview with the dietitian on 2/28/24 at 4:30 PM confirmed hand sanitizer should not be used in the kitchen and removed the bottle at that time. 3. Observation on 2/26/24 at 4:04 PM showed the Traulsen freezer had opened original bags, of what appeared to be breaded meat, which was not labeled with an open or expiration date. The Continental freezer showed multiple plastic bags, with what appeared to be breaded meats, which were not labeled with an open date or an expiration date. The [NAME] upright freezer showed multiple plastic bags, both original and resealable, which were unlabeled and undated and had what appeared to be a build-up of frost. Interview with the dietitian on 2/28/24 at 4:30 PM revealed opened frozen food should be transferred to a storage bag and labeled with the open date and an expiration date of 6 months. The dietitian was unable to locate a food storage guide for staff to reference. 4. Observation on 2/26/24 at 4:04 PM showed the kitchen contained a [NAME] high-temperature dishwashing machine. Review of the December 2023, January 2024, and February 2024 CC Dishmachine Temps log sheets showed the temperature of the wash and rinse water was to be measured 3 times per day. Review of the [NAME] dishmachine manufacturer's instructions showed the minimum wash temperature was 150 degrees Fahrenheit and the minimum rinse temperature was 180 degrees Fahrenheit. The following concerns were identified: a. Review of the temperature log sheets showed the required temperature of the wash and rinse water was not documented on the form. b. Review of the December 2023 log sheet showed the temperature of the wash and rinse water was not checked 28 out of 93 opportunities. Of the 65 recorded temperatures the wash water was below 150 degrees Fahrenheit 41 times and the temperature of the rinse water was below 180 degrees Fahrenheit 21 times. c. Review of the January 2024 log sheet showed the temperature of the wash and rinse water was not checked 9 out of 93 opportunities. Of the 84 recorded temperatures the wash water was below 150 degrees Fahrenheit 38 times and the temperature of the rinse water was below 180 degrees Fahrenheit 14 times. d. Review of the February 2024 log sheet showed the temperature of the wash and rinse water was not checked 23 out of 77 opportunities. Of the 54 recorded temperatures of the wash water it was below 150 degrees Fahrenheit 26 times and the temperature of the rinse water was below 180 degrees 2 times. e. Interview with dietary aide #1 on 2/27/24 at 8:15 AM revealed she was not aware of what the temperature ranges for the dishwasher were supposed to be and only recorded the results. The dietary aide stated she had been an employee for approximately 1 month. f. Interview with the dietitian on 2/28/24 at 4:30 PM revealed it was her expectation the temperature of the wash and rinse water be monitored as directed on the log sheet. In addition, the dietitian confirmed the temperature ranges of the wash and rinse water were not readily available for staff to reference. 5. Interview on 2/27/24 at 8:18 AM with cook #1 revealed breakfast was served from 6 AM to 9 AM and was the only meal which was prepared in the facility. The hospital kitchen prepared the noon and evening meals for the residents. The hospital was located across the parking lot and the food was brought to the facility via an enclosed foodservice cart and placed on the steam table. The following concerns were identified: a. Review of the January 2024 food temperature log showed 82 out of 93 opportunities failed to show documentation of the food's temperature before it was served to residents. b. Review of the February 2024 food temperature log showed 64 out of 72 opportunities failed to show documentation of the food's temperature before it was served to residents. c. Review of the December 2023, January 2024, and February 2024 Cool Check Temp Log which was used to monitor the temperature of the juice and milk which was kept outside of the storage units during each meal. The December log sheet showed 58 out of 93 opportunities had not been recorded. The January log sheet showed 37 of 93 opportunities had not been recorded. The February log sheet showed 57 out of 78 opportunities had not been recorded. d. Observation and interview with dietary aide #1 on 2/27/24 at 8:15 AM showed the dietary aide was checking the temperature of the juice and the milk. The dietary aide stated she was unaware of when the temperature of the cold liquids should be taken and did not know where the temperatures were recorded. e. Interview with the dietitian on 2/28/24 at 4:30 PM revealed it was her expectation the temperature of the cold liquids should be obtained prior to being placed back into storage after the meal service, and the temperature of food items should be taken prior to meal service. 6. Review of the policy and procedure titled Food Service Uniforms/Grooming, last revised in 2019, showed Policy: To establish and maintain a high standard of cleanliness .Procedure: 1. Hair must be clean and neatly groomed while on duty .Hair needs to be secured in a surgical cap or hair net. 2. Mustaches should be kept to moderate length and well trimmed. Extremely long or full mustaches will not be permitted. 7. Review of the 2022 FDA Food Code showed 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 8. According to the 2022 FDA Food Code showed 2-301.16 Hand Antiseptics. In the 2005 Food Code, the use of the term hand sanitizer was replaced by the term hand antiseptic to eliminate confusion with the term sanitizer, a defined term in the Food Code, and to more closely reflect the terminology used in the FDA Tentative Final Monograph for Health-Care Antiseptic Drug Products for OTC Human Use, Federal Register: June 17, 1994. In addition, 2-301.16 Hand Antiseptics (A) A hand antiseptic used as a topical application, a hand antiseptic solution used as a hand dip, or a hand antiseptic soap shall: (1) Comply with one of the following: (a) Be an APPROVED drug that is listed in the FDA publication Approved Drug Products with Therapeutic Equivalence Evaluations as an APPROVED drug based on safety and effectiveness; (b) Have active antimicrobial ingredients that are listed in the FDA monograph for OTC Health-Care Antiseptic Drug Products as an antiseptic handwash, . 9. According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 10. Review of the 2022 FDA Food Code showed 4-703.11 Hot Water and Chemical. Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. Other parameters, such as rinse pressure, temperature, and chemical concentration are used in combination with time to achieve sanitization. When surface temperatures of utensils passing through warewashing machines using hot water for sanitizing do not reach the required 71 C (160 F), it is important to understand the factors affecting the decreased surface temperature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in SS 4-501.112 and 4-501.113. If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Pressures below the specified limit will result in incomplete coverage of the heat-conveying sanitizing rinse across utensil surfaces. 11. Review of the policy and procedure titled PREPARING AND HOLDING FOODS, last reviewed in 2019, showed PROCEDURE .11. Food Items (sic) will be prepared in batches and placed on the tray line no more than 1/2 hour prior to meal service. Temperatures of foods in heated holding units are recorded previous to service of each meal, and recorded on each hour the food is held in heated holding units to insure (sic) the safety of food is maintained.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure residents' private health information was protected for 3 out of 16 (#11, #19, #26) resident rooms observed and during multiple random observations of the medication cart. The census was 28. The findings were: 1. Random observation on 2/26/24 from 4 PM to 6 PM showed LPN #1 left the medication cart unattended (not in the vicinity) several times with private medical information observable on the computer screen (EMR) which included the resident's name, medication, medication dose, and administration time, and was visible for unauthorized people to read. Staff from different departments, visitors, and other residents were noted to pass by the medication cart during this timeframe. 2. Observation on 2/27/24 at 8:03 AM showed LPN #2 left the medication cart with the EMR visible and unsecured in the dining room. 3. Observation on 2/28/24 at 9:21 AM showed LPN #1 had left the medication cart unsecured with visible EMR in the intersection of the 100 and 200 hallways. 4. Observation on 2/28/24 showed residents (#11, #19, #26) had their care plans pinned to the cork board immediately upon entrance into each of the resident's rooms and visible from the hallway. The information included the resident's birth date, medications, their incontinence status, transfer requirements and wound information. 5. Interview on 2/28/24 at 4:52 PM with the RAC confirmed the resident care plans should have been located inside the resident's closet and not pinned to the cork board. 6. Interview on 2/29/24 at 11:12 AM with the RAC, while observing EMR unsecured information on the medication cart, revealed it was the facility's expectation to follow HIPAA (Health Insurance Portability and Accountability Act) policies. 7. Review of the facility policy titled HIPAA 0042, dated April 14, 2003 showed: 1. The purpose of this policy is to maintain an adequate level of security to protect patient, resident, client and facility information from unauthorized access .

Based on medical record review and staff interview, the facility failed to ensure an advanced directive was formulated for 1 of 16 residents (#25) reviewed. The findings were: 1. Review of the electronic medical record (EMR) showed resident #25 was listed as do not resuscitate (DNR). Further review of the medical record showed no evidence of an advanced directive signed by the resident or the resident's representative. 2. Interview on 2/27/24 at 2:21 PM with the NHA and the RAC confirmed the facility did not have a record of the DNR status of the resident.

Based on medical record review, staff interview, and review of facility policies and CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 2 of 5 sample residents (#7, #20) reviewed for immunizations. The findings were: 1. Review of the medical record showed resident #7 was [AGE] years old. Further review showed the resident received the pneumococcal 13 valent conjugate (PCV13) on 2/1/18. There was no evidence the resident was offered a pneumococcal immunization since the last administration in 2018. 2. Review of the medical record showed resident #20 was [AGE] years old. Further review showed the resident received the PCV13 on 10/28/14. There was no evidence the resident was offered a pneumococcal immunization since the last administration in 2014. 3. Interview with the NHA on 2/28/24 at 5:53 PM revealed the facility followed CDC recommendations for immunizations and confirmed there was no evidence resident #7 or resident #20 were offered pneumococcal immunizations in accordance with CDC guidelines. 4. Review of the facility's policy Pneumococcal Immunization, effective 10/9/07, showed 1. Upon admission and annually, resident's immunization history will be obtained, including compliance with current CDC recommendations for pneumococcal vaccination . 5. According to the Adult Immunization Schedule by Age by CDC located at https://www.cdc gov/vaccines/schedules/hcp/adult.html (accessed on 3/12/24) showed individuals [AGE] years or older who previously received only the PCV13 vaccine should receive 1 dose of either the PCV20 or PCVS23 vaccine at least 1 year after the last PCV13 dose.

Based on observation, review of temperature log sheets, staff interview, and manufacturer's instructions, the facility failed to ensure the temperature of 1 of 1 medication storage refrigerator was monitored. The findings were: 1. Observation on 2/28/24 at 10:25 AM of the medication storage room showed a GE refrigerator contained medications for resident use which included Ozempic (a diabetic medication) and eye drops. The follow concerns were identified: a. Review of the temperature monitoring logs from 2/24/24 to 2/28/24 showed the facility failed to record the temperature of the medication storage refrigerator. b. Observation on 2/28/24 at 10:25 AM showed the thermometer inside the refrigerator read 32 degrees Fahrenheit. 2. Interview on 2/28/24 at 4:11 PM with the RAC revealed it was the facility's expectation the temperature of the medication storage refrigerator be monitored every shift and be recorded. 3. Review of the Temperature Ranges For GE Refrigerators with no date, provided by the facility on 2/29/24 at 12:38 PM showed The temperature ranges available .can vary depending on which model you have. However, in general, here's what you can expect:. the coldest setting 34 degrees Fahrenheit and 42 degrees Fahrenheit for the warmest setting with a default of 37 degrees. 4. According to https://www.ozempic.com/how-to-take/ozempic-pen.html?showisi=true&&utm_source=google&utm_medium=cpc&utm_term=storage%20ozempic&utm_campaign=1_All_Shared_BR_Branded_Specifics_2023&mkwid=s-dc_pcrid_676991889727_pkw_storage%20ozempic_pmt_p_slid__product_&pgrid=158457156870&ptaid=kwd-450547815488&gad_source=1&gclid=CjwKCAiAxaCvBhBaEiwAvsLmWA2ppY3FA1OKj4n6UpEAzmPLZfnDsX_O4tvOjCzi7Aw8RF6KM1YmuhoC38EQAvD_BwE&gclsrc=aw.ds retrieved on 3/6/24 at 11:23 AM showed: How to store your Ozempic(R) pen . Store your new, unused Ozempic(R) pens in the refrigerator between 36 F to 46 F (2 C to 8 C) and Do not freeze Ozempic(R). Do not use Ozempic(R) if it has been frozen.

Based on observation, staff interview, review of the food code, and policy and procedure review, the facility failed to ensure sanitary meal service during 1 of 2 meal observations. The census was 32. The findings were: 1. Observation on 2/2/22 at 4:20 PM showed cook #1 left the griddle area and without removing her gloves or performing hand hygiene, obtained a pot holder, opened the oven, and removed a tray of bacon. She checked the bacon, opened the oven, and returned the bacon to the oven. The cook left the service area and entered the storage area, opened a drawer, and obtained a pair of tongs. Without removing her gloves or performing hand hygiene she returned to the griddle area, touched a slice of french toast with her gloved left hand and tongs in her right hand, to remove the french toast from the griddle. She placed the french toast on the steam table and used her gloved left hand to reposition the french toast in the pan on the steam table. The cook returned to the griddle and without removing her gloves or performing hand hygiene, reached into the bread bag, and obtained two more slices of bread which she placed in the egg mixture. She used the tongs to place the slices on the griddle. 2. Observation on 2/2/22 at 4:39 PM showed after donning clean gloves and preparing additional french toast, cook #1 then touched the refrigerator door, a tray, the steam table surface, the refrigerator door, raw eggs, and a gallon of milk. The cook reached to the top of her head, removed a pair of glasses resting in her hair, and placed the glasses in her pocket. Without changing gloves or performing hand hygiene, she returned to the griddle area, removed two slices of bread from the bag with her gloved hand, placed them in the mixture, and used tongs to place them on the griddle. 3. Observation on 2/2/22 at 4:50 PM showed cook #1 used her gloved left hand to pull the bottom of her facemask out and then returned it to her face. The cook entered the food storage area, obtained a tray of ham sandwiches and a tray of fruit from the refrigerator, and returned to the steam table where she placed the sandwiches and fruit on a cart near the steam table. The cook used tongs to pull half the cooked french toast off of the steam table and placed it on a cutting board. Without changing gloves or performing hand hygiene, the cook placed her gloved left hand on the top of the cooked french toast and cut it with a knife in her right hand. 4. Observation on 2/2/22 at 4:54 PM showed cook #1 continued to wear the same gloves, and obtained a pot holder, opened the oven, and removed a tray of meat patties. She placed the meat patties on the steam table, went to the food storage area, obtained a robocoup container, and placed some meat patties in the container. The cook returned to the food storage area, placed the robocoup container on the base, and turned it on to puree the meat patties. After running the device and while wearing the same gloves, she removed the container, placed her gloved finger in the mixture, and moved it around. 5. Interview with the dietary manager on 2/3/22 at 10:06 AM revealed the facility expectation was for staff to perform hand hygiene and change gloves anytime they touch an area that may have been contaminated and when a new task was started. Further interview confirmed hand hygiene and glove changes were necessary to prevent food-borne illnesses. 6. Review of the policy titled Hand Washing For Food Service last reviewed 2019 showed .Frequency: 1.) Before starting work in the kitchen. 2.) After handling soiled dishes and utensils. 3, Before and after handling foods with bare hands (the making of homemade bread items). 4.) After going to the toilet, after sneezing, after using a handkerchief or kleenex. 5.) Before and after eating or smoking. 6.) After leaving a patient' or resident' room. 7.) After touching bare human body parts other than the clean hands and clean, exposed portions of the arms. 8.) When switching between working with raw food and working with ready to eat foods. 9.) During preparation as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . 7. According to Food Code 2017, U.S. Public Health Service: 2-301.14 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLE and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on resident and staff interview and medical record review, the facility failed to ensure resident preferences were assessed and implemented for 3 of 4 sample residents (#3, #17, #82) reviewed for bathing. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive physical assistance of 1 person for dressing, toilet use, personal hygiene, and bathing. Further review showed the resident felt it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. The following concerns were identified: a. Interview with the resident on 2/1/22 at 11:51 AM revealed s/he received a shower or bath one time each week; however, s/he would like to bathe more often. Further interview revealed s/he would have to stay up until after everyone else was asleep for additional bathing requests. b. Review of the bathing record from 11/1/21 to 2/2/22 showed the resident usually received bathing 1 time per week; however, there was no documented bathing or resident refusal from 12/22/21 until 42 days later on 2/2/22. c. Review of the care plan showed no evidence of the resident's bathing preferences. 2. Review of the annual MDS assessment dated [DATE] showed resident #82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The resident required limited physical assistance of 1 person for personal hygiene and total physical assistance of 2 or more people for toilet use and bathing. The following concerns were identified: a. Interview with the resident on 2/1/22 at 2:29 PM revealed the resident received a shower or bath one time per week; however, s/he would like one more often. b. Review of the bathing record between 11/1/21 and 2/1/22 showed the resident usually received bathing one time per week; however, the resident did not receive bathing for 21 days between 12/13/21 and 1/3/22, 14 days between 1/3/22 and 1/17/22, and there was no documented bathing for 16 days between 1/17/22 and 2/1/22. c. Review of the care plan showed no evidence of the resident's bathing preferences. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS assessment dated [DATE] showed the resident felt it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. The following concerns were identified: a. Interview with the resident on 2/1/22 at 1:52 PM revealed the resident received a shower or bath one time per week; however, s/he would like at least 2. b. Review of the bathing record between 11/1/21 and 1/31/22 showed the resident received bathing 1 time per week. c. Review of the care plan showed no evidence of the resident's bathing preferences. 4. Interview with CNA #2 on 2/3/22 at 9:11 AM confirmed residents were scheduled to receive showers or baths 1 time per week. She confirmed there were a couple residents who wanted to be bathed more frequently and the facility was able to do it for them because they were more independent. 5. Interview with RN #1 on 2/3/22 at 9:17 AM revealed the facility discussed bathing at the time of admission; however, she was unsure how it was determined one bath per week was enough. Further interview revealed the facility did not assess residents for bathing preferences and bathing preferences were not included on the care plan. 6. Interview with the DON on 2/3/22 at 10:26 AM revealed the bath aide offered a tub bath once per week and residents could have showers more frequently. Further interview revealed activitiy personnel asked residents about bathing preferences; however, she was unsure what happened to the information after the assessment was performed.

Based on medical record review, and resident and staff interview, the facility failed to ensure residents received assistance with bathing for 3 of 4 sample residents (#3, #82, #132) reviewed for bathing. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 15 out 15, which indicated the resident was cognitively intact. The resident required extensive physical assistance of 1 person for dressing, toilet use, personal hygiene, and bathing. Further review showed the resident felt it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. The following concerns were identified: a. Interview with the resident on 2/1/22 at 11:51 AM revealed s/he received a shower or bath one time each week; however, s/he would like to bathe more often. Further interview revealed s/he would have to stay up until after everyone else was asleep for additional bathing requests. b. Review of the bathing record between 11/1/21 and 2/2/22 showed the resident usually received bathing 1 time per week; however, there were no documented baths or resident refusals from 12/22/21 until 42 days later on 2/2/22. c. Review of the care plan showed no evidence of the resident's bathing preferences. 2. Review of the annual MDS assessment dated [DATE] showed resident #82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 15 out 15, which indicated the resident was cognitively intact. The resident required limited physical assistance of 1 person for personal hygiene and total physical assistance of 2 or more people for toilet use and bathing. The following concerns were identified: a. Interview with the resident on 2/1/22 at 2:29 PM revealed the resident received a shower or bath one time per week; however, s/he would like to bathe more often. b. Review of the bathing record between 11/1/21 and 2/1/22 showed the resident usually received bathing one time per week; however, the resident did not receive bathing for 21 days between 12/13/21 and 1/3/22, 14 days between 1/3/22 and 1/17/22, and there was no documented bathing for 16 days between 1/17/22 and 2/1/22. c. Review of the care plan showed no evidence of the resident's bathing preferences. 3. Review of the admission history and physical dated 1/10/22 showed resident #132 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed mentating well, clear speech. The following concerns were identified: a. Interview with the resident on 2/3/22 at 11:06 AM revealed the resident's preference for bathing was to bathe every third day. b. Review of the bathing record between 1/10/22 and 2/3/22, showed the resident had only received baths on 1/14/22, 1/18/22, and 1/24/22. There were no documented baths or refusals or after 1/24/22. c. Review of a progress note dated 1/13/22 showed social services documented the resident's family expected the resident to receive a bath every 3-4 days. d. Review of the care plan showed no evidence of the resident's bathing preferences. 4. Interview with CNA #2 2/3/22 at 9:11 AM revealed the staff member who was scheduled to perform bathing that day had called in, the DON performed some of the bathing that day, and the staff member who usually performed bathing was on light duty. 5. Interview with the DON on 2/3/22 at 10:26 AM revealed residents should receive a bath at least once per week and the facility did not have a bathing policy. Further interview revealed the facility had difficulty with staffing due to COVID-19.

Based on observation, medical record review, and staff interview the facility failed to ensure the comprehensive care plan was revised when resident care needs changed for 1 of 13 sample residents. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident did not have any pressure injuries. Review of the quarterly MDS assessment dated [DATE] showed the resident had 4 pressure injuries. The following concerns were identified: a. Observation of a dressing change on 2/1/22 at 2:31 PM showed healing wounds on the top of the second and fourth toes on the right foot and second and third toes of the left foot. b. Interview with LPN #1 on 2/1/22 at 2:31 PM revealed that she frequently did the dressing changes and presumed the care plan directed the activity. c. Review of the care plan dated 1/21/21 showed resident #3 will be/remain free of impaired skin integrity thru next qtr [quarter]. Care of open wounds was not addressed.

Based on observation, medical record review, staff interview, and review of resident rights, the facility failed to ensure residents were treated with dignity and respect during 1 of 2 meal observations, which affected resident #25. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident required total physical assistance of 1 person for eating. The following concerns were identified: a. Observation on 2/2/22 at 5:22 PM showed CNA #1 was seated at a dining table and was assisting the resident to eat. The CNA received a phone call, on her personal cell phone, reached into her pocket to obtain the phone, and answered the call. The CNA placed the phone between her ear and shoulder, and held the phone with her head. The CNA continued to assist the resident to eat his/her meal. Continued observation showed the CNA stood up and left the dining room table. The resident's meal was left on the table in front of the resident and no additional assistance was provided until the CNA returned. b. Interview with CNA #1 on 2/2/22 at 6:10 PM revealed the facility expectation was for staff to step out of the dining room if they received a personal call while assisting residents to eat. c. Interview with the DON on 2/3/22 at 10:19 AM revealed staff should not take personal calls while assisting residents to ensure they are engaged with the resident and ensure the resident feels important. Further interview confirmed staff should tell the resident they have to step away and take personal calls outside of the dining area if it was necessary. 2. Review of the Nursing Home Residents' Rights provided by the facility on 2/3/22 showed Residents have the right to: .Right to a Dignified Existence: Be treated with consideration, respect, and dignity; .

Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications for 3 of 6 residents reviewed (#15, #20, #35) for medications. The findings were: 1. Review of the medical record for resident #15 showed the resident was admitted to the facility on [DATE] with a physician order [REDACTED]. 2. Review of the medical record for resident #20 showed the resident was admitted to the facility on [DATE] with a physician order [REDACTED]. 3. Review of the medical record for resident #35 showed the resident was admitted to the facility on [DATE]. Review of the physician orders [REDACTED]. Further review showed no evidence the resident's physician had provided justification for the continued use of the antibiotic. 4. Interview with the facility's pharmacist on 2/25/21 at 9:37 AM revealed she had recently addressed resident #35's use of the [MEDICATION NAME] antibiotic with the physician and had recommended the medication be discontinued due to the antibiotic being ineffective. Further, she stated resident #15 and resident #20 were new admissions to the facility and she liked to let them settle in before adjusting their medications.

Based on observation, staff interview, product label review, and review of the 2017 food code, the facility failed to ensure food was properly stored and distributed under sanitary conditions in 2 of 2 food storage areas observed (main kitchen, first floor resident pantry) and failed to ensure outdated dairy products were not served to residents during 1 random observation which involved resident #12. The findings were: 1. Observation of the resident refrigerator labeled Pantry on 2/22/21 at 3:55 PM showed a quart-sized container of Dairy Pure half and half with a use by date of 2/17/21, a thickened dairy drink with a use by date of 1/6/21, and a peach nectar drink dated 10/13/20 with a label which stated .refrigerate after opening and consume within 3 days. The refrigerator had a dried brown substance on the top shelf that had dripped down to the second through fifth shelves. In addition to the brown substance the bottom of the refrigerator also had dried orange debris adhered to the surface and the side storage compartments were discolored. 2. Observation on 2/24/21 at 10 AM of the same Pantry refrigerator showed the thickened dairy drink had been discarded, the Dairy Pure half and half with a use by date of 2/17/21 had been replaced with a carton that had a use by date of 2/21/21, and the peach nectar drink remained. The brown and orange substances in the refrigerator had been cleaned, however some orange stains were still visible behind the bottom storage unit, and the side storage compartments remained discolored. 3. Observation on 2/22/21 at 3:55 PM of the(NAME)heavy duty freezer found in the main kitchen showed: a. One plastic storage bag dated 5/15/20 was labeled pancake for puree and showed visible frost build-up in the bag. b. One plastic storage bag dated 6/6/20 was labeled french toast for puree and showed visible frost build-up in the bag. c. One plastic storage bag dated 8/15/19 was labeled gluten free wild blueberry muffins and showed visible frost build-up in the bag. d. One plastic storage bag dated 7/20/20 was labeled gluten free muffins and showed visible frost build-up in the bag. e. A loaf of soft white bread in the original packaging had a date of 9/5/20 and showed visible frost build-up in the bag. f. A plastic storage bag dated 11/19/19 was labeled gluten free rolls and showed visible frost build-up in the bag. g. One plastic storage bag dated 2/16/20 was labeled birthday cake and showed visible frost build-up in the bag. h. One box of Vans gluten free blueberry waffles had a use by date of 2/20/21. i. One box of Vans gluten free original waffles had a use by date of 1/6/21. 4. Observation on 2/24/21 at 4:30 PM showed a quart-sized carton of half and half with a use by date of 2/21/21 was on the cold storage area of the service line in preparation for the evening meal. At 5:01 PM a CNA was observed pouring some of the half and half into a mug of coffee and then served the beverage to resident #12. 5. Interview with cook #1 on 2/24/21 at 4:39 PM revealed the Pantry refrigerator/freezer had snacks, juice, and ice cream available to the residents after the kitchen closed in the evening. 6. Interview and observation of the Pantry refrigerator with the dietary manager on 2/25/21 at 10:34 AM revealed it was the night CNA's responsibility to clean and discard the outdated food in the Pantry refrigerator. In addition, she stated the(NAME)freezer was used to store gluten-free products for a resident that no longer resided at the facility. The dietary manager discarded the outdated food from the Pantry refrigerator and the half and half from the cold storage area of the service line at that time. 7. According to Food Code 2017, U.S. Public Health Service: 4-601.11 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation and staff interview, the facility failed to ensure medications available for use were not expired in 1 of 1 medication storage areas. The findings were: 1. Observation of the medication storage area on [DATE] at 10:41 AM showed approximately one half of a box of [MEDICATION NAME] 10 milligram suppositories stored in the refrigerator had an expiration date of ,[DATE]. Interview with RN #1 at that time revealed she was unsure whose responsibility it was to check for outdated medication. Further, she stated outdated medication should not have been accessible for resident use. 2. Interview with the DON on [DATE] at 11:10 AM confirmed the outdated medications should have been removed from the medication storage room.

Based on observation, medical record review, staff and resident interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that MDS assessment information was an accurate reflection of resident status for 1 of 12 sample residents (#11). The findings were: 1. Review of the [DATE] quarterly MDS assessment showed resident #11 was admitted to the facility on [DATE] and wandered 4 to 6 times during the 7-day look-back period. The following concerns were identified: a. Observation starting at [DATE] at 9:10 AM showed the resident propelled his/her wheelchair either to the dining room or to the common area of the facility. b. Review of the progress notes from [DATE] through [DATE] showed no wandering was documented during that time period. c. Review of care plan showed wandering had not been addressed. d. Interview with MAC #1 on [DATE] at 9 AM revealed wandering had never been a concern for the resident. Further, the resident was confined to a wheelchair due to weakness, and never traveled more than from the resident's room to the dining room or to activities. e. Interview with the resident on [DATE] at 5:11 PM revealed s/he had not been able to walk for several years, was wheelchair bound, and relied on the staff for assistance. 2. Interview with the resident assessment coordinator on [DATE] at 2:21 PM revealed she had always coded the resident for wandering, however was unsure as to where the information came from. 3. According to the MDS RAI Manual version 1.71.1 page 201 E0900 .Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to his or her physical or safety needs. The resident may have a purpose such as searching to find something, but he or she persists without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes she must find her mother, who staff know is deceased ) .Traveling via a planned course to another specific place (such as going to the dining room to eat a meal or to an activity) is not considered wandering.

Based on medical record review, incident report review, emergency medical services report review, emergency room note review, and staff interview, the facility failed to ensure adequate supervision to prevent falls and/or injuries for 1 of 4 sample residents (#2) with falls. The findings were: Review of the quarterly MDS assessment dated [DATE] showed resident #2 had [DIAGNOSES REDACTED]. Review of the care plan, last modified on 4/22/19, showed the resident had impaired thought process and decision making, impaired ADL function with a high risk for falls/potential for injury, and required staff assistance of one for transfers to bed, wheelchair, and toilet. Review of the fall record which was attached as part of the care plan showed the resident had falls on 3/26/18, 5/12/18, 6/22/18, 7/12/18, and 10/24/19. The following concerns were identified: a. Review of the incident report dated 10/24/19 at 3:30 PM showed the resident was on an activity outing at a local movie theater. The resident was seated in his/her wheelchair in the lobby while other residents were being moved to the lobby. The resident was able to independently propel the wheelchair, left the lobby area, rolled down a ramp, and tipped the wheelchair outside. The report showed the resident was not supervised by staff during the incident. b. Review of the emergency medical services report dated 10/24/19 and timed 4:29 PM showed the patient had some pain upon palpation to the right side of the hip and some pain in the lower c-spine. We noted an abrasion and contusion to the top of the patient's head which was not actively bleeding. c. Review of the emergency room note dated 10/24/19 and timed 5:46 PM showed following a head CT (computerized tomography) and x-ray of hip/pelvis a clinical impression of fall with contusions, abrasions. Patient will rest, use ice for swelling, continue current medications, and follow-up in the ED (emergency department) or with primary care physician with any concerning symptoms. The resident returned to the facility that same evening. d. Interview with activity aide #1 on 12/12/19 at 4:20 PM revealed the resident was one of our best and most active residents .went everywhere and did everything. The aide stated the resident had been to the senior movie night at the theater before. During the incident we had left a few residents in the lobby and (had) gone to get the others. Why (she/he) left and went outside we don't know. We just found (him/her) at the bottom of the ramp by the bus. e. Interview with the DON on 12/13/19 at 9:22 revealed following the incident on 10/24/19 education was provided to the activity staff and new procedures were established. She provided a document stating the incident was discussed at the facility's meetings and future outings that include residents getting off the bus would require 4 staff members to be present. The DON verified there was no documented monitoring of resident outings since the incident; however, she was confident there had been no outings since with less than four staff members to provide needed supervision.

Based on observation, medical record review, and staff interview, the facility failed to ensure bed rails were assessed for safety for 3 of 3 sample residents (#5, #27, #92) with bed rails. The findings were: 1. Observation on 5/13/19 at 3:19 PM showed resident #5 had bed rails attached to the upper portion of his/her bed. Review of a side rail safety assessment showed it was completed on 5/15/19. 2. Observation on 5/13/19 at 3:08 PM showed resident #27 had an air mattress and bed rails attached to the upper portion of the bed on each side. The right side of the bed was against the wall. Review of the medical record showed the last side rail safety assessment was completed on 1/10/17. 3. Observation on 5/13/19 at 3:10 PM showed resident #92 had a raised perimeter air mattress and bed rails attached to the upper portion of the bed. Review of a side rail safety assessment showed it was completed on 5/15/19. 4. Interview with the DON on 5/15/19 at 5:36 PM revealed there were no previous side rail assessments for resident #5 or #92 and the facility did not have a timeline for re-evaluation of side rails. Further she revealed the facility wanted to update the form and then complete all side rail assessments.

Based on resident and staff interviews and medical record review, the facility failed to consistently provide restorative nursing care for 5 of 10 sample residents (#10, #27, #28, #37, #40) who required this care to maintain range of motion. The findings were: 1. Review of the 2/12/19 annual MDS assessment showed resident #10 had a brief interview for mental status (BIMS) score of 13 (cognitively intact), limited mobility, and inability to balance and transfer without assistance. Review of the 4/12/19 and 5/14/19 occupational therapy evaluation notes showed the resident had positioning, balance, and lower extremity functional deficits. Review of the (MONTH) 2019 nursing orders and problem activity records showed restorative interventions included lower extremity adduction, passive range of motion for ankle dorsiflexion, and passive range of motion for hamstring strength 3 to 5 times weekly. This review also showed group exercises and active range of motion were to be provided 1 to 3 times weekly. Review of the 4/1/19 to 5/14/19 (a total of 6 weeks) problem activity records showed some or all of the restorative interventions were performed on only 6 days (4/8/19, 4/19/19, 4/30/19, 5/6/19, 5/7/19, and 5/13/19). Further review showed on 6 days during the same time period staff documented the resident did not want restorative interventions due to pain, or declined without giving a reason. 2. Review of the 3/18/19 significant change MDS assessment showed resident #27 had a BIMS score of 5 (severely impaired), limited range of motion in the upper and lower extremities, and an inability to balance and transfer without assistance. Further review showed the resident required extensive assistance of 1 person for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of the (MONTH) 2019 nursing orders and problem activity records showed restorative interventions included supine knee flexion/extension 5 to 10 repetitions 1 to 3 times weekly, seated marching 10 repetitions 1 to 3 times weekly, seated knee flexion 10 repetitions, 1 to 3 times weekly, shoulder flexion/extension 10 repetitions 1 to 3 times weekly, group exercise 1 to 2 times weekly, neck passive range of motion 1 to 3 repetitions for 30 seconds 1 to 3 times weekly, bilateral heel cord stretch 5 times 1 minute or 1 to 5 minute stretch, and bilateral elbow flexion/extension 10 repetitions 1 to 3 times weekly. Review of the 4/1/19 to 5/14/19 (a total of 6 weeks) problem activity records showed no restorative activities or refusal of restorative was documented between 4/23/19 and 5/8/19 (16 days). 3. Review of the 3/18/19 significant change MDS assessment showed resident #28 had a BIMS score of 15 (cognitively intact), limited range of motion due to a stroke, and inability to balance and transfer without assistance. Review of the 3/15/19 occupational therapy evaluation notes showed the resident had decreased active and passive range of motion and the functional mobility goals were to participate with restorative exercises and walking 3 to 5 times weekly. Review of the 3/15/19 to 5/14/19 (a total of 8 weeks) problem activity records showed some or all of the restorative interventions were performed on only 11 days. Further review showed on 7 days during the same time period, staff documented the resident did not want restorative interventions due to pain or declined without giving a reason. Interview with the resident on 5/14/19 at 8:40 AM revealed s/he did not receive much benefit from the restorative program because it was primarily exercising during activities. The resident further stated it was not the same as having range of motion for specific areas of the body. 4. Review of the 4/14/19 quarterly MDS assessment showed resident #37 had a BIMS score of 15 (cognitively intact), and [DIAGNOSES REDACTED]. Review of the 1/4/19 occupational therapy evaluation notes showed the resident had mobility and balance deficits and was at risk for developing contractures. This review also showed the functional mobility goals were to participate with a restorative program and walk with the restorative CNAs 3 to 5 times weekly. Review of the 4/1/19 to 5/14/19 (a total of 6 weeks) problem activity records showed some or all of the restorative interventions were performed on only 13 days. Further review showed on 6 days during the same time period, staff documented the resident did not want restorative interventions due to pain or declined without giving a reason. 5. Review of the 4/21/19 quarterly MDS assessment showed resident #40 had a BIMS score of 15 (cognitively intact), required assistance with ambulation and had unsteady balance. Review of the current list of restorative interventions for the resident showed 11 different restorative interventions were to be performed 3 to 5 times weekly. Further review showed the 12th intervention was ambulation and it was to be performed 5 to 7 times weekly. Review of the 4/1/19 to 5/14/19 problem activity records showed the 11 interventions were not performed 3 to 5 times weekly; nor was ambulation performed 5 to 7 times weekly. Interview with the resident on 5/13/19 at 4:48 PM revealed s/he did exercises 3 times a week as an activity with other residents. 6. On 5/16/19 at 11:15 AM interview with restorative aide #1, activity director, and occupational therapist #1 revealed the restorative program was not formalized, and they did not have a system for evaluating and reassessing interventions or effectiveness. At that time the occupational therapist verified the restorative program did not include restorative plans with interventions based on individualized assessed needs, goals, and a process for reviewing refusals related to pain or other reasons to determine the best approach.

Based on observation, medical record review, and staff interview, the facility failed to ensure medications were administered per manufacturer instructions for 3 of 25 medication administration observations, resulting in an error rate of 12%. The findings were: 1. Review of the (MONTH) 2019 physician orders [REDACTED].#31 showed orders initiated on 8/23/18 for [MEDICATION NAME] inhalant twice daily. Observation on 5/13/19 at 5:40 PM, showed MA-C #1 administered the inhaler to the resident in the dining room. Continuous observation showed the resident stopped eating, used the inhaler and returned to eating without performing an oral rinse after using the inhaler. 2. Review of the (MONTH) 2019 physician orders [REDACTED].#28 showed orders for [MEDICATION NAME] inhalant daily. Observation on 5/13/19 at 5:45 PM, showed MA-C #1 administered the inhaler to the resident and did not provide an oral rinse after administration. 3. Observation on 5/15/19 at 8:15 AM showed MA-C #1 administered [MEDICATION NAME] inhalant to resident #31 during breakfast in the dining room. Further observation showed the resident stopped eating, used the inhaler and returned to eating without performing an oral rinse after using the inhaler. 4. Interview on 5/15/19 at 8:48 AM with the medication aide revealed she usually asked the residents to rinse after inhalers, and was not sure why she had not done it during the surveyor observations. 5. Interview on 5/15/19 at 11:10 AM, with the pharmacist revealed the expectation was for staff to follow the United States Food and Drug Administration (FDA) recommendations that required residents to rinse with water after using [MEDICATION NAME] and [MEDICATION NAME] inhalers.

Based on observation, resident and staff interview,and medical record review, the facility failed to ensure medication was administered according to physician orders [REDACTED].#40) who received insulin. This failure resulted an incident of [DIAGNOSES REDACTED] requiring emergency treatment at the hospital for resident #40. The findings were: 1. Observation on 1/23/17 at 5:29 PM showed resident #40 was seated in the dining room with a plate of uneaten food in front of him/her. The resident was sweating, twitching, and combative. CNA #1 notified RN #1 of the situation. The RN asked for a glucometer and orange juice and then transferred the resident from the dining room chair into a wheelchair and removed the resident from the dining area. The resident's glucose level at that time was measured at 22 mg/dL (milligrams/deciliter). The resident was given a glucose gel orally and was taken to the emergency department (ER). 2. Review of the emergency room Note dated 1/23/17 showed the resident's blood glucose was measured at 23 mg/dL upon arrival at the hospital. 3. Review of a physician order [REDACTED]. The following concerns were identified: a. Review of the medication record revealed the resident's blood sugar was measured at 83 mg/dL on 1/23/17 at 4:40 PM, and 3 units of [MEDICATION NAME] was administered to the resident at that time. b. Review of the medication record showed between 11/30/16 and 1/23/17 [MEDICATION NAME] was administered 7 times when the resident's blood sugar measured between 100 mg/dL and 120 mg/dL. Further, [MEDICATION NAME] was administered 5 times when the blood sugar was below 100 mg/dL. 4. Interview with the resident on 1/25/17 at 4:50 PM revealed that s/he had not been aware of the drop in his/her blood sugar on 1/23/17 when s/he had to go to the ER. In addition, s/he stated that s/he knew his/her blood sugar was too low (83 mg/dL) to receive the insulin and s/he knew it was too soon before dinner for the insulin to be administered, but s/he figured the nurse knew what she was doing. 5. Interview with the DON on 1/25/17 at 11:25 AM revealed the nurse should not have administered the medication when the blood glucose was below 120 mg/dL. Further, each time the medication was administered outside the physician's parameters, a medication variance should have been completed and it was confirmed medication variances were not completed. 6. Interview with the DON and team leader #1 on 1/25/17 at 12:20 PM revealed the computer system did not provide a prompt or notification for the nurse not to administer the medication if the blood glucose was below the parameters for administration.