Every finding on record at Benderson Family Skilled Nursing and Rehab Center

Based on observation, interview and record review, the facility failed to ensure quality of care by not following physicians' orders for 3 residents (#13, #133, and #29) of 3 residents reviewed for following physician's orders. The findings included: Review of the Policy for Physician Services dated 11/28/17 #8 revealed, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. 1. Review of the medical revealed Resident #13 was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) with a target date of 5/12/25 revealed Resident #13's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. The MDS revealed Resident #13 did not reject care and was dependent on staff for dressing of the lower body. The MDS included, but was not limited to, hyperlipidemia, dementia, and asthma. Review of the physician's orders revealed an active order dated 3/14/25 for Ted hose on during day, off at night. (TED hose, also known as thrombo-embolic deterrent hose, is an acronym that refers to a type of compression hosiery. They are specifically designed to help prevent blood clots, or thromboembolism, by applying pressure to the legs and feet.) Review of the Medication Administration Record for June 2025 revealed on 6/1/25, 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/6/25, 6/7/25, 6/8/25, 6/9/25, and 6/10/25 the nurses documented the [NAME] hose were applied to the resident's legs. Review of Resident #13's medical record did not reveal information that the resident refused the [NAME] hose. On 6/9/25 at 12:05 p.m., observed Resident #13 in the activity dining room area sitting in the wheelchair. Resident #13 was not wearing the [NAME] hose. On 6/9/25 at 2:49 p.m., Resident #13 was observed in the wheelchair being pushed down the hall by a friend. Resident #13 was not wearing the [NAME] hose. On 6/10/25 at 9:53 a.m., observed Resident #13 sitting in the wheelchair watching TV in the bedroom. The [NAME] hose were not applied to the legs. During an interview, the resident said she never wears [NAME] hose. She said she wore them years ago but does not wear them now and no one applies them. She said if someone told her to wear them, she would refuse. Resident #13's private duty aid was sitting in the chair near the resident. The private duty aid said she dressed the resident this morning and did not apply the [NAME] Hose. The private aid said no one ever told her to apply them. * On 6/10/25 at 2:58 p.m., during an interview Certified Nursing Assistant (CNA) Staff A said if the resident refuses to put on the [NAME] hose, you tell the nurse. She said the nurse, or the CNA can apply them. Staff A said Resident #13 has a private duty sitter that dresses her and puts on the compression hose. She said the nurse would tell her to put them on if she needed them. Staff A said no one told her to apply the [NAME] Hose. On 6/10/25 at 3:23 p.m., Registered Nurse (RN) Staff C said she documented in the MAR (Medication Administration Record) the [NAME] hose were applied to Resident #13, but she was not sure they were applied. She said she thought the private duty aid applied them. On 6/10/25 at 3:30 p.m., RN Staff C went to the room and saw Resident #13 was not wearing the [NAME] hose. On 6/10/25 at 4:04 p.m. the Director of Nursing (DON) said the RNs should not document any treatment that was not completed, including the [NAME] hose. If the resident refuses a treatment or the [NAME] hose, the nurse should document the refusal in the medical record and notify the physician. On 6/11/25 at 9:58 a.m., the DON said private duty sitters do not apply [NAME] hose for the residents. 2. Review of the medical revealed Resident #133 was admitted on [DATE]. Diagnoses included aftercare following joint replacement and left artificial knee joint with a history of atherosclerotic heart disease. Review of the physician's orders revealed an active order dated 6/6/25 at 7:00 p.m. for Knee high ted hose both legs every shift. Review of the MAR for June 2025 revealed the nurses documented the [NAME] hose were applied on 6/7/25, 6/8/25, 6/9/25, and 6/10/25. Review of Resident #113's medical record did not contain information that the resident refused the [NAME] hose. On 6/09/25 at 12:17 p.m., observed Resident #133 in the room wearing shorts. There were no [NAME] hose applied to the legs. The resident said he does not wear [NAME] Hose, and no one asked him to wear them. He said he came to the facility with an Ace Wrap for the left leg, but it was removed the next morning and there has been nothing else for the legs since then. The original surgical dressing was observed to the left leg. On 6/10/25 at 10:12 a.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 2:56 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 3:04 p.m., CNA Staff B said she has taken care of Resident #133. She said the nurse did not tell her to apply the [NAME] hose and she has not. On 6/10/25 at 3:36 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 3:34 p.m. RN Staff C confirmed she documented in the MAR Resident #133 was wearing the [NAME] hose, when the resident was not wearing them. Staff C said she had not put them on the resident, and she did not instruct the CNA to do it. Staff C looked for a pair of [NAME] hose in the room, but there were none. On 6/10/25 at 4:04 p.m., the DON said the nurses should not be documenting the hose were on if the hose were not. The DON said the medical record was inaccurate. 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Review of the record revealed an order dated 12/7/24 for Depakote Sprinkles 125 milligrams (mg) Give 250mg by mouth every 12 hours for mood disturbance. On 1/14/25 the physician ordered a Depakote blood level to be drawn in the morning. Review of the laboratory results, progress notes, and MARS revealed the facility had not obtained the Depakote blood level in the morning on 1/15/25. Review of the medical record revealed the nurse had not documented why the blood level was not obtained. Review of the laboratory results revealed a Depakote blood level was collected on 4/2/25. On 6/11/25 at 12:32 p.m., the DON said the facility had not obtained the Depakote blood level in the morning of 1/15/25 as the physician ordered. He said he expects the nurses to follow the orders and document in the medical record the reason if the nurse could not follow the physician's order. *Photographic evidence obtained

Based on observation, interview and record review, the facility failed to ensure accurate medical records for 2 residents (#13 and #133) of 3 residents reviewed for accuracy of medical records. The findings included: 1. Review of the medical revealed Resident #13 was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) with a target date of 5/12/25 revealed Resident #13's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. The MDS revealed Resident #13 did not reject care and was dependent on staff for dressing of the lower body. The MDS diagnoses included, but was not limited to, hyperlipidemia, dementia, and asthma. Review of the physician's orders revealed an active order dated 3/14/25 for Ted hose on during day, off at night. (TED hose, also known as thrombo-embolic deterrent hose, is an acronym that refers to a type of compression hosiery. They are specifically designed to help prevent blood clots, or thromboembolism, by applying pressure to the legs and feet.) Review of the Medication Administration Record for June 2025 revealed the nurses documented the [NAME] Hose were applied on 6/1/25, 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/6/25, 6/7/25, 6/8/25, 6/9/25. On 6/9/25 at 12:05 p.m., observed Resident #13 in the activity dining room area sitting in the wheelchair. Resident #13 was not wearing the [NAME] hose. On 6/9/25 at 2:49 p.m., Resident #13 was observed in the wheelchair being pushed down the hall by a friend. Resident #13 was not wearing the [NAME] hose. On 6/10/25 at 9:53 a.m., observed Resident #13 sitting in the wheelchair watching TV in the bedroom. The [NAME] hose were not applied to the legs. During an interview, the resident said she never wears [NAME] hose. She said she wore them years ago but does not wear them now and no one applies them. She said if someone told her to wear them, she would refuse. Resident #13's private duty aide was sitting in the chair near the resident. The private duty aide said she dressed the resident this morning and did not apply the [NAME] Hose. The private aide said no one ever told her to apply them. * On 6/10/25 at 2:58 p.m., during an interview with Certified Nursing Assistant (CNA) Staff A, she said if the resident refuses to put on the [NAME] hose, you tell the nurse. She said the nurse, or the CNA can apply them. Staff A said Resident #13 has a private duty sitter that dresses her and puts on the compression hose. She said the nurse would tell her to put them on if she needed them. Staff A said no one told her to apply the [NAME] Hose. On 6/10/25 at 3:23 p.m. Registered Nurse (RN) Staff C said she documented in the MAR (Medication Administration Record) that the [NAME] hose were applied to Resident #13. Staff C said the hose were not applied and the MAR is not accurate. On 6/10/25 at 3:30 p.m., RN Staff C went to the room and saw Resident #13 was not wearing the [NAME] hose. On 6/10/25 at 4:04 p.m. the Director of Nursing (DON) said the RNs should not document any treatment that was not completed, including the [NAME] hose. The DON said the MAR was not accurate. 2. Review of the medical revealed Resident #133 was admitted on [DATE]. Diagnoses included aftercare following joint replacement, left artificial knee joint, and history of atherosclerotic heart disease. Review of the physician's orders revealed an active order dated 6/6/25 at 7:00 p.m. for Knee high ted hose both legs every shift. Review of the MAR for June 2025 revealed the nurses documented the [NAME] Hose were applied on 6/7/25, 6/8/25, 6/9/25, and 6/10/25. On 6/09/25 at 12:17 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing the [NAME] Hose. The resident said he has not worn [NAME] Hose at the facility and does not have a pair. The resident said no one at the facility told him to wear them. He said he came to the facility with an Ace Wrap for the left leg, but it was removed the next morning, and he had not worn anything since. The original surgical dressing was observed to the left leg only. On 6/10/25 at 10:12 a.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 2:56 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 3:04 p.m., CNA Staff B said she has taken care of Resident #133. She said the nurse did not tell her to apply the [NAME] hose and she has not. On 6/10/25 at 3:36 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 3:34 p.m., RN Staff C confirmed she documented in the MAR Resident #133 was wearing the [NAME] Hose, but she had not confirmed the resident had them on. Staff C said they did not put them on the resident or ask the CNA to do it. Staff C looked for a pair of [NAME] Hose in the room, but there were none. On 6/10/25 at 4:04 p.m., the DON said the nurses should not be documenting the [NAME] Hose were applied to the resident if they were not. The DON said the medical record was inaccurate. *Photographic evidence obtained

Based on staff interview, resident interview, observations and resident medical record review, it was determined that the facility failed to ensure the residents' right to call light access for two residents (Resident #3 and Resident #4) out of eight residents observed during the survey. The findings included: During an initial tour of the facility which commenced on 1/13/25 at 10:00 a.m., Resident #3 was observed sitting up in her wheelchair on the window side (left side) of her bed. There was no call light observed within her reach. In an interview with Resident #3 conducted on 1/13/25 at 10:05 a.m., she was asked how she would get the staff's attention if she needed anything. She stated I guess I'd push the button. Oh, wait this is the TV remote. I don't know where the button is. The call light was observed to be on the floor, on the opposite (right) side of her bed from where she was sitting, out of her reach. She was asked if she could reach her call light where it was. She smiled and said, No, how could I get there? She was asked if her call light was usually within her reach. She stated, Not always. I can't reach it now. Photographic evidence obtained. Employee A, a certified nurses' aide (CNA) entered the room at 10:17 a.m. He was asked if he was caring for Resident #3 today. He stated yes. He was asked if she had access to a call light. He looked around and stated, Oh, it's on the floor. He was asked to confirm the call light was out of the resident's reach. He stated, When I made her bed earlier, I forgot it. I usually only work the weekends, so she is usually in bed when I am working, and I usually attach her to her blankets. She got up today and I must have forgot it because I'm not used to her being up. A medical record review conducted for Resident #3 revealed: An MDS (Minimum Data Set) admission assessment conducted on 12/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 10. A score of 8-10 suggests moderate cognitive impairment. Further record review for Resident #3 revealed a care plan which showed: Focus: (12/28/24): I have impaired balance and weakness. I have impaired cognition. Goal: I will have no falls with current interventions through the next review date. Interventions: Call light in reach when in bed and bedside chair. Focus: (12/28/24): I was admitted with occasional incontinence. Goal: I will have no complications related to incontinence with current interventions through the next review date. Interventions: Call light in reach when in bed and bedside chair, remind to call for assistance with urge to use the bathroom and answer promptly. On 1/13/25 at 10:23 a.m., Resident #4 was observed in her room, lying in bed, awake with the television on. Her call light was observed not within reach. It was observed clipped to back of the head of her mattress. Resident #4 presented as unable to interview. She was saying words but not answering simple questions correctly. Photographic evidence obtained. A medical record review conducted for Resident #4 revealed: An MDS (Minimum Data Set) admission assessment conducted on 12/7/24 revealed a Brief Interview for Mental Status (BIMS) score of 07. A score of 0-8 suggests severe cognitive impairment. Further record review for Resident #4 revealed a care plan which showed: Focus: (12/26/24) I was readmitted with a decline in functional mobility related to increased weakness and decreased balance from recent hospitalization for UTI (urinary tract infection), gastroparesis (delayed gastric emptying), poor nutrition. I am under the care of Continuum Hospice. I do not want to get OOB (out of bed). Goals: My daily care needs will be anticipated and met by staff daily as evidenced by a clean, well-groomed, and odor free appearance through the next review date Interventions: Encourage the resident to use bell to call for assistance. A policy regarding call lights was requested at the entrance conference. In an interview with the Administrator on 1/13/25 at 10:44 a.m., she stated the facility does not have a policy. She stated this is covered during orientation. She stated they are able to monitor call light answer times with their system, which records each call light by room that is activated and how long in minutes it takes for the call light to be answered. In a second interview on 1/13/25 at 2:13 p.m., she was asked if the facility monitors call light placement to ensure the call lights remain within the resident's reach. She provided documentation for Resident #1 and stated they had kept track of this Resident's call light placement for approximately two weeks in response to a family member's complaint that they call light was found out of reach of three occasions. The record revealed this occurred April 22, 2024 through May 2, 2024. She was asked if there was any documentation of any other call light placement audits. She stated no.

Based on clinical record review, and staff interview, the facility failed to ensure 1 (Resident #30) of 1 sampled resident with admitting diagnoses of serious mental illness had a complete and accurate Preadmission Screening and Resident Review (PASRR). The findings included: Clinical record review revealed Resident #30 was admitted to the facility on [DATE]. The admitting diagnoses included Major Depressive Disorder, single episode, moderate, Generalized anxiety disorder, and Psychosis. The Admission Minimum Data Set (MDS) assessment with an assessment reference date of 11/29/23 listed diagnoses of anxiety disorder, Depression and Psychotic disorder. Review of the undated level 1 PASRR showed Resident #30 had a primary diagnosis of dementia, and was not a provisional admission. The form did not list the admitting diagnoses of Major Depressive Disorder or Psychosis, indicated no diagnosis or suspicion of serious mental illness and a level II PASRR evaluation was not required. On 1/4/24 at 11:45 a.m., in an interview the Director of Nursing (DON) said the level 1 PASRR was inaccurate and did not include the admitting diagnoses of Major Depressive Disorder or Psychosis.

Based on medical record review, review of facility's policies and procedure, staff, and resident interviews the facility failed to ensure 3 (Residents #4, #5 and #13) of 16 residents reviewed for advance directive were informed and provided written information of advance directive rights and ensure their advance directive wishes were followed. The findings included: The facility's policy and procedure titled, Resident Right - Advanced Directive Tracking Program dated [DATE] noted, It is the facility policy to honor the advance directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or update their existing directives. Procedure: 1. During the admission process the Social Service Director (SSD) or designee will discuss with each resident and/or the person accompanying the resident the following: a. Whether they have an advance directive . b. Whether they have a Uniform Do Not Resuscitate (DNR) form. c. If so, is it printed on yellow (goldenrod) paper? d. If they have the forms with them? If so, secure copies . 4. Social Services or the appropriate designee will carefully review any and all advanced directive related documents to ensure the information is complete and that the requirements of the law are met. If there is a question it is the responsibility of the reviewer to seek clarification. 5. Social Services or the appropriate designee should visit the resident and discuss advance directives with them to ensure that he/she has executed the advance directives that he/she would want. 6. Social Services should also ensure that information was given to the resident on admission. Social Services will advise the resident that at any time he/she may amend, revoke or write a new advance directive and staff will assist . 8. The individual who visited the resident as described in #5, 6, and 7 should document this conversation in the resident's social services notes . 1. On [DATE], a review of Resident #4's medical record revealed an admitted [DATE]. Resident #4's medical record revealed a plan of care dated [DATE] stating Resident #4 is a full code. Further review of Resident #4's medical record revealed no documentation the Social Service Director (SSD) or a facility representative discussed with Resident #4 and/or their representative Resident #4's advance directive wishes and placed a copy of the Resident's advance directive forms in the medical record as required by the facility's Resident Rights for Advance Directive policy. The medical record lacked a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 10:55 a.m., in an interview Licensed Practical Nurse (LPN) Staff B, said she has been working at the facility for several years. She said the Social Service department is responsible to talk with the resident or their representative to determine the resident's advance directive wishes, get a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of the interview, LPN Staff B reviewed Resident #4's electronic and hard (paper) copy of the medical record and said she was unable to find a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said because there is no documentation in the medical record of Resident #4's advance directive and code status wishes she would treat Resident #4 as a full code and perform cardiopulmonary resuscitation (CPR). On [DATE] at 11:02 a.m., during an interview with the Assistant Director of Nursing (ADON) and MDS (Minimum Data Set) Coordinator, they said when a resident is admitted to the facility the SSD is responsible to interview the resident or their representative about advance directive wishes, get a copy of the advance directive for the medical record, and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the nurse is unable to find a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator reviewed Resident #4's medical record and confirmed the SSD created a plan of care dated [DATE] and noted Resident #4 was a full code. She said she was unable to find any documentation the SSD spoke with Resident #4 or their representative about their advance directive and code status wishes. She also stated the SSD did not obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:29 a.m. during an interview the SSD said had been working at the facility for two weeks. She said as part of the admission process the SSD was required to meet with the resident and/or their representative to determine the resident's advance directive wishes, place a copy of the advance directive in the medical records, document the conversation in the medical record and get a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The SSD reviewed Resident #4's medical records and verbally confirmed there was no documentation the previous SSD obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD confirmed there was no copy of Resident #4's advance directive in the medical record as required per their policy. 2. On [DATE] medical record review revealed Resident #5 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. Further review of the record revealed a Social History Evaluation dated [DATE] which noted Resident #5 possessed a Health Care Power of Attorney and Living Will. On [DATE] record review revealed the facility had not obtained copies of advanced directives for Resident #5 including HCPOA, Living Will, or Do Not Resuscitate (DNR) form specifying end of life wishes. The Baseline Care Plan in the medical record for Resident #5 dated [DATE] revealed Resident #5's Goal for Advanced Directives was DNR (Do Not Resuscitate). The comprehensive Care plan initiated on [DATE] revealed Resident #5 was a Full Code (Administer cardiopulmonary resuscitation if the resident had no heartbeat and is not breathing). The interventions were Code status per resident. On [DATE] record review for Resident #5 revealed there was no record of code status selection for Resident #5. On [DATE] at 10:32 a.m., in an interview, Resident #5 said she has everything for advanced directives including a Healthcare Surrogate and living will. She said her daughter and son are her healthcare surrogates. On [DATE] at 11:06 a.m., the Social Services Director (SSD) said she met with Resident #5 but has not discussed advanced directives or code status with the Resident. The SSD confirmed there was no order for code status or any indication of code status in the electronic medical record. On [DATE] at 3:24 p.m., LPN Staff B said when a code is called for a resident, she looks at the code status in the electronic medical record and then double checks the hard chart medical record. She said the code status is always listed at the top under the picture in the electronic medical record. She said if nothing is in the electronic medical record hard chart medical record, the resident is a full code. On [DATE] at 5:07 p.m., Resident #5 said she understands the term Do Not Resuscitate (DNR) and she wishes to be a DNR. She said she does not remember anyone at the facility asking her preference. On [DATE] at 9:02 a.m., the SSD said on [DATE] she and the Minimum Data Set (MDS) Director audited Resident #5's medical record and discovered there was no order for code status in the medical record. She said at that time, the MDS Director created a Full Code order for Resident #5. The SSD said she talked with Resident #5 on [DATE] and her preference was Full Code. The SSD could not recall the time of the conversation and said she did not document the conversation. The SSD said the MDS Director was not present during the conversation. The SSD looked through the hard chart medical record and confirmed the Baseline Care Plan dated [DATE] indicated DNR selection for advanced directive. The SSD confirmed Resident #5 comprehensive care plan was Full Code. The SSD confirmed the baseline and comprehensive care plans contradicted each other. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the SSD progress note dated [DATE] at 9:47 a.m., revealed the social worker, spoke to resident in regard to code status. This social worker educated the resident on full code and DNR. This resident confirmed she wants to be a DNR. This social worker will initiate DNR. 3. Review of the Minimum Data Set (MDS) assessment with an assessment reference date of [DATE] revealed Resident #13 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the Social History Evaluation form dated [DATE] showed Will bring copy was checked off for Advanced Directives. The clinical record lacked documentation of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A handwritten physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 5:02 p.m., in an interview Resident #13 said if her heart stops beating, she does not want to be resuscitated. She said she is [AGE] years old and does not think it is good to do that. On [DATE] at 8:47 a.m., the Social Services Director (SSD) said Resident #13 was readmitted to the facility on [DATE] for long term care. She confirmed the medical record contained no advanced directive or indication of code status for Resident #13. The SSD confirmed there was an order from the physician on [DATE] to clarify code status and the order was not carried out. The SSD said she had not interviewed Resident #13 for code status, and since there was no record of DNR, she is considered a full code.

Based on interview and record review, the facility failed to develop a comprehensive care plan containing interventions to address the cardiac pacemaker for 1 (Resident #26) of 2 residents reviewed for cardiac pacemaker. The findings included: The Minimum Data Set (MDS) dated [DATE], reveals Resident #26 has an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] According to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/15/22 at 10:04 a.m. during a telephone conversation, Resident #26's wife said she is not sure how the facility is treating the device. According to the Care Plans reviewed on 3/15/22 at 3:47 p.m., Resident #26 does not possess a care plan for Cardiac Pacemaker including interventions on how to care for the device. On 03/15/22 at 3:27 p.m., Registered Nurse (RN) Staff G said she's worked at the facility for a long time. She said there is no machine at the facility to check the cardiac pacemaker. She said she is not sure if Resident #26's cardiac pacemaker functions. On 3/15/22 at 3:38 p.m., the Director of Nursing (DON) confirmed Resident #26's medical record did not contain a care plan for the cardiac pacemaker or documentation about how the facility was addressing the cardiac pacemaker. The DON said there is no facility policy for cardiac pacemakers. On 03/16/22 at 1:00 p.m., Licensed Practical Nurse (LPN) Staff A said she does not care for the resident very often and does not know what is being done for the pacemaker. On 3/16/22 at 1:17 p.m., the Minimum Data Set (MDS) Director said she is responsible for creating care plans for residents at the facility. She said she did not create a care plan for Resident #26's cardiac pacemaker. She said she is not sure what is being done for the cardiac pacemaker.

Based on record review and resident and staff interview, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for 1 (Resident #5) of 1 reviewed for showers. The findings included: The facility policy, Activities of Daily Living (ADLs)/Maintain Abilities dated 11/28/17 stated: .care and services provided are person-centered and honor and support each resident's preferences, choices, values, and beliefs. On 3/14/22 at 10:35 a.m., Resident #5 (room [ROOM NUMBER]), said she has been at the facility since December 2021 and has had 3 showers since she's been at the facility. Resident #5 said it bothers her. She said the therapist told nursing staff Resident #5 should be getting showers Monday, Wednesday, and Friday. On 3/16/22 at 10:48 a.m., Certified Nursing Assistant (CNA) Staff D said the scheduler will put the shower on the CNA assignment sheet. She said when she gives a resident a shower, she fills out the shower and documents the care in the computer. She said if not given, she reports it to the nurse. According to record review of the shower schedule, Resident #5 was scheduled for showers on Monday, Wednesday, and Friday. According to the Documentation Survey Report V2, for December 2021, Resident #5 received 3 showers at the facility from 12/11/21 - 12/31/21 and should have received 9 showers. According to the Documentation Survey Report V2 for January 2022, Resident #5 received 6 showers at the facility from 1/1/22 - 1/31/22 and should have received 13 showers. According to the Documentation Survey Report V2 for February 2022, Resident #5 received 8 showers from 2/1/22 - 2/28/22 and should have received 12 showers. According to the Documentation Survey Report V2 for March 2022, Resident #5 received 2 showers from 3/1/22 - 3/14/22 and should have received 6 showers. On 03/16/22 at 10:50 a.m., Licensed Practical Nurse Staff A confirmed she receives shower sheets from the CNAs after they give a resident a shower. Staff A said she gives the shower sheets to the DON. On 3/17/22 at 10:35 a.m., the Director of Nursing (DON) confirmed Resident #5 did not receive showers 3 times per week. The DON confirmed Resident #5 had not received any showers from 2/27/22 - 3/11/22, a total of 13 days. He said there were no shower sheets for Resident #5. He said there were no progress notes explaining why Resident #5 did not receive the scheduled showers.

Based on clinical record review and staff interviews, the facility failed to maintain documentation of rationale to justify an increase in [CONDITION(S)] medication (medication that affects a person's mental state) for 1 (Resident #27) of 5 sampled residents reviewed for unnecessary medications. This has the potential to lead to the administration of unnecessary medications. The findings include: Based on clinical record review and staff interviews, the facility failed to maintain documentation of rationale to justify an increase in [CONDITION(S)] medication (medication that affects a person's mental state) for 1 (Resident #27) of 5 sampled residents reviewed for unnecessary medications. This has the potential to lead to the administration of unnecessary medications. The findings include: Review of Resident #27's medical record revealed her last documented admission to the facility was on 11/09/2019. The medical record revealed a physician's order dated 11/28/21 for [MEDICATION(S)] 0.5 mg PRN (as needed) for anxiety every 8 hours. Review of the medication administration record (MAR) revealed Resident #27 received the medication 2 times on 11/28/21 and 1/30/22. There was no Behavior/Intervention Monthly Flow Record created in November 2021 and no documentation in Resident #27's medical record noting why she received the [MEDICATION(S)] on 11/28/21. Review of the Behavior/Intervention Monthly Flow Record for January 2022 revealed no behaviors noted on 1/30/22. There was no documentation noting why she received the [MEDICATION(S)] on 1/30/22. Review of the consultant pharmacist medication regime for Resident #27's medications revealed he recommended on 12/4/21 for Resident #27's primary care physician to evaluate the use of the PRN [MEDICATION(S)] 0.5 mg ordered on 11/28/21 and write a justification for the use of the [MEDICATION(S)] .5 mg as required by federal regulations. The pharmacist also wrote on 12/4/21 on the consultant pharmacist medication regimen form: PRN [CONDITION(S)] medication cannot exceed 14 days without the prescribing physician documenting the rationalization for use of the PRN [CONDITION(S)] mediation and indicate the duration of use for the PRN [CONDITION(S)] medication per federal regulations. On 1/6/22 Resident #27's primary care physician wrote on the consultant pharmacist medication regime form dated 12/4/21, to increase the use of the PRN [MEDICATION(S)] for anxiety to 180 days. Further review of Resident #27's medical record, noted the required justification documentation by the primary care physician for why he ordered PRN [MEDICATION(S)] 0.5 mg for anxiety and the justification for ordering the medication for 180 days, when federal regulations states PRN [CONDITION(S)] medication cannot exceed 14 days without justification was not present in Resident #27's medical record. The psychiatric ARNP (Advance Registered Nurse Practitioner) documented on 11/3/21, he visited Resident #27 that day for follow-up therapy. He documented Resident #27 denied homicidal or suicidal thoughts and denied depression and anxiety at that time. The ARNP documented the resident denied anxiety, worry, irritability, racing thoughts or panic and that staff denied evidence of anxiety symptoms. Staff voiced no complaints about Resident #27. The psychiatric ARNP wrote he reviewed Resident #27's medication and would continue to monitor for changes in mood, appetite, or sleep. The psychiatric ARNP documented on 11/17/21 he visited Resident #27 that day for a follow-up for medication check. The ARNP documented Resident #27 said she did not feel any different since decreasing her [MEDICATION(S)] dosage and was in a good mood. In the ARNP notes, he documented the resident denied current depression, anxiety, trouble sleeping and had a good appetite. The ARNP documented the resident denied anxiety, worry, irritability, racing thoughts or panic and that staff denied evidence of anxiety symptoms. The staff voiced no complaints about Resident #27. The ARNP stated he reviewed Resident #27's medication and would continue to monitor for changes in mood, appetite, or sleep. The psychiatric ARNP documented on 12/1/21 he visited Resident #27 that day for an acute change in condition. The ARNP wrote Resident #27 had a urinary tract infection ([CONDITION(S)]) and received 3 courses of antibiotics but had been verbally more sad aside from being tired. Resident #27 did not admit to any anxiety and was still eating well. The ARNP documented the resident denied anxiety, worry, irritability, racing thoughts or panic and that staff denied evidence of anxiety symptoms. The ARNP stated he reviewed Resident #27's medication and would continue to monitor for changes in mood, appetite, or sleep. Resident #27's primary care physician's progress note dated 12/2/21 stated he visited Resident #27 who had a chief complaint of [CONDITION(S)] and confusion. Confusion etiology may be related to the [CONDITION(S)] for a positive urinary analysis. The primary care physician's progress note documented Resident #27 was on multiple pain medications with possible confusion side effects. Medication included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. He documented staff noted increase depression and reported Resident #27 had crying episodes. He noted a plan to increase [MEDICATION(S)] to 100 mg which could have taken a few weeks to reestablish stable levels. The physician noted Resident 27's confusion had exact etiology unknown and he would continue to follow. Further review of Resident #27's primary care physician progress notes dated 12/2/21, 12/9/21 and, 1/20/22 noted Resident #27 was cooperative with exam, cognitive function intact and no agitation. Review of Resident #27's Behavior/Intervention Monthly monitor form was not started until January 2022. From January 1, 2022, to March 15, 2022, the facility document 2 episodes of increased anxiety on 1/4/22 which was relieved with repositioning and changing of the temperature. Medication was not documented as given as a method to reduce the anxiety noted on 1/4/22 in 2 episodes. On 3/16/22 at 9:55 a.m. during an interview with Staff B, she said she had been working at the facility for several years. She said Resident #27 was pleasant and easy to work with. She said she had not observed and/or heard of Resident #27 having episodes of increased anxiety. On 3/16/22 at 1:29 p.m. during an interview with the Director of Nursing (DON), he stated Resident #27 was admitted to the facility on [DATE]. He confirmed Resident #27 was started on [MEDICATION(S)] 0.5 mg on 11/28/21 for anxiety. He said the [MEDICATION(S)] 0.5 mg order was renewed by the primary care physician on 1/09/22 for 180 days after the consulting pharmacist wrote on 12/4/21 a PRN [CONDITION(S)] medication order cannot exceed 14 days without the prescriber documentation for the rationalization of use and must indicate the duration for the PRN order. The DON reviewed Resident #27's medical record and said he was unable to find documentation Resident #27 was having increased anxiety to justify why [MEDICATION(S)] 0.5 mg PRN for anxiety was stared on 11/28/21. He said the facility did not start monitoring Resident #27 for increased anxiety until January 1, 2022. He said from January 1, 2022, to March 15, 2022, the facility documented 2 episodes of increased anxiety, both on 1/4/22. The DON stated the interventions which were effective to reduce the anxiety for Resident #27 on 1/4/22 did not include medications and staff was able to reduce her anxiety with non-pharmacological interventions as documented on the behavior monitoring sheets. The DON confirmed the consultant pharmacist wrote on 12/4/21 after reviewing Resident #27's medication regime that the primary care physician needed to document the justification for use of the PRN [MEDICATION(S)] 0.5 mg for anxiety ordered on 11/28/21 and the duration of the medication. The consultant pharmacist wrote on the 12/4/21 medication regimen form, PRN [CONDITION(S)] medication cannot exceed 14 days without the prescribing physician documenting the rationalization for use of the PRN [CONDITION(S)] medication and should indicate the duration of use, not to exceed 14 days, for the PRN [CONDITION(S)] medication without justification as per federal regulations. The DON confirmed Resident #27's primary care physician wrote on 1/6/22 on the consultant pharmacist medication regime form dated 12/4/21 to increase the duration of the PRN [MEDICATION(S)] for anxiety to 180 days. The DON said he was unable to find the required justification documentation by the primary care physician why he ordered PRN [MEDICATION(S)] 0.5 mg for anxiety. He also stated the primary care physician did not document the justification for ordering the medication for 180 days, when federal regulations states PRN [CONDITION(S)] medication cannot exceed 14 days without justification by the ordering physician.

Based on observation, staff and resident interviews, and medication record review, the facility failed to identify and monitor the safe and proper storage of medications for 2 (Resident #191 and Resident #13) of 2 residents reviewed for medication storage. The findings included: The review of the facility Medication Storage Policy, Section 4.3 Bedside Medication Storage Policy dated 09/2018 states bedside medication administration is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgement of the nursing care center's interdisciplinary resident assessment team. Procedures included: The interdisciplinary team (IDT) will review and approve resident competencies and understanding prior to permission of bedside storage of medications as established in the nursing care centers policies and procedures . A written order for the bedside storage of medication is present in the resident's medical record . Bedside storage of medications is indicated on the resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The manner of storage prevents access by other residents. Lockable drawers or cabinets are required . All nurses and nursing aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse . The nurse will oversee storage security and accountability of bedside medications. During an observation on 3/14/22 at 10:34 a.m. a prescription eye drop bottle for Resident #191 was seen on her nightstand. The bottle read [MEDICATION(S)] Ophthalmic Solution 0.2% for use in the eyes only. There were no identifying labels on the bottle. In an interview with the resident, she said that she had brought her own prescription eye drops from home and self-administers them daily. On 3/16/22 at 9:11 a.m. during review of Resident #191 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication Order for [MEDICATION(S)] Ophthalmic Solution 0.2% reads to instill 1 drop to both eyes two times a day for [CONDITION(S)] and to be administered by clinician. There were no Physician orders for Resident #191 to store or administer her own medications. On 3/16/22 at 9:41 a.m. in an interview with Licensed Practical Nurse (LPN) Staff A who was assigned as Resident #191's nurse, she said the resident had her own bottle of [MEDICATION(S)] Ophthalmic Solution 0.2% that she had brought from home. The facility also stored the eye drops in the medication cart. She said most of the time the resident administered her own eye drops from her own bottle. On 03/16/22 at 1:05 p.m. in an interview with the Director of Nursing (DON), discussed the self-administration and storage of medications for Resident #191. The DON said LPN Staff A told him about Resident #191 having the [MEDICATION(S)] Ophthalmic Solution 0.2% at the bedside. The DON was aware of Resident #191 self-administering eye drops and the medication stored on bedside table in plain sight accessible to anyone who may enter the room. He admitted the medication should be kept safe and secure in locked drawer and he has already started the process of re-educating his staff on the proper procedures for securely storing medications at the resident's bedside. When asked about secured medication in the room the DON said the process was there but was not followed. On 3/16/22 at 09:33 a.m., Resident #13 was observed in her room lying in bed. A bottle of eye drops was sitting on Resident #13's bedside tray table which was located next to the bed. Resident #13 said she places an eye drop in each eye once a day. According to the physician's orders for Resident #13, there is no order for eye drops. On 3/17/22 at 10:53 a.m., the Director of Nursing (DON) confirmed the eye drops were on Resident #13's bedside tray table. The DON said Resident #13's medical record did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation and interviews the facility failed to ensure infection control measures were maintained during medication administration for 2 residents (Resident #13 and Resident #141) of 3 reviewed for medication administration and infection control. The findings included: On 3/16/22 at 8:41 a.m. Licensed Practical Nurse Staff A went into room [ROOM NUMBER] to administer [MEDICATION(S)] spray to Resident #141. During that time, Staff A took the nasal spray box into the room and placed it on the bedside tray table. Staff A did not place a barrier between the bedside tray table and the nasal spray box. When Staff A had completed the task, she took the nasal spray box out of the resident's room and placed it on the medication cart, without a barrier. Staff A then placed the nasal spray inside the medication cart. Staff A did not place the box inside of a clean plastic bag before placing it inside the medication cart. On 3/16/22 at 9:33 a.m., LPN Staff B went into room [ROOM NUMBER] to administer [MEDICATION(S)] Gel to Resident #13. During that time, Staff B took the gel box into the room and placed it on the nightstand. Staff B did not place a barrier between the nightstand and the gel box. When Staff B had completed the task, she took the gel box out of the resident's room and placed it inside of the facility treatment cart. On 3/16/22 at 11:36 a.m., LPN Staff A said each resident has their own glucometer, and Resident #141 has hers inside of a black case brought from home. Staff A took the black case from the medication cart and went into room [ROOM NUMBER] to assess blood glucose level for Resident #141. Staff A placed the black case onto the bedside tray table. Staff A did not place a barrier between the black case and the bedside tray table. After Staff A had completed the task, she exited the room and placed the black case back into the medication cart, again without a barrier. Staff A did not place the black case inside a clean plastic back before placing it inside the medication cart. On 3/17/22 at 10:53 a.m., the DON said the [MEDICATION(S)] Gel is house stock and the box should not have gone into the resident's room. He said the [MEDICATION(S)] spray box should not have gone into the room. The DON said staff should only take into the residents' room what they will be using to ensure infection control measures are maintained.

Based on interview and record review the facility failed to report immediately, but no later than 2 hours, to the state agency that one resident, (Resident #1), of two residents surveyed, had sustained a fracture to her right arm of unknown origin. The facility failed to take immediate actions when finding out there was a potential for abuse to the resident resulting in a staff member, identified by the facility as a potential perpetrator, to continuing to finish her shift and come to work the next day, this placed the resident at potential risk of retribution and continued abuse. The Findings included: The Policy/Procedure Reporting of Reasonable Suspicion of a Crime & Alleged Violation, dated 11/28/2017, Reads: In response to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury . On 12/8/20 at 10:15 a.m., Physical Therapy Assistant, Staff D stated on the morning of 11/26/20 the resident had complained of pain to her right shoulder. Staff D said the resident said, the pain started while she was showering. He said the resident told him her shirt had become tangled while getting dressed and the aide was in a hurry when she took the resident's shirt off. Staff D said he had a short session with the resident and then reported what the resident had said to Licensed Practical Nurse, Staff C. A progress note dated 11/26/20 at 2:14 p.m., shows Registered Nurse, Staff E spoke with the resident regarding her pain. Staff E documented, She (Resident #1) denied falling or banging her shoulder into any objects. She stated that the pain just came on. A progress note dated 11/26/20 shows Resident #1 was transferred back to the hospital at 7:00 p.m., and the resident was diagnosed with [REDACTED]. The note shows Licensed Practical Nurse, Staff B, reported Resident #1's injury to The Director of Nursing at 7:40 p.m. On 12/8/20 at 12:15 p.m., the Assistant Director of Nursing (ADON) said she was not working at the time the incidents happened. The ADON said she would report the potential abuse within 24 hours. On 12/8/20 at 1:50 p.m., Licensed Practical Nurse, Staff B verified she was made aware of the resident's fracture at 7:00 p.m. on 11/26/20. Staff B said she was aware Resident #1 had reported to the day shift staff that an aide had been rough with the resident when she was showering. Staff B said Staff C had not completed an incident report on 11/26/20 regarding the incident. Staff B verified she reported to the DON on 11/26/20 at 7:40 p.m., that Resident #1 had a fracture to her right arm. Staff B said the DON said he would have to report the incident to the state within 24 hours. On 12/8/20 at 2:30 p.m., The Abuse Coordinator said the potential abuse was reported to her on 11/27/20 at approximately 10:00 a.m. by the DON. She said she reported to the DON at that time that if there is an injury of unknown origin which is a serious injury it should be reported within 2 hours. The Abuse Coordinator said she then went immediately called the Department of Children and Families (DHF) and the state investigator came to the facility that day. On 12/8/20 at 4:00 p.m., Certified Nursing Assistant, Staff A verified her written statement that she had completed on 11/27/20 at 12:52 p.m., Staff A said LPN Staff C reported to her on 11/26/20 that Resident #1 told Staff C the aide had been rough while doing her shower. On 12/8/20 at 4:30 p.m., the Administrator verified she had been aware that the injury had not been reported to DCF until 11/27/20. The Administrator said she was not aware the incident should have been reported within two hours. The Administrator verified Staff C had not been suspended until 11/27/20.

Based on interview and record review the facility failed to report a fracture of unknown origin within 2 hours, to the required state agencies for one resident, (Resident #1) of three residents surveyed. The Findings included: The Policy/Procedure Reporting of Reasonable Suspicion of a Crime & Alleged Violation, dated 11/28/2017 specified: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a)Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source . are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to the other officials (including to the State survey Agency and adult protective services) in accordance with State law through established procedures . Review of the clinical record revealed a nursing progress note dated 11/26/20 at 1:58 p.m., that read Patient had c/o (complained of) right shoulder pain after patient was given a shower this morning given Tylenol for pain with no relief of paint at that time . the right shoulder disproportioned at that time. Dr exam her and gave orders to send patient out to hospital. A progress note dated 11/26/20 at 2:14 p.m., showed Registered Nurse, Staff E spoke with the resident regarding her pain. RN Staff E documented, She (Resident #1) denied falling or banging her shoulder into any objects. She stated that the pain just came on. A progress note dated 11/26/20 at 7:00 p.m., showed Resident #1 was transferred to the hospital and was diagnosed with [REDACTED]. The note showed LPN Staff B reported Resident #1's injury to The Director of Nursing (DON) on 11/26/20 at 7:40 p.m. On 12/8/20 at 10:15 a.m., during an interview Physical Therapy Assistant (PTA) Staff D said on the morning of 11/26/20 Resident #1 complained of pain to her right shoulder. The resident said the pain started while she was showering. Her shirt had become tangled while getting dressed and the aide was in a hurry when she took the resident's shirt off. Staff D said he had a short session with the resident and then reported what the resident had said to Licensed Practical Nurse (LPN) Staff C. On 12/8/20 at 12:15 p.m., the Assistant Director of Nursing (ADON) said she was not working at the time of the incident. The ADON said she would report the potential abuse within 24 hours. On 12/8/20 at 1:50 p.m., LPN Staff B verified she was made aware of the resident's fracture on 11/26/20 at 7:00 p.m. Staff B said she was aware Resident #1 reported to the day shift staff a Certified Nursing Assistant (CNA) had been rough with her when she was showering. LPN Staff B said LPN Staff C did not complete an incident report on 11/26/20. Staff B verified she reported to the DON on 11/26/20 at 7:40 p.m., Resident #1 had a fracture to her right arm. LPN Staff B said the DON said he would have to report the incident to the state within 24 hours. On 12/8/20 at 2:30 p.m., The Abuse Coordinator said the DON reported the potential abuse to her on 11/27/20 at approximately 10:00 a.m. She said she informed the DON at that time any injury of unknown origin which is a serious injury should be reported within 2 hours. The Abuse Coordinator said she then went immediately called the Department of Children and Families (DCF) and the state investigator came to the facility that day. Review of CNA Staff A's statement dated 11/27/20 at 1:22 p.m., revealed she showered Resident #1 on 11/26/20. A few minutes later, LPN Staff C walked by and stated Resident #1 reported she was rough while doing her shower. On 12/8/20 at 4:00 p.m., Certified Nursing Assistant, Staff A verified she wrote a statement on 11/27/20 at 1:22 p.m., indicating LPN Staff C told her Resident #1 said she had been rough while doing her shower. On 12/8/20 at 4:30 p.m., the Administrator verified she had been aware the injury had not been reported to DCF until 11/27/20. The Administrator said she was not aware the incident should have been reported within two hours. The Administrator verified Staff C had not been suspended until 11/27/20.

Based on record review and interview the facility failed to take immediate actions to protect one (Resident #1) of three residents reviewed after report of a potential for abuse to the resident. The facility allowed a staff member identified by the resident and facility as a potential perpetrator, to continue her shift and come to work the next day. This placed the resident at potential risk of retribution and continued abuse. The findings included: The Policy/Procedure Reporting of Reasonable Suspicion of a Crime & Alleged Violation, dated 11/28/2017 specified In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a) Have evidence that all alleged violations are thoroughly investigated. b) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress . Review of the clinical record revealed a nursing progress note dated 11/26/20 at 1:58 p.m., that read Patient had c/o (complained of) right shoulder pain after patient was given a shower this morning given Tylenol for pain with no relief of paint at that time . the right shoulder disproportioned at that time. Dr exam her and gave orders to send patient out to hospital. A progress note dated 11/26/20 at 7:00 p.m., showed Resident #1 was transferred to the hospital and was diagnosed with [REDACTED]. The note showed LPN Staff B reported Resident #1's injury to The Director of Nursing (DON) on 11/26/20 at 7:40 p.m. On 12/8/20 at 1:50 p.m., LPN Staff B verified she was made aware of the resident's fracture on 11/26/20 at 7:00 p.m. Staff B said she was aware Resident #1 reported to the day shift staff a Certified Nursing Assistant (CNA) had been rough with her when she was showering. LPN Staff B said Staff C did not complete an incident report on 11/26/20. Staff B verified she reported to the DON on 11/26/20 at 7:40 p.m., Resident #1 had a fracture to her right arm. Staff B said the DON said he would have to report the incident to the state within 24 hours. Review of CNA Staff A's statement dated 11/27/20 at 1:22 p.m., revealed she showered Resident #1 on 11/26/20. A few minutes later, LPN Staff C walked by and stated Resident #1 reported she was rough while doing her shower. On 12/8/20 at 4:00 p.m., Certified Nursing Assistant, Staff A verified her written statement she had completed on 11/27/20 at 12:52 p.m. Staff A said LPN Staff C reported to her on 11/26/20 Resident #1 told Staff C the aide had been rough while doing her shower. On 12/8/20 at 4:30 p.m., the Administrator verified Staff C had not been suspended until 11/27/20.

Based on observation, record review, resident and staff interview, the facility failed to attempt alternatives prior to the use of bed rails for 11 (Residents #5, #16, #19, #22, #24, #31, #34, #35, #37, #93 and #193) of 13 residents reviewed for accident hazards. The findings included: The facility's policy for Bedrail's, dated 11/28/17, indicated under procedure; 1. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. 1. On 2/18/19 at 11:29 a.m., Resident #93 was observed lying in bed with bilateral bed rails raised. The resident said he had been here for a couple of weeks and the bed rails were already on the bed. Record review revealed a consent for bed rails was signed on 2/3/19. Under the section of alternatives to bed rails no alternatives was written. 2. On 2/19/19 at 9:22 a.m., Resident #37 was observed in bed with bilateral bed rails raised. Record review revealed a consent for bed rails was signed on 1/17/19 and no alternatives were listed as being attempted. 3. On 2/19/19 at 9:31 a.m., Resident #35 was observed sitting in bed with bilateral bed rails in the raised position. The resident said the rails had been there the whole time and he was not aware of any alternatives being offered. Record review revealed a consent for bed rails was signed on 1/4/19 and no alternatives were listed as being attempted. On 2/19/19 at 1:27 p.m., Licensed Practical Nurse Staff C said bed rails were discussed with residents on admission and if they wanted them a consent was signed. Staff C said she was not aware of any alternatives to bed rails. 4. On 2/19/19 at 7:59 a.m., quarter side rails were noted in the up position on the bed of Resident #5. On 2/20/19, record review revealed no documented evidence of alternatives attempted prior to the installation of the bed rails on the bed of Resident #5. 5. On 2/20/19 at 7:40 a.m., quarter side rails were noted in the up position on the bed of Resident #16. On 2/20/19, record review revealed no documented evidence of alternatives attempted prior to the installation of the bed rails on the bed of Resident #16. 6. On 2/20/19 at 7:44 a.m., quarter side rails were noted in the up position on the bed of Resident #31. On 2/20/19, record review revealed no documented evidence of alternatives attempted prior to the installation of the bed rails on the bed of Resident #31. 7. On 2/20/19 at 7:42 a.m., quarter side rails were noted in the up position on the bed of Resident #193. On 2/20/19, record review revealed no documented evidence of alternatives attempted prior to the installation of the bed rails on the bed of Resident #193. 8. On 2/18/19 at 9:56 a.m., quarter rails were noted in the up position on the bed of Resident #22. On 2/20/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #22. 9. On 2/18/19 at 10:19 a.m., quarter rails were noted in the up position on the bed of Resident #34. On 2/20/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #34. 10. On 2/18/19 at 10:44 a.m., quarter rails were noted in the up position on the bed of Resident #19. On 2/20/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #19. 11. On 2/18/19 at 11:29 a.m., quarter rails were noted in the up position on the bed of Resident #24. On 2/20/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #24. On 2/20/19 at 10:08 a.m., in an interview, the Director of Nursing confirmed no alternatives were offered or attempted prior to installation of the bed rails on the beds of Residents #5, #16, #19, #22, #24, #31, #34, #35, #37, #93 and #193.

Based on observation, staff interview and menu review, the facility failed to follow the menu for 100% of the 42 residents who consumed diets orally resulting in the potential for nutritional inadequacy and not following physician-ordered therapeutic diets. The findings included: On 2/12/18 at 12:30 p.m., during observation of the lunch meal service trayline, residents were served a grilled cheese and tomato sandwich or 4 ounces of seafood noodle casserole and mixed garden vegetables. The Service Cook served the vegetables with a slotted spoon instead of a portion-control device. Per the menu, residents were to be served 3 ounces grilled cheese sandwich or seafood noodle casserole (except for those on consistent carbohydrate diets who were to receive 3 ounces of grilled blackened fish), a dinner roll, 4 ounces of mixed garden vegetables and 4 ounces of ice cream. There were no rolls or grilled blackened fish on the trayline. The Registered Dietitian said the seafood noodle casserole should have contained 3 ounces of protein and agreed the portion size served was inadequate and a portion-control device should have been used for the mixed garden vegetables. The Certified Dietary Manager said the grilled blackened fish listed on the menu was a mistake. However, the Registered Dietitian was present during the observation and had not approved any changes to the written menu.

Based on record review, observation, and staff interview, the facility failed to provide a clean, safe, and sanitary environment in the kitchen, by not having clean floors in food storage areas and clean surfaces on food preparation equipment. In addition food was not being stored and served in a sanitary manner to prevent potential contamination for 2 of 2 meal service observations. This failure had the potential to cause food borne illness in residents receiving an oral diet. The findings included: The facility's policy for food storage indicated food was to be stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 1. On 2/12/18 at 9:35 a.m., during the initial tour of the kitchen, the following was observed. The floors in both walk in freezers were heavily soiled with debris. There were food particles, paper, food drippage, and other trash on the floor and under the food storage racks. The door from the kitchen to the outside was observed to be ajar. On 2/15/18 at 9:18 a.m., during a second tour of the kitchen, the floors in the walk in freezers were still heavily soiled with food spillage, trash and food debris. The door from the kitchen to the outside was propped open with a hammer. The Certified Dietary Manager (CDM) was present during the observation and confirmed the floors were not clean. The CDM said the door being propped open was because the door will lock if staff go outside. The CDM acknowledged this practice had the potential to allow pests from the outside to enter the kitchen and be a source of contamination. 2. On 2/12/18 at 12:18 p.m., during observation of noon meal service cook Staff A brought food cart to main dining room and did not plug in the cart. At 12:33 p.m., Staff A washed his hands for less than 8 seconds and turned off the faucet with his wet hands. Staff A applied gloves and preceded to place the pans of food into the steam table to serve to residents. Staff A did not test the temperature of the food that had come from the kitchen and had sat in an unheated cart for over 15 minutes. At 12:44 p.m., Staff A removed his gloves and washed his hands for 3 seconds, then turned off the water with his wet hands. On 2/13/18 at 8:33 a.m., during observation of the breakfast meal service, service cook Staff A was observed washing his hands for 8 seconds and then turned off the faucet with his wet hands. Service cook Staff B was assisting and with gloved hands was observed repeatedly touching potentially contaminated surfaces, to include touching his nose, and then placing his thumb on the inside surface of the plates as he handed them to Staff A. The facility's handwashing policy indicated staff were to wash their hands under running water for 20 seconds, dry their hands with a paper towel; and turn off the water with a paper towel. On 2/13/18 at 11:06 a.m., the CDM said staff were to take the temperature of the food at point of service. The CDM defined this as when getting ready to serve from steam table. Reviewed steam table temperature logs for meals served from 1/17/18 through 2/12/18 and 48 of the 76 meals served did not have documentation of temperatures being obtained prior to being served. The CDM confirmed service cook Staff A should have taken the temperature of the food prior to be served to residents. The CDM acknowledged service cook Staff A did not wash his hands in accordance with facility policy and service cook Staff B did not handle plates in a manner to prevent contamination. 3. On 2/13/18 at 11:27 a.m., an open cart containing individual bowls of salad and fruit was observed inside the walk in refrigerator #2. The bowls were uncovered leaving the food exposed to potential contamination from staff entering the refrigerator. On 2/13/18 at 2:05 p.m., the same open food cart with a plastic cover was observed sitting in the dining room. The cart contained trays of fresh fruit salad, green salad, Israeli salad, tuna salad sandwiches, egg salad sandwiches, tuna salad plates with fruit, and egg salad plates with fruit. The bowls of fruit and salad were not individually covered. A dietary worker was observed removing the cart from the dining room, taking it back down to the kitchen, and placing it back into walk in refrigerator #2. On 2/15/18 at 9:18 a.m., the CDM acknowledged food should have been individually wrapped to prevent contamination. The CDM said staff should have disposed of the leftover food from the dining room and not returned it to the refrigerator for potential use. 4. On 2/15/18 at 9:12 a.m., the meat food slicer was observed to have pieces of meat hanging off the blade, and meat juice on the slicer plate surface. Dietary worker Staff D said she had been slicing turkey for sandwiches but then went to prepare salads. The CDM was present and said dietary worker Staff D should have cleaned and sanitized the machine before going on to prepare something else. 5. On 2/13/18 at 11:33 a.m., dietary worker Staff C was observed to have her hair unrestrained, large hoop earrings, bracelet, watch, and rings on both her hands with long painted fingernails extending past the tips of her fingers. Staff C was also wearing a mask. Staff C indicated the mask was because she had a cough and her duties included preparing beverages, silverware and working in the dish room. On 2/15/18 at 9:28 a.m., dietary worker Staff C was observed to again have unrestrained hair and wearing the same jewelry. The CDM observed Staff C and confirmed she was not in accordance with the facility's dress code for the kitchen. **photos on file**

Based on observation, staff interview and review of facility policy and procedures, the staff failed to ensure linen and laundry was handled in a manner to prevent infection and maintain a sanitary environment in the laundry room as evidenced by rust, dust and miscellaneous debris. The findings included: On 2/15/18, a review of the facility policy and procedure titled Infection Control - Linen Management dated November 28, 2017 documented: it is the policy of the facility to ensure linens are handled in a way to prevent cross-contamination and the spread of infection in accordance with state and federal regulations, and national guidelines. (2) Clean linens are not to come into contact with staff clothing. (4) Laundry equipment should be properly maintained according to manufacturer's instructions. (5) Clean and dirty linen areas should be separate and clearly designated. Only clean linens are transported on clean carts and only dirty linens are transported in containers designated for dirty linens. During a tour of the laundry room on 2/15/18 at 12:06 p.m., with ADON and the Director of Environment and Laundry Aide Staff N revealed the following: (a) A large amount of debris and a large lilt pile was observed behind the washing machines. Observed a large dirty folded blanket under a trashcan in between the washing machines. Observed numerous dark brown spots on the front of the washing machines. (b) Observed miscellaneous debris and silverware on top of the washing machines. (c) Observed dust and rust on and in the bottom vents of the washing machines. (d) The pathway to the sink in the the laundry room was blocked by 3 large laundry bins of dirty laundry. The sink had no soap or hand towels for the laundry staff to wash their hands and had a large amount of dirt and dust in the bottom of the basin around the faucets. (e) The ADON observed laundry aide Staff N folding clothes in the clean (dryer) room. Staff N was observed folding the clothes against her body and leaning on the clean folding table with her clothing touching the table. On 2/15/18 at 12:15 p.m., laundry aide Staff N said the laundry staff was responsible for sweeping and mopping the washing and drying areas. She said she did not know when it was last done. Staff N said she uses the same bin from when it enters the laundry room with the dirty laundry through to the folding table. She had to disinfect the bin before she could take the clothes out of the washer and bring it to the dryer. She stated, I spray it and wipe it out with a cloth. I ran out of the spray cleaner this morning and have to get some more. During the interview, observed 2 bins of washed, wet clothes waiting for the dryer. Observed Staff N removing dry laundry from a dryer and stated, On 2/15/18 at 12:17 p.m., the Environmental Director (ED) said either the laundry staff or environmental staff should be cleaning the laundry room. He said they were supposed to use the spray to clean out the bins after the dirty clothes were put into the washer and then could be used to transport them to the dryer. He said he would need to get more spray from the storage area. The ED acknowledged the debris behind the washers, on the front of the washers and in the entryway. He said these areas needed to be cleaned. **Photos on file**

Based on observation and staff interview, the facility failed to maintain the kitchen, the third floor food service station and third floor nourishment room in a clean and sanitary manner for 3 of the 3 food service areas in the nursing home. In addition, the dietary staff failed to handle food in a manner to prevent cross contamination. The findings included: 1. The kitchen in the skilled nursing facility has two, fully equipped, food preparation, cooking and serving stations in mirror image (North and South) and three walk-in refrigerators, one for vegetables and two combined with walk-in freezers. During the initial tour of the kitchen on 4/17/17 at 9:20 a.m. the following was observed: The walls behind the beverage stations, the cooking equipment and the preparation tables were dirty with greasy, sticky residue and food debris. The floor under the cooking equipment in the south kitchen was dirty with food debris. The cooking equipment in the south kitchen; the convection oven, the stove, and the deep fryer had a build up of grease and grimy residue. The top of the oven was coated with grease and lint. The shelf over the stove was coated with sticky residue. The drip pan in the stove, under the burners, was thick with burnt food residue. The sides of the deep fryer were coated with grease. The sheet pan used to cover the fryer and a frying basket stored on the sheet pan were coated with grease with grease pooling on the sheet pan. The shelf above the south kitchen steam table and the shelf under the prep table next to the steam table were dirty with food debris and sticky residue. A cutting board and chef's knife dirty with food residue was left out on the prep table. The back side of the pallet warmer was dirty with sticky residue and food debris. The ice scoop was found in the ice bin of the ice machine. The can opener was coated with sticky food residue. The cooking equipment in the north kitchen was dirty with food debris. The floor stand mixer was coated with a white powdery substance and a sticky residue. The shelf under the prep table was dirty with food residue. Clean plates were stacked on the shelf. The drip pan in the stove, under the burners, was thick with burnt food residue. The shelves and racks on which clean pots and pans are stored were rusted and corroding. The flour bin on the floor under the prep table was open. Food was being prepared on the table above the open flour bin. In the two walk-in combined refrigerator/freezers, boxes were stacked on the floor. Boxes had burst open with food packages spilled out. Salads and desserts prepped for lunch were stored on uncovered trays in the walk-in refrigerator. The racks in the walk-in refrigerator were observed to have fuzzy growth on slides which receive the trays. Two of the refrigerators did not have internal thermometers. *** pictures on file*** 2. On 4/17/17 at 11:45 a.m., during observation of lunch service on the third floor, the dining room serving station was found to be dirty with liquid residue and food debris on the glass guard over the steam table, the counter at the back of the steam table and in the drawers in the counter. The steam table wells were dirty with food particles and rust. 3. On 4/19/17 at 7:00 a.m., the breakfast preparation and tray line service was observed. The prep-cook prepped and plated ready-to-eat meat (Smoked Salmon) with bare hands. The cook was multi-tasking while plating the breakfast at the steam table; cooking eggs on the stove, retrieving items from the refrigerator and getting dishes out of a warming cart, going from one task to the next without washing her hands. The cooking equipment; stoves, ovens, and the pellet warmer were still filthy with greasy grime and food debris. The prep table surfaces were dirty with food debris. The ice scoop was again found in the ice bin. The wall behind the ice machine was coated with a greasy residue and lint. The can opener was still dirty with sticky food residue. The pallet warmer was still dirty with sticky food residue. Boxes of food were still staked on the floor in the walk-in refrigerator/freezers and in the dry storage room. On 4/19/17 at 7:30 a.m., the certified dietary manager (CDM) confirmed the cooking equipment was still soiled. The CDM confirmed the prep-cook should have worn gloves when handling ready-to-eat meat. On 4/19/17 at 10:50 a.m. the kitchens were again visited. The cook was observed in the north kitchen grilling raw chicken. When finished cooking the chicken, using her bare hands, the cook picked up the items she used for the raw chicken prep; cutting board, utensils and debris and placed them on a utility cart. Without washing her hands, the cooked walked to the Robocoup (food processor), lifted the lid, picked up a scraper and scraped down the inside of the food processor which contained beans for lunch. The cook then transport the cart with the chicken residue to the dirty dish area. The cook came back to food prep area, did not wash her hands, picked up a dry cloth and wiped the surface of the prep table, leaving pieces of raw chicken and meat juices on the prep table. She then placed a box of foil and a box of plastic wrap on the table surface, got out clean serving pans, for the steam table, placing them on the prep table. The cook began transferring hotdogs from a steamer into the serving pans using tongs. After placing hotdogs into the pan, she transferred the beans from the food processor into a serving pan using a wooden handled scraper. She rinsed out the processor bowl and took it to the dishwasher. During this time the cook never washed her hands after handling raw chicken with her bare hands and although a bucket with sanitizer was on the shelf under the table, did not use it to sanitize the food prep surface. Food was observed cooking in the convection oven and steamer. The exhaust hood was not turned on. Water was condensing under the hood and observed dripping off the front edge of the hood onto the stove and potentially onto food coming out of the oven and the steamer. On 4/19/17 at 11:00 a.m., the CDM noticed the prep table had not been cleaned and proceeded to wipe the table down with a sanitizer solution. The CDM did not use warm soapy water to clean the surface before using the sanitizer solution. The CDM acknowledged the cook did not wash her hands after handling the raw chicken. The CDM confirmed work surfaces and food-contact equipment (e.g., food processors, preparation tables and, can openers) had not been cleaned and sanitized between uses. The CDM stated all food contact surfaces should be cleaned with detergent and hot water, rinsed, air-dried and wiped with a sanitizing solution (at the effective concentration). 4. On 4/20/17 at 11:00 a.m., with the CDM and regional food service manager, beef roasts were observed being prepared and the cooked roasts carved on the north kitchen prep table. After carving a roast, the cook covered the cutting board with foil. The cook left the carving knife on the cutting board. Meat particles were left on the cutting board and meat juices and particles had spilled from the cutting board onto the table surface. A dietary aide approached the prep table carrying a clean cutting board and knife. The diet aide started to place the clean cutting board on the soiled prep table surface. The aide was advised the table surface was contaminated and the clean cutting board should not be placed on the table. The aide balanced the clean cutting board on a clean serving pan on the steam table and left the area. The aide did not clean the table surface. The CDM proceeded to clean the prep area by removing the soiled cutting board. When she looked for a cleaning cloth, the CDM found there was one bucket of solution on the shelf under the table. The bucket contained sanitizer solution. The CDM confirmed the surface should be cleaned with soapy water, rinsed and then sanitized with a solution of the proper concentration of sanitizer. The CDM confirmed there was no soapy water available for cleaning the contaminated table surface. On 04/20/17 at 12:19 p.m., the regional manager (RM) for dietary services stated there was no documentation of safe food handling in-service for the diet aides. He said the cooks had received training in food service management which included modules on safe food handling. He produced a training certificate for the cook. On 4/20/17 at 3:00 p.m., the RM and CDM confirmed they could not find proof of training in safe food handling for the diet aides.

Based on observation and staff interview, the facility failed to maintain kitchen equipment for safe operation in 2 of 3 food service areas of the nursing home. This practice has the potential for the spread of food born pathogens. The findings included: 1. During the initial tour of the kitchen on 4/17/17 at 9:20 a.m. the warewasher, two hand washing sinks and a roll in refrigerator were found to not be functioning properly. The temperature gauges on the warewasher were not working. Observation of five wash and rinse cycles revealed the gauge needles did not fluctuate but stayed rigidly fixed on one number. The warewasher reaching the proper wash temperature could not be determined. One of the hand washing sinks was clogged and drained slowly leaving dirty residue which potentially had harmful bacteria that could be picked up by other users. Another hand washing sink had a hole in the drain pipe that discharged dirty water onto the floor. There was no floor drain near the sink so the water puddled under the sink. The roll-in refrigerator, in the kitchen, was leaking water from the refrigerator ceiling onto the food items on the rolling cart inside the refrigerator. Water was observed pooling in a sheet pan on the top shelf of the rolling cart and in a container of milk cartons. The drain and condenser pan in the refrigerator could harbor harmful pathogens. The water dripping from the refrigerator onto food had the potential to contaminate the food. The certified dietary manager (CDM) and the regional dietician, touring with the surveyor, confirmed the equipment failings at that time. 2. On 4/19/17 at 7:00 a.m., breakfast preparation and tray line service was observed. The hand washing sinks had not been repaired; one was still draining slowly and the other still had a hole in the drain pipe. The roll-in refrigerator was still dripping water from its ceiling with the water pooling on a sheet pan. On 4/19/17 at 7:30 a.m., the CDM acknowledged the hole in the drain pipe and the leaking refrigerator had not been repaired and were still in use. 3. On 4/19/17 at 2:00 p.m. observation in the nourishment room on the third floor found the roll-in refrigerator was leaking water from its ceiling. The water was dripping onto plates of food stored on the cart in the refrigerator in the same manner as the roll-in refrigerator in the kitchen. On 4/19/17 at 2:10 p.m., the CDM observed the nourishment room refrigerator and acknowledged water was dripping onto the food stored in the refrigerator. .

Based on record review, observation, and interview, the facility failed to have an effective Quality Assessment and Assurance (QAA) program to evaluate processes when inspection reports and audits revealed sanitation issues in the kitchen. The QAA program was not effective in ensuring safe sanitation practices were being maintained in the kitchen. The lack of sanitary food practices places all residents at risk for potential food borne illness. The findings included: During the initial tour of the kitchen on 4/17/17 at 9:20 a.m. the following was observed: The walls behind the beverage stations, the cooking equipment and the preparation tables were dirty with greasy, sticky residue and food debris. The floor under the cooking equipment in the south kitchen was dirty with food debris. The cooking equipment in the south kitchen; the convection oven, the stove, and the deep fryer had a build up of grease and grimy residue. The top of the oven was coated with grease and lint. The shelf over the stove was coated with sticky residue. The drip pan in the stove, under the burners, was thick with burnt food residue. The sides of the deep fryer were coated with grease. The sheet pan used to cover the fryer and a frying basket stored on the sheet pan were coated with grease with grease pooling on the sheet pan. The shelf above the south kitchen steam table and the shelf under the prep table next to the steam table were dirty with food debris and sticky residue. A cutting board and chef's knife dirty with food residue was left out on the prep table. The back side of the pallet warmer was dirty with sticky residue and food debris. The ice scoop was found in the ice bin of the ice machine. The can opener was coated with sticky food residue. The cooking equipment in the north kitchen was dirty with food debris. The floor stand mixer was coated with a white powdery substance and a sticky residue. The shelf under the prep table was dirty with food residue. Clean plates were stacked on the shelf. The drip pan in the stove, under the burners, was thick with burnt food residue. The shelves and racks on which clean pots and pans are stored were rusted and corroding. The flour bin on the floor under the prep table was open. Food was being prepared on the table above the open flour bin. In the two walk-in combined refrigerator/freezers, boxes were stacked on the floor. Boxes had burst open with food packages spilled out. Salads and desserts prepped for lunch were stored on uncovered trays in the walk-in refrigerator. The racks in the walk-in refrigerator were observed to have fuzzy growth on slides which receive the trays. Two of the refrigerators did not have internal thermometers. *** pictures on file*** 2. On 4/17/17 at 11:45 a.m., during observation of lunch service on the third floor, the dining room serving station was found to be dirty with liquid residue and food debris on the glass guard over the steam table, the counter at the back of the steam table and in the drawers in the counter. The steam table wells were dirty with food particles and rust. 3. On 4/19/17 at 4:17 p.m., the Administrator confirmed issues with kitchen sanitation had been identified in audits and Health Department inspections. The Administrator said she did have a company come in and do overall cleaning of kitchen about a month ago as a result of the last inspection report.