Every finding on record at Chautauqua Guest Home #2

Based on record review, staff interviews, and policy review the facility failed to provide or offer as needed (PRN) pain medication in a timely manner, non-medication pain relief, and/or notify the resident's physician of new onset and increased pain for 1 of 3 residents reviewed for pain after a fall (Resident #14). Despite Resident #14 reporting increased amounts of pain to her leg, the facility failed to provide her with additional medication or request the physician review her medication orders. The facility learned Resident #14's pain occurred due to a fracture of the femoral neck (hip fracture). The facility reported a census of 38 residents. Findings include:Resident #14's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Resident #14 required substantial/maximal assistance (helper does more than half the effort) with transferring and walking up to 10 feet. In addition, the MDS listed Resident #14 as dependent (helper does all of the effort or, the assistance of 2 or more helpers is required for the resident to complete the activity) with rolling left to right in bed. The MDS also documented diagnoses of hemiplegia (paralysis or weakness that only affects half of the body), diabetes mellitus, anxiety, depression, non-Alzheimer's dementia, and encounter for palliative care (a type of care between nursing home care and hospice level of care). The Fall Progress Note dated 9/13/25 at 9:40 AM, documented the staff heard Resident #14's chair alarm sounding and upon entering her room, the staff found her lying on the floor on her right side screaming my leg and back hurts, while touching her left thigh. The nurse assessed her range of motion (ROM) within normal limits and took her vital signs. The assessment didn't identify any injuries to her left leg or back. The nurse gave Resident #14, as needed (PRN) acetaminophen.The Fall Follow Up Progress Note dated 9/13/25 at 3:10 PM, documented Resident #14 refused to walk and she stated my leg is broken. The nurse assessed passive ROM to Resident #14's left leg. The assessment reflected ROM within normal limits, with her skin intact with no swelling and no bruising noted.The Fall Follow-Up Progress Note dated 9/14/25 at 5:50 AM, documented Resident #14 screamed on and off throughout the night. She complained of pain to her left leg and back. During routine cares was observed holding her left leg and refuses to give pain level and continues to say, It hurts me. Documentation also revealed Resident #14 left leg has been a chronic issue for a while now and will notify her Physician if she can go over for x-rays for her left leg.The Fall Follow Up Progress Note dated 9/14/25 at 1:11 PM, documented the staff obtained Resident #14 vital signs and she had no pain to her right extremities and had full ROM. The staff reported Resident #14 described her left leg as tender. The staff gave her PRN acetaminophen. The staff observed Resident #14 lifting up her legs and bending both knees while in her recliner chair. The staff didn't note any injuries.Resident #14's September 2025 Medication Administration Record (MAR) listed the following orders:8/27/25: Acetaminophen oral tablet 500 milligrams (mg). Give 2-tablets by mouth one time a day in the evening related to pain in leg, unspecified.7/30/24: Tramadol oral tablet 50 mg. Give 50 mg by mouth two times a day for leg pain.5/31/23: Acetaminophen oral tablet 325 mg. Give 2-tablets by mouth every 6 hours as needed for pain and/or fever PRN. Resident #14 received the medication at the following times:9/13/25 at 10:10 am - 4 pain level (0 equals '=' no pain, 10 = the worst pain ever)9/14/25 at 11:46 am - 2 pain levelThe MAR reflected Resident #14 only received the PRN acetaminophen once before her fall on 9/13/25.The Physician Contact Progress Note dated 9/15/25 at 9:00 AM, documented Resident #14's Advanced Register Nurse Practitioner (ARNP) came to the facility that morning. The staff updated them on Resident #14's pain from her fall lessened but they would contact her if they didn't see improvement.The Family Contact Progress Note dated 9/15/25 at 11:24 AM, documented Resident #14's Daughter visited with her on 9/14/25. Resident #14 didn't wish to go out of the building and/or have an x-ray at that time.The Progress Note dated 9/15/25 at 6:10 PM, documented Resident #14 had a lot of pain during supper despite receiving her scheduled pain medications Tramadol and Tylenol 30-minutes before getting her up for supper. In addition, she refused to eat and begged the staff to lay her in bed, and refused to have a bath. She displayed facial grimacing (an involuntary facial movement that involves twisting or contorting the face, often in a way that appears painful or disgusted). The nurse took her vital signs and discovered an elevated blood pressure of 142/88 (typical 120/80). The staff assisted Resident #14 to lay down early to bed and re-positioned her for comfort with the head of the bed elevated.The Progress Note dated 9/16/25 at 2:35 AM, documented the staff heard Resident #14's floor alarm sounding as a pillow fell on the floor and set it off. The nurse obtained vital signs and noted her blood pressure elevated at 142/87. The nurse assessed Resident #14's lungs and heard crackles (abnormal breath sounds that sound like popping, crackling, or bubbling) in her bottom right lung. Resident #14 complained of pain to her left hip and left foot. The nurse observed her left foot internally rotated with 1+ pitting edema (indicates a mild degree of swelling) and her left hip with non-pitting edema (a type of swelling that didn't leave a dent when pressure is applied to the affected area). The nurse didn't observe bruising or redness to her left hip or thigh. The nurse noted her left elbow had a faint bruise and abrasion (a superficial wound caused by the skin rubbing or scraping against a rough surface, leading to the wearing away of the outer skin layers). The staff checked her blood sugar and the machine read 570 (normal for non-diabetic 70-110 and normal for diabetic 2 hours after a meal less than 180) as her blood sugar ran high on 9/15/25 and she received extra insulin then. The staff conducted a COVID test and received a negative result.The Progress Note dated 9/16/25 at 5:54 AM, documented Resident #14 had the following events on 9/16/25:a. 3:35 AM: Blood sugar reevaluated twice (x2) with both readings of HI (above 600). Resident #14 reported she wanted to have her hip looked at the hospital.b. 3:40 AM: The nurse updated Resident #14's ARNP. The ARNP gave an order to send to the local emergency room (ER).c. 3:42 AM: Resident #14 family notified she would be evaluated in the ER.d. 3:45 AM: The nurse notified the ambulance services.e. 4:10 AM: The nurse gave report to the ambulance services when they arrived about Resident #14.f. 4:15 AM: Resident #14 left the facility.The ER Physician Documentation Report dated 9/16/25 documented at 4:32 AM, reflected Resident #14 went to the ER and received 6 milligrams (mg) of Morphine (pain medication) by an Intramuscular Injection (IM). Her vital signs reflected an oxygen saturation (O2) of 84% on room air (normal is above 90% on room air). The staff applied oxygen at 3 Liters (L) and her O2 went up to 96%. She had a blood sugar level of 721. The hospital admitted her inpatient with diagnoses of pleural effusion (condition where excess fluid accumulates in the space between the lungs and the chest wall), left hip fracture, acute kidney failure, and congestive heart failure (CHF).The current Care Plan Focus related to pain control dated 9/17/25 documented Resident #14 had the following interventions dated 5/31/23:a. Anticipate Resident #14's need for pain relief and respond immediately to any complaints of pain.b. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.c. Monitor and document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations (seeing or hearing something not really there), dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician.d. Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing).e. Monitor/record/report to Nurse Resident #14's complaints of pain or requests for pain treatment.f. Monitor, record, and report to the nurse a loss of appetite, refusal to eat, and/or weight loss.g. Notify physician if interventions are unsuccessful or if current complaint is a significant change from Resident #14's past experience of pain.h. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care.i. Report to the nurse any change in usual activity attendance patterns or refusal to attend activities related to signs, symptoms, complaints of pain, or discomfort.During an interview on 9/18/25 at 8:58 AM Staff G, Licensed Practical Nurse (LPN), reported she worked with Resident #14 after she fell on 9/13/25 and every night shift leading up to her going to the hospital on 9/16/25. She kept saying she had pain in her left leg and the Nurses had the impression her family didn't want her sent out. She explained Resident #14 never really told anyone if something was wrong, but you could see it in her face.During an interview on 9/18/25 at 11:03 AM with Staff E, Register Nurse (RN), revealed she worked on 9/13/25 when Resident #14 fell. Staff E said Resident #14's chair alarm went off and when she entered the room, she found her screaming on the floor. Resident #14 laid on her right side touching her left leg, she told the staff her leg and back hurt, but she denied hitting her head. Staff E reported her assessment showed everything normal. When the staff put her in the recliner, she had facial grimacing, so Staff E gave her an as needed (PRN) acetaminophen. On 9/14/25, Staff E worked with Resident #14 from 2:00 PM to 6:00 PM, they started using the full-body mechanical lift as she still had pain. Staff E reported the staff talked about having her physician see her and get an x-ray on 9/15/25. On 9/15/25 they continued to use the full-body mechanical lift. Resident #14 was quiet, but she still had left leg weakness and refused to take a bath.During an interview on 9/18/25 at 10:57 AM Staff D, Certified Nurse Aide (CNA), explained she worked with Resident #14 on the night of 9/13/25 into 9/14/25 after she fell and had a lot of pain. Staff D reported she told the nurse who worked that night, and she told her Resident #14 normally had a lot of pain.During an interview on 9/18/25 at 11:49 AM the Director of Nursing (DON) stated she didn't see Resident #14 from 9/13/25 to 9/16/25. She did speak with Resident #14's doctor and daughter regarding her pain on 9/15/25. They told her they planned to have Resident #14 remain at the facility unless she requested to go to the ER.During an interview on 9/18/25 at 12:00 PM Staff F, RN, said she arrived to work on 9/15/25 at 8:00 PM. She reported being the nurse for Resident #14 and the nurse leaving reported Resident #14 had high blood sugars, so Resident #14 received extra insulin. The nurse told Staff F, Resident #14 complained her hips hurt and she didn't eat supper. She stated Resident #14 slept and she checked everything on her. Around 2:30 AM when Resident #14's floor alarm went off, Staff F decided to check her vital signs. Resident #14 had a blood sugar of 570. Resident #14 only complained of pain when the staff moved her leg.In an e-mail correspondence on 9/18/25 at 12:28 PM the Administrator indicated the facility's follow-up request to the physician for pain control determined Staff E cared for Resident #14 on the evening shift of 9/15/25, she charted Resident #14 had pain and facial grimacing. She reported she didn't contact the provider because after they assisted Resident #14 to bed and repositioned her for comfort, she was comfortable and slept until the end of her shift (10:00 PM). In addition, Staff F sent Resident #14 to the ER. Staff F reported she didn't contact the provider at the beginning of her shift because she slept comfortably until about 2:30 AM. At that time her alarm went off because a pillow fell and triggered the alarm. Staff F explained she noted congestion and began an assessment for respiratory status. Her full assessment triggered her to contact the provider and Resident #14 agreed to go to the ER for evaluation.During an interview on 9/18/25 at 1:02 PM the Administrator explained if a resident complained of pain, typically the nurse would try PRN pain medicine and alternative interventions such as massage, a change in environment, and change in position. If none of the interventions worked, then the facility should notify the doctor.The undated Incident Reports policy instructed the following:a. When an incident occurred, the staff would notify the charge nurse, complete an appropriate assessment of the resident and document their findings. The nurse would then notify the attending physician and family. Notification can be in person, by telephone, through fax, and/or envelope delivery. The Charge Nurse would initiate the incident report and complete it as described on the form. When the nurse completed the form, they must turn it in to the nurse manager.b. At any time, professional nurses may analyze and initiate nursing interventions that could prevent a recurrence of the incident. The nurse manager will formally complete this analysis and document any necessary actions prior to turning the completed form into administration. This includes the provision of first aid and documenting actions completed.The undated Pain Protocol Policy directed the facility to ensure any residents with pain receive proactive care to alleviate or minimize pain through the collaborative efforts of the interdisciplinary health care team including the attending physician. The policy listed the following:a. Pain indicators i. Verbalization of pain ii. Increase in agitation iii. Thrashing type behaviors/restlessness iv. Combativeness v. Change in level of consciousness/lethargyb. Non-medicinal methods of relieving pain i. Application of hot/cold ii. Massage therapy iii. Relaxation exercises, guided breathing iv. Social services counseling v. Isolation/stimulation vi. Light/Dark vii. Oxygen therapy viii. Reposition, body supports, immobilizations ix. Physical Therapy interventions

Based on observations, staff interviews, Certified Dietary Manager (CDM) interview, facility policy review, and review of the 2022 United States (US) Food and Drug Administration (FDA) Food Code, the facility failed to prevent soiled gloves coming into contact with food during food preparation, failed to serve milk below 40-degrees Fahrenheit, failed to ensure kitchen fans and shelves are free of dust, failed to cover the garbage, and failed to date stored food when opened and free of fuzzy growth. The facility reported a census of 38 residents. Findings include:During an initial kitchen tour on 9/15/25 at 9:15 AM observed the following:a. The large garbage can, located by the eye wash station sink, and the large garbage can, located by the dishwasher, both uncovered and overflowing with garbage. b. A box fan measuring approximately 20 inches tall with thick, gray dust covering the front grille, and facing 2 storage racks. The fan blew air directly towards the bottom 3 shelves of the 2 storage racks containing clean coffee cups, coffee mugs, and glasses turned upside down on trays. c. In the kitchen's food storage room had i. A 24-count bag of Hawaiian buns with 12 of the buns covered with a gray fuzzy substance. ii. An open and undated 20 count bag of flour taco shells, with 6 flour taco shells remaining, a 12-count bag of hamburger buns with 7 remaining in the bag, and a bag of cinnamon bread with 3 slices of bread remaining. d. 2 refrigerators didn't have an internal thermometer located inside (Victory refrigerator and Continental freezer). During the kitchen tour conducted 9/15/25 at 9:51 AM observed the following: a. The freezer with the thermometer displayed in the upper right thermometer insecurely attached with piece of duct tape. The location of the thermometer made it difficult to view.b. The Victory refrigerator didn't have a thermometer.c. The Continental freezer didn't have a thermometer. d. A dusty fan blew air in the kitchen towards 2 racks of clean cups. In addition, the kitchen had 3 racks of cups in direct line of the fan. The bottom 2 racks contained coffee mugs and cups, turned upside down on trays.e. The following remained in the kitchen i. An undated and opened bag of 12 buns, with 7 buns remaining. ii. A 20 ct. flour tortilla shell bag with 6 shells left. iii. An unopened package of Hawaiian buns: covered with mold across half the buns with a sell date 9/2/25.f. The microwave appeared visibly dirty with food on the turning plate and rust along the back inside of the microwave.g. An undated and open half bag of raisin bread, an undated and open half bag of cinnamon bread, and 3 slices of bread left in a bag not dated. h. The steam table had grease buildup underneath and around the griddle top stove.i. The stove top had a brown and black discoloration over half.j. The garbage can near the eye wash station overflowed without a cover.k. The drawers near the sink appeared dirty.During a follow-up kitchen observation on 9/16/25 at 10:47 AM revealed the following observations: a. The large garbage can located by the eye wash station sink and a large garbage can positioned by the dishwasher both remained uncovered. b. The facility removed the box fan from the kitchen. c. The dish rack inside the kitchen with the coffee pot had a thick layer of gray dust covering the surface of the lowest shelf that stored bowls, plates, and smaller dessert bowls. During the noon meal service on 9/16/25 at 10:49 AM observed Staff C, Dietary Aide, prepare multiple servings of white milk, chocolate milk, and juice into glasses and Styrofoam cups, then placed them on a tray. Staff C then placed the tray with the drinks on the preparation table by the coffee pot. During an observation in the kitchen on 9/16/25 at 11:01 AM the stove continued to have a thick buildup of a dark brown residue to the left side of the griddle, extending approximately 6 inches to the mid griddle and approximately 12 inches on the back of the griddle. During the noon meal service on 9/16/25 at 11:06 AM observed Staff B, Dietary Cook, apply (don) gloves, touch the outside of a bread bag with gloved hands, reach into the bread bag, pull out a slice of bread, place the slice of bread in the blender, and pureed the bread mixture.During the noon meal service on 9/16/25 at 11:39 AM observed Staff B check the temperature of a Styrofoam cup containing white milk. The thermometer revealed a temperature of 58.6 degrees Fahrenheit while Staff C distributed the milk for multiple room trays. During an interview on 9/16/25 at 1:20 PM Staff A, Dietary Aide, stated he wouldn't touch food or the plates, he would only grab the edge of the plate with his thumb. In addition, he stated he didn't usually handle the food. Staff A said he checked the refrigerator temperatures both on the inside and outside of the freezer. During an interview on 9/16/25 at 1:23 PM Staff C reported they expected her to wash her hands both before and after removing gloves. She knew the garbage cans should have lids on them but said, we just don't use them. Staff C reported when she opened up the food items, she needed to date items after she opened them. Staff C noted she checked the inside thermometer and the outside thermometer. During an interview on 9/16/25 at 1:25 PM Staff B reported, we have lids. We just don't use them. Staff B knew items need to be initialed and dated after opening. In addition, she wore gloves when she needed to butter bread. They expected her to wash hands before and after wearing gloves. During an interview on 9/16/25 at 1:42 PM the CDM reported the followinga. Maintenance assisted with helping to stock food and didn't put the dates on food. b. They expected the staff to date food items when opened. c. Leftovers should only be stored up to 3 days. d. All staff are to wash hands before and after using single use gloves. e. Gloves that touched other surfaces or items shouldn't touch food. They should change their gloves after they touch anything. f. They should cover all garbage.g. Staff should use tongs to get the bread out of the bread bag. h. Staff should take out the garbage after each meal. i. Staff should handle plates by the bottom of the plate, then slide it into their hand so that they didn't touch the inside of the plates. j. Staff shouldn't serve milk if the temperature is over 40 degrees. During a follow-up of the kitchen on 9/17/25 at 11:20 AM observed the following:a. Staff had the garbage cans covered with no overflow. b. The kitchen had a clean steam table shelf.c. The kitchen had a clean area under the coffee prep table. d. The staff sealed the cracked tile above the kitchen sink with caulk. e. The staff put thermometers inside the refrigerator and the freezer. f. The CDM educated the dietary staff. g. The staff cleaned the grease on top of the griddle/stove. During an Interview on 9/17/25 at 11:20 AM the CDM explained he would have the dietary staff scrub the griddle/stove more tonight with a stone.The Policy related to storing leftovers after meal services included the following: a. Label and date all containers.b. You may keep food for up to 3 days, then must throw away if not used.c. Everything open needed labeled and dated.d. All food items shall be prepared in such a manner as to meet the nutritional needs and preferences of the patient.e. All foods shall be prepared in a sanitary method with handwashing at appropriate intervals. The 2022 US FDA Food Code under 2-301.14 directed the staff when to wash (hands) clean their hands and exposed portions of their arms immediately before engaging in food preparation, afterhandling soiled equipment or utensils, during food preparation, as often as necessary to remove soil andcontamination and to prevent cross contamination when changing tasks, before donning gloves toinitiate a task that involves working with food, and after engaging in other activities that contaminatethe hands.The Food code at 3-301.11 Preventing Contamination from Hands directs food employees may notcontact exposed, ready to eat food with their bare hands, and should use suitable utensils such as deli meat.

Based on resident record reviews, staff interviews, and policy review, the facility failed to ensure all resident's personal fund accounts, including savings accounts, that the facility manages had a surety bond in place to cover the total amount. The facility reported a census of 41 residents. Findings include: The untitled document dated 3/14/22 provided by the facility documented that the facility managed 21 residents' personal fund's accounts. The 21 accounts combined equaled $9,327.09, of the 21 accounts 8 of the accounts also had money in their own individual savings account and total money in the savings accounts equaled $8,052.00 of the $9,327.09. The record review of a billing notice renewal period of 5/16/21 to 5/16/22 revealed a resident fund bond covering $3,000, which is less than 9,327.09. During an interview on 3/17/22 at 12:25 PM Staff E revealed that she was not aware the money in the savings account needed to be covered by the surety bond. She explained the surety bond does cover everything, but not in the savings account. During an interview on 3/17/22 at 12:40 PM the Administrator revealed that she was not aware that the money in the savings account needed to be covered by the surety bond and had discussed this with Staff E. The record review of the undated facilities polices for resident fund accounts lacked policies or procedures regarding the surety bond for resident funds.

Based on observation and staff interviews the facility failed to talk with residents for whom they are providing assistance rather than conducting social conversations with other staff. A facility staff member also failed to speak with residents politely, respectfully, and communicate personal information in a way that maintains confidentiality for 2 of 3 meals observed. The facility reported a census of 41 residents. Findings include 1. During an observation on 3/14/22 at 11:58 AM, Staff D, Certified Nurses Aide (CNA), while assisting Resident #25 with their meal service, remarked that the food was not lasagna and laughed. Staff D then commented it's supposed to be a brownie or cookie or something and laughed again. During an observation at 3/14/22 at 12:01 PM Staff D while assisting Resident #25 got up and walked out of the dining room with no one to replace her. Staff D returned at 12:03 PM and stated in a loud voice that Resident #25 looks tired today like they were off in a daze and laughed. During an observation on 3/14/22 at 12:08 PM Staff D while assisting Resident #25 in a loud voice yelled over to another resident's table, do you even know what your talking about and laughed. She then returned to helping Resident #25 to eat, then in a loud voice stated, did you fall asleep mid conversation and laughed. During an observation on 3/14/22 at 12:17 PM Staff D in a loud, almost yelling, voice, vocalized, does it have no flavor without salt and laughed. Staff D then continued to repeat the same statement two (2) more times and continued to laugh. During observations on 3/14/22 during the noon meal service, other facility staff were present and no interventions were implemented for Staff D's behavior. 2. During an observation on 3/15/22 at 12:04 PM of Staff D while assisting Resident #4 with meal service, observed her ask Resident #4 if the food was good. When Resident #4 replied, no, Staff D laughed and failed to offer intervention or alternative to Resident #4. During an observation on 3/15/22 at 12:11 PM Staff D told another coworker present in the dining room about her days off coming up and a birthday party. During observations on 3/15/22 during the noon meal service, the other facility staff failed to implement interventions behaviors for Staff D while present during the observations of Staff D. During an interview on 3/17/22 at 12:35 PM the Administrator and Director of Nursing (DON) revealed they were aware of Staff D's inappropriate comments at times. They expressed that they would not expect inappropriate comments to be made to residents. They revealed that the dining service environment should be focused on the residents eating their meals.

Based on resident's record review and staff interviews the facility failed to keep 3 of 3 residents reviewed (Resident #6, #34, and #91) personal funds in an interest bearing account for funds that exceeded one hundred dollars ($100). The facility reported a census of 41 residents. Findings include: The record review of an untitled document dated 3/14/22 provided by the facility revealed that the facility managed 21 resident account funds. The form documented 8 of the 21 accounts received interest, however 3 of the accounts that exceeded the $100 amount were not receiving interest. During an interview on 3/16/22 at 2:08 PM Staff E explained that she was not aware that the three (3) accounts over $100 needed to receive interest. During an interview on 3/17/22 at 12:22 PM Staff E expressed that she was opening a savings account for the residents whose accounts exceeded $100 dollars. During an interview on 3/17/22 at 12:46 PM the Administrator said they were going to open savings accounts for any resident's account over $100 dollars. The undated Resident Trust Fund Evening and Weekend Fund Availability lacked policies or procedures on when a resident's personal funds account would receive interest. The undated Authorization Form for Personal Fund Allowed provided to residents by the facility lacked information related to interest bearing accounts for the resident trust.

Based on observation, staff interviews and policy review the facility failed to ensure nursing staff followed professional standards of practice during medication administration for 2 of 6 residents reviewed (Resident #30 and #17). A facility nurse failed to verify if giving the correct pain medication for Resident #30 when observations and interviews revealed she was not present during the dispensing of the medication to ensure she gave the right drug. A facility nurse also failed to follow standards of practice for supervising medication administration when the nurse left a resident unattended to take his medications. The facility reported a census of 41 residents. Findings include: 1. During an observation on [DATE] at 11:32 AM of Resident #30's medication administration revealed the following: A. Staff C, Certified Medication Aide (CMA), observed Staff F, Licensed Practical Nurse (LPN), dispense and verify the following order: [MEDICATION(S)] Tablet ,d+[DATE] MG ([MEDICATION(S)]-Acetaminophen) 1 tablet, give by mouth, three times a day while Staff C observed. B. Staff F then preceded to sign it off on Resident #30 Individual Narcotic Record. C. Staff C then left stating she will give the pain medication to give to Resident #30 and did not sign #30 Individual Narcotic Record. During an interview on [DATE] at 11:33 AM Staff F declared that the staff come and get narcotic medication for Resident #30 when they need it. Staff F added that the staff who administer the medication to Resident #30 do not cosign the narcotic record book to show it was in their possession. Staff F then revealed that she didn't verify or observe if the narcotic medication is given to Resident #30. During an observation on [DATE] at 11:33 AM of Resident #30's Individual Narcotic Record revealed only Staff F's initials. Resident #30's Medication Administration Record (MAR) for [DATE], documented the noon dose of their [MEDICATION(S)] Tablet ,d+[DATE] MG ([MEDICATION(S)]-Acetaminophen) 1 tablet, give by mouth, three times a day order, revealed Staff A, Registered Nurse (RN), signed the medication off as given. However, Staff A was not present during the observation of the medication set up and did not sign off on the narcotic record that she was in possession of the narcotic. During an interview on [DATE] at 2:08 PM Staff A, Registered Nurse (RN), reported being busy with another resident that day, so they had Staff C go up front to get Resident #30's noon narcotic medication. She stated she and Staff C stood together as she gave the medication to the Resident #30. She then signed on the MAR that she had administered the medication. She commented that she couldn't verify if the medication was correct as she didn't see the MAR or the pill card before giving the medication. During an interview on [DATE] at 2:03 PM Staff C, reported that she asked the nurse to get the resident's narcotic medication out of lock up. Staff C looked at the MAR and the medication card to confirm that the nurse was giving her the correct medication. Staff C then took the medication down to the unit, opened the MAR to review the order to administer the medication herself or gives it to the nurse to administer. During an interview on [DATE] at 2:40 PM the Director of Nursing (DON) revealed she has not instructed staff to cosign the narcotic record book when taking the narcotic medication out to administer to Resident #30. The DON explained that as of the time of the interview, they implemented that after being made aware. The DON commented that she would expected Staff C to administer Resident #30's narcotic pain medication since she was present when the medication was dispensed and able to verify it is the correct medication instead of Staff A who was not present. 2. Resident #17's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS documented Resident #17 independent with eating. Resident #17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised [DATE] documented Resident #17 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor/document for side effects and effectiveness. The Care Plan also documented that the resident received anti-Parkinson therapy related to [CONDITION(S)] and directed the nursing staff to administer anti-[CONDITION(S)] medications as ordered by the physician, revised [DATE]. The Medication Review Report, signed by the attending physician on [DATE] documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. Two orders for [MEDICATION(S)]-[MEDICATION(S)] Tablet ,d+[DATE] Milligram (MG). Give 3 tablets by mouth once a day related to [CONDITION(S)]. Start Date [DATE]. b. Three orders for [MEDICATION(S)]-Levadopa Tablet ,d+[DATE] MG. Give 4 tablets by mouth once a day related to [CONDITION(S)]. Start Date [DATE]. A Consultation Note from the Department of Neurology, dated [DATE], documented Resident #17 had noticed being slower in the morning and more fatigued. Resident #17 reported that it took about ,d+[DATE] hours to start moving well. The Consultation Note documented a new plan to up-titrate (adjust dosage by adding medication slowly) his medication as follows: A. Increase the 6:00 a.m. dose to 3.5 tablets for 3 days, if tolerated increase to 4 tablets in the morning. B. After 3 days of this if he tolerates the dosage change, increase the 11:00 p.m. dose to 3.5 tablets. C. After 3 more days increase 11:00 p.m. dose to 4 tablets if tolerated. If he tolerates this titration his final dos would be: a. 6:00 a.m. 4 tablets b. 10:00 a.m. 4 tablets c. 2:00 p.m. 3 tablets d. 7:00 p.m. 4 tablets e. 11:00 p.m. 4 tablets. The Consultation Note, dated [DATE], did not the name of the medication, route or dose of the medication to be administered. The [DATE] Medication Administration Record (MAR) listed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 4 tablet by mouth one time a day related to [CONDITION(S)] scheduled for 10:30 a.m The MAR documented on [DATE] at 10:30 a.m. the dose administered to the resident by Staff A, Registered Nurse. During an observation on [DATE] at 11:02 a.m. the resident sat in the recliner in his room with 4 circular yellow pills laid out on a napkin. He proceeded to place each pill into a small plastic cup of applesauce. Resident #17 then put the spoon in his mouth and took the pills. Resident #17 remained in his room without any facility licensed nurse present to observe the medication administration. Resident #7's Spouse stated that he took the medication for his [CONDITION(S)] and he doesn't always remember well. During an interview on [DATE] at 4:00 p.m., Resident #17 stated he preferred to take his medication on his own. He asks the nurses to leave his medication so that he can take in applesauce himself. He administered his medications at home prior to coming to the facility and wanted to continue to be able to do this at the facility. He stated it upsets him that not all of the nurses will leave his medications at the bedside. He reported the nurses know he likes to have his medication left for him to take on his own. During an interview on [DATE] at 2:11 p.m. Staff A, Staff B, Certified Medication Aide, (CMA), and Staff C, CMA, all stated they were to supervise medications being taken by the residents. Staff A stated if a resident wants to take their own medications it would have to be assessed and care planned. She stated the DON would take care of the assessment and then it would be care planned and communicated to the nurses and CMA's. During an interview on [DATE] at 2:06 PM the Director of Nursing (DON) revealed that she expected the nurses to stay with a resident while they were swallowing their pills. The DON explained that the nurse must be present until the pills are gone. She reported that she wished Resident #17 would have told her because they have an option for self medication - the Occupational Therapist (OT) completes an evaluation and gets an physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She reported none of the staff nurses had informed her they had been leaving the resident's medications for him to take without supervision. During a follow-up interview on [DATE] at 3:25 p.m. the DON reported that none of the nurses came to her to inform her Resident #17 wanted his medication left at the bedside to take on his own. She stated she would have expected the nurses to report it to her if the resident wanted medication left at the bedside of they couldn't follow the policy to supervise the taking of medications. On [DATE] at approximately 8:25 a.m. after the review of the Consultation Note dated [DATE], the DON stated technically the Consultation Note didn't contain a complete medication order and it should have been clarified. The undated, Medication Administration Policy provided by the facility documented the Purpose was that the facility accepted the following types of medication orders to meet quality and professional standards. The Procedure listed under titrating orders explained that the dose was adjusted in response to the resident's status. The required elements of a complete medication order include: the name of the medication, dose, route, and indication for use. If a written or faxed order is incomplete, illegible, or unclear, the nurse will contact the prescriber to clarify. Part D. Medication Administration, General Principles documented the following: A. At the facility, medications were administered independently by professional nurses including Registered Nurses and Licensed Practical Nurses. Certified Medication Aides may also administer medications under the supervision of a professional nurse via routes that they have proved proficient in. B. Before administration, the individual administering the medication would visually inspect the medication for particulates, discoloration, or other loss of integrity. C. Before administration, the individual administering the medication verifies that the medication matches the order, the label, that it wasn't expired, or was contraindicated. D. Before administration, the individual administering the medication verifies that the medication was administered at the proper time, in the prescribed dose, and by the correct route. E. Before administration if any irregularities were noted, these were discussed with the physician and/or professional nurses involved with the resident's care for resolution. F. Before administration of a new medication, the resident and/or family was informed of any potential clinically significant adverse side effects or other concerns regarding the medication. The Medication Administration Policy regarding Self-Administration of Medication recored that the facility would allow residents to self-administer medications when requested by the resident and then ordered by the attending physician. The Procedure documented the following: 1. When a resident receives an order to self-administer medications, the Occupational Therapist, (OT), would be notified. The OT will then screen the resident. Mental status will be evaluated and documented as part of this screen. 2. If the OT believes that self-administration of medication was appropriate, the physician will be contacted for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. When the order is received by the therapist, an individualized self-administration plan will be formulated as a component of the therapy treatment. 4. The therapist will assure that medication education was provided to the residents and involve family regarding the medication name, type, and reasons for use. They also instruct on the process of how to administer the medications, time, frequency, route, and dose. Instructions also cover anticipated actions and potential side effects as well as monitoring the effects of the medication. The therapist will also observe and monitor the resident to assure that medication administration is correctly completed and documented by the resident. 5. The therapist will also assure that medications are safely stored to prevent tampering by other residents. 6. At the end of therapy, the therapist will submit the individualized plan to the interdisciplinary team for inclusion in the resident's plan of care. 7. Compliance with the plan will be evaluated by the team. The Medication Administration Policy Checklist for dispensing medication documented the med pass was complicated and had the potential to produce most medication errors. A widely published checklist of ten rights focused on the important steps to administer medications to residents under effective and safe circumstances. When followed in a medication pass, the guidelines could minimize errors and assure the medications were able to provide the desired results. Those guidelines were: 1. Right Medication - The nurse should be sure the medication to be administered is that ordered by the physician and appropriate to the resident's medical condition. 2. Right Dosage - The nurse should assure that the dosage ordered was appropriate to the resident, their physical, and their medical condition. 3. Right Patient - New patients, patients with similar names, and new employees could lead to the wrong person getting the medications of another patient. To prevent this, a photo, armband, and/or self identification by the resident were necessary each time medication was dispensed. 4. Right Manner and Route - Crushing pills to be hidden in food should not be done with delayed absorption medication and someone vomiting may need oral medication administered in another approved form and/or route. 5. Right Time - Keeping medication at the same level in the body may require adhering to a right schedule of dispensation. 6. Right Documentation - An accurate record of the medication taken by the resident was important so the dispensing nurse could complete the necessary record keeping before moving on to the next resident. 7. Right Assessment - An immediate condition, such as blood pressure, may be determined if a medication decreased blood pressure was to be given without harm to the resident. 8. Right Education - The patient should know why they were getting the medication and effects they should expect, the food, or the beverages they should avoid or encourage, and how to report any undesirable effects. 9. Right Evaluation - The resident should be observed to assess the outcome of the medication. Is the drug having the positive effect expected? 10. Right to Refuse Medication - The right to refuse medication should be respected with the nurse determining why the refusal and inform the physician and care planning team of the refusal for medication adjustments that would address the medical concern. The Long Term Care Center's Pharmacy Services and Procedure Manual, revised ,d+[DATE], provided by the facility documented a new order should include: 1. Date of order 2. Resident name 3. Identification number 4. Date of Birth 5. Medication name, strength, dosage, time or frequency, and route of administration; 6. Physician's/prescriber's name; and 7. Pertinent ancillary instructions 8. Reason for use 9. Stop order date, as appropriate 10. Administration parameters

Based on observation, policy review, clinical record review, and interviews with staff, family, community members and police officer, the facility failed to provide adequate supervision to protect 1 of 4 residents from hazards. Record review revealed Resident #1 with a known history of attempts to exit the facility unattended and the resident wore a Secure Care alarm bracelet. On 10/16/17, Resident #1 wandered a few block away from the facility without staff knowing her whereabouts. Interviews with staff revealed one staff turned off the door alarm after hearing it but could not distinguish the difference between the Secure Care bracelet alarm and the door alarm; and this also staff failed to completely search the area. Staff interviews revealed no staff were aware of Resident #1 whereabouts until alerted by the city police. The findings constitute an immediate jeopardy to resident's health and safety. The facility identified a census of 52 residents. Findings include: An Admission Record form dated 10/18/17 indicated Resident #1 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment form dated 7/26/17, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 and ambulated independently. A Care Plan with a focus area initiated 2/13/17 indicated the resident had been at risk for wandering/elopement related to disorientation to place and a history of attempts to exit the facility unattended. A Resident Care Guidelines form dated 5/8/17 indicated the resident wore a Secure Care bracelet (wanderguard device) dated 8/2/17. A Wandering Risk Scale form dated 7/30/17 at 1:42 p.m. indicated the resident had been at risk to have wandered. An Analysis of Fall Risk Assessment form dated 2/13/17 indicated the resident as at a low risk for falls. An Analysis of Fall Risk Assessment form dated 10/26/17 indicated the resident as at a medium risk for falls. Review of the facilities Treatment Administration Records (TAR) documented the facility staff recorded the number of times the resident attempted to elope as follows: a. August 8, 2017- 2 times (x) on the evening shift. b. August 13th - 1 x on the evening shift. c. August 21st - 2 x on the day shift. d. August 23rd - 3 x on the evening shift. e. August 25th - 3 x on the day shift. f. August 30th - 1 x on the evening shift. g. September 4th - 1 x on the day shift. h. September 8th, 16th, 22nd and 23rd - 1 x on the evening shift. i. October 7th and 16th - 1 x on the evening shift. Review of the facilities Progress Notes included the following entries as dated: a. 6/4/17 at 4:49 p.m. - The resident had been at the door and attempted to go outside by himself/herself. A Secure Care bracelet had been applied. b. 9/20 at 9 p.m. - The resident had been exit seeking all evening however easily redirected by staff. c. 9/28 at 7:20 p.m. - The resident got confused at times and thought he/she could have left the building however easily redirected. d. 10/16 at 8:15 p.m. - The resident left the facility undetected after 2:30 p.m. and the city Police Department (CCPD) notified the facility he/she had been found at 804 2nd Street in (NAME) City. The facility staff went to the residence and the resident returned with them. The resident told the staff he/she wanted to go for a walk and get some fresh air but guessed he/she went too far. Temperature 98.9 degrees, pulse 115, respirations 22 and a blood pressure of 149/120. The resident had a superficial abrasion with eschar that measured 1.6 centimeters (cm) x 0.3 cm. (the documentation failed to include the location). The resident had been in no distress. During an interview 11/8/17 at 3:57 p.m., a community member indicated she just happened to walk out of her house and observed the resident and another gal standing on the sidewalk just past her house. The community member approached them and asked if they needed help. As they turned around she recognized the resident and found out he/she had gone for quite a walk. The community member went back to her house and retrieved a chair and some water for the resident. The gal that had been with the resident called 911 and a police officer arrived along with staff members who returned the resident to the facility. During an interview 11/8/17 at 10:42 a.m., a community member indicated the resident had walked to Johnson Street when another community member 1st observed the resident and walked with the resident past her house as someone else from the community text her to ask what had been going on because the police had been outside of her house. This community member looked out her window and observed the resident with a police officer and the community member that had escorted the resident to that location. At that point the resident had been setting in a lawn chair with a glass of water. Staff from the facility then arrived and escorted the resident back to the facility. During an interview 11/8/17 at 3:30 p.m., a police officer (CCPD) confirmed he responded to the call which originally gave the location of the resident as on Johnston Street but when he arrived to the area no one had been present. When he did find the resident he had been told a community member attempted to walk with the resident back to the facility when the resident became tired and sat down on a lawn chair on 2nd street and given a glass of water. When the police officer visited with the resident he/she identified his/her first name so he called dispatch and requested they call the facility to see if a resident by that name resided there. When the dispatcher called the facility the person that answered the telephone stated she did not know if a resident by that name resided at the facility and she would have to check. The police officer continued conversation with the resident who later identified his/her last name so he called dispatch again and requested they call the facility and have their staff come pick up the resident. During an interview 11/7/17 at 2:40 p.m., the resident indicated it had been a beautiful sunny day when he/she went for a walk and he/she never gave it any thought but rather tore a little ground. The resident indicated he/she went out the east door and then changed and stated the west door of the facility. The resident had been unaware if he/she had fallen but thought he/she had been a little tired after the stroll. An observation 11/9/17 at 8:20 a.m. revealed the speed limit on 11th Street located in front of the facility as 25 miles per hour (mph) west to main street. The speed limit North on Main Street had 25 mph until 4th street where the speed limit increased to 30 mph which continued past 2nd Street. During an interview 11/8/17 at 9:36 a.m., Staff A, Licensed Practical Nurse (LPN) confirmed she had been the charge nurse the day the resident eloped. The staff member stated visitors entered the building around 2:30 p.m. and the door alarm sounded but she never paid any attention to the type of sound to distinguish if the door alarm had been the front door or the Secure Care alarm. The staff member then showed the visitors how to properly code into the building so the alarm would not sound. The staff member thought the resident must have slipped out when the visitors entered. The staff member stated she used the key pad on the wall across from the nurse's station and pointed to the key pad on the wall outside of the front door at which time she looked down the front sidewalk of the building but failed to go to the door and look around (east, west and or north). The staff member indicated the resident had been exit seeking during the time period of the elopement because he/she had a urinary tract infection but the attempts had not been as bad on that day. The staff member confirmed she received a call from the CCPD at an unknown time and had been informed a visitor by the name of the resident required help. The staff member called a code purple but the staff had been unable to locate the resident. The staff member then stated she called the CCPD back and wanted confirmation the person who required assistance had been the resident but the dispatcher had been unable to confirm so the staff members continued to look for the resident. Eventually the CCPD returned call and stated an officer had been on the scene and confirmed it had been the resident. Staff B, Administrator and a couple of the girls went to get the resident. When the resident returned to the facility he/she had been tired, warm and thirsty and wanted to sit down. The staff member assessed the resident and found a scratch on his/her left outer ankle. During an interview 11/8/17 at 9:15 a.m., a physician confirmed when a resident had [DIAGNOSES REDACTED] their cognitive status had been known to come and go and a person just never knew where they would be at cognitively from minute to minute. During an interview 11/7/17 at 3:27 p.m., the Activity Director confirmed the resident arrived for a manicure in the dining area at around 2:15 p.m. The staff member knew a visitor had been there around 2:30 p.m. but after that she could not recall the time elements of events. During an interview 11/7/17 at 2:26 p.m., Staff C, LPN confirmed Staff A told her she received a telephone call from the CCPD that the resident had been at someone's house so they called a code purple to check for any missing residents. Staff were looking in and around the building while Staff B went in her car to look for the resident. Staff A received another call the police had been with the resident but he/she refused to go with the officer so the Administrative Secretary and Assistant Administrative Secretary went to get the resident. When the resident re-entered the building the Secure Care alarm sounded and she knew it had been the Secure Care alarm because it made a different sound than the front door alarm. During an interview 11/8/17 at 10:25 a.m., Staff B confirmed she had been outside of the building when she heard the code purple over the paging system. When she entered Staff A informed her she received a call about a visitor by the same name of the resident in the community. The staff searched the building and the grounds and could not locate the resident. The plan at that point had been for staff to return call to the CCPD to clarify if the person in the community had been the resident as Staff B left the facility in her car to search for the resident. While driving she called back to the facility and received clarification as to where the resident had been located so she drove to that location. The staff member found the resident setting in a lawn chair in front of a residential house drinking a glass of water with a police officer present and 3 ladies from the community. When the staff member spoke with the resident he/she could not recall the path he/she had taken to the current location but he/she knew he/she had not fallen but he/she had stumbled at one point. Additionally the resident stated he/she sat a rested on a park bench at one point. The staff member asked the resident if he/she had been ready to go home and the resident said yes. As they started to walk to her car the Administrative Secretary and Assistant Administrative Secretary arrived and assisted the resident into that car and returned to the facility. All the while the resident kept saying he/she just wanted to go for a walk. This staff member also provided a typed statement dated 10/17/17 which included the following documentation: When she asked the family friend what the resident said during the telephone call around 3 p.m. the resident placed via his/her cell phone during the walk the family friend stated the resident said he/she had been somewhere that he/she had not belonged. During an interview 11/7/27 at 2:55 p.m., the Maintenance man confirmed he responded to the code purple and checked the grounds which included all of the gaits in the courtyard which had been all secured with intact locks. During an interview 11/7/17 at approximately 1:39 p.m., the Assistant Administrative Secretary confirmed Staff A entered her office and said the Resident had been with family and refused to come back to the facility related to a telephone call she had received. The facility staff called a code purple and checked the facility and the grounds. The facility received another telephone call who informed them the resident had been on 2nd Street. The Assistant Administrative Secretary and the Administrative Secretary went to get the resident. When they arrived the resident had been standing with Staff B by her car and when asked if he/she had been ready to go home, and she said yes, she was thirsty. The staff member assisted the resident into the Administrative Secretaries car and while they drove she asked the resident what he/she had been doing and the resident stated he/she wanted to go for a walk. The staff member asked him/her what door he/she exited the facility from and he/she said I think the front door but I cannot remember. When they re-entered the facility the Secure Care alarm sounded and they assisted the resident to his/her room, assisted the resident into the recliner and gave him/her some water. During an interview 11/8/17 at 10 a.m., the Administrative Secretary confirmed she received a call from the CCPD so she transferred the telephone call to Staff A. Staff A then pointed towards the resident's room as if for her to check and see if the resident had been present however the resident had been gone. Staff A called a code purple so the facility staff checked the building and the grounds. Staff A received another telephone call at which time she was informed the resident needed to have been picked up so herself and the Assistant Administrative Secretary went to get the resident. When they arrived Staff B had been present along with 2 ladies from the community. The Assistant asked the resident what he/she had been doing and the resident stated he/she just wanted to go for a walk and get some fresh air. When the staff members assisted the resident into the car the Assistant asked the resident what door he/she went out and the resident thought the front door of the facility but he/she could not remember. The resident mentioned she had been tired and would have liked a drink of water. During an interview 11/7/17 at 3:35 p.m., Staff D, Certified Nursing Assistant (CNA) confirmed she assisted with the code purple and then went back to her own work. The staff member observed the Administrative Assistant code into the building when she returned with the resident and the Secure alarm sounded upon entry. During an interview 11/7/17 at 10:53 a.m., a family friend confirmed the resident called him/her at around 3 p.m. and said he/she wanted to do something and that he/she had been at the court house. During an interview 11/8/17 at 1:30 p.m., the Director of Nursing (DON) confirmed the facilities front door Secure Care alarm (wanderguard) sounded with an intermittent beeping sound and the front door Advantage 1000 door alarm sounded continuously until both had been disarmed. Review of the facilities October 2017 activity calendar indicated manicures had been scheduled 10/16/17 at 2:30 p.m. A Code Purple policy (not dated), directed the facility staff on the proper procedure to have been performed when a missing or a resident elopement had been identified. The policy included the following: All public exit door are equipped with a Secure Care Alarm, and there are 2 types of alarms. Door alarms are equipped with the basic panel and sound if the door is opened and a resident with a monitoring alarm bracelet is close or had gone through (the door). The policy addressed the purpose of the secure care alarms was to assure residents did not elope from the facility undetected. On 10/16/17, the facility abated the IJ when they re-educated all staff on the distinguishable difference between the Secure Care Alarm bracelet alarm and the door alarms sounds. At this same time the facility also provided retaining on the facility Code Purple Missing or Elopement policy for conducting a comprehensive search ( including searching outside & accounting for all residents) . The facility provided demonstrations, and asked staff questions to ensure staff knew the difference between the alarm sounds of the secure care code door alarm verse the secure care monitoring bracelet alarm. Individual training was completed for Staff A (and other staff not present for the in-service prior to working). The maintenance staff verified and continued to monitor the functioning of all door alarms and all residents(3) with secure care bracelets. The resident was also moved to the CCDI unit.

Based on observation and staff interview, the facility failed to ensure staff labeled all refrigerated foods, thawed meat properly, maintained the food preparation areas in a clean and sanitary condition, and changed gloves and washed their hands appropriately during meal service. The facility reported a census of 50 residents. Findings include: 1. Observation during the initial tour of the kitchen on 10/13/14 at 8:55 a.m., revealed a two door freezer with the following contents: a. A large clear bag of meat patties dated 9/13 without a label. b. A large clear bag of meat dated 10/12 without a label. At the time of the observation, the dietary manager stated the bag contained diced turkey. c. The bottom of a two-door cooler had two shallow plastic serving trays with four large clear unlabeled bags of chicken thawing. One of the bags hung over the side of the tray. During the same tour, observation revealed a fuzz-like debris directly over pans on the stove, which the surveyor could pull off of the light. During observation of the lunch meal on 10/14/14 at 11:39 a.m., Staff A (Cook) wore gloves while plating food. Staff A touched 3 pan lids and various utensil handles, then removed the skin from a baked potato wearing the same gloves. Staff A touched a wood counter on the steam table, then removed a peel from another baked potato with their hands wearing the same gloves. Staff A touched the outside of a tub of butter wearing the same gloves and then removed the skin from another potato with out changing gloves. During the same observation, Staff C (Dietary Aide) dropped a tray card holder on the floor, then picked it up and placed it on a counter over a steam table where trays sat for food plating. At 12:15 p.m., Staff B (Dietary Aide) began to wash dirty dishes. Staff C asked for ranch dressing for a resident in the dining room. Staff B went to a cupboard, removed two Styrofoam containers and poured ranch dressing into them from a large bottle. Staff B did not wash their hands after touching the dirty dishes. During an interview with the Dietary Manager on 10/16/14 at 7:05 a.m., they stated they had been able to find a few dates on some items in the refrigerator but not everything.

Based on observation and staff interview, the facility failed to ensure staff maintained the kitchen in a clean and sanitizable manner. The facility reported a census of 50 residents. Findings include: 1. During the initial tour of the kitchen on 10/13/14 at 8:55 a.m., observation revealed the following: a. dried food on the back of the stove b. dried food on the side of a toaster. c. a large amount of food debris and crumbs along the side of the stove. d. a wheeled plastic cart with two large juice dispensers on it. The surface of the cart had a burn like mark in the plastic. 2. Observation of meal preparation on 10/14/14 at 10:40 a.m., revealed the following: a. Nine of 10 plastic dish racks with a large amount of black build-up on them. b. A large dried brown drip down the front of a steam table in the kitchen. 3. Observation in the kitchen during meal preparation on 10/14/14 at 11:08 a.m., revealed the following: a. a butcher-block like counter surface attached to the steam table with various cuts in the wood, and a black build-up on it. b. various dried food drips on the stove. c. a tea kettle on the stove with a greasy black build-up. d. a dust-like substance on a ceiling light. d. numerous cracks in the ceiling paint with areas of chipped paint over the dishwashing area. b. a build-up of a wet food debris on the top clean side of the dishwasher. c. An area under the sink missing the wall covering, with a large amount of exposed insulation. d. An area on a bottom corner of the wall near the refrigerators with a sign on it that read "wet." The wall tiles under the sign had a black substance around them. During interview on 10/15/14 at 1:15 p.m., the facility Dietary Manager stated staff was responsible for wiping the steam table, stove and appliances nightly. Maintenance cleaned the fixtures around and over the stove. At the time of the interview, the surveyor showed the Dietary Manager the wood counter surface attached to the steam table, which still had the blackish build-up on it and how the build-up scraped off. The Dietary Manager agreed they needed to clean the items in the kitchen. Additionally, at the time of the interview, the dried food/drips remained on the stove surface, side of toaster, dust on the lights, food debris on dishwasher, and black build up on dish racks all remained. During an interview with the facility Administrator at 3:15 p.m., they stated they had not been aware of the large crack or the missing wall tiles in the kitchen.

Based on observation, document review, and staff interview, the facility failed to follow State Fire Marshal guidelines for plugging electrical equipment into surge protectors (CCDI). The facility census was 50 residents. Findings include: During the Environmental tour of the facility 10/15/14, observation at 10:25 a.m. in the CCDI Unit resident lounge area revealed 2 electric lift chairs plugged into a metal surge protector at which time the Maintenance Supervisor unplugged the 2 lift chairs. Examination of the surrounding area revealed no open outlets for the chairs to be plugged in to other than the surge protector. A letter from the State Fire Marshal's Office dated 10/8/13, states the following regarding surge protectors. "Electrical surge protectors may be used for computers and related equipment, facsimile machines, photocopiers, electronic scanning machines, and other consumer electronic devices such as VCR's, DVD players, televisions, and stereo equipment in a resident's room and other locations in a facility provided the electrical surge protector shall be of metal construction and approved by Underwriters Laboratories (UL 149) or ANSI/IEE C62.4 1-1980" The facility provided a document titled "power strips waiver utilized" that referred to a centers for Medicare & Medicaid Services (CMS) Survey & Certification letter (S&C) 14-46 LSC (Life Safety Code) stating the facility elected to Clarification from the State Fire Marshals Office on 10/27/14 revealed the following information. 1. The S&C letter will only apply to long term care facilities that provide life support services & all hospitals. It ' s pretty clear that the S&C letter exempts long term care facilities & residential care facilities if they don ' t use the line-operated electrical appliances. 2. Our surge protector policy will remain in effect and applies to all health care facilities.

Based on observation and staff interview, the facility failed to post nurse staffing data at the beginning of each shift listing the licensed and unlicensed staff directly responsible to care for the residents. The facility census was 53 residents. Findings include: 1. Observation on 07/22/13 at 9:32 a.m., revealed a staffing plan for July 22, 2013, posted on the south wall of the nurses station. The form listed the number of unlicensed and licensed staff scheduled for all three shifts for the day, but failed to have actual hours the unlicensed and licensed staff worked, and failed to include any shift to shift changes. 2. Observation on 07/23/13 at 7:01 a.m., revealed a staffing plan for July 23, 2013, posted on the south wall of the nurses station. The form listed the number of unlicensed and licensed staff scheduled for all three shifts for the day, but failed to have actual hours the unlicensed and licensed staff worked, and failed to include any shift to shift changes. During interview on 07/25/13 at 9:22 a.m., the facility assistant administrator stated they failed to have the correct information posted regarding the actual hours worked.

Based on clinical record review and staff interview, the facility failed to utilize non pharmacological interventions prior to the administration of psychoactive medications for four of ten residents interviewed. The facility census was 54 residents. (Resident #6, #7, #8 & #12) Findings include: 1. The minimum data set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment revealed the resident had disorganized thinking that fluctuated in occurrence and severity and had a history of [REDACTED]. Nurse notes reveal the resident experienced a fall with fracture on 10/26/11. The resident's plan of care completed 4/26/12, included approaches to care for the resident as follows: a. Involve in facility, small group and individual diversional activities optimally-likes to be busy. b. Converse with resident during cares-was a homemaker; enjoys cards, baseball, walking, TV, reading, news, and used to sew and crochet. c. Provide books and other individual diversional activities d. Allow resident to reminisce, talk about interests and past accomplishments. e. 1:1 to allow the resident to express their feelings. A physician order [REDACTED]. Review of the Medication Administration Records (MAR) revealed the [MEDICATION NAME] was administered on 5/16/12, 5/26/12, 4/2/12, 4/30/12, 3/2/12, 3/4/12, 3/7/12, 3/13/12 and on 3/31/12. Further review failed to reveal non pharmacological interventions utilized prior to the administration of the medication. During interview on 6/28/12 at 6:50 a.m., Staff A, Director of Nursing acknowledged non pharmacological interventions for the [MEDICATION NAME] use was not documented in the clinical record. Staff A commented the interventions should be charted on the behavior form or in the nurse notes. 2. The MDS assessment dated [DATE], documented Resident #7 required extensive assistance for transfers, bed mobility, ambulation, dressing, toilet use and hygiene needs. The Resident's care plan completed 5/10/12, indicated [DIAGNOSES REDACTED]. The care plan included the following approaches for the resident: a. Provide 1:1 visits as needed b. Can be resistive to cares, therapy, etc. If resistive may need to re-approach, have different staff member attempt cares c. Can be short with staff. May need to re-approach A physician order [REDACTED]. Review of the MAR indicated [REDACTED]. Further review failed to reveal the facility documented non pharmacological interventions utilized prior to the administration of the [MEDICATION NAME]. 3. The MDS assessment dated [DATE], documented Resident #8 had [DIAGNOSES REDACTED]. The MDS revealed the resident experienced behaviors that included inattentiveness, disorganized thinking and delusional behaviors. Review of the Resident's plan of care reviewed 5/2/12, included the following approaches: a. Provide 1:1 activities/interactions when able b. Likes to be outdoors assist as weather allows c. Likes music Review of a physician order [REDACTED]. May have one tab every 6 hours. Review of the MAR indicated [REDACTED]. Further review failed to reveal the facility documented non pharmacological interventions utilized prior to the administration of the [MEDICATION NAME]. 4. The MDS assessment dated [DATE], documented Resident #12 had [DIAGNOSES REDACTED]. The MDS revealed the resident experienced moderately impaired cognitive function. The resident's plan of care with a goal date of 6/29/12, indicated approaches that included: a. May need redirection at times-cue and redirect as allowed b. May become upset if staff are too forward, make sure he/she knows that he/she has choices c. Assist with telephone contacts to daughters A physician order [REDACTED]. The MAR indicated [REDACTED]. Review of the June, 2012, behavior form and nurse notes, failed to reveal non pharmacological interventions utilized prior to the administration of the medication.

Based on observation and staff interview, the facility failed to ensure resident food items were properly labeled and secured. The facility census was 54 residents. Findings include: 1. On 6/26/12 at 9:00 a.m., the facility kitchen freezer contained the following frozen food items that were undated: a. A partially filled, clear plastic opened bag of what appeared to be frozen chicken with no visible date of when opened on the plastic bag. b. A partially filled plastic bag of what appeared to be frozen cauliflower closed with a tie and no date of when opened on the plastic bag. During interview on 6/26/12 at 9:05 a.m., Staff C, Dietary Supervisor stated the expectation would be for all foods to be dated. Staff C reported the unlabeled items would be thrown away immediately.

Based on observation, clinical record review and staff interview, the facility failed to ensure safety devices were used for one of six residents reviewed. The facility census was 52 residents. (Resident # 8) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident had moderately impaired cognitive skills with disorganized thinking and required extensive assistance of one for locomotion on the unit. The Plan of Care dated 5/19/11, documented a problem of impaired physical mobility/potential for falls/injury related to old right hip fracture, fractured humerus, and dementia exhibited by needs fall prevention approaches. Interventions included for staff to follow posted Resident Care Guidelines and the Rehabilitation Care Plan. A Resident Care Guidelines updated 4/8/11, documented the resident used a wheelchair with standard right and left foot rest. Staff to use foot rest when off unit. During observation on 5/18/11 at 12:05 p.m., the resident sat in his/her wheel chair at the end of a hallway near an exit door and sounded the door alarm. Staff B, Certified Nurse Aide (CNA) responded to the alarm and pushed the resident down the hallway to his/her room with no foot pedals on the wheelchair and the residents feet sliding along the floor. During an interview on 5/19/11 at 2:15 p.m., Staff C, Director of Nursing (DON) stated residents displaying behaviors should have foot pedals placed on the wheelchair prior to being pushed.

Based on observation and staff interview, the facility failed to ensure all opened resident food items were stored properly with a label and date and stored under sanitary conditions. The facility census was 52 residents. Findings include: 1. Observation during the environmental tour on 5/19/11 at 10:00 a.m., revealed a partial gallon container of ice cream and an opened granola bar with a bite taken out of it in a freezer in the medication room. Neither item had a label with name or open date on it. The inner surface of the freezer had numerous dried brown drips on the shelves. At the same time observation revealed on the top of the freezer: a. An open package of puff popcorn with no date opened or label and the contents completely exposed to the elements; b. A plastic ziplock bag with three cookies with no date or label; c. A clear plastic ziplock bag with what appeared to be rice cakes with no date or label. Observation revealed the surface on the top of the freezer with a large amount of dust build-up, on which the food items sat. During the observation, Staff A, Registered Nurse (RN) verified the freezer needed to be cleaned and the items belonged to residents. Staff A did not know for sure who would be responsible for cleaning the freezer.