Every finding on record at Brookdale Carriage Club Providence

Based on record review, observations, and staff interviews, the facility failed to ensure the resident census for the skilled unit was accurate on the daily nurse staffing sheets for 4 of 4 days of the recertification survey (5/4/2026 through 5/7/2026).The findings included:a. An observation on 5/4/2026 at 10:37 AM revealed a census of 17 on the posted nurse staffing sheet. Review of 5/4/26 census report for the skilled unit revealed a census of 5.b. An observation on 5/5/2026 at 8:30 AM, 3:46 PM, and 4:48 PM revealed a census of 1 on the posted nurse staffing sheet. Review of the 5/5/26 census report for the skilled unit revealed a census of 5. c. An observation on 5/6/2026 at 11:43 AM revealed a census of 17 on the posted nurse staffing sheet. Review of the 5/6/26 census report for the skilled unit revealed a census of 5. d. An observation on 5/7/2026 at 9:37 AM revealed a census of 17 on the posted nurse staffing sheet. Review of the 5/7/26 census report for the skilled unit revealed a census of 5. On 5/7/2026 at 1:33 PM an interview with the Scheduler revealed she was responsible for completing the posted nurse staffing sheet. She stated she was trained to complete the posted nurse staffing sheet by the previous Administrator. The Scheduler explained she would open the facility's electronic health system and would count all residents present on both the skilled unit and the non-skilled long term care unit to obtain the census total. The Scheduler then reported she would record the same total census number in the section titled Resident Census at Start of Shift on the posted nurse staffing sheet for 1st shift (7:00 AM to 3:00 PM), 2nd shift (3:00 PM to 11:00 PM), and 3rd shift (11:00 PM to 7:00 AM). The Scheduler communicated she had not been properly trained on how to correctly separate the resident census by unit and complete the posted nurse staffing sheet for the skilled unit.An interview with the Director of Nursing (DON) on 5/7/2026 at 12:07 PM revealed the process of posting the nurse staffing sheet should include posting the skilled unit resident census and the non-skilled long-term care resident census separately. She explained that her lack of awareness regarding the correct procedure was due to not having received training. The DON stated she was not aware the skilled unit resident census and the non-skilled long term care resident census should have been separated. The DON further explained it was important for the posted nurse staffing sheet to be accurate because accuracy was essential as it reflected staffing coverage and alignment with the Centers for Medicare and Medicaid Services (CMS) guidelines for resident care. In an interview with the Administrator on 5/7/2026 at 2:20 PM she stated it was important for posted nurse staffing information to be accurate because accuracy was essential to ensure appropriate care for residents. She explained that she had been in her current role for three months and believed the process failed because the Scheduler received inaccurate training in the past.

Based on observation and staff interviews, the facility failed to perform hand hygiene between handling soiled and then clean dishes to prevent cross-contamination of the clean dishes. These practices had the potential to affect food served and distributed to 9 of 9 residents who received an oral diet. Findings included: A continuous observation of the skilled nursing satellite kitchen was conducted on 04/02/25 from 1:09 PM through 1:16 PM. Dietary Aide #1 was observed operating the dish machine and washing dishes. Dietary Aide #1 had gloves on both hands with left hand glove observed with large ripped in area over the palm. While waiting for the dish cycle to complete, she removed food debris from soiled plates in the sink area located to the right of the dish machine in the dish room and then moved to the drying area side of the dish machine wearing the same gloves. Dietary Aide #1 then opened the dish machine after the washing cycle was completed. She removed all the clean dishes which consisted of 8 bowls, 2 plates, 1 soup bowl, 4 ice cream scoops, 5 pieces of silverware, and 3 metal food storage bins out of the dish machine without removing her gloves or washing her hands and placed these items on a drying rack in the drying area. During the observation, the Kitchen Supervisor stepped into the dishwashing area and asked Dietary Aide #1 for a pair of tongs. Dietary Aide #1 was observed reaching for the tongs on the wall holder with the same torn gloved hand. Dietary Aide #1 touched the tooth area of the tongs but could not get the tongs off the wall holder. The Corporate Kitchen Supervisor then entered the dishwashing area and grabbed the tongs down from the drying area and exited the dishwashing area with the tongs. An interview with Dietary Aide #1 was conducted 04/02/25 at 1:16 PM who stated she was behind in food service today and that was why she had not changed her gloves or washed her hands between touching soiled plates and then clean dishware. She indicated that she usually wears 3 pairs of gloves to remove a pair when contaminated between the dirty and clean dishes. Dietary Aide #1 had been trained on the dish machine when she was hired. She verbalized she was aware that she should have washed her hands and changed her gloves before going from dirty to clean dishes, and if gloves were soiled or torn. She explained what occurred today had been due to being behind on service. An interview with the Dietitian and Corporate Kitchen Supervisor on 04/02/25 at 1:24 PM revealed staff performing dishwashing would not handle dirty dishes and then touch clean dishes without removing gloves and washing their hands in between. The Dietitian stated that multiple gloves should not be used and if a glove was torn, it should be changed immediately. An interview with the Administrator on 04/02/25 at 03:43 PM revealed that she was not familiar with the specific dishwashing procedure the facility follows.

Based on record review and staff interviews, the facility failed to treat 1 of 3 sampled residents with dignity by performing care in a manner that the resident felt was rude and hurried (Resident #117). The findings included: Resident #117 admitted to the facility on [DATE] with diagnoses which included a compression fracture of the second lumbar vertebra. A review of Resident #117's comprehensive care plan dated [DATE] revealed a focus area for alteration in musculoskeletal status related to the compression fracture of the second lumbar vertebra. The interventions included that she required the mechanical lift for transfers. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #117 was cognitively intact. An initial allegation report dated [DATE] revealed an allegation of abuse. The allegation indicated on [DATE] Resident #117 called the Administrator to her room to express concerns about NA #1 when she was providing her care the evening of [DATE]. Resident #117 told the Administrator that NA #1 was getting her into bed for the night and turned her on her side and her legs hit one another and she yelled out oh, that hurts. NA #1 stated I need to get these off referring to her shoes and socks. Resident #117 stated she proceeded in a rude and hurried fashion. Resident #117 requested NA #1 not come back to her room in the future. The initial allegation report was signed by the Administrator. A telephone interview on [DATE] at 12:58 PM with NA #1 revealed that she (NA #1) did not recall Resident #117. She further revealed she had never had any issues with any residents during a mechanical lift transfer. A telephone interview on [DATE] at 11:19 AM with NA #2 revealed on [DATE] she was assisting with Resident #117's transfer back to bed when NA #1 moved the mechanical lift in a jerky, rushed manner which caused the mechanical lift to swing and resulted in Resident #117 yelling out in pain. NA #2 stated she intervened and told NA #1 to slow down and be more careful. NA #2 indicated she moved to the other side of the bed to guide Resident #117 in the mechanical lift and ease her down onto the bed. Resident #117 asked for pain medication. Once secure in bed, she (NA #2) left the room to find Nurse #1 to advise that Resident #117 was asking for pain medication and to also report NA #1 as NA #2 thought her behavior was unsafe and not caring toward Resident #117. NA #2 also reported the incident to the Administrator the morning of [DATE]. NA #2 stated she cared for Resident #117 after the incident and never saw any new bruising or visible injuries. NA #2 stated Resident #117 was alert and oriented, could direct her own care and never displayed any behavior issues. NA #2 stated she had left the room to locate Nurse #1 and did not witness NA #1 taking off Resident #117's pants without removing her shoes first. A telephone interview on [DATE] at 11:49 AM with Nurse #1 revealed that she was giving report on [DATE] to the next shift nurse when NA #2 advised her Resident #117 requested pain medication and reported NA #1 had been rude to Resident #117, used the mechanical lift in a hurried fashion and had not shown concern when Resident #117 had expressed pain. Nurse #1 stated NA #2 told her NA #1 had not treated Resident #117 properly or in a caring manner. Nurse #1 stated she reported the incident to the Administrator on [DATE]. A social services progress note dated [DATE] indicated Resident #117 was in a pleasant mood, reported progress in her physical therapy and expressed no concerns. The investigation report dated [DATE] revealed additional details that included NA #1 was very rushed in her care of Resident #117 on [DATE] and attempted to remove Resident #117's pants without removing her shoes first. NA #1 had been using the mechanical lift to transfer Resident #117 into bed and NA #2 witnessed NA #1 rushing through the transfer process causing the mechanical lift to swing. NA #1 was suspended on [DATE] and employment subsequently terminated for lack of customer service and care. The investigation report was signed by the Administrator. A nursing progress note dated [DATE] at 4:28 PM stated Resident #117 was pronounced deceased by Hospice at 4:06 PM. An interview on [DATE] at 2:37 PM with the Administrator revealed she was called to Resident #117's room the morning of [DATE]. Resident #117 reported that NA #1 had been rude and hurried when getting her back into bed using the mechanical lift and when taking off her pants without removing her shoes first. The Administrator stated after the facility's investigation, the resident's abuse allegation was not substantiated. NA #1 was terminated due to poor customer service and care.

Based on record review, and staff and nurse practitioner interviews, the facility failed to maintain accurate advance directive information throughout the electronic and paper medical records for 1 of 3 residents reviewed for advance directive (Resident #119). The findings included: Resident #119 was admitted to the facility on [DATE]. A review of the nursing admission note dated [DATE] at 2:42 PM indicated that Resident #119 was alert and verbal. A review of Resident #119's electronic medical record revealed an order written by the nurse practitioner dated [DATE] for full code status. This order was created by the Director of Clinical Services. A review of Resident #119's comprehensive care plan revealed a focus area for advance directives initiated on [DATE] indicating Resident #119's code status was a full code. The goal was for Resident #119's wishes and directives to be carried out in accordance with her advanced directives through the next review date. An intervention was to honor resident choice for code status. A review of the paper medical record revealed on [DATE] Resident #119 signed a Medical Orders for Scope of Treatment (MOST) form for do not attempt resuscitation (DNR/no cardiopulmonary resuscitation (CPR). Further review of the paper medical record revealed a Golden Rod DNR form signed on [DATE] by the Nurse Practitioner. Resident #119's admission Minimum Data Set (MDS) dated [DATE] revealed that it was in progress. An interview on [DATE] at 10:19 AM with the Nurse Practitioner (NP) revealed she met with Resident #119 on [DATE] and confirmed Resident #119's advance directive choice which was a DNR status. The NP stated the order for a full code was not correct and should have been updated when the MOST form and Golden Rod form were completed. An interview on [DATE] at 11:30 AM with the Director of Clinical Services revealed she recalled there was confusion regarding what Resident #119's advance directive wishes were on admission. She stated she discussed advance directive choice with Resident #119 on admission. She was not clear what Resident #119 wanted after the discussion. As a result of this confusion, the Nurse Practitioner and the Director of Clinical Services made Resident #119 a full code status until the Nurse Practitioner could discuss advance directives further with Resident #119. The Director of Clinical Services reported if Resident #119 had experienced an emergency, the nurse would have followed the information in the electronic medical record which showed full code status. The Director of Clinical Services stated that both the electronic medical record and paper medical record should always reflect the same information regarding advance directives. She stated the Nurse Practitioner order should have been updated after Resident #119 signed the MOST form dated [DATE]. She indicated she was responsible for the care plan and should have updated it to reflect Resident #119's DNR status as of [DATE]. An interview on [DATE] at 2:19 PM with the Administrator indicated Resident #119's advance directive information was not correct across the electronic medical record and the paper medical record. She stated that advance directive information was very important and should always be accurate and up to date to reflect the resident's choice.

Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use, discard dented canned goods stored for use, maintain a utility cart in clean condition that was used to transport clean dishware, keep a food storage area clean and orderly, failed to ensure a scoop was stored without the potential for cross-contamination, failed to dry metal prep pans and plastic plate covers prior to stacking, failed to ensure metal plate warmers were clean prior to use, and failed to maintain a hand washing sink in good repair. These practices occurred in the walk-in refrigerator, walk-in freezer, dry goods storage area, and had the potential to affect food served to residents. The findings included: 1. An initial tour of the main kitchen occurred on 2/19/24 at 9:45am with the Dietary Manager (DM). The main kitchen served all buildings on campus. The following concerns were identified: a. Items in the walk-in refrigerator that were not sealed included: -cut pineapple in a metal serving pan not completely covered with plastic wrap with a prep date of 2/16/24 -cut watermelon in a metal serving pan not completely covered with plastic wrap with a prep date of 2/16/24. -cut carrots, celery, and onions in metal prep pan not completely covered with plastic wrap with a prep date of 2/19/24. -large plastic container of chicken soup without the lid secured with a prep date of 2/18/24. -acorn squash placed on trays in a tray cart labeled but with no covering with a prep date of 2/19/24. -premade frozen pizzas placed on trays in a tray cart labeled with no covering with prep date of 2/19/24. b. Items in the walk-in refrigerator were opened and not dated included: -a five-pound bag of bacon bites. -a bag of opened fresh spinach. -mashed potatoes in a metal prep pan. c. Items in the reach in freezer that were opened and not dated included: -a bag of two fish filets. -a bag of French fries. d. Items in the reach in refrigerator that were opened and not dated included: -a bag of parmesan cheese crumbles. -a bag of parmesan cheese flakes. -a bag of mild cheddar cheese cubes. -a squeeze bag of whipped topping. e. Two 108-ounce corned beef hash cans were observed with dents approximately two inches in length along the seal and were found next in rotation in the dry food storage area. f. A plastic utility cart was observed with food particles and a dried brown sticky liquid. The utility cart had clean serving dishes to include plates, cups and plastic fruit bowls placed on the utility cart. These dishes had the potential to be used in multiple dining areas including the skilled nursing unit. g. The walk-in refrigerator floor was sticky and littered with paper, lettuce pieces, an onion bag, and a large carrot next to a bag of carrots that was open on the bottom shelf. h. A scoop was left in the bin of rice with the handle touching the rice in the dry food storage area. i. Ten small rectangular metal prep pans stacked on a utility cart were stacked wet (wet-nested) and seven larger rectangular prep pans stacked on a shelf near the dishwasher were wet-nested. An interview with the DM on 2/19/24 at 10:05am revealed he educated his staff on proper storage, labeling and dating of opened food items in the refrigerators. A tour of the satellite kitchen area on 2/20/24 at 4:25pm revealed 10 prepared food lids were wet-nested and 10 warming trays to be placed under prepared plates were dirty with a dried, brown substance. An interview with the DM on 2/21/24 at 10:46am revealed the Executive Chef was tasked with a kitchen inspection to include a walk around to make sure everything was correct. The Executive Chef worked a regular shift the previous weekend, so she was not able to manage her task. The DM stated that the kitchen was short on staff. He revealed he did not work on the weekends but served as Manager on Duty once a quarter. The DM explained the kitchen utilized a cleaning log binder that indicated the kitchen was scheduled for a deep clean on 2/18/24 and it indicated the task was completed. He stated that staff were trained in the correct process for labeling and dating opened food and the correct procedure for stacking pans to prevent wet nesting. An interview with the Administrator on 2/21/24 at 11:43am revealed that the DM was responsible for the management of the kitchen and kitchen staff and was unaware of the food storage concerns in the kitchen. 2. An observation made on 2/19/24 at 9:45am revealed a leaking wash station sink to the right of a food preparation area. Water was observed under the sink and the floor area to the right of the sink had visible standing water. Multiple water line hoses were visible behind the pedestal of the sink. When the sink was in use, water was observed leaking from behind the sink pedestal. The food preparation table to the left had cut up pieces of fruit in a metal container. An interview with Dietary Manager (DM) on 2/19/24 at 10:15am revealed he was not previously aware of the leak, and he attempted to tighten the valve behind the sink but was unsuccessful. He was observed notifying the Maintenance Department of the leak and sent a picture on his phone. An interview with Maintenance Director #1 on 2/21/24 at 9:44am revealed the facility utilized an online maintenance request system. All staff who had access were able to put in a request and it would stay in the system until it was completed. Maintenance Director #1 confirmed that he can go back and see if the work was completed, and all maintenance staff had access to the system. He was not aware of the leak. An interview with the DM on 02/21/24 at 10:46am revealed the sink had not been repaired and that he had reminded the maintenance department of the concern earlier that morning. An interview with Maintenance Director #2 on 2/21/24 at 3:58pm revealed the sink was repaired before 12:00pm on 2/21/24. He stated the valve on the water connection in the wash station sink did not work when the foot pedal was pressed, and water leaked out. An interview with the Administrator on 2/21/24 at 11:43am indicated she was not aware there was an issue with the wash station sink and expected the kitchen staff to report their concerns to the Maintenance Department.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and to monitor interventions that the committee had previously put in place following the recertification survey on [DATE]. This was for a deficiency in the area of food safety requirements (F812). The continued failure since the previous survey of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag was cross referenced to: F812: Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use, discard dented canned goods stored for use, maintain a utility cart in clean condition that was used to transport clean dishware, keep a food storage area clean and orderly, ensure a scoop was stored without the potential for cross-contamination, dry metal prep pans and plastic plate covers prior to stacking, failed to ensure metal plate warmers were clean prior to use, and maintain a hand washing sink in good repair. These practices occurred in the walk-in refrigerator, walk-in freezer, dry goods storage area, and had the potential to affect food served to residents. During the recertification survey conducted on [DATE], the facility was cited for failure to store milk products at a temperature of 41 degrees Fahrenheit or below; to discard expired foods; to discard potentially hazardous thawed food; to label and date; to ensure frozen items were not open to air and dated; to repair a malfunctioning freezer unit; and to maintain a clean walk-in refrigerator for 1 of 1 reach-in refrigerators in the satellite kitchen, 1 of 1 walk-in refrigerators in the main kitchen, 1 of 1 reach-in freezers in the main kitchen, and 1 of 1 walk-in freezers which had the potential to affect food served to residents. The Administrator was interviewed on [DATE] at 5:37 pm. She reported that she was aware of the previous food safety citation, that the processes put in place by Quality Assurance were not sustained due to changes in leadership, and that the new processes were not carried over to the new Dietary team.

Based on observations, resident and staff interviews, and record reviews the facility failed to honor food choices for 3 of 3 sampled residents (Residents #8, #10, #4) reviewed for preferences. The deficient practice had the potential to affect 9 residents who received food from the kitchen. The findings included: a. Resident #8 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #8 was cognitively intact. The MDS also indicated Resident #8 needed partial or moderate assistance when eating. A review of Resident #8's care plan dated 1/29/24 revealed Resident #8 was at increased nutrition/hydration risk related to variable food intakes related to frequent nausea and was at risk for weight loss and malnutrition. The goal identified no significant weight change. Interventions included monitoring meal intake with each meal, offering supplements as ordered, and monitoring weights as ordered. An interview with Resident #8 on 2/19/24 at 11:37 a.m. indicated she was not aware of any food choices for meals. The interview further revealed she was not aware of any food choices when she did not like what she had to eat. She was not aware of any other options for food. b. Resident #10 was admitted to the facility on [DATE]. The admission MDS 1/28/24 revealed that Resident #10 was cognitively intact. The MDS also indicated Resident #10 required supervision and touching assistance when eating. A review of Resident #10's care plan dated 1/28/24 revealed Resident #10 had an Activities of Daily Living (ADL) self-care performance deficit. The goal identified maintenance of current level of function. Interventions included Resident #10 had upper and lower dentures. An interview with Resident #10 on 2/19/24 at 3:23 p.m. revealed the staff placed a dish in front of her at mealtime but she was not aware of any menu choices as explained by a staff member or on a paper menu. c. Resident #4 was admitted to the facility on [DATE]. The admission MDS dated [DATE] revealed Resident #4 was moderately cognitively impaired. The MDS also indicated Resident # 4 required eating setup or clean up assistance. A review of Resident #4's care plan dated 1/19/24 revealed Resident #4 was at nutritional risk related to diagnosis of dementia. The goal identified no significant weight change through the next review date. Interventions included Resident #4's weights, meal intake, and labs and Accuchecks would be monitored. An interview with Resident #4 on 2/19/24 at 2:30 p.m. revealed the facility staff tells her what she has to eat, and she was not aware of any food choices regarding her meals. An observation of the dining room on 02/19/24 at 12:18 p.m. revealed residents received a plate of food in front of them. No conversations about food choices were discussed by staff. An interview with Dietary Aide #1 on 2/20/24 at 9:41 a.m. revealed the residents who were able to choose their meals were given a paper menu. She explained the residents would circle the menu when care staff gave it to them. If the meal was delivered to them and they didn't like it, they could send it back and have the other choice. Dietary Aide #1 indicated their were options like sandwiches, burgers and hot dogs that could be ordered from the main kitchen if a resident wanted another choice. She stated that all food choices were posted outside in the hallway on the menu, which included the always available foods. An observation on 2/20/24 at 9:50 a.m. of the posted menu in the hall revealed the breakfast, lunch, and dinner choices, with a snack option, but there was no notice of an always available menu. An interview on 2/20/24 at 4:21p.m. with the Activity Director revealed new menus were posted every Friday. She explained that the nurse would deliver the menus to the residents, and she would often times help out when needed. The menus were marked with selections by the residents and sent back to dietary for the following week. She explained there were substitutions on the list. The Activity Director further explained that when residents were new the CDM would assist them with writing down their preferences. When residents were new, they would write down all their preferences. There was an Always Available menu for residents who didn't like the meal choices. They could choose between cottage cheese and fruit, peanut butter and jelly or another sandwich, toast, etc. She explained the dietary department had a process for alerting new residents to the Always Available food choices. An observation of dinner on 2/20/24 at 4:25 p.m. revealed three dinner menus on the bulletin board next to the tray line service area. The menus were filled out by residents not residing in the skilled nursing unit. An interview with Nurse Aide #1 on 2/21/24 at 9:56 a.m. indicated that staff went to each room with a menu for the week. One copy of the menu was left in the resident rooms for them to reference and the other completed copy was taken to the dining room for staff to reference. The staff based the residents' food choices on the completed copy. If the resident did not want the selection, she explained she would get them another option. Nurse Aide #1 explained if a resident wanted a grilled cheese, peanut butter and jelly sandwich, etc., the staff would alert them to the Always Available menu. An interview with the Dietary Manager (DM) on 2/21/24 at 10:46 a.m. revealed the Certified Dietary Manager (CDM) received the menus from the main kitchen and took them to the satellite kitchen and delivered them. The menus were formatted as a week at a glance from Sunday to Saturday. An interview with the CDM on 2/21/24 at 11:22 a.m. revealed residents would mark their choices on paper menus on Friday. The Activity Director would ask the residents to make their choices and then the paper menus would go on the board next to the tray line service area. She showed the stack of filled out menus in her hand and explained that the process for the Activity Director helping residents with menus started on 2/20/24. The CDM explained before this new process was adopted, the nurse aides were supposed to alert the kitchen of the residents' choices for meals. She also revealed that the Always Available menu was not posted anywhere in the building. An interview with the Director of Nursing (DON) on 2/21/24 at 11:32 a.m. revealed nurse aides would tell the kitchen what each resident wanted, but management was in the process of implementing a new process for the Activity Director to pass out paper menus to the residents to make their food selections. She was not aware the residents were not getting a choice in their menu prior to 2/20/24.

Based on observations, residents and staff interviews, the facility failed to maintain lighting, cabinets, and walls in good repair for 1 of 1 hall (resident rooms 214, 222) and 1 of 1 activity room nutrition area reviewed for clean, comfortable and homelike environment. The findings included: a. An observation on 2/19/24 at 11:18am revealed a brown, dried splatter on the wall across from the resident bed in room [ROOM NUMBER]. A second observation was conducted on 2/21/24 at 9:30am with the Administrator, Maintenance Director #1, and the Housekeeping Supervisor. The observation revealed a brown, dried splatter on the wall across from the resident bed. An interview with the Housekeeping Supervisor on 2/21/24 at 9:46am revealed that housekeeping staff were responsible for cleaning rooms, bathrooms, dispensers, toilets, sinks, sweeping and mopping, wiping down televisions, beds, remotes, and bedside tables. The bathroom vent covers were to be cleaned during a deep cleaning session, not on a regular basis. The walls would be cleaned if dirt was present. She completed weekly environmental rounds in the building. The Housekeeping Supervisor was not aware of the issues brought up to the team. She stated housekeepers would be alerted by other staff if something needed to be cleaned. If the concern was a bigger issue, a request would be entered into the online maintenance tracking system. She was not aware of any requests logged into the system. b. An observation on 2/19/24 at 2:22pm in room [ROOM NUMBER] revealed a dusty exhaust fan cover, a burned-out lightbulb out in vanity light above sink, and a burned-out heat lamp bulb in ceiling. A second observation was conducted on 2/21/24 at 9:30am in room [ROOM NUMBER] with the Administrator, Maintenance Director #1, and the Housekeeping Supervisor. The observation revealed a revealed a dusty exhaust fan cover, a burned-out lightbulb out in vanity light above sink, and a burned-out heat lamp bulb in ceiling. An interview with Maintenance Director #1 on 2/21/24 at 9:44am revealed the facility utilized an online maintenance request system. All staff who had access were able to put in a request and it would stay in the system until it was completed. Maintenance Director #1 confirmed that he could go back and to see if the work was completed, and all maintenance staff had access to the system. He stated that Maintenance staff perform weekly, monthly, and quarterly building tasks for each building and there is a lead technician in each building. Maintenance Director #1 revealed that he was not made aware of the concerns. c. An observation on 2/20/24 at 4:40pm revealed the overhead light was not working in the nutrition kitchen area. The bottom two cabinet drawers in the nutritional area were dirty with dried, brown staining and brown, dust-like debris. A second observation was conducted on 2/21/24 at 9:36am in the nutrition area with the Administrator, Maintenance Director #1, and the Housekeeping Supervisor. The observation revealed the bottom two drawers in the cabinets in the nutrition kitchen area were dirty with dried straining and brown, dust-like debris. The overhead light was not working. The Administrator, Maintenance Director #1 and the Housekeeping Supervisor were not aware of these concerns. An interview with the Director of Nursing (DON) on 2/21/24 at 11:32am revealed staff called her when there was a maintenance concern, and she would enter it into the online system and then call Maintenance Director #2 who was assigned to the building. She stated that if the matter was very urgent, the DON would call Maintenance Director #1 immediately. She stated that she always has her cell phone with her. An interview with the Administrator on 2/21/24 at 9:45am indicated that she was not aware of the concerns and expected staff to alert housekeeping and maintenance when there was a concern. She was able to place concerns in the online maintenance tracking system as well.

Based on observations, record review, and Physician and staff interview the facility failed to provide a treatment as ordered by the physician to a non-pressure wound for 1 of 1 resident (Resident # 214) reviewed for wound care. The findings included: Resident # 214 was admitted to the facility on [DATE]. The Care Plan dated 02/01/2024, revealed Resident # 214 had a potential/actual impairment to skin integrity. The Care Plan documented goal for Resident # 214 was to be free from skin breakdown. Resident # 214 interventions included, to evaluate skin condition on a daily and weekly basis, keep skin clean and dry, use lotion on dry skin and not apply to area of skin breakdown, wound, or between toes. The Minimum Data Set (MDS) dated [DATE], revealed Resident #214's cognition was moderately impaired and she had no behaviors. The MDS documented Resident #214 had no refusal of care and she had no documentation of her skin tear noted. The physician's order dated February 2024, revealed Resident # 214 was to receive daily wound care treatment on the right lower wrist. During the initial observation on 02/19/2024 at 11:18am, Resident # 214 was observed sleeping in bed. Resident # 214's family was also present in the room sitting by the resident's bed. Resident # 214 was observed to have a padded bandage placed on her lower right wrist dated 2/17/24. The padded bandage was wrinkled and the skin around the padded bandage was dry. Review of Resident # 214's Treatment Administration Record (TAR) for February 2024, revealed the resident had received wound care treatment to her lower right wrist on 02/18/2024 by Nurse #1. On 02/21/2024 at 9:23am, during an interview with Nurse #1, she reported providing care for Resident # 214 on 02/18/2024. Nurse #1 also mentioned, an agency Nurse #2 (she could not remember who) was working on the floor with her from 7:00am to 7:00pm. She stated it was getting close to the end of the shift, she was doing blood sugar checks on a few residents, and Nurse #2 had offered to complete the wound care dressing for Resident #214 since she was near the resident's room. Nurse #1 verbalized that she agreed to let the other nurse complete Resident # 214's wound care dressing and went ahead with documenting the task as being completed for 02/18/2024. Nurse #1 confirmed she had not verified that the wound care had been completed. An attempt was made to contact agency Nurse #2, but the facility did not have her contact information. On 02/20/2024 at 3:19pm, during an interview with the Wound Care Physician, he reported Resident # 214 has an order to change the bandage on her right lower wrist daily. The Wound Care Physician stated Resident # 214's wound on her right lower wrist was a skin tear measuring approximately 0.5 millimeters (mm) in size, with no drainage or slough, and was healing well with a scab starting to grow. He further indicated, if Resident # 214's wound care was not done daily, there would be no significant damage that would occur. The Wound Care Physician did expect the nurses to follow his wound care orders. On 02/21/2024 at 3:30pm, an interview was conducted with the Director of Nursing (DON) and Administrator. The DON stated all wound care orders were in the resident's TAR and during shift change each nurse reported resident concerns and needs to the nurse for the oncoming shift. The DON verbalized on the days she works; she usually audited the resident's TAR to make sure wound care was done. She further stated that no nurse should ever sign the TAR as a treatment being completed if the nurse had not completed the treatment herself.

Based on observations and staff interviews the facility failed to remove loose garbage, food, and debris from around 1 of 1 trash receptacle located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents. The findings included: An observation of the outdoor trash receptacle area on 2/19/24 at 2:20pm revealed a clear bag of trash on the ground outside of the receptacle and boxes of used COVID tests on the ground underneath the bag. The ground around the enclosure was littered with food scraps to include an apple, vegetable peeling, and labels from boxes and a dark brown sludge. During the observation the receptacle door was noted to be open and there was a broken dining tray cart on the left side of the dumpster and a discarded beverage serving cart on the ground outside of the receptacle enclosure. An interview with Dietary Manager (DM) on 02/21/24 at 10:46am revealed the kitchen staff was responsible for the outdoor trash area. An interview with the Administrator on 2/21/24 11:43am indicated she was not aware there was an issue with garbage/ refuse cleanup and expected all garbage and refuse to be maintained by housekeeping and kitchen staff.

Based on observations, record review and staff interview the facility failed to post a Registered Nurse (RN) on the daily staff posting sheet, accurately post licensed staff, and post daily resident census from December 2023 through February 2024 for 16 of 83 days reviewed for daily posted staffing (12/06/2023, 12/17/2023, 12/27/2023,12/31/2023, 01/04/2024, 01/08/2024, 01/18/2024, 01/19/2024, 01/20/2024, 01/21/2024, 01/24/2024, 01/27/2024, 01/28/2024, 01/29/2024, 02/02/2024, 02/06/2024). Findings included: Upon entering the facility on 02/19/2024 at 9:30am, an observation was made of the facility's daily posted staffing sheet. The daily posted staffing sheet was located on the ledge of the nursing station at the front entrance and revealed there was no RN coverage documented for the 7:00am to 7:00pm shift or the 7:00pm to 7:00am shift, for 02/19/2024. On 02/21/2024 a review of the daily posted staffing sheets from December 2023 through February 2024 revealed, there was no RN documented, inaccurate number of licensed staff and/or no resident census data listed on the following dates: No resident census data listed for the following dates: 12/06/2023, 12/27/2023,12/31/2023, 01/04/2024, 01/08/2024, 01/18/2024, 01/19/2024, 01/21/2024, 01/24/2024, 01/27/2024, 01/28/2024, 01/29/2024, 02/02/2024. Daily posted staffing sheets were in accurate on the following dates: 12/17/2023 - the daily posted staffing sheet had 1 Registered Nurse (RN) RN listed for 7:00am to 7:00pm while the daily schedule had 2 RNs listed. 01/20/2024 - no RN was listed for both shifts (7:00am to 7:00pm and 7:00pm to 7:00am) on the daily posted staffing sheet while the daily scheduled had 1 RN listed. 02/06/2024 - no RNs were listed on the daily posted staffing sheet, but the daily schedule had 1 RN listed. An interview with the Director of Nursing (DON) and the Administrator occurred on 02/21/2024 at 3:30pm. The DON confirmed she oversaw the staff schedules and would review the daily posted staffing for accuracy each morning. She reported the resident census data on the daily posted staffing sheets reflected the number of residents for the skilled nursing unit and the long-term care unit. The DON and Administrator both acknowledged there had been some staffing challenges at the facility.

Based on observations and staff interviews , the facility failed to store milk products at a temperature of 41 degrees ( ) Fahrenheit (F) or below, discard expired foods, discard potentially hazardous thawed food, label and date, failed to ensure frozen items were not open to air and dated, repair a malfunctioning freezer unit and maintain a clean walk-in refrigerator for 1 of 1 reach-in refrigerators in the satellite kitchen, 1 of 1 walk-in refrigerators in the main kitchen, 1 of 1 reach-in freezers in the main kitchen and 1 of 1 walk-in freezer which had the potential to affect food served to residents. The findings included: 1. An initial tour of the satellite kitchen in the health center was conducted with the Certified Dietary manager (CDM) on [DATE] at 10:52 AM, the thermometer in the refrigerator read 48 F. The following concerns were identified with the temperature of the reach in refrigerator: * (2) 32-ounce (oz) containers of thickened milk, one of which was opened and unlabeled or dated. * (2) 1-gallon containers of milk, one of which was opened and dated [DATE]. An observation was made on [DATE] at 12:00PM of the reach in refrigerator in the satellite kitchen in the health care, there were two thermometers in the refrigerator that both read 48 F. The following items were stored in the reach-in refrigerator: * (2) 32-ounce (oz) containers of thickened milk, one of which was opened and unlabeled or dated. * (2) 1-gallon containers of milk, one of which was opened and dated [DATE]. A follow up observation was conducted with the CDM on [DATE] at 12:15PM of the satellite kitchen in the health center. The following concerns were identified. * A plastic container with coffee grounds dated prepped [DATE] and use by [DATE]. There were two scoops lying in the coffee. An interview with Certified Dietary Manager (CDM) on [DATE] at 12:15PM revealed she would be contacting a repair person to fix the refrigerator and would be discarding the (2) 1- gallon milk containers and moving all the other items to the main kitchen. On [DATE] at 12:17PM the CDM was observed to remove the scoops from the coffee container and discarded the coffee. An interview with the CDM on [DATE] at 1:53 PM revealed the scoops should not have been left in the coffee container. She explained the staff probably were refilling the coffee but never changed the label on the container and should have changed the label with each new refill. A follow up observation of the reach in refrigerator in satellite kitchen in healthcare was made on [DATE] at 11:34AM and the thermometer in the refrigerator read 40 F. Follow-up interview with the CDM on [DATE] at 4:18PM revealed the reach in refrigerator was thought to have been cycling down and they did not feel it needed repair. She added the thickened liquid that was open should have been discarded due to the high temperature in the reach in refrigerator. Interview with the Administrator on [DATE] at 4:30 PM revealed all the kitchens regardless of their location on campus to have followed all regulations at all times. 2. An initial tour of the main kitchen's walk-in refrigerator was conducted with the DSM on [DATE] at 11:25AM. The following concerns were identified: * large plastic container of ,d+[DATE] chicken quarter legs with a label that read prep date [DATE] and used by date of [DATE]. * a quarter of a cooked ham prep date of [DATE] and used by date of [DATE]. * a plastic container of cucumber dip (Tzatziki) which was watery once opened with an expiration date of [DATE]. * a 13-quart container with sliced sweet potatoes in a clear liquid with a prep date of [DATE] and use by date of [DATE]. * a 2-quart container of lemon slices with a prepped date of [DATE] and no used by date. * The floor of the walk-in refrigerator had debris on it which included empty water bottles, green leafy vegetables, raw pasta, tomatoes and pieces of plastic. An observation was made on [DATE] at 11:35AM of the Associate Director of Dining Services (ADDS) removing the labels from the chicken quarter legs and cooked ham and relabeling the items with a prep date of [DATE] and use by date of [DATE]. An interview was conducted with the Chef on [DATE] at 11:37AM. The chef revealed the chicken and ham were good for use for 7 days and should have had a used by date of [DATE]. The Chef added the sweet potatoes should have been used by [DATE] and therefore should have been tossed. The Chef also added the sliced lemons should have been discarded within 3 days of prep. He explained the dishwasher should sweep the floors daily and he would have swept it but he was too busy. An interview was conducted with the DSM on [DATE] at 11:38AM revealed the chicken and ham should have been tossed within 3 days and the cucumber dip (Tzatziki) by expiration date. An interview was conducted with the ADDS on [DATE] at 11:40AM stated he relabeled the chicken, ham and sweet potatoes because they were good for 7 days and that the person who labeled them made a mistake by making the used by date 3 days. A follow up interview was conducted with the ADDS on [DATE] at 11:25AM revealed the walk-in floors should be kept clean and free of debris. Interview with the ADDS on [DATE] at 3:07 PM revealed the DSM informed him and the Chef that the ham and marinated chicken should have been discarded after ,d+[DATE] days and the ham was discarded by the chef on [DATE]. Interview with the Administrator on [DATE] at 4:30 PM revealed all the kitchens regardless of their location on campus to have followed all regulations at all times. 3. An initial tour of the main kitchen's reach in freezer was conducted with the DSM on [DATE] at 11:44AM. The following concerns were identified: * 2 (2lb) bags of shrimp that were soft to touch and defrosted. The DSM was observed to stop the ADDS from discarding the bags of shrimp and instruct him to leave them in the freezer. Interview with the DSM on [DATE] at 11:45AM revealed the bags shrimp were taken out of the freezer [DATE] for an event and were not used. He added the staff left them in the refrigerator and placed them back in the freezer the morning of [DATE]. Interview with the ADDS on [DATE] at 3:03PM revealed the shrimp should not have been placed back in the reach in freezer after thawing but should have been discarded. The ADDS added the shrimp were discarded [DATE]. Interview with the Administrator on [DATE] at 4:30 PM revealed all the kitchens regardless of their location on campus to have followed all regulations at all times. 4. An initial tour of the walk-in freezer was conducted with the DSM on [DATE] at 11:45AM. The following concerns were identified: *1 (2lb) bag of Brussel sprouts open to air undated and unlabeled. *1 (20lb) box of corn kernels open to air with ice crystal observed on the corn undated and unlabeled. *right side of the freezer wall, with icicles formed on the pipes approximately ,d+[DATE] inches in length and dripping water. The ice was observed on 26 boxes stacked under the pipes. Interview with the DSM was conducted on [DATE] at 11:48AM revealed the freezer unit was repaired ,d+[DATE] weeks ago. An interview with the ADDS on [DATE] at 3:23PM revealed the items in the freezer should have been bagged once opened, labeled and dated. The ADDS added the freezer unit created ice crystals and it caused the fan to stop or malfunction. He explained the facility had called the repair company and frequently had to call them to repair the freezer unit. Interview with the Administrator on [DATE] at 4:30 PM revealed all the kitchens regardless of their location on campus to have followed all regulations at all times.

Based on a kitchen observation, staff interviews and record review, the facility failed to employ a full time certified professional as director of food and nutrition services for 7 months (April 2021 - November 2021). This had the potential to affect a census of 7 of 7 residents on the skilled nursing unit. The findings included: The Dietary Manager (DM) was observed in the kitchen on 11/02/21 at 11:12 AM providing instruction to the dietary staff regarding hot foods for the lunch meal. During an interview with the DM on 11/02/21 at 11:20 AM, he stated that he completed a training class in 2003 to become a certified dietary manager (CDM), but that he had not completed the CDM examination. He stated he was not certified. The DM further stated that he managed a department of 3 full time employees since April 2021. The DM also stated that the registered dietitian (RD) provided onsite consultation twice monthly and as needed by phone. A telephone interview on 11/04/21 at 10:06 AM with the RD revealed she began nutrition consultation services for the facility in August 2021 and that the current DM was already in place at that time. The RD stated that it was not her practice to verify the credentials for a manager who was already in place at the time she began consulting. The RD stated she expected that verification of credentials for the DM would have already been completed. The RD stated she assumed that the DM was certified. The RD stated she provided dietary consultation onsite twice per month and by phone as needed. During her onsite visits, the RD stated she completed quarterly kitchen audits, tray line observations and nutrition assessments for high-risk residents and new admissions. During her onsite visits she stated she spent 2 - 3 hours in the facility per visit to complete these tasks and provided education to staff in the dietary department as needed. The RD stated that she also completed an annual competency evaluation for the position of DM, which was due for the current DM. She further stated that she was unable to complete the competency evaluation at her visit in October 2021 because the DM was unavailable. During an interview on 11/04/21 at 11:38 AM, the Administrator stated the DM was hired as the CDM and provided a copy of the letter for hire. Review of the letter for hire revealed the current DM was hired on 4/25/21 as the CDM. The Administrator also stated that the DM completed the NC Dietary Managers Training (NCDMT) and provided a copy of the certificate. Review of the certificate revealed the DM completed the NCDMT on 7/26/01. The Administrator further stated that she was aware that the DM needed to register for and complete the examination to become a CDM, but that she was under the impression that the DM had coordinated plans to complete the exam and she had not followed up.

Based on record reviews and staff interviews, the facility failed to prevent the use of a restraint for convenience on 1 of 1 resident reviewed for restraints (Resident #157). Findings included: Resident #157 was admitted to the facility 4/5/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) admission assessment dated [DATE] assessed Resident #157 to be severely cognitively impaired. The MDS documented Resident #157 was sometimes understood with speech and would sometimes understand others. The MDS documented Resident #157 had a percutaneous gastrostomy (PEG) tube for nutrition and he had received 51% or more of his calories via the PEG tube while he was a resident. The MDS assessed he had limited range of motion of his upper body on one side. A care plan dated 4/6/2021 addressed Resident #157's difficulty with communication and the goal for the plan included using appropriate hand gestures with the right hand and responding to yes/no questions. A care plan dated 4/6/2021 with a revision dated of 4/14/2021 addressed the cognitive changes Resident #157 was experiencing. The interventions included always using an abdominal binder (added on 5/26/2021) and to report changes in cognitive function to the physician. A care plan dated 4/6/2021 with a revision date of 4/14/2021 addressed Resident #157 need for tube feeding with intervention included to always using an abdominal binder (added 5/26/2021). A nurse practitioner note dated 5/13/2021 noted Resident #157 had right basal ganglia intercranial hemorrhage with intraventricular hemorrhage (bleeding in the brain which can result from a stroke). The note documented Resident #157 had dense left [CONDITION(S)] (left-sided paralysis). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note written by the Administrator dated 5/25/2021 at 4:00 PM documented Writer along with Nurse #1 notified resident representative of incident that occurred regarding use of restraint. A nursing note written by Nurse #1 on 5/25/2021 at 4:00 PM documented physician notification regarding the incident. A facility incident investigation dated 5/25/2021 noted the incident occurred around 11:00 AM and was reported to the Administrator at 1:10 PM. A care plan dated 5/26/2021 addressed the psychosocial well-being changes due to a recent incident, and interventions included staff to monitor for usual response to problems and Social Worker to visit 3 times to monitor for changes. An interview was conducted with Nurse #2 on 11/3/2021 at 11:26 AM. Nurse #2 reported she was the nurse assigned to Resident #157 on 5/25/2021. Nurse #2 reported she had gone into Resident #157's room to administer a PEG tube feeding about 11:00 AM and thought that his PEG tube appeared to have been pulled out. Nurse #2 reported Resident #157 did not have an abdominal binder in place, and she had been told the abdominal binder was dirty and in the laundry. Nurse #2 explained she went to get Nurse #4 (the former Director of Nursing [DON]) and Nurse #3 (the former Assistant Director of Nursing [ADON]) for help. Nurse #2 reported Nurse #4 and Nurse #3 discussed how to prevent Resident #157 from pulling out the PEG tube and they decided to put a sock over Resident #157's right hand. Nurse #2 explained that Resident #157 did not have use of his left hand and he could not talk, so he used the right hand to communicate using a thumbs up or thumbs down signal for answering yes and no questions. Nurse #2 reported Resident #157 used his right hand to use the call light for help. Nurse #2 reported she was called to the Administrator office after the sock had been removed and saw it had tape on the sock. Nurse #2 reported she did not know who put the tape on the sock. Nurse #2 reported she had received education related to restraints before the incident. Nurse #2 reported she thought it was ok to apply the sock to his right hand because Nurse #4 and Nurse #3 had decided to use it. Nurse #2 reported she wasn't certain if the sock over Resident #157's hand was a restraint. An interview was conducted with Nurse #3 on 11/3/2021 11:48 AM. Nurse #3 reported she had been the ADON at the time of the incident. Nurse #3 reported on 5/25/2021 she was asked by Nurse #2 to come to Resident #157's room to look at his PEG tube. Nurse #3 reported Resident #157 was tugging on his tube with his right hand, and because he had pulled the PEG tube out in the recent past, she was concerned he would pull it out again. Nurse #3 reported Nurse #4 suggested applying a sock to Resident #157's right hand would prevent him from pulling on the PEG tube. Nurse #3 reported she did not think the sock on his hand was a restraint, because the sock was going to protect him from pulling out the PEG tube. Nurse #3 did not know who put tape on the sock. Nurse #3 explained she was aware Resident #157 used his right hand for communication, but because Nurse #4 had many years of experience in long-term care, she thought putting the sock on his hand was ok and not a restraint. Nurse #3 reported she had been told by Nurse #2 that the abdominal binder was in the laundry and did not think Resident #157 had an extra binder in his room and she thought the sock would remain on Resident #157's hand until the abdominal binder was returned to his room. Nurse #3 reported she did not look in Resident #157's room for another abdominal binder. Nurse #3 reported she had received education on restraints during orientation but did not think the sock would be considered a restraint. Nurse #4 was interviewed on 11/3/2021 at 12:22 PM. Nurse #4 reported she was the former agency interim DON for the facility on 5/25/2021. Nurse #4 reported she and Nurse #3 were called to Resident #157's room by Nurse #2 because Nurse #2 thought Resident #157 had pulled out his PEG tube. Nurse #4 reported she held Resident #157's hand while Nurse #3 checked for placement of the PEG tube. Nurse #4 explained she was told Resident #157 had abdominal binders to use to protect the PEG tube, but the binder was in the laundry. Nurse #4 reported they had not looked in the room for another binder because she was told he only had one binder. Nurse #4 reported she intended to keep the sock on Resident #157's hand until an abdominal binder could be located. Nurse #4 reported Resident #157 continued to wave his hand around while she was holding it and while she applied the sock to his right hand. Nurse #4 reported she did not apply tape to the sock to prevent it from coming off Resident #157's right hand. Nurse #4 reported she had not called the facility physician to notify him she had placed a sock over Resident #157's hand and she was not aware Resident #157 used his right hand to communicate. Nurse #4 reported she had received education related to restraints but did not think the sock on his right hand was a restraint. Physical therapist (PT) was interviewed on 11/3/2021 at 2:51 PM. The PT reported she went to Resident #157's room to provide a therapy session on 5/25/2021 around 1:00 PM and she found him with a sock taped over his right hand. The PT reported she got the Occupational Therapist (OT), and they removed the sock from his right hand, which was taped to prevent Resident #157 from removing it. The PT described Resident #157 was waving his right hand in the air and shaking his hand and he appeared agitated until they removed the sock, then Resident #157 returned to his baseline. The PT reported she and the OT reported the incident to the Social Worker (SW) and Administrator. The PT concluded by explaining she looked in Resident #157's closet and found 2 abdominal binders. The PT reported she applied an abdominal binder to Resident #157. The PT reported Resident #157 did not appear distressed after the sock was removed from his hand. An interview was conducted with the OT on 11/3/2021 at 3:10 PM. The OT reported she had provided treatment to Resident #157 related to communication and he was able to use his right hand to give a thumbs up for yes and a thumbs down for no. The OT reported she was called into Resident #157's room on 5/25/2021 by the PT and she saw him in bed with a sock on his right hand, and he was waving his right hand in the air and appeared to be trying to shake off the sock. The OT reported Resident #157 appeared to be agitated when the sock was on his right hand. The OT reported the sock was taped around his wrist to prevent him from removing the sock. The OT reported they removed the sock and reported the incident to Nurse #2 and the SW and Administrator. The OT reported she and the PT looked in Resident #157's closet and found 2 abdominal binders and they applied an abdominal binder to Resident #157. The OT reported Resident #157 was not in distress once they removed the sock from his right hand. An interview was conducted with nursing assistant (NA) #1 on 11/4/2021 at 11:42 AM. NA #1 reported she had been assigned to Resident #157 on 5/25/2021, but did not see the sock on Resident #157's right hand on 5/25/2021. An interview was conducted with the SW on 11/4/2021 at 12:43 PM. The SW explained that Resident #157 was paralyzed on his left side and used his right hand for communication and to use the call light. The SW reported she was alerted by the PT and OT Resident #157 had a sock taped over his right hand on 5/25/2021. The SW reported she went to see Resident #157 after the incident and he was unable to communicate to her if he was upset, but he did not appear to be in distress. The Administrator was interviewed on 11/4/2021 at 12:06 PM. The Administrator reported the SW, PT, and OT reported to her that Resident #157 was found with a sock taped over his right hand on 5/25/2021. The Administrator reported she completed a 24-hour Health Care Personnel Registry report and initiated an investigation into the incident. The Administrator reported the facility started education on restraints for all staff, the policies and procedures for restraints were reviewed. The Administrator explained Nurse #3 and Nurse #4 were new to the facility, but they had received education related to restraints and were aware the facility had a no restraint policy in place. The Administrator reported the facility had been unable to determine who applied the tape around the sock. The Administrator reported it was her expectation that no device was used to restrict the movement of any resident. The facility physician (MD) was interviewed on 11/5/2021 at 12:47 PM. The MD reported he was not contacted by Nurse #3 or Nurse #4 to report Resident #157 was trying to pull out his PEG tube and they had applied a sock to his right hand. The MD reported after the incident, he was notified by the facility.

Based on observations, staff interviews, and Pharmacy Consultant interview, the facility failed to date an opened multi-dose bottle in 1 of 1 medication storage room refrigerators. Findings included: An observation on 11/04/21 at 12:15 PM of the refrigerator in medication room [ROOM NUMBER] with the Corporate Director of Nursing (DON) revealed 1 of 4 bottles of lorazepam (a medication used to treat anxiety) oral concentrate was opened and available for use without an opened date recorded. 4 of 4 bottles were labeled with a resident's name and the date they were received from the pharmacy. 3 of 4 bottles were opened and 1 of the 3 opened bottles was not dated when it had been opened. An interview with the DON on 11/04/21 at 12:15 PM revealed all multi-dose medications should have been dated when opened and discarded in 28 days. She indicated she had reviewed the medication storage room and ensured all medication was labeled and dated. She was unsure why the bottle was not labeled. She indicated the bottle was received from the pharmacy on 10/25/21 and that was the earliest date in which the bottle could have been opened. An interview with the Pharmacy Consultant was conducted on 11/05/21 at 1:45 PM. She revealed she conducted a 10% audit monthly. She usually checked 1 cart a month and 1 medication room a month. She indicated opened multi-dose medications should be dated and discarded in 28 days. If she identified an opened multi-dose medication that was not labeled, the medication was recorded, staff was notified, and a new bottle was dispensed.

Based on staff interviews, medical record review and review of facility records, the facility failed to prevent and protect a cognitively impaired resident with behaviors from staff to resident abuse. Resident #1 accused Nurse Aide #1 of striking him on the head twice, forcefully putting him to bed, screaming in his face and repeatedly telling him to shut up. When assessed, Resident #1 was noted with an unexplained skin tear on his left arm, an unexplained bruise on his right cheek and an unexplained bruise on his forehead. This occurred for 1 of 3 sampled residents reviewed for abuse. The findings included: Resident #1 was admitted to the facility [DATE] from the hospital, transferred to the hospital on [DATE] for a medical procedure and returned to the facility on [DATE] with Hospice services. Resident #1 expired in the facility on [DATE]. [DIAGNOSES REDACTED]. A nursing admission data collection tool dated [DATE], assessed Resident #1 as able to understand/be understood, clear speech, alert to person, place and time with intact short-term and long-term memory, adequate vision with corrective lenses, adequate hearing with hearing aids bilateral, a skin tear to the right forearm and a stage 2 sacral pressure sore. An admission Minimum Data Set assessment, dated [DATE], assessed Resident #1 with clear speech, understood/understands, adequate vision with corrective lenses, adequate hearing with bilateral hearing aide, moderately impaired cognition, verbal behavior to include threatening others, screaming at others, and cursing at others, required extensive to total assistance with activities of daily living (ADL) (bed mobility, transfers, locomotion, dressing, personal hygiene, bathing, toilet use), and had a stage 2 sacral pressure ulcer. An initial care plan, dated [DATE], and a revised care plan, [DATE], identified Resident #1 required skin interventions due to actual impairment to his skin on admission as evidenced by a skin tear to the right forearm, a surgical incision for placement of a pace maker and a stage 2 pressure sore to his coccyx. Interventions included, in part, to assist with positioning; reduce friction/shearing with use of lift/transfer sheets; evaluate his skin on a daily/weekly basis; monitor/document location, size and treatment of [REDACTED].#1 was also identified with self - care performance deficits related to his diagnoses, need for an assistive device with transfers, and risk for falls. Interventions included, in part, to assist Resident #1 with ADL and to monitor his skin integrity. The revised care plan dated [DATE] also identified Resident #1 was at risk for impaired behavioral patterns due to yelling out. The care plan goal was that Resident #1 would not sustain injury related to his impaired behavioral patterns. Staff were to anticipate his needs, approach him calm, and monitor for the occurrence of the targeted behavior (yelling). Daily nursing progress notes for each shift from [DATE] - [DATE] recorded no new skin concerns for Resident #1. An Initial Allegation of Abuse Report, dated [DATE], completed by the Administrator, documented an allegation of resident abuse. The Initial Allegation of Abuse Report documented, in part, that Resident #1 rang his call bell at 7:34 AM on [DATE]. When Nurse #1 responded, Resident #1 voiced that the male nurse aide (NA #1), told Resident #1 to shut up and was rough, which resulted in a skin tear. Nurse #1 observed Resident #1 with a skin tear to his left forearm. A written statement from Nurse #1 dated [DATE] at 8:00 AM, which accompanied the Initial Allegation of Abuse Report, documented that Nurse #1 observed Resident #1 with a skin tear on his left forearm. When Nurse #1 asked Resident #1 what happened, he stated NA #1 grabbed him, punched him twice in the head, screamed in his face and repeatedly told him to shut up. The statement also documented that Resident #1 stated NA #1 was very aggressive and mean. Nurse #1 documented in her statement that she spoke to NA #1 who admitted to telling Resident #1 to shut up and stop screaming. NA #1 denied striking the Resident. Nurse #1 documented in her statement that she told NA #1 not to go back into Resident #1's room. A Weekly Skin Integrity Review, dated [DATE] at 9:00 AM, recorded Resident #1 had a new skin issue, a skin tear to his left forearm, redness to his forehead and a bruise to his right cheek. A Comprehensive Nursing Note, dated [DATE] at 2:07 PM, recorded in part, Resident #1 was alert and oriented to person, place, time and situation, remained with bruises to his extremities and a dressing to his left forearm was in place for a skin tear. A progress note, dated [DATE], recorded by the Nurse Practitioner, documented that on [DATE], Resident #1 sustained a large skin tear to his left forearm which measured 3 cm by 4 - 5 cm. An Investigation of Abuse Report, dated [DATE], completed by the Administrator, documented an unwitnessed allegation of resident abuse regarding the same accusation as recorded on the Initial Allegation of Abuse Report. Additionally, the Investigation of Abuse Report described Resident #1 as alert with confusion noted at times and fearful of NA #1. The Investigation of Abuse Report recorded that Resident #1 reported the same allegation to the Administrator with the details unchanged. Resident #1 stated NA #1 hit him twice, once in the head and once in the cheek. The Administrator documented that Resident #1 was observed with a red spot on his forehead, and his left forearm was bandaged with notable bruising. The Administrator spoke to NA #1 via phone. He admitted to verbal abuse, denied physical abuse and was suspended. The allegation was substantiated for verbal abuse, reported to law enforcement and NA #1 was terminated. During a telephone interview with NA #1 on [DATE] at 9:55 AM, he stated that on [DATE] he worked the 11 PM - 7 AM shift and worked independently with Resident #1 that night. He described Resident #1 often left his feet hanging off his bed and made frequent attempts to get out of his bed unassisted. NA #1 said this resulted in a history of falls where he sustained multiple bruises and skin tears to his skin. NA #1 stated that on the night of [DATE], Resident #1 constantly yelled out help me, help me over and over, which was his typical practice. NA #1 described this behavior as a little frustrating. NA #1 stated You could not ignore him, every time he yelled out, we had to go check on him because you did not know what could be wrong. NA #1 said he was in and out of the Residents room several times that night because Resident #1 continued to yell out and get out of bed without assistance. NA #1 stated he had to help Resident #1 put his legs back in the bed. NA #1 further stated I had to use some muscle to get his legs back in the bed because he was a big guy. NA #1 denied being aggressive/rough with Resident #1 and stated, I did not hurt him. NA #1 stated that once he put Resident #1 in bed, put his bed in a low position and a fall mat next to his bed, he left the room and Resident #1 yelled out again. NA #1 then stated, I was frustrated because he was keeping me from getting to my other patients. NA #1 stated he returned to the Resident's room, the Resident was yelling Help me over and over while attempting to get out of his bed again. NA #1 said he got right in the Resident's ear because he was hard of hearing and said, Hush all that fuss and advised the Resident that he was going to put him back to bed. NA #1 described being close to the Resident and stated that their heads touched. NA #1 said that when their heads touched, Resident #1 said Ouch you hit me in the head. NA #1 told the Resident that he did not hit him in the head. NA #1 said Nurse #1 came to him later in the shift, asked him what happened and advised him of an allegation of abuse made by Resident #1 against him. NA #1 said he told Nurse #1 he told Resident #1 to shut up but that he did not hurt him. Nurse #1 told NA #1 not to go back into the Resident ' s room. NA #1 said Nurse #1 asked him about the skin tear to the Resident's left forearm and he told Nurse #1 I noticed it, but I had nothing to do with it. NA #1 said this occurred between 6:30 AM and 7:00 AM, he did not go back to Resident #1's room and left the facility at the end of his shift. NA #1 said that once he got home, he received a phone call sometime after 8:00 AM from the Administrator to advise him that he was suspended pending an abuse investigation. NA #1 said he told the Administrator the same thing that he told Nurse #1, that he told Resident #1 to shut up, but that he did not hurt the Resident. NA #1 said he received abuse and neglect training during orientation training at the facility and that he knew what abuse was and that it was not allowed. NA #1 further stated he did not return to the facility; the allegation of verbal abuse was substantiated and that he was terminated from employment. A telephone interview occurred on [DATE] at 1:45 PM with Nurse #1. During the interview, Nurse #1 stated she was the assigned Nurse for Resident #1 on [DATE] for the 11 PM - 7 AM shift. She described Resident #1 as alert/oriented, required extensive/total staff assistance with his nursing care, and frequently used his call bell to request staff assistance. Nurse #1 stated NA #1 was the assigned nurse aide for Resident #1 that night, he was a new employee who she had not previously worked with before. Nurse #1 stated that around 5:30 or 6:00 AM on the morning of [DATE], while the nurse aides completed their final rounds, Resident #1 put his call light on. She stated that she observed NA #1 enter Resident #1's room, turned off the Resident's call light and after a short time, he left the Resident's room. Nurse #1 stated moments later, Resident #1 put his call light back on while yelling Help me repeatedly. Nurse #1 stated it was common practice for Resident #1 to yell out. She responded to the Resident's call light and observed Resident #1 bleeding from a skin tear to his left forearm, a bruise to his right cheek and a bruise to his forehead. Nurse #1 stated these were new changes to his skin that she had not observed on him earlier in the shift. When she entered the room, she stated Resident #1 screamed That guy beat me up and told me to shut up; don't let him back in here. Nurse #1 stated to calm Resident #1 down, she had to assure him that NA #1 would not be allowed back into his room; she cleaned him up with staff assistance and dressed the skin tear. Nurse #1 asked Resident #1 to tell her what happened. Resident #1 stated that NA #1 got in his face, struck him twice in the head, forcefully put him in bed and told him to shut up because he kept yelling. Nurse #1 stated after Resident #1 was cleaned up, she found and confronted NA #1. Nurse #1 stated she asked NA #1 what happened with Resident #1. NA #1 told Nurse #1 I just told him to shut up and be quiet. Nurse #1 said she advised NA #1 that he could not speak to a resident that way and told NA #1 not to go back into Resident #1's room. Nurse #1 said she told NA #1 that Resident #1 accused him of abuse and did not want him back in his room. Nurse #1 stated she contacted the Administrator, left a voice message and completed a nursing round on all the residents who were assigned to NA #1 that shift. Nurse #1 stated I went behind him to make sure no other residents were abused, because if he would do that to an alert and oriented resident, I did not know what else he would do. Nurse #1 stated that she did not identify any other signs of abuse. Nurse #1 then stated when the Administrator returned her call, Nurse #1 advised the Administrator of the allegation of abuse Resident #1 made against NA #1. Nurse #1 said the Administrator asked Nurse #1 if NA #1 was still in the facility and she told the Administrator that he had already left. Nurse #1 stated she could not recall the specific time the Administrator returned the phone call, or the specific time NA #1 left the facility. Nurse #1 stated the Administrator arrived at the facility around 8:00 AM and asked Nurse #1 to write a statement about the abuse allegation and to conduct a second nursing round on all residents. Nurse #1 stated she conducted a second round on all residents assigned to NA #1 that shift and on all other residents in the facility; she stated that she did not find evidence of abuse for any other resident. During a telephone interview on [DATE] at 3:30 PM, the Administrator stated while she was at home, she received a voice message from Nurse #1 around 7:34 AM and returned the call. The Administrator stated Nurse #1 told her that Resident #1 stated NA #1 struck him twice in the head, put him back to bed forcefully and told him to shut up. The Administrator said she asked if NA #1 was still in the facility and Nurse #1 told her he had already left shift. The Administrator said she immediately went to the facility, asked Nurse #1 to complete a round on all residents regarding any signs of abuse and interviewed Resident #1. The Administrator stated Nurse #1 did not identify any signs of abuse for other residents. The Administrator stated when she interviewed Resident #1, his statement was consistent with what he told Nurse #1. The Administrator stated she called NA #1, asked him to tell her what happened; he stated he told Resident #1 to shut up, but denied any physical abuse. The Administrator stated she told NA #1 he would be suspended pending an investigation of an allegation of abuse for Resident #1. During the interview, the Administrator reviewed the Initial Allegation of Abuse Report and the Investigation of Abuse Report and stated both reports were accurate. The Administrator stated she reported the abuse allegation to the police, a police report was filed, but no charges were filed. She stated the facility substantiated the allegation of verbal abuse as NA #1 admitted to aggressively telling Resident #1 to shut up; but did not substantiate physical abuse because the staff to resident interaction and unexplained injuries were unwitnessed.

Based on staff interviews and review of facility records, the facility failed to implement its abuse policy for protection of residents. The facility allowed Nurse Aide #1 to continue a nursing assignment, unsupervised, after Resident #1 accused Nurse Aide #1 of staff to resident verbal and physical abuse for 1 of 3 sampled residents reviewed for abuse. The findings included: The facility policy, Abuse, Neglect & Exploitation Policy, effective [DATE], last revised [DATE], recorded in part, Protection of Resident, upon learning of alleged abuse, neglect, mistreatment or exploitation, the administrator or supervisor on duty should attempt to take necessary steps to ensure that residents are protected from subsequent episodes of abuse neglect, mistreatment or exploitation. If an allegation of abuse, neglect or mistreatment, or exploitation is made against an associate or associates, the accused individual should be suspended until the matter has been investigated and a determination made as to the underlying allegation. Resident #1 was admitted to the facility [DATE] from the hospital, transferred to the hospital on [DATE] for a medical procedure and returned to the facility on [DATE] with Hospice services. Resident #1 expired in the facility on [DATE]. [DIAGNOSES REDACTED]. A nursing admission data collection tool dated [DATE], assessed Resident #1 as able to understand/be understood, clear speech, alert to person, place and time with intact short-term and long-term memory, adequate vision with corrective lenses, adequate hearing with hearing aids bilateral, a skin tear to the right forearm and a stage 2 sacral pressure sore. An admission Minimum Data Set assessment, dated [DATE], assessed Resident #1 with clear speech, understood/understands, adequate vision with corrective lenses, adequate hearing with bilateral hearing aide, moderately impaired cognition, verbal behavior to include threatening others, screaming at others, and cursing at others, required extensive to total assistance with activities of daily living (ADL) (bed mobility, transfers, locomotion, dressing, personal hygiene, bathing, toilet use), and had a stage 2 sacral pressure ulcer. An initial care plan, dated [DATE], and a revised care plan, [DATE], identified Resident #1 required skin interventions due to actual impairment to his skin on admission as evidenced by a skin tear to the right forearm, a surgical incision for placement of a pace maker and a stage 2 pressure sore to his coccyx. Interventions included, in part, to assist with positioning; reduce friction/shearing with use of lift/transfer sheets; evaluate his skin on a daily/weekly basis; monitor/document location, size and treatment of [REDACTED]. Interventions included, in part, to assist Resident #1 with ADL and to monitor his skin integrity. Daily nursing progress notes for each shift from [DATE] - [DATE] recorded no new skin concerns for Resident #1. A Weekly Skin Integrity Review, dated [DATE] at 9:00 AM, recorded Resident #1 had a new skin issue, a skin tear to his left forearm, redness to his forehead and a bruise to his right cheek. A Comprehensive Nursing Note, dated [DATE] at 2:07 PM, recorded in part, Resident #1 was alert and oriented to person, place, time and situation, remained with bruises to his extremities and a dressing to his left forearm was in place for a skin tear. A progress note, dated [DATE], recorded by the Nurse Practitioner, documented that on [DATE], Resident #1 sustained a large skin tear to his left forearm which measured 3 cm by 4 - 5 cm. An Initial Allegation of Abuse Report, dated [DATE], completed by the Administrator, documented an allegation of resident abuse. The Initial Allegation of Abuse Report documented, in part, that Resident #1 rang his call bell at 7:34 AM on [DATE]. When Nurse #1 responded, Resident #1 voiced that the male nurse aide (NA #1), told Resident #1 to shut up and was rough, which resulted in a skin tear. Nurse #1 observed Resident #1 with a skin tear to his left forearm. A written statement from Nurse #1 dated [DATE] at 8:00 AM, which accompanied the Initial Allegation of Abuse Report, documented that Resident #1 accused NA #1 of punching him in the head twice, screamed in his face and repeatedly told Resident #1 to shut up. Nurse #1 documented in her statement that she spoke to NA #1 who admitted to telling Resident #1 to shut up and stop screaming. NA #1 denied striking the Resident. Nurse #1 documented in her statement that she told NA #1 not to go back into Resident #1's room. An Investigation of Abuse Report, dated [DATE], completed by the Administrator, documented an unwitnessed allegation of resident abuse regarding the same accusation as recorded on the Initial Allegation of Abuse Report. Additionally, the Investigation of Abuse Report described Resident #1 as alert with confusion noted at times and fearful of NA #1. The Investigation of Abuse Report recorded that Resident #1 reported the same allegation to the Administrator with the details unchanged, NA #1 admitted to verbal abuse and was suspended. The allegation was substantiated, reported to law enforcement and NA #1 was terminated. During a telephone interview with NA #1 on [DATE] at 9:55 AM, he stated that on [DATE] he worked the 11 PM - 7 AM shift and worked independently with Resident #1 that night. He described Resident #1 often left his feet hanging off his bed and made frequent attempts to get out of his bed unassisted. NA #1 said this resulted in a history of falls where he sustained multiple bruises and skin tears to his skin. NA #1 stated that on the night of [DATE], Resident #1 constantly yelled out help me, help me over and over, which was his typical practice. NA #1 described this behavior as a little frustrating. NA #1 stated You could not ignore him, every time he yelled out, we had to go check on him because you did not know what could be wrong. NA #1 said he was in and out of the Residents room several times that night because Resident #1 continued to yell out and get out of bed without assistance. NA #1 stated he had to help Resident #1 put his legs back in the bed. NA #1 further stated I had to use some muscle to get his legs back in the bed because he was a big guy. NA #1 denied being aggressive/rough with Resident #1 and stated, I did not hurt him. NA #1 stated that once he put Resident #1 in bed, put his bed in a low position and a fall mat next to his bed, he left the room and Resident #1 yelled out again. NA #1 then stated, I was frustrated because he was keeping me from getting to my other patients. NA #1 stated he returned to the Resident's room, the Resident was yelling Help me over and over while attempting to get out of his bed again. NA #1 said he got right in the Resident's ear because he was hard of hearing and said, Hush all that fuss and advised the Resident that he was going to put him back to bed. NA #1 described being close to the Resident and stated that their heads touched. NA #1 said that when their heads touched, Resident #1 said Ouch you hit me in the head. NA #1 told the Resident that he did not hit him in the head. NA #1 said Nurse #1 came to him later in the shift, asked him what happened and advised him of an allegation of abuse made by Resident #1 against him. NA #1 said he told Nurse #1 he told Resident #1 to shut up but that he did not hurt him. Nurse #1 told NA #1 not to go back into the Resident's room. NA #1 said Nurse #1 asked him about the skin tear to the Resident's left forearm and he told Nurse #1 I noticed it, but I had nothing to do with it. NA #1 said this occurred between 6:30 AM and 7:00 AM, he did not go back to Resident #1's room, but that he did complete another round of nursing care on the remaining residents he was assigned and left the facility at the end of his shift. NA #1 stated he did not recall exactly how many residents he assisted the rest of his shift, but estimated he worked with approximately 7 residents independently after Nurse #1 told him about the allegation of abuse. NA #1 said that once he got home, he received a phone call sometime after 8:00 AM from the Administrator to advise him that he was suspended pending an abuse investigation. NA #1 said he told the Administrator the same thing that he told Nurse #1, that he told Resident #1 to shut up, but that he did not hurt the Resident. NA #1 said he received abuse and neglect training during orientation training at the facility and that he knew what abuse was and that it was not allowed. NA #1 further stated he did not return to the facility; the allegation of verbal abuse was substantiated and that he was terminated from employment. A telephone interview occurred on [DATE] at 1:45 PM with Nurse #1. During the interview, Nurse #1 stated she was the assigned Nurse for Resident #1 on [DATE] for the 11 PM - 7 AM shift. She described Resident #1 as alert/oriented, required extensive/total staff assistance with his nursing care, and frequently used his call bell to request staff assistance. Nurse #1 stated NA #1 was the assigned nurse aide for Resident #1 that night, he was a new employee who she had not previously worked with before. Nurse #1 stated that around 5:30 or 6:00 AM on the morning of [DATE], while the nurse aides completed their final rounds, Resident #1 put his call light on. She stated that she observed NA #1 enter Resident #1's room, turned off the Resident's call light and after a short time, he left the Resident's room. Nurse #1 stated moments later, Resident #1 put his call light back on while yelling Help me repeatedly. Nurse #1 stated she responded to the Resident's call light and observed Resident #1 bleeding from a skin tear to his left forearm, a bruise to his right cheek and a bruise to his forehead. Nurse #1 stated these were new changes to his skin that she had not observed on him earlier in the shift. When she entered the room, she stated Resident #1 screamed That guy beat me up and told me to shut up; don't let him back in here. Nurse #1 stated to calm Resident #1 down, she had to assure him that NA #1 would not be allowed back into his room; she cleaned him up with staff assistance and dressed the skin tear. Nurse #1 asked Resident #1 to tell her what happened. Resident #1 stated that NA #1 got in his face, struck him twice in the head, forcefully put him in bed and told him to shut up because he kept yelling. Nurse #1 stated after Resident #1 was cleaned up, she found and confronted NA #1. Nurse #1 stated she asked NA #1 what happened with Resident #1. NA #1 told Nurse #1 I just told him to shut up and be quiet. Nurse #1 said she advised NA #1 that he could not speak to a resident that way and told NA #1 not to go back into Resident #1's room. Nurse #1 said she told NA #1 that Resident #1 accused him of abuse and did not want him back in his room. Nurse #1 said she did not immediately suspend NA #1 because there was no one to replace him; but allowed him to complete his nursing rounds independently. Nurse #1 stated she contacted the Administrator, left a voice message and completed a nursing round on all the residents who were assigned to NA #1 that shift. Nurse #1 stated I went behind him to make sure no other residents were abused, because if he would do that to an alert and oriented resident, I did not know what else he would do. Nurse #1 stated that she did not identify any other signs of abuse. Nurse #1 then stated when the Administrator returned her call, Nurse #1 advised the Administrator of the allegation of abuse Resident #1 made against NA #1. Nurse #1 said the Administrator asked Nurse #1 if NA #1 was still in the facility and she told the Administrator that he had already left. Nurse #1 stated she could not recall the specific time the Administrator returned the phone call, or the specific time NA #1 left the facility. Nurse #1 stated the Administrator arrived at the facility around 8:00 AM and asked Nurse #1 to write a statement about the abuse allegation and to conduct a second nursing round on all residents. Nurse #1 stated she conducted a second round on all residents assigned to NA #1 that shift and on all other residents in the facility; she stated that she did not find evidence of abuse for any other resident. Nurse #1 stated that she received abuse and neglect training several times over the prior 2 years of her employment at the facility, but that she was not aware of the facility's policy to suspend a staff member accused of abuse. During a telephone interview on [DATE] at 3:30 PM, the Administrator stated while she was at home, she received a voice message from Nurse #1 around 7:34 AM and returned the call. The Administrator stated Nurse #1 told her that Resident #1 stated NA #1 struck him twice in the head, put him back to bed forcefully and told him to shut up. The Administrator said she asked if NA #1 was still in the facility and Nurse #1 told her he had already left shift. The Administrator said she immediately went to the facility, asked Nurse #1 to complete a round on all residents regarding any signs of abuse and interviewed Resident #1. The Administrator stated Nurse #1 did not identify any signs of abuse for other residents. The Administrator stated when she interviewed Resident #1, his statement was consistent with what he told Nurse #1. The Administrator stated she called NA #1, asked him to tell her what happened; he stated he told Resident #1 to shut up, but denied any physical abuse. The Administrator stated she told NA #1 he would be suspended pending an investigation of an allegation of abuse for Resident #1. During the interview, the Administrator reviewed the Initial Allegation of Abuse Report and the Investigation of Abuse Report and stated both reports were accurate. The Administrator stated she reported the abuse allegation to the police and a police report was filed. The Administrator stated that she was not made aware that NA #1 continued his assignment after Resident #1 accused him of physical/verbal abuse. The Administrator further stated NA #1 should have been suspended immediately, pending the outcome of the investigation and not allowed to care for other residents unsupervised.

Based on observations, a test tray, resident interviews (Residents #7, #9, #4, #5, #8, and #61), staff interviews, and a Resident Council Meeting, the facility failed to serve palatable foods to residents according to their preference for temperature and taste. The findings included: 1a. Resident #7 was admitted to the facility on [DATE]. Review of an admission minimum (MDS) data set [DATE] assessed Resident #7 with adequate hearing/vision, able to be understood, understand others, clear speech, intact cognition, and required supervision and one person physical assist with eating. Resident #7 was interviewed on 10/8/19 at 10:19 AM. During the interview, he stated, The food is not good. It is cold and does not taste good. Resident #7 was observed with his lunch tray on his bedside table in his room on 10/8/19 at 12:34 PM. He reported he did not like the taste of the bratwurst. He stated that he would drink his supplement and other liquids. He ate only 10% of his food. Resident #7 was observed on 10/9/19 at 9:28 AM. He reported he was in pain and the breakfast was always the same. He stated he would drink his supplement after he received pain medication. 1b. Resident #9 was readmitted to the facility on [DATE] . Review of an admission minimum (MDS) data set [DATE] assessed Resident #9 with adequate hearing/vision, able to be understood, understand others, clear speech, intact cognition, and supervision with eating, set up only. Resident #9 was interviewed on 10/8/19 at 3:28 PM. During the interview, the Resident stated The food is not hot. It is either room temperature or cold. She also stated, breakfast was usually cold. Resident #9 was observed feeding herself in her room on 10/09/19 at 10:08 AM. She reported, breakfast was okay, not as hot as I like it. 1c. Resident #61 was admitted to the facility on [DATE]. Review of an admission minimum (MDS) data set [DATE] assessed Resident #61 with adequate hearing/vision, able to be understood, understand others, clear speech, intact cognition, and able to feed herself independently requiring encouragement and set up help only. Resident #61 was interviewed on 10/08/19 at 11:25 AM. During the interview, the Resident stated The food is okay. Some of it's good, some of it's not so good. Breakfast is cold and by the time I get my coffee, it's cold. Resident #61 was observed feeding herself lunch in the main dining room on 10/08/19 at 12:15 PM. She received a taco salad, potato/bacon soup and water. During the meal, she was asked how her food was, Resident #61 shook her head side to side and frowned. She ate approximately 50% of her meal. Resident #61 was observed on 10/09/19 at 08:30 AM in the main dining room with her breakfast meal. She was observed to put butter on her toast and the butter did not melt but remained congealed and intact on her toast. She stated, Look at the butter, it does not melt because the toast is cold. 1d. Resident #8 was admitted to the facility on [DATE]. Review of an admission minimum (MDS) data set [DATE] assessed Resident #8 with adequate hearing/vision, unclear speech, able to understand others, be understood, moderately impaired cognition and required staff assistance with meals. Resident #8 was interviewed on 10/08/19 at 11:46 AM. During the interview, the Resident stated, The food is ok, it's not 5 star, I have lost weight because I don't eat all of my food. Resident #8 was observed during the lunch meal on 10/8/19 at 12:38 PM and ate approximately 75% of his meal. 1e. Resident #4 was admitted to the facility 9/14/19. Review of an admission minimum (MDS) data set [DATE] assessed Resident #4 with adequate hearing/vision, clear speech, able to be understood, understand others, intact cognition and able to feed herself independently, requiring encouragement and set up help only. Resident #4 was interviewed on 10/08/19 at 03:28 PM. During the interview, she stated Don't talk to me about the food, eggs are terrible. The eggs must be powdered eggs. Why don't you use fresh eggs? I have told them about the food many times, they just offer me something else which does not make it better. On 10/09/19 at 08:27 AM, Resident #4 was observed in her room feeding herself breakfast. She received scrambled eggs. She returned the eggs and requested coffee and more bacon instead. Resident #4 stated I don't want the powdered eggs and they were cold. 1f. During a Resident Council Meeting (RCM) held on 10/08/19 at 3:00 PM, Residents #8, #5 and #61 expressed that they did not receive fresh eggs, but rather routinely received powdered eggs which were always cold. The residents also stated that vegetables were served cold The Residents stated these were ongoing concerns that had not been resolved. The activity director (AD) was interviewed on 10/08/19 at 04:40 PM. She stated the RCM occurred once monthly. The AD also stated that cold food and food quality had been an ongoing issue brought up during RCM since (MONTH) 2019. The AD stated that because Residents also had a dietary meeting that usually occurred right after RCM, she did not include their dietary comments in the minutes. 1g. An observation of the breakfast meal tray line occurred on 10/09/19 at 08:06 AM. The menu included scrambled eggs, waffles with strawberries, and sausage links. Temperature monitoring was observed and resulted in eggs at 178 degrees Fahrenheit (F) and waffles at 152 degrees F. A test tray was requested at 08:15 AM, the tray reached the Medicare Unit at 08:22 AM and after all residents were served, the test tray was sampled at 08:32 AM. The Dietary Manager (DM) conducted temperature monitoring of the test tray and sampled the foods. He gave the following descriptions of the foods on the test tray: - Scrambled eggs, no visible steam, butter added remained congealed on the eggs, described as luke warm, not hot, and could be hotter - Waffles, no visible steam, butter added remained congealed, described as luke warm not hot, and could be hotter Interviews with alert and oriented residents who received the breakfast meal on 10/09/19 revealed the following: - Resident #9 stated on 10/09/19 at 08:46 AM that her eggs could have been hotter. - Resident #4 stated on 10/09/19 at 08:47 AM that she received the powdered eggs and they were cold. - Resident #61 stated on 10/09/19 at 08:48 AM that her breakfast was the same ole thing, butter doesn't melt on the toast, they keep the butter in the freezer which makes it hard to melt, by the time I got to my coffee it was cold, my eggs were dry/cold, and the bacon was cold. - Resident #8 stated on 10/09/19 at 08:56 AM that his breakfast was cold, but edible. The DM was interviewed on 10/09/19 at 09:00 AM. He stated he met with residents right after the RCM and discussed foods/menus. The DM also stated that one of the cooks had some difficulty transitioning into her role which resulted in some concerns with late meals and that this may have contributed to residents receiving cold foods. The DM also stated that meals for residents who ate in their rooms were placed on an open cart that was delivered to the assisted dining room first. Once all the residents who ate in the assisted dining room received their lunch, then room trays, which were stored on this open cart were delivered to residents who ate in their rooms. The DM stated this could also contribute to cold foods to those residents who ate in their rooms. The DM also stated that residents complained they received powdered eggs, but that the eggs were not powdered, but rather liquid. An interview with the Administrator occurred on 10/09/19 at 10:44 AM. The Administrator stated that the requests for fresh eggs rather than liquid eggs and hot foods should have already been resolved by the dietary department.

Based on observation and staff interviews, the facility failed to discard expired medications (a narcotic and antihypertensive) available for use on 1 of 1 medication cart and in 1 of 1 medication storage room. The findings included: An observation of the medication storage room with Nurse #1 on 10/8/19 at 10:44 AM revealed one tablet of [MEDICATION NAME] and [MEDICATION NAME] (narcotic) 7.5 mg (milligrams)/325mg that expired (MONTH) 2019. An observation on 10/8/19 at 10:57 AM of the skilled medication cart with Nurse #1 revealed Resident #61's medications including ten [MEDICATION NAME] 5 mg tablets that expired 8/31/19 and twenty-nine [MEDICATION NAME] 5mg tablets that expired 9/30/19 available for use. On 10/8/19 at 11:05 AM, Nurse #1 reported Resident #61's expired medications were brought from the assisted living facility when she was admitted on [DATE] to be used when corresponding medication ran out during her stay in the skilled facility. Nurse #1 also stated the medication room, cart and refrigerator were checked by the night nurse once a month. During an interview with Nurse #3 on 10/9/19 at 3:15 PM, she reported the medication room, cart and refrigerator were checked once a month on the last Friday of the month. Nurse #3 also reported she checked the medication storage room, cart and refrigerator on 9/27/19. Nurse #3 stated it was an oversight that the expired narcotic found was still available for use. Nurse #3 reported that no medications on the medication cart were expired on 9/27/19. On 10/10/19 at 1:18 PM, interviews were conducted with Nurse #2 and the Director of Nursing (DON). Both nurses confirmed medications were stored in the skilled care medication cart brought from assisted living. The interview further revealed medication stored in the excess drawer on the medication cart were available for use if needed when out of current medications sent from pharmacy. During an interview with the Pharmacy Consultant on 10/10/19 at 11:53 AM, she reported checking only the skilled medication cart on 10/1/19. The pharmacy consultant provided a report of expired medications discarded during her visit. The pharmacy consultant reported that each medication storage cart, medication room and refrigerator were checked quarterly. The pharmacy consultant stated she had not checked the medication room and refrigerator on 10/1/19. The pharmacy consultant stated there were no expired medications stored for Resident #61 at the time she checked the medication cart. An interview was conducted with the DON on 10/8/19 at 4:06 PM. The DON stated her expectation was no expired medications were available for use in the medication storage room, medication cart and medication refrigerator. The DON also stated that most likely it was an oversight by the third shift nurse and the nurse who placed Resident #61's medication on the cart to leave the medications available for use. The DON reported nurses were educated on checking the expiration date before administration, when placing medication in the medication cart, and at the end of the month.

Based on resident interviews during a Resident Council Meeting (Residents #5, #8 and #61), staff interviews, and review of minutes from Resident Council Meetings (July 2019 - (MONTH) 2019), the facility failed to resolve grievances regarding food choices and palatable foods communicated during Resident Council Meetings and provide privacy during a Resident Council Meeting. The findings included: 1a. Review of (MONTH) 2019 - (MONTH) 2019 Resident Council Meeting (RCM) Minutes revealed residents requested more variety with the breakfast meal as a result of receiving the same foods for the breakfast meal each month. The (MONTH) 2019 RCM Minutes recorded that the request for a pastry bar had not been resolved. During a RCM held on 10/08/19 at 3:00 PM, Residents #5, #8 and #61 expressed they were served the same foods for breakfast, powdered eggs, bacon and toast, waffles or biscuits. The Residents stated they did not receive fresh eggs, but rather routinely received powdered eggs which were always cold, vegetables were served cold and they wanted a variety of pastries. The Residents stated they shared these concerns with the dietary manager (DM), but they still received powdered eggs, which were often cold, the breakfast meal still lacked variety and the pastries were not consistent. The Residents expressed these were ongoing requests that had not been resolved. The activity director (AD) was interviewed on 10/08/19 at 04:40 PM. The AD stated that cold food and food quality had been an ongoing issue brought up during RCM since (MONTH) 2019. The AD stated that because Residents also had a dietary meeting that usually occurred right after RCM, she did not include their dietary comments in the minutes. The AD stated Residents asked for more variety with foods at breakfast and a pastry bar. The AD further stated that the facility had been trying to get a pastry bar going but it just had not gotten off the ground. The Dietary Manager (DM) was interviewed on 10/09/19 at 09:00 AM. He stated he met with Residents right after RCM and discussed foods/menus. Review of minutes from (MONTH) - (MONTH) 2019 revealed that during these months residents requested more pastries, fresh fruit and omelets for breakfast. The DM stated an omelet station was offered occasionally now, donuts and pastries would be added to the breakfast meal, and fresh fruit was available for every meal now. The DM also stated that one of the cooks had some difficulty transitioning into her role which resulted in some concerns with late meals and that this may have contributed to residents receiving cold foods. The DM also stated that meals for residents who ate in their rooms were placed on an open cart that was delivered to the assisted dining room. Once all the residents who ate in the assisted dining room received their lunch, then room trays were delivered to residents who ate in their rooms. The DM stated this could also contribute to cold foods to those residents who ate in their rooms. The DM also stated that Residents complained they received powdered eggs, but that the eggs were not powdered, but rather liquid eggs or boiled eggs. He confirmed that fresh eggs were not served routinely. An interview with the Administrator occurred on 10/09/19 at 10:44 AM. The Administrator stated that the requests for fresh eggs and pastries should have already been resolved by the dietary department. The Social Worker (SW) was interviewed on 10/10/19 at 09:05 AM. During the interview the SW stated that when she received a grievance from RCM, she discussed the concern during stand-up meetings with all department heads present and gave the grievance to the appropriate department head for follow up. The SW stated that since the dietary concerns that were mentioned during RCM were not documented, she was not aware that during (MONTH) - (MONTH) 2019 residents expressed the same concerns with cold foods, more variety with breakfast and requested a pastry bar so she did not follow up to make sure these concerns were resolved. 1b. During the RCM held on 10/08/19 at 3:45 PM, a staff member opened the door to the activity room and a family member entered the room, walked to the refrigerator, removed a nutritional supplement and stated she needed to obtain this for her mother. Residents #5, #8 and #61 stated their meetings and group activities were often disturbed with staff coming in and out to go to the refrigerator to get things. They further expressed that they would rather their meetings not be disturbed. An interview occurred with nurse aide #1 (NA#1) on 10/08/19 at 04:29 PM. NA #1 stated she opened the door to the RCM after it had started because another resident wanted to attend, but then a family member came in too. NA #1 stated the family member told her that she wanted to go to the refrigerator to get a nutritional supplement for her mother and so she let the family come in. NA #1 further stated I didn't know this was a Resident Council Meeting, I thought it was just another resident activity. The Activity Director (AD) was interviewed on 10/08/19 at 04:40 PM. She stated the RCM occurred once monthly but that she did not post a Do Not Disturb sign. The AD further stated that there were occasional disturbances of staff/visitors coming into the activity room to go to the refrigerator, but that she would put up a sign to remind people not to disturb the meetings. An interview with the Administrator occurred on 10/09/19 at 10:44 AM. The Administrator stated that at times the door to activities remained open and at times it was closed, but that a sign was not posted to advise visitors not to disturb residents during activities. The Administrator also stated that staff/family did enter the activity room at times to get items out of the refrigerator. The Administrator stated that signage should be posted to allow residents to have privacy during activities/meetings.