Every finding on record at Carlyle Place

Based on observation, staff interviews, and review of the facility policy titled Food Safety Management System, the facility failed to ensure items stored in the cooler were labeled, dated, and not beyond their expiration date. The facility also failed to ensure that items in the dry storage area were labeled and dated. In addition, the facility failed to ensure that food was held at a safe temperature until served, measured before serving to ensure appropriate serving sizes, and that staff ensured hairnets covered all hair. This deficient practice had the potential to adversely affect 31 of 31 residents receiving an oral diet. Findings include:Review of the facility policy titled Food Safety Management System, revision date of 5/31/2025, included: C-24 Hot and Cold HoldingHot foods must be held and served at a temperature of 140 degrees F or above. C-26 Date Marking Ready to Eat TCS FoodsRefrigerated, ready to eat, TCS food prepared and held in a food establishment for more than 24 hours must be clearly marked with a use by/discard date.Food that is required to be date marked must be discarded if it: is in a container or package that does not bear a date or day mark. Is inappropriately marked with a date or day that exceeds 7 days. On 9/19/2025 at 8:00 am, the initial kitchen tour began revealing the following observations:1. In the dessert cooler, there were six pies, a tray with 14 slices of cheesecake, a large pan of cobbler, multiple boxes of fruit tart base, a metal container with a red substance, and a container with a pie. The items did not have a storage or discard date. 2. In the dessert cooler, there was a bag of coconut with 8/12 written on the bag. There was no indication of the meaning of the numbers.3. There were three containers (Breadcrumbs, Sugar, and Flour) that were partially full and did not have an in-date or an expiration date. The containers were also noted to have a black and brown substance on the outside, in addition to having substances built up around the tops of the containers. 4. In a second reach-in cooler, on the same wall as the stove in the back, there was a box of oranges that did not have an in-date or use-by date. 5. In the dry food storage area, there was a box of rice that had been opened and not securely closed, with the rice in the box exposed, and a container of oatmeal that had a brown substance on the top, and the top of the container was not tightened. 6. There was one loaf of bread in the dry food storage that had a use-by date of 9/18/2025 and a second loaf of bread that did not have a use-by date. 7. On a shelf in the dry food pantry, there were two boxes of potatoes that were undated, and one of the boxes contained three potatoes with a white substance growing on them. 8. There was one can of mustard and a can of hoisin sauce that had a brown sticky substance on them. 9. There were six boxes of tea and a box of graham crackers that did not have an in-date or a use-by date on them. 10. There were dented cans (one can of milk and four cans of pineapple juice) observed mixed in with the dry goods that had not been removed. 11. In the walk-in cooler, there were two bags on a shelf identified as [NAME] sauce that did not have any dates listed on them. 12. On the bottom rack, there were two pans of meat, with the pan on the bottom not being fully covered, exposing the meat. 13. There was a box of parsley that revealed a gray fuzzy substance growing on the parsley in addition to the parsley being green and yellow. 14. There was a box of strawberries and a box of yellow squash with a delivery date of 9/17, which had a container with a white substance growing on some of the strawberries and a white substance growing on the yellow squash. 15. There was a box of zucchini with a date of [DATE] that had a substance growing on some of them. 16. In the walk-in cooler, there were boxes of bacon, chicken, and pork that did not have expiration dates. 17. In the walk-in freezer, there was a bag with sausage patties that had been open and reclosed, and a bag of chicken, which had neither an open date nor a use-by date. 18. In the walk-in freezer, there was a bag with waffles and a frozen sealed piece of turkey that was not labeled with an in-date or expiration date. During an interview and observation with the Dietary Manager (DM) on 9/19/2025 at 8:15 am, he confirmed the uncovered and undated items in the dessert cooler but reported they were leftovers from yesterday and would all be discarded today. He confirmed that the 8/12 date on the coconut was the date it was placed in the refrigerator. He was unable to give a date when the unmarked pie crust was placed in the cooler or when it should be discarded. During an interview on 9/19/2025 at 8:13 am with the Pastry Chef, it was reported that the three large containers with breadcrumbs, sugar, and flour were cleaned when refilled. He reported that they were last filled yesterday and cleaned at that time. The DM confirmed that there were no dates on the containers, and the containers should have dates indicating when they were placed.During an observation and interview with the DM and Director of Dining (DOD) on 9/19/2025 at 8:30 am, the opened boxes of rice and oatmeal were verified. They also confirmed the presence of the white substance on the potatoes. The brown substance on the cans was confirmed, but they did not know what the substance was. The DOD removed the cans to rinse them off. It was further reported that the canned items were good for one year from the date received, and neither could identify an expiration date for the boxes of tea on the shelf in the dry pantry area. The DOD reported that dented cans were checked during delivery, and any cans identified would be removed and placed in the Chef's office. They then confirmed the dented can of milk and the four cans of pineapple juice. They clarified that on delivery day, by the end of the day, the person receiving the groceries should be checking. The receiver and Executive Chef were identified as the responsible parties for checking this. During an interview and observation on 9/19/2025 at 8:57 am with the DOD, she confirmed that the two bags of [NAME] sauce did not have an in-date or a use-by date, the meat on the bottom shelf was not fully closed, substances were growing on the parsley, strawberries, yellow squash, and zucchini. She also confirmed that there was no expiration date for the bacon, chicken, and pork in the walk-in cooler. At 9:12 am, she confirmed the undated bag of sausage, bag of waffles, bag of chicken, and turkey in the walk-in freezer. On 9/20/2025 at 11:20 am, observations and interviews began in the prep kitchen. Upon entry into the prep kitchen, one cart with lunch trays was prepared and exited the area to be served in the hallway at 11:21 am. There were two black carts that could hold six trays each that remained in the prep kitchen.Observation of puree preparation began on 9/20/2025 at 11:25 am with Health Care Server CC. She reported that she had a total of three residents for puree. She consulted with the Dietary Manager to determine if she needed to prepare one meal or prepare all three at once. It was decided that she would prepare all three at one time. Health Care Server CC was noted to have a hairnet on, but her hair was not tucked under the hairnet on the left front side.The puree observation with Health Care Server CC revealed the following:At 11:31 am, she began using a ladle to put soup into the machine. The soup was pureed, and then it was poured into containers directly from the mixer.At 11:34 am, tongs were used to pick up the pulled pork and add it to the mixer bowl for pureeing. Barbecue sauce was used as a liquid to thin the meat out. Once pureed, the mixture was scooped from the mixing bowl using a spoon.At 11:42 am, four scoops of macaroni and cheese were placed into the mixer, and milk was used to thin it out. A regular spoon was used to scoop into each plate.At 11:49 am, green beans were placed in the bowl with a green-handled spoon and then plated with a regular spoon.At 11:51 am, puree was completed, and one plate was placed on the black cart, and the other two plates were placed on the shelf above the steam table.From 11:55 am to 12:07 pm, mix and moist trays were prepared by Health Care Server CC. The pulled pork was placed in the mixing bowl with the tongs, and again it was not measured before placing the pulled pork, macaroni and cheese, or green beans on plates.At 12:00 pm, one puree plate was delivered to the dining room.At 12:04 pm, a second cart was delivered to the dining room.On 9/20/2025 at 12:13 pm, the temperature of the pureed plate was taken, resulting in the following:Puree green beans at 115.2 degrees Fahrenheit (F).Puree pork at 117.7 degrees F.Macaroni and cheese at 120 degrees F.On 9/20/2025 at 12:15 pm, temperatures for food on the steam table began resulting in the following:Barbeque chicken at 124.3 degrees F.Okra and tomato mixture at 132.7 degrees F.During an interview on 9/20/2025 at 12:19 pm, the DM stated that there was not a particular temperature that the food had to be when it goes out, as long as it is palatable. He went on to state that the temperature of the food was checked prior to coming from the main kitchen and then checked again once it was in the prep/holding kitchen. He further stated that they were not checking the food temperatures while holding the food, because the food is technically safe for two hours.During an interview on 9/20/2025 at 12:23 pm, Health Care Server CC placed her hair under the hairnet when asked if she was aware that the hair was not completely covered. When questioned about how she ensured the correct serving size of the food, since she was using tongs specifically for the pulled pork and a regular spoon for the other items when plating, Health Care Server CC did not answer, but looked to the DM. The DM reported that as long as the meat portion was as thick as a deck of cards, it was fine. Health Care Server DD then reported that the green handle spoon, which is four ounces, should have been used for serving the pork, and proceeded to show the spoon.During an interview on 9/20/2025 at 1:19 pm, the DM reviewed the policy section, which stated that hot foods should be held and served at a temperature of 140 degrees F or above. The DM continued to state that they had two hours to use the food, and they took the temperature both before and after it was in the holding kitchen.In an interview on 9/21/2025 at 9:14 am, the Administrator confirmed that items in the refrigerator and freezer should be labeled and dated. He also confirmed that dietary staff should not be guessing about serving sizes.

Based on observations, staff and resident interviews, and record review, the facility failed to assess one out of 30 sampled residents (R) (R6) to determine if it was clinically appropriate to safely self-administer medications. This failure had the potential to place R6 at risk for adverse consequences.Findings include:Review of the Electronic Medical Record (EMR) revealed R6 was admitted to the facility with diagnoses that included, but were not limited to, surgical wound to left hip, s/p (status post) left femoral fracture with repair, melanoma removal to right forehead, and cataract surgery to both eyes.Review of the admission Minimum Data Set (MDS), dated [DATE], for R6 revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 10 (indicating moderate cognitive impairment). Section M (Skin Conditions) revealed a box checked yes for the use of applications of ointments/medications other than to the feet. Review of physician's orders dated 9/3/2025 for R6 revealed, apply Steri-strip and dry dressing to left elbow skin tear, leave them on until they fall off, then discontinue order-observe daily. Further review of physician orders revealed no orders for over-the-counter (OTC) lubricant eye drops or OTC clotrimazole USP 1% (percent) antifungal cream.Review of the care plan dated 8/28/2025 for R6 revealed that there was no care plan for self-administration of medication.Review of the most recent Resident Functional assessment dated [DATE] under the section titled Medication indicated, R6 Requires complete supervision and administration of meds.Review of the EMR for R6 revealed that a Medication Self-Administration Assessment form had not been completed.During an observation on 9/19/2025 at 9:35 am and at 11:07 am revealed a bottle of OTC lubricant eyedrop sitting on top of the bedside table.Observation and interview on 9/19/2025 at 1:49 pm revealed a bottle of OTC lubricant eyedrop still remained sitting on top of the bedside table. An interview conducted with R6 revealed that it was there because he administered his own eye drops. Further observation revealed a tube of clotrimazole USP 1% antifungal cream sitting on top of the dresser that was sitting across from the bedside table.Observation and interview on 9/20/2025 at 8:35 am revealed a bottle of OTC lubricant eyedrop sitting on top of the bedside table and a tube of clotrimazole USP 1% antifungal cream sitting on top of the dresser. In an interview, R6 revealed that he applied the antifungal cream to his left elbow to treat his skin rash. In an observation on 9/20/2025 at 3:04 pm in R6's room, the Director of Nursing (DON) confirmed a bottle of OTC lubricant eyedrop was sitting on top of the bedside table, and a tube of clotrimazole USP 1% antifungal cream was sitting on top of the dresser. Interview with the DON confirmed that the medication should not be in R6's room. The DON revealed that residents would need to be assessed by a nurse and meet the requirements to self-administer medications. The DON revealed that the medication self-administration assessment form was completed on admission, quarterly, and as needed. The DON further revealed that a medication self-administration assessment form would not have been completed for R6 because the resident was not capable of administering his own medications due to his impaired cognition.In an interview on 9/20/2025 at 3:15 pm, a record review was conducted with the DON, who confirmed there was no medication self-administration assessment form completed, and that the last Resident Functional Assessment was completed on 5/7/2024 for R6. The DON revealed that the expectation for nurses was to ensure medications were not left in the resident's room, and if they found medications in the room, they should remove them, provide education, and complete an assessment to self-administer medications, if needed.In an additional interview on 9/20/2025 at 3:40 pm with the DON, she explained that the resident functional assessments were completed on residents that reside on the personal care units and not the skilled nursing unit was the reason why it had not been completed for R6 on admission to the skilled nursing unit however, she reiterated that R6 did not have cognitive ability to self-administer medications. The DON further revealed that they did not have any residents on the skilled nursing unit who self-administered medications. The surveyor requested the facility's policy but was informed by the DON that the facility did not have a policy for self-administration of medications or medication administration.

Based on observations, staff interviews, and review of facility policy titled, C-26 Marking Ready to Eat TCS/PHF Foods the facility failed to remove ice build-up on top of food items to prevent contamination in the walk-in freezer; failed to ensure dietary staff label and date opened food items; and failed to ensure no wet nesting with stacks of steam table pans to prevent bacteria growth. The facility census was 32 residents, and all residents were consuming an oral diet. Findings include: 1. Observation on 8/23/2024 at 8:40 am of the walk-in freezer revealed the fan housing to the air condenser was covered with a layer of ice and frost. Icicles were formed on the pipes at the back of the air condenser. Continued observation revealed a case of frozen peaches on the food storage shelf under the right side of the air condenser. The top of the peaches had a layer of ice as well as a mound ice that was three inches in height and three inches in diameter. Further observation revealed a white plastic type pan covered with clear plastic labeled diced mango to the left of the case of peaches. The entire white plastic pan was covered with frost and ice. The top of the diced mango was a mound of ice that was two inches in height and one inch in diameter. During an interview on 8/23/2024 at 8:40 am the Dining General Manager (DGM) confirmed that there was ice on the top of the case of peaches as well as ice/frost on the white pan of diced mango. The DGM revealed that maintenance has been notified by work order that air condenser in the walk-in freezer has ice build-up. The DGM revealed that dietary staff should not have been storing food items directly under the air condenser due to the ice. Observation on 8/25/2024 at 8:05 am of the walk-in freezer revealed the fan housing to the ice condenser continued to be covered by ice/frost. Continued observation revealed a large pan had been placed directly under the air condenser towards the right side. To the left side of this large pan was a case of frozen tart cherries and the sides and top of the case were covered with ice. A mound of ice one inch in height and two inches in diameter was noted on the case of cherries. During an interview on 8/25/2024 at 8:05 am the Healthcare Dining Manager (HDM) confirmed that there was ice on the case of tart cherries. The HDM revealed that dietary staff should have placed additional pans under the entire air condenser to prevent ice from forming on the cases of food. The HDM also revealed that dietary staff should have removed food items directly under the air condenser. 2. Review of the facility policy titled C-26 Marking Ready to Eat TCS/PHF Foods revealed: Refrigerated, ready to eat TCS/PHF (Time/Temperature Control for Safety/Potentially Hazardous Foods) food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened. Observation on 8/23/2024 at 8:45 am of the dry storage area revealed the following food items had been opened and stored with no open date. penne pasta spaghetti noodles rainbow pasta Macaroni pasta gallon container of teriyaki sauce gallon container of soy sauce gallon container of hot sauce gallon container of salsa gallon container of apple cider vinegar 24-ounce glass jar of dijon mustard During an interview on 8/23/3024 at 8:45 am the HDM confirmed that the opened food items identified in the dry storage area did not have an open date. The HDM revealed that dietary staff are expected to label, and date opened food items prior to placing on storage shelf in the dry storage area. Observation on 8/23/2024 at 8:50 am of the two-door reach-in refrigerator located in the corner of the kitchen revealed the following food items had been opened and being stored with no open date. sliced ham wrapped in plastic wrap gallon container of blue cheese salad dressing gallon container of honey mustard salad dressing gallon container of ranch salad dressing gallon container of 1000 salad gallon container of Greek vinaigrette gallon container of balsamic Vinaigrette 24-ounce glass jar of Dijon mustard During an interview on 8/23/2024 at 8:50 am the HDM and DGM both confirmed that the food items identified in the reach-in refrigerator did not have open date. The HDM revealed that dietary staff should be using either a sticker type label to date opened items or to mark directly on the container with a marker. Observation on 8/23/2024 at 8:55 am of the storage shelf under the food preparation table in the dessert area of the kitchen revealed an 11-pound plastic container of chocolate fudge icing and an 11-pound plastic container of vanilla creme icing. Both icing containers had been opened and stored with no open date. During an interview on 8/23/2024 at 8:55 am, the DGM confirmed that both icing containers had been opened and had no open date. The DGM revealed that all dietary staff need to date food items after opening. Observation on 8/25/2024 at 8:15 am of the shelf under the food preparation table revealed that the plastic containers of chocolate fudge icing and vanilla creme icing continue to not be dated after opening. During an interview on 8/25/3034 at 8:15 am the HDM confirmed that both icing containers did not have an open date and expects dietary staff to place open date before storing on shelf. 3. Observation on 8/23/2024 at 9:10 am of the pot and pan storage rack revealed multiple stacks of steam table pan of various sizes. A stack of four small square pans was pulled apart and the inside of the top two pans had moisture. Continued observation revealed a stack of five medium sized square steam table pans were pulled apart and the inside of the top three pans had moisture. Further observation of a stack of large rectangle steam table pans revealed the top two pans were pulled apart and the inside had moisture. During an interview on 8/23/2024 at 9:10 am the DGM and HDM both confirmed that the steam table pan pulled apart from the stacks all had moisture inside. The HDM revealed that dietary staff are expected to air dry pans completely before stacking and storing. During an interview on 8/23/2024 at 2:15 pm the HDM revealed that the facility does not have a policy regarding air drying pot/pans before stacking and storage. The HDM revealed that dietary staff are expected to follow manufacturer's recommendations which indicates to air dry dishware before storing.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Concentrator-Work Instruction-[Facility Name], the facility failed to ensure humidification was provided for one of six residents (R) (R11) receiving oxygen (O2) therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings Include: Review of the facility's policy titled Oxygen Concentrator-Work Instruction-[Facility Name] dated 10/27/2023 under the section titled Purpose revealed, To establish responsibilities for the care and use of oxygen concentrators. Under the section titled Explanation and Compliance Guidelines revealed, 4. (e) Fill the humidifier container to the correct level with distilled water and attach to concentrator or use a disposable humidifier. 5.(c) Nurse responsibilities: (ii) Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer. Review of R11's Profile Face Sheet revealed, diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD), anemia, heart failure, unstable angina, and atherosclerotic heart disease. Review of R11's Physician's Order dated 4/29/2024 revealed, an order for oxygen at 2-5 LPM/NC (liters per minute/nasal cannula) continuously, check O2 sat (saturation) q (every) shift for diagnoses of COPD and emphysema. Review of R11's Quarterly Minimum Data Set, dated dated dated [DATE] for Section O (Special Treatments, Procedures, and Programs) revealed, R11 received oxygen while a resident. Observation on 8/23/2024 at 9:45 am and at 2:30 pm revealed, R11 receiving O2 at 2 LPM via NC from an O2 concentrator that did not have a humidifier container, or a disposable humidifier attached to it. Observation on 8/24/2024 at 8:29 am revealed R11 receiving O2 at 2 LPM via NC from an O2 concentrator that remained without a humidifier container or disposable humidifier. Observation and interview on 8/24/2024 at 9:05 am with Licensed Practical Nurse (LPN) AA confirmed R11 was receiving O2 at 2 LPM via NC from the O2 concentrator without a humidifier container or disposable humidifier. LPN AA acknowledged there should be a humidifier bottle attached to the concentrator with O2 delivery. LPN AA revealed that the nurses on night shift were responsible for making sure humidifier bottles were attached when they change out the O2 tubing. She reported all nurses were responsible for replacing it as needed. Interview on 8/24/2024 at 9:20 am with the Director of Nursing (DON) revealed her expectations of nurses were to follow policy procedures for O2 administration and make sure O2 concentrators have humidifier bottles attached with the delivery of O2.

Based on interviews, record reviews, and review of the job summaries for the Administrator and Director of Nursing (DON), the facility Administration failed to effectively oversee an abuse prevention program to promote, foster, and maintain an abuse-free environment. The facility census was 32. On 4/16/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/27/2023. At the time of exit on 4/19/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Review of job summary for the Administrator revealed, is responsible for directing the day- to- day functions of the Health Centers in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing and personal care facilities. Is appointed by the governing board as Administrator of Record of the skilled nursing area per state and federal regulations. The description included job duties and responsibilities for the categories: strategic direction, results accountability, process improvement, interpersonal communication, leadership skills, safety, corporate and regulatory compliance, and operation improvement. Experience: Five years of healthcare experience in a skilled nursing center, including demonstrated management experience. Knowledge of healthcare regulatory standards, fraud, and abuse laws and state regulations is required. Review of job summary for Director of Nursing revealed, plan, organize, develop, and direct the overall operation of the skilled nursing department as well as all clinical staff in other nursing areas in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed, by the Director of Health Services, and the Medical Director. Collaborates with other disciplines and departments in providing a continuum of care to residents, assisting in budget and financial planning and control, establishes and monitors nursing standards and nursing plan for provision of care and services, nursing performance review, and quality assurance. The description included job duties and responsibilities for the categories: strategic direction, results accountability, process improvement, interpersonal communication, leadership skills, safety, corporate and regulatory compliance, and operation improvement. 1. Administration failed to ensure that one resident (R) (R4) was free from involuntary seclusion when one side of his bed was pushed against the wall, and the other side of the bed was barricaded with a mattress lying perpendicular against the side of the bed and supported by chairs. The mattress and wall blocked R4's view of his room, and he could not get out of his bed from approximately 10:30 pm on 10/27/2023 until 7:30 am on 10/28/2023 when a nurse discovered R4. Cross-reference: F603 2. The Administration failed to protect the resident's right to be free from physical abuse by staff by failing to report an allegation of abuse in a timely manner to the State Agency (SA) for one of three residents (R)(R4) reviewed for abuse. Cross-reference: F609 3. Administration failed to investigate, correct, and prevent allegations of abuse by staff for one of three residents (R) (R4) reviewed for involuntary seclusion. Specifically, when staff used a mattress and chairs to barricade R4 in his bed for more than eight hours. Cross-reference: F610 4. Administration failed to identify concerns and effectively implement Quality Assurance Process Improvement (QAPI) plans related to the abuse prevention system, including staff to resident abuse allegations and implementing all components of the abuse policies. Cross-reference: F867 During an interview on 4/11/2024 at 11:05 am, with DON revealed that Administrator BB (the previous Administrator) informed her that Licensed Practical Nurse (LPN) QQ had barricaded R4 in his room. The DON stated the incident occurred while she was on leave. The DON stated that Administrator BB stated he had addressed the incident internally. The incident was not reported to the SA. The DON further revealed that no facility-wide in-service was conducted, LPN QQ was not suspended or dismissed from employment while an investigation occurred, and LPN QQ continued providing care to residents, including R4. During an interview on 4/12/2024 at 11:30 am, with Administrator BB it was revealed that on 10/27/2023, he was the Administrator on record. Administrator BB stated that on 10/28/2023, Registered Nurse (RN) OO reported that she discovered R4 barricaded with a mattress and chairs against his bed, and the other side of the bed was pushed against the wall. RN OO expressed that R4 was unable to get out of bed and was unable to view his surroundings. Administrator BB stated LPN QQ should never have used a mattress to barricade R4 in his bed. Administrator BB confirmed staff were not in-serviced, LPN QQ was given a warning, and there was no further investigation. Administrator BB stated he did not notify the Medical Director (MD) regarding the incident and did not report it to the SA. Administrator BB acknowledged a complete investigation should have been conducted. During an interview on 4/15/2024 at 5:34 pm, with MD revealed he was not made aware R4 was restrained involuntarily on 10/27/2023. The MD stated he would have expected staff to report the incident to the SA and that involuntary seclusion was not permitted and was against facility policy. The MD was a member of the QAPI committee and stated the incident was never discussed by the QAPI committee. During an interview on 4/17/2024 at 2:57 pm, with Administrator AA it was revealed that he was the Executive Director in October 2023 and in charge of the entire facility. He acknowledged on 10/28/2023, Administrator BB reported to him that LPN QQ had involuntarily restrained R4 in his room. He further stated that the incident was not reported to the SA or investigated further. Administrator AA stated he believed proper channels of investigating and reporting to the SA were not followed, and the incident was not addressed in the QAPI meeting.

Based on staff interviews, record review, and a review of the facility's policy titled QAPI Change Process- Work Instruction, the facility failed to identify concerns and effectively implement Quality Assurance Process Improvement (QAPI) plans related to abuse prevention system, including staff to resident abuse allegations and implementing all components of the abuse policies. The facility census was 32. On 4/16/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/27/2023. At the time of exit on 4/19/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of the facility policy titled QAPI Change Process- Work Instruction, revised date 10/24/2023 revealed the purpose: 1.0 The facility has established and utilizes a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained. c. Once a potential problem is identified, the committee utilizes a systematic approach (e.g. Five Whys, flowcharting, fishbone diagram, Failure Mode and Effect Analysis, etc.) (specify one or more methods) to help identify the root cause of the problem. d. As corrective actions are taken, the committee continues to collect and analyze data to determine the effectiveness of any changes. 4. Corrective action - a. Once the root cause of a problem is identified, the QAA committee oversees the development of an appropriate corrective action. An appropriate corrective action is one that addresses the underlying cause of the issue comprehensively, at the systems level. b. Corrective action plans include: i. A definition of the problem -which includes determining contributing causes of the problem; ii. Measurable goals; iii. Step-by-step interventions to correct the problem and achieve established goals; and iv. A description of how the QAA committee will monitor to ensure changes yield the expected results. Record review of a facility document Memo of Understanding, dated 10/30/2023 and signed by Licensed Practical Nurse (LPN) QQ, showed Administrator BB (the previous Administrator) documented the following: Physical restraints are any manual or physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom or normal access to one's body. Each resident has the right to be free from actual or threatened physical or chemical restraints. Physical restraints are prohibited unless indicated by the physician with the proper documentation, care planning, assessments, and physician order. A discussion was held with you on the use of a fall mat for a fall intervention that may have been considered a restraint. Fall mats are to be used on the floor at the bedside. Other interventions such as assisting the resident to the nursing station or providing resident with an activity are acceptable. The memo concluded that by signing below, LPN QQ understood the protocol on physical restraints and the utilization of other interventions for fall prevention, signed by the Administrator BB and LPN QQ. Administration failed to ensure concerns were identified and QAPI plans implemented, in a timely manner related to the abuse prevention system, including staff to resident abuse allegations, and implementing all components of the abuse polices. As part of the QAPI committee, facility administration failed to identify areas of concern for resident abuse, in a timely manner, and effectively implement interventions to prevent recurrence. A review of facility QAPI documentation revealed that the QAPI committee met quarterly on 10/10/2023, 1/9/2024, and 4/9/2024. There was no evidence in these meetings that identified the abuse allegation concern or the abuse prevention program implementation review prior to start of survey. Record review of the facility letter dated 4/18/2024 and titled Teammate Memorandum for Record, Administrator AA documented in a letter addressed to LPN QQ, on 10/27/2023 LPN QQ placed a mattress on the edge of the bed, resulting in R4 being secluded and restrained. LPN QQ's actions violated safe practices and danger to the life of self or others. As a result, the violation was considered serious in nature and resulted in termination on 4/18/2024. During an interview on 4/12/2024 at 11:30 am with Administrator BB (the previous Administrator) revealed on 10/27/2023 that the incident should have been brought to the QAPI committee and addressed for corrective action. Administrator BB stated that involuntary seclusion was considered a restraint, and the use of restraints and involuntary seclusion was against facility policy and was not permitted. During an interview on 4/15/2024 at 5:34 pm with Medical Director (MD) revealed he was not made aware R4 was restrained involuntarily on 10/27/2023. The MD revealed that he was a member of the QAPI committee and stated the incident was never discussed in the QAPI meeting. During an interview on 4/17/2024 at 10:15 am with Quality Analysis (QA) Registered Nurse (RN), revealed that she was not made aware LPN QQ had barricaded R4 in his room and the incident was not brought before the QAPI committee. The QA RN stated she would have expected the facility to report the incident immediately to the State Agency, investigate the incident, determine the root cause analysis, educate all staff, and provide corrective action as indicated in the facility QAPI policy. During an interview on 4/17/2024 at 12:37 pm, DON said she was a member of the QAPI committee, and the involuntary seclusion that occurred on 10/27/2023 had not been discussed with the QAPI committee, nor was the committee made aware of the incident.

Based on staff interviews, record review, and review of the facility policy titled Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention - Work Instruction, the facility failed to ensure that one resident (R) (R4) was free from involuntary seclusion when one side of his bed was pushed against the wall, and the other side of the bed was barricaded with a mattress lying horizontally on chairs. The mattress and wall blocked R4's view of his room, and he could not get out of his bed from approximately 10:30 pm on [DATE] until [DATE] at 7:30 am when a nurse discovered R4. The facility census was 32. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director were informed of the Immediate Jeopardy (IJ) on [DATE] at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of the facility policy titled Abuse Neglect and Exploitation - Work Instruction, revised on [DATE], revealed the purpose 1.0: to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 3.0 Abuse means willful infliction of injury, unreasonable confinement or punishment resulting in mental anguish. Involuntary Seclusion refers to the separation of Resident from other residents or from his/her room or confinement to his/her room against the Resident's will or the will of the legal representative. Record review of the Electronic Medical Record (EMR) revealed R4 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, psychophysiological insomnia, dementia, and right femur fracture. Record review of the most recent Admission Minimum Data Set (MDS) assessment for R4, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating moderate cognitive impairment. Maximal assistance with toileting, walking not attempted, and no assistive devices. Two falls since admission. R4 expired in the facility on [DATE] due to comorbidities not associated with this seclusion. A review of a facility document titled Memo of Understanding, dated [DATE] and signed by Licensed Practical Nurse (LPN) QQ, revealed the previous Administrator BB documented the following, LPN QQ understands the protocol on physical restraints and the utilization of other interventions for fall prevention. During an interview on [DATE] at 12:10 pm, LPN QQ revealed that R4 had dementia and she had worked with him on multiple occasions. LPN QQ stated R4 had recurrent falls, and she wanted to keep him safe. LPN QQ revealed on [DATE], she worked the evening shift (7:00 pm to 7:00 am). She stated at approximately 9:30 pm, R4 was seated in a geriatric chair, and she wanted to lay the resident in his bed. She stated that R4 was uncooperative, and she asked for assistance from a Certified Nursing Assistant (CNA) and put R4 in bed. LPN QQ further revealed that R4 refused to stay in bed and repeatedly tried to get out of bed. At approximately 10:30 pm, LPN QQ stated she took a single mattress and barricaded the resident from getting out of bed. LPN QQ further stated she placed a single mattress perpendicularly against R4's bed, blocked the resident from getting out of bed, and had the other side of the bed pushed against the wall. LPN QQ stated that R4 continued to knock the mattress down and she took a chair or two and supported the mattress from falling. LPN QQ stated she was unable to recall how many chairs in total she used to support the mattress from falling. LPN QQ further revealed she wanted R4 to stay in bed and believed R4 was not restrained. LPN QQ stated she had tried multiple times to keep R4 in bed, but R4 consistently failed to follow her orders and continued to knock the mattress down multiple times. LPN QQ stated R4 was a large, combative man, and she had to barricade him to make him stay in bed. LPN QQ demonstrated and drew a diagram showing how she barricaded R4 in his room. During an interview on [DATE] at 1:33 pm, Registered Nurse (RN) OO revealed she was a weekend supervisor and was familiar with R4. RN OO stated R4 was a high fall risk and had hip surgery and an open wound. RN OO stated she recalled that on [DATE], she came in that morning and observed staff had used a mattress and blocked R4 from getting out of bed. RN OO observed a mattress placed perpendicular and leaned against R4's bed and the other side of the bed against the wall. RN OO stated she felt like that was not the correct intervention, so she removed the mattress and laid it down on the floor. RN OO further revealed she could not recall the number of chairs that were used to support the mattress from falling and stated the mattress blocked R4's view of his surroundings from the bed. RN OO stated she reported the findings to Administrator BB. During an interview on [DATE] at 1:56 pm, LPN PP revealed R4 liked to sit in a geriatric chair but would try and get out of the geriatric chair without help, and he could not ambulate without assistance. LPN PP stated that R4 was confused but not combative and was able to follow directions. During an interview on [DATE] at 11:05 am, the DON revealed that the previous Administrator BB had informed her that LPN QQ had barricaded R4 in his room. According to the DON, the incident occurred while she was on leave. The DON stated Administrator BB addressed the incident internally with a verbal warning and LPN QQ continued providing care to residents, including R4. During an interview on [DATE] at 11:30 am, Administrator BB revealed on [DATE], he was the Administrator on record. Administrator BB stated that on [DATE], RN OO reported that she discovered R4 barricaded with a mattress and chairs in his room. RN OO stated that R4 was unable to get out of bed. Administrator BB further revealed that LPN QQ should never have used a mattress to barricade R4 in his bed. Administrator BB stated that it was considered a restraint and that the use of restraints and involuntary seclusion was against facility policy and not permitted. Administrator BB confirmed staff were not in-serviced, LPN QQ was given a warning, and there was no further investigation. During an interview on [DATE] at 5:34 pm, the Medical Director (MD) revealed he was not made aware that R4 was restrained involuntarily on [DATE]. The MD stated he would have expected staff to report the incident to the State Agency. The MD further revealed that involuntary seclusion was not permitted and was against facility policy. During an interview on [DATE] at 2:17 pm, R4's Resident Representative (RR) revealed she was unaware R4 was barricaded in bed on [DATE]. The RR stated she would have preferred to be notified of the incident. During an interview on [DATE] at 2:57 pm, Administrator AA revealed he was the Executive Director in [DATE] and in charge of the entire facility. He stated that on [DATE], Administrator BB reported to him that LPN QQ had involuntarily restrained R4 in his room. During an interview with the Rehabilitation Director (RD) on [DATE] at 1:01 pm, she revealed that R4 participated in rehabilitation services. The RD stated that R4 was not combative but rather inquisitive. The RD revealed that R4 liked to be up in a geriatric chair most of the day. During an interview on [DATE] at 10:45 am, CNA CCC revealed that on [DATE], she worked the night shift with LPN QQ. CNA CCC stated that R4 was very confused, and LPN QQ wanted R4 to stay in his bed. CNA CCC further revealed on [DATE] that there was not enough staff to offer one-on-one care to sit in R4's room, and LPN QQ made the wrong decision and barricaded R4 in bed all night. She stated LPN QQ overstepped her boundaries and thought she was helping CNAs.

Based on staff interviews, record review, and review of the policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention - Work Instruction, the facility failed to protect the resident's right to be free from physical abuse by staff by failing to report an allegation of abuse in a timely manner to the State Agency (SA) for one of three residents (R)(R4) reviewed for abuse. On 4/16/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director (HD) were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/27/2023. At the time of exit on 4/19/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of the facility policy titled Abuse Neglect and Exploitation - Work Instruction, last revised on 10/24/2023, revealed the facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: A. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. Record review of the most recent Admission Minimum Data Set (MDS) Assessment for R4, dated 11/06/2024, revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating moderate cognitive impairment. During an interview on 4/10/2024 at 1:33 pm with Registered Nurse (RN) OO revealed on 10/28/2023 at approximately 8:00 am, after observing that a mattress was perpendicularly placed and leaned against R4's bed and held up by chairs, she removed the chairs and laid the mattress down. RN OO stated it was against facility policy to barricade and restrain residents from movement. RN OO stated that R4 was involuntarily restrained, and she reported the incident to the abuse Coordinator, Administrator BB. During an interview on 4/11/2024 at 11:05 am with Director of Nursing (DON) revealed that the previous Administrator BB informed her that Licensed Practical Nurse (LPN) QQ had barricaded R4 in his room. The DON stated that Administrator BB said he addressed the incident internally, but that Administrator BB should have reported it to the SA. During an interview on 4/12/2024 at 11:30 am, with Administrator BB revealed on 10/27/2023, he was the Administrator on record. He stated on 10/28/2023; RN OO reported to him that she discovered R4 barricaded with a mattress and chairs in his room. RN OO stated that R4 was unable to get out of bed. Administrator BB revealed that he did not notify the Medical Director (MD) regarding the incident, and he did not report the incident to the SA. During an interview on 4/17/2024 at 2:57 pm, with Administrator AA revealed he was the Executive Director in October 2023 and in charge of the entire facility. On 10/28/2023, Administrator BB reported to him that LPN QQ had involuntarily restrained R4 in his room. Administrator AA confirmed the incident was not reported to the SA and that Administrator BB told him he had addressed the situation. Administrator AA stated the proper channels of reporting to the SA were not followed.

Based on staff interviews, record review, and a review of the facility's policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention - Work Instruction, the facility failed to investigate, correct, and prevent allegations of abuse by staff for one of three residents (R) (R4) reviewed for involuntary seclusion. Specifically, when staff used a mattress and chairs to barricade R4 in his bed for more than eight hours. On 4/16/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator AA, Director of Nursing (DON), and Hospital Director, were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 11:30 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 10/27/2023. At the time of exit on 4/19/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of the facility policy titled Abuse Neglect and Exploitation - Work Instruction, revised on 10/24/2023 and effective on 10/17/2023, documented that the facility will develop and implement written policies and procedures to investigate abuse, neglect and exploitation of residents and misappropriation of resident's property. 4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. Record review of a facility document titled Memo of Understanding, dated 10/30/2023 and signed by Licensed Practical Nurse (LPN) QQ, showed Administrator BB documented the following: Physical Restraints are any manual or physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or normal access to one's body. Each resident has the right to be free from actual or threatened physical or chemical restraints. Physical Restraints are prohibited unless indicated by the Physician with the proper documentation, care planning, assessments, and physician order. By signing below, LPN QQ understands the protocol on physical restraints and the utilization of other interventions for fall prevention. During an interview on 4/11/2024 at 11:05 am with the DON, she revealed that the previous Administrator BB informed her LPN QQ had barricaded R4 in his room. According to the DON, the incident occurred while she was on leave. The DON stated Administrator BB addressed the incident internally with a verbal warning, and LPN QQ continued providing care to residents, including R4. During an interview on 4/10/2024 at 12:10 pm, LPN QQ revealed that she was spoken to by the Administrator a few days after the incident with R4 related to a verbal warning. LPN QQ further revealed she continued working after the warning and confirmed she did take care of R4 after 10/27/2023. During an interview on 4/12/2024 at 11:30 am, Administrator BB revealed on 10/27/2023, he was the Administrator on record. Administrator BB stated that on 10/28/2023, RN OO reported that she discovered R4 barricaded with a mattress and chairs against his bed and the other side of the bed against the wall. RN OO stated that R4 was unable to get out of bed, and the mattress blocked his view of his surroundings. Administrator BB stated LPN QQ should never have used a mattress to barricade R4 in his bed. Administrator BB stated that it was considered a restraint and that the use of restraints and involuntary seclusion was against facility policy and not permitted. Administrator BB confirmed staff were not in-serviced, LPN QQ was given a warning, and there was no further investigation. Administrator BB further revealed a complete investigation should have been conducted. During an interview on 4/17/2024 at 2:57 pm, Administrator AA revealed he was the Executive Director in October 2023 and in charge of the entire facility. He stated that on 10/28/2023, Administrator BB reported to him that LPN QQ had involuntarily restrained R4 in his room. Administrator AA stated that the incident was not investigated further and that the proper channels of investigation were not followed.

Based on observations, staff interviews, and review of facility policies titled, Food Safety Product Labeling and Dating and Cleaning and Sanitizing Frequency, the facility failed ensure food items were properly dated and labeled, the facility also failed to ensure that kitchen equipment was clean and sanitary. The deficient practice had the potential to affect 28 residents receiving an oral diet. Findings include: Review of facility policy titled, Food Safety Product Labeling and Dating dated 4/1/2022 revealed Refrigerated, ready to eat, TCS/PHF food prepared and held in a food establishment must be clearly marked with a consume by/discard date. Refrigerated, ready to eat, TCS/PHF food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened. Review of the facility policy titled, Cleaning and Sanitizing Frequency dated 4/1/2022 revealed Non-food contact surfaces must be cleaned at a frequency necessary to preclude the accumulation of soil residues. Observation on 4/29/2023 at 10:13 a.m. of the main kitchen dry foods pantry revealed the following food items were not properly labeled or dated during follow-up tour. Soy Sauce 1 gallon (half used no open or discard date), Teriyaki Glaze 5 pounds (lb.) 10 ounces (oz.), Citrus Seasoned dressing and Sauce 2 quart (qtr.), Unsulphured Molasses 1 gallon (GAL), Classic Worcestershire Sauce 1 gal., Chicken Fryer mix (opened not sealed), Liquid smoke 1 gal. All observations were confirmed by Dietary Manger. Observation on 4/29/2023 at 10:30 a.m. of walk-in cooler located in the main kitchen revealed the following items were stored on a utility cart not labeled and dated, small white container of peaches, pineapples, pears, boiled egg pieces, and pickles. Continued observation also revealed a medium sized white container that contained baby spinach, green leaf lettuce, seasoned rice. All observations were confirmed by Dietary manager at time of observation. Observation on 4/29/2023 at 10:45 a.m. of the main stove located in the back of kitchen revealed dark crusted debris around the top pf the burner base on all six burners. The side of the flat top grill streaks of a dark brown substance dripping mid-way down, on the side nearest to the stove top. There was also food crumbs and other debris noted to the base of the flat top grill as well. There was also an observation of the deep fryer located in the main kitchen that had used greased and copious amount of fried food crumbs noted to the base of the fryer. There was also a thick layer of brown substance into the base of the fryer and on the inside of both doors where the draining of the oil is conducted. Observation on 4/29/2023 at 10:45 a.m. of gas grill located to the left of the main stove in the kitchen revealed there were brown streaks streaming down the front of griddle by the temp regulating knobs across the entire front of the griddle. continued observation of the convection oven also revealed there was a buildup of black debris to the base of the oven floor as well as both doors on the inside were covered with a brown substance as well. Observations were confirmed by the Dietary Manager at time of the observations. Interview on 4/29/2023 at 10:50 a.m. with Dietary Manager revealed that all food items should be dated and labeled when they are opened. There should always be an open date and an expiration date on the food item. Continued interview also revealed that she expects for all foods to be labeled properly after they are opened. Continued interview also revealed that there is not cleaning schedule for the staff to follow for the oven and stove top that she was aware of. Interview on 4/29/2023 at 11:00 a.m. with Cook EE revealed that the outside of the oven is wiped down daily but the inside not so much. Staff member could not recall the last time the oven had been cleaned. Interview on 4/29/2023 at 11:12 a.m. with the Administrator revealed that the kitchen staff is contracted out by Sodexo and the expectation is that they follow their policy and procedure for label and dating and cleaning and sanitizing of the kitchen. The main kitchen is responsible for supplying food to the entire community and should be kept clean and sanitary. Interview on 4/29/2023 at 11:30 a.m. with [NAME] Cross Director of Dinning revealed that the kitchen equipment is cleaned weekly on the weekends and then all equipment is broken down quarterly and thoroughly cleaned. There is a cleaning schedule that is followed, and the head Chef is responsible for ensuring that the tasks are completed. When the deep fryer is cleaned the oil is removed and the inside bin is cleaned and sanitized, and new oil is put into fryer weekly. Continued interview also revealed that the bottom of the fryer where the oil is removed should be wiped clean as well not cause build-up of oil and debris. During interview it was also disclosed the expectation is that all equipment in the kitchen is to be kept clean and sanitized.

Based on record review and staff interviews the facility failed to ensure that a comprehensive plan of care was developed for two of three residents (R) (R# 26 and R#86). Specifically, the facility failed to develop a plan of care for R#26 that addressed his Suprapubic Catheter care needs, the facility also failed to develop a plan of care that addressed the behavioral needs of R#86. Findings include: Record review for R#26 revealed resident was admitted to the facility with the diagnoses of Kidney Failure, Alzheimer's disease, Type 2 Diabetes, hyperlipidemia, abnormalities of gait, Dementia, Psychophysiological insomnia, slow Transit constipation, Benign prostatic hyperplasia with lower urinary tract symptom, retention of urine. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of three (3) indicating resident did have a cognitive impairment. Review of residents' plan of care did not address the care needs of the suprapubic catheter that was being utilized by R#26. Interview on 4/30/2023 at 11:35 a.m. with MDS Coordinator confirmed that a plan of care for R#26 suprapubic catheter was not initiated. Record review for R#86 revealed resident was admitted to the Skilled Unit on 4/4/2023 with diagnoses of Alzheimer's disease, major depressive disorder, hypothyroidism essential hypertension, age related physical debility. Review of Interdisciplinary notes revealed resident was exhibiting behaviors of hitting, kicking, spitting, biting, and scratching of staff during care and administering medications on 4/6/2023, 4/15/2023,4/16/2023, 4/21/2023, 4/22/2023, and 4/27/2023. Review of Care plan did not indicate that resident was exhibiting behavioral symptoms. Interview on 4/29/2023 at 2:20 p.m. with Registered Nurse (RN) Supervisor revealed that resident is often combative with staff and will refuse care at times. The staff must approach resident with caution and bring another staff member in when providing care. Further interview also revealed that resident is currently on medications for her aggressive behavior but there are still some episodes of refusing care and striking out at staff due to residents' dementia. Interview on 4/29/2023 at 3:30 p.m. with MDS Coordinator confirmed that R#86 did not have a plan of care that addressed her behavioral symptoms. During interview it was revealed that that R#86 was recently admitted to the skilled unit from the secured Dementia unit downstairs on 4/4/2023. Continued interview revealed that residents that have any behavioral concerns are discussed weekly and R#86 was not on the list of residents that was exhibiting behaviors and therefore residents' behaviors where not captured on the care plan and should have been. Continued interview also confirmed that there had been documentation by the Licensed nursing staff that indicated that resident was exhibiting aggressive behaviors towards the staff during care and medication administration starting after admission to the Skilled Unit. Interview on 4/30/2023 at 9:45 a.m. with Director of Nursing (DON) revealed that when a resident in the facility is having behaviors it is documented in the behavioral notes that are reviewed daily. If there are any concerns with residents that are having behaviors, they are discussed weekly with Interdisciplinary Team (IDT) weekly. Further interview also revealed that staff member could not recall rather R#86 was discussed during the IDT meeting that is conducted. Continued interview also revealed that her expectation is that any resident is exhibiting any behaviors that the care plan should be initiated.

Based on record review and staff interview the facility failed to ensure that a Discharge Minimum Data Set (MDS) assessment was transmitted within 31 days of completion to CMS (Center for Medicare and Medicaid Services) of Quality Improvement evaluation system (QIES) Assessment Submission and Processing (ASAP) for one of three discharged residents (R) (R#28). Findings Include: Record review for R#28 revealed that an Admission Assessment reference date (ARD) of 12/7/2022 was the last MDS transmitted for the resident. The resident was discharged from the facility on 12/22/2022, there was no completed and transmitted discharge assessment noted. Review of the Resident Assessment Instrument (RAI) guidelines revealed that discharge was defined as the date the resident left the facility. The RAI guidelines stated that there were two required discharge assessments, discharge- return anticipated, and discharge return not anticipated. Further review of the (RAI) guidelines further reveals that the discharge assessment must be submitted within a maximum of 31 days from the discharge date . Interview on 4/29/2023 at 2:23 p.m. with MDS Coordinator confirmed that she did not transmit the discharge assessment for R#28 who was discharged to the community on 12/22/2022. Continued interview revealed that the discharge MDS for R#28 was incomplete and not transmitted due to the missing signature from a Registered Nurse.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, AHNCP Oxygen Concentrator, Nebulizer Therapy and CPAP/BIPAP Cleaning the facility failed to ensure oxygen equipment was properly stored while not in use and failed to have a current physicians order for oxygen administration for 3 of 10 residents (R) (#33, #22, #23) receiving treatment for respiratory care. Findings include: Review of policy titled AHNCP Oxygen Administration revised 10/25/2022, Explanation and Compliance Guidelines: 2. revealed oxygen is administered under the orders of the attending physician, except in the case of an emergency. 4. Use of Concentrator: a. The nurse shall verify the physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.). L. Keep delivery devices covered in plastic bag when not in use. Review of policy titled Nebulizer Therapy revised 4/14/2022, Policy Explanation and Compliance Guidelines: 16. Disassemble and rinse the nebulizer with sterile or distilled water and allow it to air dry. Care of the Equipment: 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. Review of policy titled CPAP/BiPAP Cleaning revised 1/9/2023, Policy Explanation and Compliance Guidelines: 2. Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. 5. If humidification is required, distilled or sterile water will be used to fill the humidified chamber. Empty the chamber completely after each use and wipe dry. 1. Review of the clinical record for R#33 revealed she was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), Asthma, Heart Failure unspecified with Hypoxia or Hypercapnia Record review of the baseline care plan for R#33 revealed that the resident is on oxygen therapy with an approach to provide Oxygen and nebs (nebulizers) per MD (Medical Director) orders. Record review of the April 2023 Physician orders for R#33 revealed an order dated 4/29/2023 for Oxygen two liters via nasal cannula (N/C) continuous and Levalbuterol Solution 1.25 mg (milligrams) inhale 3 milliliters (MLs) by nebulization twice daily. Record review of R#33's April 2023 Medication Administration Record (MAR) from 4/10/2023 through 4//28/2023 revealed there was not a physician's order for oxygen therapy. Observation on 4/28/2023 at 9:25 a.m., 4/29/2023 at 8:42 a.m., and 12:28 p.m. revealed the resident sitting in the recliner in her room with oxygen intact at 2 liters via nasal cannula. The nebulizer is on the bedside dresser with the mask not properly stored in a bag while not in use. 2. Record review of the clinical record for R#22 revealed the resident has a diagnosis including but not limited pleural effusion and heart failure. Record review of the care plan for R#22 revealed that the resident has a problem related to impaired self-care deficit regarding dressing, grooming, personal hygiene, and extensive assistance with ADL care due to CHF, and pleural effusions with an approach of Nebs treatment as ordered. Record review of the April 2023 Physician orders for R#22 revealed an order dated 4/29/2023 for Albuterol Inhalation solution 2.5 mg/3 ml. Inhale one vial into the lungs via nebulizer every six hours as needed for shortness of breath/wheezing. Order date12/5/2022. Observation on 4/28/2023 at 9:11 a.m., 4/29/2023 at 8:23 a.m., and 12:39 p.m. revealed R#22 sitting in the wheelchair. The nebulizer machine is on the windowsill with the mask not properly stored in a bag while not in use. 3. Review of the clinical record for R#23 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to Sleep Apnea. Record review of the care plan for R#23 revealed that the resident uses a CPAP at night, resident prefers that the CPAP be put on right before she is ready to go to sleep. Goal: Resident will not have any complications with CPAP, resident will express breathing more easily with CPAP. Observation on 4/28/2023 at 8:30 a.m., 4/29/23 at 8:31 a.m., and 12:36 p.m. revealed R#23 lying in bed. The CPAP is on the dresser not in use. The CPAP reservoir has water and condensation while not in use. The reservoir was not emptied and allowed to air dry after use. Interview on 4/29/2023 at 12:41 p.m. with RN Supervisor revealed that respiratory supplies are supposed to be bagged when not in use and she believes the CPAP reservoir should be emptied after each use. She further stated that all staff is responsible for ensuring that this is done. Interview on 4/29/2023 at 12:56 p.m. with Certified Nursing Assistant (CNA) DD revealed that she has worked at the facility for seven months. CNA DD stated that if the respiratory tubing touches the floor, it should be thrown in the trash and replaced with a new one. She further revealed that it is everyone's responsibility to make sure that the tubing is put away in a plastic bag if the residents are not using it. Interview on 4/29/2023 at 1:01 p.m. with Licensed Practical Nurse (LPN) BB revealed that the respiratory tubing should be covered or placed in a plastic bag while not being used. LPN BB stated that the reservoir of the CPAP machines should be emptied after each use and allowed to air dry, and this is everyone's responsibility as they enter resident rooms to render care. She further stated that R#33 has used supplemental oxygen since admission to the facility and she was not aware that the resident did not have a physician's order for the medication. Interview on 4/29/23 at 1:19 p.m. with Director of Nursing (DON) revealed that she is not sure of the facility's policy on the storage of respiratory supplies and would like to review the policy before she makes a statement. She stated that she worked in August 2021, and she has asked the staff to store supplies in a zip-lock bag when not in use. The DON further revealed that any nurse that enters the room is responsible for ensuring that it is done. She stated that her expectation is that the nurses follow the policy as far as the CPAP is concerned, but she is not sure of their policy. The DON made walking rounds with the surveyor and confirmed that nebulizer masks for R#33 and R#22 were not properly stored. The DON also confirmed that R# 33 had been using oxygen without an order prior to 4/29/2023. DON observed and confirmed that the reservoir of the CPAP for R#23 had not been emptied after use. A follow up interview with DON on 2/29/2023 at 1:58 p.m. revealed that all residents receiving oxygen should have a Physician order. The DON confirmed that Infection Control Nurse (ICP) obtained an order for oxygen on R#33 on 4/29/2023, but the resident had used oxygen since admission. The DON further revealed that the nebulizer mask should be cleaned, dried, and stored in a plastic bag when not in use and the CPAP reservoir should be emptied after each use to reduce the risks of respiratory infections.

Based on staff interviews, record review, and review of the facility's policy titled, Medication Orders: Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for antipsychotic medications, for one of six residents (R) (R#7) reviewed for unnecessary medications. Specifically, the facility failed to implement a stop date for two antipsychotic medications ordered as needed (PRN) for R#7, increasing the potential for adverse consequences. Findings include: A review of the facility's undated policy, Medication Orders-Stop Orders, revealed that all as needed (PRN) antipsychotics will automatically be stopped in 14 days. Record review of the electronic medical record (EMR) for R#7 revealed the resident had a diagnosis including but not limited to secondary parkinsonism, Alzheimer's Disease with late onset, psychophysiological insomnia. Record review of the Physician orders for R#7 on April 29, 2023, at 3:32 p.m. revealed a medical doctor's (MD) order for haloperidol 1 milligram (mg) by mouth every six hours as needed for behavior changes/nausea. The order had a start date of 4/7/2023, but the order had no stop date. Record review of the Medication Administration Record (MAR) for April 2023 revealed an MD order for lorazepam 1 mg by mouth/sublingually every four hours as needed for anxiety, restlessness, and shortness of breath. The order had a start date of 4/7/2023 and a discontinued date of 4/28/23. Further review revealed that staff administered R#7 Lorazepam 1 mg by mouth on 4/25/2023. Interview on 4/30/2023 at 9:26 a.m. with Licensed Practical Nurse (LPN) CC revealed that he is aware that PRN psychotropic medications are for 14 days. He further stated that R#7 is on Hospice services and Hospice is responsible for obtaining new orders for the resident's medications. LPN CC further revealed that the orders for the Haldol and lorazepam are current orders. Observation on 4/30/2023 at 9:30 a.m. of the medication care revealed resident had a blister pack containing six tabs of Haldol dispensed from the pharmacy on 4/7/2023. Also, there is a blister pack of lorazepam containing five tabs dispensed on 4/7/2023 and a blister pack containing 30 tabs dispensed on 4/28/2023. Interview on 4/30/2023 at 9:38 a.m. with RN Supervisor AA revealed that PRN psychotropic medications are renewed every two weeks. RN AA stated that the facility has a system with the MD and the pharmacy informs the staff at the facility why the medication needs to be continued or discontinued. Interview on 4/30/2023 at 9:41 a.m. with Director of Nursing (DON) revealed that PRN psychotropic medications she believes are ordered for 14 days. The DON further stated that the pharmacy recommendations are looked at by the Physician to evaluate whether the medications are to be continued or discontinued. She stated that if residents need to stay on the PRN medications, the medication cart nurse discusses it with the physician and should input a new order and document the reasoning for continuing the medication in a progress note. The DON confirmed that there is Haldol, and the original lorazepam order has been onboard for longer than 14 days without sufficient documentation regarding a rationale and duration for continued use of the medication. In addition, DON confirmed, that the new order input on 4/28/2023 for the lorazepam did not have supporting documentation for the new order. The DON stated that the pharmacy sometimes renews the orders in the system automatically when the orders end.

Based on record review and staff interview, the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to one of three residents (R) reviewed (R #49), who was discharged off Medicare Part A services and remained in the skilled nursing facility. The facility census was 31, and the sample size was 21 residents. Findings include: Review of R #49's Notice of Medicare Non-Coverage (NOMNC) form noted that her skilled services ended on 5/20/17. During interview with the Administrator on 8/12/17 at 12:21 p.m., she stated that R #49 remained in the skilled nursing facility after coming off Part A services. During an interview with the Minimum Data Set (MDS) Coordinator on 8/12/17 at 12:39 p.m., she stated that she had never issued a notice other than a NOMNC when a resident's skilled services ended. During an interview with the community's Executive Director on 8/12/17 at 3:34 p.m., he stated that even though the facility did not issue the SNFABN when residents came off skilled services, the residents received the services that they needed.

Based on observation, record review, and staff interview, the facility failed to follow the care plan related to securing an indwelling urinary catheter to the thigh for one resident (R) #18. The sample size was 21 residents. Findings include: Review of the facility's policy Catheter Application-External noted: Apply strap to secure catheter to thigh of resident, leaving enough slack for comfortable movement. Review of R #18's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of the Care Area Assessment Summary (CAAS) for this MDS revealed that Indwelling Catheter triggered as a care area of potential concern, with the decision to care plan. Review of R #18's care plan for [MEDICAL CONDITION] with a start date of 7/11/17 revealed a goal that the resident would be free of complications of an indwelling catheter. Further review of this care plan revealed an approach for care of urinary catheter per facility policy, and that the penis was splitting due to prolonged catheter use. During observations on 8/11/17 at 9:07 a.m. and 10:52 a.m.; 8/12/17 at 8:48 a.m. and 9:54 a.m.; and 8/13/17 at 10:31 a.m. revealed that the tubing of the urinary catheter was brought through R #18's pants leg, and the urine collection bag the tubing was attached to was in a privacy bag underneath the seat of the wheelchair. During an interview with Certified Nursing Assistant (CNA) DD on 8/13/17 at 12:07 p.m., she stated that she made sure that residents with a catheter had a leg strap on. During interview with Licensed Practical Nurse (LPN) BB on 8/13/17 at 3:09 p.m., she stated that all residents who had a catheter should have a butterfly anchor to keep the tubing from pulling on them. During observation on 8/13/17 at 3:15 p.m., R #18's Foley catheter tubing was noted to be directed down and through his pant leg and into the urine collection bag, and neither the catheter or tubing was secured to his leg in any manner. This was verified during interview with CNA AA at this time, who stated that she had already done catheter care earlier that day, and that the resident did not have a catheter strap or anchor on at that time, either. During an interview with the Director of Nursing on 8/13/17 at 3:26 p.m., she stated that her expectation was that if a resident had a Foley catheter, the catheter would be secured to their leg.

Based on observation, record review, and staff interview, the facility failed to reposition one resident (R) #18 at least every two hours, to prevent the potential for skin breakdown. The sample size was 21 residents. Findings include: Review of R #18's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that he had short- and long-term memory problems and moderately impaired decision making; was totally dependent on staff for bed mobility; needed extensive assist for transfers; and did not walk during the assessment period. Review of a cognitive deficit care plan with a start date of 7/17/17 revealed a goal that R #18 would have his ADL (activities of daily living) needs met per staff. Review of his ADL self-care deficit related to dementia care plan with a start date of 7/17/17 revealed approaches to assist with transfers daily, up daily in reclining high back wheelchair, and offer rest periods mid-afternoon and prn (as needed). Review of R #18's potential for skin breakdown care plan with a start date of 7/11/17 revealed a problem of immobility, with need for assistance for transfers and bed mobility. On 8/11/17 at 9:07 a.m., 10:16 a.m., 10:52 a.m., 11:15 a.m., 11:59 a.m., 12:32 p.m., 2:44 p.m., 3:31 p.m., and 5:45 p.m.; on 8/12/17 at 8:00 a.m., 8:48 a.m., 9:54 a.m., and 2:33 p.m.; and on 8/13/17 at 2:14 p.m., R #18 was observed seated in a high-back wheelchair. During continuous observations on 8/13/17 from 7:50 a.m. to 12:05 p.m., R #18 was observed in his high-back wheelchair without ever being repositioned. Specific observations during this time revealed that at 8:31 a.m., Licensed Practical Nurse (LPN) BB wheeled R #18 into his room to give him his eye medication, but afterwards she took him back out to the common area on the unit without repositioning him in the wheelchair. Further specific observation during this time revealed that at 10:31 a.m., Certified Nursing Assistant (CNA) AA took R #18 to his room to wash his face and empty his urinary catheter bag, but she was not observed to stand him up or otherwise offload the pressure off his bottom. On 8/13/17 at 3:15 p.m., R #18 was observed to be in his bed, and observation of the skin on his bottom at this time revealed that it was pink, but no evidence of skin breakdown was seen. During an interview with CNA DD on 8/13/17 at 12:07 p.m., she stated that for residents who could not turn themselves, she would use a mechanical lift to either stand them up or place them in their bed to check them for incontinence, and to get them off their bottom. During an interview with LPN BB on 8/13/17 at 3:09 p.m., she stated that dependent residents should be repositioned every two hours.

Based on observation, record review, and staff interview, the facility failed to secure an indwelling urinary catheter to help avoid excessive tugging on the catheter during care that could cause tissue injury for one resident (R) #18. The sample size was 21 residents. Findings include: Review of R #18's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] noted that the resident had short- and long-term memory problems and moderately- impaired decision making; had an indwelling catheter; was totally dependent on staff for toilet use (which includes managing a catheter); and had a [DIAGNOSES REDACTED]. Review of R #18's care plan for [MEDICAL CONDITION] with a start date of 7/11/17 revealed use of a urinary catheter and potential for infection related to sensory and/or motor impulse impairment and flaccid bladder as evidenced by inability to void without a urinary catheter, and overflow incontinence. Review of the goal for this care plan included that the resident would be free of complications of an indwelling catheter. Review of the approaches for this care plan revealed that an attempt for bladder retraining had failed; care/changing of urinary catheter per facility policy; and that the penis was splitting due to prolonged catheter use but a suprapubic catheter placement had been declined by the family. Review of a Nurse's Note dated 6/23/16 revealed the discussion with family for the resident to have a suprapubic catheter. Review of a physician progress notes [REDACTED]. On 8/11/17 at 9:07 a.m., R #18 was observed actively participating in physical therapy, and the tubing of a urinary catheter was observed to be looped under his wheelchair and into a privacy bag. Further observations on 8/11/17 at 10:52 a.m., 8/12/17 at 8:48 a.m. and 9:54 a.m., and 8/13/17 at 10:31 a.m. revealed that the tubing of the urinary catheter was brought through the resident's pants leg, and the urine collection bag the tubing was attached to was in a privacy bag underneath the seat of the wheelchair. During an interview with Certified Nursing Assistant (CNA) DD on 8/13/17 at 12:07 p.m., she stated that catheter care was done before residents were gotten up for breakfast, and that she made sure a leg strap was on and the catheter tubing was not kinked. During an interview with Licensed Practical Nurse (LPN) BB on 8/13/17 at 3:09 p.m., she stated that all residents who had a catheter should have a butterfly anchor to keep the tubing from pulling on them, unless this anchor caused irritation. During further interview with LPN BB, she stated that R #18 wiggled in his wheelchair, and she didn't know if the anchor would cause the catheter tubing to pull on him more. LPN BB further stated that the resident had a tear in his urinary meatus that he has had for a long time. During observation of R #18's skin on 8/13/17 at 3:15 p.m., the Foley catheter tubing was noted to be directed down and through his pant leg and into the urine collection bag, and neither the catheter or tubing was secured to his leg in any manner. This was verified during interview with CNA AA at this time, who stated that she had already done catheter care earlier that day, and that the resident did not have a catheter strap or anchor on at that time, either. During an interview with the Director of Nursing on 8/13/17 at 3:26 p.m., she stated that her expectation was that if a resident had a Foley catheter, the catheter would be secured to their leg. Review of the facility's policy Catheter Application-External noted: Apply strap to secure catheter to thigh of resident, leaving enough slack for comfortable movement.

Based on observation, record review, and staff interview, the facility failed to ensure that an emergency medication box (e-box) (a box that contained a small quantity of commonly used medications that may be needed when pharmacy services were not immediately available) in one of one medication room refrigerators was kept locked, and that there was an accounting for all of the medications in the box, including the controlled substance, Lorazepam (Ativan). The facility census was 31 residents. Findings include: During observation in the medication room refrigerator in the locked medication room with Licensed Practical Nurse (LPN) BB on 8/12/17 at 5:04 p.m., a clear plastic e-box was observed that had no lock on it. Further observation revealed that inside this e-box were four vertical partitions creating five sections, and two of the sections were empty. Continued observations revealed that there was no packing list, so the original contents of the box were unknown. Observed in one section of the e-box was a package labeled as containing Lorazepam 2 mg (milligrams) per mL (milliliter) injection, with a quantity of two vials packaged. Further observation inside this opened package revealed that there was only one vial of the Lorazepam inside. This was verified during interview with LPN BB at this time, who stated that whoever broke the lock and opened the e-box was responsible for calling the pharmacy to get a code for removing the controlled substance, so that it could be logged in the automated pharmacy system, and was also responsible for putting another lock on the e-box. During further interview with LPN BB at this time, she stated that the night shift was responsible for checking the contents of the medication refrigerator nightly. LPN BB further stated that they did not check the contents of the e-box at the end of each shift when they reconciled the controlled substances in the medication carts with the oncoming shift. During interview with LPN CC at this time, who was called into the medication room by LPN BB, she stated that she did not know anything about the opened e-box. During interview with LPN BB on 8/12/17 at 5:39 p.m., she stated that they located a one-time order for the injectable Ativan to be given to resident (R) #6 for seizures, and were trying to contact the nurse on duty at the time because they did not see any documentation that she actually gave this medication. During further interview, she verified that for three days after the order for the injectable Ativan, that no staff had noticed that the e-box had been opened and not locked back. Review of a Controlled Substance Prescription New/Refill Authorization form for R #6 dated 8/9/17 revealed a physician order [REDACTED]. During an interview with LPN BB on 8/13/17 at 10:50 a.m., she stated that the nurse on duty on 8/9/17 never gave R #6 the Ativan, as the resident's seizure stopped, and that this nurse denied removing the injectable Ativan from the e-box. During an interview with the Director of Nursing on 8/13/17 at 1:42 p.m., she stated that her expectation when staff removed a controlled substance from the e-box was that the Pharmacy would be notified, and that the nurse signed the drug out and put another lock on the e-box. Review of a DEA (Drug Enforcement Administration) website page (https://www.dea.gov/druginfo/ds.shtml) revealed the following: Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are Ativan. Review of an FDA (Food and Drug Administration) website page (https://www.fda.gov/ohrms/dockets/ac/03/briefing/3978B1_07_A-FDA-Tab%206.pdf) revealed the following: Controlled substances may be dispensed by a practitioner by direct administration, by prescription, or by dispensing from office supplies. Records must be maintained by the practitioner of all dispensing of controlled substances from office supplies and certain administrations. Review of the facility's undated Medication Storage in the Facility policy and procedure revealed the following: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. All controlled medications and if deemed appropriate, other medications subject to abuse are stored under double lock in a permanently affixed compartment separate from all other medications. A Controlled Drug Record' is prepared by the dispensing pharmacy for all controlled medications. The following information is completed: 1) Name of resident 2) Prescription number 3) Name, strength, and dosage form of medication 4) Date received 5) Quantity or number of doses received At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately. The Director of Nursing documents irreconcilable discrepancies in a report to the Administrator.

Based on observation and interview, the facility failed to maintain an environment free from scuffs, large nail holes, loose wallpaper, stains, and chipped and flaking paint in four (4) of thirty-four (34) resident rooms and on three (3) of three (3) halls. Findings include: The following observations were made during the initial tour on 2/22/16 at 10:50 a.m.: 1. The wall at the entryway into room 305 was scuffed in an area approximately two feet wide by one foot in length. On entering room 305 there were two large nail holes on the left wall of the room. 2. The wall on the right side at the entryway into room 301 was scuffed in an area approximately 2 feet wide by 1 foot in length. 3. In room 318 the border on the upper wall around the entire room was loose and hanging down off the wall. Two medium nail holes and four larger nail holes were on the wall to the right and left of the window drapes. 4. In room 327, there were five large nail holes on the wall on the left side of the window drapes. When entering the room, there was a white substance splattered on the lower portion of the wall in an area approximately two feet wide and three feet long. 5. In the hallway of room 318, there were four grab bars with chipped and flaking paint. 6. In the hallway of room 343, there were four grab bars with chipped and flaking paint. 7. In the hallway directly across from the television room, there was one long grab bar with chipped and flaking paint. 8. In the television room, on the wall to the left of the piano, there was a scuffed area of missing paint approximately one foot long and two inches wide. During an interview and observation on 2/25/16 at 2:22 p.m., the House Services Supervisor (Maintenance Director) confirmed the previously listed findings. He stated that when staff observed an area that needed to be painted or something that needed to be repaired, they would put in a work order and then maintenance would correct the problem. However, he also stated that there had not been any work orders entered for these areas.