Every finding on record at Briarwood Nursing and Rehabilitation Center, Inc

Based on observations and interviews, the facility failed to ensure garbage and refuse were disposed of properly for 2 of 2 dumpsters observed. The findings are: On 05/13/25 at 9:25 AM, and again on 5/13/25 at 12:16 PM, a large black piece of plastic and a large piece of cardboard were hanging out of the top of the dietary trash dumpster #1. A large broken white awning was lying on the ground behind dumpster #1. The awning had a large brown oval stain that measured approximately 2 feet long by 1 foot wide. The brown oval area was holding water in the covering of the awning. The fenced area around dumpster #1 did not have a gate to enclose dumpster #1. On 5/15/25 at 8:20 AM, the Administrator stated the Maintenance Director was responsible for cleaning the dumpster areas and he checked them every day. The Administrator stated they do not have a policy for garbage and refuse disposal. On 5/15/25 at 8:40 AM, the Maintenance Director (MD) stated he checked the dumpsters every day, Monday through Friday, to ensure the garbage was in the dumpster and the doors were closed. The MD stated he checked the dumpsters first thing on Monday and last thing on Friday to ensure everything was picked up and in the dumpsters. The MD stated the garbage truck picked up every day and had already picked up the trash today, 5/15/25. The MD stated the white awning lying behind dumpster #1 broke when the storms came through the area a couple of weeks ago and he had not had an opportunity to take it apart. On 5/15/25 at 8:43 AM, dietary dumpster #1 had the same large white awning lying on the ground behind the dumpster with water standing in the awning. The open-fenced area left the dumpster and broken awning, with standing water, exposed. Dumpster #2 ' s, referred to by the MD as the facility trash dumpster #2, gates were left standing open, one of the lids on the top of dumpster #2 was missing, and the side door of dumpster #2 was left open, exposing two white trash bags in the dumpster. On 05/15/25 at 10:14 AM, the MD stated it was important to keep the dumpsters clean and closed because you did not want to have critters in them, and we do not want to spread whatever was inside the dumpsters. The MD continued to state the water standing in the awning could cause mosquitoes and flies to harbor in it. The MD stated he did not have any documentation on the dumpster checks, it was just part of his normal duties.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a catheter bag did not touch the floor for 1 (Resident #42) of 1 resident during 2 of 2 observations to prevent hospital readmissions and the risk of infection in a resident with a suprapubic catheter and history of Urinary Tract Infections (UTI). The findings include: Review of Resident #42 ' s medical diagnosis revealed diagnoses which included heart failure, chronic kidney disease, and obstructive reflux uropathy (A condition where urine flow is blocked or reduced in the urinary tract). Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/2025, indicated a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Review of the Care Plan for Resident #42 revised on 11/27/2023, revealed the resident had an indwelling suprapubic catheter positioned below the bladder, and staff were to monitor for output, pain or discomfort. Review of Emergency Department Notes, dated 01/22/2025, indicated Resident #42 was recently admitted with E. Coli UTI and sepsis which required treatment in the Intensive Care Unit. Review of Hospital Discharge Summary dated 01/22/25-01/27/25, indicated Resident #42 was admitted with sepsis, UTI, and discharged on antibiotic to continue to treat lower UTI. Review of Hospital Notes from 03/18/2025, indicate Resident #42 was seen for altered mental status and suspicion of UTI. Resident #42 was started on antibiotic. Impressions from assessment were acute delirium, uncontrolled high blood pressure, UTI, catheter, and possible sepsis. Resident #42 ' s history of extended spectrum beta-lactamase (an enzyme that makes some bacteria resistant to common antibiotics) was noted. Review of Urology Report, dated 05/09/2025, revealed Resident #42 had recurrent UTIs and urinary retention. Resident #42 received one dose of antibiotic in the clinic. On 05/13/2025 at 2:23 PM, Resident #42 was observed resting in bed with suprapubic catheter tubing secured to the left upper thigh, tubing ran under the right leg and the catheter bag rested flat on the floor, under the bed. Resident #42 said staff used the lift to place the resident in bed, and they secured the catheter tubing after getting the resident in bed. On 05/14/2025 at 2:15 PM, Certified Nursing Assistant (CNA) #1 was asked how to determine the side of the bed a catheter bag was hung from. CNA #1 stated the catheter bag should be hung from the lower bed rail to drain urine and prevent problems, and revealed the catheter bag should never touch the floor because it could cause infection. Licensed Practical Nurse (LPN) #4 revealed that she was the nurse for 300 hall the last 3 days and did not realize Resident #42's catheter bag had been on the floor. LPN #4 stated catheter bags should never rest on the floor and stated urine could back up because it could not flow properly with the bag on the floor. LPN #4 also revealed catheter bags should never touch the floor to prevent illness. On 05/14/2025 at 7:07 PM, this surveyor entered Resident #42's room and observed an uncovered catheter bag resting in the middle of the floor on the right side of the bed, with the tubing attached to Resident #42's left leg. CNA #6 revealed that she placed the catheter bag on the floor and was assisting in personal care. CNA #6 was asked to describe the procedure used for storing the catheter bag during personal care, and stated she always kept the catheter bag below the bladder. CNA #6 stated she was not sure why catheter bags should not touch the floor. During an interview with LPN #3 on 05/15/2025 at 9:15 AM, LPN #3 sated she assisted in placing Resident #42 in bed, and revealed if staff were doing perineal care they clean the tubing in a direction taking germs away from the resident and the catheter bag was hung from the non-moving part of the bedframe. LPN #3 stated the catheter bag should never be on the floor, because it could cause infections, and revealed Resident #42 had been in the hospital a couple of times since admission due to UTIs. LPN #3 reported teaching staff to provide good perineal care and teaching the CNAs how to make sure the catheter bag was in a blue bag and hung under the wheelchair or bedframes so that it was not touching the floor to prevent infections, and noted catheters can cause pain if they gets pulled. LPN #3 revealed the catheter prongs were stiff and did not attach well to the bed frames. On 05/15/2025 at 9:46 AM, the Assistant Director of Nursing (ADON) stated catheter bags should be hung from a bed rail, always below the bladder, and should never be on the floor for safety and sanitary reasons. When a resident was in a wheelchair the catheter bag should be in a blue bag and hung under the wheelchair. If a resident had chronic UTIs and had a catheter, the ADON stated staff make sure the perineal area was cleaned well, and good catheter care was performed. The ADON said it would never be appropriate for a catheter bag to be on the floor, because of the risk of infection and staff were in-serviced on perineal and catheter care annually, as well as in-serviced on competencies. On 05/15/2025 at 11:37 AM, the Infection Preventionist (IP) stated part of monitoring was to refer Resident #42 to urology and noted the resident has had a couple of visits. The majority of Resident #42's antibiotics were started by the clinic and the facility followed antibiotic stewardship. The IP stated Resident #42 was admitted with a UTI and has had multiple complications with the catheter which required a few cultures and referral to urology. The IP revealed that catheter bags should be below the bladder and attached to the bed frame away from anything that could impede the tubing. The IP stated it did not matter which side of the bed the catheter bag was attached to but would pull it to the side where the lock was facing away from the door for privacy. The IP stated the catheter should never touch the floor in any setting, even if it was in a bag, no part should touch the floor due to contamination. On 05/15/2025 at 2:15 PM, the Medical Director stated catheter bags should not be on the floor, and she believed Resident #42 to be colonized and prone to infection, and despite hospitalization and going to urology they have had very little suggestions to prevent infection. Review of a policy on suprapubic catheter care, revised 11/22/16, indicated clean gloves, explain procedure to the resident, assist to dorsal recumbent position, clean around catheter well with soap and warm water, clean any crusted material well from the insertion site, do not pull on catheter or advance into the bladder, rinse and dry well, apply thin film of antiseptic ointment to edges of opening for suprapubic, observe for signs of infection, remove gloves, assist to comfort, wash hands, and report abnormal findings to the charge nurse, and any signs if infection, obstruction or irritation. A facility in-service dated 03/14/2025, which covered perineal care was requested but not provided.

Based on observations, record reviews and interviews, it was determined that the facility failed to immediately report to the Office of Long-Term Care (OLTC), an allegation of verbal and physical abuse for one (Resident #317) of one resident reviewed for abuse and neglect. The findings are: 1. Review of an Office of Long Term Care (OLTC) Incident and Accident Report with a discovery date of 03/31/2025 revealed the ADON was called to the room of Resident #317, where Resident #317 reported two facility Certified Nursing Assistants (CNAs) had gotten the resident out of bed following an episode of incontinence. Resident #317 alleged one CNA pushed the resident ' s shoulder into the wall and verbally abused them. The resident was unable to identify the alleged perpetrator. 2. A review of an Admission Record indicated the facility admitted Resident #317 with diagnoses that included mild cognitive impairment, anxiety disorder, and psychophysiologic insomnia. a. The admission Minimum Data Set with an Assessment Reference Date of 03/17/2025 revealed Resident #317 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #317 did not have verbal, physical, or other behaviors symptoms directed toward others. b. The Care Plan Report, initiated 03/11/2025, did not identify Resident #317 as exhibiting behaviors or delusions, or making false accusations towards staff. 3. During a phone interview on 05/14/25 at 09:21 AM, the officer who responded to a call regarding the incident stated he received a phone call from the facility, arrived at the facility, and was told the incident happened on the March 23 or 24, 2025. The officer interviewed the staff and spoke with the alleged victim and their spouse. The officer reported he was told the resident had dementia of some sort and had been known to have delusions. He stated the resident only said, they were black, when asked to identify the alleged perpetrators, and was unable to provide names. The officer stated, There were no witnesses or physical signs of abuse, but I made the report. 4. During an interview on 05/14/25 02:20 PM, the Assistant Director of Nursing (ADON) stated, After the investigation it was determined there were no findings to indicate any abuse happened. The family was informed and satisfied with the results. 5. During an interview on 05/15/25 08:40 AM, the Administrator stated, It couldn't have happened because there was one white CNA and one black CNA working that night. She stated, The investigation was conducted by the team and discussed with QA with no findings to support the claim. 6. During an interview on 05/15/25 10:40 AM, the ADON was asked if the abuse allegation should have been reported. She stated, No, we were able to prove with the internal investigation it did not happen and there were not two black girls that night. 7. During an interview on 05/15/25 11:10 AM, the Administrator was asked if the abuse allegation had been reported to the State Agency. The Administrator stated it had not. When asked if it should have been reported, the Administrator stated, No, we completed our internal investigation and proved there were not two black girls giving her a bath. 8. During an interview on 05/15/25 01:04 PM, the Director of Nursing (DON) was asked if the abuse allegation should have been reported. She stated, It was reported to the police officers. She stated, I don't think it should have been reportable because of our internal investigation was completed. 9. During a phone interview on 05/15/25 02:15 PM, the Medical Director said she was familiar with Resident #317 and was notified of what happened. She was asked if the abuse allegation should have been reported to the State Agency. She stated, No, the facility completed an investigation with no findings, the family was informed and satisfied with the investigation.

Based on observation, record review, interview, and Centers for Disease Control guidance, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) during wound care. Specifically, the Treatment Nurse failed to wear a gown when performing wound care for 1 sampled (Resident #7) resident during 1 of 1 observation to prevent cross contamination and the risk for infection. The findings include: A review of the Medical Diagnosis portion of the electronic health record revealed Resident #7 had diagnoses which included dementia, bipolar disorder, and cellulitis of the left lower leg. A review of the Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/2025 indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #7 required nonsurgical dressing changes, with application of ointments or medications. A review of Centers for Disease Control (CDC) Guidance for EBP, dated 06/2021, revealed gowning and gloving during high contact resident care, including wound care, was used to prevent multidrug resistant organisms (MDRO). MDROs in nursing home facilities contribute to comorbidities and mortality. Implementation of EBPs included training staff on the proper use of equipment. Healthcare workers can spread MDROs from pathogens on hands and clothing during resident care. A review of Physician Orders, dated 12/12/2024, revealed EBP were expected to be followed during Resident #7's wound care every shift. A review of a Care Plan for Resident #7 revealed a diagnosis of cellulitis of the left knee (dated 02/04/2025), and included interventions such as: monitor cellulitis of the left knee before and during negative pressure therapy, assure dressing was applied with a tight seal, give antibiotics for infection, and weekly documentation including measurements. A review of an In-Service Training Report, dated 03/14/2025, revealed staff were trained on EBP and how to care for residents with dementia. Education material for EBP training was not provided. A review of a Physicians Order, dated 05/08/2025, revealed instructions to treat Resident #7 ' s chronic ulcer of the left lower extremity. The instructions included cleanse the area with a topical antiseptic, pat dry, then use skin prep, apply antibiotic to the wound bed, pack, cover, and apply a dry dressing. Change dressing daily and as needed. On 05/14/2025 at 9:29 AM, this surveyor observed Licensed Practical Nurse (LPN) #3 perform hand hygiene, put on gloves, and set up for a dressing change for Resident #7's left lower extremity. LPN #3 was observed wearing gloves, without a gown, while removing old bandages and collagen from the left lower extremity. The Advance Practice Registered Nurse (APRN) was present during the dressing removal but did not assist. The APRN went to the bedside to assess the wound. LPN #3 performed hand hygiene and changed gloves, then proceeded to cleanse the wound with a topical antiseptic, around the outside and inside the wound area. LPN #3 then changed gloves and used alcohol gel, before putting on new gloves, without wearing a gown. On 05/14/2025 at 9:44 AM, this surveyor observed LPN #3 place collagen, with silver 1/4 sheet on Resident #7 ' s wound, dress their wound, then LPN #3 rolled up the table cover and discarded the trash into a clear bag. On 05/14/2025 at 9:50 AM, LPN #3 and the APRN revealed EBP signage indicated precautions should be worn during dressing changes for a resident with an open wound. The APRN confirmed that a gown should have been worn during wound care. LPN #3 stated she completely forgot to wear a gown and gloves during Resident #7's wound. On 05/14/2025 at 11:41 AM, the Administrator, the Assistant Administrator, and the Assistant Director of Nursing (ADON) were asked their expectations from staff, when performing wound care on a resident with open wounds that was on EBP. The ADON stated that staff were expected to follow EBP guidelines when caring for a resident on EBP. The Administrator stated staff were expected to follow EBP, because it was an infection control issue, and if the APRN was assisting with the wound, then they would be expected to gown and glove, as well. The Assistant Administrator agreed that EBP guidelines should be followed for residents on EBP. On 5/15/2025 at 2:30 PM, the Medical Director stated that her expectations were staff would follow EBP guidelines for infection control reasons. During an interview with the ADON, on 05/15/2025 at 5:00 PM, this surveyor requested the educational component of the facilities EBP in-service. The Administrator confirmed the facility did not have an EBP policy, but the facility followed CDC Guidance. A review of documents provided by the facility including, Infection Prevention, Control and Immunizations, CMS (2024), revealed EBP was evaluated during (high contact care) wound care, enteral feeding, and urinary catheter care. High contact care includes residents with chronic wounds, not skin breaks or tears with an adhesive bandage. Further documentation titled Enhanced Barrier Precautions, revealed they were used with standard precautions and include the use of gown and gloves during high contact resident care that could provide the opportunity to spread MDRO's on the hands and clothing of staff.

Based on observation, record review and interviews, the facility failed to ensure 2 of 2 refrigerators and freezers used for the storage of food items was clean and sanitary; food items stored in the refrigerator and freezers were labeled and dated to prevent potential cross-contamination and minimize the potential for food borne illness; the main facility kitchen failed to provide open dates on food items; expired food items were properly disposed of; open food items were not in sealed containers or had open dates. These failed practices had the potential to harm 99 residents. On [DATE] at 12:29 PM, in the 500-hall dining room, Surveyor observed 9 cups of water, 3 cups of flavored drink, and 3 cups of tea, on the dining hall cart without covers. The straws placed in the drinks were not covered. At 12:31 PM, Surveyor observed Certified Nursing Assistant (CNA) #10 take the drink cart into the food pantry to place paper towels over the drinks. CNA #10 then transported the drinks down the hallway. At 12:43 PM, Surveyor observed the paper towels did not fully cover the drinks. On [DATE] at 11:05 AM, Surveyor asked Dietary Manager if it was proper for drinks to be in the dining hall without being covered and straws already in the drinks. The Dietary Manager confirmed the drinks should have lids. The kitchen has wrap to cover the drinks if needed. The Dietary Manager confirmed the straws should be placed in the drinks if the resident chooses to have a straw. That should be the residents' choice. On [DATE] at 07:25 AM, surveyor observed the following food items on the kitchen storage room shelving unit with the potential to be given to the residents. 14 chocolate chips and 17 Lemon cookies (Named) soft baked cookies that were individually wrapped had expired on [DATE]; 24 ounces chocolate syrup expired ,d+[DATE]; 11 pounds chocolate fudge icing did not have an open date; and fish bread coating one-eighth of the bag left did not have open date. On [DATE] at 8:00 AM, in the Kitchen serving area the reach-in refrigerator a pitcher containing orange juice did not have a label and was not closed; 1 box of individual serving bags had the top open with 1 serving bag that had debris on top. On [DATE] in the food prep area, the following food items did not have an open date: poultry seasoning 12 ounces; ground mustard 16 ounces; rubbed sage 6 ounces; Italian Seasoning 6.25 ounces; Lemon and Pepper Seasoning Salt 28 ounces; Cajun Seasoning 18 ounces; Whole Celery Seed 16 ounces; Unseasoned Meat Tenderizer 35 ounces; Ground Allspice 16 ounces; Garlic Powder 21 ounces; Ground Cumin 14 ounces; Mediterranean Style Oregano leaves 5 ounces; Classic Ground Pepper 18 ounces; Classic Ground Cinnamon 18 ounces; Classic Paprika 16 ounces; Imperial Pure Lemon Extract 16 Fluid Ounces; Peppers in Vinegar 6 Fluid Ounces. Food items on bottom tier of food prep area that did not have an open date: Vegetable oil with natural flavor 1 gallon; Browning and Seasoning sauce 32 fluid ounce; Imitation Vanilla Flavor 128 fluid ounces; [NAME] Distilled Vinegar 1 gallon; Creamy Peanut Butter 5 pounds; and All-Purpose Greek Seasoning 5 pounds. 1 box opened Mashed Potatoes 57 ounces was in a food storage container that was not sealed. 5. On [DATE] at 08:31 AM in the second floor dining hall the following was found: the refrigerator held Variety Fruit Pack containing 4 diced peaches, 8 mixed fruit, 4 mandarin oranges was labeled to a resident had expired on [DATE] and did not have a receive date; 1 Mildly Thick Nectar consistency 46 fluid ounces did not have an open date; 1 Thickened Sweetened Tea with Lemon flavor 46 Fluid Ounces did not have an open date; 1 Thick and Easy Honey Consistency Hydrolyte Thickened Water with Hint of Lemon 46 fluid ounces did not have an open date; 1 Hormel Thick and Easy Nectar Consistency Thickened Water with Hint of Lemon 46 fluid ounces did not have an open date. 2 cups filled with fluids for residents to drink were on the counter without covers. 3 cups filled with fluids for residents did not have covers and were on the dirty dish return counter ledge next to plates and cups picked up from tables. Surveyor asked Dietary Manager if drinks poured into a cup should be left uncovered. The Dietary Manager confirmed the cups with fluids need a cover. Surveyor asked Dietary manager cups filled with fluids for residents to drink should be kept beside the dirty dishes. Dietary Manager confirmed they should not be next to the dirty dishes. Surveyor asked, Certified Nursing Assistant (CNA) #4 when the drinks without lids were poured. CNA # 4 confirmed the drinks were poured prior to 7:20 AM. They are extra drinks. Surveyor asked if pests with the drinks uncovered is a concern. CNA #4 confirmed if pests were around, they could get in the drinks. This could affect other drinks. Surveyor asked CNA #4 if the cups filled with fluid next to the dirty dishes were for the residents to drink. CNA #4 confirmed they were extra drinks for the residents. Surveyor asked CNA #4 if the drinks are for the residents should they be placed next to dirty dishes. CNA #4 said I don't know what to tell you. Surveyor asked CNA #4 what the concern would be if the drinks went to the residents. CNA #4 confirmed if it goes to the residents' concern would be cross contamination. 6. On [DATE] at 8:50 AM, in the 500 Floor Kitchenette, the following food items were found in the refrigerator 2 cups of white creamy substance without a label or received date and 24 cartons, 8 fluid ounces each, of Nutritional Drink Wild Berry without a received date. The following items were found in the freezer 1 Vanilla drink 6 fluid ounces and 3 kiwi strawberry dinks without a received date. 7. On [DATE] at 9:24 AM, the following was found in the cupboards and drawers: 9 bowls not covered and laying on their side on the top shelf; 25 white and 50 tan coffee filters were opened without being stored in a closed container; 6 coffee filter pack roast coffee filters with coffee opened without being stored in a closed container; 1 storage bag containing condiments had debris on the outside of the bag; 1 Sugar Free Liquid sweetener 12 fluid ounces did not have a received date. The drawer where the condiments and coffee were kept had coffee stains, brown loose debris, and brown dried substance on the inside. Surveyor asked Dietary Manager to describe the drawer. The Dietary Manager confirmed the coffee stains and debris in the drawer. Surveyor asked Dietary Manager what the concern for the coffee filters and coffee filters with coffee is to not be in a sealed container after being opened. The Dietary Manager confirmed cross contamination. Surveyor asked Dietary Manager what would be your concern with receiving something from the storage bag containing condiments that had debris on the outside of the bag. The Dietary Manager confirmed I would not want something from there. Surveyor asked Dietary Manager how should bowls and cups be stored? The Dietary Manager confirmed they should be kept in a closed container, or the plastic cover should be closed for nothing to get into them. Surveyor asked Dietary Manager when the liquid sweetener was received. The Dietary Manager confirmed I do not know where that came from. 8. On [DATE] at 9:42 AM, surveyor observed the refrigerator second shelf had a brown liquid accumulated underneath the glass and the shelving lip was cracked. The refrigerator floor had red fluid pooled in the back left corner and red spill spots on the front right side. Surveyor asked the Dietary Manager to describe what the refrigerator looked like. The Dietary Manager confirmed the refrigerator needed to be cleaned. Surveyor asked what the concern with the refrigerator is. The Dietary Manager confirmed the broken areas can influence cooling the refrigerator. The cleanliness can cause cross contamination the longer it sits and grows bacteria. 9. On [DATE] at 09:25 AM, Dietary #1 raised the lid on the ice machine located in the main kitchen on the first floor, and the Surveyor observed a black substance on the rubber seal above the milk cartons. 10. On [DATE] at 11:44 AM, CNA #8 was observed carrying a cup of water and tea by resting CNA 8's fingers around the rims and placing in front of a resident. 11. on [DATE] at 9:57 AM, the Dietary Manager provided the policy Storage of Dry Food and Supplies Policy The Dietary Department will store dry food and supplies according to policy guidelines and state regulation, .3. Use metal or plastic containers with tight-fitting covers to store products. Label top of containers ., 5. Reseal open boxes effectively. Bulk products, such as crackers, cereal, cookies, pasta, etc., are to be stored in properly labeled and sealed containers or tightly closed food-grade plastic bags after being opened . 12. On [DATE] at 10:34 AM Dietary Manager provided the policy Food Safety - Infection Control Food Storage which states If an item with no content label is removed from a box, place a label with the contents and date on the item ., .When items such as cereal, cake mixes, etc. are opened but the entire contents of the package are not used, place the unused food in a NSF approved container with a securely fitting lid. Be sure to label and date the container. Folding the top down, taping, or wrapping the item in plastic wrap is not sufficient . On [DATE] at 09:25 AM, Dietary #1 raised the lid on the ice machine located in the main kitchen on the first floor, and the Surveyor observed a black substance on the rubber seal above the milk cartons. The Surveyor touched the rubber seal, and a dry, black crumbly substance came off on the Surveyors fingers and could easily fall to the milk cartons below. The Surveyor asked Dietary #1 what the dark substance looked like, and if she had any concerns with the unidentified substance on the ice machine's rubber seal. Dietary #1 did not identify the substance, and pointed out the cartons below were sealed. [DATE] 09:36 AM, The Surveyor observed 9 rolls of stacked plates, and 13 rolls of stacked dessert bowls resting under the prep table face up, in the main floor kitchen. The Surveyor observed small brown and black particles resting in 2 of the bowls. The Surveyor asked Dietary #1 if the normally the process used to stack dishes. Dietary #1 said no there is normally plastic wrap placed over the dishes stored under the prep table. The Surveyor asked why they would want to cover the dessert bowls and plates. Dietary #1 said staff prep food above the dishes, and it would keep food from falling into the dishes below. Dietary #1 said she also thinks that when people come in and out of the kitchen it can bring in dust and debris. On [DATE] at 11:44 AM, CNA #8 was observed carrying a cup of white and a cup of brown fluid by resting CNA 8's fingers around the rims and placing in front of a resident. On [DATE] at 11:45 PM, the Surveyor asked CNA #8 what procedure staff used to handle glasses. CNA #8 said cups are not to be held by the rim. The Surveyor asked CNA #8 why staff are not supposed to hold cups by the rim, and CNA #8 said, It's due to infection risk. On [DATE] at 10:06 AM, the Assistant Director of Nursing [ADON] was asked what process staff are expected to follow when passing out cups and plates? The ADON said they are supposed to hold cups and plates from the bottom so their fingers do not touch where a resident's mouth may touch for sanitary reasons. The ADON expects staff to follow this procedure. 49413

Based on observation, interview, and record review, the facility failed to develop care plans to address one resident with a pressure ulcer for 1(Resident #99) one resident receiving a tube feeding (Resident #173) 2 residents receiving anticoagulant medications (Resident #111 and 173), and one resident receiving antianxiety and antidepressant medications (Resident #173) to ensure appropriate coordination of care. This failed practice had the potential to affect 6 residents that had pressure ulcers, 2 residents that had tube feedings, 25 residents that received anticoagulant medications, 18 residents that received antianxiety medications and 48 residents that received antidepressant medications. The findings are: 1. Resident #99 had diagnoses of Heart failure, Dementia, and Polyneuropathy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2024 documented that the resident scored 8 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS) and had a stage 3 pressure ulcer. a. A physician's order dated 02/22/2024 documented, .TX (Treatment) to stage 3 to left heel: Clean with [named product]. Pat dry. Apply skin prep to perineal wound. Apply [named product] to wound bed. Cover with dry dressing q MWF (Monday, Wednesday, Friday) and PRN (as needed) every day shift every Monday, Wednesday, Friday for 2 Weeks . b. On 03/05/2024 at 10:09 AM, Resident #99 was sitting up in the wheelchair in the day room with a lift pad under her buttocks. The resident had an off-loading boot on their left foot. c. On 03/06/2024 at 11:30 AM, Resident # 99 ' s care plan did not have an intervention that addressed the pressure ulcer on their left heel. d. On 03/07/2024 at 09:05 AM, the Surveyor asked Minimum Data Set (MDS) Coordinator #2, Does (Resident #99) have a pressure ulcer on his/her left heel? Licensed Practical Nurse LPN #2 stated, Yes, he/she does. The Surveyor asked MDS Coordinator #2, Does Resident #99's care plan address that [the resident] has a pressure ulcer? MDS Coordinator #2 looked in the electronic record and stated, Yes, it does. The Surveyor asked MDS Coordinator #2, When was the care plan addressing the residents pressure ulcer put in place? MDS Coordinator #2 stated, It was done 03/06/2024. The Surveyor asked MDS Coordinator #2, When did the resident develop a pressure ulcer on her heel? MDS Coordinator #2 stated, I am not sure. I will have to ask the treatment nurse. The Treatment Nurse stated, The resident developed a pressure ulcer on 2/8/24. The Surveyor asked MDS Coordinator #2, When should the care plan addressing the residents pressure ulcer on their heel have been developed? MDS Coordinator #2 stated, It should have been put on the care plan when it [the pressure ulcer] developed. The Surveyor asked the MDS Coordinator #2, Why is it important that the pressure ulcer on the resident's heel was addressed on the care plan when it occurred? MDS Coordinator #2 stated, So everyone was aware of [the resident ' s] skin issues and the proper care was given according to the care plan. 2. Resident #173 had diagnoses of Quadriplegia, Malnutrition, and Dysphagia. The Quarterly MDS with an ARD of 1/2/24 documented that the resident scored 3 (0-7 indicates severe impairment) on the BIMS and received more than 51% of their total calories through a tube feeding. a. A Physicians order dated 12/14/2023 documented, .four times a day [named formula/feeding] 1.5, 250 ml, if patient consumes <50% of meals. Flush Mw(with)/50 ml(milliliters) H2O (water) pre/post (before and after) feeding . b. On 03/06/2024 at 10:00 AM, the Surveyor reviewed Resident #173 care plan with an initiation date of 11/15/23 and it did not address the residents had a gastrostomy tube for feedings. c. On 03/07/24 at 08:45 AM, the Surveyor asked MDS Coordinator #2, does Resident #173 have a feeding tube? MDS #2 stated, Yes. The Surveyor asked MDS Coordinator #2, Does Resident #173's care plan address that they have a feeding tube? MDS Coordinator #2 looked at the electronic record and stated, No. The Surveyor asked MDS Coordinator #2, Should the residents care plan address they have a feeding tube? MDS Coordinator #2 stated, Yes. The Surveyor asked MDS Coordinator #2, Why is it important that the residents care plan addresses the use of a feeding tube? MDS Coordinator #2 stated, It is important so that staff know how [the resident eats and receives medication]. 3. Resident #173 had diagnoses of Quadriplegia, Respiratory failure, and Atrial fibrillation. The Quarterly MDS with an ARD of 1/2/24 documented that the resident scored 3 (0-7 indicates severe impairment) on the BIMS and received an anticoagulant medication. a. A physician's order dated 09/28/2023 documented, . Eliquis Oral Tablet 5 MG (Milligrams) (Apixaban) Give 5 mg via PEG (Percutaneous Endoscopic Gastrectomy)-Tube two times a day related to ATRIAL FIBRILLATION (I48.91) 1 tablet by Per G (Gastrostomy) Tube route 2 (two) times daily . b. On 03/06/2024 at 10:00 AM, the Surveyor reviewed Resident #173 care plan with an initiation date of 11/15/23 and noted it did not address the use of anticoagulant medication. c. On 03/07/2024 at 08:55 AM, the Surveyor asked MDS Coordinator # 2, Does (Resident #173) receive an anticoagulant medication? MDS Coordinator #2 looked at the electronic record and stated, Yes. The Surveyor asked MDS Coordinator #2, Does (Resident #173's) care plan document that she receives an anticoagulant medication? MDS Coordinator #2 looked at the electronic record and stated, No. The Surveyor asked MDS Coordinator #2, Should the residents care plan address that she is on an anticoagulant? MDS Coordinator #2 stated, Yes. If she is on one, it should address it. The Surveyor asked MDS Coordinator #2, Why is it important that the residents care plan addresses the use of anticoagulant medication? MDS #2 stated, To know that if she has any falls that unexplained bleeding could be attributed to the anticoagulant. 4. Resident #111 had diagnoses of Medically complex conditions, Atrial fibrillation, Anxiety, and Atrial flutter. The MDS with an ARD of 1/16/24 documented that the resident scored 5 (0-7 indicates severe impairment) on the BIMS and received an anticoagulant medication. a. A physician's order 1/12/2024 documented .Eliquis Oral Tablet 2.5 MG (Apixaban) Give 2.5 mg by mouth two times a day related to ATRIAL FLUTTER (I48.92); ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) Take 1 tablet by mouth 2 (two) times daily . b. A physician's order dated 02/24/2024 documented, .BusPIRone HCl Oral Tablet 5 MG (Buspirone HCl) Give 2 tablet by mouth two times a day related to ANXIETY DISORDER, AND Give 1 tablet by mouth one time a day related to ANXIETY DISORDER c. A physician's order dated 02/22/2024 documented, .Zoloft Oral Tablet 25 MG (Sertraline HCl) Give 2 tablets by mouth one time a day related to ANXIETY DISORDER d. On 03/06/2024 at 08:45 AM, Residents #111 ' s care plan did not address the use of antianxiety, antidepressant and anticoagulant medication. e. On 03/07/2024 at 09:05 AM, the Surveyor asked MDS Coordinator #1, Does (Resident #111) receive antidepressant, antianxiety and anticoagulant medications? MDS Coordinator #1 looked in the electronic record and stated, Yes she does. The Surveyor asked MDS Coordinator #1, Does (Resident #111's) care plan address that she receives antidepressant, antianxiety and anticoagulant medications? MDS Coordinator #1 looked in the electronic record and stated, No. The Surveyor asked MDS Coordinator #1, Should the residents care plan address the use of antidepressant, antianxiety and anticoagulant medications? MDS Coordinator #1 stated, Yes. The Surveyor asked MDS Coordinator #1, Why is it important that the residents care plan addresses them receiving antidepressant, antianxiety and anticoagulant medications? MDS Coordinator #1 stated, Because of the risk of falls and so that staff are aware that the resident is receiving the medications. f. On 03/07/24 at 10:00 AM the Assistant Director of Nursing stated, We do not have a policy on care plans.

Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately to reflect that a resident was receiving anticoagulant medication for 1(Resident #17) sampled resident. The failed practice had the potential to affect 8 (Residents #68, #99, $73, #56, #31, #323, #4 and #116) sampled residents. The findings are: Resident #17 had diagnoses of Atrial fibrillation and Intervertebral disc degeneration, lumbar region and was prescribed an anti-inflammatory. a. The Quarterly MDS for Resident #17 with an Assessment Reference Date (ARD) of 02/02/2024 was identified as having an MDS discrepancy as evidenced by incorrect coding of an anti-inflammatory medication as an anticoagulant. b. MDS #2 was asked, Would you look up your last MDS assessment and clarify the anticoagulant coded? MDS #2 stated, Well, I have Aspirin listed and I realize that is not an anticoagulant, I'll have to fix that. The Surveyor asked, Why do you need to have correct coding on your assessments? MDS #2 stated So they know and understand the correct medications and information. The Surveyor asked, What guideline do you follow for assessments and changes? MDS #2 stated I use the Resident Assessment Instrument Manual. c. On 03/07/2024 at 09:20 AM, the Assistant Director of Nursing (ADON) was asked, What is your policy on MDS and care plans? The ADON stated We don't have one.

49688 Based on interview and record review, the facility failed to complete discharge Minimum Data Set (MDS) assessments in a timely manner for 7 (Resident #9, #23, #32, #36, #54, #77 and #97) sampled residents, and failed to complete admission MDS assessments in a timely manner for 2 (Resident #46 and #274) sampled residents. The failed practice had the potential to affect 135 residents who discharged home in the past 120 days and 124 residents admitted in the last 120 days. The findings are: On 03/05/2024 at 05:16 PM, record review showed MDS assessments 120 days overdue for 7 (Residents # 9, #23, #32, #36, #54, #77 and #97 with no discharge information. On 03/06/2024 at 09:45 AM, during interview with MDS #1, the Surveyor asked, What is the timeline to do discharge assessments? MDS #1 stated I have a week to do them so about a week. The surveyor asked, Would you look up Resident (R) #77 and tell me when the discharge summary was completed? MDS #1 stated I have not done it yet. The Surveyor asked, Would you look up R #32 and tell me when a discharge summary was completed? MDS #1 stated I have not done it yet; I can tell you I'm behind on all of them. The Surveyor asked, I have a few more to look up. MDS 1 stated, There is no need to keep looking them up I admit I am behind on all of them. On 03/07/2024 at 09:20 AM, the Assistant Director of Nursing (ADON stated We do not have a policy on discharge MDS assessments. On 03/05/2024 at 11:37 AM, the Surveyor noted during record review for Resident #274 the Admission MDS was in progress and initiated on 02/12/2024. Resident #274 was admitted (re-entry) to the facility on [DATE]. On 03/06/2024 at 10:37 AM, the Surveyor noted during record review for Resident #46 that Admission MDS) was in progress and initiated on 02/12/2024. Resident #274 was admitted (re-entry) on 02/16/2024. On 03/06/2024 at 09:45 AM, the Surveyor asked MDS #1 how many days does the facility have to complete an Admission MDS after the Resident is admitted to the facility? MDS #1 stated, 14 days. On 03/06/2024 at 11:20 AM, the Surveyor asked the ADON, How long does the facility have to complete an Admission MDS after the Resident is admitted ? ADON initially stated, 7 days let me clarify that ADON later stated 14 days. 03/06/24 12:00 PM, the Surveyor asked the MDS Coordinator does the MDS not being completed in a timely manner affect the Resident's care directly? MDS #1 stated No. The Surveyor asked MDS #1, Does MDS trigger care area that need to be care planned? MDS #1 stated, It does ADL (Activities of Daily Living), Pain, Psych. ADL is the biggest one and we do that on admission. The Surveyor asked MDS #1, What about any changes after admission, for example a catheter? MDS #1 stated, Well, the nurse care plan it when he/she gets the order or if I catch it, it's everybody's job.

Based on observation, record review and interview, the facility failed to properly store and maintain a denture cup and toothbrush in a safe, clean, sanitary manner to prevent the risk of cross contamination for 1 (Resident #96) of 4 sampled (Resident 11, R#21, R#91, R#96) with the potential to affect 23 residents on 400 hall dependent on staff for receiving oral care for personal hygiene. The facility failed to ensure that staff used proper hand hygiene while assisting Residents (#22, #30, #59, #86, #275) with meal service and while aiding with bed bath for Resident #116. The facility also failed to ensure that staff refrained from placing items used during care on the floor. This failed practice had the potential to cause the spread of infectious disease throughout the facility. The findings are: 1. Resident #96 with a diagnosis of OTHER DISPLACED FRACTURE OF UPPER END OF LEFT HUMERUS, SYNCOPE AND COLLAPSE, and DEPRESSIVE DISORDERS. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01/08/2024 indicated a Brief Interview for Mental Status score of 15 (13-15 suggest cognitively intact). Resident #96 requires set up assistance for meals, and oral care. Resident #96 requires moderate assistance for bed mobility, transfers, bathing, dressing, toileting, and personal hygiene. a. On 03/04/24 at 10:22 AM, the Surveyor noted a white denture cup slightly open with no label, and an uncovered white toothbrush with bristles facing down resting on the left side of the bathroom sink near the faucet in Resident #96 ' s room. Resident #96 was asked if she wears dentures, and she told the surveyor Yes, and told the Surveyor she had to rely on staff for assistance with care. b. On 03/05/24 at 09:10 AM, Resident #96 was resting, and the Surveyor observed an uncovered white toothbrush resting with the bristles facing down resting on the left side of the sink near the faucet, and there is a white, unlabeled denture cup that is slightly open. The toothbrush and denture cup appear to be in the same position as on 03/04/2024. Resident #96's roommate confirmed the denture cup, and white toothbrush did not belong to her. c. On 03/06/24 at 07:25 AM, the Surveyor observed a slightly open white denture cup resting on the left side of the sink and a white toothbrush with bristles facing down resting on the sink in Resident ' s room. The toothbrush and denture cup appear to be in the same position. d. On 03/06/24 at 10:35 AM, Certified Nursing Assistant [CNA] #6 was asked to accompany Surveyor to room Resident #96 ' s room CNA #6 confirmed she was familiar with Resident #96 but did not provide care to resident often. To the left of the sink Surveyor and CNA #6 observed a slightly opened, unlabeled white denture cup and white toothbrush with a dark substance on the back head of the toothbrush. The toothbrush is resting with its bristles against the sink near the faucet. The Surveyor asked CNA #6 about the procedure for storing toothbrushes and dentures. CNA #6 said the toothbrush, and denture cups should be kept closed. CNA #6 was asked to describe the dark substance on the back head of the toothbrush. CNA #6 said it looks tan, and black. It could be from some food. The Surveyor asked why their procedure is to store toothbrushes covered and keep denture cups closed. and CNA #6 said stuff could be flying in the air and get in them. The Surveyor asked if the toothbrush and denture cup were stored in a safe, sanitary, and clean manner and CNA #6 said, No, they are not. e. On 03/07/24 at 09:55 AM, the Assistant Director of Nursing [ADON] was asked what process is used for storing toothbrushes and dentures. The ADON said dentures should be kept in a cup, and the cup should be closed when not in use. Toothbrushes should be kept in a cup, plastic bag, or holder. The Surveyor asked if a resident is unable or needs assistance with dental care who is responsible for that, and she stated, CNA's. The Surveyor asked why toothbrushes and denture cups are expected to be covered and the ADON stated To keep bacteria from getting on them. The Surveyor asked if leaving a dental cup open, and a toothbrush being left uncovered, with bristles resting on the sink is clean, safe, and sanitary. The ADON stated, No, ma'am. because it's open to air, and anything can get on it. f. On 03/07/2024 at 02:39 PM, the Surveyor asked for dental care policy, and the ADON said they do not have a policy on dental care. 2. Resident #116 had diagnoses of Age-related osteoporosis and Fracture to left patella. According to MDS Resident #116 scored 14 (13-15 cognitively intact) on BIMS and required substantial/maximal assistance with shower/bathe. According to the care plan Resident #116 was incontinent of bowel and bladder. a. On 03/05/24 at 02:45 PM, the Surveyor observed CNA #3 placed 1 clear bag on the floor next to bed for disposal of dirty gloves and 2 clear bags in Resident's restroom for dirty linen while providing a bed bath for Resident #116. CNA #2 gathered all clear bags placed on the floor with linen inside, placed the bags into larger clear bag, and placed larger clear bag on the floor next to the Resident's bed. While observing CNA #2 and #3 provide Resident #116 with a bed bath, the Surveyor observed CNA #2 removed and donned clean gloves 5 times without sanitizing hands between and CNA #3 removed and donned clean gloves 3 times without sanitizing hands between. b. On 03/05/24 at 03:56 PM, the Surveyor asked CNA #3 between glove changes what should you do? CNA #3 stated sanitize hands The Surveyor asked CNA #3 did you all do that? CNA #3 stated, not every time. The Surveyor asked CNA #3 should there be anything on the floor when providing care? CNA #3 stated, no. The Surveyor asked CNA #3 why not? CNA #3 stated dirty. The Surveyor asked CNA #3 was there anything on the floor? CNA #3 stated, yes ma'am. c. On 03/06/24 at 10:29 AM, the Surveyor asked licensed Practical Nurse (LPN) #1 what should be done between glove changes? LPN #1 stated, hand sanitize wash hand. The Surveyor asked LPN #1 should anything be on the floor when providing care? LPN #1 stated no. The Surveyor asked LPN #1 why not? LPN #1 stated, infection disease. The Surveyor asked LPN #1 was there anything on the floor while care was being provided to Resident #116? LPN #1 stated yes ma'am. d. On 03/06/24 at 02:45 PM, the Surveyor asked CNA #2 what should you do between glove changes? CNA #2 stated, I did not sanitize my hands. The Surveyor asked CNA #2 when providing care should anything be on the floor? CNA #2 stated, No nothing should have been on the floor. The Surveyor asked CNA #2 was there anything on the floor during care? CNA #2 stated, Yes ma'am we put a linen bag on the floor. 3 a. Resident #30 had a diagnosis of Alzheimer's disease and was on hospice. According to Quarterly MDS with ARD of 01/18/24 Resident #30 was unable to complete the BIMS. According to the care plan Resident #30 requires set up assistance with meals and able to feed self. 3 b. Resident #86 had a diagnosis of dementia moderate with agitation and altered mental status. According to Quarterly MDS with ARD 02/20/24 Resident #86 was unable to complete the BIMS. The Care Plan documented that Resident #86 required supervision with meals requiring set up assistance at times. 3 c. On 03/06/24 at 08:00 AM, the Surveyor observed CNA #4 assisting Resident #30 and Resident #86 with meal service. Surveyor CNA #4 touched Resident #30 clothing with left hand and then assisted Resident #86 with meal service using left hand without using hand sanitizer. Resident #30 was observed holding CNA #4 ' s left hand several times when hand was resting on the table next to Resident. CNA #4 went back and forth several times assisting Resident #30 and #86 with meal service handling each Resident's utensils without using hand sanitizer between touch. Resident #86 was later observed with mouth on the utensil twice that had been handled several times by CNA #4 to assist him with meal service. 3 d. On 03/06/24 08:40 AM, the Surveyor asked CNA #4 while assisting Resident #30 and Resident #86 with meal service at any time did you use hand sanitizer other than after positioning? CNA #4 stated, no. 4 a. Resident #59 had a diagnosis of dysphagia and Hemiplegia following cerebral infarction affecting left dominant side. According to Annual MDS with ARD 01/17/24 Resident #59 was unable to complete the BIMS. According to the care plan Resident #59 was dependent on staff for meals, she receives consistent carbohydrate puree diet with nectar thick liquids. 4 b. Resident #22 had a diagnosis of Dementia. According to Quarterly MDS with ARD 01/31/24 Resident #22 was unable to complete the BIMS. According to care plan Resident #22 required (substantial/maxima assistance) by (1) staff to eat, staff to assist with/feeding resident and setup including the opening of packages and cutting of foods, and resident may also need verbal cueing at mealtimes and encouragement. 4 c. Resident #275 had a diagnosis of Alzheimer's disease and dysphagia. Admission MDS was in progress and Surveyor was unable to retrieve information. The Care Plan did not address any Activities of Daily Living (ADLs). 4 d. On 03/06/24 08:00 AM, the Surveyor observed CNA #5 assisting Resident #22, #275, and #59 with meal service. Surveyor observed CNA #5 touch Resident #59 ' s blanket then gives the Resident a bite of biscuit with her hand. CNA #5 did not use hand sanitizer between or after picking up Resident #59 ' s biscuit with her hand. CNA #5 then gave Resident #22 a bite of food. Resident #22 was coughing and CNA #5 with her right-hand patted Resident #22 on the back then continued assisting with meal service without using hand sanitizer. Resident #59 sneezed with mouth uncovered CNA #5 used clothing protector to wipe Resident #59's mouth with right hand and then proceeded to assist Resident #22 with meal service. CNA #5 opened Resident #275 straw and with her right hand touching the tip (the end left outside of cup) of the straw and place inside of cup for Resident #275. 4 e. On 03/06/24 08:45 AM, the Surveyor asked CNA #5 while assisting Resident #22 and Resident #59 with meal service at any time did you use hand sanitizer? CNA #5 stated, no. The Surveyor asked CNA #5 at any time did you touch the Resident ' s clothing while assisting with meal service (Resident #22 ' s shirt and Resident #59 ' s blanket and clothing protector)? CNA #5 stated, yes. The Surveyor asked CNA #5 did you sanitize your hand after contact? CNA #5 stated, no. 4 f. On 03/06/24 11:20 AM, the Surveyor asked the ADON when staff are assisting multiple Residents with meal service what should they do between each Resident? The ADON stated, They should sanitizer their hands. 4 g. On 03/06/24 11:00 AM, the Surveyor was provided a policy titled Handwashing/ Hand Hygiene This facility considers hand hygiene the primary means to prevent the spread of infection. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 2. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc ) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 4. An alcohol-based hand rub may be used if there is no visible soiling. 6 The use of gloves does not replace hand washing/hand hygiene. Integrating glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review, the facility failed to ensure that oral care was provided for 1 (Resident #96) of 4 (Resident #11, #21, #91, #96) sampled residents with the potential to affect 23 residents on 400 hall dependent on staff for receiving oral care and the facility failed to ensure that 1 (Resident #116) of 2 sampled Residents (#116, #324) was cleaned in a sanitary manner to promote good body hygiene. This failed practice had the potential to cause skin breakdown, infection, and poor hygiene for 4 Residents on 500 hall who were dependent on staff for bathing assistance. The findings are: 1. Resident #96 had diagnoses of Fracture of upper end of left humerus, Syncope and collapse, and Depressive disorder. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01/08/2024 indicated a Brief Interview for Mental Status [BIMS] score of 15 (13-15 suggest cognitively intact). Resident #96 requires set up assistance for meals, and oral care. Resident #96 requires moderate assistance for bed mobility, transfers, bathing, dressing, toileting, and personal hygiene. a. A Care Plan documented, .The resident has an (Activities of Daily Living) ADL self-care performance deficit r/t(related/to) impaired mobility (Revision on: 01/09/2024) The resident will maintain current level of function in ADLs through the review date. PERSONAL HYGIENE: The resident requires (part/mod (moderate) assistance) by (1) staff with personal hygiene and oral care . TRANSFER: The resident requires (sub/max (maximum) assistance) by (1) staff to move between surfaces as necessary . b. On 03/04/2024 at 10:22 AM, Surveyor observed an unlabeled white denture cup and an uncovered white toothbrush with the bristles facing down resting on the left side of the bathroom faucet in Resident ' s Room. Resident #96 was asked if they wear dentures and was told, Yes. c. On 03/05/2024 at 09:10 AM, the Surveyor observed an uncovered white toothbrush resting with the bristles facing down resting on the left side of the bathroom sink near the faucet. There is a white denture cup that is slightly open that is not labeled. Resident #96's toothbrush appears to be in the same position as yesterday. d. On 03/06/2024 at 07:25 AM, Resident #96 is complaining of left arm pain and the Surveyor had to talk near the resident ' s ear and detected a faint sour smell. The Surveyor observed a slightly open white denture cup resting on the left side of the sink and a white toothbrush with the bristles facing down resting on the sink near the faucet. The toothbrush and dentures appear untouched. e. On 03/06/2024 at 10:35 AM, Certified Nursing Assistant [CNA] #6 was asked to accompany Surveyor to Resident ' s room. CNA #6 and the Surveyor observed a slightly opened, unlabeled white denture cup and white toothbrush with a dark substance on the back head of the toothbrush with the bristles resting on the left side of the faucet in the bathroom. The white toothbrush and dental cup appear to be in the same position since 03/04/2024. The Surveyor asked CNA #6 about the procedure for storing toothbrushes and dentures. CNA #6 said denture cups should be kept closed. The Surveyor asked what the process was for providing dental care for residents that wear dentures. CNA #6 said on nightshift dentures are cleaned and soaked while the resident sleeps. The Surveyor asked if Resident #96 can do their own oral care. CNA #6 confirmed Resident #96 requires assistance. The Surveyor asked how often residents should get oral care and CNA #6 said, Every night and as needed. f. On 03/07/24 at 09:55 AM, the Assistant Director of Nursing [ADON] was asked what process staff were expected to use for storing toothbrushes and dentures. The ADON said dentures should be kept in a cup, and the cup should be closed when not in use. Toothbrushes should be kept in a cup, plastic bag, or holder. The ADON said they have toothbrush holders if a resident needs one. The Surveyor asked if a resident is unable or needs assistance with dental care who is responsible for that, and she said, CNA's. The Surveyor asked how often staff is expected to address dental care for residents that need assistance. The ADON said once a shift, or at least after meals. Ideally twice a day at least. g. On 03/07/2024 at 02:39 PM, The Surveyor asked for dental care policy, and the ADON said they do not have a policy on dental care. 2. Resident #116 had diagnoses of Age-related osteoporosis and Fracture to left patella. According to Admission MDS with ARD of 01/29/24 Resident #116 scored 14 (13-15 cognitively intact) on BIMS and required substantial/maximal assistance with shower/bathe. The care plan documented that Resident 116 was incontinent of bowel and bladder. a. On 03/05/2024 at 02:45 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 and #3 a bed bath for Resident #116. The Surveyor observed CNA #2 wiping from dirty to clean areas while cleansing the perineal area, without performing hand sanitation. b. On 03/05/2024 at 03:56 PM, the Surveyor asked CNA #3, When cleaning the perineal area, how many times should you wipe? CNA #3 stated, Three. The Surveyor asked CNA #3, Did you all wipe 3 times? CNA #3 stated, No. The Surveyor asked CNA #3, Between glove change what should you do? CNA #3 stated Sanitize hands. The Surveyor asked CNA #3, Did you all do that? CNA #3 stated, Not every time. The Surveyor asked CNA #3 should there be anything on the floor when providing care? CNA #3 stated, no. The Surveyor asked CNA #3 why not? CNA #3 stated dirty. The Surveyor asked CNA was there anything on the floor? CNA #3 stated, yes ma'am. c. On 03/05/2024 at 04:10 PM, the Surveyor was informed by ADON that the facility did not have a bed bath policy. d. On 03/06/2024 at 10:29 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1 who observed the bed bath provided to Resident #116 and how many times do you wipe the perineal area? LPN #1 stated, Three I thought I saw three. e. On 03/06/2024 at 11:00 AM, the Surveyor was provided a policy titled Perineal/Incontinence Care that documented, Females: with gloved hands gently open labia with one hand using the other hand to gently cleanse. Repeat until complete cleansing is achieved. Do not use washcloth/wipe more than one time, then turn and discard. f. On 03/06/24 at 02:45 PM, the Surveyor asked CNA #2, How many times do you wipe when cleaning the perineal area? CNA #2 stated, Three, but our policy says until clean The Surveyor asked CNA #2, What policy? CNA #2 stated I don't know that's what LPN #1 told me. The Surveyor asked CNA #2, Did you wipe 3 times? CNA #2 stated, yes ma'am. 48977

Based on observation, interview, and record review, the facility failed to ensure that oxygen tubing was dated and stored correctly for 2 (Resident #46 and #275) sampled residents to reduce the potential for respiratory complications. This failed practice had the potential to affect 11 residents that had physicians for oxygen therapy. The findings are: 1. Resident #275 had diagnoses of Heart Failure, Alzheimer ' s disease, and polyneuropathy. a. Medication Administration Record for Resident #275 (Dated 03/01/2024) . Oxygen via nasal cannula at 2 liters. b. On 03/04/2024 at 12:30 PM, Resident #275 was observed in the dining room on 2 liters nasal cannula with portability, and the oxygen tubing was not dated. c. On 03/04/2024 at 01:04 PM, the Surveyor observed Resident #275 in residents ' room on 2 liters nasal cannula and noted portable tubing is not dated. d. On 03/05/2024 at 08:43 AM, Resident #275 was seated at the nurses ' station on 2 liters, and the Surveyor observed the portable oxygen tubing was undated. e. On 03/05/24 at 09:05 AM, Licensed Practical Nurse [LPN] #4 said all oxygen tubing should be dated and changed on Friday at the same time as the tubing on the concentrator. The Surveyor asked LPN #4 why tubing is changed every Friday. LPN #4 stated, It could grow mold in it. f. On 03/07/2024 at 02:10 PM, the Surveyor spoke with the Assistant Director of Nursing [ADON] and asked how often staff are expected to change oxygen tubing, and why. The ADON said oxygen tubing should be changed out every 7 days, because it gets dirty. h. On 03/07/2024 at 02:39 PM, the Surveyor asked for a policy on oxygen tubing, and the ADON said they do not have a policy on oxygen tubing or signage. 3. Resident #46 had diagnoses of Heart failure and Acute and chronic respiratory failure with hypoxia. Admission Minimum Data Set (MDS) was in progress but initiated on 2/22/24. According to the care plan Resident #46 had oxygen therapy related to Congested Heart failure (CHF) at 3 liters per minute via nasal cannula with humidity and required extensive assistance from staff member with transfer to move between surfaces as necessary. a. On 03/05/24 at 10:00 AM, the Surveyor observed Resident #46 sitting in wheelchair with oxygen in place via nasal cannula at 2 liters. Resident was receiving oxygen from portable oxygen tank on the back of wheelchair. Surveyor noted concentrator at bedside turned off with tubing lying on bed uncovered. b. On 03/05/24 11:51 AM, the Surveyor observed Resident #46 lying in bed with oxygen in place via nasal cannula at 3 liters. Resident #46 was receiving oxygen from the concentrator. The Surveyor noted the portable tank at foot of bed turned off with tubing wrapped around top of tank and arm of wheelchair uncovered. c. On 03/05/24 at 02:30 PM, the Surveyor observed Resident #46 lying in bed with oxygen in place via nasal cannula at 3 liters. Resident #46 was receiving oxygen from the concentrator. The Surveyor noted portable tank at foot of bed turned off with tubing wrapped around top of tank and arm of wheelchair uncovered. d. On 03/05/24 at 11:52 AM, the Surveyor asked Resident #46 did you put yourself to bed, or did someone assist you? Resident 46 stated, Someone assisted me to bed. e. On 03/05/24 at 02:37 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 (while standing at Resident #46 bedside) did you assist Resident #46 to bed? CNA #1 stated, Yes ma'am. The Surveyor asked CNA #1 when Resident #46 is in the wheelchair does she use the portable oxygen tank? CNA #1 stated, Yes ma'am. The Surveyor asked CNA #1 when Resident #46 is in the bed does she use the concentrator? CNA #1 stated, Yes ma'am. The Surveyor asked CNA #1 where do you store the tubing for the portable tank when Resident is using the concentrator? CNA #1 stated, Rolled up to the back of wheelchair, (while demonstrating wrapping the tubing around the arm of the wheelchair). The Surveyor asked CNA #1 where do you store the tubing for the concentrator when Resident #46 is using the potable tank? CNA #1 stated, Tucked at the top of the concentrator, (while point to an opening just under the handle at the top of the concentrator). f. On 03/06/24 at 02:23 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 when oxygen tubing is not in use how should it be stored? LPN #2 stated, Should be in bag, labeled, and dated. The Surveyor asked LPN #2 why should the tubing be stored in a bag? LPN #2 stated, So it won ' t get dirty and stay clean. if it is not in a bag, it is a fall hazard for the Resident and staff. g. On 03/06/24 at 11:00 AM, the ADON stated that the facility did not have any policy other than what was provided which did not contain any pertinent information pertaining to deficient practices. 48977

Based on observation, interviews, and record review, the facility failed to ensure the resident environment was free from hazards by leaving the storage room door unsecured, allowing residents access to supplies that are not for human consumption. This failed practice had the possibility of affecting 6 (Residents #43, #61, #323, #324, #326, #327) sampled residents with a Brief Interview for Mental status score (BIMS) of 13 or below out of 29 residents the reside on 500 Hall. The facility failed to ensure a mechanical lift was in safe operational condition to prevent possible injury for 1 (Resident #11) of 2 sampled residents (Residents #11 and #21) with the potential to effect 6 residents on 400 hall requiring mechanical lift assistance. The findings are: 1. On 03/04/24 at 11:40 AM, Surveyor observed the storage door on 500 hall unlocked without staff present to ensure residents did not enter the room. The following items were on the shelving unit Second Shelf held 3 (Named) Deodorant 1.5 fluid ounces containing active ingredient of Aluminum Chloralhydrate 10% - Anhydrous Base with Warning For external use only, keep out of reach of children; (Named) No-Rinse Foam Cleanser (2) 8 fluid ounces and (1) 4-ounce bottle with For External Use Only printed on the back label; (Named) 36 Twin Blade Blue Razor. Third shelving unit a container had the following items in: (6) (Named) Moisturize Skin Cream Vanilla scent 4 fluid ounces with For External Use Only printed on the back label; (3)(Named) Prevent Silicone Cream Vanilla scent 4 fluid ounces with For External Use Only printed on the back label; 6 (Named) Roll-On Anti-perspirant 1.5 fluid ounces containing active ingredient of Aluminum Chloralhydrate 10% - Anhydrous Base with Warning For external use only, Keep out of reach of children, if accidentally swallowed, get medical help or contact Poison Control Center right away; (Named) Cleanse No-Rinse Foam Cleanser (2) 8 fluid ounces and (4) 4 ounce bottle with For External Use Only printed on the back label. a. On 03/04/24 at 11:49 AM, the Surveyor asked Certified Nursing Assistant (CNA) #9, Should the storage room door be unsecure? CNA #9 secured the door. Surveyor asked CNA #9, Why it is important to keep residents from getting into the storage room. CNA #9 stated If there was not noise coming from the storage room, we would not know they were in there. The room is used to keep sanitary items like butt cream, mouth wash, and other clean things. The reason the room is locked is mainly safety. 2. Resident #11 had diagnosis of Malignant neoplasm of unspecified site of right female breast, Anemia, and Gastro-esophageal reflux disease. The Annual Minimum Data Set [MDS] with an Assessment Reference Date of [ARD] 02/20/2024 indicated a [BIMS] score of 13 (13-15 suggest cognitively intact). Resident #11 requires set up assistance with meals, and maximum assistance with bed mobility, toileting, bathing, dressing and personal hygiene. a. A Care Plan (October 10, 2022) documented, .The resident has an ADL self-care performance deficit related to history of Left HUMERUS FRACTURE, poly neuropathy . TRANSFER: The resident is dependent on (2) staff VIA Hoyer lift to move between surfaces and as necessary . b. On 03/04/2024 at 12:53 PM, Certified Nursing Assistant [CNA] #5 and CNA #7 were observed using a mechanical lift to move Resident #11 from the wheelchair to the bed. The Surveyor observed that there was a missing silver clip on the middle hook located on the front hanger bar. The Surveyor asked what their understanding is of the clips. CNA #5 said, It is extra security. CNA #5 asked if they were using the right type of lift pad. The Surveyor asked CNA #5 why she thought the lift pad was not the right kind of lift pad for this lift machine. CNA #5 said because the lift pad has 4 places to attach, and this machine has 6 hooks. c. On 03/06/2024 at 09:45 AM, the Surveyor asked the Assistant Director of Nursing [ADON] what process staff would follow if the lift they are using is missing a clip from the hooks located on the hanger bar. The ADON said staff should only be using the two outer hooks with clips to attach the lift pads. The Surveyor asked if ADON could ensure that all staff know not to use the middle hooks. The ADON said she is not able to ensure that all staff know not to place lift pad straps on the middle hooks. The ADON was asked if there were any concerns with a lift missing a clip. The ADON said if staff used the middle hook without the clip a resident could potentially be dropped but reiterated that staff should be using the two outside hooks with clips. The Surveyor asked for a copy of the lift manufacture guidelines, and lift policy. d. On 03/06/2024 at 10:41 AM, The ADON told the Surveyor that they do not have a lift policy and provided a user manual titled [named] 450 RPL450-2 (2018) documenting, . 2 SAFETY Transferring the patient WARNING When elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed). If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem . Performing Maintenance .After the first year of use, the hooks of the hanger bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear, If these parts become worn, replacement must be made . Regular maintenance of patient lifts and accessories is necessary to assure proper operation . 7.3 Attaching a Sling . [named] lift hanger bars have three hookup points per side. The middle hookup is ONLY used for slings that have three sets of straps per side . 10 Maintenance 10.1 Maintenance Safety Inspection Checklist . THE HANGER BAR . Check sling hooks for wear or deflection . 10 MAINTENANCE 10.3 Detecting Wear and Damage If is important to inspect all stressed parts, such as slings, hanger bar and any pivot for slings for signs of cracking, fraying, deformation, or deterioration. Replace any defective parts immediately and ensure that the lift is not used until repairs are made . e. On 03/06/2024 at 12:45 PM, the Surveyor requested dementia, and in-service documentation and the ADON printed a copy of an in-service titled In-Service Training Report dated 11/10/2023, subject covered was Rehabilitative nursing, transfers, sit/stand, use of lift, proper alignment, Range of Motion Passive vs active, and use of a gait belt. Signature sheet, and quiz were included. 49413

Based on observation, record review, and interview the facility failed to ensure 1 (Resident #11) received double portions as part of a dietary intervention to prevent weight loss and malnutrition for 1 of 3 residents receiving double portions. The findings are: 1. Resident #91 with a diagnosis of CEREBRAL INFARCTION, PAROXYSMAL ATRIAL FIBRILLATION, and MILD PROTEIN-CALORIE MALNUTRITION. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] or 12.25.2023 indicates a Brief Interview for Mental Status score of 03 (0-7 suggest severe cognitive impairment). Resident #91 requires supervised eating and extensive assistance for dressing, bathing, transfers, bed mobility and personal hygiene. a. On 03/04/2024 at 12:04 PM, Resident #91 observed eating in the dining area. Meal slip indicates resident #91 is on a pureed diet, with double portions. b. On 03/04/2024 at 12:17 PM, Licensed Practical Nurse [LPN] #3 was asked how staff can tell when someone has a special diet. LPN #3 said, It is on their meal tickets, and in the system. The Surveyor asked if a resident has double portions on their meal slip how does that work. LPN #3 told the Surveyor that they submit a meal ticket with a resident's diet and the kitchen is supposed to send it up. The Surveyor asked LPN #3 to look at the meal ticket for Resident #91 and LPN #3 said he has a pureed diet, double portion, and it looks like he was served alfredo, mashed potatoes, green beans, or salad, and some kind of meat. The Surveyor asked if Resident #91 was served double portions. LPN #3 told the Surveyor the only thing that looks double is the alfredo, the meat and potatoes are not a double portion. LPN #4 looked at Resident #91's plate and meal ticket and agreed with LPN #3 that only the alfredo looked like a double portion. c. On 03/07/2024 at 10:16 AM, While interviewing the Assistant Director of Nursing [ADON] the Surveyor asked what process staff is expected to follow if they receive a food tray that does not match the meal slip. The ADON told the Surveyor that they should return the tray to the kitchen to be fixed. If is is a special diet like puree they should give the plate to the resident and ask the kitchen for another plate. ADON was asked why it would be important for residents to receive the appropriate diet interventions. The ADON responded that they needed to make sure the resident does not lose weight and gets the nutrients that they need. d. On 03/07/2024 at 02:00 PM, The Surveyor spoke to Dietary #1 and was told the kitchen is responsible for putting double portions on resident trays. Dietary #1 confirmed that if a resident is getting double portions it should be on the plate, and if the double portions are not correct the plate should be sent back to the kitchen. If the resident is on a pureed diet, Dietary #1 said then they should be served the plate and staff should notify the kitchen so they can send out another plate. e. On 03/07/2024 at 02:39 PM, The Surveyor asked for a policy on dietary recommendations, and the ADON said they do not have a policy on dietary.

Based on record review and interview, the facility failed to review and revise care plans and reassess the effectiveness of interventions to meet resident needs for 1 (Resident #2) of 3 sampled residents. This failed practice had the potential to affect 8 residents that had falls in the last 3 months. The findings are: 1. On 02-14-2024 at 10:00 AM, reviewed Resident #2 ' s (R#2) care plan for revisions related to frequent falls in last 3 months. Unable to locate care plan intervention for fall dated 02-09-2024. a. On 02-14-2024 at 12:35 PM, review of R#2's list of falls since being admitted on [DATE], documented 2 falls in December 2023, 4 falls in January 2024, and 1 fall in February 2024. Reviewed record Incident and Accident (I/A) notes for each fall. I/A note dated 12-18-2023 documented witnessed fall no injury. I/A note dated 12-28-2023 documented unwitnessed fall with injury. I/A note dated 01-02-2024 unwitnessed fall no injury. I/A note dated 01-12-2024 unwitnessed fall no injury. I/A note dated 01-24-2024 witnessed fall no injury. I/A note dated 01-27-2024 witnessed fall no injury. And I/A note dated 02-09-2024 unwitnessed fall with injury. b. On 02-14-2024 at 03:00 PM, review of R#2 ' s care plan for each fall and intervention related to date of fall showed the care plan failed to show fall interventions related to falls on dates 12-18-2023, 01-02-2024, 01-24-2024, 01-27-2024, and 02-09-2024. c. On 02-14-2024 at 04:10 PM, the Director of Nursing (DON) was interviewed regarding care plan revisions and processes, and when care plans were to be revised with interventions related to falls. DON stated, Any department head can revise the care plans, like Dietary, Rehab, ADON (Assistant Director of Nursing), and DON. They should be revised with any change in condition, of course, any change in resident needs. We do an Incident and Accident note, and I do a follow up and investigate the fall, the Care plan is revised with the fall, a new intervention is placed on the care plan due to whatever intervention on there is not working and try to prevent future falls. Surveyor asked, Should the care plan have a fall intervention related to each fall? DON,stated, Yes with each fall is my understanding. d. On 02-15-2024 at 09:10 AM, the ADON was interviewed regarding R#2 and the care plan revisions for each of the falls, asking Was the care plan revised to show a new intervention with each fall? ADON stated, The care plan was not revised with interventions for this resident and the falls. e. On 02-15-2024 at 01:30 PM, the ADON reported, There is no policy for care plan revision.

Based on observation and interview, the facility failed to ensure the ice machine in the kitchenette on the 300 Hall and the 400 Hall was maintained in a clean and sanitary condition and expired food was not available for resident use in the kitchenette; and failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 102 residents who received meals from the kitchen (total census: 103) as documented on a list provided by Dietary Employee (DE) #1. The findings are: 1. On [DATE] at 12:44 PM, the initial tour was conducted with DE #1. 2. On [DATE] at 1:08 PM, the following observations were made in the kitchenette on the 300 Hall and the 400 Hall: a. The top panel of the ice machine in the kitchenette on the 300 Hall and the 400 Hall, had an accumulation of black residue on it. The Surveyor asked DE #1 to wipe off what was observed on the ice machine top panel. She did so, and the black/grayish residue easily transferred to the tissue. The Surveyor asked her to describe what was wiped off. She stated, It was grayish/black residue. The Surveyor asked, How often do you clean the ice machine and who uses ice from the ice machine? She stated, The maintenance Supervisor cleans it. Everyone on 500 Hall and the CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. At 1:19 PM, the Surveyor asked the Maintenance Supervisor, How often do you clean the ice machine? He stated, Once a month. b. Three boxes of buttermilk pancake mix were on a shelf in the freezer in the kitchenette with an expiration date of [DATE]. 3. On [DATE] at 3:10 PM, DE #2 turned on the hand washing sink faucet in the dish room and washed his hands. He turned off the faucet with his bare hand, did not wash his hands, picked up the blade and attached it to the base of the blender and pureed food for the residents' supper meal. 4. On [DATE] at 3:26 PM, DE #2 turned on the kitchen hand washing sink and washed his hands. He turned off the faucet with his bare hand, picked up the blade and attached it to the base of the blender and pureed food for the residents' supper meal. 5. On [DATE] at 3:35 PM, DE #2 turned on the hand washing sink faucet and washed his hands. He turned off the faucet and without with his bare hand, picked up clean dishes, his fingers touched the interior surfaces of the dishes when he stacked them on the counter. At 3:56 PM, the Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment or food items? He stated, I should have washed my hands. 6. On [DATE] at 3:48 PM, DE #3 opened the walk-in refrigerator door and removed a container of pimento cheese, a container of tuna salad and a zip lock bag that contained slices of cheese and placed them on the counter. At 3:51 PM, she put on an apron and tied it around her waist. She picked up gloves and placed them on her hands which contaminated her hands. She untied the bread bag and used her contaminated gloved hand to remove 3 slices of bread from the bag and placed them on the plates on the counter. She spread pimento cheese on two slices of bread, and tuna salad on a slice of bread. She removed slices of cheese from the bag and placed them on top of each slice of bread on the plates. At 3:53 PM, she removed her gloves and washed her hands. At 3:54 PM, she picked up a bag of bread from the bread rack and placed it on the counter. She then placed gloves on her hands, which contaminated the gloves. She untied the bread bag and used her contaminated gloved hands to remove slices of bread from the bag and placed them on top of the bread to be served to the residents who requested a pimento cheese and cheese sandwich and a tuna salad with cheese sandwich with their supper meal. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, Washed my hands.

Based on observation, record review and interview, the facility failed to ensure a medication cart was kept locked when unattended to prevent the potential loss of medication and/or access by residents who were able to ambulate with or without assistance. This failed practice had the potential to affect 14 (Residents #4, #10, #23, #28, #32, #33, #37, #38, #39, #42, #45, #60, #66 and #67) sampled residents who were mobile and would be able to access the unsecured cart on 300/400 hall as documented on a list provided by the Director of Nursing (DON) on 12/9/22 at 9:28 AM. The findings are: a. On 12/07/22 at 10:40 AM, Licensed Practical Nurse (LPN) #1 walked away from an unlocked medication cart and out of sight. LPN #2 walked by at 11:05 AM and locked the medication cart. The Surveyor asked LPN #1 as she walked back to the nurses' desk, Is this your cart? She answered, Yes. The Surveyor asked, Did you realize that you left your cart unlocked? She answered, No. The Surveyor asked, What could happen when you leave a medication cart unlocked with cognitively impaired residents around? She stated, Well obviously they can get into it. b. On 12/7/22 at 11:25 AM, LPN #2 was asked, How should the medication cart be secured when not in use? She answered, Locked, but she had to get to a resident that forgot her walker. The Surveyor asked, What could happen if the cart is not securely locked? She answered, A resident could get into it. c. On 12/9/22 at 9:10 AM, the Surveyor asked the DON, How should the medication cart be secured when not in use? She answered, It should be locked. The Surveyor asked, What could happen if the cart was left unlocked and the nurse walks out of sight? She answered, Residents can get into it. We try to have a nurse at the desk at all times to double man the carts. d. The facility policy titled, Medication Storage in the Facility, provided by the DON on 12/9/22 at 9:28 AM documented, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .

Based on observation, record review, and interview, the facility failed to ensure food was labeled and dated as to when it was received and opened; bread was discarded when beyond its shelf life; dietary staff washed their hands between dirty and clean tasks, and the ice machine and convection oven were maintained in clean condition to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 88 residents who received meals from the kitchen (total census: 91), as documented on a list provided by the Dietary Manager on 08/31/21. The findings are: 1. On 08/30/21 at 11:14 AM, there were 2 opened packages of King's Hawaiian rolls on the bread cart with an opened date of 08/16/21. 2. On 08/30/21 at 11:17 AM, there was a small black spot, less than the size of a dime inside the right side of the ice machine in the kitchen. The Dietary Manager (DM) wiped the spot with a white paper towel and was able to remove the spot. She was asked what she thought the spot was. She stated, I don't know. I clean this ice machine every week. I just cleaned it yesterday. She was asked what the ice machine is used for. She replied, It is used for the residents; ice water and whatever else they need. 3. On 08/30/21 at 11:27 AM, the following items were in the freezer and had been opened. There was no opened date or received date documented. a. 3 boxes of egg rolls b. 1 bag of omelets 4. On 08/30/21 at 11:32 AM, the following items were in the freezer and did not have a received date: a. 5 boxes of Thrive ice cream b. 2 boxes of tortilla soup c. 2 boxes of vanilla ice cream 5. On 08/30/21 at 11:34 AM, in the dry storage area, there was one bin of flour and one bin of sugar with no identification label or date. 6. On 08/30/21 at 11:35 AM, there was a container of taco seasoning on the bottom shelf below a prep table. The canister had been opened. There was no open date documented. 7. On 08/30/21 at 11:37 AM, there was container of meat tenderizer sitting on a rack, with the lid open. There was no open date documented. There was a container of garlic power sitting on the shelf with the lid open. There was no open date documented. 8. On 08/30/21 at 11:38 AM, the convection oven had a thick, black, cooked on residue on the inside bottom of the oven. There was a dark brown coating on the inside of the glass on the doors. The DM was asked to describe the inside of the oven. She stated, It looks like grease wasted in the bottom. 9. On 08/30/21 at 11:41 AM, inside the ice machine on the second floor, there was a black residue on the lip inside of the machine. The DM wiped the surface with a white paper towel and the residue was removed. The DM was asked to describe the black substance in the ice machine. She replied, It looks like black mold. She was asked what the ice machine was used for. She stated, The staff use it to pass ice to the residents on the 2nd floor. 10. On 08/30/21 at 11:43 AM, there were two pitchers of juice in the refrigerator in the dining area on the second floor. There were no open dates documented. There was an unsealed bottle of A-1 sauce in the refrigerator with no open date. 11. On 08/30/21 at 11:59 AM, Dietary Employee (DE) #1 washed her hands then touched the box of gloves as she was pulling gloves out. She then picked up a tray card. Then she applied gloves, contaminating the gloves. She then went to the serving line, uncovered the pans of food, and began to scoop rice out of a pan onto plates that were to be served with the resident's lunch. 12. On 08/30/21 at 12:02 PM, DE #1 stepped away from the service line and opened the plate warmer while wearing gloves. Without washing her hands or changing her gloves, she returned to the service line and began scooping rice and placing it on plates. 13. On 08/30/21 at 12:06 PM, DE #2, with no gloves on, placed a plate with German chocolate cake on a tray to be served to a resident for lunch. When the plate was placed on the tray, DE #2 had chocolate icing on his finger. The cake was left on the tray to be served to a resident for lunch. 14. On 08/30/21 at 12:08 PM, there was chocolate cake, uncovered, on each tray on the 500-hall cart. 15. On 08/31/21 at 1:38 PM, DE #1 was asked what she should do, after touching contaminated items, before returning to the tray line. She replied, Wash my hands. 16. On 08/31/21 at 2:05 PM, DE #2 was asked what he should do if he gets food on his hands off a tray while serving a meal. He replied, Wash my hands. He was asked if he should leave the food item on the tray. He replied, No. 17. On 08/31/21 at 2:07 PM, the Dietary Manager was asked what employees should do between clean and dirty tasks. She replied, Wash their hands. She was asked if an employee gets food on their hands off a tray, what should they do. She replied, Wash their hands. She was asked if they should leave the food item on the tray. She replied, No. The DM was asked what dates should be labeled on each food item. She replied, The date received, and the date opened. She was asked how long bread was good once it was removed from the freezer. She replied, Seven days. 18. On 08/31/21 at 2:15 PM, the DM provided a policy that documented, Hand Washing . Purpose: To remove contamination . before donning gloves for working with food, after engaging in other activities that contaminate the hands.

Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for [CONDITION(S)] or other respiratory complications for 2 (Residents #10 and #87) of 4 (Residents #10, #80, #87 and #93) sampled residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/21 documented the resident scored 12 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS); was totally dependent on two-plus person assistance for transfers and bathing, and received oxygen while a resident. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May be off for ADLs [Activities of Daily Living], every shift. b. A Care Plan revised on 3/12/21 documented, .OXYGEN SETTINGS: O2 via nasal cannula @ [at] 2 L [liters] continuously . May be off for ADLs & [and] showers . c. On 08/30/21 at 11:27 am, Resident #10 was sitting in the dining room with O2 at 2 L/M via portable tank. The indicator on the tank's gauge was in the red zone (indicating the tank was empty). Licensed Practical Nurse (LPN) #1 was informed the O2 tank was empty and was asked if the resident was on continuous or as-needed O2. The LPN stated, Continuous. The LPN was asked to check the resident's O2 saturation. The LPN refused to check resident's O2 saturation until after she had placed a new O2 tank on the resident's chair and turned on the O2. d. On 08/30/21 at 11:42 am, LPN #1 was asked if a resident should run out of oxygen if they were supposed to be on continuous O2. The LPN stated, Never. e. On 09/02/21 at 1:04 pm, the DON was asked, if a resident has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, No. 2. Resident #87 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), required extensive assistance of 2-plus people for bed mobility and transfers and received oxygen therapy. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 2L [liters] via nc [nasal cannula] cont. [continuous] may be off for ADL every shift . b. A Care Plan revised on 8/6/21 documented, .The resident has oxygen therapy r/t [related to] [CONDITION(S)], potential for impaired gas exchange . oxygen settings at 2 LPM via nc continuous . c. On 08/30/21 at 11:01 AM, Resident #87 was sitting in a geri chair with oxygen at 1.5 liters per minute via nasal cannula. d. On 08/30/21 at 01:50 PM, Resident #87 was lying in the bed, oxygen on and running at 1.5 liters per minute via nasal cannula. e. On 09/01/21 at 09:07 AM, LPN #3 was asked what the resident's O2 flow rate was supposed to be. LPN #3 stated, Two liters a minute. f. On 09/02/21 at 12:43 PM, LPN #1 was asked, Why should residents' oxygen be administered per the physician orders? LPN #1 stated, It's an order. g. On 09/02/21 at 12:59 PM, the DON was asked, Why should residents' oxygen be administered per the physician orders?' The DON stated, It's an order, and we follow whatever the physician tells you to do.

Based on observation, record review and interview, the facility failed to ensure expired medications were removed and placed into an area for destruction to prevent potential administration to residents who received medications from a medication storage room on 1 (300/400 Hall) of 3 (100, 200, 300/400 Halls) halls. The facility also failed to ensure medication vials were dated when opened to prevent potential administration of expired medication from 2 (100 and 300/400 Halls) of 3 (100, 200 and 300/400 Halls) medication carts in the facility. The facility also failed to ensure medications were stored in their original, labeled container and in a secure location until time for administration to prevent potential medication errors and failed to ensure there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #31 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to nose topically at bedtime related to postnasal drip. b. On 08/30/21 at 11:26 AM, Resident #31 was lying in bed with her eyes closed. There were two 30-milliliter (mL) plastic medication cups on the overbed table that contained a cloudy, whitish, thick, jelly-like substance. c. On 08/30/21 at 2:20 PM, Resident #31 was lying in bed. There were two 30-mL plastic medication cups on the overbed table that contained a cloudy, whitish, thick, jelly-like substance. She was asked, What is in those cups? She answered, Those have Vicks in them. I put it in my nose until they can get me some nasal spray. I also like to put it on my lips. A container of Aspercreme with [MEDICATION(S)] was on the resident's nightstand. She stated, I like to put that on my itchy skin. A package insert for Vicks [MEDICATION(S)] documented, .Do not use . in nostrils . If swallowed, get medical help or contact a Poison Control Center right away . A package insert for Aspercreme with [MEDICATION(S)] documented, .If swallowed, get medical help or contact a Poison Control Center right away . d. On 08/31/21 at 10:13 AM, Resident #31 was asked, Where is your Vicks and Aspercreme this morning? She answered, I think they put it in the drawer. Are you from the state? e. On 09/01/21 at 1:35 PM, a policy titled, Medications - Self Administration of was provided by the Director of Nursing (DON). It documented, .Storage of medications in the resident's room must be such that it will prevent access by other residents . Only the medications permitted for self-administration shall be left at the bedside . Medications must remain in the original container . f. On 09/01/21 at 2:30 PM, a document titled, Nsg [Nursing] Medication Self Administration Safety Screen, (which handwritten) was provided by the DON. It documented, .Effective Date: 7/1/21 . Vicks [MEDICATION(S)] Ointment 4.7-1.2-2.6% apply to nose topically at HS . 7. The resident can demonstrate secure storage of medications kept in room . Not Applicable . IDTC (Interdisciplinary Team) Review Summary (safety concerns/recommendations, communication to physician: Keep medication stored on med [medication] cart . g. On 09/01/21 at 2:30 PM, a sheet of white paper provided by the DON with no resident name documented, 7/12/21 Resident may self-administer Vicks [MEDICATION(S)] Ointment 4.7-1.2-2.6% apply to nose topically at HS [bedtime]. This was signed by Physician #1. h. On 09/01/21 at 2:30 PM, the DON was asked, If a resident is assessed to safely self-administer medications and the medications are stored in the resident's room, should the medication have a label? She answered, Yes. She was asked, If a resident is assessed to safely self-administer medications, should the medication be stored in the original container? She did not answer. She was asked, Per your policy, if a resident is assessed to safely self-administer medication, should the medication be stored in the original container? She answered, Yes. i. On 09/01/21 at 2:40 PM, the Infection Preventionist was asked, Should a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes. She was asked, If a resident is assessed to safely self-administer medications, and the medications are stored in the resident's room, should the medication have a label? She answered, Yes. She was asked, Per your policy, if a resident is assessed to safely self-administer medication, should the medication be stored in the original container? She answered, Yes. She was asked to provide a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #31] was assessed to self-administer. She stated, She is the only resident we have who self-administers medication and to my knowledge, the Vicks is the only one she is supposed to self-administer. j. On 09/02/21 at 09:00 AM, Licensed Practical Nurse (LPN) #1 was asked, Does [Resident #31] have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? He checked the computer and answered, I don't see one. He was asked, Should all active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? He answered, We have standing orders in a binder at the desk but if we are going to use one, we add it to the Electronic Record. He was asked, What could happen if a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? He answered, It could be given incorrectly. He was asked, What could happen if medications are stored unlabeled or not in the original container at the bedside? He answered, They could overdose or have a drug interaction. 2. On 08/31/21 at 1:04 PM, during an inspection of the 100 Hall medication cart with Registered Nurse (RN) #1, there was a bottle of opened and undated [MEDICATION(S)] on the cart. RN #1 was asked, Do you have anyone using [MEDICATION(S)]? RN #1 stated, Not that I know of. RN #1 was asked, Should the opened, undated and unlabeled bottle of [MEDICATION(S)] be on the medication cart? RN #1 stated, No. 3. On 08/31/21 beginning at 1:09 PM, the 300/400 Hall medication storage room and 400 Hall medication cart were inspected with Licensed Practical Nurse (LPN) #1, with the following findings: At 1:12 PM, there was 1 opened bottle of sterile water with an expiration date of 6/14/2020; one unopened bottle of sterile water with an expiration date of 8/23/2020; and one unopened bottle of sterile water with an expiration date of 10/29/2020. LPN #1 was asked, Should these expired medications be in the cabinet? LPN #1 stated, No. 4. On 08/31/21 at 1:17 PM, the 300 Hall medication cart was inspected with LPN #3. A bottle of [MEDICATION(S)] Insulin was opened and partially used had no opened date. LPN #3 was asked, Do you know when this insulin was opened? LPN #3 stated, I think it was 8/16/21, but I'm not for sure. LPN #3 was asked, Should insulin be dated when opened? LPN #3 stated, Yes. A [MEDICATION(S)] package insert acquired on the Food and Drug Administration (FDA) website at https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/ 6s000lbl.pdf documented, .Storage and Handling: .In-use (opened) vials . must be used within 28 days or be discarded . 5. On 09/01/21 at 8:19 AM, the DON was asked Should expired medications be left in the medication carts and in the medication cabinets? The DON stated, No. The DON was asked, Should insulin be labeled with an opened date? The DON stated, I'll have to check the insulin policy. 6. On 09/02/21 at 12:43 PM, LPN #1 was asked, How long is [MEDICATION(S)] insulin good after opening? LPN #1 stated, 28 days. LPN #1 was asked, Why should insulin vials be dated with the opened date? LPN #1 stated, So you know when it expires. LPN #1 was asked, Why should expired medications be removed from the medication carts and medication rooms? LPN #1 stated, So they won't accidently be dispensed or administered to a resident. LPN #1 was asked, Why should vials of [MEDICATION(S)] injectable be labeled with opened date and resident name? LPN #1 stated, So you know who it belongs to and the date it expires. LPN #1 was asked, Who is responsible for ensuring insulins are dated with an opened date? LPN #1 stated, All charge nurses on that cart. LPN #1 was asked, Who is responsible for ensuring unused and expired medications are removed from the medication carts and the medication rooms? LPN #1 stated, The nurses remove from the cart and place in the destruction bin, then the DON and pharmacy representative destroy them once a month.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. On 08/30/21 at 12:05 PM residents on regular, mechanical soft, and pureed diets were served fried pork chops for the noon meal. 2. On 08/30/21 at 2:49 PM, the Dietary Manager (DM) provided the menu for lunch, which documented, SMTH PRK CHP [Smothered pork chop] . The recipe documented, Smothered Pork Chop . Dredge in flour. 2. Sauté chops on both sides on grill or large skillet. 3. Place chops . in baking pan . 4. Place sliced celery, chopped onions and chopped peppers on top of chops . 5. Add boiling water to the pan . Bake at 300F [Fahrenheit] until chops are tender .7. Cover chops with gravy and bake . 3. On 08/31/21 at 1:40 PM, the cook (Dietary Employee #1) was asked how she prepared the pork chops yesterday. She replied, They were breaded and fried. She was asked if fried pork chops were on the menu yesterday. She replied, I did that [fried] over [instead of] smothered pork chops, because the residents don't like gravy on their pork chops. 4. On 08/31/21 at 1:43 PM, the DM was asked if the cook should change the menu on the day of the meal? She replied, No, I should be notified if the residents don't like something. I could talk to the dietician and have the gravy taken off the menu.

Based on observation, record review and interview, the facility failed to ensure necessary treatment and services, including planned pressure relief interventions, were promptly and consistently provided to promote healing of an existing pressure ulcer and prevent the development of additional pressure sores for 1 (Resident #115) of 8 (Residents #9, 19, 38, 72, 102, 115, 03, and #428) case mix residents who were dependent on staff for pressure ulcer prevention. This failed practice resulted in a pattern of harm for Resident #115, who had unidentified deep tissue injuries to both heel and multiple Stage II pressure sores to the buttocks, and had the potential to cause more than minimal harm to 19 other residents who were dependent on staff for pressure ulcer prevention, as per a list provided by the Assistant Director of Nursing (ADON) on 5/23/18 3:10 p.m. The findings are: Resident #115 had a [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an assessment reference date of 4/30/18 documented the resident scored 12 (8-13 indicates moderately impaired) on the Brief Interview for Mental Status; required extensive assistance of one person for bed mobility; was at risk for pressure ulcer development; had no pressure ulcers; and required pressure relieving devices to bed and chair, turning and repositioning program, and nutrition/hydration to manage skin problems. a. The Plan of Care (PoC) revised 5/19/18 did not document any problems with pressure ulcers, and there were no interventions documented to prevent the formation of pressure ulcers. The Closet Care Plan, copied on 5/22/18 at 8:30 a.m., did not have any interventions highlighted to alert the Certified Nursing Assistants (CNAs) of any planned interventions to prevent pressure ulcer development. b. A weekly wound observation document dated 5/17/18 documented a pressure ulcer, deep tissue injury measuring 1.0 cm (centimeters) x (by) 0.8 cm to the right buttock. The interventions documented, AP/LAL mattress (low air loss mattress) and heels elevated/boots. There was no documentation of any other pressure ulcers. c. On 5/20/18 08:14 p.m., the resident was lying in bed on her back. Her heels were directly on the bed, and there was no specialty mattress on the bed. d. On 5/22/18 at 8:20 a.m., the resident was in her wheelchair. She was asked, Do you have any sores? She replied, Yes, I have an area on my buttocks and my heels, and they really hurt. She was asked, What are they doing for them? She stated, They put a dressing on my buttocks, but have not done anything for my heels. She was asked, Have they ever put a different mattress on your bed? She replied, No. e. On 5/22/18 at 8:35 a.m., Certified Nursing Assistant (CNA) #1 was asked, Has this resident ever had a specialty mattress on her bed? She replied, Don't believe so. f. On 5/22/18 at 10:35 a.m., the treatment nurse came in to put a clean dressing on the right buttock wound. The resident was turned to the right side. The following pressure ulcers were discovered at this time: 1) Distal left buttock, Stage II, 0.3 cm x 0.5 cm. 2) Left medial buttock, Stage II, 0.3 cm x 0.3 cm 3) Left proximal buttock, State II, 0.5 cm x 1.5 cm 4) The top of the buttocks, Stage II, 1.7 cm x 1.5 cm 5) The distal right buttock, Stage II, 0.7 cm x 1.5 cm 6) The proximal right buttock, Stage II, 1.5 x 1.5 The Treatment nurse stated, This has changed (development of multiple pressure ulcers). 7) The left heel deep tissue injury, 4 cm x 2.5 cm with 0.5 cm x 0.7 cm of necrotic area inside the wound bed. 8) The left inner heel, 1.5 cm x 1.5 cm deep tissue injury with eschar 9) The right outer heel, 3 cm x 2 cm eschar 10) The right inner heel, deep tissue injury, 1.5 cm x 1.5 cm. The Treatment Nurse stated at this time that he would call the physician for orders, put a low air loss mattress on her bed and put pressure relief boots on her heels. g. On 5/23/18 at 10:25 a.m., the Director of Nursing (DON) was asked, When a resident is identified to be at risk for pressure ulcers, what interventions do you put into place to prevent pressure ulcer formation? She stated, It is individualized per resident. She was asked to look at this resident's PoC to determine what interventions were implemented. She reviewed the PoC and stated, I did not see one. She was asked to review the closet care plan for interventions. She reviewed it and was asked, What intervention on this closet care plan should have been highlighted to ensure the CNAs know what intervention to do? She replied, Float heels. h. On 5/23/18 at 10:30 a.m., CNA #2 was asked, How do you know which residents should have their heels floated? She replied, In the closet care plan. i. On 5/23/18 at 10:43 a.m., CNA #3 was asked, How do you know which resident should have their heels floated? She replied, In the closet care plan. j. On 5/23/18 at 11:00 a.m., the resident was lying in bed on her back, with a low air mattress in place. She was asked, How do you like your new mattress? She stated, I like it; it is comfortable. She was then asked, Are your heels still hurting? She replied, No, not since they put these boots on them. k. On 5/23/18 at 10:40 a.m., Licensed Practical Nurse (LPN) #1 was asked, How do you know which residents should have their heels floated? She stated, If they are at risk. She was then asked, Has (Resident #115) ever had an overlay or low air loss mattress before yesterday? She replied, No, not that I recall. l. On 5/23/18 at 10:41 p.m., LPN #2 was asked, How do you know which residents should have their heels floated? She replied, If they are not able to move, require turning every 2 hours and if they have a pressure ulcer or [MEDICAL CONDITION] on their feet. She was asked, Why did (Resident #115) not have her heels floated? She stated, We are just going to have to train our staff. She was then asked, Should this resident have had her heels bridged? She replied, Yes. m. The facility's Procedure for Pressure Injury, Prevention and Management, obtained from the facility receptionist on 5/23/18 at 8:15 a.m., documented, .Interventions and preventative measures for those residents at risk or who currently have a pressure injury will be care planned, implemented and monitored by the treatment nurse and nursing staff .