Every finding on record at Bethany Center for Rehabilitation and Healing LLC

Based on facility policy review, medical record review, and interview, the facility failed to ensure the care and services for the use of a Negative Pressure Wound Therapy (NPWT) (a machine used on a wound to promote healing) machine and wound treatments were completed as ordered by the Physician for 3 of 7 (Resident #2, #55, and #147) sampled residents reviewed for pressure ulcers/wounds. The findings include: 1. Review of the facility policy titled, WoundCare (Wound Care), dated 10/7/2024, revealed .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Verify that there is a physician's order for this procedure.The following information should be recorded in the resident's medical record.The type of wound care given.The date and time the wound care was given.The position in which the resident was placed.The name and title of the individual performing the wound care.Any change in the resident's condition.All assessment data.obtained when inspecting the wound.How the resident tolerated the procedure.If the resident refused the treatment and the reason (s) why.The signature and title of the person recording the data. Review of the facility policy titled, Charting and Documentation, dated 10/7/2025, revealed .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Treatments or services performed.Documentation in the medical record will be objective.complete, and accurate.Documentation of procedures and treatments will include care-specific details, including.the date and time of the procedure/treatment was provided.the name and title of the individual(s) who provided the care.the assessment data and/or any unusual findings obtained during the procedure/treatment.how the resident tolerated the procedure/treatment.whether the resident refused the procedure/treatment.the signature and title of the individual documenting. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Moderate Protein-Calorie Malnutrition, Diabetes, and Pressure Ulcer of Sacral (a large, flat triangular bone located at the base of the spine) Region. Review of the Care Plan dated 3/23/2026, revealed .Alteration in skin integrity actual pressure injury present upon admission.Interventions.Administer treatments/medications as ordered and monitor for effectiveness. Review of the Physician Order dated 6/9/2026, revealed Sacrum Stage 4 with NPWT In Use. Monitor for Active Bleeding, Ensure Dressing is Clean/Dry and Intact, Clamps Open, Plugged In and Turned On Continuous@ [at] 125 mm/hg [millimeters of mercury] Every Shift. Review of the Treatment Administration Record (TAR) dated 6/1/2026 through 6/30/2026, revealed missing documentation for care and use of the NPWT machine on the following days: a. 6/9/2026, 7:00 AM-3:00 PM shift b. 6/10/2026, 3:00 PM-11:00 PM shift c. 6/11/2026, 3:00 PM-11:00 PM shift d. 6/12/2026, 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts e. 6/15/2026, 3:00 PM-11:00 PM shift f. 6/16/2026, 3:00 PM-11:00 PM shift g. 6/17/2026, 3:00 PM-11:00 PM shift h. 6/18/2026, 3:00 PM-11:00 PM shift i. 6/24/2026, 3:00 PM-11:00 PM shift j. 6/26/2026, 11:00 PM-7:00 AM shift k. 6/29/2026, 3:00 PM-11:00 PM shift Review of the TAR dated 7/1/2026 through 7/31/2026, revealed missing documentation for care and use of the NPWT machine on the following days: a. 7/3/2026, 7:00 AM-3:00 PM shift b. 7/12/2026, 7:00 AM-3:00 PM shift c. 7/17/2026, 3:00 PM -11:00 PM shift d. 7/18/2026, 7:00 AM-3:00 PM shift e. 7/19/2026, 7:00 AM-3:00 PM shift f. 7/23/2026, 3:00 PM-11:00 PM shift g. 7/25/2026, 7:00 AM-3:00 PM shift h. 7/26/2026, 7:00 AM-3:00 PM and 3:00 PM- 11:00 PM shifts i. 7/29/2026, 7:00 AM-3:00 PM shift Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Noted to be at risk for pressure ulcers/injuries, and unhealed pressure ulcers/injuries. 1 stage 4 (a wound with full-thickness tissue loss exposing muscle, tendon, ligament, or bone) pressure ulcer noted present upon admission/entry or reentry. Resident #2 was noted for pressure ulcer/injury care. Review of the Physician Orders dated 7/30/2026, revealed Wound Treatment: Left Lateral Calf Skin Tear. Cleanse with Normal Saline. Apply Santyl [a prescription topical ointment to remove dead tissue] to Wound Bed and Cover with Foam Dressing Daily and PRN [as needed] for Loose, Soiled, or Missing Dressing. Every day shift. Review of the TAR dated 8/1/2026 through 8/31/2026, revealed missing documentation for treatments on the following days: a. 8/1/2026 b. 8/2/2026 The facility failed to ensure wound treatments were provided and documented as prescribed and in accordance with facility policy. 3. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including, Cerebral Infarction (stroke), Diabetes, Anemia, and Obesity. Review of the Care Plan dated 10/12/2024, revealed .has potential/actual impairment to skin integrity.Interventions.Follow facility protocols for treatment of injury.Alteration in skin integrity-actual pressure injury present upon admission.Interventions. Administer treatments/medications as ordered and monitor for effectiveness. Review of the Physician Order dated 5/12/2026, revealed Wound Treatment: Right Back Stage 4 Cleanse with Daikins [Dakin's] [an antiseptic solution]. Apply Zinc Oxide [a barrier cream used to protect skin] to Wound Bed Every Shift and PRN. Review of the TAR dated 5/1/2026 through 5/31/2026, revealed missing documentation for treatments on the following days: a. 5/12/2026, 3:00 PM -11:00 PM shift b. 5/13/2026, 3:00 PM -11:00 PM shift c. 5/16/2026, 11:00 PM-7:00 AM shift d. 5/19/2026, 3:00 PM -11:00 PM shift e. 5/21/2026, 3:00 PM -11:00 PM shift f. 5/22/2026, 3:00 PM -11:00 PM shift g. 5/23/2026, 7:00 AM- 3:00 PM and 3:00 PM -11:00 PM shifts h. 5/24/2026, 7:00 AM-3:00 PM shift i. 5/26/2026, 3:00 PM -11:00 PM shift j. 5/27/2026, 3:00 PM -11:00 PM shift k. 5/29/2026, 3:00 PM -11:00 PM shift l. 5/30/2026, 11:00 PM-7:00 AM shift Review of the TAR dated 6/1/2026 through 6/30/2026, revealed missing documentation for treatments on the following days: a. 6/1/2026, 3:00 PM-11:00 PM shift b. 6/2/2026, 3:00 PM-11:00 PM shift c. 6/3/2026, 7:00 AM-3:00 PM shift d. 6/4/2026, 3:00 PM-11:00 PM shift e. 6/5/2026, 3:00 PM-11:00 PM shift f. 6/6/2026, 11:00 PM-7:00 AM shift g. 6/7/2026, 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts h. 6/9/2026, 3:00 PM-11:00 PM shift i. 6/10/2026, 3:00 PM-11:00 PM shift j. 6/11/2026, 3:00 PM-11:00 PM shift k. 6/12/2026, 3:00 PM-11:00 PM shift l. 6/15/2026, 3:00 PM-11:00 PM shift m. 6/16/2026, 3:00 PM-11:00 PM shift n. 6/17/2026, 3:00 PM-11:00 PM shift o. 6/18/2026, 3:00 PM-11:00 PM shift p. 6/24/2026, 3:00 PM-11:00 PM shift q. 6/28/2026, 11:00 PM-7:00 AM shift r. 6/29/2026, 3:00 PM-11:00 PM shift Review of the TAR dated 7/1/2026 through 7/31/2026, revealed missing documentation for treatments on the following days: a. 7/4/2026, 3:00 PM-11:00 PM shift b. 7/5/2026, 11:00 PM-7:00 AM shift c. 7/10/2026, 11:00 PM-7:00 AM shift d. 7/12/2026, 7:00 AM-3:00 PM shift e. 7/16/2026, 11:00 PM-7:00 AM shift f. 7/17/2026, 3:00 PM-11:00 PM shift g. 7/18/2026, 7:00 AM-3:00 PM shift h. 7/19/2026, 7:00 AM-3:00 PM shift i. 7/23/2026, 3:00 PM-11:00 PM shift j. 7/26/2026, 7:00 AM-3:00 PM and 3:00 PM- 11:00 PM shifts k. 7/30/2026, 3:00 PM-11:00 PM shift Review of the TAR dated 8/1/2026 through 8/31/2026, revealed missing documentation for treatments on the following days: a. 8/1/2026, 7:00 AM-3:00 PM shift b. 8/2/2026, 11:00 PM-7:00 AM shift c. 8/5/2026, 3:00 PM-11:00 PM shift The facility failed to ensure wound treatments were provided and documented as prescribed and in accordance with facility policy. Review of the annual MDS assessment dated [DATE], revealed Resident #55 scored a 5 on the BIMS assessment, which indicated he was severely cognitively impaired. He was noted for 1 stage 4 ulcer that was present upon admission/entry or reentry and pressure ulcer/injury care. 4. Review of the medical record revealed Resident #147 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Pressure Ulcer of Sacral Region, Stage 4, and Severe Protein-Calorie Malnutrition. Review of the Physician Order dated 5/22/2026, revealed Wound Treatment: Left Hip Stage 4 Cleanse with Daikins [Dakin's]. Apply Zinc and Nystatin Powder to Periwound [the area of skin surrounding a wound]. Fill with Daikins Moistened Gauze. Apply ABD [abdominal pad] an absorbent dressing] Pads to Gauze. Cover with ABD Pads and Secure with Tape. Change BID [twice a day] and PRN for Loose, Soiled, or Missing Dressing. Review of the TAR dated 6/1/2026 through 6/30/2026, revealed missing documentation for treatments on the following days: a. 6/7/2026, night shift b. 6/10/2026, day shift c. 6/11/2026, day shift d. 6/16/2026, night shift e. 6/21/2026, night shift f. 6/23/2026, day shift g. 6/24/2026, night shift h. 6/25/2026, night shift i. 6/30/2026, day shift Review of the TAR dated 7/1/2026 through 7/31/2026, revealed missing documentation for treatments on the following days: a. 7/6/2026, day shift b. 7/8/2026, day shift c. 7/19/2026, day shift Review of the TAR dated 8/1/2026 through 8/31/2026, revealed missing documentation for treatments on the following days: a. 8/1/2026, night shift b. 8/2/2026, night shift Review of the Physician Order dated 5/22/2026, revealed Wound Treatment: Sacrum and Bilateral Buttocks Stage 4 Cleanse with Daikins [Dakin's]. Apply Zinc and Nystatin Powder to Periwound. Fill with Daikins Moistened Gauze. Apply ABD Pads to Gauze. Cover with ABD Pads and Secure with Tape. Change BID and PRN for Loose, Soiled, or Missing Dressing. Review of the TAR dated 6/1/2026 through 6/30/2026, revealed missing documentation for treatments on the following days: a. 6/7/2026, night shift b. 6/10/2026, day shift c. 6/11/2026, day shift d. 6/16/2026, night shift e. 6/21/2026, night shift f. 6/23/2026, day shift g. 6/24/2026, night shift h. 6/25/2026, night shift i. 6/30/2026, day shift Review of the TAR dated 7/1/2026 through 7/31/2026, revealed missing documentation for treatments on the following days: a. 7/6/2026, day shift b. 7/8/2026, day shift c. 7/19/2026, day shift Review of the TAR dated 8/1/2026 through 8/31/2026, revealed missing documentation for treatments on the following days: a. 8/1/2026, night shift b. 8/2/2026, night shift Review of the quarterly MDS assessment dated [DATE], revealed Resident # 147 scored a 15 on the BIMS assessment, which indicated Resident #147 was cognitively intact. He was noted for 3 stage 4 pressure ulcers that were present upon admission/entry or reentry, pressure ulcer/injury care. Review of the Care Plan dated 6/29/2026, revealed .has Alteration in skin integrity-actual pressure injury present upon admission.Interventions.Administer treatments/medications as ordered and monitor for effectiveness. Review of the Physician Order dated 6/29/2026, revealed Wound Treatment: Right Knee Abrasion Cleanse with Normal Saline. Apply Xeroform [a non-adhering petroleum dressing] to Wound Bed. Cover with Dry Dressing. Change Every Tuesday, Friday, Sunday and PRN for Loose, Soiled, or Missing Dressing. Check Daily for Intact Dressing. Review of the TAR dated 7/1/2026 through 7/31/2026, revealed missing documentation for treatments on the following days: a. 7/19/2026 The facility failed to ensure the wound treatments were provided and documented as prescribed and in accordance with facility policy. During an interview on 8/6/2026, the Director of Nursing (DON) was asked if staff should follow the Physician Orders as prescribed. The DON stated, Yes. The DON was asked if all treatments and services provided to a resident that require a Physician Order should be documented and signed off. The DON stated, Yes. The DON was asked if all documentation, including the TAR, should be accurate and complete. The DON stated, Yes. The DON was asked to review the missing documentation on Resident #2, #55, and #147's TAR and confirmed it was incomplete. The DON was asked who was responsible for ensuring the documentation was complete and accurate. The DON stated, The Nurses, Unit Managers, Supervisors, and myself. The DON was asked if there were any reports available to verify completion of documentation on the TAR. The DON stated, Yes, it is actually something recently I have learned that I can pull. The DON was asked if a resident refuses a treatment, should it be documented to reflect the refusal. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 4 of 19 staff members (Certified Nursing Assistant (CNA) F, G, H and Activity Assistant E) failed to perform hand hygiene and handled food with barehand during dining observations, and when 1 of 2 staff (Dietary [NAME] I) failed to perform proper hand hygiene when preparing meal trays. The facility had a census of 166 with 166 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled Handwashing/Hand Hygiene, dated 10/2023, revealed .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors .Perform hand hygiene before applying non-sterile gloves. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. When removing gloves .turning the glove inside out .Perform hand hygiene . Review of the undated facility policy titled, Food Sanitation, revealed .All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way . 2. Observation in the 1st floor dining room on 3/31/2025 at 12:00 PM, revealed Activity Assistant E repositioned Resident #57's grilled cheese on the plate with bare hand during meal setup. Observation in the 1st floor day room on 3/31/2025 at 12:11 PM, revealed CNA G opened Resident #72's milk carton by pulling it open with her finger in the carton and assisted resident to eat without performing hand hygiene. Observation during dining in the Resident's room on 4/1/2025 at 7:56 AM, revealed CNA F held Resident #85's toast in her bare hand to spread jelly on it. Observation in the Resident's room on 4/1/2025 at 7:58 AM, revealed CNA H repositioned Resident #48 in the bed and repositioned pillow under resident's left arm and continued to feed resident without performing hand hygiene. 3. Observation in the Kitchen on 4/1/2025 from 5:01 PM to 5:26 PM, revealed Dietary [NAME] I with gloved hands preparing meal trays at the steam table. Dietary [NAME] I was observed leaving the serving line multiple times with gloved hands to open the warming oven door to obtain food items and then returned to the serving line to prepare food trays with the same gloves. Dietary [NAME] I changed gloves multiple times and did not perform hand hygiene prior to donning new gloves. 4. During an interview on 4/3/2025 at 12:19 PM, the Director of Nursing (DON) confirmed that staff should not touch food items with their bare hands during tray setup, and staff should not place their finger in a milk carton to open it. During an interview on 4/3/2025 at 12:38 PM, the Certified Dietary Manager (CDM) confirmed that staff should perform hand hygiene and change gloves prior to handling or serving food.

Based on Quarterly Payroll Based Journal (PBJ), staffing time sheets, and interview the facility failed to submit accurate staffing data for Quarter 2, Quarter 3, and Quarter 4/2024. The findings included: 1. Review of the PBJ Staffing Data Report for Quarter 2 2024 (January 1-March 31) revealed excessively low weekend staffing. Review of the PBJ Staffing Data Report for Quarter 3 2024 (April 1-June 30) revealed one star staff rating and excessively low weekend staffing. Review of the PBJ Staffing Data Report for Quarter 4 2024 (July 1-September 30) revealed excessively low weekend staffing. 2. Review of the Direct Care Staffing which included the facility census, direct care staff hours, and PPD (Per Patient Day-total hours of Registered Nurse Hours, Licensed Practical Nurse Hours, and Certified Nursing Assistant hours divided by the resident census = hours of care provided to each resident in a facility) provided by the Administrator via email on 4/11/2025 revealed the following: Saturday 3/16/2024 Total PPD 2.83 Saturday 4/27/2024 Total PPD 2.96 Saturday 5/25/2024 Total PPD 2.74 Saturday 7/6/2024 Total PPD 2.96 Saturday 9/8/2024 Total PPD 3.16 Review of the Direct Care Staffing revealed the facility had PPD greater than 2.7 over 5 random Saturdays reviewed for excessively low staffing on the weekends during Quarter 2, Quarter 3, and Quarter 4. 3. During a telephone interview on 4/11/2025 at 12:33 PM, Staffing Director was asked about the PBJ that reflected excessively low staffing on the weekends for the last 3 quarters for 2024. The Staffing Director stated, .yes, it is low staffing due to call ins, agency staff was included in the numbers . During a telephone interview on 4/11/2025 at 12:52 PM, the Administrator was asked about the facility PBJ reports for quarter 2, quarter 3, and quarter 4 which reflected excessively low weekend staffing. The Administrator stated, .we staff the same way on the weekends as we do on the weekdays .I will need to look back at the reports .If you will provide me the dates you want to review, I can send the staffing for those dates . During a telephone interview on 4/11/2025 at 2:33 PM, the Administrator concluded the facility was not excessively low for staffing on the weekends during the quarters, but the facility failed to code direct care hours for a Certified Nursing Assistant that works in staffing, central supply, and medical records.

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 4 of 33 sampled residents (Resident #21, #71, #77 and #108) reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled Advance Directives, revised on 9/2022, revealed .The resident has the right to formulate an advance directive .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive . 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including of Alzheimer's Disease, Anxiety, Depression, and Diverticulosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score 99, which indicated Resident #21 was severely cognitively impaired. The facility was unable to provide the completed documentation that the resident representative was educated regarding advance directives and/or to formulate an advance directive. 3. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Hypertension. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #71 was severely cognitively impaired. The facility was unable to provide the completed documentation that the resident representative was educated regarding advance directives and/or to formulate an advance directive. 4. Review of the medical record revealed Resident # 77 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Diabetes, Depression, Bipolar Disorder, and Parkinson's Disease. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident # 77 was cognitively intact. The facility was unable to provide the completed documentation that the resident was educated regarding advance directives and/or to formulate an advance directive. 5. Review of the medical record revealed Resident # 108 was admitted to the facility on [DATE], with diagnoses including Left Femur Fracture, Cerebral Infarction, Anxiety, Dementia, Osteoporosis and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score was not completed due to Resident #108 was severely cognitively impaired. The facility was unable to provide the completed documentation that the resident representative was educated regarding advance directives and/or to formulate an advance directive. 6. During an interview on 4/1/2025 at 1:34 PM, the Social Services Assistant confirmed that the facility was unable to provide Advance Directive documentation for Residents #21, #71, #77, and #108. 51365

Based on policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 23 of 23 CNAs (CNA G, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, and EE) employed for a full year received at least 12 hours of in-service training. The findings include: 1. Review of the facility's policy titled In-Service Training, Nurse Aide, dated august 2022, revealed .all Personnel are required to participate in regular in-service education .Annual in-service: Ensure the continuing competence of nurse aides; are no less than 12 hours per year . 2. Review of the Inservice Training Hours revealed: a. CNA G had a hire date of 3/30/2024 and had only competed 8.50 in-service hours from 4/3/2024 -present. b. CNA J had a hire date of 9/13/2006 and had only competed 4.0 in-service hours from 9/18/2024 -present. c. CNA K had a hire date of 11/9/2023 and had only competed 2.0 in-service hours from 11/20/2024 -present. d. CNA L had a hire date of 1/31/2023 and had only competed 10.50 in-service hours from 2/5/2024 -present. e. CNA M had a hire date of 8/15/2019 and had only competed 4.0 in-service hours from 9/18/2024 -present. f. CNA N had a hire date of 8/9/2013 and had only competed 5.0 in-service hours from 8/13/2024 -present. g. CNA O had a hire date of 3/30/2023 and had only competed 8.50 in-service hours from 4/3/2024 -present. h. CNA P had a hire date of 3/4/2011 and had only competed 9.50 in-service hours from 3/6/2024 -present. i. CNA Q had a hire date of 12/20/2022 and had only competed 10.50 in-service hours from 2/5/2024 -present. j. CNA R had a hire date of 1/17/2000 and had only competed 10.50 in-service hours from 2/5/2024 -present. k. CNA S had a hire date of 6/29/2023 and had only competed 6.0 in-service hours from 7/9/2024 -present. l. CNA T had a hire date of 1/17/2024 and had only competed 10.50 in-service hours from 2/5/2024 -present. m. CNA U had a hire date of 1/10/2023 and had only competed 10.50 in-service hours from 2/5/2024 -present. n. CNA V had a hire date of 2/28/2023 and had only competed 9.50 in-service hours from 3/6/2024 -present. o. CNA W had a hire date of 8/3/2012 and had only competed 5.0 in-service hours from 8/13/2024 -present. p. CNA X had a hire date of 11/21/2014 and had only competed 2.0 in-service hours from 11/20/2024 -present. q. CNA Y had a hire date of 9/7/2023 and had only competed 4.0 in-service hours from 9/18/2024 -present. r. CNA Z had a hire date of 5/25/2023 and had only competed 7.0 in-service hours from 6/5/2024 -present. s. CNA AA had a hire date of 7/3/2024 and had only competed 5.0 in-service hours from 7/7/2024 -present. t. CNA BB had a hire date of 2/14/2022 and had only competed 10.50 in-service hours from 2/5/2024 -present. u. CNA CC had a hire date of 4/12/2022 and had only competed 8.0 in-service hours from 5/14/2024 -present. v. CNA DD had a hire date of 6/29/2020 and had only competed 6.0 in-service hours from 7/9/2024 -present. x. CNA EE had a hire date of 7/20/2023 and had only competed 5.0 in-service hours from 8/13/2024 -present. 3. During an interview on 4/3/2025 at 3:09 PM, Staff Development was asked how many CNA in-service hours are required for a year. The Staff Development confirmed 12 hours yearly. The Staff Development stated, .they have not completed any hours for 2025 yet .I do 6 months at one time .I start in January and go through December not from hire date to hire date .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 4 staff members (Registered Nurse (RN) II) left the medication unattended and out of sight at the bedside in Resident #10's room. The findings include: 1. Review of the facility's policy titled Medication Labeling and Storage, dated 5/19/2023, revealed .trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . 2. Observation on 4/2/2025 at 3:40 PM, revealed Register Nurse (RN) II left the medication on the over bed table in Resident #10's room. RN II went into the bathroom with the door almost closed completely, with a small crack toward the hall, to wash her hands and left the medication out of sight and unattended on the over bed table by B bed. During an interview with surveyors present, on 4/3/2025 at 11:23 AM, the Director of Nursing (DON) was asked should medications be left unattended and out of sight. The DON stated, Did you ask the nurse .was it A bed or B bed .Did she not take the medicine with her .

Based on policy review, medical record review, observation, and interviews, the facility failed to ensure infection control practices to prevent the spread of infection were used when 1 of 5 (Registered Nurse (RN II) nurses failed to perform hand hygiene during medication administration and Certified Nursing Assistant (CNA) LL was not following Enhance Barrier Precautions (EBP)s while providing care for Resident #311. The findings include: 1. Review of the facility policy titled Instillation Eye Drops, dated 1/2014, revealed Should both eyes require instillation, wash and dry your hands thoroughly before treating each eye. Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/2024 revealed, .Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Dementia, Insomnia, Cerebrovascular Disease, Fracture of Sacrum and Fracture Left Femur. Review of the Physician Order dated 8/9/2024, revealed Systane Solution 0.4-0.3% [percent] Instill 1 drop in both eyes four times a day for dry eyes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated Resident #10 was severely cognitively impaired. Observation on 4/2/2025 at 3:40 PM, in Resident #10 ' s room, revealed RN II administered one drop of Artificial Tears to right eye and immediately administered one drop to the left eye. RN II failed to change gloves or perform hand hygiene between treating each eye. During an interview on 4/3/2025 at 12:10 PM the Director of Nursing (DON) was asked what should nurses do if administering eye drops to both eyes. The DON confirmed nurse should change gloves between eyes and do hand hygiene when they remove gloves. 3. Review of medical record revealed Resident #311 was admitted to the facility on [DATE], with diagnoses which included Sepsis, Cerebral Palsy, Infection and Inflammatory Reaction due to other Urinary Catheter, Unspecified Intellectual Disabilities, and Urinary Tract Infection. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #311 had a Brief Interview for Mental Status score of 0 which indicated severe cognitive impairment. Continued review revealed Resident #311 had an indwelling catheter. Further review revealed Resident #311 had 1 stage 3 pressure ulcer upon admission and received antibiotics over the last 7 days. Review of the care plan dated 3/21/2025, revealed a focus for PICC (Peripherally Inserted Central Catheter) line for administration of medication, a focus for Indwelling Catheter, and a focus for actual Pressure Injury on admission 3/22/2025 Right Lateral Thigh Stage 3. Observation and interview when entering Resident #311's room on 4/2/2025 at 10:25 AM, with Licensed Practical Nurse (LPN) KK, CNA LL was in the room standing by his bed. A used brief was laying in the floor adjacent to where CNA LL was standing. Resident #311 was laying on his back with no shirt and a clean brief was noted on the resident. CNA LL stated, I was about to get the resident up. LPN KK was asked if Resident #311 was on EBPs and LPN KK stated, Yes. LPN KK was asked if the CNA providing care should be wearing a gown. LPN KK stated, Yes. CNA LL stated, .Why should I be wearing a gown is there a sign on the door . LPN KK stated, Yes there is a sign on his door. LPN KK was asked why the resident would be on EBPs. LPN KK stated, .he has a catheter, he has a PICC line, and he has ESBL [Extended Spectrum Beta-Lactamase a group of enzymes produced by certain bacteria resistant to a wide range of antibiotics] . LPN KK was asked if the used brief should be thrown on the floor unbagged. LPN KK stated, No, and the curtain should have been pulled around the resident for his privacy. During an interview on 4/3/2025 at 12:19 PM, the Director of Nursing (DON) was asked if a resident was under EBPs what a CNA should be wearing while providing care. The DON stated, .PPE [Personal Protective Equipment] a gown and gloves . The DON was asked if a soiled brief should be placed in the floor unbagged. The DON stated, .soiled briefs should be disposed of in a garbage and no it should not be in the floor . the curtain should have been pulled .EHPs is used to protect the resident who has an opening on his body that would be a source of infection .it is to prevent infections. 44724 49269

Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure a comprehensive care plan was updated to address how a resident was to be transferred for 1 (Resident #6) of 11 residents whose care plans were reviewed. Findings included: Review of a facility policy titled, Comprehensive Person-Centered Care Plans, dated 03/08/2023, revealed, 11. Assessment of residents are ongoing and care plans are revised as information about the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment. A review of Resident #6's Admission Record revealed the facility admitted the resident on 11/20/2020 with diagnoses that included end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. A diagnosis of right humerus fracture was added on 05/16/2023. A review of the significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of two persons for transfers and had limited range of motion to an upper extremity on one side and to both lower extremities. The resident received scheduled pain medication and occasionally had pain of 5 on a scale of 0-10, with 10 being worst. The resident's pain limited their day-to-day activities. A review of Resident #6's care plan, initiated on 01/24/2023, indicated the resident required assistance with activities of daily living related to decreased mobility, weakness with decreased endurance, end stage renal disease - dialysis, diabetes mellitus, history of cerebrovascular accident, and range of motion impairment. An intervention, initiated on 05/27/2023, instructed staff that Resident #6 required extensive assistance of two staff. A review of an incident form, dated 05/16/2023 at 2:36 PM, revealed two staff were transferring Resident #6 to the shower chair and upon lifting the resident, Resident #6 told staff they had heard a pop and complained of pain. The certified nursing assistants (CNAs) denied hearing a pop but placed the resident back to bed. One of the CNAs notified the nurse. The resident indicated they felt a pop to the right shoulder and complained of increase in pain. The incident form indicated the CNAs were provided gait belt training. The incident form also indicated the care plan was followed and updated. A review of a Radiology Results Report, dated 05/16/2023, revealed x-rays were taken of the right shoulder and there was no evidence of an acute fracture, dislocation, or osseous lesion. There was evidence of a chronic healing fracture to the proximal humerus. During an interview on 07/25/2023 at 12:48 PM, Resident #6 indicated they had had a broken shoulder. Resident #6 stated they heard it pop when two CNAs transferred them. Resident #6 indicated they no longer did a stand-up transfer and now they were transferred by a sheet onto a cart. Further review of Resident #6's care plan revealed the care plan was not updated to address a change in transfer technique, which included using a sheet for transfers. During a telephone interview on 07/28/2023 at 11:36 AM, the MDS Coordinator indicated therapy would put a Resident's transfer requirements in the task section of the electronic medical record and those requirements would then rollover to the care plan. The MDS Coordinator indicated extensive assistance of two meant that the resident was able to bear their own weight with two people assisting and the resident was able to transfer with a mechanical lift. During an interview on 07/28/2023 at 1:03 PM, the Director of Rehabilitation (DOR) indicated Resident #6 required extensive assistance of two staff, which meant two people could do the transfer and if they had to or could use a mechanical lift. The DOR indicated staff were educated during orientation on how to transfer and that was the purpose of having the task there (in the electronic health record) to tell them what to do. During an interview on 07/28/2023 at 2:49 PM, CNA #6 indicated Resident #6 did not get up except to shower and go to dialysis. CNA #6 indicated Resident #6 required a two-person extensive assist and indicated staff used a sheet to transfer the resident to the shower gurney or to the gurney to go to dialysis. CNA #6 stated they went to the computerized charting system or the Kardex to learn how to care for residents. During an interview on 07/28/2023 at 3:01 PM, CNA #7 indicated a sheet was used to transfer Resident #6 when they went to dialysis. CNA #7 indicated he had not seen the resident up for any other reason. CNA #7 indicated how to care for a resident was on the computerized charting system. At 4:43 PM, CNA #7 stated a regular bed sheet was used to transfer the resident. During an interview on 07/28/2023 at 3:04 PM, Certified Medication Technician (CMT) #8 indicated a sheet was used to transfer or pull Resident #6 up in bed. CMT #8 indicated the care plan was in the computerized charting system. At 4:38 PM, CMT #8 indicated a regular bed sheet was used for transfers. During an interview on 07/28/2023 at 3:08 PM, CNA #9 indicated Resident #6 was moved using a sheet. CNA #9 indicated staff had to use a sheet to transfer the resident to the shower gurney for a shower. During an interview on 07/28/2023 at 4:59 PM, the DON indicated each department updated their own care plan and then the information was pulled into the task section of the electronic medical record. The DON was informed the resident and staff stated the resident was transferred to the shower gurney and pulled up in bed by a sheet. The DON indicated bed mobility was done with a draw sheet, and that staff were allowed to do what made them feel safe. The DON was asked what her expectation was for the care plan to be updated with the sheet transfer, and the DON indicated she needed to confirm what was being done. During an interview on 07/28/2023 at 6:28 PM, the Administrator indicated the Kardex and care plan were updated with resident status changes, therapy changes, and when clinical meetings necessitated change. The Administrator indicated the MDS Coordinator was responsible for the oversight of care plan changes, but each department completed their own changes.

Based on the facility policy review, medical record review, observations, and interview, the facility failed to prevent the use of unnecessary medications without indications for the use for 3 of 10 sampled residents (Resident #1, Resident #2, and Resident #5) The Findings include: Review of the facility's policy titled, Anticoagulation - Clinical Protocol, dated 2/22/2021 revealed, .as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of [CONDITION(S)] [DVT], or heart valve replacement, [CONDITION(S)] or those who have had recent joint replacement surgery .assess for signs of symptoms related to adverse drug reactions due to the medication alone or in combination with other medications .the nurse shall assess and document/report the following .current anticoagulation therapy, including drug and current dosage .recent labs, including therapeutic dose monitoring .other current medications .all active diagnoses .the physician will prescribe anticoagulation therapy .appropriately, consistent with recognized guidelines .in general, long-term subcutaneous administration of [MEDICATION(S)] in chronically bed-bound individuals is not indicated or of proven benefit for long-term DVT prophylaxis .the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, prothrombin time test/international normalized ratio [PT/INR], and stool for occult blood .the physician will review the progress of individuals who are being anticoagulated; for example, to see whether recent-onset [CONDITION(S)] has resolved or to evaluate the status of any [CONDITION(S)] .if an individual on anticoagulation therapy shows signs of excessive bruising, Hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant . Review of the facility's undated policy titled, Polypharmacy/Unnecessary Medication Evaluation Policy, revealed, .Medications are reviewed by Nurse Practitioner [NP]/ Medical Director [MD] upon admission and as necessary ensuring that medications are clinically appropriate and appropriately monitored. The consultant pharmacist performs Medication Regimen Review monthly to ensure appropriate prescribing and monitoring of medications. Elements of Review: Appropriate indication .Monitoring .Dosing .Clinical rationale for duration .Unnecessary medications are discontinued as deemed necessary by prescriber . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged to hospital on 5/15/2021. Resident #1 admitted to the facility with diagnoses which included Protein-Calorie Malnutrition, Intervertebral Disc Degeneration, Idiopathic [CONDITION(S)], and Arthropathy. Review of the 5-day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognitive abilities. Continued review of the MDS revealed Resident #1 had received anticoagulant ([MEDICATION(S)]) 4 days from her admitted [DATE] through her assessment reference date of 5/14/2021. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Sodium [[MEDICATION(S)]] 5000 Unit/Milliliter [ML] solution injection subcutaneous [sq] every [q] 8 hours at 6:00 AM, 2:00 PM, 10:00 PM given for Prophylaxis . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #2 was admitted to the facility 1/7/2022 with diagnoses which included Orthopedic Aftercare following Surgical Amputation, [CONDITION(S)], Type 2 Diabetes Mellitus (DM), and Obstructive and Reflux [CONDITION(S)]. Review of the Admission MDS dated [DATE] revealed Resident #2 had a BIMS assessment score of 15 indicating intact cognitive abilities. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #2 revealed he received [MEDICATION(S)] injections daily at 9 AM from 1/20-1/31/2022. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Hypo-Osmolality and [CONDITION(S)], Coronavirus Disease (COVID-19), Dysphagia, and [CONDITION(S)] Obstruction. Review of the MDS assessment revealed an entry assessment completed for 1/28/2022. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the DON and Assistant DON (ADON) on 2/2/2022 they were asked to review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON and ADON reviewed orders and confirmed no diagnoses in the orders for the use of the anticoagulant medications.

Based on facility policy review, medical record review, observations, and interview, the facility failed to implement a Care Plan for Anticoagulant therapy for 1 of 10 sampled residents (Resident #4) receiving Anticoagulant therapy. The findings include: Review of the facility's policy titled, Anticoagulation - Clinical Protocol, dated 2/22/2021 revealed, .as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of [CONDITION(S)] [DVT], or heart valve replacement, [CONDITION(S)] or those who have had recent joint replacement surgery .assess for signs of symptoms related to adverse drug reactions due to the medication alone or in combination with other medications .the nurse shall assess and document/report the following .current anticoagulation therapy, including drug and current dosage .recent labs, including therapeutic dose monitoring .other current medications .all active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .appropriately, consistent with recognized guidelines .in general, long-term subcutaneous administration of [MEDICATION(S)] in chronically bed-bound individuals is not indicated or of proven benefit for long-term DVT prophylaxis .the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, prothrombin time test/international normalized ratio [PT/INR], and stool for occult blood .the physician will review the progress of individuals who are being anticoagulated; for example, to see whether recent-onset [CONDITION(S)] has resolved or to evaluate the status of any [CONDITION(S)] .if an individual on anticoagulation therapy shows signs of excessive bruising, Hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant . Review of the facility's undated policy titled, Minimum Data Set[MDS]/Care Plans, revealed, .the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence as per the RAI Process .A baseline Care Plan must be developed as per Centers for Medicare and Medicaid Services [CMS] within 48 hours of admission .the MDS Coordinator will schedule the dates in Point Click Care [PCC] upon completion of the MDS assessment and the care plan team will subsequently complete the care plan in PCC in the assigned timeframe the care plan will be closed in PCC by the care plan team .Goals and objectives are reviewed and / or revised .when there has been a significant change in the resident's condition .when the desired outcomes has and/ or has not been achieved .when the resident has been readmitted to the facility from the hospital .at least quarterly . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score assessment of 9 indicating moderate cognitive abilities. Continued review of the MDS revealed Resident #4 required extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. Further review of the MDS revealed no internal bleeding. Continued review of the MDS revealed Resident #4 received anticoagulant 7 days of the assessment period date. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 5 mg tab give 1 tablet by mouth at bedtime every Tue, Thu, Sat, Sun for Chronic Embolism and [CONDITION(S)] of unspecified vein . Review of the Care Plan dated 12/13/2021, revealed no Care Plan implemented for use of anticoagulant therapy. Interview with with Director of Nursing (DON) and Assistant Director of Nursing (ADON) were asked to review Care Plan for Resident #4 in Point Click Care (PCC) computer system and verify implementation of the use of anticoagulant medications. ADON was only able to provide a three page Care Plan from PCC that did not address the use of Anticoagulant therapy.

Based on facility policy review, observation, and interview the facility staff failed to remove a disposable isolation gown before exiting 1 of 5 rooms which were on observation for COVID 19. The findings include: Review of the facility policy titled, Personal Protective Equipment-Using Gowns Level l revised 2/22/2021 revealed .Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room . Observation and interview on the blue unit on 10/25/2021 at 12:19 PM revealed the Certified Occupational Therapist Assistant (COTA) exited room [ROOM NUMBER] while wearing a disposable gown. The COTA removed the gown in the hallway and disposed of it in the trash bin on the hall. The COTA stated she had always thrown the isolation gown after usage in the trash bin outside in the hall. During an interview on 10/25/2021 at 1:23 PM, the COTA stated she followed the directions of the signage beside the door of room [ROOM NUMBER]. Continued interview the COTA confirmed she used the trash bin on the hall to dispose of the isolation gown. Continued interview the COTA stated I did not know we could throw it away in the room. I always come out with the gown and throw them away in the blue zone trash . During an interview on 10/25/2021 at 2:00 PM, the Director of Rehabilitation confirmed I expect them to understand and perform the appropriate isolation precaution protocols on the floors.

Based on the glucometer manufacturer guideline, medical record review, observation and interview, the facility failed to follow standard precautions during the performance of routine fingerstick blood glucose testing resulting in potential exposure of residents who required blood glucose testing to the spread of bloodborne infections in the facility for 3 (#26, #99 and #117) of 32 diabetic residents. The Administrator was informed of the Immediate Jeopardy (IJ) on 10/22/19 at 1:15 PM in the Director of Nursing's office. F-880 was cited at a scope and severity of K. An extended survey was effective from 10/22/19 to 10/23/19. The Immediate Jeopardy was effective on 10/22/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy was received on 10/23/19 at 11:34 AM and corrective actions were validated onsite by the surveyors on 10/23/19. The findings include: Review of the Glucometer manufacturer guideline, Caring for Your System undated, revealed .to minimize the risk of transmission of bloodborne pathogens, the cleaning and disinfection procedure should be performed as recommended .the meter should be cleaned and disinfected after use on each patient .Germicidal Disposable Wipe for disinfecting the meter which included bleach germicidal disposable wipe containing bleach 1:10 dilution . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #26's Medication Administration Record [REDACTED]. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #99's Medication Administration Record [REDACTED]. Medical record review revealed Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #117's Physician order [REDACTED].strict isolation-Urinary .ESBL (Extended Spectrum Beta-Lactamase) . Medical record review of Resident #117's Medication Administration Record [REDACTED]. Observation and interview on 10/22/19 at 9:25 AM in Resident #117's room revealed LPN #1 did not disinfect a glucometer prior to performing a fingerstick blood glucose testing on Resident #117. Continued observation revealed LPN #1 left the isolation room, cleaned the glucometer with an alcohol prep then placed the glucometer into the D/E Hall medication cart. When LPN #1 was asked what is the procedure for disinfecting the glucometer she stated, The night nurses clean the glucometer. Further interview when asked when she would clean the glucometer she stated I would clean it when visibly soiled. When asked what disinfectant she would use to clean the glucometer she stated I would clean it with alcohol. When asked if she had performed any other fingerstick blood glucose testing prior to Resident #117 she stated yes, on (named Resident #26). When asked if she had disinfected the glucometer after performing Resident #26's fingerstick blood glucose testing, she stated No, I don't think so. Interview with the DON on 10/23/19 at 8:28 AM in her office confirmed the process of disinfecting the glucometers was for the nurses to disinfect the glucometers with an appropriate cleaner/disinfecting wipe before and after each resident use. The DON stated, {named LPN #1} should have cleaned the glucometer before and after each use with a germicidal wipe. The surveyors verified the A[NAME] by: 1. On 10/22/19 the glucometer was immediately removed from the medication cart E, cleaned and disinfected by the Unit Manager according to the manufacturer's guidelines. All other glucometers in the facility were cleaned by the Unit Managers according to the manufacturer's guidelines. The nurse on D/E Hall medication cart was educated on 10/22/19 by the Unit Manager as well as a Glucometer Competency was completed. The 3 residents that received blood glucose monitoring by this nurse on D/E Hall were assessed by the Nurse Practitioner (NP) on 10/22/19. The surveyor observed the Unit Manager remove two (2) glucometers from D/E Hall medication cart and disinfect the 2 glucometers per manufacturer's guidelines. The surveyor reviewed the glucometer cleaning log performed by the Unit Managers dated 10/22/19. The surveyor reviewed D/E Hall nurse's education and glucometer competency. The surveyor reviewed the 3 residents NP Assessments which revealed no signs or symptoms of an infectious process was identified. 2. The Unit Managers educated all licensed nurses present on 10/22/19 regarding glucometer cleaning and performed competencies. The Director of Nursing (DON) and Unit Managers ensured each nursing medication cart had 2 glucometers on 10/22/19. An Adhoc Quality Assurance Performance Improvement (QAPI) meeting was conducted by the Administrator on 10/22/19 to ascertain root cause and discuss the facility plan. The surveyor reviewed all nurses present on 10/22/19 education and competencies. The surveyor observed 2 glucometers on each medication cart in the facility. The surveyor reviewed the QAPI meeting plan. The surveyor observed nurses perform fingerstick blood glucose with proper disinfecting technique of the glucometer per manufacturer's guideline. 3. Licensed Nurses were educated by Unit Managers/ADON on 10/22/19 related to proper disinfecting of glucose monitoring machines. The Unit Managers will audit all medication carts weekly for 12 weeks to ensure 2 glucometers are present. The Unit Managers or DON or ADON will observe 3 blood glucose accuchecks (fingerstck blood glucose testing) per shift for 5 days a week for 2 weeks, then 2 blood glucose accuchecks per shift for 5 days a week for a week, then 1 blood glucose accuchecks per shift for 5 days a week and finally 3 blood glucose accuchecks per shift monthly for 2 months. Audits will be reported to QAPI committee monthly for 2 months (Medical Director, Administrator, DON, ADON, Dietary Manager, Activity Director, Rehab Director, Environmental Director, HR Director, Business Office Manager, Social Services Director, Director of concierge, Discharge Planner, Registered Dietician, and Admissions Director) for review and recommendations. The noncompliance of F-880 continues at a scope and severity of [NAME] level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide food and beverages at a palatable and appetizing temperature for 1 tray delivery cart, containing 22 resident meal trays, of 3 tray delivery carts delivered to the 1st floor. The findings include: Review of the undated facility policy, Food Temperatures, revealed .Foods should be transported as quickly as possible to maintain temperatures for delivery and service . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #54's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident was moderately cognitively impaired. Interview with Resident #54's family member on 10/21/19 at 1:52 PM in Resident #54's room, on the 1st floor, revealed the food was not hot when it arrived and stated she was present for the lunch meal daily. Medical record review revealed Resident #93 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #93's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14 indicating the resident was cognitively intact. Interview with Resident #93 on 10/21/19 at 9:45 AM in the resident's room, on the 1st floor, revealed during all meals the hot food was cold, the cold food was hot and the ice cream was always melted. Observation and interview with Resident #93 on 10/21/19 at 12:10 PM in the resident's room during the lunch meal revealed the food was warm and the ice cream was melted. Observation of the mid-day tray line meal service on 10/22/19 at 11:40 AM in the dietary department revealed the following food temperatures were obtained by the Food Service Director: 1. Pork Chop - 186 degrees Fahrenheit (F) 2. Pureed Chicken - 193 degrees F 3. Mechanical altered Pork - 177 degrees F 4. Cabbage - 199 degrees F 5. Pureed Cabbage - 158 degrees F 6. Pinto Beans - 192 degrees F 7. Pureed Pinto Beans - 190 degrees F 8. Milk - 41.6 degrees F, already above acceptable serving temperature of 40 degrees 9. Ice Cream - 16.5 degrees F Observation on 10/22/19 at 12:05 PM revealed the tray delivery cart, including the test tray, left the dietary department and was delivered to the 1st floor. All residents were served and eating at 12:49 PM. Continued observation revealed meal service delivery time was a total of 43 minutes. Observation on 10/22/19 at 12:49 PM, in the 1st floor common area, of the test tray temperatures taken by the Food Service Manager revealed the following: 1. Pork Chop - 119.8 degrees F, a loss of 66.2 degrees 2. Pureed Chicken - 115 degrees F, a loss of 78 degrees 3. Mechanical altered Pork - 116.8 degrees F, a loss of 60.2 degrees 4. Cabbage - 121.6 degrees F, a loss of 77.4 degrees 5. Pureed Cabbage - 119 degrees F, a loss of 39 degrees 6. Pinto Beans - 115.5 degrees F, a loss of 76.5 degrees 7. Pureed Pinto Beans - 114.8 degrees F, a loss of 75.2 degrees 8. Milk - 55 degrees F, an increase of 13.4 degrees 9. Ice Cream - 29.5 F, and was melted, an increase of 13 degrees Interview with the Food Service Director on 10/22/19 at 12:49 PM in the 1st floor common area confirmed temperatures weren't maintained on the 1st floor tray line meal service; the hot food was too cold; and the milk and ice cream were too warm.

Based on review of facility policy, review of a facility reported incident, medical record review, observation, review of a facility surveillance video, and interview, the facility failed to protect 2 (#316, #26 ) of 5 residents reviewed for physical abuse and 1 Resident (#1) of 6 residents reviewed for neglect. The abuse resulted in actual Harm to Resident #316. Findings include: Review of facility policy Abuse Prevention, revised [DATE] revealed, .The facility has a zero tolerance policy for abuse .physical abuse .is prohibited .The Abuse Policy applies to anyone involved with Residents of this facility, including, but not limited to, all facility staff .Abuse .willful infliction of injury .with resulting .physical harm or mental anguish .willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #316 was admitted to the facility on [DATE], was placed on Hospice [DATE] and expired on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #316 was rarely/never understood and had short and long term memory problems. She had unclear speech, and rarely/never understood others. She required extensive assistance of 2 or more people for bed mobility, and transfers. She required extensive assistance of 1 person for dressing and toileting. She was totally dependent with assistance of 1 person for locomotion on and off the unit, eating and bathing; and was dependent with assistance of 2 or more people for personal hygiene. She did not require pain medications. Review of a facility reported incident dated [DATE] revealed 2 Certified Nurse Assistants (CNAs) having a verbal argument and CNA #1 threw a plate lid at CNA #2. The plate lid hit Resident #316 in the face and she was transported to the hospital for care. CNA #1 was arrested on site by the local Police Department. Review of a hospital emergency department physician's note dated [DATE] at 9:18 AM revealed, .4 cm (centimeter) laceration with area of deep puncture extending below right eye, does not involve eye .facial plastics (plastic surgeon) at bedside .will repair laceration .discussed with nephew who is point of contact at bedside who is comfortable with patient's return to .facility . Review of a computed tomography (CT) scan report dated [DATE] revealed, .The patient has a [MEDICAL CONDITION] right nasal bone at the nasomaxillary junction (right side of the bridge of the nose) with subcutaneous [MEDICAL CONDITION] (gas or air in the layer under the skin) . Review of Discharge Instructions from the hospital dated [DATE] revealed the reason for the visit was a facial laceration. [DIAGNOSES REDACTED].Assault by striking with a [MEDICATION NAME] or thrown object, initial encounter .Alzheimer's dementia without behavioral disturbance .Closed fracture of nasal bone, initial encounter . Telephone interview with an Adult Protective Services (APS) Supervisor on [DATE] at 10:56 AM revealed they substantiated the alleged abuse based on the video. Further interview revealed, The video shows the CNA throwing the plate lid and it hit the resident . Observation on [DATE] at 8:00 AM in the State Survey office of a 1 minute digital video dated [DATE] at 7:30 AM recorded by the facility and provided by APS revealed 6 residents were in a day room along with 2 CNAs (CNA #1 and CNA #2) and 1 Licensed Practical Nurse (LPN) #2. 3 residents were seated in wheelchairs at one table and 3 residents were seated in wheelchairs at another table. LPN #2 had a medication cart at one doorway of the day room and was administering medications to a male resident seated at the table by CNA #2. CNA #1 was removing breakfast items from the breakfast tray and setting up the meal for a resident by placing used condiment wrappers and straw wrappers into an upside down hard plastic plate lid resting on the table. CNA #2 was at the other table approximately ,[DATE] feet away placing clothing protectors on the 3 residents. Both CNAs were seen talking to each other, CNA #1 stopped what she was doing, faced CNA #2 and put her left hand on her hip. CNA #2 kept talking to her. CNA #1 had the empty food tray in her left hand then picked up the plate lid with her right hand and threw it forcefully in the direction of CNA #2 who was standing between 2 residents; a male resident and Resident #316. The plate lid hit Resident #316 on the right side of her face. Her head was seen moving backward then forward. CNA #2 turned her head and right shoulder to the left to avoid being hit. The plate lid rolled out of another door of the day room. LPN #1 had her back to CNA #1 at the time she threw the lid and was giving medication to the male resident seated at the table by CNA #2. LPN #2 immediately stepped between the 2 CNAs and walked CNA #1 out of the room. As she was leaving the room, CNA #1 dropped the empty food tray on the floor by the door. There was no audio on the recording. Interview with the Administrator with the Director of Nursing (DON) present on [DATE] at 12:50 PM in the DON's office stated he was notified by phone sometime between 7:00 AM and 8:00 AM on [DATE] by LPN #5 that a resident was hit by a tray or something by CNA #1. The Administrator was driving to the facility at the time and instructed the nurse to bring CNA #1 to his office and have the Social Worker (SW) and LPN #5 view the video recording from the camera in the day room. After viewing the video, the police were notified and arrested CNA #1 at the facility. Interview with LPN #2 on [DATE] at 1:35 PM in the DON's office revealed the incident occurred in the F hall day room which is the secured dementia unit. Continued interview revealed, .The techs were setting up breakfast trays and one (CNA #2) told the other one (CNA #1) about not bringing drinks to the day room and (CNA #1) was like, 'I forgot.' I was in the room and I heard (CNA #1) say 'I'm gonna do something.' (CNA #2) said 'What you gonna do?' Then I told them to cool it or something to that effect. Next thing I heard a tray drop. I separated the 2 CNAs and called the supervisor. I put (CNA #1) on A hall and kept (CNA #2) on F hall. When I went back to F hall to finish my meds, (CNA #2) said, 'You need to look at (Resident #316's) face.' When I looked at it she had a gash on her face and it was bleeding a little bit at that time . Telephone interview with LPN #5 on [DATE] at 2:26 PM revealed she was the night supervisor and the only management person in the building on [DATE]. Continued interview revealed LPN #5 stated she received a phone call from LPN #2 telling me you need to come ASAP (as soon as possible) because I have 2 CNAs who aren't getting along and I have to have 2 CNAs on the secured unit .About ,[DATE] minutes later (LPN #2) comes to get me and tells me I need to come quick because a resident is hurt. The Nurse Practitioner (NP) was there, so I grabbed her and all 3 of us are in the elevator when (LPN #2) said she thinks CNA #1 threw a tray and she saw it bounce on the floor . Continued interview revealed LPN #5 stated, .(Resident #316) doesn't speak. She was in a high back wheelchair and I saw a laceration from her inner eye to her cheek approximately ,[DATE] centimeters .we called 911 .me and the Director of Maintenance viewed the video. There was no volume only video. I could see the CNA's hand gestures and (CNA #1) put her hands on her hip .the nurse was at the med cart .(CNA #1) threw the whole tray and the lid flew in (CNA #2's) direction and it hit the resident in the face. She can't verbally respond. Her head went back and forward and she can't move her arms very well, she's very, very weak Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Give ,[DATE] tablet (2XXX,[DATE].5 mg) by mouth every 4 hours as needed for pain. Continued review revealed Resident #316 received a dose of pain medication on [DATE], [DATE], and [DATE]. In summary, upon medical record review, observation and interview, the facility failed to protect Resident #316 from physical abuse resulting in actual Harm when CNA #1 injured the resident by throwing a plate lid in her direction on [DATE]. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating he was cognitively intact with a resident mood interview indicating moods occurring ,[DATE] days and no behaviors documented. Continued review revealed Resident #26 was independent with eating requiring set-up only by 1 staff person. Further review revealed the resident's mobility was independent with set up by 1 staff person in his electric wheelchair. Review of the facility investigation dated [DATE] revealed Resident #26 made derogatory remarks and racial slurs to Dietary Aide #3 after she brought him the wrong food order from the alternative food menu. Continued review revealed when the resident persisted with the derogatory remarks and racial slurs Dietary Aide #3, with her closed fist, punched Resident #26 on the left side of his face. Continued review revealed the Unit Manager immediately removed Dietary Aide #3 from the situation and placed her in a room, took her statement, and terminated her employment in the facility. Continued review of the facility investigation revealed video footage from a surveillance camera (from the facility's investigation) in the main dining room and a written statement from LPN #7. The written statement revealed on [DATE] at 7:47 PM Resident #26 and Dietary Aide #3 appeared to be arguing with Dietary Aide #3 aggressively finger pointing in the resident's face. At 7:51 PM, the same evening, the Dietary Aide #3 struck Resident #26 with a closed fist to the left side of his face and left the main dining room. Medical record review of the Nurse's Notes dated [DATE] revealed the resident's left ear was reddened and ordered pain medication was given as requested by the resident. Continued review revealed the resident felt safe and unthreatened. Telephone interview with an Adult Protective Services counselor on [DATE] at 10:01 AM revealed Resident #26 ordered food from the alternative food menu for dinner. Continued interview revealed Dietary Aide #3 delivered the food to Resident #26. Further interview revealed upon receipt of the food Resident #26 told Dietary Aide #3 it was not what he ordered and began yelling the derogatory remarks and racial slurs at the teh Dietary Aide #3. As the yelling persisted Dietary Aide #3 hit Resident #26 with her closed fist on the left side of his face. Continued interview revealed the Unit Manager immediately removed Dietary Aide #3 from the situation and placed her in a room, took her statement, and terminated her. Interview with the DON on [DATE] at 10:40 AM in the DON's office confirmed Dietary Aide #3 did physically abuse Resident #26 after he made racial slurs and called her names. Continued interview confirmed as a facility employee Dietary Aide #3 represented the facility and did deliberately punch the resident with her closed fist instead of initially walking away from the situation. Further interview confirmed the facility failed to prevent physical abuse to Resident #26. Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Based on review of facility policy, medical record review, observation and interview, the facility failed to change a soiled dressing Percutaneous Inserted Central Catheter (PICC) (a line that goes into your arm and runs all the way to a large vein near the heart for long term intravenous therapy) as ordered for 1 (#1) of 7 residents reviewed. Findings include: Review of facility policy IV Tubing and Dressing Changes dated [DATE] revealed .PICC line dressings will be changed weekly . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].change PICC line dressing ,[DATE] hours after insertion of line if dressing is soiled and then every 7 days . Observation on [DATE] at 9:50 AM in Resident #1's room revealed an old soiled transparent dressing, covering the PICC line of the upper left arm with a date of [DATE]. Observation and interview with the Unit Manager on [DATE] at 9:52 AM in Resident #1's room confirmed the transparent dressing was dated [DATE] to Resident #1's PICC line. Further interview confirmed the Unit Manger stated I see it and nodded her head in agreement that the facility failed to change the soiled dressing weekly as ordered resulting in neglect.

Based on review of facility policy, medical record review, observation and interview, the facility failed to change a soiled dressing Percutaneous Inserted Central Catheter (PICC) (a line that goes into your arm and runs all the way to a large vein near the heart for long term intravenous therapy) as ordered for 1 (#1) of 7 residents reviewed. Findings include: Review of facility policy IV Tubing and Dressing Changes dated 10/1/07 revealed .PICC line dressings will be changed weekly . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].change PICC line dressing 24-48 hours after insertion of line if dressing is soiled and then every 7 days . Observation on 7/10/18 at 9:50 AM in Resident #1's room revealed an old soiled transparent dressing, covering the PICC line of the upper left arm with a date of 6/20/18. Observation and interview with the Unit Manager on 7/10/18 at 9:52 AM in Resident #1's room confirmed the transparent dressing was dated 6/20/18 to Resident #1's PICC line. Further interview revealed the Unit Manger stated I see it and nodded her head in agreement that the facility failed to change the soiled dressing weekly as ordered.

Based on review of facility policy, observation, and interview, the facility failed to ensure food was served under sanitary conditions when a male dietary employee with facial hair was observed working on the tray line without wearing a beard net on 1 of 3 observations. Findings include: Review of facility policy, General Sanitation of Kitchen dated 2013 revealed .beard nets are required when facial hair is visible . Observation of the noon meal on 7/9/18 at 11:35 AM in the dietary department revealed one male dietary employee working on the residents tray line with visible facial hair not wearing a beard net. Interview with the Dietary Manager on 7/9/18 at 11:36 AM in the dietary department confirmed the male employee failed to wear a beard net to cover facial hair while working on the tray line.

Based on facility policy review, observation, and interview, the facility failed to maintain dietary equipment in a clean and sanitary manner, and failed to store and maintain frozen food in a sanitary manner in 1 of 1 dietary observations made; affecting 153 of 155 residents. The findings included: Review of a facility policy Food Storage dated 9/2007, revealed .Foods that are in direct contact with freezer burn (ice crystals) will be discarded .Items removed from the original container, should be .labeled with the contents and date placed in storage . Observation with the Dietary Manager (DM) on 6/19/17 at 9:20 AM, in the dietary department, revealed: A. 1 of 4 work tables with dried food debris on the table top and bottom shelves. B. The tray line conveyor with dried debris on the rollers, sides, and bottom. C. 2 of 2 convection ovens with thick burnt debris on the bottom of the ovens. D. 3 of 6 dry food storage containers with dried debris. E. The meat slicer blade with rust colored debris on the blade. Observation with the DM, on 6/19/17 at 9:35 AM, in the freezer, revealed the freezer contained a build up of ice on the floor and on food items. Interview with the DM identified the food items as: A. Two 10 pound (#) Buffet Hams B. Six 8# Pork Loins C. Five 5# rolls of Ground Beef Interview with the Dietary Manager on 6/19/17 at 9:50 AM, in the kitchen, confirmed the facility failed to maintain food service equipment in a clean and sanitary manner and failed to store and maintain frozen foods in a sanitary manner. Interview with the Administrator on 6/20/17 at 1:44 PM, outside the conference room, confirmed the failed to maintain the kitchen in a sanitary manner.

Based on facility policy review, observation, and interview, the facility failed to maintain the dish machine to ensure dishes were sanitized, failed to maintain food serving equipment in a clean and sanitary manner, and failed to store and maintain food in a sanitary environment, affecting 128 of 130 residents. The findings included: Review of the facility policy Dishwashing Machine Use dated 5/1/09, revealed, .Dishwashing machine chemical sanitizer concentrations .chlorine 50-100ppm (parts per million) . Review of the facility policy Manual Dishwashing/Storage dated 9/10/07 revealed .check all dishes to be sure they are clean . Review of the facility policy Food Storage dated 9/10/07 revealed .Items removed from the original container, should be .labeled with the contents and date placed in storage . Observation in the dish room, with the Dietary Manager (DM) on 7/5/16 at 10:25 AM, revealed the dish machine was not receiving adequate sanitizer during the cycle to sanitize the dishes. Further observation revealed the sanitizer could not be detected on the sanitizer test strips, times 3 attempts. Continued observation of the kitchen revealed 3 of 6 six inch steam table pans with white debris, and 4 of 10 four inch steam table pans with dried food debris. Interview with the DM on 7/5/16 at 11:00 AM, in the dish room, revealed the sanitizer had been checked and was not up to our standards. Further interview confirmed she felt the sanitizer strips were old and the dish machine company had been called to bring new strips. Interview with the DM on 7/5/16 at 11:05 AM in the kitchen confirmed the facility failed to maintain food serving equipment in a clean and sanitary manner. Interview with Administrator #2 on 7/5/16 at 11:15 AM, in the dish room, confirmed the dish machine was not functioning properly and was not sanitizing the dishes. Continued interview confirmed the test strips were not detecting sanitizer. Observation in the first floor nourishment room, with Administrator #1 on 7/6/16 at 8:55 AM, revealed 6 of 7 house supplements thawed, with no label containing storage placement date or use by date. Interview with Administrator #1 on 7/6/16 at 8:55 AM, in the first floor nourishment room confirmed 6 of 7 house supplements thawed, with no label containing storage placement date or use by date, and available for resident consumption.

Based on review of facility policy, review of facility cleaning schedule, observation, and interview, the facility failed to maintain a sanitary kitchen for one undated, repackaged prepared frozen food, one open to air, repackaged plastic bag of frozen food, and dust debris on a single cooling fan for one of one walk-in refrigerator for one of one kitchen reviewed. The findings included: Review of facility policy, Food Storage, Shelf Stable Food, undated revealed .close/seal all opened foods.date all opened foods with current date. Review of facility policy, Food Storage, Freezer Foods, undated revealed .all opened foods must be sealed. Review of facility cleaning schedule, Special Cleaning Schedule, undated revealed .Every Wednesday Unless Otherwise Noted.fans in walk-ins every month. Observation with the Registered Dietician/Dietary Manager (RD/DM) on 7/6/15 at 10:25 AM, in the walk-in freezer of the kitchen revealed a hand twisted plastic bag, undated, with 15 fried chicken patties. Continued observation revealed an opened, unsealed blue plastic bag with 30 pieces of fried fish. Observation with the RD/DM on 7/6/15 at 10:40 AM, in the walk-in refrigerator revealed a single cooling fan with dust debris. Continued observation revealed 10 shelled eggs sitting in an egg container under the blowing fan. Interview with the RD/DM on 7/6/15 at 10:45 AM, in the kitchen confirmed the facility failed to date and seal the frozen bags of food in 1 of 1 walk-in freezer and failed to maintain sanitary conditions in 1 of 1 walk-in refrigerator.

Based on facility policy review, observation, and interview, the facility failed to ensure all medications were in date for one of two medication rooms. The findings included: Review of facility policy, Storage of Medication, undated revealed . N. Outdated, contaminated, or deteriorated medications and those medications in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedure for medication disposal and reordered from the pharmacy. Observation on [DATE] at 10:05 AM, with Licensed Practical Nurse (LPN) #3 in the second floor medication room revealed two Lorezapam (antianxiety medication) 0.25 mg (milligrams) syringes containing 1 ml (milliliters) of white cloudy solution in refrigerated lock box. Continued observation revealed the pharmacy label expiration date was [DATE] on the package containing syringes. Further observation revealed an additional white sticker on the package with an expiration date [DATE]. Interview with LPN #3 on [DATE] at 11:24 AM, at the second floor nurses station confirmed I would expect those Lorazepams to be thrown out when they are found with past due expiration dates. The pharmacy verified that the medication was expired.