Every finding on record at Aston Park Health Care Center

Based on observations, record reviews, and staff interviews, the facility failed to maintain a clean floor in of 1 of 2 walk-in coolers (walk-in cooler #2). The findings included:On 4/13/26 at 9:50 AM, an observation of the kitchen's walk-in cooler #2 was made with the Food Services Manager. The back right corner of the cooler had 3 dark spots that were sticky to the touch on the floor under a cart where tea decanters were stored. The spots were 4 to 5 inches each, sticky to the touch in the centers with dried non-sticky brown circles around the edges. Further observation of walk-in cooler #2 revealed an area in the left front corner covering an 8 x 12-inch area of the floor where a dark, thick liquid substance that was sticky to the touch had pooled to 1/4 inch depth in the corner and was partially dried at the edges. Streaks of this substance stretched 5 feet from the pooled area through the doorway with scattered spots of the sticky material visible on the kitchen floor area 6 inches in front of the cooler door. During an interview with the Food Services Manager on 4/13/26 at 10:10 AM he stated the spots in the back of the cooler were likely from tea having dripped from the decanter spouts. The Food Services Manager explained he thought the pooled area and streaks in the front of the cooler were likely juice, and the streaks may have been from the wheels of a cart and might have been there about an hour.Review of the Dietary Aide Weekly Cleaning Schedule indicated the coolers were swept and mopped on Thursdays in the evening.In an interview with the Food Services Manager on 4/15/26 at 11:39 AM he stated kitchen floor cleaning between breakfast and lunch involved the floors being spot swept and mopped in all areas, and at night when closing all floors got swept and mopped with floor cleaner/degreaser. The Food Services Manager revealed there was not a sign off sheet for but this but the Assistant Food Services Manager did rounds early in the mornings to ensure the kitchen was clean before starting for the day. The Food Services Manager stated he would have expected that staff would have cleaned spills in the walk-in cooler when observed by staff.During an interview on 4/15/26 at 11:55 AM with the Assistant Food Services Manager she stated she usually came in at 5:00 AM and one of the first things she did was make sure the kitchen was clean and that the dietary staff had done their cleaning jobs the night before. The Assistant Food Services Manager explained she had come in the morning of 4/13/26 and pulled carts out of the coolers to check dates and look at the floors and did not notice any spills on the floors. She further explained that none of the other kitchen staff had told her there had been any spills in the cooler. The Assistant Food Services Manager indicated she thought the dark sticky material on the cooler floor may have been grape or prune juice from a larger juice pitcher or something from a dessert bowl that had spilled over.In an interview on 4/16/26 at 12:26 PM with Administrator she explained the sticky material on the cooler floor was in the morning so maybe it had been something that had spilled during breakfast preparations. The Administrator stated kitchen staff did a great job with cleanliness and sanitation, and this was an anomaly.

Based on observations, record reviews, and staff interviews, the facility failed to follow their infection control policies and procedures for hand hygiene while feeding residents when Facility Aide #1 handled food with bare hands while feeding Resident #59. In addition, Facility Aide #2 handled food with bare hands while feeding Resident #59 and did not perform hand hygiene in between feeding Resident #59 and Resident #27 after touching Resident #59's food and hands. This deficiency occurred for 2 of 12 staff members observed for infection control practices while feeding residents (Facility Aide #1 and Facility Aide #2). The findings included:Review of the facility's policy titled Standard Precautions revised 11/30/22 indicates: Hands are to be washed with soap and water when visibly soiled, after direct or indirect contact with dirt, body fluids, before eating, and after using the restroom. Hand hygiene should also occur after using gloves and between resident contacts. Review of the facility's policy titled Teammate Hygiene and Handwashing revised 7/ 9/25 indicated:Teammates should never use bare hand contact with any foods, ready to eat or otherwise. All teammates should wash their hands per hand washing policies and procedures.Teammates do not need to wear gloves when distributing food to residents at the dining tables or when assisting residents to dine, unless touching ready-to-eat food.Handwashing is required to prevent cross contamination when changing tasks or activities that contaminate the hands.a. On 04/13/26 at 12:14 PM, observation was made of Facility Aide #1 assisting Resident #59 with her meal. Facility Aide #1 cut a hamburger on a bun with a knife and fork then picked up a piece of the bun and burger with her hand without using a barrier and placed it in Resident #59's hands. Resident #59 had trouble grasping the piece of bun, so Facility Aide #1 reached with both her uncovered hands and grasped both of Resident #59's hands to reposition the food in the resident's hands. Facility Aide #1 continued to feed Resident #59 using uncovered hands to pick up pieces of hamburger. During an interview on 4/13/26 at 12:21 PM with Facility Aide #1 she explained she was taught not to touch residents' food with bare hands. Facility Aide #1 stated she should have used gloves when she had to hold Resident #59's food.b. An observation was made on 04/14/26 at 12:39 PM of Facility Aide #2 placing pieces of cut meat patty in Resident #59's hands with her left hand without using a barrier. Twice while putting the food in Resident #59's hands, Facility Aide #2 touched the resident's hands with both her bare hands. Facility Aide #2 then used her left hand to pick up a spoon to feed Resident #27 without sanitizing her hands. After spoon feeding 2 bites to Resident #27 with her left hand, she then picked up a cup with her left hand without sanitizing her hands and gave Resident #59 a drink. In an interview with Facility Aide #2 on 4/14/26 at 12:50 PM she explained she had assisted Resident #59 with eating, and the resident used her fingers to feed herself but sometimes needed help getting the food. Facility Aide #2 stated she had sanitized her own hands prior to assisting the residents with this meal. When asked what she had been taught about handling food with bare hands she stated she knew not to touch food without gloves or to use a barrier like a napkin. Facility Aide #2 further explained she had tried to put the food in Resident #59's hands with the fork first and the resident would not take it, so she just used her hands. Facility Aide #2 revealed she had been trained when feeding two residents to use a different hand for each person or just touch the end of their utensil to not spread germs and to sanitize hands in between if feeding one person at a time. Facility Aide #2 stated she was left-handed and used her left hand to feed Resident #27 after touching Resident #59's food and hands. Facility Aide #2 also stated she realized what she did was not what she had been taught in the Feeding Assistant course and did not know why she did that, just that she had been focused on Resident #27 getting the bites of food. Review of training records for Feeding Assistant training revealed the course included hand hygiene, infection prevention practices while assisting with feeding, and return demonstration of correctly feeding residents. Facility Aide #1 completed Feeding Assistant training on 1/9/26 and Facility Aide #2 completed Feeding Assistant training on 3/19/26.On 4/14/26 at 4:14 PM an interview was conducted with the Staff Development Coordinator (SDC), who taught the Feeding Assistant course to Facility Aides, and was also the Infection Preventionist. The SDC explained the hand hygiene processes taught when staff assisted residents with meals was to wash their hands before they started and sanitize their hands between residents. The SDC then explained what staff were taught when feeding two residents at the same time. She stated they needed to be careful not to break the infection prevention barrier between the two residents by keeping each resident's food and utensils separate. The SDC stated if they had broken that barrier between the two, for example by touching a resident with their hands or used the same hand to touch anything other than the end of the utensil for both residents, that they should have sanitized their hands before continuing to feed. The SDC explained she watched the Facility Aides feed residents during the Feeding Assistant course and checks on them in the dining rooms when they are first starting on their own. The SDC indicated Facility Aide #1 and Facility Aide #2 were doing well overall but had gotten confused and made a mistake. During an interview with the Assistant Director of Nursing (ADON) on 4/14/26 at 1:00 PM with Facility Aide #2 present, she explained staff were taught not to handle food with their bare hands because it was an infection risk but to hand food to a resident with a package wrapper, napkin or fork, or to wear gloves. The ADON further explained staff were taught it was alright to feed two residents at a time when using practices to prevent cross contamination. The ADON stated practices to prevent cross contamination could include using one hand for one resident and the other hand for the other resident, or to just touch the end of the resident's utensils. The ADON revealed that if staff touched a resident with their hands or used both hands while feeding one resident, they should perform hand hygiene before continuing to feed the other resident. An interview was completed on 04/16/26 at 12:35 PM with the Director of Nursing (DON), with the Administrator and SDC present. The DON explained Resident #59 had been able to use finger foods but could be a little complicated and they were trialing different ways to make it easier for staff to assist her to feed herself and stay as independent as possible. The DON stated that staff were expected to wash their hands with soap and water before handling food and to perform hand hygiene in between residents. The Administrator stated the facility usually did a good job with hand hygiene.

Based on observations and staff interviews, the facility failed to clean and maintain 1 of 1 walk-in refrigerator in the main kitchen free from debris. The facility also failed to refrigerate opened jelly containers stored in the dry food storage area, remove expired thickened beverages from the dry food storage area and expired thickened beverage from a dining area refrigerator ([NAME] dining room). This practice had the potential to affect food served to residents. Findings Included: a. On [DATE] at 9:46 AM an observation with the Dietary manager (DM) in the kitchen's walk-in refrigerator found a whiteish in color and fuzzy in appearance substance on the floor beneath the food storage rack on the left side of the refrigerator. The substance was concentrated in some areas and speckled in other areas on the floor and on the baseboard spanning the length of the wall. Further observation of the walk-in refrigerator found the ceiling area near the circulatory fan to contain grey fluffy matter. The grey matter was crumbly to touch. The DM stated during the observation that he mopped the refrigerator 2 times daily and had not noticed the substance under the storage rack and had overlooked the ceiling. b. On [DATE] at 9:50 AM an observation of the kitchen's dry food storage area with the DM found 2 opened jars of jelly located on the second shelf of the storage rack. The jelly jars did not contain an opened date, and the manufacturers label read refrigerate after opening. The observation also found one un-opened 48 ounce container of thickened beverage with an expiration date of [DATE] stored on the shelf. The DM removed the 2 jelly jars and thickened beverage container from the shelf. The DM stated during the observation he did not know how long the opened jelly jars had been on the shelf and stated they should have been refrigerated after they were opened. The DM also said the thickened beverage container was overlooked and that the dry food storage area was checked weekly on food delivery days. c. On [DATE] at 9:57 AM an observation of the [NAME] dining room refrigerator found one container of opened thickened beverage with an expiration date of [DATE]. The DM stated during the observation the refrigerator was stocked regularly each day by the dietary staff and the container had been overlooked. The Administrator stated on [DATE] at 9:18 AM the facility had switched from using and purchasing 48 oz thickened beverage containers to individual sized containers the previous summer and fall. The 48 oz thickened beverage containers should have been removed at that time. The Administrator also said the walk-in refrigerator was mopped 2 times each day by the DM, and that all areas of the walk-in refrigerator should have been cleaned.

Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets were filled out completely for 9 of 110 days reviewed during the period 10/31/24 through 2/17/25. Findings included: Review of the facility's nursing daily staffing sheets for 10/31/24-2/17/25 revealed the following: On 10/31/24 the total number of Nursing Assistants (NAs) and total number of NA hours worked was blank for the evening shift (3:00 PM-11:00 PM). On 11/4/24 the total number for each staff discipline (Registered Nurse (RN), Licensed Practical Nurse (LPN), NAs) and total hours worked for each staff discipline for the evening and night shift (11:00 PM-7:00 AM) were blank. On 11/5/24 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 12/25/24 the census was blank. On 1/3/25 the census was blank. On 1/5/25 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 1/15/25 the total hours worked for each staff discipline for the evening and night shift were blank. On 1/23/25 the total number for each staff discipline and total hours worked for each staff discipline for the evening and night shift were blank. On 2/1/25 the total number of NA's and total number of NA hours was blank for the night shift. An interview was conducted with the Administrator on 2/20/25 at 11:36 AM. The Administrator verbalized the nursing daily staffing sheet for posted staffing was supposed to be completed at the beginning of each shift by the Nurse Supervisor. She stated the total number of staff for each discipline and the total number of hours worked by each discipline was supposed to be filled out for every shift. She said the census was also supposed to be completed on the nursing daily staffing sheet. The Administrator stated the prior Director of Nursing (DON) had left in November 2024. She reported the prior DON had reviewed the daily staffing sheets to ensure they were completed correctly. She explained there had been a gap between when the prior DON left in November 2024 and when the new DON started at the end of January 2025. She said reviewing the daily staffing sheets to ensure they were completed had been missed during the gap between when the prior DON left the new DON had started. An interview was conducted with the DON on 2/20/25 at 11:46 AM. The DON stated the nursing daily staffing sheet was supposed to be completed by the Nurse Supervisor at the beginning of each shift. She stated the daily staffing sheet should be completed and include the total number of staff for each discipline for each shift, total hours worked for each discipline for each shift, and the census.

Based on record reviews, observations, and staff interviews the facility failed to follow a resident's care plan when transferring 1 of 5 residents reviewed (Resident #307). Findings included: Resident # 307 was admitted into the facility on [DATE] with the diagnoses of: non- Alzheimer's dementia with mood disturbance, anxiety, bipolar disorder, and expired on [DATE]. Resident #307's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was severely cognitively impaired, required extensive assistance with her bed mobility, toilet use and transfers. A review of Resident #307's most recent comprehensive care plan dated [DATE] stated two-person assistance with transfers. A review of Nurse #2 progress notes dated [DATE] at 8:04 AM revealed that at 6:00 AM she was alerted Resident #307 had a seizure episode during a transfer. A telephone interview was conducted with Nursing Assistant #1 on [DATE] at 7:45 AM who relayed that she had used a sit-to-stand lift by herself to take Resident #307 to the restroom on [DATE], she stated that during the transfer Resident # 307 became red in the face and would not respond when Nurse Assistant #1 called her name. Nurse Assistant #1 then stated that she laid Resident #307's head and upper body on the bed but could not get her legs on the bed because Resident #307 was so stiff, Nurse Assistant #1 then yelled for help and the nurse came into the room. Nurse Assistant #1 also revealed that at no time did Resident #307 fall either from the lift or off the bed. Nursing Assistant #1 indicated that Resident # 307 had become too heavy to transfer so she used the assist lift for the transfer. Nurse Assistant #1 also revealed that she knew that Resident # 307's care plan did not include using a sit-to-stand lift for transfers and had indicated two-person extensive assist with all transfers. An interview with the Director of Nursing on [DATE], at 2:00 PM revealed that during the transfer on [DATE] it appeared that Resident #307 had seizure like activity. The Director of Nursing further revealed that at the time of the incident that the facility investigation concluded Resident #307 had not been transferred by Nurse Assistant #1 in accordance with her care plan. An interview with the Administrator on [DATE], at 2:45 PM revealed that Nursing Assistant #1 did not transfer Resident #307 in accordance with the care plan. She further revealed that the facility had assessed Resident #307 and contacted the physician regarding her pain and seizure activity. When the facility had found out a plan of correction was established. The plan of correction initiated on [DATE] included: Root cause analysis: Resident's care plan stated 2-person assist with transfers. Certified Nursing Assistant transferred resident with a sit to stand lift with one person assist. Corrective Action: Certified Nursing Assistant was counseled and re-educated on facility transfer policy and following the care plan for transfers was completed on [DATE]. Corrective Action for Potential Deficient Practice: All current resident's care plans checked to assure they match the resident profiles was completed on [DATE]. Systematic Changes: Retraining of all staff in the facilities transfer policy, following the Resident's profile for all transfers was completed on [DATE]. Monitor Plan of Facility: The Staff Development Coordinator or designee will monitor transfers to ensure correct techniques and the transfer matches the plan of care and report to the facilities Quality Assurance Performance Improvement Committee for a 3-month period and then randomly thereafter to ensure compliance. Review of the plan of correction was completed on [DATE]. The facility's plan of correction was validated by observations of transfers during the survey that revealed transfers with and without mechanical lifts were completed by the staff in accordance with the care plan and resident profiles. Staff interviews were completed to verify they had received training on resident transfer status. And a review of staff training material regarding the proper procedures for transfers and audits completed by the facility was completed.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident (Resident #19) reviewed with a Level II Preadmission Screening and Resident Review (PASRR). Findings included: Resident #19 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] indicated Resident #19 had not been evaluated by level II PASRR and determined to have a serious mental illness, intellectual disability and/or related condition. A review of Resident #19's medical record revealed a North Carolina Medicaid Uniform Screening Tool (NC MUST) printout that included the level II PASRR number with an expiration date of 11/14/16. The PASRR number contained the letter F which indicated authorization for a 30 to 60 day limited stay, level II reviews only. During an interview on 5/12/17 at 4:20 PM MDS Coordinator #1 confirmed she had reviewed the NC MUST printout for Resident #19 prior to completing the admission MDS assessment dated [DATE]. She added she had coded the level II PASRR section as no because she had not realized Resident #19's number indicated a level II PASRR. The MDS Coordinator #1 acknowledged Resident #19's MDS dated [DATE] had been inaccurately coded and a modification would need to be submitted. During an interview on 5/12/17 at 5:03 PM the Administrator stated Resident #19's PASRR confirmation was obtained prior to admission and later scanned into the resident's electronic medical record for staff access. The Administrator confirmed Resident #19 had a Level II PASRR and if unsure, the MDS Coordinator should have asked for clarification. The Administrator stated it was her expectation for the MDS assessments to be accurately coded.

Based on observations, record review, and staff interview the facility failed to correctly document the skin condition for 1 of 5 residents (Resident #168) reviewed for body audits. The findings included: Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] had not been fully completed at the time of this investigation. The MDS noted Resident #168 required extensive assistance for bed mobility and transfers. Review of discharge records from the hospital indicated Resident #168 was admitted to the hospital from home after multiple falls that resulted in acute T10 ([MEDICATION NAME] vertebrae #10 in central back) compression fracture and pelvic fracture. Resident #168 was also noted to have healing right rib fractures. Resident #168 was on an anticoagulant (helps prevent blood from clotting) when he entered the hospital. Resident #168 had blood work at the hospital on the day of his admission (04/28/17) indicating his [MEDICATION NAME] Time (PT - time it takes for blood to clot with normal of 10 to 14 seconds) of 27.1 seconds. Due to the frequent falls Resident #168 was having, he was considered to be a poor candidate for continuation of the anticoagulant and it was discontinued prior to his discharge from the hospital to the facility on [DATE]. Review of the initial body audit completed at the facility on 05/03/17 at 6:40 PM indicated Resident #168 had the following areas of ecchymosis (bruising): right upper chest 5 centimeters (cm) x 4 cm and right lower back 25 cm x 15 cm. Further body audits indicated the following: 05/04/17 at 3:43 AM - no mention of ecchymosis on chest or back 05/05/17 at 11:32 AM - ecchymosis right upper chest 5 cm x 4 cm and right lower back 25 cm x 15 cm 05/05/17 at 11:40 PM - no mention of ecchymosis on chest or back 05/06/17 at 11:09 AM - ecchymosis right upper chest 5 cm x 4 cm and right lower back 25 cm x 15 cm 05/07/17 at 11:12 AM - ecchymosis right upper chest 5 cm x 4 cm and right lower back 25 cm x 15 cm 05/07/17 at 11:00 PM - no mention of ecchymosis on chest or back 05/08/17 at 10:32 AM - ecchymosis right upper chest 5 cm x 4 cm and right lower back 25 cm x 15 cm 05/08/17 at 11:00 PM - no mention of ecchymosis on chest or back 05/09/17 at 4:19 AM - ecchymosis to right upper chest and right lower back in various stages of healing 05/10/17 at 12:27 AM - no mention of ecchymosis on chest or back During an observation of the placement of a pain relieving patch to the back during medication administration on 05/11/17 at 8:10 AM, Resident #168 was noted to have significant ecchymosis from his middle to lower back - right side, ecchymosis 4 inches below his right axillary (armpit) to 4 inches above his right hip, and ecchymosis from just below his central chest down toward his lower abdomen on his right side. After the discrepancy in body audit information was shared with the Director of Nursing (DON,) a skin assessment form was completed on 05/11/17 which indicated ecchymosis 45 cm x 21 cm to his right lower back and distributed across his right side and right upper chest. During an interview on 05/11/17 at 5:45 PM, the Nurse Aide (NA) #2 stated she was present when Resident #168 was admitted to the facility from the hospital. NA #2 stated Resident #168 had extensive bruising below the nipple line on his right side, under his right arm and on his back. NA #2 further stated the area was pinkish when she first saw but was now darker but it appeared to be the same size to her. During an interview on 05/12/17 at 9:08 AM, the DON stated Resident #168 had been on an anticoagulant for a long time before coming to the facility. The DON further acknowledged the computer grid scale the facility used for documenting skin issues was not completely accurate. During an interview on 05/12/17 at 10:09 AM, the Assistant Director of Nursing (ADON) stated she followed up on new residents the day of their admission or the day after. The ADON stated she saw Resident #168 on 05/04/17 and noted he had [MEDICATION NAME] bruising and multiple bruises on both arms. During an interview on 05/12/17 at 5:02 PM, the DON stated she expected her staff to document exactly what they saw to the best of their ability when assessing a resident. After review of the body audits for 05/04/17 through 05/10/17, the DON acknowledged the documentation did not accurately reflect the skin condition for Resident #168. The DON also stated she felt some of this was due to an electronic documentation system that did not allow for a clear picture of what the body actually looked like due to a graph system. The DON further stated they would be going back to a paper body audits for charting that would be scanned into the computer for better accuracy of describing skin conditions.

Based on observations, record review, resident and staff interviews, the facility failed to provide assistance with shaving, grooming and nail care for 2 of 4 residents reviewed who required extensive to total assistance with activities of daily living (Resident #82 and #153). Findings included: 1. Resident #82 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded Resident #82 with severe, cognitive impairment for daily decision making. The MDS indicated Resident #82 required extensive to total staff assistance with all activities of daily living (ADL). Review of Resident #82's ADL care plan, with an onset problem date of 03/26/15, revealed a self-care deficit due to Alzheimer's dementia and inability to communicate needs. A goal listed was for her to be well-groomed and appropriately dressed daily. Interventions included for staff to provide extensive to total assistance with adl. Review of Resident #82's Resident Profile revealed showers were scheduled for Tuesday, Thursday and Saturday between 7:00 AM and 3:00 PM. An observation of Resident #82 on 05/08/17 at 3:28 PM revealed her sitting out in the hallway with several noticeable chin hairs approximately a half inch long. An observation of Resident #82 on 05/09/17 at 10:33 AM revealed her sitting out in the hallway with several noticeable chin hairs approximately a half inch long. An observation of Resident #82 on 05/10/17 at 4:30 PM revealed her sitting out in the hallway with several noticeable chin hairs approximately a half inch long. An observation of Resident #82 on 05/11/17 at 10:58 AM revealed her sitting out in the hallway, dressed in clean clothing with slightly damp hair and several noticeable chin hairs approximately a half inch long. Resident #82 was unable to be interviewed due to her severe dementia and inability to participate in conversation. Resident #82's Responsible Party was unable to be reached for a phone interview. During an interview on 05/11/17 at 11:05 AM Nurse Aide (NA) #1 confirmed she had given Resident #82 a shower that morning. NA #1 added she had not noticed her with any chin hair and had never shaved Resident #82 when providing personal hygiene care. NA #1 explained when a resident needed a shave she checked with the nurse to make sure the family had not specified other preferences. NA #1 confirmed Resident #82 had several long chin hairs that needed shaved and stated she should have checked with the nurse when she had given her a shower. During an interview on 05/11/17 at 11:36 AM Nurse #1 stated personal hygiene care was part of the bathing routine and if needed, residents should be shaved when receiving a shower unless it was specified otherwise in their care plan. Nurse #1 confirmed Resident #82 had several long chin hairs that should have been shaved when she had received a shower that morning. Nurse #1 indicated she would instruct the NA to shave Resident #82. During an interview on 05/12/17 at 10:14 AM the Director of Nursing (DON) confirmed it was her expectation staff would provide residents with personal hygiene care when needed. 2. Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) dated for 03/10/17 indicated Resident #153 had mild cognitive impairment and often felt tired or had little energy. The MDS also indicated Resident #153 required extensive assistance with hygiene. Review of the care plans indicated Resident #153 required extensive assistance with most of his activities of daily living, including hygiene. During an observation on 05/09/17 at 10:33 AM, Resident #153 was noted to have fingernails on both hands over a quarter an inch long, stubble on his cheeks, upper lip, and chin, and was wearing glasses that were smudged with a greasy type coating on both lenses. During an observation on 05/10/17 at 2:50 PM, Resident #153 was in his room visiting with his wife. Resident #153 was noted to be unshaven, had long fingernails on both hands, and had glasses on with a greasy coating on both lenses. During an observation on 05/11/17 at 2:35 PM, Resident #153 was in his room visiting with his wife. Resident #153 was noted to be unshaven, had long fingernails on both hands, and had glasses on with a greasy coating on both lenses. During an interview on 05/11/17 at 2:56 PM, Nurse #2 stated there were several ways a nurse aide (NA) knew what to do for the residents. Nurse #2 stated there was an assignment book on each hall that the NAs reviewed to know who was on the shower list for the day. Nurse #2 also stated on the residents shower days the bed linens were changed and the residents would be shampooed and shaved unless they were on a list not to have this done. Nurse #2 further stated the NAs should be doing nail care whenever it was needed, but there was not an official protocol for when or how often it was done. Nurse #2 also stated the NAs could also look at the resident profile information to know what needed to be done for a resident and the NAs all were given report from the NAs going off duty. During an interview on 05/11/17 at 4:08 PM, Resident #153 stated he had not been shaved in about a week and a half. Resident #153 further stated he was not able to cut his fingernails very well since he had a stroke and no longer had good strength in his hands anymore. Resident #153 also stated he tried to clean his glasses in the morning before putting them on but this was also difficult because of the weakness in his hands. During an interview on 05/11/17 at 4:20 PM, the Director of Nursing (DON) observed Resident #153 in his room. The DON acknowledged Resident #153's nails were too long and needed to be cut. The DON stated she would arrange for the treatment nurse to put this on the schedule to be done regularly. Resident #153 stated he would like to be shaved during his shower but this had not been done in about a week and a half so he had not been shaved. The DON also observed the glasses for Resident #153 were dirty and stated they should be cleaned as often as necessary, then asked for his glasses, cleaned them and then returned his glasses to him. During an observation on 05/12/17 at 8:15 AM, Resident #153 was noted to be clean shaven, had on clean glasses and his fingernails were cut. During an interview on 05/12/17 at 12:53 PM, NA #3 stated although he had worked with Resident #153 during the week, he had not noticed whether his nails were cut, his glasses were clean, or if he had been shaved. NA #3 stated Resident #153 had a tendency to refuse showers and that was when Resident #153 would be shaved. NA #3 acknowledged Resident #153 had never refused a shave when it had been offered to him. NA #3 stated he cleaned residents nails as needed but did not cut nails since that was a task for the restorative aides to do. During an interview on 05/12/17 at 1:53 PM, NA #4 stated Resident #153 put his glasses on independently and she had not seen that his glasses were dirty and had not offered to clean them during the week. NA #4 also stated they did resident nail care on shower days or when needed. NA #4 further stated she offered to cut Resident #153's nails and shave him twice during the current week but he refused. NA #4 stated that she had not reported to the nurse Resident #153 had refused for his nails to be cut or that he refused to be shaved. Review of nurse's notes on 05/12/17 at 3:49 PM revealed there was no documentation of refusal of care indicated between 05/08/17 and 05/11/17 for Resident #153 with the exception of refusing to be weighed on 05/10/17. During an interview on 05/12/17 at 4:00 PM, Resident #153 stated he had received a great shower, shave, nails cut, glasses clean the previous evening and he was happy. Review of the resident profile information on 05/12/17 at 4:20 PM indicated Resident #153 was supposed to have a shower on Mondays, Wednesdays and Fridays on 2nd shift (3 PM - 11 PM). The resident profile information had no information listed under a section titled Vision and no directions for how often Resident #153 was to be shaved, have his nails cut, or his glasses cleaned. During an interview on 05/12/17 at 5:07 PM, the DON stated her expectations were for the NAs to offer care multiple times if a resident refused. The DON also stated if the resident continued to refuse, another care giver should be asked to try and assist the resident and the nurse needed to be involved. The DON further explained the nurse needed to be involved to determine if refusals were problematic and if so, to notify the physician if the resident needed to be seen by another provider (i.e. psychiatric services or Veteran's Administration services). The DON further stated her expectations were for the NA's to tell the nurses if care was refused.

Based on medical record review and staff interviews the facility failed to complete an annual Minimum Data Set (MDS) assessment for 1 of 26 sampled residents in a timely manner. (Resident #87) The findings included: Resident #87 was admitted to the facility 04/08/16 with [DIAGNOSES REDACTED]. Subsequent quarterly MDS assessments for Resident #87 were dated 07/19/16, 10/18/16 and 01/16/17. Review of the electronic medical record of Resident #87 noted there were no MDS assessments completed after 01/16/17. On 05/10/17 at 11:30 AM MDS Coordinator #1 stated the assessment reference date for the annual MDS for Resident #87 was 04/18/17 and it was an oversight that the assessment was not completed. MDS Coordinator #1 stated it was her responsibility to complete the assessment and she had failed to complete the assessment in a timely manner. On 05/12/17 at 1:40 PM the Administrator and Director of Nursing stated they expected MDS assessments to be completed by the due date.

Based on observations, staff interviews and facility policy reviews the facility staff failed to perform hand hygiene and change gloves from one wound dressing site to another wound dressing site for 1 of 3 residents (resident #43). Findings included: The Handwashing/Hand Hygiene policy was reviewed from Infection Control Policy and Procedure Manual © 2001 MED-PASS, Inc. (Revised August 2009) provided by the Director of Nursing (DON) on 04/28/16 1:55:03 PM. According to policy, 4. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: a. Before and after direct contact with residents; e. Before handling clean or soiled dressing, gauze pads, etc.; h. After handling used dressings, contaminated equipment, etc. 04/28/2016 4:36:19 PM MDS Reviewed quarterly Minimum Data Set (MDS) for resident dated 03/25/16, [AGE] year old was cognitively intact. Resident #43 was admitted on [DATE] following a brief hospitalization . [DIAGNOSES REDACTED]. Reviewed care plan and addressed wound management for Stage III ulcers on sacrum and heels on both feet. Resident was being followed by wound care management and wound care physician stated on 04/26/16 that sacral wound had increased in size and changed orders for sacral wound. 04/28/2016 8:38:28 AM Nurse #3 was observed to do wound dressing treatment. Nurse #3 prepared and brought in tray with supplies for dressing. Asked if we wanted to observe both the sacral and heel wound on both feet and we agreed. Nurse #3 left the room to gather additional supplies and returned with supplies to do the dressing changes on the heels as well. Nurse #3 began by positioning resident #43 on his left side to do sacral wound. Gloved and removed old dressing from sacrum and discarded in trash bag attached to dressing tray, changed gloves after removing old dressing and put on clean gloves and cleaned wound. During cleansing and removal of black slough (dead tissue) area on sacrum, resident #43 moved his entire body towards the side rail and said ' that is sore, nurse said to resident sorry buddy when he moved during the dressing change. Nurse #3 continued with the wound care, applied the dressing and dated the dressing change. Nurse #3 did not stop wound care and proceeded on to the next area for wound care. Nurse #3 continued and removed the resident ' s socks to take off the old dressings on the heels. He removed the dressings on both heels and placed them in the trash bag attached to the dressing tray and without performing hand hygiene or changing gloves continued with the cleansing of the right heel, applied the gel to the gauze dressing and taped the dressing on the heel. The nurse moved next to the left heel with the same gloves and without performing hand hygiene and cleaned the wound and applied the dressing with gel and taped on to the resident ' s left heel with dated tape. 04/28/2016 9:30:07 AM Interviewed Nurse #3 following resident ' s wound care and asked him to describe the facility ' s procedure for a clean wound dressing. Nurse #3 was able to describe the correct procedure for performing a clean wound technique including hand hygiene, donning and changing gloves and disposal of materials. 04/28/2016 9:52:40 AM Spoke with DON about her expectations regarding clean technique dressing changes and recited correct technique for completing dressing change. Stated that there is a procedure at the main nurse ' s station for doing wound care or dressing change under clean technique and nurses could reference this procedure prior to performing wound care. 04/28/2016 2:48:30 PM Spoke with Assistant Director Of Nursing (ADON) as DON was not available and asked expectation of facility in providing wound dressings under clean technique. Stated that expectation is that gloves are worn to take dressing off and re-glove to put on new dressing. Additionally, re-glove and start over process when moving to a new area for wound treatment.

Based on observation, staff interviews, resident interview and record review, the facility failed to provide pain management strategies including provision of pain medication and positioning for comfort for 1 of 2 residents (resident #43) who verbalized pain during wound dressing change. Findings include: Resident #43 was admitted to Aston Park Health Care on 12/18/2015 following a brief hospitalization . The resident ' s [DIAGNOSES REDACTED]. 04/28/2016 4:36:19 PM MDS Reviewed quarterly Minimum Data Set (MDS) for resident dated 03/25/16, [AGE] year old cognitively intact male (BIMS score of 15) admitted [DATE] following a brief hospitalization . admitted to facility with Stage II pressure ulcers to sacrum and heels of both feet which developed into Stage III ulcers. Reviewed care plan and addressed wound management for Stage III ulcers on sacrum and heels on both feet. Resident was being followed by wound care management and wound care physician stated on 04/26/16 that sacral wound had increased in size and changed orders for sacral wound. Reviewed wound management treatment record from wound physician visit last week, on 04/19/16 the measurements for resident wounds: left heel measured 0.2 x 0.2 x 0.1, Sacrum 3 x1 x 0.1 and Right heel 0.3 x 0.3 x 0.1. Wound care physician was in on Tuesday morning, 04/26/16 and changed orders due to increase in size of sacral wound. New orders for wound care dated 04/26/16: clean buttocks with wound cleanser, apply calcium alginate AG, and cover with [MEDICATION NAME], change Monday, Wednesday and Friday (MWF) and as needed (prn). For heels clean wounds with wound cleanser, apply silver stat, cover with gauze, and secure with tape daily and prn. 04/28/2016 8:38:28 AM Nurse #3, was observed for wound treatment. Nurse #3 prepared and brought in tray with supplies for dressing. Asked if we wanted to observe both the sacral and heel wound on both feet and we agreed. Nurse #3 left the room to gather additional supplies and returned with supplies to do the dressing changes on the heels as well. Began by positioning resident #43 on his left side to do sacral wound. Gloved and removed old dressing from sacrum and discarded in trash bag attached to dressing tray, changed gloves after removing old dressing and put on clean gloves and cleaned wound. During cleansing, Nurse #3 rubbed gauze wet with house cleanser several times until removal of black slough (dead tissue on top of the pressure ulcer) area on sacrum. The wound bed started bleeding. Resident #43 moved his entire body towards the side rail and Nurse #3 said are you okay? and resident #43 said ' that is sore. Nurse #3 continued with the wound care, applied the dressing and dated the dressing change. Nurse #3 did not stop wound care and offer resident pain medication but proceeded on to the next area for wound care. Nurse #3 continued and removed the resident ' s socks to take off the old dressings on the heels. He removed the dressings on both heels and placed them in the trash bag attached to the dressing tray, continued with the cleansing of the right heel, applied the gel to the gauze dressing and taped the dressing on the heel. During the right heel wound dressing, the resident attempted to hold his leg up for the nurse as he was cleaning the wound and was unable to sustain his leg up in the air. The nurse moved next to the left heel and cleaned the wound and applied the dressing with gel and taped on to the resident ' s left heel with dated tape. During the heel wound dressing, the resident remained on his side and was not positioned for comfort with pillows to support his legs and keep his feet and heels off the bed. 04/28/2016 9:30:07 AM Interviewed Nurse #3 following resident ' s wound care and asked him to describe the facility ' s procedure for a clean wound dressing. Additionally asked him about pain management prior to wound care and stated that at times the physician will order medication to be given 30 minutes prior to wound care and then sometimes the wound physician will spray the area with a numbing spray prior to performing the wound care. Nurse #3 stated that the resident did not usually require pain medication prior to wound care or have pain during the wound care. 04/28/2016 9:35:36 AM Spoke with Nurse #4, hall nurse assigned to resident, who stated resident did not have pain medication this am prior to wound dressings. 04/28/2016 2:48:30 PM Spoke with Assistant Director Of Nursing (ADON) as DON was not available and asked expectation of facility in providing pain medication prior to wound dressings and asked for facility ' s procedure for giving pain medication prior to wound dressings. ADON stated that facility did not have a procedure on giving pain meds prior to dressing changes; however, some residents have that in place for their wound care. Discussed with her observation of resident #43 ' s wound care and resident ' s non-verbal and verbal reactions to wound care being provided and ADON stated that she would discuss with DON and wound care staff as well as all nursing staff. 04/28/2016 3:02:19 PM Went in to resident's room as his caretaker was coming out of his room and she stated Resident #43 is not having a good day. Caretaker's family member in room trying to assist resident in bed. Asked resident if it always hurt when he had dressing changed and he said no, just today. Then stated that he was still nauseated and was not feeling well. Had cool cloth on his forehead and ADON accompanied by caregiver came in to resident ' s room and ADON began to assess resident. 04/29/16 4:00:36 PM Reviewed additional documents submitted by Aston Park Health Care. Documents revealed that resident #43 did not complain of pain during previous dressing changes and did not require pain medication.

Based on observations and staff interviews the facility failed to ensure the final rinse temperature of the dish machine reached minimum requirements of 180 degrees Fahrenheit. The findings are: Review of the facility dish machine log book on 01/22/13 noted the following days the final rinse temperatures were recorded less than the minimum requirement of 180 degrees Fahrenheit (F): 1/03/13-AM temperature 175 degrees F 1/08/13-AM temperature 178 degrees F 1/09/13-AM temperature 178 degrees F 1/10/13-AM temperature 170 degrees F 1/11/13-AM temperature 176 degrees F 1/12/13-AM temperature 165 degrees F 1/13/13-AM temperature 170 degrees F 1/08/13-lunch temperature 168 degrees F 1/09/13-lunch temperature 168 degrees F 1/12/13-lunch temperature 175 degrees F 1/12/13-supper temperature 175 degrees F 1/17/13-supper temperature 173 degrees F 1/18/13-supper temperature 175 degrees F 1/19/13-supper temperature 175 degrees F Continuous observations were made of staff using the dish machine in the facility kitchen on 01/22/13 from 8:50 AM-9:35 AM. The Food Service Director (FSD) stated a new motor had been put into the dish machine approximately a month prior and there had been issues with the dish machine requiring service. The FSD identified the dish machine as a high temperature machine which required a minimum final rinse temperature of 180 degrees F to sanitize dishware. The FSD ran a rack of dishes through the dish machine at 8:50 AM and the highest final rinse temperature observed on the gauge was 158 degrees F. The FSD left the rack of dishes in the dish machine and left the dish machine area. Approximately five minutes later a dietary aide entered the kitchen, removed this rack of dishes from the dish machine and placed them in dish storage. The FSD did not intervene or provide any instruction to the dietary aide. A second aide came to the area of the dish machine and the two aides proceeded to run multiple racks of dishes through the dish machine. Observations were made of the final rinse temperatures of the dish machine throughout use by the two dietary aides. Fifteen observations revealed the highest temperature reached during the final rinse cycle varied between 174 and 178 degrees F. During these observations staff did not look at the final rinse gauge and no guidance was provided by dietary management. All dishes run through the dish machine were placed in dish storage by a dietary aide. At 9:15 AM the Registered Dietitian (RD) was asked about the dish machine. The RD reported she was aware there had been problems with the dish machine but was not aware of the specific concerns. The observed final rinse temperatures were reported to the RD and the RD stated it was a concern to have low final rinse temperatures with the dish machine. At 9:17 AM the FSD reported the service company had been notified of concerns with the dish machine on 01/21/13. The FSD stated he was aware of the low final rinse temperatures and was waiting for the service company to come in and service the machine. From approximately 9:20 AM-9:35 AM the two dietary aides continued to run dishware through the dish machine. Continuous observations of thirteen dish cycles revealed final rinse temperatures varied between 172 degrees F-177 degrees F. Dietary staff (including the FSD and RD) did not look at the final rinse gauge while the dish machine was in use or provide any guidance to staff working in the area of the dish machine. At 9:35 AM the service contractor entered the kitchen and stated he was aware there had been problems with the dish machine and came in to see if replacing the final rinse gauge would correct the issue. At 10:15 AM after replacing the final rinse gauge the service contractor reported the final rinse temperatures were reaching greater than 180 degrees F. Observations of the dish machine at 10:20 AM revealed final rinse temperatures of 185 degrees F. On 01/22/13 at 11:00 AM the facility operations manager stated the FSD was instructed that dishes should have been hand washed if there were concerns the final rinse temperature of the dish machine was not reaching minimum requirements of 180 degrees F. The facility operations manager stated the service company reported the wrong gauge had been placed on the dish machine and felt that was what caused the final rinse temperatures to be less than 180 degrees F. Based on multiple observations the dish machine temp did not reach 180 degrees during the final rinse. Based on multiple observations the dish machine temperature did not reach 180 degrees during the final rinse.

Based on observations, staff interviews, and record review the facility failed to follow interventions recommended by the Physician for one (1) of three (3) sampled residents with a pressure ulcer (Resident #30). The findings are: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with bed mobility, transfers, toileting and personal hygiene; and the resident had stage III and stage IV pressure ulcers. The Resident Assessment Protocols (RAPs) dated 9/21/10 specified the resident received treatment for [REDACTED].#1. The RAPs also specified, "He does not wear shoes due to wounds on foot. He rests on a pressure reduction mattress and has a pressure reduction cushion on his wheelchair. He is being followed by the wound specialist for current pressure ulcers." Approaches included in the resident's pressure ulcer care plan, updated 11/14/10, included (1) remind and encourage to reposition self when in bed or chair at least every two hours and assist as needed to make significant changes in position; (2) pressure reduction mattress on bed; (3) treat left lateral malleolous wound as ordered; (4) treat left foot digit #1 as ordered; (5) refer to wound care Physician for evaluation and treatment of [REDACTED]. Further review of Resident #30's medical record revealed a Physician's wound report dated 9/8/10 that specified Resident #30 had an unstageable pressure area developed in-house on his left lateral malleolous and an unstageable pressure area also developed in-house on his left foot digit #1. The Physician noted in the report "float left ankle off bed." Observations made of Resident #30 revealed: ? On 11/15/10 at 2:00 p.m. Resident #30 was in bed with his left ankle flat on the mattress. ? On 11/16/10 at 10:30 a.m. Resident #30 was in bed with his left ankle flat on the mattress. ? On 11/16/10 at 3:15 p.m. Resident #30 was in bed with his left ankle flat on the mattress. On 11/17/10 at 8:50 a.m. Nurse Aide (NA) #1 was observed to float Resident #30's heels with a pillow. NA#1 was interviewed and reported the resident preferred to be in bed and added she was supposed to put a pillow under the resident's ankle area when he was in bed. She stated this was a part of the resident's care and included in her daily assignment. She reported she relied on the resident's "Care Tracker" to know this information. Resident #30's "Care Tracker" was reviewed and revealed an entry made on 11/15/10 that specified, "Remove shoes when in bed and float heels on pillow." On 11/17/10 at 9:00 a.m. the wound Physician was interviewed and confirmed the resident's left heel should be floated when the resident is in bed. On 11/17/10 at 1:30 p.m. Licensed Nurse (LN) #1 was interviewed and reported he makes rounds with the wound Physician and is responsible to implement the Physician's interventions. He confirmed he would expect nurse aides to float Resident #30's heels when the resident is in bed. On 11/18/10 at 3:15 p.m. the Assistance Director of Nursing (ADON) was interviewed and confirmed that the wound Physician's notes and recommendations are considered to be Physician orders. She explained a licensed nurse is assigned to review the Physician's notes to ensure all recommendations are implemented. She offered no explanation why Resident #30's heels were not floated for two days of the survey.