Every finding on record at Avalon Health and Rehabilitation

Based on staff interviews, record review, and review of the facility's policy titled Abuse Prohibition, the facility failed to protect one of 42 sampled residents (R) (R81) right to be free from physical abuse by another resident. Actual harm was identified to have occurred on July 6, 2026, when R87 physically assaulted R81, causing a laceration of the left palm and an open displaced fracture of the proximal phalanx of the right ring finger. Findings include:Review of the facility's undated policy titled Abuse Prohibition revealed the Intent section included, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. The Guidelines section included, . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 1. Review of the electronic medical record (EMR) for R87 revealed admission to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease with late onset and dementia with behavioral disturbance.Review of the Annual Minimum Data Set (MDS) assessment for R87, dated 4/21/2026, revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 3 (indicating severe cognitive impairment). Section E (Behaviors) documented the resident exhibited delusions, verbal behaviors toward others, other behaviors not directed toward others, rejection of care, and wandering on one to three days during the assessment period.Review of the care plan for R87 revealed a care area, dated 6/25/2026, for behaviors. Interventions included administering medications, analyzing key times, places, circumstances, triggers, what de-escalates the behaviors, maintaining a calm manner, redirecting as needed, and removing the resident from stressful situations.Review of the physician's orders for R87 revealed an entry dated 07/06/2026 of Transfer to Hospital. Resident was 1013 (an emergency legal form used to send a person for an involuntary mental health evaluation when they are a danger to themselves or others) out to (name) psych hospital with diagnoses of restlessness and agitation.Review of the nurse's notes for R87 revealed an entry, dated 07/06/2026, that included another resident was heard yelling and staff witnessed R87 holding another resident down (R81) by her hair and bending her 4th digit back with blood dripping from the palm of her hand. R81 was assessed to have an actively bleeding 1.75 centimeter laceration to her left hand, and the 4th digit of her left hand was angled toward the 3rd digit. The physician was notified, and R81 was sent to the emergency room (ER) for treatment. Continued review of the nurse's notes for R87 revealed an entry dated 07/06/2026 stating that the resident left at 6:20 PM and was transferred to a psychiatric facility. Review of a facility-provided document dated 07/26/2026 and signed by the Medical Director revealed R87 assaulted R81, causing a physical injury, was referred out to a psychiatric facility, and was not transferred back to the facility. The document stated that the facility was unable to meet R87's needs and protect other residents.2. Record review revealed R81 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's disease with early onset, dementia in other diseases, severe, with other behavioral disturbance.Review of the Quarterly MDS for R81, dated 05/06/2026, revealed section C (Cognitive Patterns) documented a BIMS of 99, indicating severe cognitive impairment. Section E (Behaviors) documented that behaviors were not exhibited during the assessment period.Review of the hospital After Visit Summary for R81, dated 07/06/2026, revealed diagnoses of an open displaced fracture of the proximal phalanx of the right ring finger and laceration of the palm. During an interview on 07/26/2026 at 1:44 PM, the Social Worker (SW) stated R87 was sent to the psychiatric hospital via 1013 due to injuring another resident (R81) on 07/26/2026, causing a fractured finger and laceration on R81's hand. During an interview on 07/27/2026 at 8:42 AM, the Administrator stated staff were not provided education on abuse, resident safety, or altercations following the incident between R87 and R81 on 07/06/2026. During an interview on 07/27/2026 at 9:17 AM, Certified Nurse Aide (CNA) FF stated she worked on the dementia unit and was familiar with the physical incident between R87 and R81. CNA FF stated she did not receive education following the incident. During an interview on 07/27/2026, at 12:08 PM, the Director of Nursing (DON) stated R97 was sent to the hospital via a 1013 on 07/06/2026, due to physically injuring R81. The DON further stated that R87 had a history of aggressive behaviors.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage in the Care Center, the facility failed to ensure that medications were stored securely on two of two units (West Unit and the Secured Memory Unit). In addition, the facility failed to ensure opened insulin pens were labeled with an open and discard date on one of three medication carts. These deficient practices created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and had the potential to place the residents at risk of receiving medications with altered effectiveness. Findings included: A review of the facility policy titled Medication Storage in the Care Center, last revised 12/31/2025, revealed that the intent of the policy was to facilitate safe, secure, and proper storage of medications and biologicals following manufacturer recommendations or those of the supplier. It is noted that medication supply is accessible only to licensed associates or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Medication security: The Director of Nursing (DON) is responsible for controlling access to medication carts. The DON is accountable for overseeing the security of medication carts at the center. 1. During an observation on 07/25/2026 from 9:15 AM to 9:35 AM, Licensed Practical Nurse (LPN) JJ was observed passing medications in the dining room of the Secured Memory Unit. She was observed retrieving medications from her medication cart and walking over to each resident in the dining area. Her medication cart was not locked at any time when she walked away. During an observation on 07/25/2026 at 9:36 AM, LPN JJ was observed to walk away from her medication cart to administer medications to a resident. She was observed to turn her back on the unlocked medication cart multiple times. There were 11 ambulatory residents either sitting or walking around the dining room. The nurse returned to the medication cart and was asked whether the resident she was administering medications to had required her immediate, extended attention; would her medication cart be secure. She confirmed that it would not, and she should lock it when she walked away. During an observation on 07/27/2026 at 5:36 AM, the medication cart was left unattended, unlocked, and unsecured, parked near the [NAME] Unit nursing station. There was no nurse in the area of the cart. The cart was able to open, exposing medications. Two minutes passed, and LPN II approached the cart from the end of the [NAME] Unit. She was observed securing and locking the medication cart. She confirmed that she was responsible for the medication cart and had failed to lock it when she walked away. During an interview on 07/27/2026 at 7:30 AM, the DON stated that she monitored and talked with the nurses all of the time about the importance of locking their medication carts. She stated that the nurses had received education on making sure that they lock the cart whenever they walk away. She confirmed that this is especially important on the Secured Memory Unit, because the wandering residents were at risk for consuming harmful substances. 2. Observation on 07/27/2026 at 7:13 AM of the 200 Hall medication cart with Certified Medication Aide (CMA) EE revealed two opened NovoLog insulin pens without an open or discard date. During an interview on 7/27/2026 at 7:13 AM, CMA EE confirmed the two opened NovoLog insulin pens on the 200 Hall medication cart were opened and without an open or discard date. She stated the nurse who opened the insulin pens should have labeled them with the date that they were opened at the time they were opened. During an interview on 7/27/2026 at 8:06 AM, the Director of Nursing (DON) stated all insulin pens should be dated with open and discard dates when opened. The DON further stated she expected the Unit Manager (UM) to check the insulin pens for labels daily. She stated that if the pens were not labeled, a resident could receive insulin past its discard date.

Based on observations, staff interviews, record review, and review of the facility's policy titled Foley Catheter Care, the facility failed to provide appropriate care and services to manage an indwelling catheter when staff did not clean the genitalia for one of five residents (R) (R6) with an indwelling urinary catheter. This deficient practice had the potential to cause health problems, including urinary tract infections, skin breakdown, and tissue damage to R6.Findings include:Review of the facility's policy titled Foley Catheter Care, reviewed 12/27/2025, revealed the Intent section included, To promote hygiene, comfort and decrease risk of infection for patients with an indwelling catheter and is performed daily and PRN (as needed) for soiling.Review of the facility's electronic medical records (EMR) documented R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, neuromuscular dysfunction of the bladder. Review of the Quarterly Minimum Data Set (MDS) for R6, dated 06/02/2026, revealed that section GG (Functional Abilities and Goals) documented that R6 was dependent for toileting hygiene. Section H (Bladder and Bowel) documented the resident had an indwelling urinary catheter. Section I (Active Diagnosis) documented R6 had neurogenic bladder.Review of the care plan for R6, dated 06/10/2026, revealed a care area of the resident had catheter use with the goal that R6 will be free of complications from use of the catheter through the review period and interventions including care/changing of the urinary catheter as ordered.Review of the physician's orders for R6 revealed an order dated 03/23/2026 that included, Indwelling urinary catheter to bedside drainage every shift French (Fr) Size: 16; Balloon Size:10. Cath [sic] care every (q) shift. Diagnosis (Dx): Neuromuscular dysfunction of bladder.Observation on 07/26/2026 at 10:47 AM during indwelling urinary catheter care with Certified Nursing Assistant (CNA) AA and the Wound Care Nurse/Infection Preventionist (WCN/IP) revealed CNA AA did not clean R6's genitals, and she did not lift the scrotum and clean under and around the scrotum. Observation revealed CNA AA only wiped the catheter tubing from the meatus outwards and then wiped each side of the groin once with one stroke of the cleansing wipe.In an interview on 07/26/2026 at 10:55 AM, CNA AA confirmed she did not clean R6's genitals, and she did not lift the scrotum and clean under and around the scrotum. She stated that she should have cleaned R6's genitalia and she should have lifted his scrotum and cleaned the surrounding areas because the groin area had moisture and if it was not cleaned, it could cause skin breakdown and infection.In an interview on 07/26/2026 at 11:38 AM, Licensed Practical Nurse (LPN) Wound Care Nurse (WCN) and Infection Preventionist (IP) BB confirmed CNA AA did not clean R6's genitals, and she did not lift the scrotum and clean under and around the scrotum. She further stated CNA AA should have lifted R6's scrotum and cleaned under it because that area holds moisture, and if it was not cleaned, it could cause redness and moisture-associated skin damage (MASD). In an interview on 07/26/2026 at 08:56 AM, the Director of Nursing (DON) stated that she expected staff to clean the residents' genitalia during catheter care and to lift the scrotum to clean it to prevent skin breakdown.

Based on observations, staff interviews, record review, and review of the facility's policy titled Hand Hygiene, the facility failed to ensure infection control processes were followed during indwelling urinary catheter care for one of five residents (R) (R6) with an indwelling urinary catheter. This deficient practice had the potential to place R6 at increased risk of infection due to cross-contamination. Findings include:Review of the facility's policy titled Hand Hygiene, reviewed 12/27/2025, revealed the Intent section stated, It is the intent of this facility to promote and facilitate appropriate hand washing as set forth by the guidelines of CDC. The Purpose section included, Hand Hygiene is the single most important means of preventing the spread of infection. The Guideline section included, . Glove use: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious material, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment could occur. Gloves should not be used as a substitute for hand hygiene. If your task requires gloves. Change gloves and perform hand hygiene during patient care, if moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.Review of the Quarterly Minimum Data Set (MDS) for R6, dated 06/02/2026, revealed that section GG (Functional Abilities and Goals) documented that R6 was dependent for toileting hygiene. Section H (Bladder and Bowel) documented the resident had an indwelling urinary catheter. Observation on 07/26/2026 at 10:47 AM during indwelling urinary catheter care with Certified Nursing Assistant (CNA) AA and the Wound Care Nurse/Infection Preventionist (WCN/IP) revealed CNA AA did not change gloves after cleaning the catheter tube. CNA AA used the same pair of gloves she used to clean the catheter to assist R6 to turn to his right side, touched his clothes, bedding, arms, and immediate surroundings. In an interview on 07/26/2026 at 10:55 AM, CNA AA confirmed she did not change gloves after cleaning the catheter tube and used the same pair of gloves she used to clean the catheter to assist R6 to turn to his right side, touched his clothes, sheets, and immediate surroundings. She stated that she should have changed her gloves after she cleaned the catheter. She further stated the gloves would be dirty and whatever was on the catheter and groin would be transferred to everything she touched with the gloves. CNA AA stated that not changing gloves after cleaning the catheter tubing and touching the resident's clothing and immediate surroundings could place R6 at risk of infections. In an interview on 07/26/2026 at 11:38 AM, Licensed Practical Nurse (LPN) Wound Care Nurse (WCN) and Infection Preventionist (IP) BB confirmed CNA AA did not change gloves after cleaning the catheter tube and used the same pair of gloves she used to clean the catheter to assist R6 to turn to his right side, touched his clothes, sheets, and immediate surroundings. She stated that the gloves were dirty after the catheter was cleaned and should have been changed because if the used, soiled gloves were used to touch R6's clothes and surroundings, it could cause infections.In an interview on 07/26/2026 at 08:56 AM, the Director of Nursing (DON) stated that her expectation was for staff to change gloves after performing urinary catheter care and not to use the same gloves to touch the resident or surroundings.

Based on observations, staff interviews, and review of the facility policy titled, Labeling and Dating, the facility failed to discard food and seasonings by the expiration date. The deficient practice had the potential to promote foodborne illnesses associated with bacterial growth for 74 of 77 residents receiving an oral diet. Findings include: Review of the facility's policy titled Labeling and Dating dated [DATE] revealed in paragraph two, Upon receipt all items should be inspected and marked with the date it was received into your facility and the date it should be discarded or expired. Further review revealed in paragraph three, After opening any item, the date it was opened must be clearly labeled on the front of the package and a new use by date should also be noted. During a tour of the kitchen on [DATE] at 9:47 am with the Dietary Manager (DM), the following concerns were identified: One container of tarragon leaf with an expiration date of [DATE]. One container of cumin seasoning with an expiration date of [DATE]. One container of vegetable oil with an expiration date of [DATE]. Observations in the walk-in cooler revealed one bag of salad mix with an expiration date of [DATE]. Interview on [DATE] at 10:15 am with the DM revealed inventory checks were completed by her along with the kitchen staff. The DM stated each kitchen staff must participate in inventory checks, and they must discard any expired items in the storage. The DM confirmed the observed items were expired and must be discarded. Interview on [DATE] at 11:00 am with the Registered Dietician (RD) and DM revealed an in-service was completed on [DATE] and [DATE] to all kitchen staff. It was confirmed the in-service discussed the following: food safety, storage area, and labeling and dating. Interview on [DATE] at 12:20 pm with the kitchen staff revealed inventory checks are completed by all kitchen staff. It was revealed staff must discard any expired items in storage. It was also revealed the kitchen staff received an in-service training on [DATE] and [DATE]. Interview on [DATE] at 3:45 pm with the Administrator revealed his expectation for the kitchen staff was to ensure all inventory items were labeled and dated. He stated the kitchen staff must thoroughly check each item and discard any expired items in storage. The Administrator revealed staff must follow appropriate hand hygiene at all times. The Administrator confirmed an in-service training was provided to the kitchen staff regarding food storage, safety, and labeling and dating.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 18 residents (R) (R35) reviewed were free from accident hazards. Specifically, the facility failed to ensure R35 was free from exposure to harmful chemicals and aerosols. Findings include: A facility policy for accidents and hazards was requested, however, the facility advised they did not have a policy. Review of R35's electronic medical record (EMR) revealed R35 was admitted with diagnoses of but not limited to Alzheimer's disease with late onset and dementia in other diseases classified elsewhere, mild, with anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Observation and interview on 4/8/2025 at 10:47 am revealed R3S peeking out of his bathroom door with a bottle of some type of cleaning agent. He had to use the bathroom and did not want to talk to the Surveyor or let Surveyor in his room. Observation and interview on 4/9/2025 at 10:30 am with R35, he revealed he kept his cleaning products in the bottom drawer of his dresser and opened the drawer. The drawer contained two bottles of bathroom cleaner and two aerosol cans of room deodorizer. Interview on 4/9/2025 at 11:45 am with Licensed Practical Nurse (LPN) AA revealed that under no circumstances should a resident have any type of cleaning chemicals in their rooms. She also revealed that aerosol cans are not allowed per policy. Interview on 4/9/2025 at 11:48 am with LPN BB revealed that R35 was not allowed to have any cleaning chemicals or aerosol cans in his room. She confirmed both were present in R35's drawer; and she removed the products immediately. Interview on 4/9/2025 at 11:50 am with the Director of Nursing (DON) revealed residents were not allowed to have aerosols or any type of cleaning agents. She revealed that the family and resident were educated upon admission and that the charge nurse was going to call the family and re-educate them. She revealed having cleaning chemicals and aerosols was a potential hazard, the resident or residents could ingest and could lead to serious problems or death. Interview on 4/10/2025 at 2:45 pm with the Administrator revealed his expectations were for residents not to have cleaning chemicals or aerosols in their possession. He revealed upon admission; residents and their families were given education on what was allowed in the facility. He revealed some families needed reminders.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to encode and transmit a discharge Minimum Data Set (MDS) for one of one resident (Resident (R) 61) reviewed for Resident Assessment. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1, dated 10/2019, revealed a discharge MDS was to be completed within 14 days of the discharge, dated and transmitted within 14 days of the completion date. Review of the electronic medical record (EMR) Face Sheet for R61 revealed an admitted [DATE] and a discharge date of [DATE]. During an interview on 10/04/2023 at 11:00 AM, the Minimum Data Set Coordinator (MDSC) revealed the facility used the Resident Assessment Instrument (RAI) manual for directions for when to complete a MDS and when the document was to be transmitted. The MDSC confirmed the MDS to be completed at discharge for R61 had not been completed.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Skilled Nursing Services: Restorative Policy, the facility failed to provide Range of Motion (ROM) services for two of three Residents (Residents (R) R7 and R115) reviewed for positioning/mobility. Specifically, R7 and R115's splints were not applied consistently per their plans of care creating the potential for pain or worsening of contractures. Findings include: Review of the facility policy titled, ''Skilled Nursing Services: Restorative Policy'' dated 12/30/2022 read, in pertinent part, ''This center promotes nursing interventions that assist the patient in his/her ability to adapt and adjust to living as independently as possible. When clinically appropriate, these interventions may be captured in a formalized restorative nursing care plan overseen by Restorative Nursing Supervisor (s);'' and ''The Restorative Team or Skilled Therapy may develop a restorative program. The plan of care will be outlined in electronic medical record (EMR) and will be followed by staff trained in restorative care. Inability to provide care per the plan of care should be communicated to the Restorative Nurse(s).'' 1. Review of R7's undated ''Face Sheet,'' located in the electronic medical record (EMR) under the ''Demographics'' tab, indicated R7 was admitted to the facility with diagnoses which included history of stroke and right-hand contracture. Review of R7's quarterly ''Minimum Data Set (MDS),'' with an Assessment Reference Date (ARD) of 8/28/2023, indicated a ''Brief Interview for Mental Status (BIMS)'' score of six out of 15, indicating R7 was severely cognitively impaired. The assessment indicated R7 had Range of Motion (ROM) impairment to her upper extremity on one side of her body, and that a splint or brace had not been applied on any of the seven days prior to the ARD. Review of R7's ''Range of Motion Care Plan,'' dated 5/09/2022 and found in the EMR under the ''Care Plan'' tab, indicated R7 had an actual contracture to her right hand. Interventions included: ''Put the blue brace/protector in her hand most of the time to prevent contracture;'' and ''Resident is wearing the splint on her (R) (Right) hand, remove the splint at 6:30 pm and change to blue brace/protector to prevent hand contracture. Put the splint in the drawer.'' Review of R7's ''Resident Consolidated Orders,'' found in the EMR under the ''Orders'' tab, indicated an order for ''wear bolster hand splint 2 to 3 hours on and 2 hours off with palm guard in hand when splint is off and then for nighttime pt [patient] is to wear blue hand posey/guard'' with a start date of 5/09/2022. Review of R7's restorative documentation provided by the facility revealed nothing to indicate the resident's hand splint/palm guard had been recently applied. R7 was observed on 10/02/2023 at 1:30 PM, on 10/03/2023 at 9:14 AM and 3:27 PM, on 10/04/2023 at 9:01 AM, 10:22 AM, 12:16 PM, 2:36 PM, and 4:38 PM, and on 10/05/2023 at 9:02 AM and 4:42 PM. R7 was either up in her wheelchair in the day room or laying in her bed awake during all the observations. R7 was not observed to be wearing her splint or her palm guard during any of the observations. During an interview on 10/04/2023 at 4:42 PM with Certified Nursing Assistant (CNA) 2 and CNA4, both indicated they were familiar with R7 and indicated the splints were not routinely put on the resident since the splints were ''Hard to put on'' the resident. Both CNA2 and CNA4 indicated they thought therapy staff was responsible for putting R7's brace/palm guard on. CNA2 and CNA4 accompanied the surveyor into R7's room and the resident's brace/splint and palm guard were located on the resident's bedside table next to the resident's bed. During an interview on 10/05/2023 at 9:24 AM, CNA3 indicated she was familiar with R7 and stated she was not aware of the resident ever wearing a splint or palm guard. During an interview on 10/05/2023 at 9:30 AM, Resident Care Coordinator (RCC) 2, a licensed practical nurse, stated she was aware R7 had a contracture to her right hand and stated she had recently put in a therapy referral for the resident due to her contracture. RCC2 stated she had never seen R7 wearing a splint. During an interview on 10/05/2023 at 10:02 AM, the Rehabilitation Director confirmed she was familiar with R7 and stated, ''I have addressed her contracture and have issued a splint and a palm guard, and I have a wear schedule that nursing is supposed to be following. I even had it up on the wall at one point. I did educate the staff on how to apply the splint and how to stretch her hand so she could tolerate the splint. They should be putting it on her.'' During an interview on 10/05/2023 at 10:34 AM, the Director of Nursing (DON) stated her expectation was R7 should be wearing her splint and staff should be following the resident's plan of care and physician's orders related to splinting. 2. Review of R115's undated ''Face Sheet,'' found in the electronic medical record (EMR) under the ''Demographics'' tab, indicated R115 was admitted to the facility with diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side. Review of R115's quarterly ''MDS,'' with an ARD of 8/09/2023, indicated a ''BIMS'' score of 14 out of 15, indicating R115 was cognitively intact. The assessment indicated R115 had a Range of Motion (ROM) impairment to her upper extremity on one side of her body, and that a splint or brace had not been applied on any of the seven days prior to the ARD. Review of R115's ''Limited Mobility Care Plan,'' dated 9/07/2023 and found in the EMR under the ''Care Plan'' tab, indicated R115 had an actual contracture to her left hand. Interventions included: ''Refer to therapy as indicated.'' There was nothing documented in R115's plan of care to indicate the use of a splint. Review of R115's ''Resident Consolidated Orders,'' a list of all R115's current orders, dated 10/06/2023 and found in the EMR under the ''Orders'' tab, indicated no orders for the use of a splint/brace. Review of R115's restorative documentation provided by the facility revealed nothing to indicate a hand splint had been recently applied. R115's ''Occupational Therapy Daily Note,'' dated 6/22/2023 and provided directly to the survey team, indicated the resident was being discharged from therapy services on that date and read, in pertinent part, ''palm guard placed to open palm space to prevent worsening of contracture. The resident's Occupational Therapy Notes indicated staff had been trained on the application of the resident's hand splint and indicated a wear schedule for the splint had been established. R115 was observed on 10/02/2023 at 9:39 AM and 3:29 PM, on 10/04/2023 at 10:25 AM and 12:14 PM, and on 10/05/20023 at 09:04 AM. The resident was either in bed or in the facility hallway preparing to leave for dialysis during each of the observations. R115 was not observed to be wearing a splint on her upper left extremity during any of the observations. During an interview on 10/02/2023 at 9:39 AM, R115 stated she was supposed to have a splint on her left hand for contracture management and stated, ''I don't know what happened to that. I would wear one [a splint] if available.'' During an interview on 10/05/2023 at 9:06 AM, CNA1 stated she was familiar with R115 but was not aware of the resident having a splint for her left hand. During an interview on 10/05/2023 at 9:26 AM, CNA3 stated she was familiar with R115 but was not aware of the resident ever wearing a splint of any kind. During an interview on 10/05/2023 at 9:27 AM, Licensed Practical Nurse (LPN) 2 indicated she was familiar with R115 and stated she was not aware of the resident ever wearing a splint. During an interview on 10/05/2023 at 9:29 AM, RCC2 indicated she was familiar with R115 and stated she had never seen the resident wearing a splint. During an interview on 10/05/2023 at 10:07 AM, the Rehabilitation Director stated R115 was supposed to be wearing a palm guard. The Rehabilitation Director stated R115's splint had been on back order and her palm guard seemed to be working well, so the resident was supposed to be wearing the palm guard. She stated, ''It [the palm guard] was issued to her [R115] to wear and nursing staff need to help her put it on. It [the palm guard] can be worn throughout the day and night.'' The Rehabilitation Director stated she communicated with all staff and let nursing know about the resident's splints. On 10/05/2023 at 10:12 AM the Rehabilitation Director accompanied the surveyor into R115's room to look for the resident's palm guard and was not able to locate it. R115 was laying in her bed during the observation and stated, ''Yes. I had one [a palm guard] but I don't know what happened to it.'' During an interview on 10/05/2023 at 10:39 AM, the DON stated her expectation was R115 should be wearing her palm guard per her therapy documentation.

Based on resident and staff interviews, observations, record review, and review of the facility policy titled, Abuse Prohibition Policy, the facility failed to ensure timely reporting of potential abuse and injuries of unknown origin to facility Administration and the State Agency related to two of 20 sampled residents (Resident (R) R55 and R5). Specifically, a staff member witnessed potential verbal abuse perpetrated against R55 by another resident residing in the facility (R18) and did not report the potential abuse to the Administrator, who was the facility's designated Abuse Coordinator. Also, R5's injury of unknown origin was not reported as an injury of unknown origin. Findings include: Review of the facility policy titled, ''Abuse Prohibition Policy,'' dated/revised 12/20/2022 indicated, ''It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion;'' and ''Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a patient, such as telling a patient that she will never be able to see her family again;'' and ''Any person observing any abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of property, or exploitation must immediately report it to the Administrator, the Social Services Director, the Director of Nursing, any other department head or the nurse in charge . It will be the responsibility of any department head receiving the complaint of alleged abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation to inform the administrator or designee immediately.'' 1. R55's undated ''Face Sheet,'' found in the EMR under the ''Demographics'' tab, indicated the resident was admitted to the facility with diagnoses including acute kidney failure and chronic pain. R55's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 8/11/2023 indicated a ''Brief Interview for Mental Status (BIMS)'' score of 15 out of 15, indicating R55 was cognitively intact. The assessment indicated R55 required extensive assistance from staff to transfer in and out of bed and move about the facility. The assessment indicated the resident had not been exhibiting any behaviors. R18's undated ''Face Sheet,'' found in the EMR under the ''Demographics'' tab, indicated the resident was admitted to the facility with diagnoses including history of stroke. R18's quarterly MDS'' with an ARD of 8/11/2023 indicated a BIMS'' score of 15 out of 15, indicating R18 was cognitively intact. The assessment indicated R18 required extensive assistance from staff to move about the facility. The assessment indicated the resident had not been exhibiting any behaviors. R18's ''Progress Note,'' dated 8/2023 and found in the EMR under the ''Notes'' Tab, read, ''@0500 [at 5:00 AM] Resident [R18] threatened to harm his roommate [R55] and called him a racial slur. Safety maintained. Will continue to monitor.'' During an interview on 10/03/2023 at 9:50 AM, R55 stated he had concerns related to his previous roommate (R18) displaying verbally and physically aggressive behavior toward him. R55 stated staff were aware of R18's aggressive behavior toward him, and R18 had been moved to a different room earlier in September of 2023. R55 stated R18 had threatened to hurt him at one point, but that had occurred before R18 was moved to a different room. R55 stated he felt better since R18 was no longer his roommate. Review of the facility's Reportable Occurrences, Incident Log, and Grievance Log revealed nothing related to the potential abuse of R55 on 8/20/2023. During an interview on 10/04/2023 at 12:08 PM, the Administrator/Abuse Coordinator reviewed the facility's reportable occurrences and confirmed the potential abuse perpetrated by R18 to R55 on 8/20/2023 had never been reported to him, and therefore not investigated by him. The Administrator stated his expectation was all potential allegations of abuse were to be reported to him directly and immediately, stated R18's threat to harm R55 qualified as potential abuse, and stated the incident should have been reported to him on the morning of 8/20/2023. During an interview on 10/04/2023 at 12:44 PM, Licensed Practical Nurse (LPN) 1 confirmed she was the author of the 8/20/2023 Nurse's Note and stated she did not report the potential abuse because R18 and R55 had been arguing for days, R18 did not indicate precisely how he would harm R55 during the incident, and she assumed administration was already aware R18 and R55 had not been getting along. LPN1 confirmed she had received abuse training upon hire at the facility the previous summer and stated she was now aware she should have reported the incident on 8/20/2023 to the Administrator as potential abuse. 2. Review of R5's face sheet revealed the following diagnoses: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant. Review of R5's ''Resident Consolidated Orders,'' found in the EMR under the ''Orders'' tab, included an order for Skin barrier Protective wipe Monday, Thursday, Saturday every am shift. Cleanse open area on right outer knee with normal saline/wound cleaner. Apply skin barrier. Cover with dressing, started 10/03/2023. Review of the facility provided Incident Report dated 10/01/2022 through 10/03/2023 revealed there were no incident reports started for R5's injury to her right knee. During an observation on 10/02/2023 at 9:44 AM, it was revealed R5 had a bandage to the right side of her right knee. Record review of R5's MDS with an ARD of 9/04/2023 revealed a BIMS of six out of 15 which indicated R5 was severely cognitively impaired. During an interview and observation on 10/03/2023 at 3:17 PM in R5's room, R5 showed this surveyor the bandage on her right knee. The bandage was dated 10/2, and R5 stated she did not remember how she got the injury. During an interview on 10/04/2023 at 9:07 AM, Certified Nursing Assistant (CNA) 5 stated she was not working on the day R5 got the injury, and she did not know how the incident occurred. During an interview on 10/04/2023 at 9:09 AM, Resident Care Coordinator (RCC) 2 stated R5 self-propels in her wheelchair, and sometimes pulls herself alongside the wall. RCC2 stated she thought that was how R5 got the injury, but no one saw it happen. During an interview on 10/04/2023 at 9:14 AM, Certified Medication Aide (CMA) 1 stated the Administrative Assistant (AA1) told her about the injury and she then alerted Licensed Practical Nurse (LPN) 3 to the injury. During an interview on 10/04/2023 at 9:19 AM, LPN3 stated she was not at work when R5 got injured. LPN3 stated when a resident was found with an unknown injury the staff was to notify the doctor and family. She stated the injury should be treated per physician order, she further stated a change of condition should be documented, and the injury should be added to the 24-hour nurse report. During an interview on 10/04/2023 at 9:24 AM, RCC2 stated CNA6 told her about R5's injury. RCC2 stated she cleaned the injury, called the family, and left a message. RCC2 further stated she told the Nurse Practitioner (NP). During an interview on 10/04/2023 at 9:29 AM, the AA1 stated she saw the injury on 10/02/2023 in the early morning between nine and ten and told CMA1. During an interview on 10/04/2023 at 9:32 AM, CNA6 stated RCC2 was in the shower room with her when the injury was noticed. CNA6 stated R5 did not want to take a shower that day. During an interview on 10/04/2023 at 9:36 AM, the Director of Nursing (DON) stated when an injury of unknown origin occurs with a resident, an incident report should be done to determine how the injury occurred; and instead, it was entered as a change in condition. During an interview on 10/04/2023 at 9:39 AM with the Division Nurse (DN), she stated when an injury of unknown origin occurs with a resident, an incident report should be done. She further stated the doctor and the resident's family should be notified. During an interview on 10/04/2023 at 12:50 PM, the DON and DN stated there was no policy and procedure on incidents. 27375

Based on observation, record review, review of facility policy titled Enteral Tube Medication Administration, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 34 medication opportunities were observed, and there were three errors for one of four residents (R) (R #1) for an error rate of 8.82%. Findings include: Observation on 4/24/22 at 8:39 a.m. revealed Licensed Practical Nurse (LPN) AA prepared medications to administer to R#1 via gastrostomy tube (g-tube). The medications were [MEDICATION(S)] 500 milligrams (mg), Vitamin C 500 mg, and Vitamin D3 10 micrograms (mcg). The three medications were crushed and combined into a medicine cup. LPN AA then added water to the cup and entered the resident's room. She checked residual and poured the medication mixture into the syringe for the g-tube. She added water so that the medications would go down the tube. She then poured feeding into the syringe for the g-tube several times also adding water so that the feeding would go down the tube. She did not appear to be measuring the water. Interview with LPN AA immediately after medication administration revealed that it is the facility's policy to crush g-tube medications and to mix them together without keeping them separate during administration. She stated she used the measurement lines on the syringe to flush the tube with 30 ml of water before the feeding, 30 ml of water after the feeding, and she gave 5 ml of water with the medications. She stated she always crushes the medications for the g-tube and administers them together at one time. Interview with the Director of Nursing (DON) on 4/24/22 at 9:00 a.m. revealed that she believes the facility policy does not indicate to crush medications and administer separately for g-tube medications. Review of facility policy titled Enteral Tube Medication Administration dated 2019 revealed under guideline: it is recommended that crushed medications not be combined and given all at once via feeding tube in order to avoid obstructing the tube and to ensure the complete delivery of each medication. Review of the April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] [MEDICATION(S)] 500 mg tablet per PEG Tube (g-tube) two times per day for seven days, feeding tube flush with 30 ml before meds, 5 ml between each med, 30 ml after all meds, vitamin C 500 mg tablet per feeding tube two times per day and vitamin D 1000 IU (25mcg) one tablet per feeding tube two times per day. Interview and observation with LPN BB on 4/24/22 at 9:25 a.m. revealed the medication carts had the wrong bottle of vitamin D3 (the 10 mcg) but now have the right one, which is the 25 mcg tablet.

Based on complainant and staff interviews, resident's medical records, and the hospital emergency room (ER) records, the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of ER notes dated 7/17/2021 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Ortho fracture care-injury left shoulder with greater humeral tuberosity fracture. Procedure details include immobilization with sling and follow up with Orthopedic surgery. Review of Nurses' notes dated 7/20/2021 indicated resident to follow-up with bone and joint clinic. Resident educated to keep arm in sling and elevate arm up. Review of R#4's medical record indicated no referral made for orthopedic follow-up from 7/17/2021 ER visit. Review of ER notes dated 8/5/2021 chief complaint pain in left shoulder. Follow up information: Schedule an appointment as soon as possible for a visit in 2 days. Review of R#4's medical records indicated no referral made for orthopedic surgery follow-up from ER visit dated 8/5/2021. Interview on 8/16/2021 at 9:41 a.m. with R#4's family, revealed she received a call from the ER doctor who had seen R#4 on 7/16/2021 and again on 8/5/2021. The ER doctor revealed that R#4 had a fractured left wrist and shoulder on visit on 7/16/2021; and, that he did not see a cast on R#4 left arm. The ER doctor revealed to the complainant that he compared the x-rays from 7/16/2021 and 8/5/2021 and that the x-ray from 8/5/2021 showed that the fractures had increased. The ER doctor revealed that the facility had not done an orthopedic follow-up as ordered. Interview on 8/16/2021 at 1:20 p.m. with the Administrator revealed that the referral for R#4 for orthopedic services was not done. Interview on 8/16/2021 at 1:30 p.m. with the Director of Nursing (DON) revealed that they did not see any discharge instruction from the hospital from the resident's first visit on 7/17/2021. She revealed that there were no orders in R#4's chart. She revealed that Medical Records staff was asked to request the get records from hospital. She revealed that the facility has been unable to find the original discharge paperwork from the hospital ER visit. She revealed that an ortho consult was recommended in the Medical Doctor's (MD) progress notes. She revealed that she did not find an MD order for a referral to ortho. She revealed that she did find Emergency Department (ED) orders from second visit; ortho referral not made. Interview on 8/16/2021 at 2:37 p.m. with Registered Nurse (RN) JJ revealed that when a resident is admitted to the facility, she will put hospital orders into the system from the Medical Doctor (MD) and Nurse Practitioner (NP) or the hospital ER. She revealed that this was not done for R#4 because she never saw discharge orders. She revealed that she did not know of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed that the resident returned to the facility on [DATE] and the MD placed the order for the Orthopedic referral into the system on 7/20/21. She revealed that there were no orders for R#4 from last ER visit on 8/5/2021. She revealed that no orthopedic referral had been made for R#4, from the 7/17/2021 or the 8/5/2021 ER visit, until this survey.

Based on observations, staff interviews, and review of the facility's policy entitled Procedure for collecting soiled linen . and Procedure for Delivering Clean Linen, the facility failed to ensure that a clean linen cart used to deliver linen to three (3) of four (4) units was covered to prevent the potential for transmission of infection. The findings include: On 9/2/20 at 10:45 AM Laundry Aid (LA #1) was observed on the West Hall pushing an uncovered cart with clean linen. She wore gloves and was restocking a stationary linen cart on the West hall. During an interview with LA#1 on 9/2/20 at 10:45 AM, she stated her process for restocking the stationary linen carts on the halls. She reported the laundry was located on the back grounds outside of the facility. She filled the flat cart with clean linen and without a cover, began to take the linen to the different halls (East Hall, Middle Hall (COVID-19 Residents) and West Hall). LA#1 stated she rang the bell to enter the facility on the East Hall, then restocked the stationary linen cart on that hall. She traveled to the Middle Hall (COVID Unit) and restocked the stationary linen cart and then continue to the West Hall to restock the stationary linen cart. LA#1 was observed wearing several pairs of gloves but stated she did not need to change them when handling clean linen. The Director of Nursing was present during this observation and interview with LA#1 on 09/02/20 at 10:45 AM. She reminded the LA#1 that wearing several pairs of gloves was not policy, and she needed to perform hand hygiene each time gloves were put on and/or removed. On 09/02/20 at 12:25 PM an interview was conducted with the Environmental Director (ED). He stated it was the policy that all laundry transported from the laundry room to the halls should be covered. The ED stated he did not have copies of the staff orientation training or in-service on transporting clean linen. The ED provided a one page, Procedure for collecting soiled linen . and Procedure for Delivering Clean Linen. 1. Take covered linen delivery cart, 2. Do not use gloves to deliver clean linen, 3. Fill carts and put cover down, 4. Proceed to all stops. Revised 09/02/20.

Based on observation, interview, and record review, the facility failed to ensure the adequate oversight of the visitor and staff entrance screening process for the month of June. The screening process was intended to prevent persons potentially positive for coronavirus (COVID)-19 from entering the facility and having contact with the residents. The failure had the potential to promote the transmission of COVID-19 to residents who came into contact with individuals who were not properly screened, that could have been COVID positive. Findings include: Review of facility's Daily Symptom Screening Form COVID-19 revealed The Center staff screeners are required to take the person's temperature and verbally ask the screening questions to visitors and associates immediately upon entry to the Center and complete the form. Information gathered on the form included: date and time the visitor/associate entered and exited the facility, name of visitor or associate, exposure to COVID in last 14 days, review of symptoms, and documentation of the facility's screener initials. On 6/22/2020 at approximately 10:20 a.m., the surveyor was given access into the facility by the screener/staff member. The screener instructed the surveyor to utilize the thermometer to take her temperature and answer the questions on the Daily Symptom Screening Form. The screener left the surveyor to complete the screening questionnaire. This was completed without oversight from the staff member. Observation on 6/22/2020 at approximately 10:45 a.m. revealed two [MEDICAL TREATMENT] transportation assistants were granted access by a staff member into the facility. The transportation staff performed their own COVID screening including taking their own temperatures and filling out the forms. The facility provided no oversight of the screening process. Observation of the main entrance door on 6/22/2020 at approximately 1:25 p.m. revealed, a visitor ring the facility doorbell. A staff member allowed the visitor entrance and instructed the individual to perform handwashing. Then the staff member instructed the interviewee to perform the screening process (including temperature check). Continued observation revealed the visitor completed the symptom screening questionnaire and took a temperature without staff oversight Review of the facility's Daily Symptom Screening Form COVID-19 for June (6/1/2020 thru 6/22/2020), in the presence of the Director of Nursing (DON), revealed the facility utilized a staff screener sporadically. The screening form revealed that multiple visitors and staff performed and documented the COVID screening themselves. The screening form identified a place for the screener's initials; however, majority of the time is was left blank. Interview with a Hospice Certified Nursing Assistant on 6/22/2020 at 1:30 p.m. revealed the facility educated her on signs and symptoms of COVID. Additional, education included how to utilize the daily screening form. She stated the facility staff performed the COVID screening at times. However, there were multiple times in which she had been permitted to self-screen. Phone interview with the Director of Nursing (DON) and Infection Control Nurse on 6/23/2020 at 8:30 a.m. revealed either the DON, Infection Control Nurse or an appointed designee would be responsible for completing the COVID screening assessment. The DON and Infection Control Nurse validated, without consistent oversight of the screening process, the facility would be unable to effectively track possible infection control breeches.

Based on observation, review of the policies titled Housekeeping Services and Pharmacy Services-Medication Administration/General, and staff interviews, the facility failed to provide an environment that was free from potential accidents and hazards on two of three nursing units. Specifically, the facility failed to properly identify and dispose of a medication found on the floor and failed to ensure a medication signed out as given was not left at the bedside of one resident (R) (#17) that was sleeping. Findings include: 1. During the observational medication pass conducted with Licensed Practical Nurse (LPN) AA on 8/14/19 at 8:30 a.m., in the hallway outside the dining room of the secured East Memory Unit, a small white pill with ridge on top was observed on the floor next to the Floor Tech's dry mop. The Floor Tech was in the process of sweeping around the medication cart with the medication and other floor debris present. When alerted regarding the pill on the floor, Floor Tech BB stated ok and continued to sweep the pill with the other floor debris. During an observation with LPN AA of the pill on the floor at this time, she stated ok and that it wasn't hers, it must be from night shift. LPN AA left the pill on the floor until asked if she should discard it. At the time of the medication discovery, one male resident was observed wandering in the hall. During an interview on 8/14/19 at 9:40 a.m., the Director of Nursing (DON) explained the procedure the LPN and Floor Tech should follow when finding a medication on the floor. The DON stated the expectation is for the nurse to place the pill in the sharp's container, try to identify it, who it might belong to, and then replace the medication if easily identified as belonging to the resident. The DON explained that housekeeping staff have been taught to tell the nurse when they find medications in the room or on the floor, and the nurses would handle it from there. An interview was conducted on 8/15/19 at 10:16 a.m. with the Housekeeping Supervisor (HS) where he explained he was new to the facility, as of three weeks ago, but confirmed he was responsible for the floor techs, housekeepers and the laundry staff. The HS confirmed he has had talks with his housekeeping staff that if they find medication or pills in the rooms or on the floor, they are to stand over the medication, call for a Certified Nurse Assistant (CNA) or nurse, and not to leave the medication until someone comes. He confirmed he had this talk with his staff about three days ago but could not recall an exact time. 2. An observation was conducted on the West Unit on 8/14/19 at 12:15 p.m. of R#17 who was observed asleep in his shared room. A large white pill in a medication cup was observed on his bedside table. The medication nurse, Registered Nurse (RN) CC, was asked about the medications at the bedside, where she explained the resident likes to take his medications on his own time. At this time, the resident was awakened by the nurse and asked to take his medication. Review of the electronic Medication Administration Record [REDACTED]. Documentation reflected that [MEDICATION NAME] was scheduled to be given before meals at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m. It was documented as given on 8/14/19 at 11:30 a.m. During an interview with the DON on 8/14/19 at 1:19 p.m., she confirmed that it is her expectation that no medication is left at the bedside, if the resident is unable to take the medication or refuses, the nurse is to remove it and sign refused, then reattempt later. The DON confirmed that RN CC had come to her and told her what medications she had left in the room. A review was conducted of the facility policy titled, Housekeeping Services dated (MONTH) 2019 documenting the intent of the center to maintain a clean and sanitary center that is free from odor and environmental factors that may affect the quality of life of the patients. Review of the undated facility policy titled Pharmacy Services-Medication Administration/General revealed that medications are to be administered as prescribed, in accordance with good nursing principals. Procedural Guidelines: 4. Medications are administered at the time they are prepared. 17. For patients not in their rooms or otherwise unavailable to receive medication on the pass, the MAR indicated [REDACTED].

Based on observation, staff interview, and record review, the facility failed to follow the plans of care related to behaviors for two residents (#29, and #65) from a sample of 23 residents. Findings include: 1. Review of the clinical records for Resident (R)#29 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed a Quarterly MDS of 3/1/18 which documented a Brief Interview for Mental Status (BIMS) score of 1 (indicative of a severe cognitive disability), some mood symptoms, and active [DIAGNOSES REDACTED]. The assessment also documented behaviors such as rejection of care and wandering which occurred 1-3 days during the assessment period. Further review of the MDS records revealed the last comprehensive MDS - the annual assessment - was completed for R#29 on 8/29/17, which revealed that the assessment also documented wandering and rejection of care behaviors. Under the Care Area Assessment Summary (CAAS) of the comprehensive assessment, cognitive loss/dementia and behavioral symptoms triggered and the decision was made to create a plan of care for these areas. A review of a plan of care dated 4/17/18 for R#29 related to behavioral changes revealed the resident's goals were to have decreased episodes of anxiety and for her behaviors not to have a negative impact on herself or others. Staff interventions included reducing stimuli, moving her to a quieter environment during anxious episodes, and redirecting and refocusing her. Observation on 5/29/18 at 3:24 p.m. revealed that R#29 was noted to be sitting in her room when R#65 wandered in and walked to the window. Soon after R#65 entered the room, R#29 shouted in a loud, angry voice: get your ass out of this room! this is not your room! Staff in the vicinity did not intervene to redirect or refocus either resident. Observation on 5/30/18 at 8:40 a.m. revealed R#29 was sitting quietly in her room when R#65 wandered in and headed towards the window at the far side. R#29 immediately jumped up and yelled in an angry voice, get your ass out of here! I'm calling the sheriff to come get you! Go on, get out! As R#65 turned and ambled slowly out of the room, R#29 followed and slammed the door shut behind him. Staff in the vicinity did not intervene to redirect or refocus. 2. Review of the clinical records for R#65 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Annual Minimum Date Set (MDS) assessment of 4/24/18 the revealed resident had such a severe cognitive deficit that the Brief Interview for Mental Status could not be completed. The assessment also documented some existing depression symptoms; behaviors such as daily rejection of care and daily wandering, and active [DIAGNOSES REDACTED]. Under the Care Areas Assessment Summary (CAAS) behavioral symptoms use triggered and the decision was made to complete a plan of care for that area. Review of the resident's plan of care dated 4/23/18 for behaviors, including ambulating aimlessly, and pacing, revealed a goal for the resident's behaviors to not have a negative impact on self or others. Interventions directed staff to: assist to return to room as needed; distract with activity or food or beverage; monitor behaviors for frequency; move to quieter environment as needed; redirect/refocus; reduce stimuli; and remove from situation. Observation on 5/29/18 at 3:09 p.m. revealed that R#65 wandered up and down hallway and in and out of the dining room and seven residents' rooms (several of them on multiple occasions) on his unit without staff intervention; On one occasion, he entered room [ROOM NUMBER] (the resident's room was room [ROOM NUMBER]) as a Certified Nursing Assistant exited the room, but she did not redirect him. Observation on 5/29/18 at 3:24 p.m. revealed that R#65 wandered in and walked to the window of room [ROOM NUMBER]. Soon after R#65 entered the room, R#29, one of the occupants of that room, shouted in a loud, angry voice: get your ass out of this room! this is not your room! Staff in the vicinity did not intervene. Observation on 5/30/18 beginning at 8:35 a.m. revealed that R#65 was noted to be roaming up and down the hallway of the locked unit, entering several rooms on the hallway, some occupied, some not; several members of staff passed him during his wanderings, but did not redirect him. Observation on 5/30/18 at 8:40 a.m. revealed that R#65 wandered in and walked to the window of room [ROOM NUMBER]. Soon after R#65 entered the room, R#29, one of the occupants of that room, immediately jumped up and yelled in an angry voice, get your ass out of here! I'm calling the sheriff to come get you! Go on, get out! As R#65 turned and ambled slowly out of the room, R#29 followed and slammed the door shut behind him. Staff in the vicinity did not intervene. An interview on 5/31/18 at 2:00 p.m. with the Director of Nursing (DON) revealed that R#29 experiences anxiety related to others encroaching on her personal space and this anxiety and accompanying behaviors such as lashing out verbally and physical at staff and other residents had escalated in recent weeks. While other residents encroaching on the resident's personal space was recognized by staff as one of the triggers to this lashing out, they would not prevent other residents from wandering into her room because this is what residents on the secure unit do. The residents on that unit had the right to wander freely, including wandering into the room of R#29 and staff of the facility would not impede that right. Cross-refer to F740

Based on observation, staff interview, and review of records, the facility failed to minimize/eliminate situations that triggered emotional distress for one cognitively impaired resident (#29) by refusing to limit the intrusion of other cognitively impaired residents into her personal space. The sample size was 23 residents. Findings include: Review of the clinical records for Resident (R)#29 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed a Quarterly MDS of 3/1/18 which documented a Brief Interview for Mental Status (BIMS) score of 1 (indicative of a severe cognitive disability), some mood symptoms, and active [DIAGNOSES REDACTED]. The assessment also documented behaviors such as rejection of care and wandering which occurred 1-3 days during the assessment period. Further review of the MDS records revealed the last comprehensive MDS - the annual assessment - was completed for R#29 on 8/29/18. That assessment also documented wandering and rejection of care behaviors. A review of the nurses' notes of 4/28/18 at 3:28 p.m. revealed that the resident was very agitated all evening, cursing at other residents and staff, being physically abusive to staff, hitting, kicking, pushing and threatening serious bodily injury to staff, and unplugging the television in day room stating it belonged to her and threatening to call the police; A review of a Facility Reported Incident dated 4/28/18 revealed R#29 was involved in a physical altercation with another resident after the other resident exited the room of R#29 and accused R#29 of trying to jump on her. The incident was recorded as occurring at 8:20 p.m. that evening. A review of the nurses' notes during the evening of 4/29/18 revealed documentation that the resident continued with behaviors like that of the evening before. A review of the monthly nurses' note of 5/15/18 documented under the mood section that the resident had an abnormal sleep pattern, showed little interest in anything, was restless/fidgety/anxious, short-tempered and annoyed. Under behaviors was listed inappropriate verbal behaviors, refusal of care, wandering, and being at risk for elopement/intruding on others. Review of the current behavior monitoring records revealed R#29 was being monitored for physically aggressive behaviors. During observation on the secure unit on 5/29/18 at 3:24 p.m. R#29 was noted to be sitting in her room when R#65 wandered in and walked to the window. Soon after R#65 entered the room, R#29 shouted in a loud, angry voice: get your ass out of this room! this is not your room! Staff in the vicinity did not intervene. During observation on 5/30/18 at 8:40 a.m. R#29 was observed sitting quietly in her room when R#65 wandered in and headed towards the window at the far side. R#29 immediately jumped up and yelled in an angry voice, get your ass out of here! I'm calling the sheriff to come get you! Go on, get out! As R#65 turned and ambled slowly out of the room, R#29 followed and slammed the door shut behind him. Staff in the vicinity did not intervene. During an interview with Licensed Practical Nurse (LPN) AA on 5/30/18 at 2:01 p.m., it was revealed that staff were aware that R#65 wanders on the unit and into other residents' rooms, but staff does not usually intervene. They consider the facility to be the residents' home, as a result, they can do what they would normally do in a home setting, including wandering into other rooms. There were some situations under which residents would be redirected on entering another resident's room. For example, if R#65 (or any resident on the unit) wandered into another resident's room while that other resident was receiving personal care, then he/she would be redirected. The other residents are usually not bothered by R#65 wandering in and out of their rooms. If, occasionally, another resident does object to R#65 being in his/her room, staff would then redirect. For the most part, however, the staff allows the residents on the unit to wander freely. During an interview with Certified Nursing Assistant (CNA) BB on 05/30/18 at 5:00 p.m., it was revealed that staff allows the residents to wander freely on the secured unit. The staff sometimes redirects residents when they go into other residents' rooms and lie on other residents' beds. However, the residents usually just return a few minutes later to do the very same thing. Most residents do not seem to care when other residents come into their room. R#29 is the only resident who seemed to care when other residents intrude into her room and will usually ask them to leave. This is usually not a problem, however, since R#29 is not always in her room to see other residents when they come in uninvited. Interview with (LPN) CC on 5/31/18 at 9:48 a.m. revealed the staff sometimes try to redirect the residents when they wander up and down the hallway and into other residents' rooms. However, it is hard because they have so many walkers. R#29 does object when the other residents enter her room uninvited. She becomes very upset and has tried to hit some of them in the past. On some occasions, however, she sits in her room and just watches them as they walk in and out. It is as if she knows they are going to do it anyway, so why bother? Interview on 5/31/18 at 11:04 a.m. with CNA DD revealed R#29 becomes upset when other residents wander into her room, especially if the resident who wanders in is a male. At such times, she might complain to staff that someone is in her room or she will tell the resident to leave. Staff will try to redirect the resident who wanders into her room and keep the door closed when she is not in her room to deter them. The resident does become upset when R#65 wanders into her room. Most often, however, before she can say anything to him, he has wandered in and out again. During an interview on 5/31/18 at 2:00 p.m. with the Director of Nursing (DON), it was revealed that R#29 experiences anxiety related to others encroaching on her personal space and this anxiety and accompanying behaviors such as lashing out verbally and physical at staff and other residents had escalated in recent weeks. While other residents encroaching on the resident's personal space was recognized by staff as one of the triggers to this lashing out, they would not prevent other residents from wandering into her room because this is what residents on the secure unit do. The residents on that unit had the right to wander freely, including wandering into the room of R#29 and staff of the facility would not impede that right.

Based on observation, interview and record review, the facility failed to ensure that food was stored in a proper manner related to uncovered food items in the walk-in refrigerator and failed to ensure that dishes were cleaned and sanitized related to the dish machine water not reaching the required temperature and a lack of sanitizer in the dish machine. The Census was 80 with one tube fed resident. Findings included: During the initial tour of the kitchen on 4/3/17 at 10:35 a.m. In the walk-in refrigerator there were two pans with individual serving bowls of pudding dated 4/1/17. All the bowls were uncovered. The Certified Dietary Manager (CDM) told kitchen staff to cover the pudding. She stated that the pudding was prepared on 4/1/17 and was just scooped into the bowl this morning and placed in the refrigerator and that it should have been covered. During the initial tour of the kitchen on 4/3/17 at 10:35 a.m. the Low Temperature Dish Machine was observed being operated by Kitchen Aide AA. The thermostat on the dish machine was observed and revealed that the water temperature measured at 100 degrees Fahrenheit for the wash cycle and 110 degrees Fahrenheit for the rinse cycle. Kitchen Aide AA was asked if she checked the thermostat today and she stated that she did not. She stated, I don't look at that. I really don't pay it any attention. She stated that she checks the sanitation. She was observed to check the sanitation at this time with the sanitation strips which measures the concentration in parts per million (ppm) (mg/L) of the sanitizing solution. The strips revealed that the sanitation was measuring at zero ppm's in the machine. She confirmed that according to the strip, there was no sanitation during this process. The Certified Dietary Manager (CDM) came over at that time and stated, It was noticed yesterday that it was not pumping and reading properly. She confirmed that the ppm's were measured earlier yesterday and the strips were reading that there was sanitation in the machine. She stated that later yesterday the strips revealed that there was no sanitation being measured in the machine. She was asked if the kitchen monitored and logged the temperature of the water. She stated, I was told that as long as long as the ppm was reading, that was sufficient. She was asked what the facility policy was on monitoring and logging the temperature of the dish machine. She stated, Im not quite sure. She confirmed that she has worked in the facility since November 2016 and that the kitchen staff has never monitored or logged the dish machine temperature. She confirmed that they only monitor the chemical sanitizer and that the logs reflect the chemical sanitizer monitoring only. She stated, As long and the water is less than 120 (degrees Fahrenheit) it's okay. When asked about the sanitizer not measuring any ppm's, she stated, We know its pumping but the strips are not reading it. She explained that she knows that the sanitation is pumping into the machine because the levels on the bucket of sanitation was going down. She stated, We know it's coming out. It's just not reading. She confirmed that due to the levels on the buckets going down, they felt that the dishes were being cleaned and sanitized. The CDM was asked for logs of the past 12 months of dish machine logs and the facility policy on the dish machine. Interview with the Administrator on 4/3/17 at 10:23 a.m. she stated that there was a problem with the dish machine in the past and that recently had it serviced. On 4/3/2017 at 11:08 a.m. Administrator stated that the Maintenance Director monitors the dish machine temperatures weekly. She stated that he documents this in the TELS system. She provided the Weekly Water Temps and Equipment Instructions dated 2004-2009 with Reviewed and Updated date of September 2014) revealed (2) Kitchen dish machine should be at least 120 degrees (Fahrenheit) or per manufactures recommendations. On 4/3/17 at 11:10 a.m. the chemical was measured by the CDM and continued to measure at zero chemical.

Based on observation and staff interview, the facility failed to store personal care and hygiene items in a sanitary manner to prevent potential cross-contamination in 14 of 18 bathrooms observed on two of two nursing units. The facility census was 80 residents, and the sample size was 27 residents. Findings include: During observations in resident bathrooms which were shared by four residents in two adjoining rooms, the following personal care items were noted to be stored unlabeled and/or unbagged: 4/3/17 at 9:57 a.m. for rooms [ROOM NUMBERS]: One unlabeled toothbrush on the sink. 4/3/17 at 10:04 a.m. for rooms [ROOM NUMBERS]: Four bath basins, one bedpan, one urinal, and one bedside commode liner on the floor, and one hair comb and one toothbrush on the sink. 4/3/17 at 10:13 a.m. for rooms [ROOM NUMBERS]: Two bath basins on the floor and one hair comb on the sink. 4/3/17 at 10:16 a.m. for rooms [ROOM NUMBERS]: one bedside commode liner and one bath basin on the floor. 4/3/17 at 10:30 a.m. for rooms [ROOM NUMBERS]: one bath basin and one urinal on the floor. 4/3/17 at 10:36 a.m. for rooms [ROOM NUMBERS]: four bath basins and one urinal on the floor. 4/5/17 at 7:34 a.m. for room [ROOM NUMBER] (this bathroom was shared by two residents in one room): One bedpan, one urinal, one half-hat specimen collection device, and an insulated drinking mug on the floor under the sink. During interview with the Director of Nursing (DON), who was also the Infection Control Coordinator on 4/6/17 at 11:59 a.m., she stated that personal care and hygiene items such as bedpans, bath basins, urinals, toothbrushes, and denture cups should be labeled with the resident's name and stored in a bag. She further stated that the facility did not have a policy and procedure related to storage of these items. During continued interview, the DON stated that she verbally told staff on a regular basis on how to correctly store personal care items, but did not have anything in writing related to ongoing education. During a walk-through of resident bathrooms with the DON on 4/6/17 beginning at 12:04 p.m., she verified the following observations related to storage of hygiene and personal care items. Unless noted otherwise, all of the following items were observed to be unlabeled and unbagged in a bathroom shared by four residents: rooms [ROOM NUMBERS]: There was one labeled urinal on the grab bar next to the commode, and the DON stated that she preferred for it to be bagged. rooms [ROOM NUMBERS]: One bath basin on top of the toilet tank cover, and one urinal on the grab bar next to the commode. rooms [ROOM NUMBERS]: One half-hat specimen collection device on the floor by the commode, and one bath basin on the floor under the sink. rooms [ROOM NUMBERS]: One half-hat specimen collection device wedged between the wall and grab bar next to the commode, one half-hat specimen collection device on the floor by the commode, and two bath basins on the floor under the sink. rooms [ROOM NUMBERS]: One urinal on the grab bar next to the commode, and one half-hat specimen collection device on the floor next to the commode. There were four bath basins nested inside each other, and these bath basins were stored on top of a bedpan on the floor under the sink. Only one of the four basins was labeled. rooms [ROOM NUMBERS] (shared by three residents): One urinal on the grab bar next to the commode, and two bath basins nested together on the floor under the sink. rooms [ROOM NUMBERS]: One urinal hooked on the frame of the commode extender, and one unlabeled toothbrush in a cup on top of the paper towel dispenser. rooms [ROOM NUMBERS]: Four bath basins and an emesis basin nested inside each other which were bagged and on on the floor, but only one of the bath basins was labeled. rooms [ROOM NUMBERS]: One bedpan stored on top of two bath basins nested inside each other on the floor under the sink. rooms [ROOM NUMBERS]: One upside-down half-hat specimen collection device on the floor under the sink, and one empty denture cup on the sink top. rooms [ROOM NUMBERS]: Two unlabeled bath basins on the floor under the sink. rooms [ROOM NUMBERS]: One unlabeled toothbrush on the sink top. During interview with the DON following the above observations, she stated that she would just throw out anything that was not labeled, and that the half-hat specimen collection devices were intended for one-time use only and then should be disposed of. During interview with Certified Nursing Assistant FF on 4/6/17 at 12:55 p.m., she stated that items such as bath basins were labeled with the resident's name and room number, and placed in a bag in their closet.

Based on observation, interview and record review, the facility failed to ensure that the dish machine was operating related to the water not reaching the required temperature and a lack of sanitizer and failed to ensure that one of one commercial stove was operational in a safe and functional manner related to two of six pilots lights observed not functioning. Findings included: During the initial tour of the kitchen on 4/3/17 at 10:35 a.m. the Low Temperature Dish Machine was observed being operated by Kitchen Aide AA. The thermostat on the dish machine was observed and revealed that the water temperature measured at 100 degrees Fahrenheit for the wash cycle and 110 degrees Fahrenheit for the rinse cycle. Kitchen Aide AA was asked if she checked the thermostat today and she stated that she did not. She stated, I don't look at that. I really don't pay it any attention. She stated that she checks the sanitation. She was observed to check the sanitation at this time with the sanitation strips which measures the concentration in parts per million (ppm) (mg/L) of the sanitizing solution. The strips revealed that the sanitation was measuring at zero ppm's in the machine. She confirmed that according to the strip, there was no sanitation during this process. The Certified Dietary Manager (CDM) came over at that time and stated, It was noticed yesterday that it was not pumping and reading properly. She confirmed that the ppm's were measured earlier yesterday and the strips were reading that there was sanitation in the machine. She was asked if the kitchen monitored and logged the temperature of the water. She stated, I was told that as long the ppm was reading, that was sufficient. She was asked what the facility policy was on monitoring and logging the temperature of the dish machine. She stated, I'm not quite sure. She confirmed that she has worked in the facility since November 2016 and that the kitchen staff has never monitored or logged the dish machine temperature. She confirmed that they only monitor the chemical sanitizer and that the logs reflect the chemical sanitizer monitoring only. She stated, As long and the water is less than 120 (degrees Fahrenheit) it's okay. When asked about the sanitizer not measuring any ppm's, she stated, We know its pumping but the strips are not reading it. She explained that she knows that the sanitation is pumping into the machine because the levels on the bucket of sanitation was going down. She stated, We know it's coming out. It's just not reading. She confirmed that due to the levels on the buckets going down, they felt that the dishes were being cleaned and sanitized. The CDM was asked for logs of the past 12 months of dish machine logs and the facility policy on the dish machine. Interview with the Administrator on 4/3/17 at 10:23 a.m. she stated that there was a problem with the dish machine in the past and that recently had it serviced. On 4/3/17 at 11:08 a.m. Administrator stated that the Maintenance Director monitors the dish machine temperatures weekly. She stated that he documents this in the TELS system. She provided the Weekly Water Temps and Equipment Instructions dated 2004-2009 with Reviewed and Updated date of September 2014) revealed (2) Kitchen dish machine should be at least 120 degrees (Fahrenheit) or per manufactures recommendations. On 4/3/17 at 11:10 a.m. the chemical was measured by the CDM and continued to measure at zero chemical. Initial tour of the conducted on 4/3/17 at 10:35 a.m. The stove was observed with grease build up. The CDM was asked to test the pilot lights. She confirmed that two of six pilot lights were not functioning at that time. During an interview with the Administrator on 4/5/17 at 4:25 p.m. she stated that the maintenance are to check the pilot lights annually. They last checked them on 1/17/17 and all worked. She stated that the kitchen staff are to notify the maintenance department when they have problems such as the pilot light being out. She provided the facility policy Equipment (Kitchen) service Instructions & Log last updated December 2009: All kitchen equipment should be . inspected one time per year. Check all pilot lights and burners.

Based on observations, resident and staff interview the facility failed to ensure that privacy curtains in eight resident rooms on one of two wings (East and West) provided full visual privacy for eight residents who resided in those rooms. The facility census was eighty (80). Findings include: Observation of incontinence care on 4/5/17 at 10:15 a.m. for R#122, revealed the privacy curtain would have to be drawn across the bed, and over the residents' neck and chest area to be pulled. The bed was in the corner of the room with the head of the bed against the wall. Interview 4/5/17 at 10:20 a.m. with Resident (R) #122 revealed she prefers the bed against the wall because it gives more area to move around the room in her wheelchair. R#122 confirmed the privacy curtain is not used because it would be across her chest and would not provide privacy. Interview 4/5/17 at 10:25 a.m. with Certified Nursing Assistant (CNA) BB revealed the privacy curtain cannot be used because it would be across the residents' chest and if someone opened the door the resident would be exposed. The following observations were made with the Director of Nursing (DON) on 4/6/17 between 12:10 p.m. and 12:50 p.m.: 1. An observation was conducted in room 20 A. The curtain did not give full visual privacy. If pulled the privacy curtain would be across the residents' neck and chest area. If the curtain was pulled enough to clear the bed the resident would be exposed. 2. Observation in room 35 A revealed the privacy curtain was not effectively providing visual privacy because it would extend across the bed at the level of the residents' neck and chest area. Opening the door would expose the resident becuase the curtain would not enclose the bed. 3. During observations in room 40 A the privacy curtain would extend across the residents' neck and chest if pulled. The resident would not be provided full visual privacy if the door was opened. 4. Observation in room 41 A revealed the privacy curtain did not give full visual privacy. If pulled the curtain would be across the residents' neck and chest and if the door was opened the resident would be exposed. 5. During observations in room 43 A the privacy curtain did not give full visual privacy. If pulled the privacy curtain would be across the residents' neck and chest and if pulled enough to clear the bed the resident would be exposed if the door were opened. 6. During observations in room 45 A the privacy curtain did not give full visual privacy. If pulled the privacy curtain would be across the residents' neck and chest and if pulled enough to clear the bed the resident would be exposed if the door were opened. 7. Observation in room 47 A revealed the privacy curtain did not give full visual privacy. If pulled, the privacy curtain would be across the residents' neck and chest and if pulled enough to clear the bed the resident would be exposed if the door were opened. 8. An observation was conducted in room 50 A. The privacy curtain would extend across the residents' neck and chest if pulled. The curtain would leave the resident exposed if the door was opened by staff, family or another resident. Interview on 4/6/17 at 12:50 p.m. with the DON revealed the curtains in rooms 20 A, 35 A, 40 A, 41 A, 43 A, 45 A, 47 A, and 50 A are on tracks that would cause the curtains to be pulled across the beds and the residents' neck and chest area, do not provide full visual privacy. The DON expects the curtains to give the residents full visual privacy so when any form of care is done and the door is opened by another resident, employee or family, the resident is not exposed. The DON acknowledged no one had noticed or reported the privacy curtains could not be drawn and explained there is no policy regarding visual privacy.