Every finding on record at Bainbridge Landing of Journey LLC

Based on observations, staff interviews, record review and review of the facility's policies titled, Controlled Substance Administration and Accountability and Medication Administration, the facility failed to ensure the Controlled Substances Proof of Use form was signed after narcotic administration for one of 41 sampled residents (R) R8 during review of one of two medication carts. This deficient practice had the potential to cause incorrect narcotic counts, missed or overdose of narcotic medication for R8.Findings include: Review of the facility's policy titled, Controlled Substance Medication Accountability reviewed 02/14/2024 documented Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines:1. General Protocols:. f. All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways:. ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. iii. All specially compounded or non stock Schedule Il controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy. g. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy.Review of the facility's policy titled Medication Administration reviewed 02/14/2024 documented Policy Explanation and Compliance Guidelines: .18. If medication is a controlled substance, sign narcotic book.Review of the electronic medical records (EMR) revealed R8 was admitted to the facility on [DATE] with diagnosis included but not limited to chronic pain syndrome.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 15 which indicated R8 had intact cognition, Section J (Health Conditions) R8 received as needed (PRN) pain medications, had pain over the last five days, Section N (Medications) R8 takes opioid.Review of care plan dated 08/26/2025 documented R8 is receiving an opioid medication and is at risk for or has reported actual side effects related to chronic pain. Goal: side effects will be monitored through next pain evaluation. Intervention: Monitor for Increased sensitivity to pain, monitor for symptoms of withdrawal if medication is stopped or dose held.Review of the Physician's Orders dated 03/24/2026 documented included but not limited to Acetaminophen Oral Tablet 5-325 milligram (mg) (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain related to chronic pain syndrome.Observation and interview on 03/31/2026 at 11:58 AM during review of the 100 Hall medication cart revealed the narcotics and narcotic book were checked and one signature was missing from the Controlled Substances Proof of Use form. Further observation revealed the Controlled Substances Proof of Use form documented Hydrocodone - Acet 5-325 mg tablet for R8 had 14 tablets remaining and the blister pack had 13 tablets. Licensed Practical Nurse (LPN) DD was present during the review, and she confirmed the Controlled Substances Proof of Use form documented Hydrocodone - Acet 5-325 mg tablet for R8 had 14 tablets remaining and the blister pack had 13 tablets. She stated she administered the narcotic tablet and did not sign that it was administered. She stated she always signed immediately after administration of narcotics but she was distracted by a relative of another resident, and she forgot to sign. She stated that during the mediation pass this morning she signed right after administering narcotics and she stated that during this review of all the narcotics in the 100-hall cart, only the one narcotic was found to not be signed for. LPN DD further stated she should have signed that she administered the Hydrocodone - Acet 5-325 mg tablet for R8 and since she did not sign that it was administered, there would be a discrepancy with the narcotic count, and it could seem as if she took the medications. She further stated that another nurse could give the medication to the resident and not know that it was already given and the resident could get an overdose.Interview on 03/31/2026 at 4:03 PM with the Director of Nursing (DON) revealed she stated her expectations were for the nurses to sign the narcotics they administered at the same time right after they administered it after removal. She stated the controlled sheets protect from diversion or misappropriation. The DON stated that medically, a negative outcome for the resident could be that when the nurse does not sign immediately that she administered the narcotic it could lead to possible misappropriation. If it was not signed out at the time it was given and it was signed one hour later, when the resident needed pain medication again the medication administration record (MAR) would say that it was too soon to be administered. The opposite would also happen if it were signed out before the medication was given, the MAR would say it cannot be given sooner and if it is given sooner it could lead to overdose of the medication. The DON stated if it was given too late depending on what the medication was, the resident's condition may worsen.Interview on 04/01/2026 at 4:00 PM with LPN HH revealed she stated the nurse should sign in the computer and the narcotic book whenever a narcotic medication was administered. She further stated the narcotic book should be signed immediately after administering the narcotic because persons could go back and look to see when it was last administered and it also would be accounted for. If it was not signed out it would be a medication error and the nurse could forget to go back and another nurse would give another dose of the medication to the resident which would cause overdose.Interview on 04/01/2026 at 4:03 PM with LPN II revealed that the narcotic book should be signed immediately after administering the narcotic because if it was not signed for at the time it was given, and the nurse remembered an hour afterwards and documented it, the EMR system would record it one hour later and the next dose would be too early if the other nurse gave it to the resident, not knowing that the resident already received it and this would overmedicate the resident and cause the resident distress.

Based on observations, staff interviews and review of the facility's policy titled, Medication Storage, the facility failed to place open dates on two vials of blood glucose strips in one of two carts (100 hall cart) reviewed. This deficient practice had the potential to cause inaccurate blood sugar readings for the residents.Findings include:Review of the facility's policy titled, Medication Storage revised 02/14/2024 documented Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.Observation and interview on 03/31/2026 at 11:52 AM during review of the 100 Hall medication cart revealed two blood glucose vials were in the top right drawer of the medication cart had no open dates. Licensed Practical Nurse (LPN) DD was present during the review, and she confirmed there were two blood glucose vials with no open dates in the top right drawer of the medication cart. LPN DD stated there should be open dates on the blood glucose strips because after the bottle was opened there was a depreciation of the strips and no one would know when the strips were opened if there was no open date. She stated if the strips were used on residents there would be inaccurate blood sugar readings.Interview on 03/31/2026 at 04:16 PM with the Director of Nursing (DON) revealed she stated her expectations were for the medications to have open dates. She stated that there were medications which would have a shortened shelf life and blood glucose strips would fall under that category so it should have an open date. The DON further stated if the blood glucose strips were used on the residents, there would be inaccurate blood sugar readings, medication errors and the residents could be over medicated or under medicated.Interview on 04/01/2026 at 04:00 PM with LPN HH revealed she stated blood glucose strips should have open dates. She stated that whenever the vials were opened, the strips would be exposed to air which can degrade the strip and lead to false blood sugar readings.Interview on 04/01/2026 at 04:02 PM with LPN II revealed she stated blood glucose strips should have open dates when they first opened because there was a certain time after the vial was opened for the strips to be no longer be good. She further stated if the strips were used on residents, they would get false readings such as false high blood sugar readings when they were not high or false low blood sugar readings when they were not low. The residents would be treated for the false blood sugar reading, and the residents could pass away.

Based on observations, staff interviews, record review and review of the facility's policies titled, Hand Hygiene and Infection Prevention and Control Program, the facility failed to practice infection control protocol by staff not practicing proper glove use and hand hygiene between glove change during wound care for one of six sampled residents (R) R2 with wounds, and during Foley catheter care for one of five sampled R's with Foley catheter, R42. This deficient practice had the potential to cause infection to the residents.Findings include:Review of the facility's policy titled Hand Hygiene revised 02/01/2024 documented Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's policy titled Infection Prevention and Control Program dated 03/20/2025 documented Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.1. Review of the facility's electronic medical records (EMR) revealed R2 was re-admitted to the facility on [DATE] with diagnosis included but not limited to open wound, right hip. Review of the Medicare Part A Minimum Data Set (MDS) dated [DATE] documented Section, C (Cognition) Brief Interview for Mental Status (BIMS) of 09 which indicated R2 had moderately impaired cognition, Section M (Skin Conditions) R2 had unhealed pressure ulcers and had 2 stage 4 pressure ulcers present on admission.Review of care plan reviewed 03/09/2026 documented R2 on Enhanced Barrier Precautions Infection Prevention related to (r/t) pressure ulcer wounds with interventions for appropriate precautions will be taken.Review of the Physician's Orders dated 03/27/2026 documented included but not limited to Clean right lateral thigh with Vashe, pat dry and apply Silver Sulfadiazine to areas, cover with border gauze and change x 3 weekly and as needed (PRN) if soiled or displaced one time a day every Monday, Wednesday, Friday and as needed.2. Review of the facility's EMR revealed R42 was admitted to the facility on [DATE] with diagnosis included but not limited to neuromuscular dysfunction of the bladder.Review of the Quarterly MDS dated [DATE] documented Section C (Cognition) BIMS score of 15 which indicated R42 had intact cognition, Section H (Bladder and Bowel) R42 had external catheter.Review of care plan reviewed 01/03/2023 documented R42 was at risk for urinary tract infection (uti)/moisture associated skin damage (MASD) and/or other complications related to supra-pubic catheter for neurogenic bladder. Goal: Complications will be minimized daily through [sic] next review date. Interventions: catheter (cath) care every (q) shift.Review of the Physician's Orders dated 11/20/2024 included but not limited to Cleanse around insertion site of supra pubic catheter with normal saline or wound care cleanser pat dry, apply Sure prep to surrounding skin and cover with dry dressing.Observation on 03/31/2026 at 10:25 AM during R8's wound care with the Wound Care Nurse (WCN)/Infection Preventionist (IP) BB revealed she placed gloves in her pocket, removed the gloves from her pocket and put on the gloves to use during wound care. Observation further revealed WCN BB removed used gloves and donned a new pair of gloves without sanitizing or washing her hands. She cleaned the wound, removed the gloves and put on another pair of gloves without sanitizing her hands.Observation on 03/31/2026 at 10:49 AM during R42's Foley catheter care with WCN/IP BB revealed she removed the old dressing from the suprapubic catheter site, disposed of the dressing in a garbage bag, removed gloves from her pocket and put on the new pair of gloves. WCN/IP BB did not sanitize her hands between glove change.Observation on 03/31/2026 at 11:17 AM revealed Licensed Practical Nurse (LPN) CC came out of a resident's room on the 300 hall while removing her gloves, walked with the gloves rolled up in her left hand to the nurses' station, disposed of the gloves in the garbage bin on the medication cart at the nurses' station, then donned a new pair of gloves and cleaned the a blood sugar machine on the medication cart. LPN CC did not hand sanitize between glove change.Interview on 03/31/2026 at 11:02 AM with the WCN/IP BB revealed and confirmed she removed gloves from her pocket and used them during wound care and catheter care. She also confirmed that she changed gloves without sanitizing her hands. She stated she washed her hands after removing her gloves however she did not wash nor sanitize her hands each time she removed her gloves. She stated that whenever gloves were worn, hands were to be sanitized when gloves were removed to prevent spread of germs/bacteria and to prevent spread of infection. WCN/IP stated if hands were not sanitized, the residents would get infections. The WCN/IP further stated that pockets were not ok to place gloves in for use, gloves were to come directly from a box or placed on a barrier to be used. She stated germs from pockets would cause infection to the residents.Interview on 03/31/2026 at 11:20 AM with LPN CC revealed and confirmed she did not hand sanitize between glove change. She stated she should have sanitized her hands when she removed her gloves and before putting on a new pair of gloves. LPN CC stated that when she did not hand sanitize between glove change, it could cause cross contamination because germs or whatever was on the used gloves could get on her hands when she removed them, so if she did not hand sanitize before putting on a new pair of gloves, the resident could get sick.Interview on 03/31/2026 at 04:16 PM with the Director of Nursing (DON) revealed her expectations were for hands to be cleaned prior to putting on and after removing gloves. She stated that a negative outcome for the residents would be that the residents would be at risk for infection. The DON further stated that gloves must not be kept in pockets for use by the staff, it was an infection control concern, and the residents could get infections.Interview on 04/01/2026 at 04:00 PM with LPN GG revealed hands should be sanitized before and after glove use. She stated it was an infection control issue, and germs could be passed on to the resident if hands were not sanitized or washed between glove change.

Based on observations, staff interviews, and review of the policy titled, Safe and Homelike Environment Policy and Procedure, the facility failed to maintain a clean and safe environment by ensuring that air filters in resident rooms were free from excessive dust in two of 37 sampled rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to create an unsafe and unclean homelike environment for residents.Findings include:Review of the facility's policy titled Safe and Homelike Environment Policy and Procedure, revised on 02/01/2024, documented Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions:.Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. Policy Explanation and Compliance Guidelines: .3.Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.Observation on 03/30/2026 at 11:59 AM of room [ROOM NUMBER] revealed that the air filter unit located under the window was heavily coated with dust. A second observation on 03/31/2026 at 10:15 AM of room [ROOM NUMBER] confirmed that the air filter remained heavily coated with dust. A third observation on 04/01/2026 at 9:08 AM of room [ROOM NUMBER] revealed continued accumulation of dust on the air filter.Observation on 03/30/2026 at 11:36 AM of room [ROOM NUMBER] revealed that the air filter unit located under the window was heavily coated with dust. A second observation on 03/31/2026 at 10:22 AM of room [ROOM NUMBER] confirmed that the air filter remained heavily coated with dust. A third observation on 04/01/2026 at 9:02 AM of room [ROOM NUMBER] revealed continued accumulation of dust on the air filter.Interview and concurrent observation on 04/01/2026 at 10:47 AM with the Maintenance Director confirmed that the air filters in rooms [ROOM NUMBERS] were excessively dusty, should not have been in that condition, and required cleaning. The Maintenance Director stated that air filters were cleaned monthly on the first of each month; however, no complete documentation was provided to verify that the cleaning had been performed as scheduled.Interview on 04/01/2026 at 10:52 AM with the Infection Preventionist stated that the Maintenance Director was responsible for ensuring that air filters were maintained in a clean condition.

Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure that racks were rust free and clean, air vent was clean, walls were clean, the brush was a cleanable surface, and dishes were properly sanitized in one of one kitchen and food was properly labeled and dated in one of one kitchenette in accordance with professional standards. The deficient practice has the potential to affect all 64 residents that received food by mouth. Findings include: Review of the facility's policy titled, Food Brought by Family/Visitors F813, last reviewed on 10/24, revealed Item one indicated family members would inform nursing staff of their wishes to bring in food for a resident. Item six indicated the foods would be labeled and dated. Review of the facility's policy titled, Sanitation F812, revised 10/22, revealed item two indicated utensils, counters and equipment shall be maintained in good repair (rusted shelves in walk-in, paint brush utensil used for putting butter on rolls and cooking oil on cookie sheets. Item eight indicated that sanitizing water for equipment and pots and pans shall be at 150-200 PPM [parts per million]. The policy does not address how long items that were washed shall be submerged in the sanitizing solution. Item 17 indicated that kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime (wall vent and wall above pots and pans). No such cleaning schedule was available at the time of the survey. Observation on 04/07/25 at 10:00 AM revealed two metal four rack shelves in the walk-in refrigerator in the main kitchen each measuring five feet high by four feet wide. All four shelves on each rack were severely rusted including flaking rust. The shelves were holding food items such as fruit and containers with food and vegetables. In addition, on 04/07/25 at 10:05 AM, a small two rack set of shelves were under the coffee machine table holding coffee supplies such as coffee, coffee containers, and coffee filters. The racks were also severely rusted with flaking rust. During an interview on 04/07/25 at 10:05 AM the Dietary Manager (DM) verified the condition of the shelves in both areas and stated she was considering moving the shelves and replacing them with clean plastic shelves and racks. Observation on 04/09/25 at 9:35 AM revealed a four-foot high by three-foot-wide return air vent on the wall near the prep sink to be full of dirt and grease. Interview with the DM at the time of the observation stated she put in a request for maintenance to clean. The condition of this vent was verified by the Registered Dietician (RD) on 04/09/25 at 10:30 AM. Observation of the light switch on the wall near the exit door on 04/09/25 at 9:40 AM revealed brown dirt/discoloration on the wall 12 inches below and above the light switch. Interview with the DM at the time of the observation verified the condition of the light switch. The condition of this wall was verified by the RD on 04/09/25 at 10:30 AM. Observation of the outside exit door on 04/09/25 at 9:40 AM revealed the door had a one-inch gap at the base of the door allowing for the passage of bugs and possible rodents. The wooden screen door at this exit door was open during meal service. Interview with the DM at the time of the observation verified the condition of the base of the door and the gap. The condition of this door was verified with the RD on 04/09/25 at 10:30 AM. Observation on 04/09/25 at 9:40 AM revealed the wall at the ceiling above the hanging pots and pans rack revealed large amounts of dust and dirt hanging from the wall two feet down from the ceiling extending five feet in length. Interview with the DM at the time of the observation verified the condition of the wall. The condition of this wall was verified by the RD on 04/09/25 at 10:30 AM. Observation on 04/09/25 at 9:50 AM revealed the DM was spreading vegetable oil on three large cookie sheets with a paint brush in the main kitchen. The brush had severely curled, charred bristles with a wooden handle burned in two locations. She later placed dozens of chicken breasts on each cookie sheet for which vegetable oil was applied with the paint brush. Interview with the DM at the time of the observation indicated she has been using paint brushes for years for this application and it was cleaned in the dishwasher before each use. The DM stated the same paint brush was also used for several purposes. On 04/09/25 at 1:20 PM, Dietary Aide (DA) 2 was observed spreading butter on a large cookie sheet full of dinner rolls. She dipped the paint brush noted above in warm butter and spread the butter across all of the dinner rolls repeatedly until all were coated on the top with butter. Observation on 04/09/25 at 9:55 AM revealed DA1 washing pots and pans in the three-compartment sink in the main kitchen. The sink was tested for sanitizer added to the water. The test showed 700 PPM (parts per million). DA1 stated that it was correct. The sanitation solution sink had six inches of water thus leaving a large prep bowl and another stainless-steel container eight inches wide by 18 inches long laying on top of the water and not submerged in the sanitizing solution. Interview on 04/09/25 at 10:15 AM with the DM and the RD verified the items were not properly submerged and would not sanitize the containers as intended. Further interview with the DM on 04/09/25 at 10:15 AM indicated the seal on the drain of the sink leaked causing the water to drain early leaving the pots and pan above the water line. She stated she put in a maintenance request two weeks ago. The interview with the Maintenance Director (MD) at 10:20 AM indicated he had a replacement seal for the sink and would install it immediately. He also indicated he had not received a maintenance request in Tel's (system to log and track maintenance issues) to repair the sink drain. The sink was repaired at 10:45 AM. Observation of the kitchenette near the main nursing station on 04/09/25 at 10:05 AM revealed a refrigerator freezer with chocolate ice cream container open at the top with whip cream on the top of the ice cream without a label or date, completely frozen rock solid. In the refrigerator, a Tupperware container six inches wide by 10 inches long labeled with the name of a current resident to be lacking a label of contents and date. The contents appeared to be ground beef in marinara sauce with macaroni. Interview with the Director of Nursing (DON) at the time of the observation verified the contents noted above. She indicated dietary staff were responsible for the condition of the refrigerator and she thought the family brought the food in yesterday (04/08/25) for the resident and placed it into the refrigerator without telling staff.

Based on observation and staff interview, the facility failed to ensure that it maintained a safe, comfortable, homelike interior on two of four areas/zones (100-hall and 300-hall) and one of one resident (Resident (R) 60) reviewed for environment. The deficient practice has the potential to affect the homelike environment for eight residents in four bedrooms. Findings include: Observation of bedroom [ROOM NUMBER], the bathroom shared with bedroom [ROOM NUMBER] on 04/07/25 at 3:00 PM revealed the sink to the bathroom was loosely fitted to the wall and leaning forward severely to the point water was not draining from the sink. In addition, a hole was noted behind the wall measuring four inches by four inches. The bathroom door inside bedroom [ROOM NUMBER] at the door handle was discolored and dirty for a 12-inch area. During an interview with the Administrator and Maintenance Director on 04/10/25 at 10:05 AM, both verified the conditions noted. Observation of bedroom [ROOM NUMBER], the bathroom shared with bedroom [ROOM NUMBER] on 04/08/25 at 10:36 AM revealed the sink had two wooden posts holding up each end of the sink. The sink was loosely fitted on the wall. The bed near the window to the room had a hole in the wall measuring three inches wide by eight inches high. The same wall had severe, discolored scrapes and gouges five feet long and one and half feet off the ground. During an interview, R60 verified all the noted problems listed and continued by stating when using the bathroom with his wheelchair, the bathroom was so small that he was afraid he was going to knock out one of the posts with his wheelchair and the sink would fall off the wall onto him. Observation of bedroom [ROOM NUMBER] bathroom on 04/08/25 at 11:08 AM revealed the sink was leaning forward severely and appeared to be loosely braced on the wall. Interview with the Administrator and Maintenance Director on 04/10/25 at 10:05 AM both verified the conditions noted. Observation of bedroom [ROOM NUMBER] on 04/08/25 at 3:30 PM revealed the wall between the two beds was sunken from pervious repairs with severe discolored marks measuring over three feet wide. Interview with the Administrator and Maintenance Director on 04/10/25 at 10:05 AM both verified the conditions noted. During an interview on 04/10/25 at 10:05 AM, the Administrator and Maintenance Director verified all the conditions noted above. Further interview with the Maintenance Director (MD) indicated the facility had an informal policy to use Tels (electric system for repairs). The MD stated all staff were to submit maintenance requests in Tels which in turn was submitted as a request for repair. The MD stated the maintenance staff then made the repair from the Tels report. He stated he had not received any notice of the need to repair. He also indicated he made rounds routinely with his staff and had not made a request to repair the noted items.

Based on observations and staff interviews, the facility failed to equip handrails on each side of the corridor in four examples in two of four corridors reviewed for handrails. The deficient practice has the potential to affect 25 total residents' safety. Findings include: Observation on 04/08/25 at 4:10 PM revealed the corridor in the front of the building wall at the dining room measured 21 feet lacking a handrail between the two entrance doors to the large dining room. Observation on 04/08/25 at 4:10 PM revealed the corridor in the front section of the building wall at the public restroom area measuring eight feet, lacking a handrail. Observation on 04/08/25 at 4:15 PM revealed the corridor across from the main nursing station leading to the 300 unit measuring 13 feet, lacking a handrail. Observation on 04/08/25 at 4:15 PM revealed the corridor across from the nursing station leading to the 100 unit measuring eight feet, lacking a handrail. The interview with the Administrator on 04/10/25 at 10:05 AM verified the lack of handrails in the noted areas and indicated no one has ever said anything about this in the past. Interview with the Maintenance Director on 04/10/25 at 10:06 AM verified the corridors noted were not equipped with handrails.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure the right to receive services with reasonable accommodation of needs and preferences for one of 22 sampled residents (Resident (R) 60) reviewed for accommodation of needs. This failure had the potential to affect the residents through increased isolation leading to depression. Findings include: Review of the Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease unspecified, type two diabetes mellitus, mild intermittent asthma, heart failure unspecified, ataxic gait, muscle weakness, hypertensive heart, chronic kidney disease, left side weakness, and depression Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/23/24 indicated R60 used his wheelchair to mobilize himself. His annual activity assessment indicated he preferred outings, television, movies, shopping, music, resident council, radio, and religion. Review of the quarterly MDS with an ARD of 01/26/25 indicated his Brief Interview for Mental Status (BIMS) of nine out of 15 which indicated the resident was moderately cognitively impaired. Review of the Orders tab of the EMR revealed the resident had a physician order to participate in activities as tolerated, dated 04/01/25. During an interview on 04/10/25 at 10:15 AM, R60 indicated he would prefer to be out of his room and active around the nursing facility but was not going to lug this thing around referring to his oxygen concentrator. During an interview on 04/10/25 at 10:40 AM, the Activity Director (AD) stated R60 liked to keep to himself and did very little outside of his room. The AD stated his brother frequently visited, and they spent most of their time in his room. During an observations and interview on 04/07/25 at 10:40 AM, R60 was lying in bed and stated he was bored. On 04/08/25 at 10:52 AM, he was observed in his bedroom in a wheelchair complaining of boredom. On 04/09/25 at 1:15 PM, he was observed in his room, and he stated nothing to do. On 04/10/25 at 10:10 AM, he was observed in his room stating he was bored and could not go anywhere because of his oxygen concentrator. During an interview on 04/10/25 at 10:20 AM, the Director of Nursing (DON) stated R60 used to have a tank and was more mobile, but he would sit out front all day, took the nasal cannula out of his nose, and allowed the tank to drain requiring them to frequently replace the tanks. The DON stated R60 could not tell them when his oxygen tanks were empty. During an interview on 04/10/25 at 10:30 AM, Nurse Practitioner (NP) 1 stated there was no reason R60 could not have a portable tank so he could mobilize himself in his wheelchair.

Based on record review, staff interviews, and policy review, the facility failed to ensure the comprehensive significant change assessment was completed within 14 days and reflected to include a pressure ulcer and significant weight loss for one of 22 sample residents (Resident (R) 62) reviewed for comprehensive assessments. This failure had the potential to lead to a lack of adequate care planning to heal R62's pressure ulcer and prevent further breakdown and the potential to lead to a lack of timely medical intervention, appropriate nutritional support, and compromised health outcomes. Findings include: Review of the facility's policy titled, Comprehensive Assessment with a revised date of 08/22, revealed under Policy .A comprehensive assessment will be completed with defined significant change. Under Guidelines item 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews . Item c. When there has been a significant change in the resident's condition . Review of R62's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed medical diagnoses that included morbid obesity, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, depression, and dysphagia. Review of R62's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/24 and located under the MDS tab of the EMR, revealed R62 was admitted to the facility on [DATE]. The MDS documented R62 did not have pressure ulcers on admission and that he was at risk for pressure ulcers. No unstageable wounds were documented. Review of R62's Care Plan, dated 08/29/24 and revised 09/11/24, under the Care Plan tab of the EMR, revealed Focus: Nutritional/Hydration is at risk for altered nutritional/hydration status .The Goal: will maintain present weight +/- 5% . Review of the Care Plan, initiated and revised 09/11/24, located under the Care Plan tab of the EMR, revealed Focus: Bowel/Bladder .has mixed bladder incontinence .has potential for pressure ulcer development . The goals were to have intact skin, free of redness, blisters, or discoloration and to remain free from skin breakdown due to incontinence. Review of the vital signs and weights located in the electronic medical record (EMR) under the Vital Signs/Weights tab, revealed that R62's admission weight on 08/19/24 was 224.0 lbs. (pounds). On 09/13/24, 10/04/24, 10/05/24, and 10/09/24, R62's weight was 234.0 lbs., and on 12/04/24, R62 was 199.0 lbs. sustaining a weight loss of 35 pounds. Review of the monthly skin assessment dated [DATE] revealed R62 had an open area to the coccyx area. Prior assessment date 12/11/24, 12/04/24, 11/20/24, 11/02/24 indicated the skin was intact. Review of the Care Plan initiated and revised on 03/05/25 revealed Focus: has actual skin breakdown with treatment in progress DTI [Deep Tissue Injury] on both heels and stage III to coccyx. During an interview on 04/09/25 at 1:10 PM regarding R62's weight loss and pressure sores, the MDS Coordinator (MDSC) stated I haven't reset it [the date for the change in condition MDS assessment] yet, I was going to do it, but I got busy, I will do it now. I just got back and I'm trying to get everything organized. During an interview on 04/10/25 at 2:30 PM, the MDSC was asked to clarify what constituted a significant change that would require interdisciplinary review or revision of the care plan, or both. The MDSC stated that a significant change was a condition not expected to resolve within a 14-day period that could affect one or more areas, for instance a drastic weight loss or a stage three or four pressure sore. The MDSC confirmed that the 14-day grace period passed for R62 and the change in condition should have been completed. During the same interview on 04/10/25 at 2:30 PM, the MDSC stated that changes in conditions were discussed during clinical meetings every morning. She stated that weight loss, wounds, new medications, and falls were discussed during every clinical morning meeting. During an interview on 04/10/25 at 1:05 PM, the Director of Nursing (DON) stated that changes in conditions were discussed every morning during clinical meetings and that all department heads to include the MDSC, attended the morning clinical meetings. The DON further stated that during the morning meetings weight loss/gains, new infections, psychotropic medications, wounds, and falls were discussed. The DON further stated that a comprehensive assessment to reflect the residents' status would have been completed when there was a significant change in the residents' condition.

Based on record review, staff interview, and facility policy review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of 22 sample residents (Resident (R) 21) reviewed for MDS. This failure had the potential to contribute to inaccurate assessment and care planning and for (R) 21 to not receive needed care and services. Findings include: Review of the facility's policy and procedure titled, Comprehensive Assessment, dated 03/25, revealed the following: Residents will receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Review of R21's Admission Record of the electronic medical record (EMR) located under the Admission tab, revealed an initial admitted [DATE] with a diagnosis of Alzheimer's disease. Review of R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/25 and located in the EMR under the MDS tab, revealed R21 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated R21 was moderately impaired. Nutritional Approaches revealed R21 was not on a mechanically altered diet. Review of R21's diet order and communication form dated 06/21/24 and located under the Miscellaneous tab of the EMR, revealed R21 was placed on a mechanical soft ground meat until R21's mouth healed. Review of R21's Clinical Physician Orders with a date of 01/01/25 and located under the Orders tab of the EMR, revealed R21's diet was carb-controlled diet, mechanical soft, ground meat texture, thin consistency. During an interview on 04/10/25 at 9:05 AM, the Dietary Manager (DM) stated R21 was on a mechanically altered diet where her meat was chopped for each meal. During an interview on 04/10/25 at 9:08 AM, the Nurse Practitioner (NP) 1 stated R21 had a diet change on 06/21/24 which consisted of chopped meat until R21's mouth healed. The NP1 also stated R21 had not been reassessed to change the diet order. The NP1 further stated R21 was being seen by speech therapy for cognition. The NP1 stated she transcribed R21's orders from R21's admit orders to the facility. During an interview on 04/10/25 at 9:12 AM, the MDS Coordinator (MDSC) stated R21's MDS Section K Nutritional Status should have stated R21 was on a mechanically altered diet. The MDSC stated she should have marked yes on the MDS form. The MDSC further stated she was going to modify the mistake immediately.

Based on observations, record review, staff interviews, and facility policy review, the facility failed to ensure catheter drainage bags were maintained inside a privacy storage bag and were not in direct contact with the floor for two of five residents (Resident (R) 53, and R61) reviewed for catheters out of 22 sample residents. This deficient practice created a risk for cross-contamination and increased the potential for urinary tract infections compromising the health and safety of residents. Findings include: Review of the facility's policy titled, Policy- Infection Prevention and Control Program, dated January 2024, revealed, under Policy: 1. The Infection Control Committee shall oversee the internal community system for the preventing, identifying, reporting investigation, and controlling of infections and communicable diseases . Review of the facility's policy titled, Policy -Indwelling Urinary Catheters, dated June 2022, revealed under Infection Control: .2. b. Be sure the catheter tubing and drainage bag are kept off the floor . 1. Review of R53's Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including cellulitis of the groin, and acute and chronic respiratory failure with hypoxia. R53 was admitted to hospice care on 04/04/25. Review of R53's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. R53 used an indwelling/suprapubic urinary catheter. Review of R53's Care Plan, dated 12/19/24 and located in the Care Plan tab of the EMR, revealed R53 was at risk for UTI (Urinary Tract Infection) for obstructive uropathy, and history of UTI. R53 used an indwelling urinary catheter and had a goal of signs and symptoms of urinary tract infection will be minimized daily. During an observation and interview on 04/08/25 at 11:49 AM, R53 was observed lying in bed. The indwelling catheter urinary container bag was not covered in a privacy storage bag and was lying on the floor in direct contact with the floor. Licensed Practical Nurse (LPN) 1 revealed that foley catheter bags usually had a liner cover on them, and confirmed indwelling foley container drainage bags should not be lying on the floor to prevent the spread of infection. 2. Review of R61's Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including polyneuropathy, diabetes mellitus, and urethral stricture. Review of R61's quarterly MDS with an ARD of 02/01/25, located in the MDS tab of the EMR, revealed a BIMS score of eight out of 15 which indicated R61 was moderately cognitively impaired and indicated R61 used an indwelling/suprapubic urinary catheter. Review of R61's Care Plan, revised on 07/29/24 and located in the Care Plan tab of the EMR, revealed R61 was on EBP (Enhanced Barrier Infection Precautions) due to suprapubic catheter. R61 used an indwelling suprapubic urinary catheter and had a goal of appropriate precautions would be taken. During an observation on 04/07/25 at 10:49 AM, R61 was observed lying in bed. The indwelling suprapubic urinary catheter container bag was not covered in a privacy storage bag. During an observation and interview on 04/08/25 at 11:49 AM, R61's indwelling suprapubic urinary catheter container bag was not covered in a privacy storage bag, and the bottom of urinary catheter container collection bag was directly touching the floor. LPN1 revealed that foley catheter bags usually had a liner cover on the container collection bag, and confirmed the indwelling foley container drainage bag should not have been lying on the floor to prevent the spread of infection.

Based on record review, staff interview, and review of the facility policy titled, Roommate Change, Roommate Notification, Choice of Roommate the facility failed to notify two of three residents (R) (R3 and R7) and/or responsible party of a room change prior to the room change and document the changes. Findings include, Review of the facility policy titled, Roommate Change, Roommate Notification, Choice of Roommate dated 4/2024. Under Policy Statement: The resident will receive a written notice, including the reason for the change before their room or roommate is changed. Under Policy Interpretation and Implementation number 2. Prior to changing a room or roommate assignment all parties involved will receive appropriate social services, to explain the move, provide an opportunity to see the new location, meet the new roommate (as applicable) and ask questions about the move. 1. Review of the medical records revealed R3 was admitted to the facility with the following diagnoses that include but not limited to cerebrovascular disease, type 2 diabetes mellitus, chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data set (MDS) dated [DATE] for R3 revealed under Section C (Cognitive Patterns) revealed a Brief Interview for Mental status (BIMS) score of 15 indicating resident has little to no cognitive impairment. Review of the progress notes revealed no evidence of any room changes or notification of those room changes. Interview on 9/18/2024 at 3:31 pm with R3 revealed that she has been moved three times to another room and no one asked her if she wanted to move. She continued to state that the social service person came to her and told her she was moving to another room, and she was moved. 2. Review of the medical records of R7 was admitted to the facility with the following diagnoses that include but not limited to secondary hypertension, ataxic gait, chronic kidney disease, and dementia. Review of the progress notes revealed no evidence of any room changes or notifications of those room changes. Interview on 9/26/2024 at 1:32 pm, the family member of R7 revealed that there had been four room changes and she was never notified of the changes. She continued to state that it was only after she came to the facility to visit was when she found out that R7 was in a different room all four times. Interview on 9/24/2024 at 11:17 am, the Social Services Director revealed when a resident is having a room change, she will talk to the resident first and get their permission for the move and then the Responsible Party (RP) will be notified that they are doing a room change. Interview on 9/24/2024 at 5:53 pm, the Administrator confirmed that there was no documentation of room changes or notification for the residents in the medical record, and that the room changes are to be documented in the residents' record when they occur.

Based record review, staff interview, the facility policy titled Administering Medications F760, the facility failed to follow physician orders for blood pressure medication for one resident ((R) R#1) of three sampled residents. Findings include: Review of the facility policy Administering Medications F760 dated 11/2017. Policy Statement Medication shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including and required time frame. 5. If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the mediation shall contact the resident's Attending Physician or the facility 's Medical Director to discuss the concerns. A closed record review of the medical record revealed R#1 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the order recap report revealed: an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/9/22, the [MEDICATION(S)] and the [MEDICATION(S)] tablets were coded 3 to indicate supply reordered. There was no evidence that the [MEDICATION(S)] tablet 0.1 mg and the [MEDICATION(S)] XL tablet had been administered as ordered, nor were these two medications listed on the MAR. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that the [MEDICATION(S)] tablet 0.1 mg and the [MEDICATION(S)] XL tablet had been administered as ordered, nor were these two medications listed on the MAR. During an interview on 10/27/22 at 11:01 a.m. Licensed Practical Nurse (LPN) AA revealed that she administered medication per the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . And had she known the medication was left off the MAR, she would have asked the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) if the medications order were to be put back into the system. During an interview on 10/27/22 at 12:36 p.m. the ADON revealed that any nurse can put in orders in the electronic medical charting. ADON explained that if the nurse did not see a discontinue order for the medications, the nurses should have questioned why the blood pressure medications were not on the MAR.

Based on staff interviews, observation, and review of the facility's policies titled, Food Receiving & Storage - Revised (MONTH) (YEAR) the facility failed to discard expired items and failed to label and date items after opening. This had the potential to affect 81 of 88 residents receiving an oral diet. Findings include: Observations during the brief kitchen tour which began on [DATE] at 11:56 a.m. with the Food Service Director (FSD) revealed the following: Observation in one of the two dried food pantries revealed a bag of powdered milk ,[DATE] full with an open date of [DATE]. The FSD confirmed, at this time, that the food items are good for seven days after opening. An observation on [DATE] at 12:05 p.m. revealed a loaf bag of opened undated Sara(NAME)bread, an undated 5 pound (lb) plastic container of ground pepper. A further observation of a 20 ounce (oz) bottle filled with black pepper had a hand written label with a best by date of [DATE]. An interview with the FSD, at this time revealed there is ,[DATE] of the loaf left and it does not have an open date. She further revealed that the original 20 oz bottle for black pepper was thrown away and they use this bottle as a refill. She was unsure as how they figured the date on the bottle because the dated label is for onion powder. An observation on [DATE] at 12:05 p.m. revealed a 20 oz plastic container of baking soda with a use by date of [DATE]. An interview with the FSD, at this time, revealed it is out of date. During an interview and observation on [DATE] at 5:08 p.m. with the FSD, she revealed that she is responsible for assuring the labeling and dating of items. During an interview on [DATE] at 8:30 a.m. the FSD revealed she has in serviced her staff on all the items that were found to be opened and not dated in the kitchen including items that are outdated and remaining in use. During in an interview on [DATE] at 10:55 a.m. with the Administrator she revealed her expectations were for kitchen items to be labeled and dated. She confirmed the Food Receiving and Storage - Revised (MONTH) (YEAR) is the current policy for the kitchen. During an interview on [DATE] at 11:06 a.m. the Director of Nursing (DON) confirmed that seven residents receive nourishment through tube feedings.

Based on observation, record review and staff interview the facility failed to ensure medications were stored and maintained at the correct temperature in one of one medication storage rooms. The facility census on 3/19/18 was 74 residents. Findings include: Observation On 03/22/18 at 2:30 p.m. to 2:46 p.m. of the medication storage room with Registered Nurse (RN) Charge Nurse (CN) EE (RN EE) revealed two refrigerators' in the mediation room, one for specimen storage and one for medication storage. The medication refrigerator had a thermometer in the bottom drawer in a basket that contained numerous unopened vials of insulin for resident and facility stock insulin. The temperature in the refrigerator was observed to register 28 degrees on the thermometer. At this same time, the temperature of twenty-eight (28) degrees, was confirmed with RN EE. The following medications were observed inside the refrigerator: One (1) vial of [MEDICATION NAME] 100 units/milliliter (ml) One (1) Intravenous piggy back of [MEDICATION NAME] 2 grams (gm) per 100 ml bag (IVPB) Five (5) IVPB's [MEDICATION NAME] 2 gm/50ml IVPB Fifteen (15) 0.5 ml syringes Influenza vaccine Eight (8) vials of Pneumococcal vaccine 0.5 ml Four (4) [MEDICATION NAME] 60 mg/ml Three (3) vial [MEDICATION NAME] 100 unit/ml One (1) vial opened and not dated [MEDICATION NAME] purified protein derivative 0.1 ml Two (2) Toujeo 300 units/ml Seven (7) [MEDICATION NAME] 1 gm/50 ml IVPB Eight (8) vials [MEDICATION NAME] R 100 units/ml Two (2) vials [MEDICATION NAME] R 100 units/ml One (1) vial [MEDICATION NAME] 100 units/ml Two (2) vials [MEDICATION NAME] 2 milligram/ml Review of the manufacture's instructions and back label for all medications stored in the refrigerator revealed that the medications should NOT be frozen and should be stored between 36 and 46 degrees. Interview on 3/22/18 at 3:05 p.m. with RN EE revealed that she checked with the DON and all the medications that were in the refrigerator should be stored between 36-46 degrees and that these medications would be discarded.

Based on observation, record review and staff interview failed to maintain infection control standard precautions during medication administration for one sampled resident during medication administration observation. The facility census was 74 residents. Findings include: Medication Administration observation on 3/22/18 at 1:30 p.m. with Licensed Practical Nurse (LPN) DD on the 100/200 Hall medication cart revealed the following: Observation on 3/22/18 at 1:36 p.m. revealed that LPN DD walked down to the 300 hall and brought back a blood pressure machine. LPN DD then went into room [ROOM NUMBER] C pulled the privacy curtain with her bare hand, handled the blood pressure cuff and machine. LPN DD was then observed to come out of the room with the blood pressure machine, took the medication cart keys out of her scrub pocket, opened the medication cart, retrieved the residents blood pressure medication and dispensed the pill into her hand and then placed the medication into the medication cup, then LPN DD went back into the room and administered the medication to the resident. Interview on 3/22/18 at 1:40 p.m. with LPN DD revealed that she did not wash or sanitizer her hands after handling the blood pressure machine equipment, that she placed the medication into her hand and then into the medication cup and then she administered it to the resident.

Based on observation, staff interviews, and review of the facility's policy titled, Food Receiving and Storage and Resident nutrition services, the facility failed to ensure that expired foods were discarded after the expiration date, dented and rusted cans were returned to the vendor, and failed to ensure that food on the steam table was maintained at safe temperatures throughout the serving process. The facility also failed to maintain food pantry refrigerators that were clean, items labeled and dated in the food pantry refrigerators, failed to label and date food items in the dry food storage and freezer. These practices could affect 66 residents receiving an oral diet. The census was 72. Findings include: Initial kitchen tour on 7/10/17 at 1:12 p.m. with Dietary Manager revealed the following: 1. Observation of the reach in refrigerator revealed a box of prune juice (4 fluid ounce (fl oz.) containers) that dietary manager was unable to tell when the items were placed in the refrigerator or when the juice should be used by. The prune juice was not dated but the dietary manager reported that the box was opened about a week ago. 2. Observation of the stand-up freezer in the kitchen there were five (5) containers of non-dairy whipped topping that did not have a received on date or an expiration date. Interview with Dietary Manager on 7/11/17 at 8:15 a.m. who reported that the prune juice was dumped because she did not have a way to determine when they were placed in refrigerator or when they expire. Documentation provided related to non-dairy whipped topping that was not dated in the freezer to show that it was received on 6/8/17. She further reported that going forward these items would remain in the box until ready to use. Observation on 7/12/17 at 11:59 a.m. with Dietary Manager revealed: 1.There was one (1) container labeled with noodles that had 1 package of drum wheat semolina pasta (elbow macaroni) that was opened but not dated. 2. One opened container of egg noodles in original package that was not labeled or dated. The expiration date on the bag is worn; 3. Disaster supplies of Six #10 cans of fruit with an in date of 9/22/16 noted to have an expiration date rust on rim of cans); 4. Fruit Six #10 cans in date of 2/11/16 no expiration date and rust on rim of cans, 5. Seven - 36 oz. boxes of Uncle Ben's rice no expiration date, 6. Five - 4 gallon waters with no date for in or expiration with dust buildup noted on bottles, 7. Three - 4 pound containers of tuna fish not labeled or date, 8. Three -- 36 oz. potato mix containers not labeled or dated, 3 56.8 oz. containers of mashed potatoes not labeled or dated, 9. Vegetables for stew with an in date of 4/20/17 with no expiration date, 10. One (1) bag of mini marshmallows with no open date. Inteview with the Dietary manager, at this same time, reported that they last had macaroni and cheese on the menu last week. Dietary Manager reported that egg noodles last used on Monday. Dietary Manager also reported that she was not aware of the rusting cans and she is not able to determine the expiration dates of the items. Observation on 7/12/17 at 12:56 p.m. revealed the Roast pork with brown gravy was 92 degrees Fahrenheit (F) on the steam table. The main dining room had been served and one hallway was served at the time of the temperature reading. On 7/12/17 at 1:27 p.m. the roast pork with brown gravy was reheated to 166.5 F. Interview on 7/12/17 at 12:39 p.m. with the Dietary Manager who reported that canned items should have the in date on them so that they know when items come in. It is reported that the tuna and salmon are on the menu for supper and, when ordered, these items are typically used within two weeks. Cans that are not currently labeled have been here maybe three weeks. Dietary Manager reported that she does not know what the codes means on the canned goods that do not have expiration dates. Observation on 7/12/17 at 1:16 p.m. of three (3) plastic containers each with cereal (rice krispies, corn flakes, fruit whirls) and one (1) container of flour but none with open date or use by date. There is also a large yellow container that has saltine crackers in it but it does not have an in date or use by date. Interview on 7/12/17 at 3:05 p.m. with the Dietary Manager who reported that she received expiration dates from her vendor regarding the fruit cocktail and peaches. Dietary Manager further reported that the vendor was not aware that there were no expiration dates on these items. Dietary Manager acknowledged that she did not have a way of knowing the expiration dates of the items that do not have expiration dates already identified. Observation of resident food pantry on 7/13/17 at 9:38 a.m. revealed the following: 1. In the refrigerator there was a 46 oz. container of Lyons Ready Care thickened orange juice with directions of once opened, store at ambient temperature for up to 8 hours or refrigerate for up to 7 days. the open date was 7/1/17. 2. There was one 6 oz container of great value blueberry yogurt with a used by date of July 1, 2017. 3. One half used 20 oz. container of ketchup with a best by date of February 28, 2017. 4. One 24 oz. container of Hunts tomato ketchup with a best by date of May 23, 2017. 5. There were four (4) 4 fl. oz. containers of Ardmore Apple Juice that did not have a use by date and was not labeled. 6. Microwave was observed to have splattered food on the back and in the top. Interview on 7/13/17 at 9:53 a.m. with the Director of Nursing (DON) revealed that she keeps a log of temperatures of the refrigerators. The DON stated that she checks the food in the resident refrigerator daily to assure items are not outdated. The DON confirmed the outdated yogurt, ketchup, thickened orange juice, and the dirty microwave. The DON revealed that she was not aware that the DON reported that she is not sure of who is responsible for cleaning the microwave. It was further reported that the Apple juice came from the kitchen but that she was unsure of which day and what the expiration date was. Review of the Food Receiving and Storage Policy revealed: 8. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the Resident nutrition services 4. To minimize risk of food borne illness, the time that potentially hazardous foods remain in the danger zone will be kept to a minimum.

Based on observations, interviews and record reviews it was determined the facility failed to implement care plan interventions for pressure ulcer treatments as ordered by the physician for two residents (#106 and #65), for monitoring of potential side effects of [MEDICAL CONDITION] medications and the ongoing signs and symptoms of depression and/or behaviors for two residents (#101 and #51) from a sample size of thiry-five (35) sampled residents. Findings include: 1. Resident #106 had a plan of care in place since 8/27/15 for skin breakdown. The plan of care included an intervention to licensed nursing staff to provide wound care as ordered by the physician. There was a physician's orders [REDACTED]. An observation of pressure ulcer treatment was done on 9/2/15 at 2:30 p.m. with licensed nurse AA. Licensed nurse AA stated that he/she did not usually provide pressure ulcer treatments but had been asked to do so at that time. During the observation of pressure ulcer treatment, Licensed nurse AA incorrectly used the same saline soaked gauze to clean each pressure ulcer. In addition, licensed nurse AA incorrectly applied the hydrogel to the open wound beds of the pressure ulcers and the surrounding intact skin before applying dry dressings to cover the pressure ulcers. The Assistant Director of Nursing (ADON) confirmed during an interview on 9/4/14 at 9:47 a.m. that the hydrogel is only applied to the open wound beds, not the surrounding intact skin. The Director of Nursing (DON) also confirmed on 9/4/15 at 10:29 a.m. that the hydrogel is for the open wound bed, not the surrounding intact skin. Cross reference to F314 2. Resident #101 had a plan of care in place since 3/22/15 for the use of an antidepressant medication. The plan of care included an intervention to monitor/document the side effects and effectiveness of the medication. There was also an intervention to monitor/document ongoing signs or symptoms of depression unaltered by the antidepressant medications. However, a review of the clinical record revealed no evidence the potential side effects or behavhiors were being monitored/documented for July or August 2015. Cross reference to F329 3. Resident #51 had a plan of care in place since 2/25/15 for a [DIAGNOSES REDACTED]. The plan of care included interventions to monitor/document for side effects of medications and for signs or symptoms of depression or risk for harming others. However, a review of the clinical record revealed no evidence the potential side effects or behaviors were being monitored/documented for July or August 2015.

Based on observations, record review and staff interviews, the facility failed to ensure adequate monitoring for adverse consequences, including behaviors and side effects per physician orders [REDACTED].#51,#80,#43,#37,and #101) receiving [MEDICAL CONDITION] medications. The census was seventy six (76) with a survey sample census of thirty five (35) residents. Findings include: Record review for Resident #43 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/05/2015 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section N - Medication documented that the resident received antidepressant medications. The current September 2015 physician's orders [REDACTED].#43 specified that the resident was to receive the antidepressant [MEDICATION NAME] 50 milligrams (mg) by mouth every day at bedtime for Depression and [MEDICATION NAME] 0.25 mg by mouth every four (4) hours as needed for agitation. Further orders are to Target Behavior for the use of [MEDICATION NAME] is defined as (crying Spells. Note the number of episodes every shift for Behavior Monitoring. Note the number of episodes or the target behavior. Review of Behavior Monitoring Flow records revealed no evidence of monitoring for the months of July, August, or Sept. Review of the residents record on 9/2/15 @ 3.30 p.m. with the DON confirmed that monitoring had not been conducted. Record review for Resident #37 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 06/25/2015 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. The current September 2015 physician's orders [REDACTED].#37 specified that the resident was to receive [MEDICATION NAME] 75 mg by mouth every morning for Depression. Further orders are for Psychoactive Behavior Monitoring the target behavior for the use of ([MEDICATION NAME]) is defined as (withdrawn). Note number of episodes) every shift for Behavior Monitoring. Note the number of episodes. Review of Behavior Monitoring Flow records reveal no evidence of monitoring for the months of July, August, or Sept. Review of the residents record on 9/2/15 @ 3.30 p.m. with the DON confirmed that monitoring had not been conducted. Record review for Resident #80 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/12/2015 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section N - Medications document resident #80 receives an Antidepressant. The current September 2015 physician's orders [REDACTED].#80 specified that the resident was to receive [MEDICATION NAME] 15 mg by mouth daily at bedtime for Depression. Further orders are for Target Behavior for the use of ([MEDICATION NAME]) is defined as (depression). Note the number of episodes every shift for Behavior Monitoring. Review of Behavior Monitoring Flow records reveal no evidence of monitoring for the months of July, August, or Sept. Review of the residents record on 9/2/15 @ 3.30 p.m. with the DON confirmed that monitoring had not been conducted. 1. Resident #51 had [DIAGNOSES REDACTED]. A review of the resident's current physician's orders [REDACTED]. 10 milligrams (mg) of [MEDICATION NAME] three times daily for anxiety, 150 mg of quetiapine [MEDICATION NAME] three times daily for [MEDICAL CONDITION], 50 mg of [MEDICATION NAME] daily at bedtime for depression, and 2.5 mg of [MEDICATION NAME] daily and 5 mg at bedtime for depression. The resident was also receiving 500 mg of [MEDICATION NAME] sodium (a mood stabilizer) twice daily for dementia with behavior disturbances. A further review of the physician's orders [REDACTED]. However, a review of the clinical record, including the Medication Administration Records (MAR's) revealed no evidence that potential side effects or target behaviors were monitored for the months of July and August 2015. 2. Resident #101 had [DIAGNOSES REDACTED]. A review of the resident's current physician's orders [REDACTED]. 60 mg of duloxetine daily for depression and 50 mg of [MEDICATION NAME] daily at bedtime for depression. The resident was also receiving 250 mg of [MEDICATION NAME] sodium (a mood stabilizer) three times daily for dementia with behaviors disturbances. A further review of the physician's orders [REDACTED].

Based on observation, interviews, and record reviews, it was determined the facility failed to provide pressure ulcer treatments as ordered for one (1) resident with pressure ulcers (#106) from a total sample of 35 residents. Findings include: A review of the pressure and nonpressure wound list provided by the facility on 9/2/15 revealed that resident #106 had three stage 3 pressure ulcers to the left buttocks, right buttocks, and left upper buttocks. There was a physician's orders [REDACTED]. An observation of pressure ulcer treatment was done on 9/2/15 at 2:30 p.m. with licensed nurse AA. Licensed nurse AA stated that he/she did not usually provide pressure ulcer treatments but had been asked to do so at that time. During the observation of pressure ulcer treatment, Licensed nurse AA incorrectly used the same saline soaked gauze to clean each pressure ulcer. In addition, licensed nurse AA incorrectly applied the Hydrogel to the open wound beds of the pressure ulcers and the surrounding intact skin before applying dry dressings to cover the pressure ulcers. The Assistant Director of Nursing (ADON) confirmed during an interview on 9/4/14 at 9:47 a.m. that the Hydrogel is only applied to the open wound beds, not the surrounding intact skin. The Director of Nursing (DON) also confirmed on 9/4/15 at 10:29 a.m. that the Hydrogel is for the open wound bed, not the surrounding intact skin.