Every finding on record at Camellia Estates

Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored securely and expired medications were removed in accordance with facility policy and regulatory requirements for one (1) of four (4) survey days. Findings include:A review of the facility policy Medication Storage revised 11/2017, revealed . A lock and key system with suitable protection against theft or access by unauthorized personnel. The locked system shall be secured when not in use by authorized personnel .A review of the facility's Destruction of Unused, Expired or Discontinued Medication with a revision date of 10/19 revealed .These will be removed during monthly inspections or any other time as such are found, and will be disposed of according to policy.On 02/17/2026 at 6:10 AM, during an observation and interview revealed a wound care cart unattended and unlocked on Hall A. Licensed Practical Nurse (LPN) #1 confirmed the cart was a wound treatment cart and acknowledged it was unlocked and unattended. A review of the cart's contents revealed in the top-drawer diclofenac gel, nystatin cream, gentamicin ointment, and moisturizing lotion. The second drawer contained three bottles of wound cleanser, two bottles of hydrogen peroxide, and one bottle of betadine. She stated it is the responsibility of all nurses and staff to ensure medication carts are locked and was unsure who last accessed the cart.On 02/17/2026 at 8:34 AM, during an interview, the Director of Nursing confirmed wound care carts should always be locked when not directly attended by a nurse. She stated failure to secure the cart could result in accidental ingestion, poisoning, or skin and eye irritation. On 02/17/2026 at 10:00 AM, during an observation of the medication storage room refrigerator with LPN #1, twenty-five prefilled influenza vaccine syringes were observed with an expiration date of 05/06/2025.On 02/17/2026 at 10:07 AM, during an interview, LPN #1 stated expired influenza vaccines should have been disposed of upon expiration and that administration of expired medication would not be effective. She stated all nurses are responsible for removing expired medications.On 02/17/2026 at 11:10 AM, during an interview, the Director of Nursing stated the pharmacy consultant informed her on 01/23/2026 to remove expired influenza vaccines. She acknowledged she checked some but not all vaccines in the refrigerator and that expired vaccines should have been disposed of. She confirmed that administration of an expired influenza vaccine may not be effective and could increase residents' risk of developing influenza and related complications, including pneumonia and other respiratory conditions.

Based on observation, interview, record review, and facility policy review, the facility failed to implement infection prevention and control practices for three (3) of five (5) residents reviewed (Resident #2, Resident #6, and Resident #11).Findings include:A record review of the facility policy Procedure for isolation Status revised August 2021 revealed . 2. In addition to Standard Precautions, use Droplet Precautions for a resident known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the resident sneezing, coughing, talking, etc. and drop from the air .A record review of the facility policy Hand Hygiene Policy revised August 2021 revealed .2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room .A record review of the facility policy Procedure for Isolation Status, revised August 2021, revealed, .Check room for hygiene supplies, toiletries, handwashing soap, paper towels, and any other equipment that is to be dedicated to that resident's care .Resident #2On 02/18/2026 at 12:10 PM, Licensed Practical Nurse (LPN) #2 was observed performing percutaneous endoscopic gastrostomy (PEG) tube site care for Resident #2, who was on droplet isolation precautions for influenza. After completing care, the nurse used a permanent marker with her bare hand to mark the dressing. While holding the marker, she removed the barrier from the bedside table with bare hands and placed it into a biohazard bag. She then carried the marker out of the room, placed it on the medication cart, and then into her scrub pocket without disinfecting it.On 02/18/2026 at 12:13 PM, during an interview, the Director of Nursing (DON) stated the marker should have been left in the room, discarded, or disinfected. She stated placing the marker on the cart and in a scrub pocket after contact with contaminated materials was not appropriate due to the risk of spreading influenza.On 02/19/2026 at 11:51 AM, during an interview, LPN #2 confirmed she held the marker while discarding contaminated items and placed it on the cart and into her pocket before performing hand hygiene. She acknowledged the DON instructed her to discard it.A record review of Resident #2's Face Sheet revealed an admission date of 12/16/25 with diagnoses that included cerebral infarction.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) o12/22/25 a Brief Interview for Mental Status (BIMS) summary score of 12 indicating Resident #2 had moderate cognitive impairment. A record review of Resident #2's Order Summary Report with active orders as of 2/18/26 revealed an order dated12/17/25 PEG tube site care: Remove dressing clean with normal saline dry with 4x4 gauze. Apply clean dry split gauze to abdomen, secure with tape. To be performed daily and prn if saturated. Monitor for s/s (signs/symptoms) of irritation or infection every day shift for peg tube related to gastrostomy status.Resident #6On 02/18/2026 at 8:48 AM, LPN #2 was observed preparing and administering Empagliflozin 10 milligrams (mg) and Aspirin 81 mg to Resident #6. After determining the medications needed to be crushed, she removed the aspirin from the medication cup using her bare, ungloved hand. She crushed the Empagliflozin and administered it in yogurt. During medication administration, she used her bare hands to touch the resident's tray, glass, and patted the resident on the back. She returned to the medication cart and began charting on the laptop without performing hand hygiene between resident contact and touching the medication cart and computer.On 02/18/2026 at 8:52 AM, during an interview, LPN #2 acknowledged she should not have touched the medication with bare hands and should have performed hand hygiene after contact with resident items before returning to the medication cart to prevent spread of infection, particularly during a flu outbreak.On 02/18/2026 at 10:05 AM, during an interview, the DON confirmed staff should never touch medications with bare hands and must perform hand hygiene when exiting resident rooms to prevent infection transmission.A record review of Resident #6's Face Sheet revealed an admission date of 1/20/26 with diagnoses that included acute respiratory failure with hypoxia.A record review of Resident #6's MDS with an ARD of 1/26/26 revealed a BIMS score of 14 which indicated the resident was cognitively intact. A record review of Resident # 6's February 2026 Medication Administration Record (MAR) revealed Empagliflozin 10mg 1 tablet by mouth was initialed by staff as given on 2/18/26.A record review of Resident #6's Order Summary Report revealed an order dated 1/21/26 for Empagliflozin Oral Tablet 10 MG. Give 1 tablet by mouth one time a day for DMII (Type 2 diabetes mellitus without complications).Resident #11On 02/17/2026 at 8:20 AM, the State Agency (SA) observed Certified Nursing Assistant (CNA) #2 enter Resident #11's room, which had a droplet precautions sign posted indicating influenza. CNA #2 entered wearing only a mask and did not don (put on) a gown or gloves. The door remained open throughout the care provided. CNA #2 carried a non-disposable breakfast tray into the room and used her bare hands to hand juice, milk, and food items to the resident. She also used her bare hands to adjust the resident's bed linens. After exiting the room, CNA #2 proceeded to another resident's room without performing hand hygiene.On 02/17/2026 at 8:25 AM, during an interview, CNA #2 confirmed the sign indicated the resident had the flu but stated she was new to the hall and unaware of the resident's diagnosis. When asked about infection control breaches, she was unable to initially identify them. Upon further questioning, she acknowledged she should have worn gown and gloves, closed the door, and performed hand hygiene after exiting the room to prevent the spread of infection.On 02/18/2026 at 10:00 AM, during an interview, the DON stated that droplet precaution signage must be followed. She confirmed gown and gloves should have been worn and hand hygiene performed after exiting the room to prevent spreading influenza.A record review of Resident #11's Order Summary Report with active orders as of 2/18/26 revealed an order dated 2/16/26 Strict isolation for droplet precautions. mask. related to influenza.All services provided in room.related to Influenza virus.A record review of Resident #11's Face Sheet revealed the resident was admitted [DATE] with diagnoses that included fracture left femur neck.A record review of resident # 11's MDS with an ARD of 1/21/26 revealed a BIMS score that was unable to be determined mental status due to being unable to be understood by staff members.

Based on observation, interviews, record review and facility policy review, the facility failed to implement the resident's care plan relating to personal hygiene for one (1) of (13) sample residents. Resident #7.Findings include: A policy review of the facility policy, The Care Plan Process revised 12/24 reveals on page 4, .The facility staff shall follow the care plan .A care plan that is based on a thorough assessment .can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan .provide for a resident's highest practical level of well-being .A record review of the Care Plan Report with a date initiated of 10/19/2025 revealed Focus: Resident needs assistance with ADLs.Interventions. Personal Hygiene: The resident needs partial/moderate assistance with personal hygiene.During an observation and interview on 2/17/26 at 8:38 AM, observed Resident# 7 with very visible long, gray hair on the upper lip, about a quarter to a half inch long, with chin hair of the same length. Resident #7 stated she would like the mustache on her upper lip and chin shaved. On 2/17/26 at 9:56 AM, Certified Nursing Assistant (CNA) #1 assigned to Resident #7, explained that removing the hair from the resident's face is a normal part of Activities of Daily Living (ADL) care of residents who are unable to do it themselves. She added that she had previously completed ADL care on Resident #7 and observed that she had long hair on her chin and upper lip but did not ask whether Resident #7 wanted it removed. She confirmed that the hair is long and appeaeds that it has not been cut in quite a few days.On 2/19/26 at 10:00 AM, in an interview the Director of Nursing (DON) revealed the general consensus is that they offer facial hair removal during ADL care. She indicates doing this is an intricate part of making sure that all the resident's needs are met.A record review of the Face Sheet revealed the facility admitted Resident #7 on 5/20/24 with diagnoses that included Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting the left non-dominant side.A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/25 revealed a Brief Interview for Mental Status (BIMS) score of (15) indicating the resident is cognitively intact.On 2/19/26 at 10:03 AM, in an interview with License Practical Nurse (LPN) #3, who works as the Care Plan nurse, explained that the care plan is designed to show the type of care residents need while they are in the facility. LPN #3 acknowledged that following the care plan is important because it enables staff to properly care for residents in a way that is individualized to their specific needs. She stated that if staff do not follow the care plan, they may not provide proper, individualized care.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure a Resident who is unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming for one (1) of (13) sampled residents. Resident #7.Findings include:A review of the facility policy, Activities for Daily Living revised 9/25 revealed, 1. ADLs are to be resident specific .2. ADLs shall include, but are not limited to personal hygiene .On 2/17/26 at 8:38 AM, during an observation and interview, observed Resident# 7 with very visible long, gray hair on the upper lip, about a quarter to a half inch long, with chin hair of the same length. Resident #7 stated she would like the mustache on her upper lip and chin shaved. During an interview and observation on 2/17/26 at 9:56 AM, Certified Nursing Assistant (CNA) #1 assigned to Resident #7, explained that removing the hair from the resident's face is a normal part of ADL care for residents who are not able to do it themselves. She further stated that she had previously completed ADL care on Resident #7 and observed that she had long hair on her upper lip and chin but did not ask whether Resident #7 wanted it removed. She confirmed that the hair is long and appeared that it has not been cut in quite a few days.In an interview on 2/19/26 10:00 AM, the Director of Nursing (DON) revealed the general consensus is that they offer facial hair removal during ADL care. She indicates doing this is an intricate part of making sure that all the resident's needs are met. A record review of the Face Sheet revealed the facility admitted Resident #7 on 5/20/24 with diagnoses that included Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting the left non-dominant side.A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/25 revealed a Brief Interview for Mental Status (BIMS) score of (15) indicating the resident is cognitively intact.

Based on observation, interview, and facility policy review, the facility failed to ensure chemicals were stored properly and secured in accordance with facility policy and regulatory requirements for one (1) of four (4) survey days. Findings included:Record review of the facility policy Storage of Chemicals revised 05/18 revealed .Chemicals are stored in a storage area, designated only for chemicals.On 02/17/2026 at 6:21 AM, during an observation and interview observed an unattended spray bottle of Virex antiviral disinfectant that was openly accessible on top of a personal protective equipment (PPE) bin on Hall A. During an interview at this time, Licensed Practical Nurse (LPN) #1 confirmed the Virex solution was easily accessible to residents and stated it should not be left in the open because ingestion or exposure could result in chemical burns or other harm. She stated the disinfectant was being used due to a flu outbreak and was unsure of the facility's storage policy for the chemical.On 02/17/2026 at 8:34 AM, during an interview, the Director of Nursing confirmed the Virex solution should have been secured and could have been stored in a drawer when not in use to prevent access by residents.

Based on observations, staff interviews, record reviews, and facility policy reviews, the facility failed to follow infection control practices by not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for multidrug-resistant organisms (MDRO) (Resident #3) and failed to practice hand hygiene during care for five (5) of thirteen (13) sampled residents (Residents #3, #11, #68, #70 and #216). Findings included: A review of the facility's policy titled, Suprapubic Catheter Site Care, revised 01/2024, revealed, Purpose * To maintain catheter patency. * To keep area clean and prevent infection . Procedure . 4. Perform hand hygiene and apply clean gloves . A review of the facility's policy titled, Hand Hygiene, dated 08/21, revealed, Purpose *To cleanse hands to prevent transmission of infection or other conditions. *To provide clean, health environment for residents, staff and visitors . Procedure . Indications for Hand Washing . 3. Before and after procedures. 4. Before and after applying gloves . A review of the facility's titled, Enhanced Barrier Precautions, revised 03/24, revealed, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions may involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . Resident #3 An observation of sacral wound care on 11/13/2024 at 10:31 AM, revealed that during care by Registered Nurse (RN) #1 and the Physical Therapist Assistant (PTA), neither RN #1 nor the PTA donned (put on) a gown prior to providing care. On 11/13/24 at 10:41 AM, during an interview, Registered Nurse (RN) #1 confirmed that neither she nor her assistant wore gowns while providing care. When asked if Resident #3 required EBP, RN #1 stated, No, we don't have anyone in the facility on that. On 11/13/2024 at 11:20 AM, during an interview, Licensed Practical Nurse (LPN) #2, the Infection Prevention (IP), explained residents are usually placed on contact or isolation precautions for infections, but she had just been informed by RN #1 that EBP included residents with catheters, Percutaneous Endoscopic Gastrostomy (PEG) tubes, and chronic wounds. She was unable to recall if staff had received training regarding EBPs. On 11/13/2024 at 12:15 PM, during an interview, the Director of Nursing (DON) stated that Resident #3 required the use of EBP, which the facility had not instituted. She explained that anyone performing close contact care with Resident #3 should wear a gown and gloves in accordance with EBP guidelines. She stated that an in-service was conducted by the facility in March when the Centers for Medicare and Medicaid Services (CMS) recommended the use of EBP, and it was her expectation that staff would follow these guidelines. She emphasized that not following them placed residents at increased risk for MDROs. A record review of the Admission Record for Resident #3 revealed that the facility admitted the resident on 09/19/24. The resident had admission diagnoses that included Pressure Ulcer of Sacral Region, Stage 2 and Pressure Ulcer of Other Site, Unstageable. Resident #11: On 11/13/24 at 2:48 PM, during an observation of PEG tube site care provided by LPN #1, revealed LPN #1 removed the soiled dressing and proceeded to clean the site. LPN#1 did not remove her soiled gloves, perform hand hygiene, and apply clean gloves before cleaning the site. During an interview on 11/13/24 at 2:55 PM, LPN #1 confirmed that she did not remove her gloves, wash her hands, or apply clean gloves before cleaning the site. She acknowledged her actions could potentially cause the resident to develop an infection. A record review of Resident #11's Admission Record revealed the facility admitted the resident on 09/23/24. The resident had diagnoses that included Parkinsonism, Dementia, and Dysphagia. Resident #68: During an observation of perineal care on 11/12/24 at 11:12 AM, with Certified Nursing Assistant (CNA) #1 revealed CNA #1 entered the room holding one pair of gloves. She did not perform hand hygiene before donning gloves, closing the privacy curtain, adjusting the bed with the remote control, and retrieving a pack of wipes from the dresser. She then proceeded with care without washing her hands. During an interview on 11/12/24 at 11:18 AM, CNA #1 admitted she did not think about washing her hands upon entering the room. She stated she performed hand hygiene in the hallway before entering but confirmed that she did not perform hand hygiene after touching the door, privacy curtains, and bed remote. CNA #1 acknowledged that her actions could result in cross-contamination, potentially causing an infection. A record review of Resident #68's Admission Record revealed an admitted [DATE] with diagnoses that included a Urinary Tract Infection (UTI), Nausea and Vomiting, and Encounter for Palliative Care. Resident #70: During an observation of perineal care on 11/13/24 at 11:03 AM, with CNA #1 revealed CNA #1 entered the room, washed her hands, and donned a pair of gloves. During the care, she retrieved pre-moistened wipes from a container four times, touching the container with soiled gloves. She then placed the container on the resident's bedside table. After cleaning the resident, CNA #1 applied barrier cream to the resident's perineal area and buttocks while wearing the same soiled gloves. She later changed her gloves but did not perform hand hygiene before applying clean gloves. During an interview on 11/13/24 at 11:15 AM, CNA #1 confirmed she had received training and understood that she should not touch objects with dirty gloves and should wash her hands before applying clean gloves. Record review of the Admission Record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses that included Urinary tract infection and Type 2 Diabetes Mellitus. Resident #216 On 11/13/2024 at 1:21 PM, during an observation, LPN #3 was observed providing suprapubic catheter care for Resident #216. LPN #3 failed to remove or change her gloves during the entire procedure. She removed the soiled dressing, placed it in the biohazard container, cleaned the site, and applied a new dressing while wearing the same gloves. On 11/13/2024 at 1:25 PM, during an interview, LPN #3 confirmed that she did not remove or change her gloves during the procedure. She acknowledged placing the soiled dressing in the biohazard trashcan in Resident #216's room and then touching the suprapubic catheter site with the same gloves. She agreed this was a break in infection prevention protocol. A record review of the Admission Record, revealed the facility admitted Resident #216 on 10/30/24. The resident had diagnoses that included Sepsis due to Methicillin-Resistant Staphylococcus Aureus (MRSA). with diagnoses including Sepsis due to methicillin-resistant Staphylococcus aureus (MRSA). On 11/13/2024 at 2:10 PM, during an interview LPN #2/Infection Preventionist (IP) verified staff are expected to follow infection prevention guidelines by changing gloves each time they are soiled and performing hand hygiene before applying new gloves. She stated that failing to do so could increase infection rates in the facility. On 11/13/2024 at 2:21 PM during an interview, the Director of Nursing (DON) stated that her expectation was for staff to clean their hands and change gloves after removing soiled dressings. She further explained that not doing so could increase the risk of infections such as UTIs and other complications due to cross-contamination. 44179 50751

Based on observation, interviews, and record review, the facility failed to ensure that dietary staff supported the nutritional well-being of residents while respecting an individual's right to make choices about their diet for one (1) of thirteen (13) sampled residents reviewed for food preferences. (Resident #169) Findings included: On 11/12/2024 at 10:50 AM, during an interview, Resident #169 stated his primary concern about the facility was the type of food he was being served. He reported that his doctor instructed him to follow a high-protein and low-carbohydrate diet. However, he stated that since being in the facility, he was served more carbohydrates than protein. He indicated that he had complained to the Dietary Manager, leading to a temporary change, but the facility reverted to serving high-carbohydrate meals. He expressed concern that this could negatively impact his health. On 11/13/2024 at 12:10 PM, during a follow-up interview and an observation, Resident #169 described his meals for the day. He reported having pancakes, eggs, and grits for breakfast and stated that he would not eat both buns of the hamburgers served for lunch and did not want the banana pudding because he is diabetic, and it would raise his blood sugar levels. An observation of the lunch meal on 11/13/2024 revealed that Resident #169 was served two hamburgers, French fries, and banana pudding. On 11/13/2024 at 1:11 PM, during an interview, the Dietary Manager confirmed that Resident #169 had expressed his preference for high-protein and low-carbohydrate meals, which she understood to be part of the doctor's orders due to surgical incisions. She admitted that the resident's breakfast and lunch meals did not align with his meal ticket and acknowledged that her staff did not consistently follow the preferences listed for Resident #169. She attributed this inconsistency to staff not understanding high-protein diets. On 11/14/2024 at 8:20 AM, during an interview, the Administrator confirmed the facility had failed to honor Resident #169's food preferences but stated it was the facility's goal to meet his and all residents' preferences. A record review of the Admission Record revealed that the facility admitted Resident #169 on 10/31/2024 with diagnoses that included Fusion of Cervical Spine, Essential Hypertension, and Type 2 Diabetes Mellitus. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/24 revealed Resident #169 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. A record review of the Registered Dietitian (RD) assessment dated [DATE] for Resident #169 revealed, Nutrition Diagnosis: 1.) Increased energy needs R/T (related to) surgical wounds .2.) Inadequate energy/protein intake .Interventions: Recommend 1.) Increase protein portions to large at meals TID (three times a day). 2.) 30 mL (milliliters) Liquid protein daily for 30 days. Record review of Resident #169's tray card dated 11/13/24 revealed Diet Order: CCD/NAS (Consistent Carbohydrate Diet/No Added Salt) High Protein .

Based on observations, staff interviews, record reviews, and facility policy reviews, the facility failed to ensure food items were stored in accordance with professional standards for food safety, as related to food items not being labeled and dated for one (1) of two (2) kitchen observations. Findings included: A review of the facility's policy titled, Food Storage Labeling with a revision date of 5/18, revealed The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the Food .Date of storage . 3. Rotation a. First In, First Out method is used to rotate food in all storage areas .Identify the food item's use by date or expiration date. Store items with the earliest use-by or expiration date in front of items with later dates . On 11/12/2024 at 10:10 AM, during an observation of the initial tour of the kitchen with the Dietary Manager, several items in the stockroom and kitchen were noted to lack open dates. These items included a six (6) pound container of rainbow sprinkles, a 16-ounce container of red shade pure food color, a 48-ounce container of Real Lemon 100% juice, a one-half (1/2) gallon of buttermilk labeled Wholesome, a clear container of seasoning salt without a date or item description, and a 32-ounce container of imitation vanilla flavor. All items were open with no open dates on the packages or containers. On 11/13/2024 at 11:47 AM, during an interview, the Dietary Manager explained that staff are required to date all open items in the kitchen. She stated that dating items indicates their shelf life and helps prevent potential outbreaks. She further stated that it is her responsibility to ensure staff adhere to this practice and that she has conducted in-service training on the importance of dating open items.

Based on interview, record review, and facility policy review, the facility failed to follow policies and procedures which addressed a process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19. This had the potential to affect 24 of 24 residents in the facility. Findings include: A review of the facility's policy, Coronavirus (COVID-19, revised 02/23, revealed . Additional Precautions: Staff who are not yet fully vaccinated, or who have been granted an exception or who have a temporary delay as recommended by the CDC (Centers for Disease Control), will adhere to additional precautions that are intended to mitigate the spread of COVID-19. These additional precautions shall include wearing a facemask while in the facility regardless of the level of COVID-19 Community Transmission . On 04/06/23 at 01:05 PM, during an interview with Director of Nursing (DON)/Infection Preventionist (IP), she stated there were four (4) facility staff who had a religious exemption for COVID-19 vaccination. She stated that staff who were not vaccinated and had an exemption were not required to do anything different than vaccinated staff. On 04/06/23 at 02:47 PM, during an interview with Dietary Staff #1, she stated she did not receive the COVID-19 vaccinations for religious reasons and the IP told her that she did not have to wear a mask anymore. She said she was never told to wear a mask since she was not vaccinated. On 04/06/23 at 03:03 PM, in an interview with the Hair Stylist and Weekend Liaison, she stated she did not get the COVID-19 vaccine due to spiritual reasons and was not told she had to do anything different because she was not vaccinated. On 04/06/23 at 03:29 PM, in an interview with the Director of Nursing (DON), she stated she did not have to do anything different with staff who are not vaccinated. She confirmed that unvaccinated staff are not tested more often than vaccinated staff. Upon review of the facility's policy, she stated the facility is not following the policy or CDC guidelines related to additional precautions and she did not know about the policy. On 04/06/23 at 03:34 PM, during an interview with Administrator, she stated that unvaccinated staff have not been wearing face masks since the county transmission rate is not high and the facility was not in outbreak status. After reviewing the facility's policy, she confirmed that the facility was not following the policy or CDC guidelines regarding additional precautions for unvaccinated staff to mitigate the spread of COVID-19.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure an ice scoop was properly stored during ice distribution for one (1) of six (6) ice chests observed on the hallway. Findings include Record review of the facility's policy, Ice Distribution, with a revision date of 8/2021, revealed .2 . Do not rest the scoop on the ice . On 5/6/22 at 8:20 AM, the State agency (SA) observed an ice chest on F Hall and there was no ice scoop visible in the designated pouch on the side of the ice chest. On 5/6/22 at 8:57 AM, in an interview and observation on F Hall, the Administrator opened the ice chest. She and the SA observed a white 8-ounce Styrofoam cup and a brown coffee cup inside of the ice chest. Both items were resting on top of the ice. The Administrator confirmed the staff should not have left the cups in the ice chest because it is an infection control issue. On 5/6/22 at 10:30 AM, in an interview with Certified Nursing Assistant (CNA) #1, she stated the ice chest should always be closed with the ice scoop on the side of the ice chest. On 5/6/22 at 11:00 AM, in an interview with CNA #2, she stated she passes out ice and performs the care for all the residents on F Hall. She stated that the ice chest should have a bag on the outside of the chest to hold the ice scoop. The ice scoop should not be inside the chest because of contamination issues.

Based on interviews, record review and facility policy review, the facility failed to administer an influenza (flu) and pneumonia vaccine after signed consent was obtained for one (1) of five (5) residents reviewed for flu and pneumonia immunizations. Resident #3. Findings include: Record review of the facility's policy, Influenza Vaccination Program for Employees and Residents, with a revision date of 8/2021, revealed, It is the policy of this facility to provide employees and residents with influenza vaccination every year between October and March . Record review of the facility's policy, Policy for Pneumococcal Vaccination of Residents, with a revision date of 2/22, revealed, . If there is no prior evidence of vaccination the vaccine will be offered to the resident at that time . Record review of the Influenza Information and Consent 2021-2022 revealed Resident #3 indicated, I consent to receiving the flu vaccine when available. The form was signed by Resident #3's Responsible Party, but the date was left blank on the form. Record review of the Pneumonia Vaccine Consent revealed Resident #3 indicated, I consent to have the: but the type of pneumonia vaccine was not checked. The form was signed by Resident #3's Responsible Party, but the date was left blank on the form. Record review of the medical chart revealed no indication that Resident #3 received the flu or pneumonia immunization. On 5/6/22 at 3:42 PM, in an interview with the Director of Nursing (DON), she confirmed Resident #3 signed the consent form for the flu and pneumonia vaccine when he was admitted to the facility on [DATE]. She verified the immunizations were not provided and they must have been overlooked. On 5/6/22 at 4:15 PM, in an interview with the DON, she stated she is responsible for ensuring resident immunizations are administered when the resident signs the consent. She should have followed up to make sure resident got the immunizations in a timely manner. She is aware of the importance of residents receiving immunizations due to the risk of getting the flu and pneumonia. On 5/6/22 at 4:44 PM, in an interview with the Administrator, she confirmed Resident #3 should have received the flu and pneumonia vaccine upon admission. It should have been given when the consents were signed. Record review of the Director of Nursing Orientation Checklist revealed, .Monitoring Resident Records (Chart Audits) .is listed on the checklist. The DON signed the form on 5/21/21. Record review of Resident #3's Face Sheet revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated he is cognitively intact.

Based on observation, record review, staff interview and facility policy review the facility failed to ensure the milk and ice cream cooler were kept in a clean and sanitary condition, for two (2) of four (4) kitchen observations. Findings include: A review of the facility's Sanitation Check List policy, dated 09/2004, revealed: The sanitation checklist shall be used as a part of an ongoing program designed to ensure sanitary conditions and to correct an sanitation deficiencies found in the food service department. The sanitation check of the food service department of the storage areas would be done at least monthly by the Dietary Manager or Dietician which would included the refrigerators and freezers. Review of the facility's Cleaning Instructions Milk Cooler policy, dated 09/2004, revealed: POLICY: Equipment shall be maintained in a clean and sanitary condition. A review of the facility's Sanitary Conditions of the Food Service Department policy, dated 09/2004, revealed, the dietary manager would develop a master cleaning schedule to include what, when, who, and how the equipment in the kitchen would be cleaned. An observation, on 01/28/2020 at 10:30 AM, during the initial tour of the kitchen, revealed,. the ice cream freezer had frost and ice inside on all four (4) walls with a temperature of 32 degrees Fahrenheit (F). The ice cream freezer also had water accumulated on the plexi-glass doors. The milk cooler's thermometer was at a temperature 32 degrees (F), with several of the milk cartons frozen. The milk cooler had accumulated ice and frost on all four (4) walls inside the cooler. The top inside of the cooler had clear water droplets that had frozen. During an observation of the kitchen, on 01/29/2020 at 11:31 AM, the milk cooler temperature measured at 28 degrees (F). The milk cooler still had ice and frost accumulation on all four sides, and the top noted with frozen water droplets hanging down. Ice and frost accumulation was also still present in the ice cream freezer, and present on several ice cream cartons. The ice cream freezer temperature measured at 28 degrees (F). During an interview with the Dietary Manager (DM), on 01/29/2020 at 11:25 AM, DM revealed there were schedules in place for monthly defrosting of ice and frost build up in coolers/freezers. The DM revealed there was the ice and frost build up in the ice cream and milk coolers, and frozen water droplets hanging in the milk cooler. The DM could not produce any documentation to indicate when the milk cooler and ice cream freezer had been defrosted or cleaned.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to revise a care plan related to hospice for one (1) of 13 resident care plans reviewed, Resident #5. Findings include: A review of the facility's Care Plan Process policy, revised 08/2017, revealed, the care plan must be reviewed and revised on an ongoing basis to reflect the services provided or arranged. A review of Resident #5's comprehensive care plan, revealed a problem that addressed hospice services, with an onset date 06/03/2016, and a goal/target date of 03/05/2020. Review of Resident #5's electronic record, revealed the physician's orders [REDACTED]. During an interview, on 01/28/2020 at 2:16 PM, Resident # 5 stated she was no longer on hospice services. An interview on 1/28/2020 at 3:05 PM, with the Administrator, revealed Resident #5 had to be discharged from hospice related to long term admission, and she was no longer a candidate for hospice services. An interview on 01/30/2020 at 11:13 AM, with Licensed Practical Nurse (LPN) #1/Minimum Data Nurse (MDS)/Care Plan Nurse, revealed, she was aware of Resident # 5's discharge from hospice because she had consulted with the Hospice Nurse on the day of discharge. LPN #1 confirmed Resident #5's care plan had not been updated or removed related to hospice services, but she was working on that today. LPN #1 stated the policy of the facility was to update the care plan as soon as possible by entering the changes in the computer and printing out a copy for the chart. LPN #1 also stated it was important to keep the care plans updated because that was what the staff used to care for the residents.

Based on observation, staff interview, record review, and facility policy review, the failed to ensure an expired medication was removed from the medication stock, for one (1) of three (3) medication storage areas observed. Findings include: Review of the facility's Destruction of Unused, Expired or Discontinued Medications policy, dated 10/2019, revealed: All outdated, discontinued and/or recalled drugs, and all containers with illegible or no labels will be given to the Director of Nursing (DON) for proper disposition. These will be removed during monthly inspections or any other time as such are found, and will be disposed of according to policy, at least quarterly. On 01/29/2020 at 10:00 AM, during an interview and observation of the medication storage room, Licensed Practical Nurse (LPN) #3 revealed a bottle of Calcium 600 milligrams (mg)/Vitamin D, 400 tablets, with an expiration date of 07/2019. LPN #3 stated the medication should have been pulled and destroyed. The LPN #3 revealed the expired medication could cause harm to the resident, if it was given. During an interview, on 01/30/2020 at 12:58 PM, the Director of Nursing (DON) revealed the expired medications should have been pulled, destroyed, and reordered. The DON stated the expired medication may not work effectively if it is out of date. The DON revealed she checks the medication stock rooms monthly or bi-monthly. The DON stated, I missed it.

Based on observation, record review, staff interview and facility policy review, the facility failed to develop a comprehensive care plan to address Depression for one (1) of 15 records reviewed; Resident #122. Findings Include: Review of the facility's policy titled, Care Plan Process, revised 08/17, revealed the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs. The comprehensive care plan is an interdisciplinary communication tool. The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged. A review of the Baseline Care Plan, dated 10/22/18, for Resident # 122 revealed there was not a care plan initiated to address Depression, or to indicate [MEDICATION NAME], an antidepressant, had been started. Review of the Face Sheet revealed Resident #122 was admitted by the facility, on 10/22/18, with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. An observation, on 11/01/18 at 2:21 PM, revealed Resident #122 lying in bed awake, but appeared sad. An interview, on 11/02/18 at 3:30 PM, with Licensed Practical Nurse (LPN) #1, who serves as the Minimum Data Set (MDS) Nurse, revealed she is responsible for updating the care plan when an order is written. LPN #1 revealed the nurse noting the order puts it in the computer, and then she gets the pink copy of the order to update the care plan. LPN #1 stated, they use the Baseline Care Plan until the final comprehensive care plan is completed. Upon reviewing the Baseline Care Plan for Resident #122 as well as looking at the computerized care plans, LPN #1 confirmed she could not locate where the order for [MEDICATION NAME] was updated to the care plan, or where there was a care plan to address Depression. LPN #1 stated, It's not there. An interview, on 11/02/18 at 5:15 PM, with the Director of Nursing (DON), revealed the MDS Nurse is suppose to update the care plan when new orders are written. The DON revealed orders are suppose to be done on a daily basis, but they make sure all orders are reviewed, and put on the care plan on Wednesday. Review of the five (5) day Admission MDS assessment, with an Assessment Reference Date (ARD) of 10/29/18, revealed this resident was unable to complete the Brief Interview for Mental Status (BIMS). Section I (Active Diagnoses) revealed Resident #122 was coded for Depression.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a sanitary kitchen to ensure the prevention of the potential for food contamination as evidenced by failure to clean the seals on the milk cooler. This deficient practice had the potential to affect all residents who received milk from the kitchen. Findings Include: A review of the facility policy titled Cleaning Schedule, with a revision date of 10/08, revealed The dietary manager shall establish a cleaning schedule for the food service department to ensure that food is stored and prepared under sanitary conditions. Observations on 03/14/17 at 7:35 AM and 03/15/17 at 7:40 AM, during tours of the kitchen, revealed the milk cooler had a thick black build up along all seals that was removable by scraping. The seal along where the lid bends open had black sludge with the feel of grease with food particles mixed in. An observation of the kitchen and interview with the Dietary Manager (DM) and kitchen staff, Dietary Services (DS) #2 and DS #3, on 03/15/17 from 7:55 AM to approximately 8:10 AM, revealed the facility had a cleaning schedule posted with monthly assignments. The DM stated that the milk cooler would be covered under assignment number one (1) and this month the tasks for assignment number one (1) were assigned to Dietary Staff (DS) #2. A review of the posted assignments and cleaning schedule confirmed the posted assignment. The DM was shown the seals to the milk cooler and the DM stated the seals are difficult to clean. The Surveyor ran her finger over the back seal and removed thick black sludge with lard consistency and food particles mixed in. DS#3 stated the food processor is used on top of the milk cooler. The DM stated it wasn't the ideal place to use the food processor but there were not many electrical outlets to utilize. The DM stated the food processor was used to puree, chop, dice, and slice food items. DS#3 stated that it appeared that some of the food items had fallen in the crack on top of the milk cooler and built up. DS#2 stated she was assigned to clean the milk cooler for the month of March. DS#2 stated she just cleaned the cooler last week. DS#2 stated she had not noticed the build up on the seals of the mild cooler and had concentrated on the inside of the cooler. She stated she had not cleaned the seals. DS#2 stated it was important to clean the seals to prevent bacteria from building up and possibly contaminating the milk. An interview with the DM on 03/16/17 at 10:00 AM, revealed it is her responsibility to check behind dietary staff to ensure cleaning tasks are done. The DM stated she had not noticed when she checked the buildup of black sludge along the seals of the milk cooler.

Based on observation, record review, staff interview and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by failure to wash/sanitize hands before and after administration of medications for two (2) of nine (9) residents observed during medication pass; Resident #5 and #9. Findings include: Review of the facility's policy entitled Hand Hygiene dated 06/14, revealed proper hand washing or hand hygiene should be performed between services to residents. An approved disinfectant gel may be used as an alternative to soap and water if hands are not visibly soiled. A review of the Infection Control Inservice dated 07/15, revealed hands are to be washed with soap and water between all resident contacts. Resident #9 An observation of medication pass on 03/14/17 at 7:55 AM, revealed LPN #1 prepared medications for Resident #9. LPN #1 pulled eight (8) medications for Resident #9 and did not wash or sanitize her hands. After administering medications to Resident #9, LPN #1 exited the room and proceeded to pull up medications for Resident #5. A review of the Face Sheet revealed the facility admitted Resident #9 on 10/13/15, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 02/16/15, revealed Resident #9 scored 15 on the BIMS which indicated cognitively intact. Resident #5 An observation of medication pass on 03/14/17 at 08:10 AM, revealed Licensed Practical Nurse (LPN #1) prepared medications for Resident #5. LPN #1 pulled six (6) medications for Resident #5 without washing or sanitizing her hands. LPN #1 administered medications to Resident #5 and then exited the room without washing or sanitizing her hands. Review of the Face Sheet revealed the facility admitted Resident #5 on 11/21/16, with [DIAGNOSES REDACTED]. A review of the current quarterly MDS with an ARD of 02/16/17, revealed Resident #5 scored 13 on the Brief Interview of Mental Status (BIMS) which indicated cognitively intact. Review of the facility's Inservice Training record revealed training on Infection Control was provided to staff in October 2016. Interview on 03/14/17 at 8:20 AM, with LPN #1, revealed she did not wash her hands between Resident #9 and Resident #5's medication administration. LPN #1 stated I forgot. LPN #1 revealed it is the facility's policy for staff to wash their hands between residents. An interview on 03/16/17 at 11:45 AM, with the Director of Nursing (DON), revealed nurses are to wash their hands or use hand sanitizer between residents. The DON further revealed that staff receive inservices on Infection Control and Hand Washing.

Based on record review, staff interview and facility policy review, the facility failed to ensure a Quarterly Minimum Data Set (MDS) assessment was completed within three (3) months for Resident #4. This affected one (1) of twelve (12) residents reviewed for MDS assessments. Findings include: Review of the facility's policy titled, MDS Process, (revised 03/2016), revealed the Minimum Data Set (MDS) Assessment Nurse is responsible for setting the Assessment Reference Date (ARD) on an allowable date and communicating scheduled Omnibus Budget Reconciliation Act/Prospective Payment System (OBRA/PPS) assessments to the interdisciplinary team. The Minimum Data Set (MDS) is a process used to provide a comprehensive assessment of each resident's functional capabilities and assists staff in identifying health problems. The Quarterly MDS Assessment ARD is to be scheduled no later than ninety-two (92) days from the previous assessment of any type. Review of Resident #4's most recent Quarterly MDS revealed an ARD of 3/21/16. Review of Resident #4's prior MDS assessment (Annual) revealed an ARD of 12/01/15. The number of days between the two ARD's was one hundred ten (110) days. In an interview on 5/24/16 at 2:30 PM, the MDS Coordinator Nurse said Resident #4's ARD had been missed due to staff transitioning into new roles during that timeframe. She said timeliness of MDS assessments was important for capturing changes in resident status and payment and reimbursement. Review of the most recent quarterly MDS with an ARD of 3/21/16, revealed Resident #4 was readmitted to the facility on [DATE]. This MDS assessed Resident #4 with severely impaired cognitive skills for decision making and being totally dependent on staff for dressing, personal hygiene and bathing. Resident #4's [DIAGNOSES REDACTED].

Based on observation, staff interview and facility policy review, the facility failed to ensure a blood glucose meter was disinfected with an approved germicidal wipe after use for Unsampled Resident A and Resident #11. The facility further failed to prevent the potential for cross contamination after Resident #12's bottle of eye drops fell to the floor and was placed back into the medication cart. Findings were for three (3) of 27 medication pass observations. Two (2) of three (3) Accu-checks observed and one (1) of one (1) eye drop administrations. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program, (dated 6/2014), revealed the facility maintains an infection prevention and control program that provides a safe and sanitary environment to help prevent the development and transmission of infection. Review of the facility's policy titled, Infection Control Policy for General Cleaning and Maintenance of Equipment, (dated 6/2014), revealed all resident care equipment is to be cleaned and decontaminated according to manufacturer's recommendation. Review of the facility's policy titled, Blood Glucose Quality Control, (dated 11/2015), revealed the blood glucose meters are to be cleaned with a disinfectant wipe after each use. Review of the manufacturer's recommendation for Cleaning and Disinfecting of the blood glucose meters used by the facility, revealed the meters were to be cleaned and disinfected after each resident using an approved germicidal (bleach) wipe. Unsampled Resident A During observation of medication pass on 5/23/16 at 3:30 PM, Licensed Practical Nurse (LPN) #1 obtained a fingerstick blood sugar with the shared blood glucose meter on Unsampled Resident A. LPN #1 wiped the meter with a 70% [MEDICATION NAME] Alcohol swab before placing it back in the medication cart. Resident #11 On 5/23/16 at 4:40 PM, LPN #1 obtained a fingerstick blood sugar on Resident #11 and then wiped the blood glucose meter with a 70% [MEDICATION NAME] Alcohol swab before placing it in the med cart. An interview was conducted with LPN #1 on 5/23/16 at 5:55 PM. During the interview, LPN #1 acknowledged that she wiped the blood glucose monitor with an alcohol swab after Unsampled Resident A and Resident #11. When questioned further about disinfection of shared blood glucose monitors, LPN #1 said she would clean the meters with disinfecting bleach wipes when she first starts her shift and again before going to another hall. In an interview with the Director of Nursing (DON) on 5/24/16 at 3:06 PM, the DON said LPN #1 reported to her on 5/23/16 about cleaning the blood glucose monitor with alcohol after use on the two residents. The DON said the facility policy was to wipe down the blood glucose monitors with disinfecting bleach wipes between each resident in order to prevent the potential for infection and blood borne pathogens. Review of the Face Sheet revealed the facility admitted Resident #11 on 5/12/16 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/18/16, revealed Resident #11 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The MDS assessed Resident #11 as requiring extensive assistance with transfers, toileting and hygiene. Resident #12 During observation of medication pass on 5/23/16 at 3:45 PM, LPN #1 administered eye drops to Resident #12. Before leaving Resident #12's room, LPN #1 dropped the bottle of eye drops on the carpeted floor. LPN #1 picked up the bottle of eye drop with her hand. She returned to the medication cart and placed the bottle of eye drops back into its box. LPN #1 then placed the box into the top drawer of the medication cart. She did not clean or discard the bottle of eye drops. During an interview with on 5/23/16 at 4:55 PM, LPN #1 confirmed dropping Resident #12's bottle of eye drops on the floor and placing the bottle back into the medication cart without disinfecting or discarding the bottle. LPN #1 said this could spread bacteria or make people sick. In an interview on 5/24/16 at 2:59 PM, the Director of Nursing (DON) said LPN #1 told her about dropping Resident #12's bottle of eye drops on the floor. The DON said LPN #1 should have wiped down the bottle with a disinfecting wipe before placing it back into the medication cart in order to prevent cross contamination. Review of the Face Sheet revealed the facility admitted Resident #12 on 8/11/14. Resident #12's [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/16, revealed Resident #12 having severely impaired cognitive skills for decision making. The MDS further assessed Resident #12 to require extensive assistance with transfers, toileting and bathing.

Based on observation, record review, staff and resident interviews, and facility policy review, the facility failed to ensure privacy was provided for one (1) of nine (9) Residents reviewed, Resident #8. Findings include: Review of the facility policy entitled, Dignity and Respect, revised 06/09, revealed, 5. Residents will be examined and treated in a manner that maintains bodily privacy. A closed door and/or drawn cubicle curtain should be utilized to maximize the privacy of each resident while rendering care. Observation of Resident #8, on 08/20/15 at 4:45 PM, revealed the Director of Nursing (DON) assisted the resident to return to bed. The blinds were open, and the resident's bed was next to the window. The DON did not pull the curtain to screen the resident, and did not close the door. As the DON positioned Resident #8 in bed, his/her underwear was visible in the hall. Interview of Resident #8, on 08/20/15 at 4:50 PM, revealed the resident was bothered when care was provided to him/her and privacy was not ensured. The resident then instructed the DON to close the door when care was provided. Interview, on 08/20/15 at 4:50 PM with the DON revealed he/she did not realize Resident #8's legs were lifted high enough to expose the resident. Review of the Face Sheet revealed the facility admitted Resident #8 on 08/03/15 with diagnoses, which included [MEDICAL CONDITION]. Review of the 14 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/15, revealed Resident #8 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she was cognitively intact.