Every finding on record at Brandon Oaks Nursing and Rehabilitation Center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain provider ordered medications for (1) one of (25) twenty-five current sampled residents, Resident #54. Findings included:A facility policy entitled Subject: Unavailable Medications with a reviewed date of 1/2022 read in part, The facility must make every effort to ensure that medications are available to meet the needs of each resident. 1. Nursing staff shall: a. Contact the pharmacy to reorder the medication. b. Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy (ies) that are available. c. Notify the responsible party/POA. d. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the Medical Director for orders and/or direction.The Resident Face Sheet indicated the facility admitted the resident #54 on 12/6/2022. According to the Resident Face Sheet, the resident had diagnoses that included unspecified dementia and major depressive disorder with psychotic symptoms.The minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/9/2026 assigned the resident a brief interview for mental status (BIMS) score of 13 which indicated intact cognition. There were no mood or behavior indicators captured for the lookback period.The Medication Administration Record (MAR) for May of 2024 was reviewed. An entry on 5/11/2024 indicated that the resident was due to receive Wellbutrin XL 150 mg at 12:00 PM. Wellbutrin is an antidepressant medication taken daily to treat major depressive disorders. The medication was not administered and the reason documented on the MAR was Not Administered: Other Comment: waiting for meds from pharmacy, MD and Rp (responsible party) aware.On 8/11/2026 at 4:25 PM the RP was interviewed. The RP stated they were not notified by the facility staff of the unavailability of the medication on 5/11/2024. They stated when they took resident #54 to an outside appointment on 5/13/2024 they had been given a copy of the MAR to take to the provider. The RP stated they read the MAR entry stating that the medication was not given and not been sent timely from the pharmacy.On 8/13/2026 the Director of Nursing was interviewed. They stated the order was changed on 5/9/2024 from Wellbutrin XL 150 mg daily to Wellbutrin XL 150 mg every other day. They stated once the order changed, the supply of the medication was removed from circulation because the label was no longer correct and the pharmacy needed to send a new supply with the correct directions on it. The DON was asked for a copy of the available medications in their backup supply at the time and stated, We've changed pharmacies since then so I'm not sure I have anything to give you.The progress notes were reviewed for 5/11/2026. There were no notes addressing the unavailable medication, so it is unknown if the attending physician was offered suggestions of alternative therapies available per the facility policy. There was no physician progress note addressing it either.The survey team met with the Administrator, DON and Admissions Director on 8/13/2026 at 1:52 PM. This concern was discussed with them at that time. The DON provided a second copy of the MAR stating the medication was unavailable and that the physician and RP had been notified, along with a second copy of the policy. The DON stated, I just wanted to show that we followed our policy.No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review, facility staff failed to ensure food was stored under safe and sanitary conditions in the main kitchen. The findings included: The facility staff failed to dispose of out of date carnation sweetened condensed milk. The box containing the cans of milk included a best before date of August 2023. 09/07/23 8:15 a.m., the surveyor toured the main kitchen area with dietary employee #1 and #2. During this observation the surveyor along with dietary employee #1 observed an opened box of carnation sweetened condensed milk (cans) with a best before date of August 2023. Dietary employee #1 removed this box from the food supply and stated they would dispose of the items. 09/07/23, the Administrator was notified that the kitchen included a box of carnation milk with best before date of August 2023. The administrative staff provided the surveyor with a copy of their policy titled, Food Safety management System. This policy read in part, .Food stock rotation consists in using products with an earlier use-by-date first and moving products with a later sell-by date to the back of the shelf. This ensures that food is used within date .Locate products with the soonest best before or use-by dates. Remove items that are past these dates . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the nursing staff correctly implemented the facility's scheduled/controlled medication monitoring system to accurately account for the facility's scheduled/controlled medications for 1 of 15 current residents. Resident #19. The findings included: For Resident #19, the facility failed to ensure narcotics were accurately accounted for. Resident #19's face sheet included the diagnoses other acute postprocedural pain, hypertension, and presence of right artificial hip joint. Section C (cognitive patterns) of Resident #19's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/22/23 included a brief interview for mental status (BIMS) summary score of 12 out of a possible 15 points. Resident #19's comprehensive care plan included the problem area pain. Approaches included, but were not limited to, administer meds as ordered and encourage resident to report when pain interventions are not effective. The clinical record included a provider order for Oxycodone 5 mg every 6 hours PRN (as needed) for pain. A review of Resident #19's medication administration records (MARs) for 07/2023 revealed that no nursing staff had documented that they had administered Oxycodone to Resident #19 until 07/20/23 when Licensed Practical Nurse (LPN) #1 documented they had administered 5 mg of Oxycodone for pain in their legs at 2:32 p.m. LPN #1 documented the medication was effective. LPN #1 was an agency nurse. The facility staff provided the surveyor with 2 controlled drug records for this medication. Drug record #1 indicating the pharmacy had delivered 16 tablets of Oxycodone on 05/13/23. LPN #6 had signed as the receiving nurse. This form was crumpled and torn. The Administrator stated LPN #1 had taken this form from the facility after their shift but had later returned it. Drug record #2 revealed that the pharmacy had delivered 16 tablets of Oxycodone 5 mg to the facility on [DATE]. LPN #3 had signed for receiving the medication. 07/20/23, LPN #1 documented on controlled drug record #1 that they had removed 1 tablet of Oxycodone 5 mg at 8:00 a.m. LPN #1 documented the word dropped beside of this entry and made a second entry at 8:00 a.m. indicating they had removed a second tablet. LPN #1 did not document they had administered this medication on Resident #19's MAR. LPN #1 documented on the MAR they had administered Resident #19 1 tablet of 5 mg Oxycodone at 1432 (2:32 p.m.) on 07/20/23. However, the count went from #16 to #14 on the controlled drug record (#2) instead of #16 to #15. A review of Resident #19's progress notes revealed LPN #1, or any other nurse had not documented Resident #19 had complained of any pain on 07/20/23. The discrepancy on sheet #2 was identified by LPN #4 when counting narcotics with another nurse on Saturday 07/22/23. LPN #4 left a note and did not immediately report the discrepancy to the administrative staff. 09/07/23 10:35 a.m., during a meeting with the Administrator they stated LPN #1 came to the facility and returned controlled record sheet #1 it was crumpled up and torn. They did not ask this nurse to complete a drug test, the agency the nurse worked for was notified, stated they would do an investigation, but they had never reached back out to this facility. LPN #1 had provided the facility with a signed written statement (no date) indicating they had dropped a medication in the residents room on the floor, wasted it in the sharps box but did not have a witness (another nurse) to sign for the disposal of the medication. LPN #1's statement read in part, I dropped a medication in a Patients room on the floor, wasted it in sharps box. I did not have a witness sign it with me. I gave the same women her medication later in the shift, I signed it in the MAR and in the book towards the end of my shift. I made an error by doing so because I gave the medication twice by accident . LPN #1 also wrote that they accidentally took the narcotic sheet home because it was mixed in with other papers on their clipboard. During this interview the surveyor reviewed camera footage with the Administrator, Administrator in Training, and Director of Nursing. On the day of 07/20/23 LPN #1 (identified by facility staff) was observed entering a resident room at approximately 8:12 a.m. The administrative staff identified this room as belonging to Resident #19. LPN #1 was not observed returning to the medication cart and obtain a second dose of Oxycodone to administer to Resident #19. At approximately 2:25 p.m. LPN #1 was observed in the nurses station, observed to open a drawer of the medication cart, leave the nurses station, and walk a few steps down the hallway, turn around and reentered the nursing station. LPN #1 was not observed to enter any residents room(s) prior to turning around and re-entering the nurses station. During the video footage LPN #1 was observed to place a clipboard in their bookbag/backpack. 09/07/23 1:23 p.m., during an interview with Resident #19 they stated staff would knock on their door and ask them if they needed anything for pain. Resident #19 voiced no complaints to the surveyor regarding their stay at this facility. 09/07/23 2:20 p.m., during an interview with LPN#3 they stated they had counted narcotics with LPN #1 on 07/20/23 they had looked at the paperwork but did not actually look at the medications. A review of the nursing schedule for 07/20/23 indicated an agency nurse (no name) and LPN #3 had both worked this unit on different shifts. 09/07/23 4:10 p.m., during an interview with LPN #4 they stated they had noticed the discrepancy when counting medications on Saturday (07/22/23) when they arrived at work. There should have been a line for #15 and #14 and there was not a line for #15. The count was correct, but it didn't match up and they had left a note. The administrative staff provided the surveyor with a copy of their policy titled, CONTROLLED SUBSTANCES. This policy read in part, .Accurate accountability of the inventory of all controlled drugs is maintained at all times . 09/08/23 8:47 a.m., during an interview with LPN #5 (unit manager) they stated they were notified on Monday 07/24/23 between 6:30 a.m. and 7:00 a.m. by LPN #6 that there was a discrepancy with Resident #19's narcotic medications. They had tried to contact the Administrator but were unable to reach them. They had informed the Administrator when they arrived at work on the same day. 09/08/23 8:57 a.m., during an interview with LPN #6 they stated when they arrived to work on Sunday night (07/23/23) they completed a count of the narcotics with LPN #4. When they got to the narcotic page for the Oxycodone LPN #4 had put a sticky note on the narcotic sheet because the numbers were not matching. LPN #4 had asked them what they should do. LPN #6 stated the only thing I could think to do was to tell the unit manager on Monday morning (next morning). The numbers actually matched up but went from #16 to #14 not #16, #15, #14. LPN #6 stated they did not have any complaints from this resident and stated Resident #19 rarely asked for anything. The Administrator provided the survey team with information to indicate Resident #19 was not charged for the medications. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to accurately code a significant change MDS assessment to capture the residents hospice status for 1 of 15 current residents, Resident #31. The findings included: The facility staff failed to code Resident #31's significant change minimum data set (MDS) assessment to indicate the resident was receiving hospice services. Resident #31's face sheet included the diagnoses cerebrovascular disease, vascular dementia, and encounter for palliative care-hospice. Section C (cognitive patterns) of Resident #31's significant change MDS assessment with an assessment reference date (ARD) of 06/20/23 had been coded 1/1/3 to indicate this resident had problems with long and short term memory and as severely impaired in cognitive skills for daily decision making. Section O (special treatments, procedures, programs) was not coded to indicate this resident was receiving hospice services. The clinical record included a provider order dated 06/14/23 to admit to hospice services. Resident #31's comprehensive care plan included the problem area palliative care, resident has elected hospice benefits. 09/06/23 8:56 a.m., when Registered Nurse #1 was asked about the missing documentation regarding hospice RN #1 stated the box for hospice services was missed on the MDS. 09/06/23 4:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Administrator in Training, the issue with the coding of the MDS in regard to hospice services was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview and facility document review, facility staff failed to ensure food was stored under safe and sanitary conditions in 1 walk-in freezer and 1 drink/prep refrigerator. The findings: 1. Frozen carrots, California blend vegetables, pre-cooked hamburger patties, and pretzel bagels were not sealed in a container within the walk-in freezer. During the initial kitchen tour accompanied by the facility's food service manager on [DATE] at approximately 4:30 p.m., there were opened boxes of frozen carrots, California blend vegetables and pre-cooked hamburger patties. These foods were in a plastic bag within the boxes with the plastic bags opened, not sealed or tied closed. There were pretzel bagels in an opened, not sealed or tied plastic bag sitting on a shelf. The food service manager reported the expectation was for all foods to be kept in a closed container within the walk-in freezer and acknowledged these items were not currently stored properly. 2. Individual milk containers in the RC kitchen's drink/prep refrigerator had expired. While observing items kept within the RC kitchen's drink/prep refrigerator accompanied by the food service manager on [DATE], six of the eight individual fat free milk containers had expired on [DATE]. Five out of five individual containers of whole milk had expired on [DATE]. There were five individual containers of 2% milk with an expiration date of [DATE]. All of the milk containers were unopened. The food service manager acknowledged the items items had expired and discussed the concern with the facility's kitchen supervisor. The facility's administrator, director of nursing and one unit manager was informed of the above described observations during an end of day meeting on [DATE]. Observations in the walk-in freezer and RC kitchen drink/prep refrigerator were made again on [DATE] at 9:29 a.m. accompanied by the food service manager. All items in the walk-in freezer were in closed containers. All items within the RC kitchen's drink/prep refrigerator had not expired.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure that residents receive treatment by following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: For Resident #9, the facility staff failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 8/12/21 assessed Resident #9 with modified independence in cognitive skills for daily decision making with intact short-term and long-term memory in section C, Cognitive Patterns. The resident was unable to complete the BIMS (brief interview for mental status) interview. On 8/22/21 at 5:20 pm, during a medication pass and pour observation, surveyor observed RN (registered nurse) #1 squeeze out a small amount of [MEDICATION(S)] 1% gel onto their gloved fingers and apply to the resident's knee. RN #1 again squeezed out a small amount of the gel and applied to Resident #9's other knee. RN #1 did not measure the [MEDICATION(S)] 1% gel prior to application to either knee. After exiting the resident's room, surveyor asked RN #1 for the ordered dosage of [MEDICATION(S)] 1% gel for Resident #9. RN #1 stated 4 grams to each knee is the order but the resident does not want all of it, (he/she) showed them yesterday and (he/she) only wants half of it. RN #1 further stated they used about 2 grams for each knee. RN #1 obtained the measuring strip from the [MEDICATION(S)] 1% gel box and showed the surveyor the dosage lines for 2 grams and 4 grams. Resident #9's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 initialed the order on the August 2021 MAR (medication administration record) as being administered on 8/22/21 at 5:00pm. Surveyor observed RN #1 apply the medication to Resident #9's bilateral knees only. Surveyor requested and received the facility's policy for medication administration entitled, Medication Administration General Guidelines which states in part: Preparation 4. FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the EMAR by reviewing the 5 Rights. Documentation 4. The resident's EMAR is initialed by the person administering the medication, and on the line for that specific medication dose administration. Initials on each EMAR are cross referenced to a full signature. On 8/23/21 at 4:26 pm during a meeting with the administrator, director of nursing, Appalachian Unit Manager, and the Blue Ridge Unit Manager, surveyor discussed the concern of RN #1 failing to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. No further information regarding this issue was presented to the survey team prior to the exit conference on 8/24/21.

Based on observation, staff interview, and facility document review, the facility staff failed to dispose stored expired injectable medications in 1 of 3 medication storage rooms, Appalachian Unit. The findings included: The facility staff failed to dispose of an expired 10-count box of Influenza Vaccine prefilled syringes and a vial of [MEDICATION(S)] Purified Protein (Mantoux) solution with an open date of 7/01/21. On 8/23/21 at 3:05 pm, the surveyor, accompanied by LPN (licensed practical nurse) #1, entered the medication room on the Appalachian Unit and observed an open, complete 10-count box of Influenza Vaccine Flucelvac Quadrivalent prefilled syringes with an expiration date of 6/30/21 and an open multi-dose half-full vial of [MEDICATION(S)] Purified Protein (Mantoux) solution with an open date of 7/01/21 written on the box containing the vial. Both medications were located in a locked refrigerator. LPN #1 took the box of Influenza Vaccine Flucelvac Quadrivalent prefilled syringes and multi-dose vial of [MEDICATION(S)] Purified Protein (Mantoux) solution and gave them to the unit manager. The expiration date of 6/30/21 for the box of Influenza Vaccine Flucelvac Quadrivalent prefilled syringes and the opening date of 7/01/21 for the multi-dose vial of [MEDICATION(S)] Purified Protein (Mantoux) solution were verified by LPN #1 and the Unit Manager. The surveyor requested and received the facility's policy for medication storage, entitled Medication Storage in the Facility which states in part: Procedure: 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, if a current order exists. Expiration Dating: 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, [MEDICATION(S)] tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. 4c. Drugs dispensed in the manufacture's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: i. In a multi-dose injectable vial 6. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. 9. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. On 8/23/21 at 4:26 pm during a meeting with the administrator, director of nursing, and unit managers, surveyor discussed the concern of the expired medications located in the medication room on Appalachian Unit. No further information regarding this issue was presented to the survey team prior to the exit conference on 8/24/21.

Based on observation, staff interview, and facility document review, the facility staff failed to properly store food in resident accessible refrigerators in 2 of 2 Nourishment Stations in the facility located on Units 1 and 3. The findings included: For Unit 1, the facility staff failed to date a pre-made sandwich prior to placing in the refrigerator and failed to discard food that was brought in from outside the facility and placed in the refrigerator without a date. For Unit 3, facility staff failed to remove out of date milk from the refrigerator. On 2/25/20 at approximately 3:30pm, surveyor observed the contents of the Unit 3 Nourishment Station refrigerator and noted two cartons of chocolate milk with a sale by date of 2/24/20 and a carton of fat free milk with the sale by date of 2/21/20. On 2/25/20 at approximately 4:05pm, surveyor spoke with the CDM (certified dietary manager) who stated the facility uses the sell by date listed on each carton of milk as the discard card. Surveyor and CDM went to the Unit 3 Nourishment Station refrigerator and the CDM removed with the three cartons of milk and stated they would discard them and check the other refrigerators in the facility. On 2/26/20 at approximately 4:15pm, surveyor observed the following in the Unit 1 Nourishment Station refrigerator: ½ of a sandwich wrapped in plastic wrap labeled ham and cheese, a clear plastic container with sliced fruit labeled with a resident's name and room number, a clear plastic bag containing an open container of [MEDICATION NAME] cheese and a container with chocolate covered strawberries labeled with a resident's name and room number, and a plastic container of soup in the freezer labeled with a resident's name , room number, and soup. None of these items included a date. The CDM was notified and observed the undated items in the refrigerator and removed the sandwich and stated they would notify the families of the other items. Surveyor requested and received the policy Food Brought Into the Facility by Visitors which stated in part: Family or visitors must label the containers with the date it was brought into the facility and the name and room number of the resident receiving it As a rule, discard time/temperature for safety (TCS) food within 7 days from the date it was made Monitor refrigerators for foods that are beyond their 7 day date and discard food items On 2/26/20 at approximately 5:35pm, the administrative team consisting of the administrator, administrator in training, director of nursing, and unit manager #1 were notified of the outdated milk in the refrigerator on Unit 3 and the undated food items in the refrigerator on Unit 1. No further information regarding these issues were presented to the survey team prior to the exit conference on 2/27/20.

Based on clinical record review and staff interview, the facility staff failed to ensure the resident's right to formulate an advanced directive by failing to ensure the advanced directive in the resident's record was complete for 2 of 19 residents, Resident #206 and #212. The findings included: 1. For Resident #206, the facility staff failed to accurately complete the resident's DDNR (Durable Do Not Resuscitate Order) form. Resident #206's [DIAGNOSES REDACTED]. Resident #206 did not have a completed MDS (minimum data set) at the time of the survey. A Nursing Admission assessment dated [DATE] documented the resident's cognitive status as alert and oriented to all spheres. Resident #206's clinical record included a current physician's orders [REDACTED]. The clinical record also included a Virginia Department of Health DDNR (Durable Do Not Resuscitate) Order form dated 2/24/20 signed by the physician and the resident's authorized representative. This DDNR read in part Under section 1 I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Number 2 was circled Section 2 of the DDNR read, If you checked 2 above, check A, B, or C below . All three options were left unmarked. The concern of Resident #206's incomplete DDNR was discussed with the administrative team consisting of the Administrator, Administrator in Training, Director of Nursing, and Unit Manager #1 during a meeting on 2/26/20 at 5:30pm. No further information was provided prior to the exit conference on 2/27/20. 2. For Resident #212, the facility staff failed to accurately complete the resident's DDNR (Durable Do Not Resuscitate Order) form. Resident #212's [DIAGNOSES REDACTED]. Resident #212 did not have a completed MDS (minimum data set) at the time of the survey. A Nursing Admission assessment dated [DATE] documented the resident's cognitive status as alert and oriented to person only with memory problems. Resident #212's clinical record included a current physician's orders [REDACTED]. The clinical record also included a Virginia Department of Health DDNR (Durable Do Not Resuscitate) Order form dated 9/24/19 signed by the physician and the resident's authorized representative. This DDNR read in part Under section 1 I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Number 2 was circled Section 2 of the DDNR read, If you checked 2 above, check A, B, or C below . All three options were left unmarked. The concern of Resident #212's incomplete DDNR was discussed with the administrative team consisting of the Administrator, Administrator in Training, Director of Nursing, and Unit Manager #1 during a meeting on 2/26/20 at 5:30pm. No further information was provided prior to the exit conference on 2/27/20.

Based on staff interview and clinical record review, the facility staff failed to notify the physician in regards to administrating routine scheduled medications as evidenced by administrating medications to 1 of 19 residents at another time other than the routine scheduled times (Resident #12). The findings included: Resident #12 was a resident in the facility at the time of this survey of 2/25/2020 through 2/27/2020. On the most recent significant change MDS (Minimum Data Set), the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 12 out of a possible score of 15. Resident #12 was also coded as requiring extensive assistance of one staff member for dressing and bathing and being totally dependent on one staff member for bathing. The resident had the following [DIAGNOSES REDACTED]. During the clinical record review that was conducted 2/25/2020 through 2/27/2020, the surveyor noted the following in the January 2020 MAR (Medication Administration Record) for Resident #12: Scheduled Date 1/5/2020 Scheduled Time 9 AM Charted Date 1/5/2020 10:46 AM Reasons/Comments .Administrated Late . This was documented for the medication [MEDICATION NAME] 875-125 mg (milligram) to be administrated to the resident twice a day. Scheduled Date 1/5/2020 Scheduled Time 9 AM Charted Date 1/5/2020 10:46 AM Reasons/Comments .Administrated Late . This was documented for the medication of Carvedilol 6.25 mg to be administrated to the resident twice a day, Scheduled Date 1/4/2020 Scheduled Time 9 AM Charted Date 1/4/2020 10:13 AM Reasons/Comments: .Administrated Late . This was documented for the medication Eliquis 2.5 mg to be administrated to the resident twice a day. Scheduled Date 1/5/2020 Scheduled Time 9 AM Charted Date 1/5/2020 10:46 AM Reasons/Comments .Administrated Late . This was documented for the medication [MEDICATION NAME] 1,000 mg to be administrated to the resident twice a day. The surveyor notified the DON (director of nursing) of the above documented findings on 2/27/2020 at 1:30 pm. The surveyor asked the DON if the staff member administrators a medication other than the scheduled times (ie: an hour and 45 minutes after the scheduled time) what is the expectation of that staff member doing regarding this. The DON stated The nurse has an hour before and an hour after the scheduled time to administer the medication to the resident without it being considered outside of the schedule time. If the medication is given outside of that scheduled time than the nurse is to notify the physician that this has occurred. The surveyor requested a copy of the facility's policy regarding the administration of medication to the residents. The suryeor asked the DON if this documentation was present in the nurses' notes for these dates and times when the medication was not given at the scheduled time. The DON stated, I could not find any documentation that the physician had been notified on these dates. At 2 pm, the surveyor received the facility's policy titled Medication Administration General Guidelines from the DON. In this policy it read in part, .If a dose of regularly scheduled medication is withheld, refused, not available or given at a time other than the scheduled time, the nurse will enter the reason the medication was withheld, refused, not available or given at the time other than the scheduled time into the electronic medication record along with documentation the physician is notified. Nursing documents the notification and physician response. The surveyor notified the administrator and the DON at 4:46 pm on 2/27/2020 of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 2/27/2020.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) for 1 of 19 residents, Resident #53. The findings included: For Resident #53, facility staff coded the resident as being discharged to an acute hospital when in fact the resident had been discharged to an assisted living facility. Resident #53's [DIAGNOSES REDACTED]. The most recent discharge MDS with an ARD (assessment reference date) of 1/24/20 assigned the resident a BIMS (brief interview for mental status) score of 8 out of 15 in section C, Cognitive Patterns. Resident #53 is coded as being discharged to an acute hospital in section A, Identification Information. A review of Resident #53's medical record revealed a signed physician's orders [REDACTED]. Outpatient PT (physical therapy) and OT (occupational therapy) to eval (evaluate) and treat as indicated. A social services progress note dated 1/24/20 12:52pm states Patient discharge to (name omitted) IAL (Intensive Assisted Living) on 1/24/20. Patient outpatient services secured with (name omitted). Patient had no DME needs. Family present at discharge. No mood issues at this time. The medical record contained a Discharge Plan of Care signed by the discharging nurse on 1/24/20 indicating discharge destination is (name omitted) IAL. A nursing progress note dated 1/24/20 12:24pm states RSD (resident) transferred to IAL with all belongings. On 2/27/20 at 10:49am, the surveyor spoke with the MDS staff, RN (registered nurse) #1 and LPN (licensed practical nurse) #1, concerning coding for A2100 Discharge Status on the 1/24/20 MDS. LPN #1 stated the question should have been coded as 1, indicating discharge to the community. On 2/27/20 at 11:20am, RN #1 provided surveyor with a modified discharge MDS with an ARD of 1/24/20 with question A2100 coded as discharge to the community. On 2/27/20 at approximately 4:45pm, the administrator and director of nursing were notified of the inaccurate MDS assessment for Resident #53. No further information was provided prior to the exit conference on 2/27/20.

Based on staff interview and clinical record review, the facility staff failed to have an interdisciplinary team prepared plan that was resident centered specifying Transfer per Handling Program on the comprehensive care plan for 1 of 19 residents (Resident #13). The findings included: Resident #13 was a resident in the facility at the time the survey was conducted. The resident was admitted with the following [DIAGNOSES REDACTED]. On the most recent MDS (Minimum Data Set), the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 7 out of a possible score of 15. Resident #13 was also coded as requiring extensive assistance of two or more staff members for dressing and personal hygiene and being totally dependent on two or more staff members for bathing, During the clinical record review on 2/26/2020 and 2/27/2020, the surveyor noted the following entry on the resident centered comprehensive care plan (CCP) under the ADL Functional/Rehabilitation Potential which stated, .Transfer per Handling Program . There was no explanation of how the resident was to be transferred according to this program. The surveyor notified the DON (director of nursing) of the above documented findings on 2/27/2020 at 2 pm. The surveyor asked the DON according to this resident centered CCP, how is this resident supposed to be transferred. The DON stated, The staff would transfer the resident according to the transfer handling program. The surveyor asked the DON, does this resident centered CCP explain to the staff how this resident is supposed to be transferred (for example, one person assist, two person assist). The DON stated, No it does not. It just states Transfer per Handling Program. The surveyor notified the administrator and the DON of the above documented findings on 2/27/2020 at 4:46 pm in the end of the day conference. No further information was provided to the surveyor prior to the exit conference on 2/27/2020.

Based on clinical record review and staff interview, the facility staff failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan as evidenced by failure to administer medication per physician's orders [REDACTED].#217. The findings included: For Resident #217, the facility staff failed to follow physician's orders [REDACTED]. Resident #217's [DIAGNOSES REDACTED]. Resident #217 did not have a completed MDS (minimum data set) at the time of the survey. A Nursing Admission assessment dated [DATE] documented the resident's cognitive status as alert and oriented to all spheres. A review of Resident #217's medical record revealed a signed physician's orders [REDACTED]. Surveyor reviewed the resident's February 2020 MAR (medication administration record) and noted Carvedilol was not administered on 2/25/20 at 9:00am with the reason documented as due to condition, pulse 50. On 2/26/20 at approximately 5:35pm, the administrative team consisting of the administrator, administrator in training, director of nursing, and unit manager #1 were made aware of Resident #217 not receiving Carvedilol as ordered on [DATE]. On 2/27/20 at 12:07pm, surveyor spoke with Unit Manager #2 who stated the resident's physician's assistant clarified the order for Carvedilol adding parameters for administration. The clarified order for Carvedilol dated 2/27/20 added the parameter to hold if pulse is under 55. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/27/20.

Based on observation and staff interview, it was determined the facility staff failed to store and prepare food in a sanitary manner. Findings: Facility staff failed to store and prepare food in a sanitary manner. The facility kitchen was toured initially on 8/28/18 at 10:59 AM. The following were observed: 1. Six shallow tin pans were nested underneath sink. The pans were observed to have moisture between them when they were separated by the surveyor. The DM (dietary manager) instructed another staff member to separate the pans until they were air dried and then restock them. 2. A used bottle of Johnson's baby lotion was observed on a rack storing food condiments. The DM said one of the staff members meant to pick that up when she left. 3. A package of Wonton Noodles was observed to have been opened and rewrapped with cellophane and was stored on a rack in the dry goods section. The package did not have a label with the date opened or an end date to discard the item. The DM said she was going to dispose of the package because she did not know when it was opened. The facility administrator and DON were informed of the surveyor's findings. No additional information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility failed to ensure 2 of 18 residents were free from the use of unnecessary medications (Resident #23 and #42). The findings included: 1. The facility staff failed to ensure Resident #23 was free from an unnecessary medication. The facility staff failed to monitor the targeted behaviors for the use of an antidepressant medication, [MEDICATION NAME], for Resident #23 The findings included: Resident #23 was readmitted to the facility on [DATE] with the following diagnoses, but not limited to heart failure, high blood pressure, [MEDICAL CONDITION] and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/4/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. Resident #23 was also coded as requiring extensive assistance of 1 staff member for dressing and bathing and limited assistance of 1 staff member for bathing. The surveyor reviewed the clinical record of Resident #23's on 8/29/18. During this review, the surveyor noted a physician order [REDACTED]. The surveyor reviewed the MAR (Medication Administration Record) along with nurses' notes for the months of June, (MONTH) and (MONTH) (YEAR). The surveyor also reviewed the behavioral monitoring for the above stated months. The surveyor could not locate monitoring of targeted behaviors in regards to [MEDICATION NAME]. On 8/29/18 at 3:30 pm, the surveyor notified the unit manager #1 of the above findings. The unit manager #1 stated, I went through all the behavior sheets last night and added targeted behaviors that the nurses' are to monitor. Before this, we were just monitoring the side effects. The surveyor notified the administrative team of the above documented findings on 8/29/18 at 4:15 pm. No further information was provided to the surveyor prior to the exit conference on 8/30/18. 2. The facility staff failed to ensure Resident #23 was free from an unnecessary medication. The facility staff failed to monitor the targeted behaviors for the use of an antidepressant medication, [MEDICATION NAME] and [MEDICATION NAME], for Resident #42. Resident 42 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/7/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 14 out of a possible score of 15. Resident #42 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. The surveyor conducted a review of Resident #42's clinical record. The physician had ordered the following medications: [REDACTED]. Take along with 150 mg to =225 mg per dose and [MEDICATION NAME] 15 mg Take 1 tablet by mouth every night at bedtime for depression/appetite . The surveyor also reviewed the behavior monitoring sheets for June, (MONTH) and (MONTH) (YEAR) along with the MAR (Medication Administration Record) for the same months. The surveyor could not locate the targeted behaviors that the staff was to be monitoring. Unit Manager #1 was notified of the above documented findings on 8/30/18 at 9 am. The unit manager #1 stated, We have been monitoring for negative side effects not the targeted behaviors. The surveyor notified the DON (director of nursing) of the above documented findings on 8/30/18 at 10 am. No further information was provided to the surveyor prior to the exit conference on 8/30/18.

Based on staff interview and clinical record review, the facility staff failed to complete a level 1 PASARR (PreAdmission Screening and Resident Review) for one of 18 residents (Resident #10). The findings included: The facility staff failed to ensure a Level 1 PASARR was completed prior to Resident #10's admission to the facility. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/3/18 assessed the resident with a BIMS (brief interview for mental status) as 4 out of 15. During clinical record review on 8/29/18 and 8/30/18, the surveyor noted there was no PASARR in the chart. The unit manager licensed practical nurse #1 was informed and checked with admissions for a PASARR. A PASARR was not found for Resident #10. The administrator informed the surveyor on 8/30/18 at 11:09 a.m. that a PASARR had not been completed for Resident #10. No further information was provided prior to the exit conference on 8/30/18.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to store, prepare, distribute and serve food under sanitary conditions in the facility kitchens. Findings: On 6/9/15 during the initial tour of the facility beginning at 10:40 AM the main kitchen was inspected. The following issues were observed: 1. The stove cook tops were observed to have built-up grease on the surface and accumulated ashes and grease in the eyes of the burners. 2. One refrigerator was observed to have food (box of bacon) that had been opened and was not rewrapped securely or dated when opened. 3. A wash tub full of dirty water was sitting in the food preparation area while food items were being prepared. It was not used by facility staff during the observation, but remained in the area. 4. The sprinkler nozzles and piping above the stove cook-top were dusty with smut taggles. 5. Food debris and splash marks were observed on the kitchen fixtures, pipes and shelving. 6. The air intake grill in the ceiling, air conditioning unit and electrical lines over a food preparation area were dusty and dirty. Kitchen staff member #1 was asked about the tub full of cleaning water. She said it was kept there during the day so it would be available if needed for clean-up. On 6/9/15 at 11:30 AM the kitchen on the rehab unit was inspected. The following were observed: 1. Two packages of frozen chicken breasts were stored in the freezer and had not been dated. 2. The ice machine had a build-up of sediment on the area surrounding the dispenser. During the observation, Kitchen staff member #2 was asked about the chicken and the cleaning schedule for the ice machine. He told the surveyor the chicken was supposed to be dated, but he did not know who had stored the items in the freezer. The staff member said the chicken had been brought over from the main kitchen freezer the day prior. He said he was unsure how often the ice machine was cleaned. Kitchen staff member #2 informed the surveyor that some of the food served was received from another kitchen on the facility's campus. The third kitchen was inspected on 6/9/15 at 12:40 PM. The following issues were found: 1. The floor was wet in the food prep area in front of the steamer. The kitchen chef told the surveyor the steamer was leaking but had been scheduled for repair that afternoon at 1:00 PM. 2. Dirt, dust, splash marks and food debris were observed throughout this kitchen unit on the walls floors, fixtures, ovens and walls. 3. The staff had stored personal food items (English muffins) in the facility freezer commingled with resident food. The chef removed it stating, That is mine I should have dated it. 4. Food items (frozen steaks) were observed to be opened and returned to the shelving in the freezer without dates or rewrapping. 5. Hand scoops were observed to be stored in bins containing bread crumbs, flour and sugar. The chef told the surveyor, I thought that was ok. 6. In the dry goods storage area, the staff had hung a coat and knapsack on the wire shelving storing food. 7. Used towels and bagged towels were commingled with food items on shelving. 8. Food items (french fried onion rings) were observed opened and stored on shelving without dates. 9. Staff had personal drink cups siting on the shelves in dry good storage and in the food preparation area. The chef told the surveyor he let staff have their drinks in the kitchen So long as they have a lid on them. 10. The floor in the dry good storage area was sticky. 11. Stacks of clean trays were observed stored on wire shelving. On inspection the trays had been stacked there and remained wet, rather than left to air dry completely before storing. 12. The sprinklers and piping over the stove top was dusty and dirty. 13. A dirty, used apron was observed to be discarded on a food preparation table. 14. Food debris was observed to soil a storage rack where a quantity of cooked bacon was stored. 15. Various food items (salads, cakes, pudding) were observed to be stored in the refrigerators and were not covered, wrapped or dated. On 6/10/15 at 11:15 AM additional observations were made in the facilities main kitchen. Kitchen staff member #4 was observed to handle ready to eat food items (sandwich, fruit cocktail, desert pudding) with her bare hands. Upon consideration the staff member obtained and donned gloves to obtain the tray line temperatures on the cold food items. She was not observed to wash her hands prior to donning gloves. On 6/10/15 at 4:00 PM the facility administrator was informed of the surveyor's observations. He was asked to provide food storage policies and policies pertaining to handwashing and gloves by food service personnel. On 6/11/15 at 8:15 AM the food storage policies were reviewed by the survey team. They read, in part, .frozen and refrigerated foods are stored immediately. All items are dated when received to ensure correct product rotation.Food items are stored separately from non-food items. Chemical are stored in a separate area.Dry bulk food storage (flour, sugar, cereal.) In metal or plastic containers with tight lids. Store scoops for these items in a separate holder.Opened foods. Cover, label and date in clean container.Cleaning supplies. Properly, adequately labeled in a secured, completely separate area away from food. The policy on sanitation and infection control, pertaining to glove use and kitchen staff practice, contained, in part, .Gloves shall be worn at all times while handling food that will not be heated to above 145 degrees.All personal shall wear gloves while preparing the following foods. All personnel shall wash hands each time before gloves are put on.(included on the foods list) sandwiches, desserts, any foods not heated to 145 degrees, any ready to eat foods.Eating drinking, and gum chewing are not allowed in production, services or equipment, and utensil washing areas. No employees' coffee mugs or drinking cups are stored at work stations.All foods prepared in operation must be covered and labeled as to content and date of preparation prior to storage in refrigerators and freezers. The facility administrator also provided the survey team with a copy of the in-service provided to one kitchen staff member on the topic of Using gloves. No other information was provided prior to the survey team exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain an effective infection control plan for 3 of 16 Residents, Resident #9, #10, and #11 and in of 1 of 2 shower rooms (unit 1). The findings included. During a medication pass and pour observation on 06/10/15 the surveyor observed LPN's (licensed practical nurses) #1 and #4 drop a medication and then administer the medication to the Residents, LPN #4 did not complete any hand hygiene prior to preparing Resident #9's medications and on 06/09/15 the bathtub in the unit 1 shower room was observed to have a pair of pink socks, a wash rag, and a white scrub brush lying in the bottom of the tub. The drain of the tub was observed to have white debris around the drain and a brown stain above the drain. 1. During initial tour of the facility on 06/09/15 the surveyor entered the unit 1 shower room at approximately 11:05 a.m. The tub in the shower room was observed to have a pair of pink socks, a wash rag, and a white scrub brush lying in the bottom of the tub. The drain of the tub was observed to have white debris around the drain and a brown stain above the drain. There was a sign on the tub that read Please clean tub after each use. On 06/09/15 at approximately 11:10 a.m. the surveyor asked CNA (certified nursing assistant) #1 how often the shower room was used. CNA #1 stated it was used everyday and the tub was cleaned after every use. On 06/09/15 at approximately 11:30 a.m. the surveyor interviewed housekeeping employee (HKE) #1. When asked how often the bathroom was cleaned HKE #1 stated it was cleaned every day. HKE #1 then stated the CNA's were responsible for cleaning the tub they didn't clean the tub. On 06/10/15 at approximately 1:40 p.m. the surveyor interviewed CNA #2. When asked about cleaning the tub CNA #2 verbalized to the surveyor that the tub was cleaned after each use and the baths/showers were done on the 7-3 and 3-11 shifts. She stated that she did use the tub for some of her assigned Residents and that the tub did get used. CNA #2 stated that maintenance had worked on the tub the last couple of weeks due to an issue with the chair and that she mostly used the shower. During an end of the day meeting with the survey team on 06/10/15 at approximately 4:00 p.m. the administrator and DON (director of nursing) were notified of the above findings. On 06/11/15 at approximately 7:55 a.m. the administrator verbalized to the surveyor that the tub had not been used in a couple of weeks as the staff were uncomfortable with the way the chair was sliding in and out. The administrator also stated that they wouldn't put a Resident in the tub with it looking like that. The facility provided the surveyor with a copy of their policy/procedure with the subject line APOLLO WHIRLPOOL TUB CLEANING/DISINFECTING PROCESS. This policy/procedure read in part Purpose: 1. Medical asepsis to control infection. 2. To reduce the risk of transmission of organisms from resident to resident. Procedure: Bath Cleaning Process (Follow after every bath). 2. On 06/10/15 beginning at approximately 7:55 a.m. the surveyor observed LPN #4 during a medication pass and pour observation. LPN #4 identified Resident #9 as the Resident she would be administering medications to. Resident #9 was admitted to the facility 06/07/15 [DIAGNOSES REDACTED]. There was no MDS information completed on this Resident. However, the Resident was alert and orientated. LPN #4 identified herself and entered the Residents room asking her if she needed any pain medication. LPN #4 picked up items from the floor with her bare hands and then exited the Residents room. LPN #4 began preparing Resident #9's medications without performing any hand hygiene. After preparing the medications LPN #4 administered Resident #9's medications and completed hand hygiene. 3. LPN #4 then identified Resident #10 as the next Resident she would be administering medications to. Resident #10 was admitted to the facility 05/31/15. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment information completed for this Resident. The Resident was alert and orientated. LPN #4 prepared Resident #10's medication for administration. While preparing the Residents [MEDICATION NAME] the pill broke in half and half of the medication fell into the medication bin and the other half into the medication cup. LPN #4 verbalized that she would need to get a pill from the stat box. However, LPN #4 picked up the medication from the bin and placed it into the Residents cup with Resident #10's other medications and administered all the medications to Resident #10. After this observation the surveyor asked LPN #4 about dropping the pill and administering the medication. LPN #4 verbalized to the surveyor that she was going to get one from the stat box but she didn't. 4. On 06/10/15 beginning at approximately 8:30 a.m. the surveyor observed LPN #1 during a medication pass and pour observation. During this observation LPN #1 identified Resident #11 as the Resident she would be administering medications to. Resident #11 was admitted to the facility 05/15/15. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/22/15 scored the Resident 15 out of a possible 15 points. LPN #1 was observed by the surveyor preparing the Residents medications for administration. LPN #1 dropped the Residents [MEDICATION NAME] onto the top of the med cart picked it up with a napkin and placed it into the medication cup with Resident #11's other medications. After LPN #1 finished preparing the Residents medications all of the medications were administered to Resident #11. After the medication administration the surveyor interviewed LPN #1. LPN #1 stated that she usually would have gotten another pill to administer but that was the end of the pill cycle and she did not have any other pills to administer to the Resident. She then stated if she had not administered the medication at that time she would have been out of compliance. On 06/11/15 at approximately 2:30 p.m. the DON (director of nursing) and administrator were notified of the infection control issues during the medication pass. On 06/11/15 at approximately 3:45 p.m., the surveyor interviewed the DON. The DON identified herself as the infection control nurse and stated she would have discarded the dropped the medications. The surveyor reviewed the facility policy/procedure with a subject line of INFECTION CONTROL WITH MEDICATION PASS. This policy/procedure read in part Make sure hands are decontaminated before and after each patient and after touching contaminated equipment. No further information regarding the infection control issues was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure a hazard free environment. The findings included. The facility staff failed to properly store hazardous chemicals in the unit 1 shower room and failed to consistently monitor the temperature of the hydrocollator units in the rehab department. A hydrocollator unit is a heating device that is used to heat and store hot packs. On 06/09/15 at approximately 11:10 a.m., during initial tour of the facility, the surveyor entered the unit 1 shower room. This shower room included a closet that was unlocked. This unlocked closet contained 2 large jugs identified on the label as machine detergent; 1 of the jugs was full the other was 2/3 full, 3 large jugs labeled machine rinse agent, and 3 large jugs labeled machine prewash agent. The entrance door to the closet did include a lock. After leaving the shower room the surveyor interviewed CNA (certified nursing assistant) #1. CNA #1 was asked how often this shower room was used and CNA #1 replied it was used everyday. On 06/09/15 at approximately 11:30 a.m. the surveyor interviewed housekeeper #1. When asked if the shower room was ever locked housekeeper #1 replied the outside door was never locked. The surveyor did not observe a lock on the entrance door to the bathroom. On 06/10/15 at approximately 9:15 a.m. the surveyor observed that the door to the closet in the unit 1 bathroom was now locked. During a meeting with the administrator and DON (director of nursing) on 06/10/15 at approximately 4:00 p.m. the administrative team was notified of the unsecured chemicals. On 06/11/15 at approximately 7:55 a.m. the administrator provided the surveyor with a copy of their policy/procedure on chemical storage. This policy/procedure ready in part. Each individual department head will be responsible for monitoring and supervising their employees daily for proper safe storage of chemicals in the workplace.Stored chemicals will be in a locked room, cabinet. The MSDS (material safety data sheets) provided by the facility for the above chemicals included the following information. Wash Agent-May be irritating to eyes, skin, inhalation, and ingestion. Flush eyes and skin immediately with water. For inhalation remove to fresh air. For ingestion dilute stomach contents with water, if conscious, See a physician. Rinse Agent-Eyes may be irritating-flush immediately with running water for 15 minutes, skin may be irritating-flush with water immediately, Inhalation, may be irritating remove to fresh air. Ingestion Dilute stomach contents with water, if conscious. See a physician. Pre Wash Agent-Irritating to eyes, skin, respiratory, and digestive tracks. May be harmful if ingested. Eyes-immediately flush with water for at least 15 minutes. Seek qualified medical attention, Skin-Remove contaminated clothing. Thoroughly wash exposed skin with water, Inhaled-Remove to fresh air, Ingestion-Drink at least 2 glasses of water. Immediately contact qualified medical personnel. On 06/10/15 at approximately 3:15 p.m. the surveyor toured the rehab department with the rehab director. The rehab department had 2 hydrocollators. These will be identified as unit #1 and unit #2. On the side of each hydrocollator the facility staff had placed a plastic sleeve. Inside these plastic sleeves was a document titled Temperature Log Hydrocollator. The first temperature on both of these logs was documented on 02/25/15. The temperatures for both units was documented as 160 degrees. For the month of 03/2015 there were only 7 documented temperatures for unit #1 and 6 for unit #2. For 04/2015 there were 8 documented temperatures for unit #1 and unit #2. For 05/2015 there were none for unit #1 and 1 for unit #2. For 06/2015 the temperatures were up to date for unit #1. For unit #2 there was no documented temperature for 06/09/15. All of the documented temperatures for both units read 160 degrees. The rehab manager was asked about the missing temperatures. The rehab manager stated the tech was responsible for obtaining and documenting the temperatures. The administrative team was notified of the missing hydrocollator temperatures on 06/10/15 at approximately 4:00 p.m. On 06/11/15 at approximately 7:55 a.m. the administrator provided the surveyor with a copy of their policy/procedure regarding the Rehab Clinic and safety. This document read in part. 10. Temperatures for all appropriate equipment (refrigerator, hot pack machines.) are to be checked and recorded daily. On 06/11/15 at approximately 9:10 a.m. the surveyor interviewed rehab employee #2. Rehab employee verbalized to the surveyor that she was responsible for the temperatures when she worked. Rehab employee #2 stated she knew she had checked the temperatures she probably just hadn't wrote them down and that there were several days in the month of May she had not worked. No further information regarding these issues was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to equip corridors with handrails. The surveyor identified 3 areas that did not have handrails (1) outside wall of the unit 1 shower room, (2) room 125, and (3) room 128. The findings included. During a walkthrough of the facility on 06/10/15 the surveyor observed that there were areas on the outside wall of the unit 1 shower room that did not have any handrails. There was also a small part of a wall/corridor outside of room 125 that did not have a handrail. The administrator and DON (director of nursing) were notified of the missing handrails during an end of the day meeting with the survey team on 06/10/15 at approximately 4:00 p.m. On 06/11/15 at approximately 8:00 a.m. the surveyor and the administrator walked to the area of the missing handrails. During this observation the surveyor also noticed that there were missing handrails outside of room 128. On 06/11/15 at approximately 10:00 a.m. the surveyor, administrator, and maintenance employee #1 toured the facility. During this tour the surveyor again pointed out the missing handrails. The administrator verbalized to the surveyor that the fire marshall had inspected the building and approved the handrails. No further information regarding this issue was provided to the survey team prior to the exit conference.