Every finding on record at Castle Manor Nursing & Rehabilitation Center

Based on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends found by surveyors during the recertification survey concerning Advance Directives (a legal document that allows you to make decisions about your future medical care). This failure had the potential for the facility to overlook trends in resident care that might have affected residents' dignity and/or health. Cross Reference: F578 Findings: On 3/27/25 at 2:15 P.M., a concurrent interview with the Administrator (ADM) and the Director of Nursing (DON) and a review of QAPI program was conducted during QAPI task. The ADM stated that the main areas that the QAPI team were monitoring were Falls and Skin Care. During the recertification survey, deficient trends in Advanced Directives were identified by surveyors. The ADM stated that this trend had not been identified by the QAA Committee and/or included in the QAPI plan. On 3/27/25 at 2:30 P.M., an interview with the ADM was conducted. The ADM stated that the expectation was the QAA Committee should have identified the deficient trend with advanced directives that was identified by the surveyors during recertification survey. In addition, the ADM stated the deficient trend should have been included in the QAPI plan. The ADM stated the importance of QAA Committee identifying deficient trends and including them in the QAPI plan was to promote the highest standard of care for their residents. Review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership dated March 2020, indicated .4. The responsibilities of the QAPI committee are to: .b. Identify, evaluate, monitor, and improve facility systems and processes that support delivery of care and services; c. Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process . Review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, indicated .Implementation .The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components include .c. Identifying and prioritizing quality deficiencies . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action, dated March 2020, indicated .1. The QAPI program, overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Design and Scope, dated February 2020, indicated .1.The QAPI Program is designed to address all systems and practices in this facility that affect residents, including clinical care, quality of life, resident choice and safety .4. The QAPI functions prioritizes identified problem areas that are high risk, high volume, and/or problem prone . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Feedback, Data, and Monitoring, dated March 2020, indicated .2. The QAPI process focuses on identifying systems and processes that may be problematic and contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making good faith effort to correct or mitigate these outcomes .

Based on observation, interview, and record review the facility failed to ensure four of twenty-one sampled residents (12,17, 231, 233) had Advanced Directives or documented discussions with Social Services Director (SSD) about Advance Directives. This failure had the potential to prevent residents from making their own decisions in the case of emergency treatment. Cross Reference: F867 Findings: 1. Review of Resident 12's (R12) Admission Record dated 3/26/25 indicated R12 was admitted for diagnoses which included: Acute Respiratory Failure(a life-threatening condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Asthma(a chronic lung disease), Congestive Heart Failure(a chronic condition where the heart muscle is weakened and cannot pump blood effectively), Myocardial Infarction( another term for heart attack)and Pneumonia(an infection of the lungs). Review of R12's physician orders dated 3/26/25 indicated .Resident is (Capable) Of Understanding Rights, And Informed Consent. Review of R12's Minimum Data Set (MDS-standardized assessment tool used in Medicare and Medicaid certified nursing homes) Section C, dated 3/2/25, indicated that R12's Brief Interview for Mental Status (BIMs-a screening tool used to assess memory and orientation in nursing homes) was scored 15 which indicated intact cognition (thinking processes). Review of R12's Care Plan Report dated 3/26/25 indicated, .Resident has the right to .formulate an advance directive .Offer the opportunity for resident .to review/complete POLST (Physician Orders for Life-Sustaining Treatment-It is a medical document that outlines a patient's wishes regarding end-of-life care) form with Physician/Nurse Practitioner as needed . On 3/24/25 at 8:30 A.M., a record review of the electronic medical record (EMR-computer based charting) was conducted for R12. No advanced directive or POLST were in the EMR. On 3/24/25 at 9 A.M., a record review or R12's paper chart was conducted. No POLST or advance directive were found in the paper chart. On 3/25/25 9:02 A.M., a concurrent interview and record review was conducted with Licensed Nurse 21 (LN21). LN21 stated she was not able to find an advanced directive in paper chart or in EMR for R12. LN21 stated that a particular physician .only writes an order for full code for all his residents and does not fill out Advance Directives for his residents . On 3/25/25 at 3 P.M., an interview with R12 was conducted. R12 stated that she had been at the facility over a month and could not remember a conversation with a physician or other staff about an Advanced Directives. R12 stated that she would not like to be put on machines to keep her alive in an emergency or be fed thru a tube. On 3/26/25 at 9:50 A.M., a concurrent interview with Director of Social Services (DSD) and record review of Advanced Directives for the following residents(12, 17, 231, 233)were conducted. The DSD stated that she could not find any documentation for Advance Directive discussions prior to admission for the four sampled residents. The DSD stated the process for Advanced Directives was to meet with the resident a few days prior to being admitted , and the interdisciplinary team discusses plan of care for resident, including Advance Directives. The DSD stated she only would document if the resident wanted more information about Advanced Directives, and not if they refused. The DSD stated that an order for full treatment during a code blue (resident stops breathing and heart has stopped beating) situation is not the same as an Advanced Directive. The DSD stated that the expectation for Advanced Directives was that after discussing with resident, it should be documented in resident's medical record if the resident wanted more information or if resident refused information about Advanced Directives. The DSD stated that the importance of discussing Advanced Directives with resident and documenting that they were discussed was to the protect the resident's right to decide what type of treatment they want during a medical emergency. On 3/27/25 at 9:40 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that expectation was that the SSD would discuss Advance Directives with residents prior to admission and document if they had advance directives, if they wanted more information, or if they refused Advance Directives. The DON stated that the importance of discussing and documenting Advanced Directives with residents was to give residents the ability to express their choices of care in the case of a medical emergency. 47466 2. Resident 231 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus ( abnormal blood sugar) and chronic obstructive pulmonary disease (chronic lung disease causing difficulty in breathing). An interview on 3/26/25 at 9:00 A.M., was conducted with Resident 231. Resident 231 stated she signed a lot of paperwork when she came but she is not sure of the Advanced Directive (a legal document indicating resident preference on end-of-life treatment decisions) and the Physicians Order for Life Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life). Resident 231 stated she does not remember signing either one but stated she wants to be resuscitated in case her heart stops at some point . A record review of Resident 231 's Minimum Data set ( MDS- a federally mandated assessment tool) dated 3/23/25 indicated Resident 231's brief interview for mental status (BIMS) score was 15 which meant Resident 231's cognition(thinking processes) was intact. A review on 3/26/25 indicated Resident 231 did not have an Advanced Directive or a POLST per her medical record but her Physician's order sheet indicated Resident 231 was a full code. An interview on 03/26/25 at 11:01 A.M., was conducted with licensed nurse ( LN) LN 31. LN 31 stated it was important, so they know what to do in case of emergency since the emergency staff usually asked for the POLST and respect what Resident 231's desires were. 3. Resident 233 was admitted on [DATE] to the facility with diagnoses that included history of falls and Hypertension (high blood pressure). An interview on 3/26/25 at 9:00 A.M., was conducted with Resident 233. Resident 233 stated she was not offered an Advanced Directive or a POLST when she was admitted to the facility. Resident 233 stated she wanted to be resuscitated in case something happens. A record review of Resident 233's Minimum Data set (MDS- a federally mandated assessment tool) dated 3/17/25 indicated Resident 233's brief interview for mental status (BIMS) score was 15 which meant Resident 233's cognition(thinking processes) was intact. A review of Resident 233's medical record indicated Resident 233 did not have an Advanced Directive nor a POLST, but her Physicians order sheet (POS) indicated she was a full code. An interview on 3/25/25 at 3:07 P.M., was conducted with licensed nurse (LN 32). LN 32 stated she cannot find the POLST or an Advanced Directive in Resident 233's medical record. LN 32 stated it was important to have the Advance Directive and the POLST in Resident 233's medical record, to respect their choice if something happens. LN 32 stated it was the Social Service Director (SSD) responsibility to make sure the advanced directive and POLST were done. On 3/26/25 at 9:50 A.M., a concurrent interview with Director of Social Services (DSD) and record review of Advanced Directives for the following residents(12, 17, 231, 233)were conducted. The DSD stated that she could not find any documentation for Advance Directive discussions prior to admission for the four sampled residents. The DSD stated the process for Advanced Directives was to meet with the resident a few days prior to being admitted , and the interdisciplinary team discusses plan of care for resident, including Advance Directives. The DSD stated she only would document if the resident wanted more information about Advanced Directives, and not if they refused. The DSD stated that an order for full treatment during a code blue (resident stops breathing and heart has stopped beating) situation is not the same as an Advanced Directive. The DSD stated that the expectation for Advanced Directives was that after discussing with resident, it should be documented in resident's medical record if the resident wanted more information or if resident refused information about Advanced Directives. The DSD stated that the importance of discussing Advanced Directives with resident and documenting that they were discussed was to the protect the resident's right to decide what type of treatment they want during a medical emergency. On 3/27/25 at 9:40 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that expectation was that the SSD would discuss Advance Directives with residents prior to admission and document if they had advance directives, if they wanted more information, or if they refused Advance Directives. The DON stated that the importance of discussing and documenting Advanced Directives with residents was to give residents the ability to express their choices of care in the case of a medical emergency. 49330 4. According to the Admission Record, Resident 17 was admitted on [DATE] with diagnoses that included Type 2 diabetes(condition with abnormal blood sugar) and depression. A review of the Minimum Data Set (MDS-an assessment tool) dated 1/14/25 indicated Resident 17 had a BIMS (tool to assess cognition) score of 13 indicating intact cognition(thinking processes). During a review of Resident 17's medical records, an Advanced Directive was not found in her electronic medical record or physical chart. On 3/26/25 at 9:10 A.M., an interview was conducted with Resident 17. Resident 17 stated she did not have an Advanced Directive, and that she wanted to initiate one. Resident 17 stated staff had not discussed an Advanced Directive with her. Resident 17 stated, .I think I had something like that a long time ago. I have four granddaughters that could help me with that . On 3/26/25 at 9:50 A.M., a concurrent interview with Director of Social Services (DSD) and record review of Advanced Directives for the following residents(12, 17, 231, 233)were conducted. The DSD stated that she could not find any documentation for Advance Directive discussions prior to admission for the four sampled residents. The DSD stated the process for Advanced Directives was to meet with the resident a few days prior to being admitted , and the interdisciplinary team discusses plan of care for resident, including Advance Directives. The DSD stated she only would document if the resident wanted more information about Advanced Directives, and not if they refused. The DSD stated that an order for full treatment during a code blue (resident stops breathing and heart has stopped beating) situation is not the same as an Advanced Directive. The DSD stated that the expectation for Advanced Directives was that after discussing with resident, it should be documented in resident's medical record if the resident wanted more information or if resident refused information about Advanced Directives. The DSD stated that the importance of discussing Advanced Directives with resident and documenting that they were discussed was to the protect the resident's right to decide what type of treatment they want during a medical emergency. On 3/27/25 at 9:48 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was important to discuss Advanced Directives with residents upon admission. The DON stated it was important to honor residents' wishes. Review of the facility policy titled ADVANCED DIRECTIVES dated 2016, indicated that .1. Prior to or upon admission of a resident .the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions .including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives .3. Prior to or upon admission .the Social Services Director or designee will inquire of the resident and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .

Based on observation, interview and record review, the facility failed to ensure confidential information was kept private for one of 4 sampled residents (181) when Licensed Nurse (LN) 11 left Resident 181's bubble wrap medications (unit dose packaging organizing medications into individual doses) unattended. As a result, Resident 181's right to privacy and confidentiality was violated. Findings: Resident 181 was admitted to the facility on [DATE] with diagnoses which included fracture (complete or partial brake in a bone) of superior rim of right pubis (upper edge of right pubic bone) per the facility's Admission Record. On 3/26/25 at 10:32 A.M., an observation of LN 11, during medication administration in room [ROOM NUMBER] A was conducted. LN 11 left three (3) bubble wrap medications of resident 181 over a medication cart, outside room [ROOM NUMBER] A, unattended. The bubble wrap medications contained residents name, medication's name and dosage (Lexapro 5 mg one tab daily- a medication for depression, Losartan 25 mg one tab daily- a medication for blood pressure control, Namenda 10 mg one tab twice a day- a medication for dementia[decline in mental ability] ) . On 3/26/25 at 10:45 A.M., an interview with LN 11 was conducted. LN 11 stated he should have not left resident 181's bubble wrap medications over the cart, exposed to the general public, unattended. LN 11 acknowledged it was a privacy and HIPAA (Health Insurance Portability and Accountability Act,- a federal law that sets national standards for protecting sensitive patient health information) issue. On 3/27/25 at 8:55 A.M., an interview with Charge Nurse (CN) 11 was conducted. CN 11 stated residents bubble wrap medications should have been placed inside the locked medication cart. CN 11 further stated leaving a resident's bubble wrap medications unattended was a privacy and HIPAA issue. On 3/27/25 at 1:10 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 181's bubble wrap medications should have not been left unattended over the cart. The DON stated resident's bubble wrap medications contained resident's name and medication. The DON stated the expectation was for LN 11 to put resident 181's bubble wrap medications inside the locked cart before going in to Resident 181's room. The DON stated it violated Resident 181's privacy and confidentiality. Per the facility's policy titled, Confidentiality of Information and Personal Privacy, revised October 2017, indicated, . Policy Interpretation and Implementation .1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .

Based on observation, interview and record review the facility failed to implement an individualized care plan for one of twenty-two sampled residents (Resident 41) with pruritis (itching) and rashes. This failure had the potential for Resident 41 to experience continued discomfort and skin breakdown. Findings: According to the Admission Record, Resident 41 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included need for assistance with personal care. A review of the Minimum Data Set (MDS-an assessment tool) indicated Resident 41 had a BIMS (a score to measure cognition) of 15, indicating Resident 41 was cognitively(thinking processes) intact. On 03/24/25 at 8:30 A.M., an observation and interview was conducted with Resident 41. Resident 41 stated he was diagnosed with scabies (a rash caused by a tiny mite which causes intense itching) in January 2025. Resident 41 lifted up his shirt and multiple red bumps were observed on his shoulders,chest, and stomach. Resident 41 stated, .These [rashes] overrun me .they're eating me up .they gave me scabies .they're hearty little suckers! Resident 41 stated although he had been treated for scabies, he is still experiencing intense itching. On 3/26/25 at 2:08 P.M., a joint interview and record review was conducted with the Treatment Nurse (TN). The TN stated he was aware that Resident 41 had been treated for scabies, but did not know that Resident 41 still had an itchy rash. The TN stated there was no written care plan for Resident 41 that addressed the rash. The TN stated it was important to have a care plan to see what can be done to treat Resident 41, and to reassess to see if the plan was effective. The TN stated, .We also need to update it as needed. If the original plan isn't working, if he is still itching, we should have updated it to help the resident . On 3/27/25 at 9:48 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 41 should have had a care plan to address his itchy rashes, even after he was already treated for scabies. The DON stated, We should have started a care plan when [the scabies] was first diagnosed and updated [the care plan] as it progressed to see if the interventions were working or not working . A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure injuries (skin breakdown caused by pressure) for one of twenty-two sampled residents (Resident 1) by failing to turn/reposition resident and failing to provide pericare (cleaning the private area) for an extended period of time. This failure had the potential to result in the decline of Resident 1's skin integrity. Findings: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] according to the Admission Record with diagnoses which included multiple sclerosis (a condition which affects the nerves and causes weakness and numbness) and dementia (a condition which causes memory impairment and affects daily functioning). A review of Resident 1's Braden Scale For Predicting Pressure Sore Risk dated 1/9/25 indicated a Score of 11, which indicated Resident 1 was at High Risk for developing pressure injuries. A review of Resident 1's MDS (Minimum Data Set-an assessment tool) dated 1/9/25 indicated Resident 1 was dependent on staff to perform all Activities of Daily Living (ADL's-daily care such as bathing, dressing, toileting etc). On 3/24/25 the following observations were made: -8:20 A.M. Resident was positioned supine (lying facing upward) on her back. -10:15 A.M. Resident was positioned supine on her back. -11:22 A.M. Resident was positioned supine on her back. -1:33 P.M. Resident was on her back with the head of bed at 90 degrees. -2:45 P.M. Resident was on her back with the head of bed at 90 degrees. On 3/25/25 the following observations were made: -8:20 A.M. Resident was sitting in a wheelchair -9:24 A.M. Resident was sitting in a wheelchair. -2:08 P.M. Resident was sitting in a wheelchair. On 3/25/25 at 2:08 P.M., an interview was conducted with Licensed Nurse 12 (LN 12). LN 12 stated, .I would say [Resident 1] is at high risk for [skin] breakdown. She's incontinent, she's very dependent on ADL's, she has limited range of motion, she doesn't move much in bed, or in the chair . LN 12 stated her expectation was for the resident to be turned as frequently as 2 hours. On 3/25/25 at 2:11 P.M., an interview was conducted with Certified Nursing Assistant 11 (CNA 11). She stated resident was up in her wheelchair when she started her shift at 7:30 A.M. CNA 11 stated Resident 1 had not been repositioned in the wheelchair. CNA 11 stated she had not provided pericare for Resident 1 yet. CNA 11 stated, .We should have checked her every 2 hours to see if she is wet .she is would get a bedsore if she stays up for a long time . On 3/27/25 at 9:08 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated, The resident should be repositioned, even if she's in the wheelchair. We are trying to prevent the reopening of wounds. We also want to prevent any new wounds . A review of the facility's policy titled Repositioning revised May 2013 indicated, Interventions .3. Residents who are in bed should be on at least an every-two-hour (q2 hour) repositioning schedule .5. Residents who are in a chair should be on an every-one-hour (q1 hour) repositioning schedule .

Based on observation, interview and record review, the facility failed to follow its policy on smoking procedures for one of twenty-two residents (Resident 41) reviewed for smoking. As a result, there was potential to jeopardize the health and safety of Resident 41. Findings: According to the Admission Record, Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included nicotine(addictive substance found in tobacco) dependence and need for assistance with personal care. A review of the Minimum Data Set (MDS-an assessment tool) indicated Resident 41 had a BIMS (a score to measure cognition) of 15, indicating Resident 41 was cognitively (thinking processes) intact. On 3/24/25 at 8:30 A.M., an interview was conducted with Resident 41. Resident 41 stated he was upset because he wanted to go outside to smoke a cigarette, but staff took his cigarettes away from him yesterday. Resident 41 stated he used to go outside to smoke cigarettes whenever he wanted to. Resident 41 stated, I smoke, all of a sudden yesterday, I need to have a baby sitter go with me in the patio .prior to yesterday I had it [cigarettes and lighter] with me .there's never been a problem with me smoking . On 3/24/25 at 2 P.M., Resident 41 was observed in the patio, smoking a cigarette. There was a staff member present and was supervising Resident 41 while he was smoking. Resident 41 stated he agreed to go to a supervised smoke break, .I gave in a little .they won and I won . Resident 41 stated he was upset because, .I always stored my cigarettes in my room .They never tried to stop me [from going outside to smoke unassisted] until yesterday . On 3/24/25 at 2:04 P.M. an interview was conducted with the Activities Director (AD). The AD stated the facility policy was that all smokers needed to be supervised by staff during scheduled smoke breaks, and that cigarettes and lighters would be kept by staff. The AD stated Resident 41 had a history of going outside by himself, without staff supervision, to smoke cigarettes. The AD stated, .[Resident 41] signed the smoking agreement, but he's not following the rules .we had IDT meetings [Interdisciplinary-a group of professionals with different areas of expertise] . The AD stated the IDT notes would be found in Resident 41's electronic medical record. On 3/25/25 at 2:43 P.M. an interview was conducted with Licensed Nurse (LN) 13. LN 13 stated, Resident 41 is not safe to smoke outside by himself. He could get burned with ashes or start a fire. He could hurt himself or other residents . LN 13 acknowledged Resident 41 kept cigarettes and a lighter in his possession, and was noncompliant with the facility rules for smoking. On 3/26/25 at 2:21 P.M. an interview was conducted with the Social Services Assistant (SSA). The SSA stated, an incident occurred several weeks ago in Resident 41's room. The SSA stated, .I went [into Resident 41's bedroom] with the nurse, I remember seeing him with a cigarette lit in his mouth . The SSA stated she confiscated Resident 41's cigarettes, but she does not know how he got them back. On 3/26/25 at 3:47 P.M., an interview was conducted with Licensed Nurse (LN)14. LN 14 stated she observed Resident 41 smoking a lit cigarette in his room. LN 14 stated, I called the Social Services Assistant .she spoke to [Resident 41] and took his cigarettes away . LN 14 stated, .I forgot to remove the cigarettes from his room .We all need to be on the same page on what is the action for him .we should have done an IDT. It wasn't safe. He can hurt himself and others . A review of Resident 41's Progress Notes dated 12/26/24 indicated, SSA was told that resident is smoking in his room. SSA and charge nurse went to patient [sic] room, and he is till [sic] smoking his cigarette. SSA asked for his cigarette, and he handed it over and he stated that he thought that he is outside smoking. SSA told him that he cannot smoke at all inside the facility only at the designated areas and he is verbalizing of understanding. SSA took his cigarette and his lighter and made him aware that if he needs to smoke to ask the charge nurse so that he can be accompanied at the smoking area, and he is verbalizing of understanding . A review of Resident 41's Electronic Health Record (EHR) indicated Resident 41 had a Smoking Risk assessment completed on 1/15/25. There was no record that a Smoking Risk Assessment was completed when Resident 41 was admitted on [DATE], and when readmitted on [DATE]. A review of Resident 41's EHR indicated there was no IDT note done when Resident 41 was found smoking a cigarette inside the facility. On 3/27/25 at 9:48 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, .We should have addressed the smoking, make sure we documented what we did about it. The IDT should have been notified .to keep [Resident 41] and other patients safe . A review of the facility's undated policy titled Smoking Policy indicated, .Smoking is only permitted in designated resident smoking areas .Smoking is not allowed inside the facility under any circumstances .Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes .d. ability to smoke safely with or without supervision .13. Resident smoking material(s) will be secured and stored at the nursing station .

Based on observation, interview, and record review the facility failed to ensure medications were administered appropriately for two of twenty-one sampled residents (41, 133). This failure had the potential for medication error resulting in decline in residents' health. Findings: 1. Review of Admission Record for Resident 133 (R133), dated 2/26/25 indicated that R133 was admitted with diagnoses that included: End Stage Renal Disease (a condition where the kidneys have permanently lost their ability to function adequately), Dysphagia (difficulty swallowing), Pneumonia (an infection of the lungs), and Congestive Heart Failure (a condition where the heart is unable to pump blood effectively). Review of Order Summary Report, dated 3/26/25, indicated Renal diet. Pureed texture. Thin Liquids consistency .per family request .Nepro with meals for Supplement .May crush medications unless contraindicated . On 3/24/25 at 9:36 A.M., an observation of R133's room was conducted during initial tour. R133 was asleep. A cup of Renal supplement (supplemental shake) with a straw and a used medication cup with residual medicine mixed with supplement observed on bedside table. On 3/24/25 at 9:47 A.M., a concurrent observation of R133's bedside table and interview with Licensed Nurse 22 (LN22) was conducted. LN22 stated that she was giving the resident crushed medication and supplement mixed in the medication cup, and that she had left some of the medication in the cup. LN22 stated the expectation for administering medications was to give the medication and dispose of the medication cup that it was mixed in after. LN22 stated that the importance of giving as much of the medication in the cup was to make sure R133 received the full dose of medication ordered. In addition, LN 22 stated disposing the medication cup after it was used prevented other residents from taking any residual medication in the cup. On 3/24/25 at 9:51 A.M., a concurrent observation of R133's bedside table and interview with Licensed Nurse 21 (LN21) was conducted; LN21 was the charge nurse on that unit. LN21 stated it appeared there was medication and supplement mixed in the medication cup, and that she had left some of the medication in the cup. LN21 stated the expectation for administering medications was to give the medication and dispose of the medication cup that it was mixed in after. LN21 stated that the importance of giving as much of the medication in the cup, and then disposing the cup after is to prevent other residents from taking the medication. On 3/27/25 at 9:40 A.M., a concurrent observation of a photo of R133's bedside table with medication cup and interview with the Director of Nursing (DON) was conducted. The DON stated the expectation for administering medication was that if crushing the medicine, the resident should receive as much of the medicine as possible from the container, and the LN should dispose of the container after medication administered. The DON stated that the importance of LN's giving the resident all the medication crushed in the cup was that the resident needed to receive the ordered dose of the medication. In addition, the DON stated the importance of discarding used medication cups was to prevent other residents from accidentally ingesting medication in error. 49330 According to the Admission Record, Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes (a condition that affects how the body uses sugars) with diabetic neuropathy (a disease of the nerves causing numbness or weakness) and need for assistance with personal care. A review of the Minimum Data Set (MDS-an assessment tool) indicated Resident 41 had a BIMS (a score to measure cognition) of 15, indicating Resident 41 was cognitively intact. On 3/26/25 at 2:07 P.M., during an interview with Resident 41, a plastic medicine cup with a yellow capsule was observed on Resident 41's bedside table. Resident 41 stated, .The nurse brought it here and put it on my table. I just forgot to take it earlier . On 3/26/25 at 2:10 P.M. an interview was conducted with Licensed Nurse (LN) 5. LN 5 stated she brought the capsule in at 1 P.M. but she turned her back and did not see Resident 41 take the medication. LN 5 stated, .I should have made sure that he swallowed it, to make sure that he took it .to make sure he got the proper dose of the medication. Also, [the bedside table] is really close to his door so we don't want anyone else to take it .it's not safe to leave a medication there . LN 5 stated since the medication was due at 1 P.M., it was now being given late. On 3/27/25 at 9:48 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated, .Medications should never be left with the resident because you can't ensure residents took it . The DON stated it was important that the nurses make sure the medication is taken before leaving the resident because there was a chance another resident could come in and take it. A review of the facility's policy titled Administering Medications, dated 2001, indicated, .Medications are administered in a safe and timely manner, and as prescribed .

Based on observation, interview, and record review the facility failed to demonstrate infection control practices when: 1. A staff member was observed leaving an isolation room wearing full Personal Protective Equipment (PPE-gown, gloves, mask, face shield). and 2. A staff did not perform hand hygiene for one of 4 sampled residents (34) during medication administration. As a result, residents were at risk for exposure to unwanted pathogens (microorganisms that cause disease). Findings: 1. On 3/26/25 at 9:20 A.M., an observation was conducted outside Resident 401's room. There was a contact/droplet sign posted outside Resident 401's room. There was a plastic PPE cart outside the room with tub of sanitizer on top. Physical Therapist (PT) 1 was observed opening the door wearing full PPE, and picked up the tub of sanitizer with gloved hands. PT 1 took the tub of sanitizer inside the room and closed the door. PT 1 was observed opening the door and placing the container back on top of the PPE cart. On 3/26/25 at 9:23 A.M., PT 1 was observed exiting the room holding a walker and a face shield. On 3/26/25 at 2:25 P.M. an interview was conducted with PT 1. PT stated he was wearing full PPE inside the room because Resident 401 had Covid-19. PT 1 stated, I shouldn't have left the room wearing PPE, especially in a Covid room. On 3/27/25 at 9:48 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, .Proper precautions should've been taken. [Staff] needs to make sure they're taking PPE off inside the room to avoid spreading Covid .since we're currently in an outbreak . A review of the facility's policy titled Personal Protective Equipment revised 10/2018 indicated, .PPE required for transmission-based precautions is maintained .inside the resident's room, as needed . 45063 2. Resident 34 was readmitted to the facility on [DATE] with diagnoses which included Acute Osteomyelitis (a serious infection of the bone that develops rapidly) per the facility's Admission Record. On 3/26/25 at 8:14 A.M., an observation of Licensed Nurse (LN) 11, during medication administration in room [ROOM NUMBER] B was conducted. LN 11 had a pair of gloves on during the following activities; First LN 11 took Resident 34's blood pressure, then went on to touch the side table and radio. LN 11 then proceed to check on Resident 34's G-tube (Gastrostomy tube- a thin flexible tube inserted through the abdominal wall and into the stomach) patency. LN 11 further proceed to touch the privacy curtains two times, then went to touch the G-tube again while trying to de-clog the tube. LN 11 used the same gloves and did not perform hand hygiene in between activities. On 3/26/25 at 11:05 A.M., an interview with LN 11 was conducted. LN 11 stated he should have performed hand hygiene and changed his gloves after touching Resident 34's personal belongings and privacy curtains and before touching Resident 34's G- tube. LN 11 stated hand hygiene was important to prevent cross contamination. On 3/27/25 at 8:52 A.M., an interview with Charge Nurse (CN) 11 was conducted. CN 11 stated LN 11 should have performed hand hygiene and put on a new pair of gloves while providing care and in between touching Resident 34's belongings and privacy curtain to prevent cross-contamination and the spread of infection. On 3/27/25 at 9:12 A.M., an interview with Infection Preventionist (IP) was conducted. The IP acknowledged LN 11 should have performed hand hygiene and put on a new pair of gloves after touching Resident 34's environment but did not. The IP further stated this should have been done to prevent cross-contamination. On 3/27/25 at 1:10 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for LN 11 to perform hand hygiene and changed his gloves in between touching Resident 34's environment and providing care to prevent cross-contamination. Per the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, indicated, Policy .Indications for Hand Hygiene .1. d. after touching a resident; e. after touching the residents' s environment .

Based on interview and record review, the facility failed to ensure licensed nurse (LN) 1 performed a complete assessment (a process that evaluates a resident's health by gathering and analyzing information) and notified the physician for one of three residents (Resident 1), when Resident 1 experienced a sudden decrease in oxygen level and blood pressure. As a result, Resident 1 was found with cold, pale skin and without pulse approximately four hours after the decreased blood pressure (Measurement of the force exerted by blood against the walls of the arteries as the heart pumps) and oxygen level was first identified. An hour later, Resident 1 was pronounced dead. Findings: On [DATE] at 1:15 P.M., an unannounced onsite visit at the facility was conducted for a complaint investigation. A review of Resident 1's medical record was conducted on [DATE]. Per the Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (infection in the system of organs that makes urine). A review of Resident 1 ' s Nursing Progress Notes, documented by LN 1, indicated the following events: On [DATE] at 11:30 P.M., Resident 1 requested for water and rested. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 12:30 A.M., Resident 1 was seen resting with eyes closed. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 2:09 A.M., Resident 1's vital sign (measurements to show how well the body functions) were BP (blood pressure) ,d+[DATE] mmHg (millimeters of mercury), HR (heart rate) 71 bpm (beats per minute), and the O2 sat (oxygen saturation - measure of how well the body is oxygenating the blood with normal range of ,d+[DATE]%) was 87 %. LN 1 applied four liters of oxygen via nasal (nose) cannula (thin plastic tube) to Resident 1. LN 1 gave Resident 1 water, and Resident 1 drank 240 milliliters. LN 1 left the pulse oximeter (an electronic device measuring oxygen saturation) on Resident 1's finger. On [DATE] at 2:33 A.M., Resident 1's vital sign was assessed. BP was ,d+[DATE] mmHg, HR 67 bpm, and O2 sat of 90%. On [DATE] at 2:37 A.M., Resident 1's BP was rechecked and was ,d+[DATE] mmHg. On [DATE] at 3 A.M., a Certified Nursing Assistant (CNA) checked Resident 1, and the O2 sat was 90%. On [DATE] at 3:30 A.M., LN 1 checked on Resident 1 and offered fluids, but Resident 1 refused. On [DATE] at 4 A.M., a CNA notified LN 1 that Resident 1's O2 sat was 95%. Resident 1 had no discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 4:30 A.M., LN 1 checked Resident 1. Resident 1 was resting. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 4:45 A.M., a CNA checked on Resident 1, and there was no labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 5 A.M., LN 1 checked Resident 1, and the O2 sat was 93% with oxygen at four lpm of oxygen. On [DATE] at 5:15 A.M., a CNA checked on Resident 1, and there was no labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 5:30 A.M., LN 1 checked Resident 1, and the pulse oximeter read that O2 saturation was stable . No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 6:05 A.M., a CNA checked Resident 1. Resident 1 was resting. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On [DATE] at 6:15 A.M., LN 1 checked Resident 1. Resident 1's skin was pale, and the body was cold. LN 1 instructed CNA to call 911 (emergency responder). Resident 1 had no pulse, and CPR (Cardiopulmonary Resuscitation- life-saving procedure) was performed. The emergency responder came to the facility and provided CPR. Resident 1 was pronounced dead at 7 A.M. A review of Resident 1's Weights and Vitals Summary log was conducted. Resident 1 had the following BP readings and HR during the night shift: [DATE] at 12:21 A.M., ,d+[DATE] and 88 bpm [DATE] at 2:47 A.M., ,d+[DATE] and 81 bpm [DATE] at 5:35 A.M., ,d+[DATE] and 63 bpm [DATE] at 1:27 A.M., ,d+[DATE] and 63 bpm [DATE] at 4:01 A.M., ,d+[DATE] and 82 bpm [DATE] at 2:09 A.M., ,d+[DATE] and 71 bpm [DATE] at 2:33 A.M., ,d+[DATE] and 67 bpm [DATE] at 2:37 A.M., ,d+[DATE] On [DATE] at 2:29 P.M., LN 1 was interviewed. LN 1 stated Resident 1 had low BP readings ranging from ,d+[DATE] mmHg to ,d+[DATE] mmHg on [DATE]. LN 1 stated he offered Resident 1 fluids, elevated the resident ' s head of the bed, provided oxygen, and elevated Resident 1's feet. LN 1 stated Resident 1's vital sign on [DATE] were not within Resident 1's normal range. LN 1 stated Resident 1 experienced a change of condition. LN 1 stated he should have immediately notified Resident 1 ' s physician regarding the resident ' s change of condition. On [DATE] at 4 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated LN 1 should have assessed Resident 1 thoroughly when the resident ' s oxygen level and blood pressure suddenly went down. The DON also stated that LN 1 should have immediately notified Resident 1 ' s physician when the resident experienced a change of condition. On [DATE] at 1:45 P.M., an interview was conducted with Resident 1 ' s physician (PH). The PH stated he expected the nurses to inform him when a resident experience a change of condition. The PH stated the license nurse should have notified him when Resident 1 experienced a change of condition. A review of the facility ' s policy and procedure, titled Change in a Resident's Condition or Status, dated ,d+[DATE], was conducted. The policy indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .

Based on interview and record review, the facility failed to ensure license nurse (LN) 3 transcribed a medication accurately for one of three residents (Resident 1) reviewed for pharmacy services, when Resident 1 ' s Carvedilol (a medication used to treat heart failure and high blood pressure) 3.125 milligrams (mg) order was incorrectly documented as Carvedilol 25 mg. As a result, Resident 1 was given a higher dose of Carvedilol than what was ordered by the physician which may cause for the resident ' s blood pressure to decrease. Finding: Resident 1 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, per the Admission Record. A review of Resident 1's medical record was conducted. Per the Hospital Discharge Order List, dated 12/27/24, the hospital physician ordered Carvedilol 3.125 milligrams twice daily. Per the facility's Order Summary, dated 12/27/24, Resident 1 had a physician order for Carvedilol 25 milligrams twice daily. Further review of Resident 1's medical record was conducted. There was no evidence of medication reconciliation of the Hospital discharge order and facility admission order for the Carvedilol medication. Licensed Nurse (LN) 3 was not available for an interview. On 2/4/25 at 4 P.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated LN 3 should ensure the orders from the hospital matched the facility ' s admission order. The DON stated that LN 3 did not transcribe the Carvedilol order correctly. On 2/29/25 at 2:52 P.M., an interview was conducted with the Pharmacy Consultant (PC). The PC stated LN 3 transcribed the order incorrectly, it was supposed to be Carvedilol 3.125 mg, and LN 3 wrote Carvedilol 25 mg. The computer system did not alert the nursing staff because the Carvedilol can be given up to 50 mg daily. The PC stated the pharmacy sent the dosage of what was ordered by the physician, which was Carvedilol 25 mg. Per the facility's policy and procedure, dated 7/17, titled Reconciliation of Medications on Admission, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosage upon admission or readmission to the facility .

Based on observation, interview, and record review, the facility failed to consistently provide wound care as ordered by the physician for four of six residents, (Residents 2, 13, 26, 226), reviewed for skin integrity. As a results, residents were at risk for wound deterioration and delayed healing. Findings: 1. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke) and need for assistance with personal care, per the facility's Admission Record. On 2/27/23 at 9:56 A.M., an observation was conducted outside Resident 2's room. Outside of the room, signage indicated contact precautions were required, and a cart containing PPE (personal protective equipment, medical supplies to maintain infection control) was present. The resident was sitting in a wheelchair watching television. On 2/28/23, Resident 2's clinical record was reviewed: The MDS (a clinical assessment tool), dated 1/23/23, listed a cognitive score of nine, indicating moderately impaired cognition. According to the physicians orders, dated 1/23/23, .bilateral lower extremities .clean with normal saline (NS), pat dry, apply xeroform (medicated dressing) and cover with dry dressing and wrap with kerlix every day .Dry skin on bilateral foot: apply skin protectant ointment every day .open wound on the sacro-coccygeal (bottom of spine) cleanse with NS, pat dry, apply santyl (medication) ointment and cover with foam dressing . According to the skin integrity care plan, dated 1/18/23, Resident 2 had an actual impairment to the skin with interventions of medications and treatments as ordered by the physician. According to the February 2023 TAR (a document for recording wound treatments), Resident 2 had no wound treatments or xeroform applied to the lower extremities on 2/5/23 and 2/7/23. No documentation of wound treatment or protective ointment for the feet was identified for 2/5/23. No wound treatment or santyl ointment for the open sacro-coccygeal wound was found for 2/5/23, 2/7/23, and 2/16/23. 2. Resident 13 was admitted to the facility on [DATE], with diagnoses which included pressure-induced deep tissue damage of left heel and dementia (memory loss), per the facility's Admission Record. On 2/28/23 at 10:24 A.M., Resident 13 was observed lying in bed with a dressing on his left foot. The heel of the foot was resting directly on the mattress and not elevated on a pillow. On 2/28/23 Resident 13's clinical record was reviewed: The MDS, dated [DATE], listed a cognitive score of eight, indicating moderately impaired cognition. According to the physicians orders, dated 2/4/23, .Left lower leg with multiple open wounds, site 1, site 2, site 3, and site 4: cleanse with NS, pat dry and apply xeroform (medicated dressing) then cover with dry dressing and wrap with kerlix every day .Left heel blister-cleanse with NS, pat dry and cover with 4X4 gauge soaked with betadine solution everyday .Bilateral LE (lower extremities) with dry skin: Apply skin protector ointment every day . According to the skin integrity care plan, dated 2/4/23, Resident 13 had actual impairment to skin integrity, with interventions such as a wound consult and treatment. The February 2023 TAR was reviewed. Resident 13 had no wound treatment or xeroform applied to site 1, site 2, site 3, and site 4 on 2/16/23 and 2/26/23. The left heel blister had no wound treatment or betadine gauze and the bilateral LE had no wound treatment or ointment applied on 2/26/23. 3. Resident 26 was admitted to the facility on [DATE], with diagnoses which included adult failure to thrive and need for personal assistance with personal care, per the facility's Admission Record. On 2/27/23 at 8:03 A.M., Resident 26 was observed asleep lying in the bed and covered with a heavy blanket. On 2/28/23, Resident 26's clinical record was reviewed. The MDS, dated [DATE], listed no cognitive assessment, due to being non-verbal. According to the physician's order, dated 2/13/23, .arterial wound (a lack of arterial blood flow to the tissue), on the left metatarsal (toe), cleanse with NS and pat dry, paint site with betadine daily and leave open every day .arterial wound on left great toe-paint site with betadine daily and leave open every day .arterial wound on left heal; cleanse with NS, pat dry, apply iodosorb gel (medication) ointment on the wound bed then paint peri-wound (around wound) with betadine and cover with dressing then wrap with kerlix every day . According to the wound care plan, dated 2/12/23, Resident 26 had interventions such as administer medications as ordered by the physician, monitor/document wound listed. The February 2023 TAR was reviewed. Resident 26 had no wound care or betadine applied to the metatarsal or the left great toe on 2/10/23. The left heel had no wound care or medicated dressing applied on 2/10/23. On 3/1/23 at 8:58 A.M., an interview was conducted with the LN 22. LN 22 stated he worked Monday through Friday, so on weekends the medication nurses were expected to complete the wound treatments. LN 22 stated wound treatments should have been performed regularly according to the physician's order to promote wound healing. LN 22 stated if wound care was not performed as ordered, the wounds could worsen or become infected. On 3/1/23 at 9:45 A.M., an interview was conducted with LN 21. LN 21 stated if wound treatments were missed or not completed, the wounds could worsen and there was a possibility of an infection. LN 21 stated the physician's order should always be followed. On 3/1/23 at 9:51 A.M., an interview was conducted with the DON. The DON stated wound treatments should have always been done according to the physician's order. The DON stated if a wound treatment was missed, there was a potential for harm with the wound worsening or infection could occur. The DON stated she expected all wound treatments to be completed during the week and on the weekends. According to the facility's job description,dated 2003 and titled Treatment Nurse, Nursing Services-MED-PASS, The primary purpose of your job description is to provide skin care to residents under the medical direction and supervision of the residents' attending physician, the Director of Nursing Services or the Medical director of the facility, with an emphasis on treatment and therapy of skin disorders . According to the facility's policy, titled Wound Care, dated October 2010, .Documentation: The following information should be recorded in the resident's medical record: .2. The date and time the wound care was given; .7. If the resident refused the treatment and the reason(s) why . 40610 4. Resident 226 was admitted to the facility 2/11/23, with diagnoses which included wound debridement (the removal of dead or infected skin tissue to help a wound heal) and needed surgical aftercare, per the facility's Admission Record. On 2/28/23, a record review was conducted. Resident 226's history and physical, dated 2/14/23, indicated Resident 226 was able to make decisions. On 2/28/23 at 9:03 A.M., an observation was conducted outside Resident 226's room. The resident's door had a posted sign indicating contact precautions were required. The sign indicated PPE was required to enter the resident's room. Resident 226 was sitting in a wheelchair wheeling herself from the bathroom to the bed. A wound vacuum (vac, a device that helps heal the wound from the inside using a small pump which removed fluid and germs from the wound) was attached in the right side of Resident 226's wheelchair. On 2/28/23, Resident 226's clinical record was reviewed. Per Resident 226's physician's orders dated 2/11/23, indicated the wound vac and dressings were to be changed every Monday, Wednesday, and Friday. Per Resident 226's skin integrity care plan, dated 2/12/23, the wound vac was to be connected upon admission and treated as ordered by the physician. Per Resident 226's February 2023 TAR (a document for recording treatments), Resident 226 had no wound vac dressing changed on 2/13/23 and 2/15/23. On 3/1/23 at 12:02 P.M., a concurrent interview and record review of Resident 226's TAR was conducted with LN 22. LN 22 stated he did not know why there were no signature on the TAR for 2/13/23 and 2/15/23. On 3/1/23 at 3:04 P.M., a concurrent interview and review of Resident 226's clinical record was conducted with the ADON. The ADON stated there should have not been blank dates in Resident 226's TAR. The ADON stated Resident 226's wound vac dressing should have been changed on 2/13/23 and 2/15/23. The ADON stated the first wound vac and dressings changed was to be done on Monday (2/13/23). On 3/1/23 at 3:30 P.M., a concurrent interview and review of Resident 226's clinical record was conducted with LN 23. LN 23 stated she wrote the late entry for 2/13/23, indicating Resident 226's wound vac dressing had been changed on 2/11/23. LN 23 stated Resident 226's treatment on 2/13/23 (Monday) was missed and the physician should have been informed. On 3/1/23 at 3:48 P.M., an interview was conducted with LN 24. LN 24 stated she changed Resident 226's wound vac dressings on 2/15/23 but she forgot to sign the TAR. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the LNs were supposed to give treatment per the physician's orders and if they did the treatment, the LNs should have documented in the TAR. The DON stated wound dressing changed and treatment was important to promote wound healing. According to the facility's job description,dated 2003 and titled Treatment Nurse, Nursing Services-MED-PASS, The primary purpose of your job description is to provide skin care to residents under the medical direction and supervision of the residents' attending physician, the Director of Nursing Services or the Medical director of the facility, with an emphasis on treatment and therapy of skin disorders . According to the facility's policy, titled Wound Care, dated October 2010, .Documentation: The following information should be recorded in the resident's medical record: .2. The date and time the wound care was given; .7. If the resident refused the treatment and the reason(s) why .

Based on observation, interview, and record review, the facility failed to assess for a decline in range of motion (ROM, distance and direction a joint can be extended) for one of one resident (Resident 42), reviewed for positioning and limited ROM. As a result, Resident 42 had the potential for contractures (shortening of muscles and tendons, often leading to permanent deformity and stiffening of joints) and a decline in movement. Findings: Resident 42 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), with right hemiplegia (paralysis on one side of the body), per the facility's Admission Record. On 2/28/23 at 8:32 A.M., an observation was conducted of Resident 42 as he laid in bed. Resident 42 appeared asleep with his eyes closed. The right arm was resting on top of the blanket with the right hand in a fist and the wrist was turned inward. On 2/28/23, Resident 42's clinical record was reviewed. The physician's order had no current or past order for physical therapy (PT) or restorative nursing assistance (RNA-a certified nursing assistant with specialized training to provide individualized range of motion exercises). Per the MDS, (a clinical assessment tool), dated 1/19/23, Resident 42 was unable to speak. The functional status indicated two-staff were required for assistance with bed mobility and transfers, with impairment to both arms. Resident 42's care plans were reviewed. There was no documented evidence a ROM or RNA plan had been developed for maintenance or improved movement. There was no documented evidence a PT assessment had been conducted. According to the facility's Nursing Weekly Observations, dated 2/6/23, 2/14/23, and 2/21/23, Section H: Musculoskeletal Assessment, Resident 42 was documented as, .dependent with all care and mobility; non ambulatory and did not have any splints, braces, or prostheses . On 2/28/23 at 1:10 P.M., an interview was conducted with the DSD. The DSD stated she oversaw the RNA program and scheduling of the RNAs. The DSD stated the CNAs were to report any concerns regarding residents to the charge nurses. The charge nurses would assess and obtain a PT evaluation as needed. On 2/28/23 at 1:13 P.M., an interview and record review was conducted with the Director of Rehabilitation (DOR). The DOR stated if the CNAs or LNs suspected a contracture or noticed a decline in range of motion, they should notify the rehabilitation department or call the physician to obtain an order for assessment and services. The DOR reviewed Resident 42's rehabilitation history and stated the resident had never been assessed by physical therapy since his admission in 2019. On 2/28/23 at 1:27 P.M., an interview was conducted with LN 21. LN 21 stated CNAs were to report any decline observed while providing care. LN 21 stated the LNs should be assessing the residents ROM and needs, during their weekly nursing evaluations, which consisted of head-to-toe assessments. LN 21 stated if a resident had a decline in ROM or beginning contractures, they should have been in the RNA program for improvement or maintenance. On 2/28/23 at 1:32 P.M., an observation was conducted of LN 21 in Resident 42's room. LN 21 assessed Resident 42's right hand. LN 21 opened the resident's fingers, and the resident moaned. LN 21 was unable to fully extend the fingers without causing increased moaning from Resident 42. LN 21 stated a PT or RNA services should have been implemented. On 3/1/23 at 9:51 A.M., an interview was conducted with the DON. The DON stated the CNAs should have identified Resident 42's decline and possible contractures. The DON stated the resident should have been receiving RNA services due to his immobility. According to the facility's policy, titled Resident Mobility and Range of Motion, dated July 2017, 1. Resident will not experience an avoidable reduction in Range of Motion (ROM). 2. Resident with limited range of motion will received treatment and services to increase and/or prevent a further decrease in ROM .Interpretation: . 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: .c. muscle wasting and atrophy; .e. contractures .

Based on observation, interviews, and record reviews, the facility failed to provide showers consistently for two of two sampled residents (Residents 19, 65) reviewed for ADLs (activities related to personal care). As a result, residents' preferences and choices were not honored and respected. Findings: 1. Resident 19 was readmitted to the facility on [DATE], per the facility's Admission Record. Resident 19's history and physical, dated 1/25/23, indicated he had the capacity to understand and make decisions. On 2/27/23, a record review was conducted. Resident 19's MDS (an assessment tool), dated 1/23/23, indicated his BIMS (test the residents' ability to recall) was 15, which indicated intact cognition. The MDS for ADL indicated Resident 19 needed physical help and required one-person physical assist. On 2/27/23 at 9:16 A.M., a concurrent observation and interview of Resident 19 was conducted in his room. Resident 19 was sitting in his wheelchair watering his plants. Resident 19 stated his shower days were Mondays, Wednesdays, and Saturdays. Resident 19 stated the physician ordered three times a week showers. Resident 19 stated he did not consistently receive the showers as per the physician's order. Resident 19 stated he complained to the DSD about it and, It was sickening, and it was all talk. On 2/28/23 at 10:23 A.M., an interview was conducted with CNA 21. CNA 21 stated she had been assigned to Resident 19 in the past. CNA 21 stated Resident 19 was very alert and oriented and required some help when receiving showers. CNA 21 stated had not given showers to Resident 19. On 2/28/23 at 10:28 A.M., an interview was conducted with CNA 22. CNA 22 stated he had not provided showers to Resident 19. CNA 22 stated he had been assigned to Resident 19 occasionally, but had not provided him with showers. CNA 22 stated Resident 19 had an order to get an extra showers each week for a total of three of Mondays, Wednesdays and Saturdays. On 2/28/23 at 10:49 A.M., an interview was conducted with CNA 23. CNA 23 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 23 stated she had not provided showers to Resident 19. CNA 23 stated all residents should have been getting their showers regularly two times a week for personal hygiene. CNA 23 stated Resident 19 used to have showers on Mondays and Saturdays, but now was ordered showers on Mondays, Wednesdays and Saturdays. On 2/28/23 at 2:10 P.M., an interview was conducted with CNA 24. CNA 24 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 24 stated she had not given showers to Resident 19. On 3/1/23, a record review was conducted. Resident 19's physician order dated 2/17/23, indicated Resident 19 had showers ordered three times a week. For December 2022, Resident 19's shower sheets indicated Resident 19 received eight out of nine scheduled showers. For January 2023, Resident 19 received three of nine scheduled showers. For February 2023, Resident 19 received four of eight scheduled showers. On 3/1/23 at 7:59 A.M., an interview was conducted with the DSD (responsible for CNAs training and development). The DSD stated the expectation was for the CNAs to ensure residents were provided showers for good hygiene and to prevent infection. On 3/2/23 at 8:11 A.M., a concurrent interview and record review was conducted with LN 21. LN 21 stated it was important for residents to have their showers for good hygiene, to prevent infection, and to do body checks to see open areas which needed treatment right away. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the expectation was for the CNAs to provide showers to the residents to promote good hygiene and prevent skin complications. A review of the facility's policy titled,Resident Self Determination and Participation, revised February 2021, indicated, .1. Each resident is allowed to choose activities .that are consistent with his or her interests .including: a. daily routine, such as .bathing schedules . 2. Resident 65 was admitted to the facility on [DATE], per the facility's Admission Record. Resident 65's history and physical, dated 11/18/22, indicated she had the capacity to understand and make decisions. On 2/27/23, a record review was conducted. Resident 65's MDS (an assessment tool), dated 2/23/23, indicated her BIMS (test the residents' ability to recall) was 15, which indicated intact cognition. The MDS for ADL indicated Resident 65 needed physical help and required one-person physical assist. On 2/27/23 at 9:54 A.M., a concurrent observation and interview was conducted with Resident 65 in her room. Resident 65 was sitting up in bed, with bandage on her left leg. Resident 65 stated her shower days were Tuesdays and Fridays. Resident 65 stated she did not get her showers for almost two weeks. Resident 65 stated it was not good because she had open wounds which needed to get healed. On 2/27/23, a record review was conducted. Resident 65' shower days were scheduled Tuesdays and Fridays. For December 2022, Resident 65 received three of nine scheduled showers. For January 2023, Resident 65 received three of nine scheduled showers. For February 2023, Resident 65 received three of seven scheduled showers. On 2/28/23 at 10:15 A.M., an interview was conducted with CNA 21. CNA 21 stated Resident 65 was very alert and oriented and required some help when receiving showers. CNA 21 stated had not given showers to Resident 65. On 2/28/23 at 10:28 A.M., an interview was conducted with CNA 22. CNA 22 stated he had not provided showers to Resident 65. CNA 22 stated he had been assigned to Resident 65 occasionally, but had not provided her with showers. On 2/28/23 at 10:49 A.M., an interview was conducted with CNA 23. CNA 23 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 23 stated she had not provided showers to Resident 65. CNA 23 stated all residents should be getting their showers regularly two times a week for personal hygiene. On 2/28/23 at 2:10 P.M., an interview was conducted with CNA 24. CNA 24 stated she was one of the CNAs primarily assigned to provide showers to the residents. CNA 24 stated she had not given showers to Resident 65. On 3/1/23 at 7:59 A.M., an interview was conducted with the DSD (responsible for CNAs training and development). The DSD stated the expectation was for the CNAs to ensure residents were provided showers for good hygiene and to prevent infection. On 3/2/23 at 8:11 A.M., a concurrent interview and record review was conducted with LN 21. LN 21 stated it was important for residents to have their showers for good hygiene, to prevent infection, and to do body checks to see open areas which needed treatment right away. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the expectation was for the CNAs to provide showers to the residents to promote good hygiene and prevent skin complications. A review of the facility's policy titled, Resident Self Determination and Participation, revised February 2021, indicated, .1. Each resident is allowed to choose activities .that are consistent with his or her interests .including: a. daily routine, such as .bathing schedules .

Based on observation, interview, and record review, the facility failed to set a Low Air Loss (LAL) mattress per the physician's order and according to the resident's weight for one of six residents (Resident 45), reviewed for pressure ulcers (injuries to the skin and underlying tissue). As a result, there was a potential for Resident 45 to develop pressure ulcers. Findings: Resident 45 was admitted to the facility on [DATE], with diagnoses to include reduced mobility, per the facility Admission Record. On 2/27/23 at 9:16 A.M., an observation of Resident 45 was conducted. Resident 45 was in bed, eating breakfast. Resident 45 appeared to be thin. Resident 45's LAL mattress was set to 260 pounds. A label applied to the LAL mattress control panel indicated the settings should have been 100 pounds. On 2/28/23 at 10:29 A.M., an observation and interview was conducted with Resident 45. Resident 45 was in bed, and stated she did not know if she had a pressure ulcer. The LAL mattress was set to 260 pounds. On 2/28/23 at 10:30 A.M., an interview was conducted with CNA 23. Per CNA 23, Resident 45 had a LAL mattress to prevent skin problems. CNA 23 stated she only checked to see if the LAL mattress was on, she was not responsible for checking the settings. On 2/28/23 at 1 P.M., an interview was conducted with LN 11. LN 11 stated she was frequently assigned to Resident 45 and was familiar with her care. Per LN 11, the LAL mattress settings were checked every shift by the nurse assigned, and were based on the physician's orders and the resident's weight. On 2/28/23 at 1:04 P.M., an observation of Resident 45's LAL mattress settings was conducted with LN 11. LN 11 changed the weight from 260 pounds to 100 pounds. Per LN 11, The settings are wrong. It (the mattress) should be set to 100 pounds. The sticker says 100 pounds. Having the wrong settings could affect her skin. On 2/28/23 at 3:27 P.M., an interview was conducted with the DON. The DON stated, My expectation is for staff to follow physician's orders. On 2/28/23, a record review was conducted. Per a physician's order, dated 12/19/22, Resident 45 was ordered a LAL mattress with settings based on comfort or weight of the resident and to check the settings every shift. The facility was unable to provide a policy regarding following physician's orders. Per a facility's policy titled Pressure Ulcer/ skin breakdown, revised April 2018, .the nurse shall .Assessment and Recognition .2. d. Current treatments, including support surfaces .

Based on observation, interview, and record review, the facility failed to ensure one of one residents reviewed for dental services received a referral to the dentist (Resident 45). This failure had the potential to lead to decreased food intake and weight loss. Findings: Resident 45 was admitted to the facility on [DATE], with diagnoses to include failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition), per the facility Admission Record. On 2/27/23 at 9:13 A.M., a concurrent observation and interview was conducted with Resident 45. Resident 45 was seated in bed, with a breakfast tray in front of her. Resident 45 stated she was not very hungry, but she would eat what she could. A denture cup with dentures inside was next to the breakfast tray. On 2/28/23 at 12:47 P.M., a concurrent observation and interview was conducted with Resident 45. Resident 45 was seated in bed, with a lunch tray in front of her, and the denture cup with dentures inside was next to the tray. Resident 45 stated she might be able to chew the roast beef if she had the dentures in. Resident 45 stated nobody had offered to assist her with the dentures. On 2/28/23 at 12:49 P.M., an interview was conducted with CNA 23. CNA 23 stated Resident 45 needed to be set up for meals. Per CNA 23, she assisted Resident 45 by opening food containers for her, and cutting up her meat. CNA 23 stated Resident 45 had her own teeth on top, and sometimes used her bottom dentures. CNA 23 stated she had not offered to assist Resident 45 with the dentures. Per CNA 23, The denture might help her eat better. CNA 23 stated if Resident 45 refused to wear her dentures, she should have informed the charge nurse but she had not done that. On 2/28/23 at 2:42 P.M., an interview was conducted with LN 11. LN 11 stated she was frequently assigned to Resident 45. LN 11 stated she was not aware Resident 45 needed a denture to chew food. Per LN 11, if Resident 45 did not have her dentures in, it could cause her to eat less. LN 11 stated if Resident 45 needed her dentures fitted, she would inform the SSD to schedule a dentist appointment. LN 11 stated she had not been told Resident 45 used, or refused to wear her denture. On 2/28/23, a record review was conducted. Resident 45's BIMS, dated 12/6/22, was 13, indicating intact cognition. Resident 45's care plan indicated she was at potential risk for diet texture intolerance and/or denture issues, with approaches to include coordinating dental care and dental consults as needed. On 2/28/23 at 2:30 P.M., an interview was conducted with the SSD. The SSD stated she was not informed of a problem with Resident 45's lower dentures. The SSD stated the nurses informed her of any dental problems and her department would order a dental consult. Per the SSD, It looks like it got missed. On 2/28/23 at 3:27 P.M., an interview was conducted with the DON. The DON stated the CNAs should have reported any concerns about dentures or eating to the nurse, then the nurse should have spoken to the SSD to arrange a dental consult. The DON stated, That did not happen today the way I would have wanted. Per a facility policy, dated October 2017 and titled Dental Services, The facility assists all residents in obtaining needed dental services .to meet the needs of each resident .

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices when a urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside) was lying on the floor for one of three residents reviewed for urinary catheter care (Resident 276). This failure had the potential for cross contamination (spread of germs and bacteria) and infection. Findings: Resident 276 was admitted on [DATE] with diagnoses which included obstructive uropathy (blockage of urinary flow) with lower urinary tract infections (UTI), per the Admission Record. During an observation on 2/27/23 at 9:35 A.M., in Resident 276's room, Resident 276 was in bed with a urinary catheter visible next to the bed. Resident 276's catheter bag and privacy bag were on the floor. During an interview with CNA 31 on 2/28/23 at 10:12 A.M., CNA 31 stated Resident 276's urinary catheter bag should have always been elevated or off the floor for infection control purposes. During an interview with LN 31 on 2/28/23 at 10:53 A.M., LN 31 stated Resident 276's privacy bag and catheter bag should have not touched the floor for infection control purposes. On 3/1/23, a record review was conducted. Resident 276's urinary catheter care plan, dated 2/14/23, indicated no part of the catheter should be touching the floor. During an interview with the interim IP on 3/2/23 at 8:32 A.M., the interim IP stated urinary catheter bag should have been off the floor, at all times. Interim IP stated that it was important for urinary catheter bag not to touched the floor to prevent cross contamination. During an interview with DON on 3/2/23 at 9:30 A.M., the DON stated staff doing direct care with residents were all trained to handle urinary catheter. The DON stated the urinary catheter bag and dignity bag should have not touched the floor for infection control issues. Per the facility's policy titled Catheter Care, Urinary, revised September 2014, indicated, .Infection Control: 2.b. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review, the facility failed to provide routine nail care to one of two residents (Resident 42), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 42 was at risk for skin injury and infection. Findings: Resident 42 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), with right hemiplegia (paralysis on one side of the body), and diabetes (abnormal sugar levels), per the facility's Admission Record. On 2/28/23 at 8:32 A.M., an observation was conducted of Resident 42 as he laid in bed. Resident 42 appeared asleep with his eyes closed. The right arm was resting on top of the covers with the right hand in a fist, with the wrist turned inward. On 2/28/23 Resident 42's clinical record was reviewed. According to the last quarterly MDS (a clinical assessment tool), dated 1/19/23, Resident 42 was unable to speak. The functional status indicated Resident 42 was impaired on both sides of his body. Per the care plan, titled ADL, dated 7/14/22, Resident 42 was completely dependent and required assistant with oral care, showers, bed mobility, dressing, toileting, and personal hygiene. On 2/28/23 at 1:27 P.M. an observation and interview was conducted with LN 21 of Resident 42. Resident 42 was lying in bed with his right hand in a fist. LN 21 extended the resident's right fingers, which revealed long fingernails on the middle finger, ring finger, and thumb. Two indentations were observed in Resident 42's right palm where the fingernails of the right middle and ring fingers met the palm of the hand. The fingernails were estimated to extend 1/2 to 3/4 inch over the fingertips. The right palm indentation remained after one minute of the fingers being extended. LN 21 stated the resident's fingernails should not have been allowed to get to that length. LN 21 stated it was the CNAs responsibility to notice when the fingernails needed trimming. LN 21 stated the LNs should have also noticed the long fingernails during their weekly head-to-toe assessments. LN 21 stated Resident 42 could have sustained a cut to his right palm from the long fingernails. On 2/28/23 at 2:11 P.M., a record review was conducted of the facility's February 2023 shower sheets. Resident 42 received showers on 2/12/23, 2/16/23, and 2/23/23. The shower sheets contained no documented evidence the fingernails were checked or trimmed. On 2/28/23, the facility's Nursing Weekly Observations, dated 2/6/23, 2/14/23, and 2/21/23 were reviewed. There was no documented evidence the fingernails had been assessed. Section P. Additional Comments indicated on the 2/6/23 document, Head-to-toe skin check done today, patient has no new skin issues at this time. The 2/15/23 and 2/21/23 Weekly Observation, documented, .Skin assessment done, no new open areas or significant rashes, otherwise skin clear and intact . On 3/1/23 at 7:54 A.M., an interview was conducted with CNA 2. CNA 2 stated if a resident's fingernails were long and they were diabetic (abnormal sugar levels in the blood), the LNs needed to be informed, so they could cut the nails. CNA 2 stated CNAs were allowed to trim fingernails of non-diabetic residents. CNA 2 stated she documented a resident's nails on the shower sheet and if they were trimmed or not. On 3/1/23 at 9:51 A.M., an interview was conducted with the DON. The DON stated the CNAs and LNs routinely checked fingernails and toenails every Saturday. The DON stated she expected all residents' fingernails and toenails to be maintained, to prevent injury or infection. The DON stated nail care was important for hygiene. According to the facility's policy, titled Activities of Daily Living (ADLs), Supporting, dated March 2018, .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .a. hygiene ( .grooming .) . According to the facility's policy, titled Fingernails/toenails, Care of, dated February 2018, .1. Nail care included regular cleaning and trimming .Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the nail care was given. 2. The name and title of the individual who administered nail care .

Based on observation, interviews, and record reviews, the facility failed to develop a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to dialysis (treatment to remove waste from the body) access care for one of two sampled residents reviewed for dialysis (Resident 19). As a result, there was the potential for undetected complications after dialysis. Findings: Resident 19 was readmitted to the facility on [DATE], with diagnoses which included dependence on dialysis, per the facility's Admission Record. Resident 19's history and physical, dated 1/25/23, indicated the physician documented Resident 19 had the capacity to understand and make decisions. On 2/27/23, a record review was conducted. Resident 19's MDS (an assessment tool), dated 1/23/23, indicated his BIMS (test the residents' ability to recall) was 15, which indicated intact cognition. Resident 19's physicians order, dated 1/24/23 indicated Resident 19's dialysis access pressure dressings was to be removed four- six hours after dialysis. There was no care plan related to dialysis access care. On 2/27/23 at 9:16 A.M., a concurrent observation and interview with Resident 19 was conducted in his room. Resident 19 was sitting in his wheelchair watering his plants. Resident 19 stated he went for dialysis on Tuesdays, Thursdays, and Saturdays. Resident 19 stated the staff had nothing to do with his dialysis access. Resident 19 stated he took all the pressure dressings the following morning after his dialysis. Resident 19 stated the doctor ordered for the nurses to remove the pressure dressings. Resident 19 stated he preferred to do it himself because when the nurses removed the dressings, they junked it up and tears my skin. On 3/2/23 at 8:11 A.M., a concurrent interview and record review was conducted with LN 21. LN 21 stated LNs were responsible to check Resident 19's access after his dialysis. LN 21 stated Resident 19 removed his own dressings. LN 21 was unable to locate a care plan related to dialysis access care. LN 21 stated it was the LNs responsibility to ensure a care plan was developed related to his dialysis access to prevent complications. On 3/2/23 at 9:04 A.M., an interview was conducted with the DON. The DON stated the LNs should have developed a care plan related to Resident 19's dialysis access care. A review of the facility's policy titled, Care Plans - Comprehensive, revised October 2017, indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing .needs is developed for each resident .

Based on observation, interview, and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed, when: 1. Prepared tuna sandwiches were not accurately cooled down to ensure food safety. 2. A dishwasher (DW) touched dirty dishes and then handled clean dishes without washing his hands. 3. A ready for use resident ice cart had small black dots resembling mold in it. 4. A nutritional shake stored with ready to use shakes was expired. 5. The dates on loaves of bread were inaccurate. These failures to mitigate potential food contamination may result in food borne illness. The facility census at the time of survey was 89. Findings: 1. According to the Food and Drug Administration (FDA) Food Code (YEAR), Section ,[DATE].14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (degrees Celsius) (41oF) (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .canned tuna. On [DATE] at 9:30 [NAME]M., a joint inspection of the facility's reach-in refrigerator was conducted with the DDS. The reach-in refrigerator's temperature was 48 degrees F (Fahrenheit). The DDS stated the refrigerator's temperature was not within an acceptable range. The DDS stated the refrigerator temperature should be at 41 degrees F or less. Inside the refrigerator there were plates of cut fruit and approximately twenty sandwiches: Chicken salad, egg salad, and tuna salad. A randomly selected chicken salad sandwich was tested for temperature and was 56 degrees F. On [DATE] at 9:34 [NAME]M., a joint observation and interview was conducted with DA 1. DA 1 randomly selected a tuna salad sandwich from the reach-in refrigerator. The tuna salad sandwich's temperature was 51 degrees F. DA 1 stated she prepared the tuna salad sandwiches around 6:30 [NAME]M. and placed them in the refrigerator around 7 [NAME]M. DA 1 stated the canned tuna had not been pre-cooled in the refrigerator and was room temperature when prepared. DA 1 stated the facility's cool down process for ambient temperature food was up to the refrigerator to get it to the proper temp (temperature). DA 1 stated the facility did not keep cool down logs. On [DATE] at 9:45 [NAME]M., an interview was conducted with the DDS. The DDS stated the facility did not have a cool down process for ambient temperature food. The DDS stated the cool down process was dependent on a working refrigerator. The DDS stated she thought the cool down process would be similar to hot food wherein the food should reach an internal temperature of 41 degrees F or less in 6 hours. The DDS stated there were no cool down logs kept, and she would rely on the residents to tell her if the sandwiches were too warm. On [DATE] at 8:38 [NAME]M., an interview was conducted with the facility's RD. The RD stated the cool down process for ambient temperature foods such as canned tuna or chicken should have been followed. The RD stated using a cool down log helped track the exact times to ensure accuracy of the process. The RD stated not following the cool down process could contribute to the development of foodborne illnesses. Per the facility's policy titled Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), dated (YEAR), Ambient Temperature Foods: Potentially hazardous foods shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Use cool down log . 2. According to the (YEAR) Federal FDA Food Code, Section ,[DATE].14, When to Wash, Food Employees shall clean their hands .immediately before .working with .clean equipment and UTENSILS .and .(E) after handling soiled equipment or utensils . On [DATE] at 9:19 [NAME]M., a joint observation and interview was conducted with DW 1 and the DDS. DW 1 was at the three compartment sink in the dish machine room. DW 1 placed dirty dishes and silverware in the last compartment sink. DW 1 turned around and cleared the clean dishes from the dish machine and placed them on the drying rack. DW 1 went back to the sink and loaded the dirty dishes on to the washing rack to be run through the dishwasher. DW 1 then went to the clean side of the dish machine to clear additional clean dishes from the dish washing machine. DW 1 stated he had moved back and forth from a dirty area of the dish washing room to a clean area. DW 1 stated the correct procedure was for staff to wash their hands when moving between dirty and clean areas to avoid cross contamination. DW 1 stated . I should have washed my hands. The DDS acknowledged DW 1 had not washed his hand between clean and dirty tasks. The DDS stated DW 1 should have washed his hands between the tasks of handling the dirty and clean dishes. On [DATE] at 8:38 [NAME]M., an interview was conducted with the facility's RD. The RD stated DW 1 should have washed his hands between handling dirty dishes and clean dishes. The RD stated it was her expectation for kitchen staff to wash their hands when moving between dirty and clean tasks. Per the facility's policy titled Hand Washing, dated (YEAR), .1. When to wash hands . f. After handling soiled equipment or utensils. g. as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks 3. On [DATE] at 8:40 [NAME]M., a joint inspection of the dry storage room was conducted with the DDS. Three rolling ice carts were observed. The DDS stated after the ice carts were thoroughly cleaned and sanitized they were placed in the dry storage room and were ready for immediate use. On [DATE] at 8:55 [NAME]M., a joint observation and interview was conducted with DW 1 and the DDS. DW 1 stated the three rolling ice carts had been cleaned inside and out and were ready to be filled with ice and delivered to the resident units. DW 1 stated there were no liners used, and when filled, the ice would come into direct contact with inside of the ice compartment. Two of the rolling ice carts were observed visibly soiled with brown stains on the outside of the ice storage compartments. Inside of each ice storage compartment, were small black dots resembling mold. DW 1 stated the black dots should not be present inside the ice compartments and that both rolling ice cart should have been better cleaned. DW 1 stated he had not completely cleaned them. The DDS stated there should not have been black dots resembling mold on the inside of the ice compartments. The DDS stated ice was considered food and the residents consumed the ice. The DDS stated the rolling ice carts should have been thoroughly cleaned. The facility's undated policy titled Procedures: Ice Machine/ Ice Cart -Cleaning & Sanitizing, did not provide guidance for cleaning and sanitizing the rolling ice carts used on resident units. 4. On [DATE] a kitchen inspection was conducted with the DDS. In the walk-in refrigerator, there was a tray of supplemental shakes. A strawberry flavored supplemental shake had a labeled date of [DATE]. The DDS stated once the supplemental shakes were pulled from the freezer, they were good for 14 days. The DDS stated the supplemental shake dated [DATE] was expired. The DDS stated it should have been pulled from circulation and discarded. The DDS stated the supplemental shakes should have been checked for expiration dates. Per the facility's policy titled Food Storage, dated (YEAR), . f.All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded 5. On [DATE] at 8:40 [NAME]M., an inspection of the dry storage room was conducted with the DDS. Multiple racks of loaves of sliced bread were observed with yellow sticker dates [DATE] ([DATE]). On [DATE] at 8:42 [NAME]M., a joint observation and interview was conducted with CK 1. CK 1 stated she received the bread delivery and the yellow sticker dates on each loaf was the receive date. CK 1 stated the bread was good for seven days after the receive sticker date and then it had to be discarded. CK 1 stated the sticker dates marked [DATE] were incorrect and was confusing. CK 1 stated it was very important that the receive dates be correct. CK 1 stated she did not check her work after dating the bread. On [DATE] at 8:50 [NAME]M., a joint observation and interview was conducted with the DDS. The DDS stated the [DATE] sticker date was wrong and should have been checked and corrected. On [DATE] at 8:38 [NAME]M., an interview was conducted with the facility's RD. The RD stated the food labeling procedure should be consistent and the dating should be accurate. The RD stated it was her expectation for kitchen staff to double check their work for accuracy. Per the facility's policy titled Food Storage, dated (YEAR), . f.All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded

Based on observation, interview, and record review, the facility failed to ensure the dietary staff were competent on the ambient temperature food cool down process and following hand hygiene standards in the kitchen. These failures placed residents at risk of foodborne illness. The facility census was 89. Findings: 1. According to the Federal Food and Drug Administration (FDA) Food Code (YEAR), Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (degrees Celsius) (41oF) (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .canned tuna. On 8/26/19 at 9:30 [NAME]M., a joint inspection of the facility's reach-in refrigerator was conducted with the DDS. The reach-in refrigerator's temperature was 48 degrees F (Fahrenheit). The DDS stated the refrigerator's temperature was not within an acceptable range. The DDS stated the refrigerator temperature should be at 41 degrees F or less. Inside the refrigerator there were plates of cut fruit and approximately twenty sandwiches: Chicken salad, egg salad, and tuna salad. A randomly selected chicken salad sandwich was tested for temperature and was 56 degrees F. On 8/26/19 at 9:34 [NAME]M., a joint observation and interview was conducted with DA 1. DA 1 randomly selected a tuna salad sandwich from the reach-in refrigerator. The tuna salad sandwich's temperature was 51 degrees F. DA 1 stated she prepared the tuna salad sandwiches around 6:30 [NAME]M. and placed them in the refrigerator around 7 [NAME]M. DA 1 stated the canned tuna had not been pre-cooled in the refrigerator and was room temperature when prepared. DA 1 stated the facility's cool down process for ambient temperature food was up to the refrigerator to get it to the proper temp (temperature). DA 1 stated the facility did not keep cool down logs. On 8/26/19 at 9:45 [NAME]M., an interview was conducted with the DDS. The DDS stated the facility did not have a cool down process for ambient temperature food. The DDS stated the cool down process was dependent on a working refrigerator. The DDS stated she thought the cool down process would be similar to hot food wherein the food should reach an internal temperature of 41 degrees F or less in 6 hours. The DDS stated there were no cool down logs kept, and she would rely on the residents to tell her if the sandwiches were too warm. On 8/26/19 at 4:30 P.M., a joint interview and record review was conducted with the DDS. The DDS reviewed the in-service training records for the dietary department and stated there had been no in-service training conducted on the topic of ambient temperature food cool down. The DDS stated as the dietary manager, she herself had not received in-service training regarding ambient temperature food cool down process. The DDS stated the dietary department as a whole was unfamiliar with the cool down for ambient temperature food and had not been educated on the process. On 8/28/19 at 8:38 [NAME]M., an interview was conducted with the facility's RD. The RD stated the cool down process for ambient temperature foods such as canned tuna or chicken should have been followed. The RD stated using a cool down log helped track the exact times to ensure accuracy of the process. The RD stated dietary staff should have been competent on the cool down process. The RD stated not following the cool down process could contribute to the development of foodborne illnesses. Per the facility's policy titled Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), dated (YEAR), Ambient Temperature Foods: Potentially hazardous foods shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Use cool down log . 2. According to the (YEAR) Federal FDA Food Code, Section 2-301.14, When to Wash, Food Employees shall clean their hands .immediately before .working with .clean equipment and UTENSILS .and .(E) after handling soiled equipment or utensils . On 8/26/19 at 9:19 [NAME]M., a joint observation and interview was conducted with DW 1 and the DDS. DW 1 was at the three compartment sink in the dish machine room. DW 1 placed dirty dishes and silverware in the last compartment sink. DW 1 turned around and cleared the clean dishes from the dish machine and placed them on the drying rack. DW 1 went back to the sink and loaded the dirty dishes on to the washing rack to be run through the dishwasher. DW 1 then went to the clean side of the dish machine to clear additional clean dishes from the dish washing machine. DW 1 stated he had moved back and forth from a dirty area of the dish washing room to a clean area. DW 1 stated the correct procedure was for staff to wash their hands when moving between dirty and clean areas to avoid cross contamination. DW 1 stated . I should have washed my hands. The DDS acknowledged DW 1 had not washed his hands between clean and dirty tasks. The DDS stated DW 1 should have washed his hands between the tasks of handling the dirty and clean dishes. On 8/27/19 at 3:30 P.M., a joint interview and record review was conducted with the DDS. The DDS stated she had conducted an in-service titled Dishwashing and Sanitation, dated 5/15/19, that included a demonstration, . 7. Sanitize hands or remove gloves before handling sanitized dishes . The DDS stated DW 1 had attended the in-service. The DDS stated she would need to in-service the dietary staff again. On 8/28/19 at 8:38 [NAME]M., an interview was conducted with the facility's RD. The RD stated DW 1 should have washed his hands between handling dirty dishes and clean dishes. The RD stated it was her expectation for kitchen staff to wash their hands when moving between dirty and clean tasks. Per the facility's policy titled Hand Washing, dated (YEAR), .1. When to wash hands . f. After handling soiled equipment or utensils. g. as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks