Every finding on record at Bangs Nursing and Rehabilitation

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 6 residents (Residents #3, Resident #10, Resident #16, Resident #17, Resident #25, and Resident #30) reviewed for care plans. 1.The facility failed when Resident #3 did not have a comprehensive care plan dated 05/13/2025 that included measurable goals related to therapeutic diet, PASRR positive status, medication use, risk for seizures and contractures, or food intake. 2.The facility failed when Resident #10 did not have a comprehensive care plan dated 07/29/2025 that included measurable goals related to nutritional needs, roommate, PASRR status, communication, medication use, falls, pain and altered comfort. 3.The facility failed when Resident #16 did not have a comprehensive care plan dated 07/29/2025 that included measurable goals related to behaviors, medication use, and antipsychotic medications. 4.The facility failed when Resident #17 did not have a comprehensive care plan dated 06/17/2025 that addressed physician ordered fluid restrictions. 5.The facility failed when Resident #25 did not have a comprehensive care plan dated 06/17/2025 that included measurable goals related to pain management, physical functioning, medication use, and nutrition. 6.The facility failed when Resident #30 did not have a comprehensive care plan dated 07/29/2025 that included measurable goals related to physical functioning, medication use, falls, edema, and hospice care. This failure could affect residents by placing them at risk of not receiving individualized care and services to achieve their goals.The findings included the following: 1. Review of Resident #3's Resident Face Sheet, dated 08/05/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses including cerebral palsy, anxiety, epilepsy, major depressive disorder, history of falls, edema, weakness, urinary tract infection, depression, and problems with swallowing. Review of Resident #3's Annual MDS Assessment, dated 04/12/2025 Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed he had a BIMS score of 3 out of 15, indicating severe cognitive impairment. Review of Resident #3's Comprehensive Care plan reviewed/revised 05/13/2025 revealed the following: Focus: [Resident] is receiving a therapeutic or altered consistency diet and is at risk for nutritional impairment. Goal: [Resident] will have adequate fluid intake . Focus: Resident has been identified as having PASRR positive status related to an intellectual disability/developmental disability. Goal: Resident will maintain his/her highest level of practicable wellbeing . Focus: Black Box warning: This medication/s has a black box warning, the strongest warning mandated by the FDA, which indicates a need to closely evaluate and monitor the potential benefits and risks of the medication. Black box warning sign due to drug use of Furosemide (diuretic or water pill), Tramadol (opioid pain medication), Linzess (used to treat irritable bowel syndrome), Depakote 9anticonvulsant), Citalopram (antidepressant), Seroquel (antipsychotic), Lorazepam (antianxiety), IBU (non-steroidal anti-inflammatory). Goal: Facility to educate him/her/representative about the risk and benefits of drug and safety measures will be maintained to prevent or lessen any adverse reactions or injury from the drug use. Focus: [Resident] has Dx of Cerebral Palsy and is at risk for seizure activity and worsening of contractures. Goal: [Resident] will be able to function at the fullest potential possible . Focus: Potential for altered comfort r/t GERD. Goal: Resident will maintain adequate intake . Goals: continued review of Resident #3's comprehensive care plan dated 05/13/2025 did not included measurable goals related to therapeutic diet, PASRR positive status, medication use, risk for seizures and contractures, or food intake. 2. Review of Resident #10's Resident Face Sheet, dated 08/05/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including anxiety, epilepsy, quadriplegia, malnutrition, difficulty swallowing, intellectual disabilities, weakness, repeated falls, impulse disorder, incontinence of bowel and bladder, inability to speak, contracture of both hands, and a vitamin deficiency. Review of Resident #10's Quarterly MDS Assessment, dated 07/22/2025 revealed she had a BIMS score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan reviewed/revised 07/29/2025 revealed the following: Focus: [Resident] is receiving a therapeutic or altered consistency diet and is at risk for nutritional impairment. Goal: [Resident] will have adequate fluid intake . Focus: Per responsible party may room with life long room mate. Goal: Provide privacy for all ADLs initiated 07/25/2022. Focus: Resident has been identified as having PASRR positive status related to an intellectual disability/developmental disability. Goal: Resident will maintain his/her highest level of practicable wellbeing . Focus: [Resident] has a communication problem r/t Profound Intellectual Disabilities. Dx of aphasia. Rarely understood/Rarely understands. Goal: [Resident's] needs will be anticipated and met through nursing judgement . Focus: Black Box warning: This medication/s has a black box warning, the strongest warning mandated by the FDA, which indicates a need to closely evaluate and monitor the potential benefits and risks of the medication. Black box warning sign due to drug use of montelukast (used to treat asthma), linzess, IBU, depakene (used to treat seizures), carbamazepine (anticonvulsant), clonazepam (antianxiety/antiseizure), medroxyprogesterone (synthetic hormone). Goal: Facility to educate him/her/representative about the risk and benefits of drug and safety measures will be maintained to prevent or lessen any adverse reactions or injury from the drug use. Focus: [Resident] is at risk for falls r/t: Hx of falls and is at risk for future falls. Impaired Safety Awareness. Constant moving and squirming in bed and chair. Rolled out of bed - no injuries. Goal: [Resident's] risks and injury potential will be minimized . Focus: At risk for pain r/t chronic disease processes. Goal: Will report reduction in pain with interventions . Focus: Potential for altered comfort r/t GERD. Goal: Resident will maintain adequate intake . Goals: continued review of Resident # 10's comprehensive care plan dated 07/29/2025 did not included measurable goals related to nutritional needs, roommate, PASRR status, communication, medication use, falls, pain and altered comfort. 3.Review of Resident #16's Resident Face Sheet, dated 08/05/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including chronic obstructive pulmonary disease (lung disease that makes breathing difficult), high blood pressure, type 2 diabetes mellitus, paranoid schizophrenia(a subset of schizophrenia characterized by delusions and hallucinations), major depressive disorder (mental illness characterized by persistent sadness), chronic pain, repeated falls, weakness, low thyroid function, heartburn, insomnia, Review of Resident #16's Quarterly MDS Assessment, dated 07/22/2025 revealed she had a BIMS score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #16's Comprehensive Care Plan reviewed/revised 07/29/2025 revealed the following: Focus: [Resident] requires psychological services provided by. Goal: [Resident] will exhibit less behaviors and needs will be met . Focus: Black Box warning: This medication/s has a black box warning, the strongest warning mandated by the FDA, which indicates a need to closely evaluate and monitor the potential benefits and risks of the medication. Black box warning sign due to drug use of tramadol, metformin (used to treat Type 2 Diabetes), Zyprexa (antipsychotic), haloperidol (antipsychotic), Wellbutrin (antidepressant), losartan (used to treat high blood pressure), metoprolol (used to treat high blood pressure). Goal: Facility to educate him/her/representative about the risk and benefits of drug and safety measures will be maintained to prevent or lessen any adverse reactions or injury from the drug use. Focus: [Resident] receives antipsychotic medications (Zyprexa, Haldol) r/t Disease process (Schizophrenia). Goal: [Resident] drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive impairment through review date. Goals: continued review of Resident # 16's comprehensive care plan dated 07/29/2025 did not included measurable goals related to behaviors, medication use, and antipsychotic medications. 4.Review of Resident #17's Resident Face Sheet, dated 08/05/2025, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including cardiomyopathy (heart disease), cerebral infarction (stroke), weakness, history of falling, high blood pressure, tremor, and anemia (low red blood cell count). Review of Resident #17's admission MDS Assessment, dated 06/11/2025 revealed she had a BIMS score of 15 out of 15, indicating intact cognition. Review of Resident #17's Comprehensive Care Plan reviewed/revised 06/17/2025 revealed the following: Focus [Resident] gets nervous and anxious at times dx anxiety. Goal [Resident] will have fewer outbursts of yelling/calling out . Record review of Resident #17's Comprehensive care dated 06/17/2025 plan did not have fluid restrictions addressed. 5.Review of Resident #25's Resident Face Sheet, dated 08/05/2025, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including cardiomyopathy, cerebral infarction (stroke), weakness, history of falling, high blood pressure, tremor, and anemia. Review of Resident #25's admission MDS Assessment, dated 06/11/2025 revealed she had a BIMS score of 15 out of 15, indicating intact cognition. Review of Resident #25's Comprehensive Care Plan reviewed/revised 06/17/2025 revealed the following: Focus Need for pain management and monitoring related to. Goal: Will achieve acceptable pain level goal . Focus Impaired physical functioning and ADLs r/t debility/weakness, fatigue. Goal Will increase physical functioning level . Focus Black Box warning: This medication/s has a black box warning, the strongest warning mandated by the FDA, which indicates a need to closely evaluate and monitor the potential benefits and risks of the medication. Black box warning sign due to drug use of clopidogrel (prevents blood clots). Goal: Facility to educate him/her/representative about the risk and benefits of drug and safety measures will be maintained to prevent or lessen any adverse reactions or injury from the drug use. Focus Potential for alteration in nutrition . Goal Will achieve and maintain a healthy weight and nutritional status . Focus At risk for or actual pain. Goal Will have reduction in pain . Goals: continued review of Resident #25's comprehensive care plan dated 06/17/2025 did not included measurable goals related to pain management, physical functioning, medication use, and nutrition. 6.Review of Resident #30's Resident Face Sheet, dated 08/05/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including chronic kidney disease, adult failure to thrive, heart disease, low thyroid function, high blood pressure, myocardial infarction (heart attack), history of falls, weakness, chronic pain, rhabdomyolysis, shortness of breath, difficulty swallowing, and malnutrition. Review of Resident #30's Quarterly MDS Assessment, dated 07/21/2025 revealed she had a BIMS score of 14 out of 15, indicating intact cognition. Review of Resident #30's Comprehensive Care Plan reviewed/revised 07/29/2025 revealed the following: Focus [Resident] has physical functioning deficit related to . Goal Resident will improve current level of physical functioning. Focus Black Box warning: This medication/s has a black box warning, the strongest warning mandated by the FDA, which indicates a need to closely evaluate and monitor the potential benefits and risks of the medication. Black box warning sign due to drug use of tramadol, levothyroxine (thyroid hormone), Lasix (diuretic or water pill), voltaren gel (used to treat inflammation associated with arthritis), and Losartan (used to treat high blood pressure). Goal: Facility to educate him/her/representative about the risk and benefits of drug and safety measures will be maintained to prevent or lessen any adverse reactions or injury from the drug use. Focus . is at risk for falls/injuries r/t arthritis, cardiac compromise, depression, fall history, gait and balance. Goal Noncompliance with safety needs. Focus Potential for complications r/t edema Edema. Goal Resident will have not significant increase of weight r/t edema . Focus Hospice Care due to diagnosis of Heart Disease. Goal Will be kept comfortable with reduced pain . Goals: continued review of Resident #30's comprehensive care plan dated 07/29/2025 did not include measurable goals related to physical functioning, medication use, falls, edema, or hospice care. During an interview on 08/07/2025 at 08:36 AM, the dietary cook stated Resident #17 had a fluid restriction of 1.5 liters per day. The cook had a paper showing how much fluid to serve at each meal to comply with fluid restrictions. The cook stated if fluid restriction was not followed the resident could have more swelling in her feet. During an interview on 08/07/2025 at 09:40 AM, LVN A stated leadership was responsible for care plans. She stated the ADON or DON will ask the staff for input prior to care plan meetings. During an interview on 08/07/2025 at 09:58 AM, the ADON stated she runs care plan meetings and was responsible for creating the baseline care plans. She explained everybody could update a care plan as changes occur. During an interview on 08/07/2025 at 10:07 AM, the DON stated the ADON/MDS Coordinator was responsible for care plans. She explained the system prepopulated a resident's care plan based on data entered from the MDS assessment. The DON stated the prepopulated selections were editable. The DON stated monitoring care plans occurred during quarterly audits performed by a corporate nurse. She stated training on the system and creating care plans was on the job. The DON explained training was also provided when the corporate nurse performed quarterly care plan audits. She stated there was no effect on the residents when the goals were not measurable because of the information included in the interventions and physician's orders provided guidance. During an interview on 08/07/2025 at 10:30 AM, Resident #17 stated did not care that the staff told her she could only have so much to drink. Resident #17 stated she got enough and did not feel thirsty. Review of facility policy titled Care Plans, Comprehensive Person-Centered dated Quarter 3, 2018, revealed in the Policy Statement A comprehensive, person-centered care plan that includes measurable objectives . The Policy Interpretation and Implementation section revealed 8. The comprehensive, person-centered care plan will: a. Include measurable objectives ., k. Reflect treatment goals, timetables and objectives in measurable outcomes

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 (Resident # 85 and Resident #19) reviewed for quality of care. 1. The facility failed to ensure Resident #85's oxygen nasal cannula and oxygen tubing were not lying in the floor. 2. The facility failed to ensure Resident #19's nebulizer mask/tubing was placed in a clear plastic bag when not in use. These failures placed residents of the facility at risk for respiratory illnesses. Findings included: Resident #85 Record Review of Resident #85's electronic Face sheet dated 07/01/2024, revealed a [AGE] year-old male admitted on [DATE], with the following diagnoses Malignant Neoplasm (uncontrolled abnormal growth of cells or tissue in the body) unspecified part of unspecified Bronchus or Lung, Anxiety, Hypertension (high blood pressure) and COPD (Chronic Obstructive Pulmonary Disease) Record review of Resident #85's Admission MDS assessment dated [DATE] revealed: Section C- Cognitive Behavior Resident # 85 had a BIMS score of 10, meaning moderately impaired cognitive function. Record review of Resident 85's Care Plan dated 06/27/2024 revealed: requires supplemental oxygen for respiratory status of COPD and SOB (shortness of breath) The goal: Resident will tolerate use of supplemental oxygen and oxygen saturation will remain within normal ranges daily. Interventions: Monitor for complications related to oxygen use (ears, nose, dry mucosa membranes), Oxygen per nasal cannula as ordered, Oxygen tubing changed per facility protocol Record review of Resident #85's Physician Orders dated 06/01/2024 revealed change (oxygen) mask/tubing every night shift every Sunday. During an observation and attempted interview on 06/30/2024 at 2:25 PM, Resident #85 was lying in bed, nasal canula for oxygen was lying on floor beside resident's bed. Resident #85 was not able to provide response. Resident #19 Record review of Resident #19's electronic face sheet dated 03/07/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: non-ST elevation Myocardial Infarction (Heart attack) and Shortness of Breath Record review Resident #19's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior Resident #19 had a BIMS Score 13 meaning no cognitive impairment; Section O -Special Treatment Resident #19 required oxygen therapy. Record review Resident #19's Care Plan dated 05/16/2024 Resident #19 Required PRN supplemental oxygen for shortness of breath to maintain O2 (oxygen) sats (saturation) above 90%. The goal: Resident will tolerate use of supplemental oxygen and oxygen saturation will remain within normal ranges daily. Interventions: Monitor for complications related to oxygen use (ears, nose, dry mucosa membranes), Oxygen per nasal cannula as ordered, Oxygen tubing changed per facility protocol Record review Resident #19's Physician orders dated 06/01/2024 Oxygen 2-4 liter per minute PRN (as needed). Change (oxygen) tubing/mask every night shifts every Sunday. During an observation on 06/30/24 at 2:30 PM Resident #19 was sitting up in her wheelchair. Her nebulizer equipment was not stored in a plastic bag or dated when tubing was last changed. Nebulizer mask was lying on a table at the resident's bedside. During an interview on 07/02/24 at 10:33 AM, Resident # 19 stated the staff did not always put her nebulizer mask in a bag. She stated she wished they would have kept the mask in bag to keep it clean. She stated that she only needed breathing treatments occasionally. During an interview on 07/02/24 at 10:45 AM, the DON stated oxygen tubing should have been in a clear plastic bag when not in use. She stated nebulizer masks or tubing and nasal canula should have been in a clear plastic bag when not in use. She stated tubing and breathing treatment supplies should have been kept in plastic bag when not in use, for infection control. She stated the Charge Nurse on the Sunday night shift was responsible for changing oxygen tubing and mask, and nebulizer device each week, and they should have been dating the plastic bag. She stated there was no harm to residents unless the supplies got dirty. She stated the best practice was to place tubing in plastic bag. She stated she did not know why this failure occurred. During an interview on 07/02/2024 at 10:50 AM, RN A stated the nebulizer tubing, mask, handheld device should have been in plastic bag when not in use. She stated if she found oxygen tubing on the resident's floor, she would have replaced it with a new oxygen tubing and nasal canula. She stated the Sunday night shift nurse should have changed the tubing and put it in a plastic bag, with the date on the bag. She stated the resident could possibly have gotten an infection if dirty tubing was used. She stated she did not know how this failure occurred. During interview on 07/02/2024 at 12:24 PM the ADMN stated he would refer any clinical questions to his DON and the staff should have followed the policies of the facility. Review of facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection dated November 2011 revealed: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among resident and staff . Steps in the Procedure: 8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use .

Based on observation, interview, and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers that were avoidable for 1 of 14 residents (Resident #28) reviewed for quality of care. The facility failed to ensure Resident #28's physician ordered pressure relief boots were placed on Resident #28's feet while he was laying in his bed. This failure could place residents at risk of having skin breakdown . Findings included: Record review of Resident #28's face sheet dated 07/02/2024 revealed a [AGE] year-old male admitted on [DATE] with an original admitted [DATE], with diagnosis of Spastic Quadriplegic Cerebral Palsy(, disorder of bone density and structure, protein-malnutrition and muscle weakness. Record review of Resident #28's Quarterly MDS assessment dated [DATE], revealed: Section C-Cognitive Patterns, Resident #28 had a BIMS score of 0 meaning Resident #28 was given the assessment because he was rarely/never understood; Section GG-Functional Abilities and Goals, Resident #28 was dependent on staff for all ADL's; Section M- Skin Conditions, Resident #28's skin intact , no pressure ulcers. Record review of Resident #28's physician orders revealed Start date of 12/30/2022 Keep bed in low position, pressure relief scoop mattress, pressure relief cushion to w/c [wheel chair], pressure relief boots to feet for prevention. Every day and night shift During an observation on 06/30/2024 at 9:10 AM , Resident #28 laying in his bed. Resident #28's bed was in lowest position. Pressure relief boots were laying on top of the covers and were not on Resident #28's feet. During interview on 07/02/2024 at 12:24 PM the ADMN stated he would refer any clinical questions to his DON and the staff should have followed the policies of the facility. During an observation and interview on 07/02/2024 at 12:55 PM, the DON stated Resident #28 should have been wearing pressure relief boots on both his feet to prevent pressure ulcers. The DON stated if the order stated every day and night shift, then the boots should be on when Resident #28 was laying in bed. The DON stated Resident #28 did not have any skin issues, the order for pressure relief boots was to prevent pressure ulcers. The DON lifted the sheet up to reveal that Resident #28 was not wearing pressure relief boots. The skin on Resident #28's feet was intact with no redness or open areas. The DON stated she did not know why the boots were not on. She stated they may have been in laundry. The DON located the boots in the top of Resident #28's closet. The DON stated her expectation was that orders should have been followed, and per orders, the boots should have been on Resident #28 feet. The DON stated the effect on resident could have been a pressure ulcer could have developed. The DON stated she did not have a response to why the boots were not on Resident #28's feet. The DON stated they did not have a policy for following physician orders.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection. PT B double gloved during incontinent and wound care for Resident #23 and did not sanitize or wash her hands in between glove changes. PT B failed to perform hand hygiene prior to leaving room after performing wound care and incontinence care. CNA C failed to perform hand hygiene or glove changes during incontinent care of Resident #25. CNA C touched residents clothing and linens with soiled gloves after conducting incontinence care. These failures could place resident's risk for cross contamination and the spread of infection. Findings included: Record review of Resident #23's admission record dated 05/23/23 indicated he was admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral region, muscle wasting and atrophy. He was [AGE] years of age. Record review of Resident #23's MDS dated [DATE] indicated in part: Bladder and Bowel: Bowel Continence = 3. Always incontinent (no episodes of continent bowel movements). Record review of Resident #23's physician orders active as of 05/23/2023 indicated in part: Cleanse stage 4 to sacrum with antimicrobial skin and wound gel and pat dry. Apply 2x2 to cover wound bed. Apply thin layer of sure-prep (A skin protectant wipe that forms a waterproof barrier on skin) )around wound and cover with dressing. LT (left) heel= After CPI (Closed Pulse Irrigation) irrigation by therapy. pat dry, apply hydrogel impregnated gauze on wound bed &cover with dry gauze and foam dressing Monday to Friday. Record review of Resident #23's care plan dated 05/17/2023 indicated in part: Focus: Potential for complications related to incontinence of bowel. Goal: Resident will be free from complications r/t incontinence as evidence by intact skin, no rash or redness to peri care, no signs or symptoms of infection daily. Interventions: Clean peri area thoroughly after each episode of incontinence, assess, assess skin after each episode of incontinence-notify nurse with any problems. Focus: Infection actual or at risk for related to: Stage 3 decubitus ulcer to sacrum. Goal: Infection will resolve without complication . Interventions: Follow standard precautions refer to Living Center Infection Control Manual. Record review of Resident #25's admission record indicated she was admitted to the facility on [DATE]. Diagnoses included epilepsy, full incontinence of urine and bowel, intellectual disabilities. She was [AGE] years of age. Record review of Resident #25's MDS dated [DATE] indicated in part: Bladder and Bowel: Bowel Continence = 3. Always incontinent (no episodes of continent bowel movements). Record review of Resident #25's care plan dated 05/17/2023 03/13/23 indicated in part: Focus: Resident has bowel/bladder incontinence and is at risk for skin breakdown and UTI's. Goal: Residents risk for septicemia will be minimalized /prevented via prompt recognition and treatment of symptoms of UTI through the review date. Resident will remain free from skin breakdown due to incontinence and brief use. Intervention: Clean peri area with each incontinence episode, handwashing before and after delivery of care. During an observation on 05/22/23 at 02:42 PM PT B performed wound care to Resident #23's coccyx area. PT B sanitized her hands and put on 1 pair of gloves on both hands. PT B undid the brief and noted the resident had a bowel movement, so she took some wipes and wiped bowel movement. While still wearing the same original gloves that she used to wipe the bowel movement, PT B took a clean pair of gloves and put them over the soiled pair of gloves she was already wearing. PT B then placed a clean cloth pad under the resident and removed the dressing from the wound on Resident #23's coccyx area. PT B then removed the first pair of gloves and placed another clean pair of gloves over the ones that she used to clean the bowel movement. PT B then took some sure-prep pads and wiped around the wound area and placed a plastic dressing over the entire coccyx are while still wearing the same double gloves. The resident had more bowel movement, so PT B wiped the bowel movement with some wipes then removed those gloves and put on another pair over the ones she already had on. PT B then took some 4x4 gauze and cleaned the wound then she removed the pair of gloves and put on a new pair over the ones she had on from the beginning. While wearing the same pair of gloves PT B took a clean cloth pad and placed it under Resident #23 then took a clean brief and fastened it to him. While wearing the same pair of gloves PT B took a clean pair of shorts and assisted the resident with putting them on. PT B then removed both gloves from her left hand but only one glove from the right hand, she then placed a new glove over the old glove on right hand and placed 2 gloves on her left hand without sanitizing or washing her hands. PT B then took a plastic dressing and placed it on Resident #23's left foot. PT B's cellphone rung so with the gloved hand took the cellphone from her shirt pocket and pressed a button to silence it, placed the phone back in her pocket and proceeded with the wound care. While wearing the same gloves PT B took the CPI machine and debrided the ankle with the sodium chloride solution. PT B then removed the plastic dressing, removed the first pair of gloves while leaving the old pair still on and then took a clean pair of gloves and donned them over the old pair. After PT B was done with the care, she placed the used items in a bag and removed her gloves and placed them in the bag and left the room without sanitizing or washing her hands. During an observation and interview on 05/23/23 at 04:00 PM, CNA C washed hands, donned gloves, pulled curtain, and used the remote to adjust bed to lay resident flat. CNA C removed resident #25's pants, and folded residents soiled brief in on itself. CNA C wiped resident's perineal area x5 with wet wipes, then rolled resident to her left side and wiped residents bottom x3 with wet wipes. CNA C removed soiled brief, and dried residents bottom with a dry towel, then placed new brief under resident and then rolled resident and dried resident front perineal area with a clean dry towel. CNA C secured residents brief. CNA C covered resident with her blankets and adjusted her pillows. CNA C lowered bed to lowest position using the remote. CNA C doffed her gloves and washed her hands. CNA C failed to perform hand hygiene, use hand sanitizer or change gloves during incontinent care of Resident #25. During an interview on 05/24/23 at 10:42 AM the ADON said staff was expected to remove their gloves if they became contaminated with bowel movement. The ADON said staff were then expected to wash their hands and the put- on clean gloves to continue the care. The ADON said staff were supposed to only put one pair of gloves at a time and not double glove. The ADON said staff were not supposed to double glove because the first pair of gloves could become damage and contaminate the other pair. The ADON said the PT staff should have removed both gloves and washed their hands before putting on another pair of gloves. The ADON said PT B not changing her gloves and washing her hands could lead to cross contamination. The ADON said she did training, on a monthly basis, regarding hand washing and glove use and all staff was present including the therapy staff. The ADON said she would do more training on the use of gloves and hand washing. During an interview on 05/24/23 at 11:56 AM PT B said she should have probably changed her gloves once they became contaminated and washed or sanitized her hands. PT B acknowledged that using double gloves was not appropriate and would not do that anymore. PT B said she attended the in-services they had at the facility regarding hand washing and glove use and she should have been more careful to prevent cross contamination. During an interview on 05/24/23 at 12:04 PM the Administrator was made aware of the observation of PT B using double gloves and not washing or sanitizing their hands in between glove changes. The Administrator acknowledged it was a concern and there would be more training regarding handwashing and glove changing. Record review of the facility's policy titled Handwashing/Hand Hygiene and dated 08/2019 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: When hands are visibly soiled. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single use disposable gloves should be used before aseptic procedures; when anticipating contact with blood or bodily fluids and when in contact with a resident or the equipment or environment of a resident who is on contact precautions. Record review of the facility's policy titled Personal protective equipment-using gloves and dated 09/2010 indicated in part: When gloves are indicated use disposable single use gloves. Wash hands after removing gloves (Note: Gloves do not replace handwashing).

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving of mistreatment, neglect, abuse or injuries of unknown source were reported immediately, but not later than 24 hours after the allegation was made to the administrator and to other officials (including to the State Agency) for 1 of 3 residents (Resident #27) reviewed for reporting an allegation of abuse. The facility failed to report to the administrator of bruising of suspicious nature in shape and/or position within 24 hours for Resident #27. This failure could result in unreported incidents of abuse/neglect and lead to diminished quality of life, and psychosocial harm for residents. Findings included: Review of Resident #27's Admission Record dated 5/23/23 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including compression fracture of the right lower leg, dementia, psychotic disorder with hallucinations, Alzheimer's Disease, Chronic Pain, and history of falls. Review of Resident #27's Admission MDS Assessment, dated 3/27/23, revealed: He had a mental status exam score of 3 of 15 (indicating severe cognitive impairment). He showed signs of delirium included inattention and disorganized thinking. He showed behavioral symptoms including physical behaviors directed toward others (4 - 6 days a week); verbal behaviors directed toward others (1 - 3 days a week); and other behavioral symptoms not directed towards others (4 -6 days a week). He resisted care (1 - 3 days a week) and wandered (4 - 6 days a week). He needed extensive assistance from two or more staff in all ADLs except eating. He used a wheelchair. He was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #27's Care Plan, started 3/27/23 revealed: Focus: Resistive with care due to cognitive loss and diagnosis of Alzheimer's and dementia Goal: Resident #27 will be compliant with all necessary care Interventions: allow resident to express preferences and follow these when possible and meet resident's needs as is possible and explain what it is being done to meet needs. Review of Resident #27's Care plan, started 3/30/23, revealed: Focus: Resident #27 sometimes has behaviors which include cursing, hitting during care, kicking, screaming, and shouting. Goal: Resident #27 will calm down with staff intervention daily Interventions: attempt interventions before resident's behaviors begin. Review of Resident #27's Order Summary Report, dated 5/23/23, revealed he was not on any anti-coagulant, anti-platelet, or Non-steroid Anti-inflammatory Drug. Review of Resident #27's Nurse's Notes 4/22/23 - 5/23/23 revealed no notes about bruises to Resident #27's arm. Review of Resident #27's only incident/ accident report revealed an incident/ accident report, dated 5/20/23, completed by LVN D that documented yellow, healing bruises. Observation on and interview on 05/22/23 at 12:26 PM revealed Resident #27 in his room up in his wheelchair. Resident #27 was observed to have a bruise near his arm. Family member pulled up the arm to his shirt and showed surveyor the bruising on the bicep of his left arm with a skin tear in the middle. Resident #27's family member told the facility she did not know what happened. The bruise on his arm was a red crescent shaped bruise to the outside of the arm. On the inner arm was a dark purple oval shaped bruise. Observation and interview 05/23/23 at 11:41AM showed Resident #27's bruises measured approximated 2.5 - 3 inches long for the crescent bruise. The inner arm bruise was approximately an inch and matched the outline of a thumb. Interview on 05/23/23 at 3:04 PM CNA C stated Resident #27 was fairly new and excessive assistance on everything. She said he got fairly aggressive at times and clocked her about a week ago. She said she was not sure how long Resident #27 had the bruise on his arm. CNA C said she became aware of the bruise when she came back from her days off last week and no one told her about them. She stated when she found the bruising on Resident #27's arm she reported it to her nurse. CNA C said she just remembered a circular bruise on his arms. CNA C stated a circular bruise might be from someone grabbing him or being pulled up CNA C stated when she found a bruise on a resident, she would bring it to her charge nurse or ADON. Interview and observation on 05/23/23 at 3:18 PM LVN A stated Resident #27 had Alzheimer's disease and had lot of behaviors. LVN A explained Resident #27 would punch and fight and kick when he was changed. LVN A said she did not know anything about a bruise on Resident #27 and stated she needed to measure it. Resident #27 was observed in bed asleep. LVN A was able to measure the bruise on Resident #27's arm; due to the way Resident #27 was laying, she was able to measure the red crescent bruise on the bicep at 1.5 cm x 1.5 cm and the skin tear was 1.5 cm long. LVN A stated she would complete an incident/accident report on the bruise. LVN A stated no one told her of any bruising in shift to shift report. LVN moved Resident #27's arm to examine the inner arm and stated the purple bruise looked like a thumb print but was unable to measure it. Interview on 05/23/23 at 3:34 PM the ADON stated she was not sure how Resident #27 got the red or purple bruises on his arm. She stated she tried to look at Resident #27's arms but Resident #27 would not let her look at it. Interview on 05/24/23 at 9:15 AM the ADON stated she went into Resident #27's room when he got undressed. The ADON stated she though the incident/accident report completed on 5/20/23 was about different bruise(ing). She confirmed she saw the bruise when he got undressed. The ADON stated she did see the inner arm bruise and stated it was purple, in-tact and non-blanchable. The ADON said she thought he hit the half-rail on his bed, she continued she thought it would form an oval bruise (the half rail was long, straight, smooth plastic bar structure for resident to grab during ADL care). When it was pointed out the half rail was long and thin, the ADON said he might have bumped it on his wheelchair (wheelchair arms are padded, long and thin). The ADON said to rule out staff mistreatment, they talked to the staff and everything. The ADON stated Resident #27 was unable to explain what happened, but if someone did something to him, he did not like he'd get you. The ADON stated if the bruise was from someone holding too tightly there would be a bruise from the fingers as well. The ADON said the 5/20/23 skin assessment did not document any new skin issues. The ADON said to investigate the bruises she called Resident's #27's Responsible Party and they did not think anything happened. Interview on 05/24/23 at 9:41 AM the Administrator stated the only bruising he was aware of was old bruising discovered 5/20/23 that was yellow. He was not aware of the red or purple bruise. He said causes of bruising could be a transfer not done right or a resident-to-resident altercation. The Administrator stated he did not look at Resident #27's arm. The Administrator admitted he did not do anything to rule out abuse or neglect. He admitted he did receive training for abuse and neglect, and it covered mandatory reporting and suspicious injuries. The Administrator stated suspicious injuries could be inner soft skin and the face. Interview on 05/24/23 at 11:00 AM LVN D said she worked 5/20/23 and did not find red or purple bruisng. LVN D said she did not know how the aides provided ADL care and not notice the red or purple bruising, but neither knew about it. LVN D said she worked on Friday 5/19/23 and no one said anything about bruising at that time. LVN D said Resident #27 was always agitated during care and needed two-people for assistance. LVN D said there was nothing abnormal about 5/19/23 or 5/20/23. Review of the facility's policy and procedure on Abuse Prevention Program, dated 1/2022, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: Develop and implement policies and procedures to aide our facility in preventing abuse, neglect, or mistreatment of our residents. Resident staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior. Identify and assess all possible incidents of abuse Investigate and report any allegation s of abuse within timeframes as required by federal requirements. Review of the facility's policy and Procedure on Abuse and Neglect - Clinical Procedure, dated 1/2022 revealed: Assessment and Recognition: The nurse will assess the individual and document related findings. Assessment data will include: a. injury assessment (Bleeding, bruising, deformity, swelling etc.) b. pain assessment c. current behavior d. Patient's age and sex e. All current medications, especiall7y anti-coagulants, Non-Steroidal, Anti-Inflammatory Drugs, salicylate. f. Other platelet inhibitors g. Vital sighs. h. Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior) i. History of any tendency towards bruising j. All active diagnoses. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents/ patients with unmanageable problematic behavior. Cause identification: the staff with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes.

Based on observation, interview, and record review the facility failed to label medications in accordance with currently accepted professional principles, and include the the expiration date , and to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one of one medication room and one (cart #1) of one treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to label multi-use vials of tuberculin and influenza formula with the open date The facility failed to ensure treatment cart #1 was locked when unattended on 05/22/2023 and 05/24/2023. These failures could place residents at risk of being administered expired medications and having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and record review on 05/23/23 at 3:02 PM the medication room was observed with LVN A present. Inside a small refrigerator there were two opened 1ml vials of tuberculin formula that did not have an open date on them. The tuberculin box indicated Discard opened product after 30 days. There also was a one opened 5ml vial influenza vaccine formula vial that did not have an open date on it. The influenza formula manufacture pamphlet dated March 2022 indicated in part: Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. During an interview on 05/23/23 at 3:12 PM LVN A said she did not know if someone was designated to check the medication room for expired medications. LVN A said she would definitely start checking for expired medications in the medication room from now on. During an interview on 05/24/23 at 10:30 AM the ADON said normally the nurses were supposed to monitor the medication room for expired medications and such. The ADON said she checked the medication room once a week but she must have missed those vials. The ADON said if they used an expired vial medication it could lead to inaccurate readings or not get the desired effect. During an interview on 05/24/23 at 12:02 PM the Administrator said it was the nurses duty to monitor the medication room for expired medications and discard them if not dated (out of date). Record review of the facility's policy titled Medication labeling and storage dated 02/2023 indicated in part: The medication label includes at a minimum - expiration date when applicable. Multi-dose vials that have been opened or accessed (e.g. needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. During an observation and interview on 05/22/2023 from 3:05 PM to 3:09 PM, treatment cart #1 was observed unlocked and unattended. There were no facility staff observed near the treatment cart or seen, all drawers of the medication cart were unlocked, and all medications, supplies, and additional items were easily accessible with no staff in eyesight of the treatment cart. Surveyor waited by cart for 4 minutes before a LVN D walked by and took the cart. During an observation and interview on 05/24/23 08:30 AM to 08:50AM, treatment cart #1 was observed unlocked and unattended. There were no facility staff observed near the treatment cart or seen, all drawers of the medication cart were unlocked, and all medications, supplies, and additional items were easily accessible with no staff in eyesight of the treatment cart. Surveyor waited by cart for 20 minutes before a LVN D arrived. LVN D was questioned about who was responsible for locking the cart. LVN D stated that she and the other nurse shared the treatment cart. Surveyor asked why the cart was unlocked, LVN D shrugged her shoulders and stated that she would lock the cart when she finished what she was doing. In an interview on 05/24/23 at 1:10 PM, the ADON stated the carts should never be left unlocked and unattended. ADON stated that her expectations were that staff should be locking carts. The ADON stated that she recently put out an in-service on unlocked carts because it had been a problem. ADON stated that she is constantly telling the nurses to lock the carts. ADON stated that she would re-educate the nurses on importance of locking carts for safety of residents. Review of the facility's policy, titled Security of Medication Cart, revised April 2007, reflected (in part): Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the residence room during the medication pass. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The card must be locked before the nurse enters the residence room. 4. Medication carts must be securely locked at all times went out of the nurses view. 5. When the medication cart is not being used, it must be locked and parked at the nurses station or inside the medication room. Review of facilities mandatory in-service, dated 04/01/2023, titled Locking Medication Carts Topic discussed: When not standing directly in front of medication heart, the cart must be locked, and the computer should not contain patient information.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #18) of 2 residents reviewed for infection control. The facility failed to ensure CNA A changed her gloves after they became contaminated during incontinent care while assisting Resident #18. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #18's admission record dated 04/11/22 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #18's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent (no episodes of continent voiding). Bowel Continence = 3. Always incontinent (no episodes of continent bowel movements). Record review of Resident #18's care plan dated 03/04/2022 indicated in part: Focus: Resident has bowel and bladder incontinence and is at risk for skin breakdown and [CONDITION(S)]'s. Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Clean peri-area with each incontinence episode. Check every 2 hours and prn for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 04/11/22 at 01:22 PM CNAs A and CNA B performed incontinent care for Resident #18. Both CNAs sanitized their hands and donned gloves. CNA A undid the resident's brief and performed peri-care to the resident's vaginal and rectal area. CNA A used some wet wipes to wipe both areas and at times her gloves came in contact with the residents vaginal and rectal areas. The brief was noted to be wet from urine. While still wearing the same gloves, CNA B applied the new brief, pulled up Resident #18's pants and adjusted her shirt. During an interview on 04/12/22 at 04:32 PM CNA A said she had forgotten to change her gloves after they became contaminated during the incontinent care, she performed for Resident #18. CNA A said she was aware that she was supposed to change them once she went from dirty to clean to prevent cross contamination. CNA A said she had received in-services on incontinent care. CNA A said if she did not change her gloves once they became contaminated then it could lead to urinary tract infections or other types of cross contamination. During an interview on 04/13/22 at 12:14 PM the unit manager said she conducted check-offs with staff such as handwashing and glove changing. The manager said this was done once a month randomly. The manager said when staff performed incontinent care and when they went to apply the clean brief they were supposed to change their gloves to prevent cross contamination. The manager said the failure probably occurred because the CNA was nervous and forgot to change her gloves. During an interview on 04/13/22 at 12:54 PM the DON said staff were supposed to perform hand hygiene and change their gloves after they performed incontinent care because their gloves were considered dirty. The DON said they conducted competency checks quarterly on all their staff. The DON said the nurses, unit manager and DON were responsible for overseeing the aides perform transfers. The DON said the failure of the CNA not changing her gloves could lead to cross contamination. During an interview on 04/13/22 at 01:18 PM the Administrator said staff were supposed to perform hand hygiene and change their gloves to prevent cross contamination. The Administrator said the DON did skills competency checks quarterly. The Administrator said the nurses, unit manager and DON were responsible for overseeing the aides. The Administrator said the failure could lead to [CONDITION(S)] and cross contamination. Record review of the facility policy titled Hand hygiene dated 2021 indicated in part: Indications for hand hygiene using alcohol-based hand sanitizer include: When moving from a contaminated body site to a clan body site during resident care.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (Resident #18) for transfers. The facility failed to ensure CNA A and CNA B demonstrated appropriate transfer techniques for Resident #18. This failure could place residents at risk of not receiving the appropriate level of assistance and supervision with the potential for falls and/or injuries. Findings include: Record review of Resident #18's admission record dated 04/11/22 indicated she was admitted to the facility on [DATE] with diagnoses which included weakness, history of falling, stiffness of right shoulder and dementia. She was [AGE] years of age. Record review of Resident #18's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Functional Status = . Transfer = Extensive assistance. Two plus persons physical assist. Record review of Resident #18's care plan dated 03/04/2022 indicated in part: Focus: Resident has an ADL self-care performance deficit r/t Intellectual Disabilities, Unsteady Gait/Impaired balance, and muscle weakness. Goal: Resident will maintain current level of function in ADL's through the review date. Interventions: The resident requires extensive assistance by (X 1-2) staff to move between surfaces as needed. During an observation and interview on 04/11/22 at 01:22 PM CNAs A and B transferred Resident #18 from her wheelchair to the bed. The CNAs took the resident from under her armpits and by the back of her pants. During the transfer the resident bended her legs and provided minimal weight bearing during the transfer. CNA B was seen wearing a gait belt around her waist. The resident was unable to state how she felt during the transfer due to her cognitive status. During an interview on 04/12/22 at 04:26 PM CNA A said residents who required a gait belt were residents who could not bear weight that good. CNA A said resident's like Resident #18 required a gait belt for transfers. CNA A said they should have probably used a gait belt on Resident #18 when they transferred her yesterday (04/11/22). CNA A said she had not used the gait belt because they got in a rush and forgot to use it. CNA A said they received in-services on the use of gait belts. CNA A said if a gait belt was not used during a transfer the resident could fall or take the staff down with them. CNA A said the resident's arm could be injured if transferred from under their arms. During an interview on 04/12/22 at 04:38 PM CNA B said residents who required a gait belt were residents who could not really bear weight with their legs. CNA B said they should have probably used a gait belt to transfer Resident #18 since her legs buckled down during the transfer. CNA B said she was in a hurry and had not used the gait belt. CNA B said the resident could have fallen or dislocated her shoulder if the transfer was not done with a gait belt. CNA B said they received in-services and training on the use of gait belts. During an interview on 04/13/22 at 12:34 PM the DON said Resident #18 could range from 1 to 2 person assist for transfers. The DON said the aides were supposed to use a gait belt for transfers and were not supposed to take the resident from her arm pits because it was unstable for the resident. The DON said they did quarterly competency checks on all their staff to include gait belt use. The DON said the nurses, unit manager and DON were responsible for overseeing the aides perform transfers. The DON said the failure could affect the residents by causing them to be uncomfortable. During an interview on 04/13/22 at 01:18 PM the Administrator said he was not sure of the step-by-step regarding transfers and it would be the DON who would know more. The Administrator said he agreed with the DON's statement that the aides were supposed to use a gait belt for transfers when required. The Administrator agreed with the DON's statements that the staff were not supposed to take the residents from their arm pits because it was unstable for the resident. The Administrator said the DON did skills competency checks quarterly. The Administrator said the nurses, unit manager and DON were responsible for overseeing the aides. The Administrator said the failure left room for error for resident or staff getting injured. Record review of the facility's competency checklist dated 03/01/22 and completed by the DON indicated CNA A had met competency regarding transferring resident from bed to chair. Objective: to transfer a patient from the bed to a wheelchair according to the standard of care. Stand in front of the patient and block the patient's toes with your feet and the patient's knees with your knees, place a gait belt over the patient's clothes around the waist, if necessary and secure it in the front and the handles on the patient's sides. Record review of the facility's competency checklist dated 01/27/22 and completed by the DON indicated CNA B had met competency regarding transferring resident from bed to chair. Objective: to transfer a patient from the bed to a wheelchair according to the standard of care. Stand in front of the patient and block the patient's toes with your feet and the patient's knees with your knees, place a gait belt over the patient's clothes around the waist, if necessary and secure it in the front and the handles on the patient's sides. Record review of the facility's document titled lift and transfer guide dated 2010 indicated in part: Direct Care Staff. Direct care staff will be responsible for the following: Lifting and transferring resident in accordance with the residents plan of care. Using proper techniques when lifting and transferring residents.

Based on observation interview and record review the facility failed to establish and maintain 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 for the current threat of COVID-19. The facility failed to ensure hand hygiene procedures were followed by staff involved in direct resident contact and when donning Personal Protective Equipment (PPE) during the COVID-19 threat. This failure placed residents at risk of infection, including COVID-19. Findings: In an interview on 4/3/20 at 10:40 am the DON stated she has in-serviced her staff over the recent changes with the COVID-19 threat, but she does not have any proof of ongoing monitoring of facility staff for compliance and understanding. In an observation on 4/3/20 at 11:55 am CNA A donned Personal Protective Equipment (PPE) to enter a resident room with no hand hygiene completed prior to donning the PPE. Observation of the PPE cart revealed instructions for donning PPE for standard, droplet, or airborne precautions, nowhere on the instruction page or the cart was there a reminder to complete hand hygiene prior to donning PPE. In an interview on 4/3/20 at 9:00 am the DON stated they have one person in isolation with pneumonia and a COVID-19 test for that resident is pending. (this was the resident CNA A worked with on 4/3/20 at 11:55 am) In an interview on 4/3/20 at 12:38 pm CNA A stated she has been in serviced to complete hand hygiene before donning PPE, but that she just forgot. In an observation on 4/3/20 at 12:02 pm the facility's Housekeeping and Laundry Manager was seen entering the building from the back door with no use of hand hygiene before moving about the facility and touching items. In an observation on 4/3/30 at 12:22 pm CNA B was observed removing lunch trays from at least 6 resident rooms with no hand hygiene between rooms. CNA B was also observed retrieving a fallen used dirty dish from the floor with no hand hygiene performed afterwards. In an interview on 4/3/20 at 12:27 pm CNA B stated every time they go in resident rooms they are to wash their hands, and if they are picking up trays they should at least use hand sanitizer. CNA B stated she didn't use hand sanitizer or wash her hands because she was in a hurry. In an interview on 4/3/20 at 1:00 pm the Administrator stated she expects hand hygiene to be done and Alcohol-based Hand Rub (ABHR) is appropriate if hands are not visibly soiled. The Administrator stated hand hygiene should be completed between resident room such as when retrieving meal trays, and hand hygiene should have been completed after picking up a used dirty dish off the floor. The Administrator also stated hand hygiene should be completed before donning PPE. The Administrator also stated they have been in-serving staff of hand hygiene, but as far as he knows the only monitoring of compliance has just been with general observation. Record review of facility policy dated 2012 revealed a policy on Hand Hygiene Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene .Using an alcohol-based hand rub is appropriate for decontamination the hands before direct patient contact; before putting on gloves . after contact with inanimate objects in the patient's environment . Record review of Centers for Disease Control and Prevention (CDC) statement for healthcare personnel on hand hygiene during the response to the international emergency of COVID-19 accessed on 4/2/20 revealed the following: CDC recommendations reflect the important role of hand hygiene for preventing the transmission of pathogens in healthcare settings for a wide range of pathogens. The ability of hand hygiene, including hand washing or the use of alcohol-based hand sanitizers to prevent infections is related to reductions in the number of viable pathogens that transiently contaminate the hands. Hand washing mechanically removes pathogens, while laboratory data demonstrate that 60% [MEDICATION NAME] and 70% [MEDICATION NAME], the active ingredients in CDC-recommended alcohol-based hand sanitizers, inactivates viruses that are genetically related to, and with similar physical properties as, the 2019-nCoV. While the exact role of direct and indirect spread of coronaviruses between people that could be reduced by hand hygiene is unknown at this time, hand hygiene for infection prevention is an important part of the U.S. response to the international emergence of COVID-19. CDC recommends the use of alcohol-based hand sanitizers with greater than 60% [MEDICATION NAME] or 70% [MEDICATION NAME] as the preferred form of hand hygiene in healthcare settings, based upon greater access to hand sanitizer. Health care providers who use alcohol-based hand sanitizers as part of their hand hygiene routine can inform patients that they are following CDC guidelines. https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html

Based on record review and interview the facility failed to ensure that a written notification of transfer was given to the resident and the resident's representative for 5 of 5 residents (ID #s 5, 13, 180, 181, and 182) reviewed for hospitalization . A written notice of transfer was not provided for the following transfers: a. Resident #5 was transferred to the hospital on [DATE]. b. Resident #13 was transferred to the hospital on [DATE] and 11/19/2019. c. Resident #180 was transferred to the hospital on [DATE]. d. Resident #181 was transferred to the hospital on [DATE]. e. Resident #182 was transferred to the hospital on [DATE]. This failure could result in residents being inappropriately transferred or discharged . The findings included: Resident #5 Review of Resident #5's face sheet dated 11/20/2019 revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her most recent hospital stay was 06/02/2019 to 06/11/2019. Her [DIAGNOSES REDACTED]. Review of Resident #5's nursing progress notes dated 07/18/2019 at 11:17 PM revealed she was transferred to local emergency room for evaluation due to labored breathing and chest pains. She was admitted to the local hospital on [DATE] at 3:50 AM. Review of the chart and electronic record for Resident #5 revealed no documentation of a written transfer notice for 07/18/2019. Resident #13 Review of Resident #13's face sheet dated 11/20/2019 revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her most recent hospital stay was 07/18/2019 to 07/23/2019. Her [DIAGNOSES REDACTED]. Review of Resident #13's nursing progress notes dated 06/02/2019 at 4:45 PM revealed she was transferred and admitted to local hospital for systolic heart failure, anasarca, and kidney injury. Review of Resident #13's nursing progress notes dated 11/19/2019 at 10:18 AM revealed she was transferred to local emergency room for evaluation due to resident decline with nausea; vomiting; increased itching; 2+ [MEDICAL CONDITION] to bilateral lower extremities, arms, and abdomen; and wet non-productive cough. She had a fistula left arm implanted on 11/15/2019 pending utilization for [MEDICAL TREATMENT]. Nursing progress note dated 11/18/2019 at 11:30 PM revealed that the facility was notified of critical blood urea nitrogen (BUN) level of 118 milligrams per deciliter (mg/dL). A high level of BUN is a sign that the kidneys are not working correctly and normal results are generally 6 to 20 mg/dL https://medlineplus.gov/ency/article/ 4.htm. Review of the chart and electronic record for Resident #13 revealed no documentation of a written transfer notices for 06/02/2019 and 11/19/2019. Resident #180 Review of Resident #180's face sheet dated 11/20/2019 revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her most recent hospital stay was 06/03/2019 to 06/06/2019. Her [DIAGNOSES REDACTED]. Review of Resident #180's nursing progress note dated 11/15/2019 at 1:39 PM revealed that she was experiencing symptomatic [MEDICAL CONDITION]. Review of electronic phone physician's orders [REDACTED]. Review of the chart and electronic record for Resident #180 revealed no documentation of a written transfer notices for 11/15/2019. Resident #181 Review of Resident #181's face sheet dated 11/20/2019 revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her most recent hospital stay was 08/25/2019 to 08/28/2019. Her [DIAGNOSES REDACTED]. Review of Resident #181's nursing progress note dated 08/25/2019 at 11:00 PM revealed that she was transferred to local emergency room due to unable to respond. Nursing progress note dated 08/26/2019 at 7:14 AM revealed she was admitted to hospital [MEDICAL CONDITION]. Review of the chart and electronic record for Resident #181 revealed no documentation of a written transfer notices for 08/25/2019. Resident #182 Review of Resident #182's face sheet dated 11/20/2019 revealed he was admitted to the facility on [DATE]. He was [AGE] years old. He was discharged to local acute care hospital on [DATE] at 7:50 PM. His [DIAGNOSES REDACTED]. Review of Resident #182's nursing progress note dated 11/08/2019 at 7:46 PM revealed that licensed nurse contact physician due to resident having critical lab of white blood cell (WBC) count of 40.5 cells per microliter. A high WBC count is indicative of leukocytosis related to an infection and normal results are generally 4.5 to 11.0 per microliter. https://medlineplus.gov/ency/article/ 3.htm. Review of verbal order in the electronic record dated 11/08/2019 at 7:15 PM revealed that he was sent to local emergency room . Nursing progress note dated 11/09/2019 at 3:17 AM revealed he was admitted to local community hospital with pneumonia and malignant neoplasm of the lung. Review of the chart and electronic record for Resident #182 revealed no documentation of a written transfer notices for 11/08/2019. In an interview with the Administrator on 11/19/2019 at 4:06 PM, he stated that that the responsible party is notified of transfers to the hospital by telephone with documentation in the resident's nursing progress notes. He also stated that he was not aware of written notification being submitted to the ombudsman due to considering transfers for emergent care as resident-initiated transfers. In an interview with the Ombudsman on 11/20/2019 at 9:28 AM, revealed that she had not received any notifications from the facility of transfer of residents to hospitals. Review of the facility Admission Agreement dated (MONTH) 2011 revealed the following: Transfer and Discharge - If a physician orders [REDACTED]. Facility will not charge the resident past the day the resident is transferred unless the resident wishes to reserve the bed for when the resident returns in accordance with the facility's bed-hold policy. The facility did not provide a policy regarding a written transfer notice.

Based on interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice and the resident's right to choose to safe guard personal belongings for one (Resident #1) of three residents reviewed for resident's rights. The facility failed to promote Resident #1's self-determination by not getting permission from resident prior to releasing his personal belongings to a family member. This failure could affect residents by causing decreased self-worth, depression, and a decreased quality of life. Findings: Review of Resident #1's face sheet dated 09/25/19 revealed he was [AGE] years-old and admitted on [DATE] with readmission 07/12/19. His [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed his Brief Interview of Mental Status (BIMS) reflected a score of 15 indicating that he was cognitively intact. Interview with Resident #1 on 09/25/19 at 1:30 pm revealed that his wallet was given to his granddaughter by the Administrator without his permission. His granddaughter was his financial Power of Attorney (POA) but that right was revoked after his bank account was depleted. Resident #1's granddaughter gained access to his bank account after obtaining his bank card from his wallet. Resident #1 stated that he was worried about paying for his stay at the facility since his Medicaid was pending. He advised that his granddaughter must have believed he was incompetent and would not have noticed the missing money from his bank account, but [MEDICAL CONDITION] did not affect his mind. Interview with Resident #1 on 09/25/19 at 3:15 pm revealed that his wallet was taken to his home for safe keeping after being returned to the facility by his granddaughter. He advised that the situation made him feel ratty. Resident #1 stated that he did file a police report and revoke his granddaughter's POA after he found out she had possession of his wallet and used his bank card to gain access his bank account and took money without his consent. Interview with Administrator on 09/25/19 at 1:41 pm revealed that upon admission residents are offered a lock box for their personal belongings. Resident #1 had his wallet in his possession upon admission and declined a lock box due to his [MEDICAL CONDITION]. The Administrator stated that he offered to keep Resident #1's wallet locked in his office and provide access upon request. The Administrator did not keep a log or record of the wallet and was not aware of the contents inside the wallet. He also did not recall the exact date that the wallet was given to the granddaughter or returned to the facility after the police became involved. The Administrator advised that Resident #1's granddaughter expressed concern over the safe keeping of the wallet and advised that she needed access to the wallet to complete Resident #1's Medicaid application. The wallet was released to Resident #1's granddaughter due to her holding financial POA earlier in the month of September. The Administrator admitted that he did not ask permission from Resident #1 prior to releasing his personal belongings to his granddaughter. This surveyor asked the Administrator if Resident #1 had ever lost or complained about stolen money from his wallet while it was in his possession. The Administrator advised that he had never received a complaint about lost or stolen items from Resident #1. The Administrator advised that the wallet was returned to the facility by Resident #1's granddaughter after the police became involved and Resident #1 revoked her PO[NAME] He stated that he does not know where the wallet is currently because it was returned to Resident #1. This surveyor asked the Administrator if Resident #1 was competent to make decisions regarding his personal property as he had a BIMS of 15, was capable of filing a police report for his wallet and revoking his PO[NAME] The Administrator advised that he would not be able to answer that question as Resident #1 has episodic confusion. Interview with Licensed Vocational Nurse (LVN) A on 09/25/19 at 2:20 pm revealed that based on her nursing judgment, Resident #1 was competent enough to make decisions about his care and personal property. She advised that he was often forgetful and needed reminders but was competent and oriented. LVN A provided an example of Resident #1 exercising his rights. She advised that Resident #1 would express, I am my own person and I can make decisions for myself. Interview with Certified Nurse Assistant (CNA) A on 09/25/19 at 3:24 pm revealed that Resident #1 was oriented but forgetful.

Based on observation and record review the facility failed to provide each resident food at a safe and appetizing temperature. Residents complain of food being served at an unappetizing temperature. This failure could affect residents who eat their meals from the facility kitchen by failing to provide food which is at an appetizing temperature which could cause weight loss. Findings include: In an interview on 1/7/19 at 3:00p.m. the acting Dietary Manager reported 29 people eat food from the kitchen, seven people eat in their rooms and 22 people eat in the dining rooms. In an interview on 1/7/19 at 3:30p.m. with the dietary manager, she said all the food for every meal served is temped by the cook on duty after being cooked and after it is placed in the steam table prior to serving. Observation on 1/8/19 at 11:20 the cook on duty was seen taking temperature of each food item to be served. The temperatures of the food were chicken 170°, pinto beans 176°, apples 160°, coleslaw 38°, lettuce/tomato salad 40°, barbeque sauce 150°. In an interview on 1/8/19 at 12:05p.m., Resident #11, #14, #21 who eat in their rooms complained the chicken was not hot or even warm. Observation on 1/8/19 at 12:07p.m., the last tray to be served was checked for appropriate temperature. The chicken temperature on the last tray to be served on Hall 1 was 100°. At 12:10p.m. the chicken on the steam table (a table with slots to hold food containers which are kept hot by steam circulating beneath them). was temped immediately and found to be at 95°, pinto beans at 135°, cooked apples at 140°. Chicken, beans and apples were warmed to 165° and service continued for the residents eating in the dining rooms. Observation on 1/8/19 at 12:30p.m. the steam table (a table with slots to hold food containers which are kept hot by steam circulating beneath them.) was checked and found to be in working order. Observation and an interview on 1/10/19 at 1:00p.m., Resident #11 and #15 reported the tator tots delivered to their rooms were cold. Tator tots on the steam table were temped prior to service at greater than 145°. Residents refused to have their food re-warmed, saying they were done with that meal. In an interview on 1/10/19 at 1:30p.m. the dietary manager said she agreed with an idea from a dietary manager from a 'sister' facility that food should be kept in the oven, remain covered or have a broth, gravy or sauce on the food to help maintain appropriate serving temperatures. Record review of the food temperature log dated January, 2019 showed it was up to date. Temperatures were recorded for each food item for each meal.

Based on observation, interviews, and record review the facility failed to store food in accordance with professional standards for food service safety in one of one nutrition/snack refrigerators reviewed for safe storage and handling of food. The facility failed to appropriately label food brought from outside the facility before storing it in the residents' nutrition/snack refrigerator located in the medication room. This failure could place residents at risk for ingesting expired food, receiving food that was not intended for them, or not receiving food that was intended for them. Findings Included: Observation of the resident nutrition/snack refrigerator in the medication room on [DATE] at 10:30 a.m. revealed two personal covered food storage containers that were not labeled with a resident's name or contents and were not dated. The freezer compartment contained two manufacturer-packaged frozen entrees that were not labeled or dated. In an interview with the DON (Director of Nursing) and LVN (Licensed Vocational Nurse) A on [DATE] at 10:35 a.m. the DON said she did not know who the food belonged to but felt sure it belonged to a resident and said the containers should have been labeled. She said the food brought in from outside in the two personal containers should not have been accepted by the staff due to potential infection control issues and would have to be thrown away. She said the manufacturer-packaged frozen entrees should have been labeled with a resident's name and date by the staff when they were brought into the facility. LVN A said the unlabeled food belonged to residents and identified one resident as being the person who it most likely belonged to because the family was making efforts to get her to eat. LVN A said she felt sure the food did not belong to staff because they stored their food in the staff refrigerator in another part of the building. The DON said she expected staff to label and date food brought in from the outside before it was stored in the refrigerator/freezer. Review of the facility's policy Storage Guidelines for Food from Outside the Facility for Staff released ,[DATE] revealed: Cold foods are stored in a refrigerator .items will be discarded after 7 days. Frozen foods will be stored in freezer .items will be discarded after 30 days. Stored items must be in an airtight package or a sealed container with the resident's name, contents and the date they are placed in storage .

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 1 of 1 resident (Resident #23) reviewed for infection control. On 01/09/18 LVN B did not follow established wound care techniques or the facility's policy while providing wound care to Resident #23. This deficient practice could place residents at risk for the development and/or spread of infection and a decline in physical health. Findings include: Resident #23 Record Review of Resident #23's face sheet revealed he was a [AGE] year-old man originally admitted on [DATE], re-admitted on [DATE] for wound care in three areas of his left leg from failed knee replacements and subsequent hardware removals, skin graft and antibiotic therapy. In an interview on 1/9/19 at 4:10 p.m. with Resident #23 and spouse revealed he had 3 artificial knee surgeries. Each had become infected and the hardware was removed. He said his left knee and calf dressings get changed on Monday, Wednesday, Friday and Sunday by nurses. Record Review of the knee and calf dressing change order dated 1/4/19 revealed Nurses are to cleanse wounds with normal saline or wound cleanser, pat dry, paint (wounds) with [MEDICATION NAME] and cover with [MEDICATION NAME] on Monday Wednesday, Friday and Sunday. Observation on 1/9/19 at 4:10 p.m. of LVN B performing Resident #23's wound care revealed the following: 1. LVN B gathered the following supplies for the dressing change: 4x4 gauze pads, [MEDICATION NAME] roll and three 2x4 Non-stick pads. [MEDICATION NAME] and wound care spray were already on the bedside. LVN B placed the supplies on the bedside table without a clean impervious barrier. 2. LVN B washed her hands and donned gloves, removed the immobilizer brace, removed the [MEDICATION NAME] wrap from his left leg. Non-stick pads were lifted, they were stuck to the wound and skin. LVN B sprayed wound care spray under pads to loosen them from the skin and wound. All soiled dressings were removed and placed in the trash. LVN B removed her gloves and put on clean gloves without washing her hands or performing any type of hand hygiene. 3. LVN B placed the unwrapped large stack of 4x4 gauze pads onto the bed without any barrier between the wound care supplies and the bed covers. LVN B soaked several gauze pads with [MEDICATION NAME] and began to clean the wound on the top of Resident #23's knee in a back and forth motion. LVN B cleaned in a zig zag pattern over wound and did not clean from the center of the wound outward. The used gauze was put in the trash. 4. LVN B picked up another stack of gauze from the bed and soaked it with [MEDICATION NAME] and began to wash back and forth, in a zig zag pattern, over wound the second wound on the top of Resident #23's knee. The used gauze was put in the trash. 5. LVN B picked up another stack of gauze from the bed, soaked it with [MEDICATION NAME] and began to wash, in a zig zag pattern, over the wound on the back of Resident #23's calf area. The used gauze was put in the trash. LVN B removed her gloves and put them in the trash. She did not wash her hands. LVN B put on clean gloves and applied non-stick pads to all 3 wounds. 7. LVN B picked up the roll of [MEDICATION NAME] and began to wrap Resident #23's left leg from just above his left knee down the leg to just above the ankle. Secured gauze with tape. Gloves were removed. LVN B did not date, time or initial the dressing. LVN B did not wash her hands before replacing Resident #23's leg immobilizing brace on his left leg. In an interview on 1/9/19 at 4:30p.m. with LVN B said she thought she did a good job changing the dressing. When asked if she followed aseptic technique (techniques used to maintain the sterility of wound care products) for cleansing the wound she said Yes. When reminded aseptic technique includes cleansing a wound in a circular motion from the center to the edges, she said, yes, that is the way it is supposed to be, I did not do that. Record review of the only facility policy concerning wound care, Wound Care Procedures for Major Wounds, dated 2012. LVN B failed to follow- C. Set up supplies on a CLEAN surface at the bedside (cover the surface with a clean impervious barrier before putting the supplies out.) . E. WASH YOUR HANDS I. Remove the soiled dressing and place in a bag at the bedside. J. Remove gloves and discard in the bag. L. WASH YOUR HANDS M. Put on clean gloves N. Clean the wound according to the order .from the center outward. P. Remove and discard gloves Q. Put on new gloves. R. Apply clean dressing S. Remove gloves and place in bag T. Initial, date and time dressing . V. Close the bag and place in the large plastic bag attached to the wound care cart. W. WASH YOUR HANDS .

Based on interview and record review the facility failed to ensure services were provided or arranged by qualified persons in accordance with each resident's written plan of care by failing to follow physician orders [REDACTED].#6) of 9 residents reviewed for physician orders. The facility did not hold Resident #6's insulin, as ordered by the physician, when her blood sugar was outside of the established parameters. This failure could affect the six residents who receive insulin, and put them at risk of not receiving treatments as ordered by the physician resulting in a delay in treatment, injury and a decline in condition. Findings included: Record review of Resident #6's Admission Record, dated 10/19/17, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Admission Record identified Physician A as Resident #6's primary care physician. Record review of Resident #6's Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated she was cognitively intact. The MDS also revealed Resident #6 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Further review of the MDS revealed Resident #6 had an active [DIAGNOSES REDACTED]. Record review of Resident #6's physician's orders [REDACTED]. At Breakfast. Hold if blood sugar is lower then 70 . According to the U.S. National Library of Medicine [MEDICATION NAME] is a long-acting, man-made version of human insulin. [MEDICATION NAME] works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy and it also stops the liver from producing more sugar. https://medlineplus.gov/druginfo/meds/a 2.html (accessed on 10/23/17) Record review of Resident #6's Medication Administration Record [REDACTED] 09/22/17 7:00 AM Blood Sugar: 61 (Initialed by LVN A) 09/23/17 7:00 AM Blood Sugar: 63 (Initialed by LVN A) 09/28/17 7:00 AM Blood Sugar: 61 (Initialed by LVN A) 10/04/17 7:00 AM Blood Sugar: 64 (Initialed by LVN A) 10/07/17 7:00 AM Blood Sugar: 60 (Initialed by LVN A) 10/18/17 7:00 AM Blood Sugar: 64 (Initialed by LVN A) Record review of Resident #6's Nurses' Notes for September 2017 and October 2017 revealed no documentation of Resident #6's insulin being held or her blood sugar being rechecked on the dates identified above. In an interview on 10/19/17 at 9:15 AM LVN A stated she administered Resident's #6's [MEDICATION NAME] as long as her blood sugar was above 60. LVN A could not recall any day where she held Resident #6's [MEDICATION NAME] because her blood sugar was too low. LVN A stated she was not aware the order was for the [MEDICATION NAME] to be held if Resident #6's blood sugar was below 70. LVN A stated that was her mistake, and that she had administered [MEDICATION NAME] when Resident #6's blood sugar was below 70. In an interview on 10/19/17 at 9:30 the DON stated his expectation was for the nurses to follow the physician's orders [REDACTED]. The DON stated if there is a trend of the resident's insulin having to be held due to the blood sugars being outside the parameters he would expect the nurse to notify the physician and get clarification on how to proceed. Record review of the facility's policy entitled Medication Administration, revised 06/2008, revealed the following: Medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the resident's age and condition or medication order is inconsistent with the resident's current [DIAGNOSES REDACTED]. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. Review of the typed list of residents on insulin (untitled and undated) provided by the ADON on 10/19/17 revealed six residents identified by the facility as receiving insulin.

Based on record review and interview the facility failed to implement the written policy and procedure on reporting results of abuse investigations to the State Survey Agency within 5 days for 1 of 4 residents reviewed for abuse (Id# 1). The facility reported an allegation of resident abuse involving Resident #1 on 08/30/2017 however, the results of the Provider Investigation Report was not provided to state authorities within 5 working days as required by facility policy and state law. It was delinquent by 30 days. This failure could affect any resident in the facility by increasing the risk of abuse or neglect. The findings included: Review of the facility Abuse Prevention Policy with a revision date of January 2017 revealed the following: Report/Respond 3. The facility will report all investigative findings to the state within 5 working days of the incident. Record review of Resident (#1)'s Face Sheet dated [DATE] revealed she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Provider Self-Reporting of Incidents dated 08/30/2017 at 5:57 PM for Resident (#1) revealed an investigation had been initiated and a resident assessment was done of the bruising and swelling to the right toes and foot. No known witnesses to the bruising or swelling of the right foot. The Physician was notified by fax, the daughter was notified by the Charge Nurse and the Social Worker was informed of the reported incident by Administration on 08/30/2017. There was no Provider Investigation Report in the facility investigation file. In an interview on 09/29/2017 at 9:15 A.M. with the Assistant Director of Nurses, she stated she checked Resident (#1)'s ankle and it was swollen but said that was normal for the resident. She stated they did do X-rays of the ankle and it showed an old fracture which was healed but no new ankle fracture. In an interview on 09/29/2017 at 1:25 P.m. with the Charge nurse, she stated she saw Resident (#1) a day or so later and the bruising to her foot looked worse so they got an X-ray and it showed an old fracture to her right pinky toe. She stated she didn't know how it happened. In an interview 10/06/17 at 9:35 a.m., the Administrator said she had turned in the 5-day report to State office regarding Resident (#1).The Administrator looked in her computer and said that she had not sent the 5-day report to State Office after she did not find the document in her sent email. Review of facility 672 form dated 09/29/2017 revealed the census was 35.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food under sanitary conditions from 1 of 1 facility kitchens. The facility failed to ensure: A. General kitchen areas were free of grease and debris B. Cooking appliances were free of grease, food particles and debris This deficient practice could affect any of the 36 residents receiving meals/snacks from the facility kitchen by creating conditions that could lead to food-borne illness. Findings included: A. General Kitchen Areas Observations on 08/01/16 between 3:08 PM and 3:35 PM of the facility kitchen revealed the following: The floor in the kitchen underneath the sink by the dishwasher was noted to have a plastic medicine cup, two used sweet-n-low packets, a plunger laying on its side, unsecured baseboard trim and multiple food particles on the floor. The sink next to the dishwasher was noted to have a brownish jelly like build up in the corners of the sink along with a brownish tinge to the entire sink itself. The trash can in the kitchen was noted to have multiple areas of food particles and dried liquid substance on lid and on all sides of receptacle. Observations on 08/02/16 at 11:40 AM and 3:43 PM of the facility kitchen revealed the following: The plastic strip door between the kitchen and the pantry were noted to be draped open and the ends were placed in a trash can in order to keep them open. The floor in the kitchen underneath the sink by the dishwasher was noted to have a plastic medicine cup, two used sweet-n-low packets, a plunger laying on its side, unsecured baseboard trim and multiple food particles on the floor in this area. Observations on 08/03/16 at 11:07 AM of the facility kitchen revealed the following: The plastic strip door between the kitchen and the pantry were again noted to be draped open and the ends were placed in a trash can in order to keep them open. The floor in the kitchen underneath the sink by the dishwasher again was noted to have a plastic medicine cup, two used sweet-n-low packets, a plunger laying on its side, unsecured baseboard trim and multiple food particles on the floor in this area. B. Cooking appliances were free of grease, food particles and debris Observations on 08/01/16 between 3:08 PM and 3:35 PM of the facility kitchen revealed the following: The drip tray to the stove was approximately 40% covered with burnt food particles that were crusted and caked on. The deep fryer had piles approximately two to three inches deep of cooked food particles around the inside lid of the fryer. The edges and sides of the fryer had visible grease build up and crusted food particles trapped in the grease. The toaster had a large amount of food particles insides the toaster and in the crumb tray. Steam table trays had food particles floating in the water and a brownish substance formed at the edge of the water. In an interview on 08/03/2016 at 11:07 AM with the Dietary Manager, she stated that the deep fryer was usually cleaned once a week and that the facility had just had fish and she had not had a chance to clean it yet. She also indicated that the floors to the kitchen are swept and mopped once a day, which should include under the dishwasher sink. She identified that there was food and debris under the sink along with the plunger lying on its side. She indicated that the plunger is used to unstop the sink at times if it gets clogged, but indicated it should be kept with the janitor supplies. She identified the brownish buildup in the sink next to the dishwasher to be excessive and that it should not be there. She indicated the sinks should be cleaned once a day and as needed to prevent buildup. She indicated the buildup in the steam tables should not be there and that they should be cleaned once a week and as needed. The crumbs in the toaster were identified and she said that they should be cleaned daily to prevent buildup. The plastic strip door was identified to be draped in the trash can and she indicated that it should not be placed in the trash can. She stated as well that the buildup on the trashcans should be cleaned daily and when visibly soiled. Record Review of the facility policy entitled Required Cleaning and Sanitation, undated, revealed To prevent cross contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. The food-contact surface of grills, griddles, and similar cooking devices, and the cavities and door seals of microwave ovens shall be cleaned at least one a day. Hot oil cooking equipment and hot oil filtering systems are exempt from this requirement. The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. Nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust dirt, food particles, and other debris. Review of the CMS 672 form, dated 08/01/16, revealed a census of 36 residents receiving food from the facility kitchen.

Based on observation, interview and record review, the facility failed to ensure that 3 of 3 Halls (Halls A, B, and C) provided a safe, functional, sanitary and comfortable environment for residents, staff and the public as evidenced by: 1. Doors and door frames were scuffed, gouged and peeling with rough edges. 2. White spots of peeling paint were imbedded in the dark vinyl flooring. 3. Privacy curtains were not completely attached to the curtain track. 4. Baseboards were scuffed and worn. 5. Walls were gouged by bed frames. This failure could affect any of the 36 residents by increasing the risk of infection due to areas not having intact cleanable surfaces or decreasing their sense of emotional well being due to areas not being maintained. The findings included: Observation on 08/02/16 at 11:14 a.m. revealed the interior bathroom door in Room 15 (A Hall) had severely scuffed, worn and peeling paint on the lower half of the door. The outer bathroom door frame was severely scuffed and worn on the lower half. Observation on 08/04/16 at 9:24 a.m. revealed Room 20 (A Hall) had white spots on the dark vinyl floor. Observation on 08/04/16 at 9:25 a.m. revealed the bottom half of the interior bathroom door of Room 19 (A Hall) was severely scuffed and scraped. The lower half of the exterior bathroom door frame paint had been scraped to bare wood. Observation on 08/04/16 at 9:26 a.m. of Room 16 A (A Hall) revealed the privacy curtain was only partially attached to the curtain track by approximately one half of the curtain hooks. Observation on 08/04/16 at 9:27 a.m. revealed C Hall baseboards along the exterior of the nurses station were scuffed and worn to bare wood. Observation on 08/04/16 at 9:28 a.m. revealed the exterior hall door frame of Room 21 (C Hall) had a deep, jagged gouge into the bare wood with splintered edges to the lower left side of the door frame. Observation on 08/04/16 at 9:29 a.m. revealed Room 22 (C Hall) had white spots on the dark vinyl floor. Observation on 08/04/16 at 9:30 a.m. revealed Room 2 (B Hall) had white spots on the dark vinyl floor. Observation on 08/04/16 at 9:31 a.m. revealed Room 6 (B Hall) had white spots on the dark vinyl floor. Observation on 08/04/16 at 9:32 a.m. revealed the walls behind both A and B bed frames in Room 12 (B hall) were deeply gouged. Observation on 08/04/16 at 9:32 a.m. revealed the interior bathroom doors shared with Rooms 10 and 12 (B hall) were scuffed, with the bottom of the doors splintered and rough. In an interview with the maintenance director on 08/04/16 at 9:37 a.m., he said that the facility was in the process of renovating rooms, but that he was aware that touch up painting needed to be done. He said that the white spots on the floors were paint chips flaking from the doors and being ground in to the grooves of the dark vinyl flooring. Review of Facility Maintenance Operations policy Physical Plant Interior Maintenance dated March 2008 did not provide information addressing these issues. Review of the CMS 672 dated 08/01/16 revealed a census of 36.

Based on observation and interview the facility failed to post in a prominent place the nurse staffing data as evidenced by the data for 08/01/16 was not observed posted. This failure could affect all residents or their responsible parties by decreasing the amount of information available to make informed decisions about their care. The findings included: During observation on 08/01/16 at 4:58 p.m. the nurse staffing data observed posted was dated 07/30/16. In an interview with the DON on 08/04/16 at 2:14 p.m. she said the 08/01/16 data should have been posted and must have been behind the other days data. Observation on 08/04/16 at 2:14 p.m. of the current days posting revealed that the 08/01/16 posting sheet was behind several other days data. Review of the Facility Nursing Operation policy dated June 2007 revealed it did not address this issue. According to the CMS 672 dated 08/01/16 there were 36 residents in the facity.

Based on observation, interview and record review, the facility failed to maintain complete and accurate clinical records for 1 of 10 residents (Resident #3) reviewed for clinical records. Resident #3 ' s diet change was not documented in the physicians orders for 36 days. This failure could affect any of the 11 resident in the facility on pureed or mechanical soft diets by increasing the risk of receiving the wrong diet texture. Findings include: Review of Resident #3 ' s face sheet dated 09/23/16 revealed that she was admitted to the facility on [DATE]. She was [AGE] years of age. Her [DIAGNOSES REDACTED]. During observation of meals on 08/01/16 at 5:45 p.m. and 08/02/16 at 12:17 p.m. Resident #3 was observed being served a mechanical soft diet. Review of Resident #3 ' s meal slip with her tray on 08/02/16 at 12:17 p.m. indicated she was on a mechanical soft diet with thin liquids. Review of Resident #3 ' s physician orders [REDACTED]. Review of a facility Order Recap Report printed 08/03/16 at 10:15 a.m. Resident #3 had an order for [REDACTED]. In an interview with the DON on 08/03/16 at 10:22 a.m., she confirmed that according to her review of the clinical record Resident #3 was on a Pureed diet. Review of the Speech Therapy Discharge Summary for Dysphagia Therapy dated 05/13/16-06/27/16 revealed a Discharge Note dated 06/27/16 which said that Resident #3 was placed on a mechanical soft diet due to a better ability to chew soft chopped proteins. Review of the In-House Communicator form dated 06/27/16 revealed a diet change request by the speech therapist to change Resident #3 ' s diet to mechanical soft with thin liquids. In an interview with the DON on 08/03/16 at 10:59 a.m., she said that Resident #3 ' s diet and been changed from a pureed to a mechanical soft, thin liquids diet on 06/27/16 by the speech therapist following the resident ' s dysphagia assessment . The DON said that the internal communication memo sent from the speech therapist to the kitchen indicating the change had not been sent to nursing and therefor had not been entered in the computer or placed on the physician's order [REDACTED]. Review of facility Medical Record Management policy Medical Record Audits dated June 2012 revealed no additional information regarding this issue. Review of the CMS 672 dated 08/01/16 indicated 11 residents were on mechanically altered diets.