Every finding on record at Christian Park Village

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 12/03/2025 at 3:20 PM, during a kitchen tour with the Dietary Manager (J), observed greyish white powdery mildew on the ceiling of the dish machine room around an electrical junction box, as well as some peeling paint in this same area. Powdery mildew was also noted in the upper corners of the room on either side of the dish machine ventilation hood system. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. On 12/04/2025 at 8:30 AM, during a tour of the separate 'sister' facility that acts as the commissary for meal service and food preparation, observed that the vegetable prep sink drain line extends down below the lip of the floor bowl, with the drain line not having a proper air gap. On 12/04/2025 at 8:47 AM, during a tour of the separate 'sister' facility that acts as the commissary for meal service and food preparation, observed the drain line from the third compartment of the three-compartment sink extends down into the floor bowl drain. The lower part of the drain line and the bowl drain were also noted as being soiled with food debris. On 12/04/2025 at 10:45 AM, these observations were confirmed during interview with Maintenance Director (I) during a tour of the separate 'sister' facility kitchen. On 12/04/2025 at 10:50 AM, during a tour of the kitchen and dining room at the separate 'sister' facility that acts as the commissary for meal service and food preparation, observed the drain line coming from the dining room ice machine extended down into the floor bowl drain, not being properly air gapped. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in ¶¶ (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. Findings include: Review of facility document titled Cooling Down Foods Temperature Log revealed that on 10/17/25, a start time and temperature of 118 degrees at 6:30 was recorded for lasagna. Two hours later the temperature was recorded at 85 degrees. Further review of the document revealed that If food is more than 70 degrees at 2 hours, reheat to 165 degrees and start over (the cooling process) or discard. During an interview on 12/2/25 at 12:15 p.m., Dietary Manager J was queried regarding what the facility does with food that is above 70 degrees after two hours. Dietary Manager J reported the facility uses the food as a supplemental food item the next day. Review of policy titled Food Safety last revised 1/9/25, read in part .Foods will be rapidly cooled from 135 degrees F (Fahrenheit) to 70 degrees F in 2 hours. During an observation on 12/2/25 at approximately 12:25 p.m., the revealed green colored mildew on the ceiling at the entrance of the dishwashing area in the kitchen. Review of emergency food storage facility on 12/2/25 at approximately 12:35 p.m., revealed the following: - 1 large box of toasted oats cereal with a received day of 1/7/25 and a discard date of 11/19/25 - 2 cans of corned beef hash with a use by date of 11/25 - 4 large cans of three bean salad that were taken out of the original box with no received date, expiration date, or use by date on the cans During an interview on 12/2/25 at approximately 12:40 p.m., Dietary Manager J reported the staff sometimes forgets about rotating out the emergency food so that it is used before the expiration date. Review of policy titled Food Purchasing and Storage last revised 12/1024, read in part .It is the policy of this facility to receive, store, and efficiently issue foods.The stock date will be rotated when stored. All food items will be dated with the in date (or delivery date) .canned goods and other products will be stocked using the first in first out (FIFO) method.which ensures that older items are used first.

Based on observation, interview, and record review, the facility failed to assess and document the wounds of one Resident (R53) of three residents reviewed for wounds. Findings include:On 12/2/25 at 2:22 PM, Resident #53 (R53) was observed lying in a medical reclining chair in his room with his eyes closed and his spouse at the bedside. R53's wife said, He's getting sores on his feet. I'm worried about it. He has such bad circulation - he's even had to have some toes amputated. According to the electronic medical record (EMR), R53 was admitted to the facility 3/4/25 with diagnoses including but not limited to Alzheimer's Disease and peripheral vascular disease (a progressive disorder of narrowed or blocked blood vessels that affects blood flow primarily to the legs and feet).A Minimum Data Set (MDS) assessment for significant change in status dated 11/20/25 documented R53 had a Brief Interview for Mental Status (BIMS) score of 00 indicating R53 had severe cognitive impairment. The MDS coded R53 as being dependent on staff for activities of daily living (ADL). The MDS documented R53 did not have pressure, venous, or arterial ulcerations.Past wound documentation in the EMR documented R53 had a facility-acquired venous ulcer on the dorsal portion (upper surface) of the right foot that developed 4/10/25. The ulcer was documented as healed on 10/21/25.The care plans for R53 did not contain a plan of care for actual skin breakdown or wounds on R53's feet.Further review of the EMR revealed a current physician's order dated 12/4/25 that read: Right foot, 4th digit, cleanse with normal saline, pat dry, cover with 2X2 border gauze every day shift. Physician's orders for R53 also included an active order dated 11/14/25 that read: Left foot between great toe and 2nd digit place 2x2 border dressing over 2nd toe for protection every day shift every other day. A review of order history disclosed an order written 11/15/25 and discontinued 12/3/25 that read: Right foot, 2nd digit, cleanse with normal saline, pat dry, cover with 2x2 border gauze every day shift.The EMR of R53 contained a hospice document dated 11/20/25 that read, in part: .CLEANSE WOUND TO TOES, 2ND DIGIT OF LEFT FOOT, 4TH DIGIT OF RIGHT FOOT, THREE TIMES WEEKLY, IRRIGATE USING NORMAL SALINE. USING ASEPTIC TECHNIQUE, APPLY GAUZE BANDAGE. FACILITY STAFF WILL PERFORM WOUND CARE COORDINATED PLAN OF CARE [sic].A Hospice Certification and Plan of Care document signed by two RN's, dated as completed 11/14/25 and signed by the attending physician on 11/19/25 documented, in part: .CLEANSE WOUND TO BILATERAL FEET, THREE TIMES WEEKLY, IRRIGATE USING SALINE, ASEPTIC TECHNIQUE, APPLY GUAZE BANDAGE. FACILITY STAFF WILL PERFORM WOUND CARE ACCORDING TO COORDINATED PLAN OF CARE [sic]. There were no documented assessments of wounds to R53's feet found in the EMR. On 12/4/25 at approximately 9:45 AM, the Director of Nursing (DON) was asked to provide all wound documentation for R53 from 10/1/25 through 12/4/25. On 12/4/25 at 10:26 AM, four documents Skin & Wound Evaluation V7.0 were provided. All four documents contained weekly assessments of the previous venous ulcer of the right dorsal foot that healed on 10/21/25.On 12/4/25 at approximately 10:50 AM, the DON was asked for any additional wound documentation for R53. The DON confirmed the four documents for the healed venous wound on the right dorsal foot that had been provided were all the wound documents R53 had for the time frame 10/1/25 through 12/4/25. On 12/4/25 at 10:56 AM, Registered Nurse (RN) E confirmed she was the facility's wound and treatment nurse. RN E was queried regarding the wounds on R53's feet. RN E said, [R53] doesn't have any wounds on his feet - he only has a skin tear. RN E was asked to assess R53's bilateral feet in the presence of the surveyor.RN E, accompanied by the Assistant Director of Nursing (ADON), removed the sock on R53's right foot. The first, second, and third toes of the right foot were observed to be absent. A bandage covered the right fourth toe. When asked about the bandage on the fourth toe, RN E said, This is just preventative. After being asked to see the toe by the surveyor, RN E removed the bandage to reveal a circular, brownish-black wound on the dorsal fourth toe with a scant amount of clear drainage. RN E said, Oh! He does have a wound. When asked when the wound on the right fourth toe was initially identified, RN E said she did not know. RN E said she would review the orders, and she exited to the room to obtain dressing supplies. The ADON was asked when the wound was initially identified. The ADON said, I'm not familiar with the wounds.RN E returned to the room and measured the wound on R53's right fourth toe as 0.3 cm (centimeters) x (by) 0.3 cm (length and width, respectively). RN E was asked by the surveyor to assess between the fourth and fifth toes of the right foot. RN E spread the right fourth and fifth toes and said, Oh, there is another one. A linear, brownish-black wound with a scant amount of drainage was evident on the inner proximal fifth toe. RN E was asked when the wound on the right fifth toe developed. She said, That must be a new one. I don't even think there's a treatment for it. The ADON shrugged her shoulder when asked when the right fifth toe wound developed. RN E measured the wound on the fifth toes at 0.6 cm X 0.2 cm.RN E removed the sock from R53's left foot. All five toes were noted to be present. A bandage was located between the first and second toes of the left foot. RN E removed the bandage to reveal a moderately-draining, brownish colored linear wound on the inner second toe. An unbandaged dark, crescent-shaped wound was also observed on the fifth toe near the base of the toenail. RN E was asked when the wounds on the left toes developed. RN E said, I'm not sure. There is an order for this one [indicated the left second toe wound]. These developed sometime within the last three months. RN E measured the wound on the second toe at 0.2 cm x 0.4 cm. The wound on the fifth toe was measured at 0.1 cm x 0.4 cm.RN E was interviewed on 12/4/25 at 12:04 PM. RN E said she had been off work on a scheduled leave and only recently returned to work. When asked if any of the current wounds on R53's bilateral feet had documented assessments, RN E said, I don't think so - not if they're [assessments] not in the chart [EMR]. RN E said wounds are expected to be assessed and documented upon identification, then every 7 days thereafter. RN E said photographs are usually included in the wound assessments and said she didn't think photographs were taken of wounds while she had been on scheduled leave.The policy Skin Management dated as last revised 8/14/2024 documented, in part: . Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Practice Guidelines: .5. The licensed nurse will initiate documentation in the electronic health record [EMR], which includes a description of skin impairment as follows: In Electronic Health record facilities, the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers. Document weekly until the area is resolved. Photos may be taken of pressure injury and vascular ulcers. 9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record.13. Residents with pressure injury and lower extremity ulcers will be evaluated, measured and staged weekly (pressure injury and vascular ulcers only) in accordance with the practice guidelines until resolved. A photo may be initiated unless the resident refuses.

Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than five percent, with three errors identified out of 27 opportunities, affecting three Residents (R4, R5, and R207) of five residents observed for medication administration, resulting in a medication error rate of 11.11 percent. Findings include: On 10/1/24 at 7:36 AM, medication administration was observed with Registered Nurse (RN) A for R4. RN A was observed preparing and dispensing 13 pills for R4. RN A dispensed two cranberry 500 milligram (mg) with vitamin C 200 mg tab into the medication cup with the other 13 pills. RN A took them to R4 and R4 consumed all 13 of their medications prepared by RN A. On 10/1/24 at 7:40 AM, an interview was conducted with RN A, and was asked if she used the correct cranberry supplement for R4. RN A reviewed the order for R4, then looked at her stock cranberry supplement and replied, No, I guess not. RN A was asked if there was another stock cranberry supplement without the added vitamin C and proceeded to the medication supply room. RN A could not locate the correct stock supply medication for cranberry only. Review of R4's physician order, dated 9/26/24, revealed cranberry oral tablet 500 mg (cranberry Vaccinium macrocarpon, give 2 tablets by mouth one time a day for urinary tract health. On 10/1/24 at 8:00 AM, medication administration was observed with RN B for R5. RN B was observed preparing six medications for R5 at the medication cart. RN B popped out a metoprolol 100 mg tab out of a medication card when the medication fell on top of the medication cart. RN B picked up the metoprolol tab with her bare hands and placed it into the medication cup with the other medications she prepared for R5. RN B then walked to R5's room and gave them to R5 who consumed their medication. On 10/1/24 at 8:25 AM, medication administration was observed with RN B for R207. RN B was preparing an insulin glargine pen for R207. RN B failed to prime the insulin glargine pen and failed to clean the tip of the pen with an alcohol swab prior to adding a disposable needle tip. On 10/2/24 at 2:30 PM, an interview was conducted with the Director of Nursing (DON) who was made aware of the medication errors during medication pass. The DON replied, Nurses should be following the medication administration policy. If the policy does not cover specific medication administration types, then nurses are expected to follow the manufactures instructions for preparing and dispensing medications. Review of the manufacture instructions for insulin glargine, read in part, .How to use your insulin glargine pen in 6 steps .Step 2. Wipe the pen tip (rubber seal) with an alcohol swab .Step 3. Dial a test dose of 2 units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times . Review of policy titled, Medication Administration, dated 10/17/23, read in part, .Procedure: 1. Follow infection control practices .a. If medications come into contact with the bare hands of the nurse/QA med tech, or with the cart, the medication should be disposed of per policy and new medications obtained .2. Verify the medication label against the medication administration record for resident mane, time, drug, dose, and route .

This citation pertains to MI00146561 Based on interview and record review the facility failed to ensure scheduled showers were completed for two Residents (#2 & #4) of four residents reviewed for Activities of Daily Living (ADLs). This deficient practice resulted in lack of personal hygiene assistance, and personal dissatisfaction with ADL care. Findings include: Review of Complaint Intake revealed an allegation that residents were not adequately groomed and scheduled showers were not being completed. Resident #2 (R2) Review of R2's Minimum Data Set (MDS) assessment, dated 8/13/24, revealed R2 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 13, reflective of intact cognition. R2 required Partial/moderate assistance for shower/bathing. During an interview on 9/4/24 at approximately 11:30 a.m., R2 was asked about showers in the facility. R2 stated, I am not really getting the showers I am supposed to get. I have not refused any showers. I am supposed to get two a week. Review of R2's Shower/Bathing Task Schedule, revealed R4 was scheduled for Shower/Bathing - prefers Tuesdays and Thursday . Review of R2's Shower/Bathing task documentation in the Electronic Medical Record (EMR) showed R2 received a shower on 8/8, 8/12, 8/29, and 9/3/24. Shower documentation on 8/20, 8/22, and 8/27 was documented as no, that no shower had been given. R2 had no shower documented between 8/12 and 8/29/24 (17 days). Resident #4 (R4) Review of R4's MDS assessment dated [DATE], revealed R4 was admitted to the facility on [DATE] with a BIMS score of 11 of 15, reflective of moderate cognitive impairment. R4 required Partial/moderate assistance for shower/bathing. Review of R4's Shower/Bathing Task Schedule revealed showers would be given on Wednesday and Sunday on Day Shift. Review of R4's Shower/Bathing task documentation in the EMR showed R4 received a shower on 8/18, 8/28 and 9/1/24. Shower documentation on 8/21 and 8/25/24 was marked as N/A (not applicable). No shower refusals were documented, and no shower/bathing was documented between R4's admission on 8/8/24 and first shower on 8/18/24 (9 days). During an interview on 9/4/24 at 1:00 p.m., Certified Nurse Aide (CNA) F was asked if the shower room had been unusable by facility residents due to having no hot water, CNA F moved closer to this Surveyor, and whispered, There have been days when we didn't have hot water in here. CNA F said Maintenance Staff had done what they could, but in the last month there were several days when there was not hot water for showers. During an interview on 9/4/24 at 2:10 p.m., the Director of Nursing (DON) agreed any refused shower should have been documented and acknowledged that task documentation for showers/bathing was not present to provide evidence scheduled showers had been completed or refused. During an interview on 9/4/24 at 4:00 p.m., the Nursing Home Administrator (NHA) and DON were both present. Both confirmed showers should be offered and given per the schedules provided on the Resident's Shower/Bathing Task Schedule. Both acknowledged R2's and R4's shower task documentation did not show they had received showers as scheduled.

Based on observation, interview, and record review, the facility failed to prevent unauthorized access to the facility's one medication room. This deficient practice resulted in the potential for unauthorized dispensing and/or diversion of the facility medication supply by unlicensed staff and had the potential to affect all 54 facility residents. Findings include: During an observation and interview on 11/15/23 at 7:29 a.m., Medical Record Clerk (Staff) A was seen opening the facility's medication room door from the inside of the room and exiting the medication room with a clear plastic trash bag. The garbage bag contained what appeared to be multiple (greater than 10) over-the-counter medication bottles at the bottom of the bag and other unrecognizable garbage near the top of the trash bag. When asked if she had been alone in the medication room, Staff A confirmed she had been alone and without supervision. Staff A said she did not have a key to open the medication room door, but nursing staff routinely opened the door and provided Staff A unsupervised access to the room. Staff A stated, I stock all of the medical supplies (including accessible over-the-counter resident medications). I do all the supplies except laundry. During an interview on 11/15/23 at 7:32 a.m., Registered Nurse (RN) B said she had unlocked the medication room door and allowed Staff A unsupervised access to the medication room. RN B said that was the usual procedure and occurred almost daily. When asked if she supervised Staff A while she was in the medication room, RN B stated, No, I open the door for her. RN B said that Staff A went into the medication room alone and was not supervised by nursing staff while in the medication storage room. Observation of the medication storage room on 11/15/23 at 10:48 a.m., showed resident over-the-counter medications were stored accessible and in clear view once entry to the medication storage room was obtained. The multiple and varied over-the-counter medications were lined up on shelves, and openly displayed for easy access in the medication storage room. During an interview on 11/15/23 at 10:51 a.m., the Director of Nursing (DON) was asked if Medical Record Staff A had been authorized by the pharmacist to have unsupervised access to the medication storage room. The DON said she was not sure. A copy of the Pharmacy contract was requested for review along with a copy of any facility policy that addressed unsupervised access to the medication room without nursing or pharmacy supervision. During an interview on 11/15/23 at 11:55 a.m., the DON provided a copy of the facility Medication Management policy, last revised 9/22/2023, but no reference to unsupervised access to the medication room was addressed in the policy. The DON said that was the only policy regarding medication storage that she could find, and no other policy addressed requirements for authorized and/or unsupervised access to the medication room by non-nursing staff. No facility policy was available for review. When asked if the DON would leave the Maintenance Director (as an example of unauthorized access) unsupervised in the medication storage room, the DON said she would not. On 11/15/23 at 12:09 p.m., review of the Pharmacy Products and Services Agreement, dated September 1, 2021, revealed no facility staff had been delegated in the contract as an authorized assistant allowed unsupervised access to the facility medication storage room. During an interview on 11/16/23 at approximately 10:00 a.m., the DON was asked they had reviewed the regulatory requirements for medication storage. The DON said she had not reviewed it thoroughly, but said she understood the concern regarding unsupervised access to the medication storage room by anyone other than licensed nursing personnel, pharmacy staff or pharmacy delegated staff.

Based on observation, interview and record review, the facility failed to maintain one ice machine and one mechanical dishwashing machine in proper operating condition. This deficient practice had the potential to result in ice being distributed to residents that was not safe and a dish machine which may fail due to improper pressure allowances, affecting all 50 residents. Findings include: On 9/12/22 at 3:27 PM, the bin ice machine, located in the dining room was observed to have a brown colored bio-film on the white plastic cube deflector shield, directly above the holding bin of the machine. On 9/13/22 at approximately 8:10 AM, the ice machine was observed again, with Maintenance Director (MD) B. An interview was conducted with MD B who acknowledged the presence of the bio film on the deflector shield. When asked about the cleaning schedule for the machine, MD B stated it was conducted monthly. When asked what procedure was followed for the cleaning, MD B opened the top panel, pointed to the instructions printed on the inside of the door panel, and stated I follow that. On 9/13/22 documentation of the ice machine cleaning was provided and documented by the Nursing Home Administrator (NHA) the machine was properly cleaned on 8/31/22. When asked who performed the cleaning, MD B stated I did. When asked how he thought that a bio film mass could accumulate in only 12 days, MD B stated I don't know. MD B was requested to provide a list of chemicals used to clean and sanitize the ice machine. At approximately 8:45 AM MD B provided a bottle of chemical used for the cleaning, which was identified as a de-scaling agent, used to remove hardness (lime) scale within the machine. When asked if there was another chemical used for the sanitizing process, MD B stated No. This is the only chemical I use. On 8/13/22 at approximately 2:30 PM, the directions for cleaning were reviewed with both the NHA and MD B. The instructions printed on the inside of the door on the top of the ice machine were again reviewed and demonstrated that steps 10-21 were the sanitizing process, following the cleaning and de-scaling of the machine. The directions were clear that removable components were to be removed and soaked in a specified diluted hypochlorite (bleach) solution by the manufacturer, and the internal components flushed with a specified dilution of the hypochlorite solution to ensure proper disinfection of the components coming in contact with the water and ice. MD B acknowledged that this step was not followed and he was not aware that it was necessary. On 8/12/22 at 3:45 PM, the mechanical dish machine, in the kitchen was observed. The machine was operated for two full cycles. The pressure gauge for the final rinse was observed to be non-functional. A review of the information data plate for the machine revealed the final rinse pressure, during the sanitizing cycle was to be between 10-30 PSI (pounds per square inch). This was also stated in the FDA Food Code 2013 at: 4-204.118 Warewashing Machines, Flow Pressure Device. (A) WAREWASHING machines that provide a fresh hot water SANITIZING rinse shall be equipped with a pressure gauge or similar device such as a transducer that measures and displays the water pressure in the supply line immediately before entering the WAREWASHING machine; and (B) If the flow pressure measuring device is upstream of the fresh hot water SANITIZING rinse control valve, the device shall be mounted in a 6.4 millimeter or one-fourth inch Iron Pipe Size (IPS) valve

Based on observation, interview and record review, the facility failed to ensure a dignified care environment for one Resident (#25) of 16 residents reviewed. This deficient practice resulted in the potential for feelings of humiliation and low self-worth based on a reasonable person standard. Findings include: Resident #25 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's most recent Minimum Data Set (MDS) assessment, dated 7/21/2022 revealed Resident #25 required extensive assistance with dressing and scored a nine out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #25 had moderate cognitive impairment. During an observation on 9/14/2022 at 11:45 a.m., Certified Nurse Aide (CNA) H transferred an unidentified Resident in a shower chair from the shower room down the hall to the right of the nurses' station. While in transit, CNA H was observed leaving the resident in the shower chair and rushing into Resident #25's room. CNA H could be heard from the hallway stating in a chastising voice, What are you doing? Upon entering the room, CNA H was observed to be kneeling in front of Resident #25, who was seated in a wheelchair with his left side facing the doorway. Resident #25 had on white athletic socks and his shoes were on the floor in front of the wheelchair. CNA H was then observed to grab Resident #25's right shoe and in a hurried manner, pushed the shoe onto the Resident's right foot. Upon picking up Resident #25's left shoe and looking toward the doorway and this Surveyor, CNA H stated, I am so sick of this [expletive]. CNA H proceeded to pick up Resident #25's left shoe and pushed the shoe onto the Resident's left foot. CNA H then walked to the Resident's closet to obtain the foot pedals for the wheelchair, attached the foot pedals and turned the Resident in the wheelchair toward the door. Resident #25 was observed to have a confused facial expression. CNA H then pushed Resident #25 to the hallway and called out for Registered Nurse (RN) G to ask for assistance transferring Resident #25 to the dining room. CNA H proceeded down the hall pushing the unidentified Resident who was waiting in the hallway. The Director of Nursing (DON) was immediately notified of the observation involving CNA H and Resident #25. The DON stated CNAs are expected to act respectfully and treat Residents in a dignified manner. On 9/14/2022 at 12:02 p.m., the Nursing Home Administrator (NHA) and DON requested an interview with this Surveyor. The NHA reported CNA H was sent home pending an investigation into the incident involving Resident #25. The NHA stated Resident #25 was interviewed and reported no recollection of the incident. The NHA reported CNA H denied saying I am so sick of this [expletive], while in the presence of Resident #25 and this Surveyor. During an interview on 9/14/2022 at approximately 1:30 p.m., Resident #25 stated he already spoke to a group of people in white coats, about the incident involving CNA H. Resident #25 declined to answer questions regarding the incident. On 9/14/2022 at 1:00 p.m., the NHA reported her investigation into the incident revealed CNA H denied her actions as witnessed by this Surveyor, and Resident #25 stated to the NHA he did not hear CNA H say I am so sick of this [expletive]. The NHA stated the incident was fabricated by this Surveyor and did not occur. CNA H was unavailable for interview after the incident and prior to survey exit on 9/14/2022 at 2:25 p.m. A review of the facility policy titled Guest/Resident Dignity & Personal Privacy, revised 4/19/2022 and provided by the DON, revealed the following, in part: The facility provides care for guests/residents in a manner that respects and enhances each guest's/resident's dignity, individuality and right to personal privacy . Dignity means that when interacting with (guests)/residents, staff carries out activities that assist the guest/resident in maintaining and enhancing his or her self-esteem and self-worth . Care for guests/residents in a manner that maintains dignity .

Based on observation, interview and record review, the facility failed to ensure appropriate indwelling, urinary catheter care according to facility policy and professional standards of practice for one Resident (#46) of three residents reviewed for catheter care. This deficient practice resulted in the potential for infection and pain. Findings include: Resident #46 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 9/14/2022 at 10:08 a.m., with the Director of Nursing (DON), revealed Resident #46 lying in bed. Urinary catheter tubing was observed to be leading out from under the Resident's blanket on the left side of the bed, leading to a dependent drainage bag attached to the left, lower bed frame. Further observation revealed a white film coating the inside of the distal end of the catheter tubing. A review of Resident #46's electronic medical record (EMR), including progress notes, evaluations, and medication/treatment administration records from 6/01/2022 through 9/14/2022, revealed the Resident's catheter and collection system was last changed during a hospitalization on [DATE]. An observation on 9/14/2022 at 11:10 a.m., revealed Certified Nurse Aide (CNA) J providing catheter care to Resident #46 in the shower room. Resident #46 was seated in a shower chair with catheter tubing leading from the insertion site at the Resident's urethral meatus to a dependent drainage bag hanging on a metal handrail attached to the wall to the right of the Resident. Further observation revealed the drainage bag was positioned approximately six inches above the level of Resident #46's bladder. A white film was observed to be adhered to the inside portion of the distal end of the tubing with amber colored urine filling the tubing and leading back toward the resident seated in the shower chair. During an interview at the time of the observation, CNA J was asked what she thought about the positioning of the dependent drainage bag. CNA J stated the bag was positioned too high and above the Resident's bladder. CNA J reported that there was no other option for hanging catheter bags in the shower room. During an interview on 9/14/2022 a1:30 p.m., the DON confirmed Resident #46's catheter and drainage system were last changed during a hospitalization on [DATE]. The DON reported dependent drainage bags should always be positioned below the level of a resident's bladder to prevent backflow of urine and infection. A review of the facility policy titled Catheter Associated urinary Tract Infection (CAUTI) Prevention, last revised 8/17/2021 and provided by the DON, revealed the following, in part: To ensure appropriate technique in the care and maintenance of indwelling catheters . Maintain unobstructed urine flow by keeping the collection bag below the level of the bladder .

Based on observation, interview, and record review, the facility failed to label, date, and store oxygen equipment per professional standards of practice for two Residents (#3 and #101) of two residents reviewed for respiratory care. This deficient practice resulted in the potential for contamination and cross-contamination of oxygen equipment and possible transmission of infectious organisms. Findings include: Resident #3 Review of Resident #3's Admission Record, revealed a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's physician order, read in part, [MEDICATION(S)] Nebulizer Solution 1.25 mg/3ml (milligrams/milliliter), 3 ml inhale orally three times a day for 1 unit inhale orally nebulizer every 6 hours for [CONDITION(S)], start date 8/3/22. On 9/12/22 at approximately 3:50 PM, a nebulizer machine was observed sitting on the bedside dresser next to Resident #3's bed. The tubing attached to the nebulizer machine was dated 9/4/22. The administration mask and medication administration container were sitting on top of the bedside dresser without a barrier between the equipment and the top of the bedside dresser. The mask and medication administration container were connected and had visible areas of fluid and condensation noted within them. On 9/13/22 at 9:20 AM, a second observation was made of Resident #3's nebulizer machine and equipment. The tubing attached to the nebulizer machine was dated 9/4/22. The administration mask and medication administration container were sitting on top of the bedside dresser without a barrier between the equipment and the top of the bedside dresser. The mask and medication administration container were connected and had visible areas of fluid and condensation noted within them. Another observation was made on 9/13/22 at 3:25 PM, of Resident #3's nebulizer machine and equipment. No change was noted from prior observation on 9/13/22 at 9:20 AM. Resident #3's nebulizer machine and equipment remained in the same condition. On 9/14/22 at 8:40 AM, an observation was made of Resident #3's nebulizer machine and equipment. Again, there was no change noted to the placement or condition as described in the above observations. An interview was conducted on 9/14/22 at 12:02 PM, with Registered Nurse (RN) F regarding Resident #3's nebulizer equipment. RN F was asked if the equipment should have been left in one piece and if the system should have been newer and responded, The nebulizer equipment should be taken apart after each use, rinsed and dried. All oxygen related equipment is changed weekly and dated on the night shift Saturday. It should have had a date of 9/11/22. Resident #101 Review of Resident #101's Admission Record, revealed medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #101's physician orders, read in part, [MEDICATION(S)] Nebulizer Solution 2.5 mg/3ml (milligrams/milliliter) 0.083%, 3 ml inhale orally via nebulizer every 2 hours as needed, start date 9/8/22 and oxygen 3 liters per nasal cannula, start date 9/8/22. On 9/13/22 at 9:10 AM, an observation was made of Resident #101 in his room lying in bed. Resident #101 had an oxygen concentrator that was connected to a humidification bottle, delivering 3 liters of oxygen via nasal cannula. Resident #101's oxygen tubing and humidification bottle both were not dated indicating the last time the equipment was changed. On 9/14/22 at 9:30 AM, an observation was made of Resident #101's nebulizer machine and equipment in his room. The nebulizer machine was sitting on his bedside dresser. The equipment was in a graduated cylinder. The medication administration container and the t-piece connector were connected and had visible areas of fluid and condensation noted within them. Resident #101 was also noted to have an oxygen concentrator in his room with a bubbler attached to the concentrator and it was noted that the bubbler was empty, not dated, and not bubbling. It was also noted that Resident #101's oxygen tubing was lying on the floor and there were food crumbs and trash on the floor near the tubing. An interview was conducted on 9/14/22 at 9:35 AM, with RN F regarding Resident #101's oxygen equipment. RN F confirmed that all oxygen equipment should be dated, the nebulizer equipment should be taken apart, rinsed and dried after being used, and the bubbler should not have been left empty. On 9/14/22 at approximately 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked how often the oxygen equipment and supplies were changed and responded, Weekly on Saturday during night shift and are dated when changed. Review of facility policy titled Use of Oxygen, revised 8/17/2021 and provided by the DON, read in part, Policy: To promote guest/resident safety in administering oxygen. The following guidelines will be observed in oxygen. I. The O2 (oxygen) cannula or mask should be changed weekly and dated. II. The tubing should be kept off the floor .VI. The O2 equipment should be cleaned regularly . Review of facility procedure titled Nebulizer Therapy Small Volume, no date and provided by the DON, read in part, .Rinse the nebulizer with sterile or distilled water and allow it to air-dry .

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced by not following accepted procedures for the cooling of a hot potentially hazardous food (Hamburgers in gravy) to ensure appropriate time frames were met. This deficient practice has the potential to result in food borne illness among any or all of the 40 residents in the facility. Findings include: It is noted here that the majority of food preparation, including cooking, storage and transportation of hot and cold foods to this surveyed facility originates in the kitchen of its' sister facility across the parking lot known henceforth as CPHC. On 6/14/21 at 2:39 PM observations of the CPHC kitchen were made during the initial tour. At this time a stainless steel pan, partially covered with aluminum foil was observed in two door refrigerator in the dry storage room. Writing on the foil identified the contents as [NAME] in gravy. No other information was written on the foil. The temperature of the product was measured using a Super Fast metal stem thermometer and found to be 94°F. At 4:30 PM, a return visit to the kitchen was conducted. The same pan of [NAME] in gravy was observed in the freezer and measured to have an internal temperature of 59°F. An interview was conducted at this time with dietary cook C and asked about the pan of [NAME] gravy in the freezer. Cook C stated he knew nothing about the pan being cooled, that no one had told him about it and it was probably put in there by the morning cook. When asked about the expectation of tracking the cooling time, Cook C stated that staff are to put the date and time the product was put in the freezer with the starting temperature. A review of facility policy DOP 506.00 Food Safety and addendum to the policy dated 4/2015 states: Food will be timestamped upon initiation of cooling procedure. Staff will utilize the time stamp in order to ensure compliance is maintained with rapid cooling guidelines. The facility could not provide any evidence as to when the product was placed into the cooling unit or the temperature at which the cooling was beginning. Review of the 2013 FDA Food Code, 3-501.14 Cooling, revealed: (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); P and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less.

Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria pathogen in the facility water system, in accordance with QSO 17-30 Hospitals/CAHs/NH, Revised 7-6-2018, and failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential to allow for the proliferation and transmission of the bacteria in the circulating water of the building and the spread of Legionella infections in all 40 residents. Findings include: On 6/15/21 at 9:44 AM, an interview with Maintenance Director/ Staff A was conducted to review the facility's WMP for the control of Legionella in the water supply system. Staff A' presented data from monitoring maintenance related issues in the water supply, but did not present any specific plan related to Legionella control concerning a water management team, critical limits and corrective action when critical limits were not met. A system to evaluate the program was also absent. The following components were absent from the facility WMP : A. The water management team consisting of facility and non-facility staff who are integral in assessing and responding to Legionella risk. B. Identification of critical limits related to the risk areas and control measures identified and which can be utilized to control the growth and spread of Legionella C. Identification of interventions/procedures to follow when critical limits are not met. D. An evaluation process to determine how the WMP is functioning.

Based on observation, interview, and record review, the facility failed to correctly implement an over-toilet shower chair according to the manufacturer's guidelines for one (#23) of six Residents reviewed for falls. This deficient practice resulted in Resident #23 sustaining a major injury ([MEDICAL CONDITION]), a decrease in Activities of Daily Living (ADLs) and increased pain. Findings include: Review of Resident #23's Minimum Data Set (MDS) assessment, dated 8/7/19, revealed the following active Diagnoses: [REDACTED]. Resident #23 scored 00 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of severely impaired cognition. Resident #23 needed extensive, two-person assistance (resident involved in activity, staff provide weightbearing support) with toilet use and transfers and was frequently incontinent of bowel and bladder. Review of the Resident Assessment Instument (RAI) Version 3.0, p. J-31, describes major injury as including bone fractures. On 9/7/19 at 2:47 pm, Resident #23 was observed in her room, lying in bed with her eyes closed. Resident #23 did not respond to a knock at the door or calling of her name. Review of Resident #23's document titled, Incident and Accident Report completed by Registered Nurse (RN) G on 9/28/19, revealed Resident #23 was found on her bathroom floor by an unnamed Certified Nurse Aide (CNA) on 9/28/19 at 7:00 PM, RN G documented Resident #23 was found lying on her back, with her left leg extended and right leg flexed, clutching her left hip with her left hand. Resident #23 complained of left hip pain and was transported to the emergency room (ER) by ambulance. Review of Resident #23's Post Fall Evaluation signed by RN G, dated 9/28/19, revealed the question, What did the resident say they were trying to do just before they fell ? RN G documented Resident #23 reported trying to go to the bathroom. A review of Resident #23's emergency room (ER) Provider notes, dated 9/28/19, revealed per report from the nursing home .(Resident #23) fell , while she was going to the bathroom. The ER report revealed a left trochanteric femur fracture ([MEDICAL CONDITION]). A review of the Skilled Nursing Facility Brief Visit Note, dated 9/30/19 and signed by Resident #23's attending physician, revealed Resident # 23 had a fall when she was transferring to the toilet and sustained a comminuted (break or splinter of bone into more than two fragments) fracture of her left inter trochanter (left [MEDICAL CONDITION]). The note revealed Resident #23's Power of Attorney decided against surgical repair of the fracture due to increase (sic) risk of intraoperative and postoperative death. Resident #23's attending physician documented the goal of treatment is to optimize her life and achieve pain control as best as possible .She is at risk of pneumonia due to bedbound status and UTI (urinary tract infection) due to Foley (urinary catheter). Review of Resident #23's progress note written by RN G, dated 9/29/19 at 2:45 AM, revealed RN G was notified during shift report at 7:00 PM on 9/28/18, Resident #23 had been found on the floor of the bathroom . RN G documented CNA stated she heard a crash and entered the bathroom to find patient on the floor . (Resident #23) appeared to have been attempting to self-transfer in the bathroom and fell while trying to pull down her brief .upon assessment it was noticed that (Resident #23's) toileting chair wheels were not locked. RN G described the positioning of Resident #23 as lying on her back, left leg extended fully and right leg flexed. Resident #23 was transported to the ER for evaluation, and fall interventions were put in place within the facility including making sure that all non-stationary toileting chairs are in locked position at all times. In a telephone interview on 10/10/19 at 9:45 AM, RN G reported during shift report at the nurse's station on 9/28/19 at 7:00 PM she was approached by CNA H and informed Resident #23 had fallen. RN G stated she immediately went to Resident #23's room and found Resident #23 on the floor of the bathroom in her room. RN G stated it appeared she was attempting to self-transfer because her wheelchair was in front of the toilet and her brief was pulled down. RN G explained Resident #23 was one of our biggest fall risks and added Resident #23 had attempted to self-transfer on other numerous occasions. When asked what was found during the Post Fall Evaluation, RN G replied, There was an issue with the over-the-toilet chairs, the wheels were not locked. RN G stated she had immediately called the Director of Nursing (DON). RN G stated the DON was informed the wheels of the shower chair positioned over the toiled had been found unlocked. RN G reported the night shift staff were instructed to check all over toilet shower chairs to be sure the wheels were locked and to check on all high fall risk residents regularly. RN G stated after the incident involving Resident #23, the facility began the process of replacing the wheeled over toilet shower chairs with stationary chairs. An observation on 10/9/19 at 5:10 PM, revealed a wheeled, shower chair positioned over the toilet in Resident #23's bathroom. Printed on the right leg of the shower chair was (Manufacturer Product Name). On 10/9/19 at 5:25 PM, RN M was asked for the manufacturer's guide for the over toilet shower chairs used by the facility. RN M handed this surveyor a two-sided form with the manufacturers name titled, Operation Instructions. Review of the operation instructions revealed the instruction to L[NAME]K ALL CASTERS BEFORE TRANSFER. An interview with the DON on 10/10/19 at 9:45 AM, revealed the DON had been notified by telephone of the incident involving Resident #23 on 9/28/19 at approximately 7:00 PM. The DON reported upon notification of the incident she immediately departed for the facility to conduct an investigation. The DON was asked if she was aware the toilet chair wheels had been found unlocked when Resident #23 was found on the floor in her bathroom. The DON reported she was informed by RN G, Resident #23's over toilet shower chair wheels were not locked at the time of the Resident's (#23) fall. The DON reported she had completed an Incident and Accident Report in addition to the report completed by RN G as part of her investigation. The DON presented the report to this Surveyor. Review of the undated Incident and Accident Report completed by the DON, revealed a summary of the event which included CNA (H) .observed Resident (#23) on bathroom floor on her back, holding her head up, holding her left hip, stating my leg hurts . At that time CNA (H) noted that Resident (#23) brief/pants were pulled half down CNA (H) noted the shower chair placed over toilet was only slightly turned toward the sink, (otherwise) still in position over (the) toilet. The DON documented Resident #23 had been helped in toileting on 9/28/19 at 2:30 PM, and had been offered assistance only once on 9/28/19 from 3:00 PM to 7:00 PM. In the Conclusion section of the summary, the DON documented Resident #23 was found in the bathroom with pants/brief partially down left buttock indicating that she was trying to transfer herself to the toilet. In a telephone interview with CNA H on 10/10/19 at 11:18 AM, CNA H indicated she was at the nurses' station during shift change on 9/28/19 at 7:00 PM. CNA H reported during shift change report she heard a sound like a crash. At that time, CNA H indicated she was worried someone had fallen. CNA H stated after hearing the crash she immediately checked the rooms closest to the nurses' station but did not find anything of concern. CNA H revealed she finished shift report then helped a Resident to the restroom and upon returning to the nurses' station noticed Resident #23's roommate sitting in her wheelchair in the doorway of the room. At that point, CNA H entered the room and saw Resident #23's wheelchair in the bathroom and Resident #23 lying on the bathroom floor. CNA H reported I thought she must have self-transferred. CNA H was asked to describe how Resident #23 was positioned on the floor. CNA H replied Resident #23 was found on her back, with her feet closest to the toilet and her head by the cabinet. CNA H reported she could not remember if the wheels were locked on the chair positioned over the toilet, although the chair was turned slightly in the position the Resident (#23) had fallen. CNA H reported after she found Resident (#23) lying on the floor, she asked another CNA to alert RN G of the incident. During an interview on 10/9/19 at 5:50 PM, RN O was asked if a Significant Change Assessment had been completed for Resident #23. RN O replied the assessment was not yet completed. Asked if the Significant Change Assessment would show a change in functional status regarding ADLs, RN O replied the assessment would show a big change. A review of Resident #23's Care Plan revealed revisions, dated 9/30/19, included: 1) (Resident #23) is at risk for urinary tract infection and catheter related trauma; 2) actual alterations in completing ADLs related to left [MEDICAL CONDITION] .requires total lift assistance with 2 caregivers, use a medium full body sling, and; 3) actual alteration in comfort related to fracture of her left (hip). The point of care (P[NAME], CNA care documentation) documentation for the time period 9/10/19 through 10/9/19, revealed Resident #23 required extensive assistance with Toilet use: Self-performance 60 times and required limited assistance 21 times during the 18 days prior to the incident on 9/28/19. Review of the P[NAME] summary indicated after the incident on 9/28/19, Resident #23 required extensive assistance 19 times and was totally dependent on staff 37 times during the 11 days after the incident. Review of Resident #23's Medication Administration Record [REDACTED]. The record indicated Resident #23 was assessed as having no pain (0 on a scale of 10, (10 being the highest)). from 9/1/19 through 9/27/19. After the incident on 9/28/19, Resident #23 was assessed to have experienced pain (ranging in severity from 3 to 7 on a scale of 10 (10 being the highest)), on 13 of 19 shifts assessed from 9/30/19 to 10/9/19. A review of Resident #23's Order Summary Report for the time period of 8/1/2019 - 10/9/19 revealed the following active orders were entered after Resident #23's unwitnessed fall on 9/28/19: 1) Non-weight bearing on the LLE (left lower extremity) every day and night shift, ordered 9/30/19; 2) [MEDICATION NAME] 5 milligrams (mg), give 1 tablet by mouth every 6 hours as needed for pain, date 9/30/19; 3) [MEDICATION NAME] 5mg, give 1 tablet by mouth every morning and at bedtime for pain, dated 9/30/19; 4) [MEDICATION NAME] sulfate solution 20mg/milliliter (ml), give 5mg by mouth every 2 hours as needed for pain, dated 10/9/19, and; 5) [MEDICATION NAME] sulfate solution 10mg/ml, give 10mg by mouth every 2 hours as needed (may increase to 10mg as needed), dated 10/9/19. A review of the facility's policy titled, Fall Management, revealed The facility will identify hazards and resident risk factors and implement interventions to minimize falls. Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervison (and) assistive devices . to minimize the risk for falls. During an interview on 10/10/19 at 10:37 AM, the NHA was asked what his expectation was regarding the engagement of wheels on a shower chair placed over the toilet. The NHA answered They should be locked.

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety as evidenced by not maintaining potentially hazardous food on the steam table at proper temperature. This deficient practice has the potential to result in a food borne illness among any or all the 53 residents: Findings include: It is noted here that the majority of food preparation, including cooking, storage and transportation of hot and cold foods to this surveyed facility originates in the kitchen of its' sister facility across the parking lot known henceforth as CPHC. On 10/07/19 at 11:30 AM, observations of the noon meal preparation and service were conducted. A deep (6) stainless steel pan of tuna salad was observed sitting on a bed of ice. The internal temperature of the tuna salad was measured using a metal stem Super Fast Thermapen thermometer and found to be 54 °F . At 11:35 AM Certified Dietary Manager (CDM) A was observed measuring the temperature of the tuna salad with a metal stem digital probe thermometer and reported the temperature to be 52°F. CDM A instructed her staff to put the product into smaller containers and place them in the freezer to cool the product down. An interview with CDM A was conducted at 11:40 AM and asked what the temperature of the tuna salad was when it was placed in the container before it was transported from CPHC to this facility. CDM A called dietary manager B at the preparing kitchen and reported back the tuna salad had been measured to be 41°F prior to leaving. At 11:55 AM, observations were made at the originating (CPHC) kitchen with Staffs B and [NAME] An interview with Staff B was conducted and asked about the tuna salad being served in his building. Staff B stated he had found the temperature to be 54°F (for the portions being served in his building) and I had the staff put it in the freezer to cool it. When asked when the tuna salad had been prepared, Staff B stated Just this morning. Staff B was asked to demonstrate the last time the product had been verified to be at or below 41°F. Staff B opened the food preparation temperature log and looked through it and stated It's not in here. Staff B then questioned the kitchen staff to determine when and who had prepared the salad. Kitchen manager D stated That was prepared on midnights last night. It was done when we got in this morning. When asked if there was any verification the product had ever met proper holding temperatures, Staff B stated It doesn't look that way. At 12:15 PM observations were once again made in the kitchen and serving area for this surveyed facility. Staff A was asked what the course of action was for the tuna salad for the noon meal. Staff A stated We are cooling it down, when it is 41°F, we can serve it. At this point staff A was instructed to dispose of the tuna salad based on the information showing the food had been held at proper temperatures being absent. It was explained to Staff A that there was no evidence the food product was ever in compliance with food holding temperatures (41°F or below) and the product could not be deemed safe to serve to residents. On 10/08/19 at 12:03 PM observations of the food service serving ling were made. Dietary Staff [NAME] was asked if the food on the steam table had been checked and verified for proper temperature to which [NAME] responded Yes. It was 170°F. The internal temperature of a 4 deep pan of manicotti was measured using a metal stem probe Super Fast Thermapen thermometer. The following temperatures were measured at various locations in the middle of the product while sitting in the steam table: 112°F; 122°F; 117°F; 115°F. Staff [NAME] was requested to use a facility thermometer to check the temperature of the manicotti, next to this surveyor's thermometer in the product. Staff [NAME] placed a metal stem digital probe thermometer in the manicotti, next to the surveyor's Thermapen thermometer and reported 112°F; 122°F and 118°F. Staff [NAME] then pushed her thermometer to the bottom of the pan and reported a temperature of 155°F. An interview with CDM A was conducted at this same time and asked what the sending facility had reported for the temperature when it had been sent. Staff A stated They said it was 179°F. On 10/8/19 at 12:15 PM CPHC dietary manager B arrived in the kitchen and requested this Surveyor take temperatures of the manicotti again. Staff B, using a large steel serving spoon, pulled a portion of the manicotti up from the lower levels of the pan, placed his metal stem probe thermometer in the product and reported a temperature of 155°F. Staff B was then directed to place his thermometer into the center portions of the pan to obtain accurate readings of the internal temperature of the product. Staff B reported temperatures of 112°F and 124°F when measuring the product in the proper manner. Staff A and Staff B were asked what the plan for the food was, to which Staff B stated We need to heat that to 145°F before we can serve it. When asked about the source of the product, Staff B stated It was a {Vendor} product, which is frozen and we just heat it. When asked why he stated it only needed to be reheated to 145°F, Staff B stated It's not a re-heat. When it was explained that the product had been prepared and frozen elsewhere, and being reheated, the requirement for attaining 165°F for a minimum of 15 seconds applied. Staff B stated I see that now. The FDA Food Code 2013 states: 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: (6) Stating the required FOOD temperatures and times for safe cooking of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD including MEAT, POULTRY, EGGS, and FISH; (7) Stating the required temperatures and times for the safe refrigerated storage, hot holding, cooling, and reheating of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above (2) At 5ºC (41ºF) or less 3-403.11 Reheating for Hot Holding. (A) Except as specified under ¶¶ (B) and (C) and in ¶ (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74°C (165°F) for 15 seconds.

Based on interview and record review, the facility failed to ensure adequate staffing to answer call lights timely for six residents (Resident #3, #19, #30, #32, #38, and #C-1) of fifteen residents reviewed for call light timeliness. This deficient practice resulted in feelings of frustration, and the potential for falls, incontinence, and skin pressure injuries. Findings include: Review of Resident #3's Minimum Data Set (MDS) assessment, reference date 6/23/19, revealed Resident #3 required total assistance for transfers, and two-person assistance with toileting. Resident #3 was 'always incontinent' of urine and 'frequently incontinent' of bowel. The Brief Interview of Mental Status (BIMS) assessment revealed a score of 15/15, which indicated 'cognitively intact'. During an interview on 10/08/19 at 10:51 a.m., Resident #3 reported, At night, the call light wait is extendedly long. (I need) two-person assistance to change my brief and get my gown on .sometimes it is 45 minutes . Resident #3 was asked what would be a reasonable amount of time to wait, and responded, A half hour (30 minutes). During the confidential group meeting on 10/08/19 at 2:00 p.m., Resident #3 reported she felt frustrated and mad; I get mad sitting (with incontinence) . when her call light was not answered timely. Review of Resident #30's MDS assessment, reference date 8/14/19, revealed Resident #30 required two-person assistance with transfers and toileting. Resident #30 was 'occasionally incontinent' urine and 'frequently incontinent' of bowel. The BIMS assessment revealed a score of 13/15, which indicated 'cognitively intact'. During an interview on 10/07/19 at 1:30 p.m., Resident #30 reported, They (staff are) late to answer the bell (call light) .(I wait) over an hour .maybe 10 minutes would be acceptable . Resident #30 reported feelings of frustration related to call light response times, and asked this Surveyor to look into her concern. Resident #30 demonstrated the ability to push her call light and could read the digital clock in her room accurately. Review of Resident #C-1's BIMS assessment, reference date 6/27/19, revealed a score of 15/15, which indicated 'cognitively intact'. On 10/08/19 at 2:00 p.m., during the confidential group meeting, Resident #C-1 reported the longest time he waits for the call light is 20 minutes; 10 (minutes) would be reasonable .I wear a brief; it frustrates me. This Surveyor asked how often this happens and when, and Resident #C-1 responded, (On the) Day shift, they (the facility staff) don't have enough help . and added, It happens frequently; a lot of days . During an interview on 10/10/19 at 11:12 a.m., the Nursing Home Administrator (NHA) was notified about reports of excessive call wait times by residents, from 20 minutes to 45 minutes, and up to an hour. The NHA responded, The upper times are too long to wait. When asked the amount of time expected for staff to answer call lights, the NHA responded, It depends on the time of day. If you (residents) are ringing at a high demand time (such as at meals) of day, 15 minutes would be a reasonable expectation. (Otherwise), I would expect it (the call light) to be answered in five minutes. This Surveyor asked the NHA if there is a system of management notification or monitoring in place. The NHA responded, There is no system to log into to check (call light wait times). We're definitely going to do something to monitor (call light timeliness), and acknowledged there was no call light monitoring at the time of this interview. The facility policy, Call lights, revised 6/2017, provided by the NHA on 10/10/19 at 11:45 a.m., did not include a time considered acceptable to answer call lights, a means of management notification, or a process for monitoring call light timeliness. The facility assessment, signed 11/21/18 by the NHA, revealed The Facility's average daily census over the past 12 months: 57 .Number of residents who require assistance with transferring: 52 .Number of residents who require assistance from staff with toileting: 51 .Overall acuity of care, isolation considerations, individual resident conditions, available and attainable resources, are taken into consideration. Staffing needs are based on census, resident's acuity, needs and plan of care . Resident #19 Review of Resident #19's MDS assessment, dated 8/1/19, revealed Resident #19 scored 14 of 15 on the BIMS, reflective of intact cognition. Resident #19 required extensive, two-person assistance for toileting, and was occasionally incontinent of urine, and frequently incontinent of bowel. During an interview on 10/7/19 at 1:54 p.m., when asked about adequate staff to address call lights, Resident #19 stated, They absolutely do not have enough staff. There have been times that I was within on the bed pan for half an hour before they answered the call light. My bottom was very sore, that is for sure. Resident #32 Review of Resident #32's MDS assessment, dated 8/16/19, revealed Resident #32 scored 15 of 15 on the BIMS, reflective of intact cognition. Resident #32 required limited, one-person physical assistance with toileting. During an interview on 10/7/19 at 12:24 p.m., when asked about call light response times, Resident #32 stated, They don't have enough staff. When asked how long it may take staff to respond to her call light, Resident #32 stated, Well, wouldn't you say 30 minutes is too long. Because I can do a lot of things myself, they (facility staff) tend to ignore me. They just don't have enough staff. Resident #38 Review of Resident #38's MDS assessment, dated 8/23/19, revealed Resident #38 scored 15 of 15 on the BIMS, reflective of intact cognition. Resident #38 required extensive, one-person assistance with toileting. During an interview on 10/7/19 at 2:04 p.m., when asked about staff response to call lights, Resident #38 stated, Sometimes it takes them a little while to come. When asked what a little while meant, Resident #38 stated, A little while is about a half hour .

Based on interview and record review, the facility failed to provide written notice of transfer to the resident representative for one Resident (#104) of two residents reviewed for transfer/discharge. This deficient practice resulted in the potential for the resident/resident representative being uninformed of their rights and/or unnecessary transfer/discharge. Findings include: Review of Resident #104's Face Sheet revealed Resident #104 had a Responsible Party, POA (Power of Attorney) Financial, and POA Care individual in place for decision-making. Review of Transfer Notices for Resident #104 on 5/28/19, 6/8/19, and 6/26/19 revealed the written transfer notice was provided to: (Resident #104) at 1630 (4:30 p.m. Central Standard Time (CST)) upon transfer to the ER (emergency room ) on 5/28/19, Resident (#104) and (Name of Emergency Transport) upon the transfer to the ED (emergency department) on 6/8/19, and Transfer form was provided to EMS upon arrival to facility on 6/26/19. Review of Resident #104's Electronic Medical Record (EMR) eINTERACT Transfer Form for 5/28/19, 6/8/19, and 6/16/19 revealed the following: Resident/Patient Decision Making Capacity? Requires Proxy and listed the Resident Representative as Guardian on all three forms. Review of the (MONTH) 2019 and (MONTH) 2019 Transfer Logs revealed Resident #104's transfers, on 5/28/19 and 6/8/19, were not documented on the forms for inclusion and submission to the Ombudsman. On 10/9/19 at 4:05 p.m., when asked about notification to the Ombudsman of Resident #104's transfers on 5/28/19 and 6/8/19, Social Services Designee (Staff) J stated, We only have notice to the Ombudsman for 6/26/19. We do not have notification (to the Ombudsman) for the other two transfers. During an interview on 10/10/19 at 7:55 a.m., when asked about notification of transfer in writing to the responsible party and the Ombudsman, the Nursing Home Administrator (NHA) stated, I am aware that notification in writing does need to be provided to the resident (if cognitively intact) or the resident's responsible party. The transfers for (Resident #104) should have been included in the monthly notification to the Ombudsman. When asked if there was evidence that the responsible party had received the written notification, the NHA said the facility did not have any evidence that the resident's representative had received the written transfer notice.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent pressure on an existing right heel pressure injury for one Resident (#48) of three residents reviewed for pressure injury care and services. This deficient practice resulted in the potential for worsening of Resident #48's right heel pressure injury and delayed wound healing. Findings include: Review of Resident #48's Minimum Data Set (MDS) assessment, dated 9/13/19, revealed Resident #48 was admitted to the facility with the following active Diagnoses: [REDACTED]. Resident #48 scored 14 of 15 on the Brief Interview for Mental Status, reflective of intact cognition. Resident #48 required extensive to total dependence with two-person assistance with bed mobility, transfers, toilet use, and bathing. Section M - Skin Condition documented Resident #48 at risk for developing pressure injuries, and the presence of one Stage II pressure injury (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister.) that was present upon admission (9/6/19). Review of Electronic Medical Record (EMR) weekly Wound Evaluations revealed Resident #48 was admitted with a Stage II right heel wound (fluid filled blister) on 9/6/19. The wound measurements included the following: 9/18/19: Length 1.68 cm (centimeters) x Width 1.16 cm, Area of 1.39 cm squared. 9/25/19: Length 1.63 cm x Width 1.27 cm, Area of 1.61 cm squared. 10/1/19: Length 1.44 cm x Width 1.52 cm, Area of 1.9 cm squared. Treatment included: Additional Care: 9/10/19 Mattress with Pump, and Turning/repositioning program .9/18/19: Cushion, Mattress with Pump, Other, Turning/repositioning . 9/25/19: Cushion, Heel Suspension/Protection device, Mattress with Pump .Turning/repositioning program .10/1/19: Cushion, Heel Suspension/Protection device, Mattress with Pump, Mobility Aid(s) provided .Turning/repositioning program . On 10/8/19 at 4:15 p.m., Resident #48's right foot was observed lying directly on the bed, with the blanket positioned tautly over and under the foot, with the right heel resting on the mattress. A gripper sock was on the right foot. Registered Nurse (RN) N removed Resident #48's right sock revealed a pressure injury on the right heel. The skin on the right heel, surrounding the wound, was reddened. No pillows/cushions were present on the bed, floor, or surrounding furniture to elevate the right heel, or the amputated left lower leg off the bed. On 10/8/19 at 4:25 p.m., Resident #48's Face Sheet, MDS assessment, and Care Plans were requested from RN/MDS Coordinator O. When asked who was responsible for care plan updates, RN O stated, Everybody does the care plan interventions . (RN M) will initiate the skin care plan . primarily it is (RN M's) care plan. Review of Resident #48's skin care plan revealed the following, in part: (Resident #48) has actual alterations of skin integrity present on admission to the facility. The areas include .stage 2 pressure injury to right heel .He continues to be at risk for impaired skin integrity/pressure injury R/T (related to): diabetes mellitus, decreased mobility and weakness .Revision on 9/25/19. Interventions included: Cue to reposition self at least every 2 hours and assist as needed. Date Initiated 9/25/19 .Pressure relieving mattress to bed .Date Initiated: 8/23/19 .Provide treatments as ordered. Date Initiated 8/23/19 . Resident #48's ADL (Activities of Daily Living) Care Plan, included the following intervention: BED MOBILITY: requires extensive assistance of 2 to reposition and turn in bed. Date Initiated 8/23/19. On 10/8/19 at 4:40 p.m., when asked about elevation of the right heel, off the bed, Resident #48 said he had never refused elevating his right heel off the bed to reduce pressure, nor had he worn any protective boot to keep pressure off of the right heel. Resident #48 was observed lying in bed with his right knee bent, and his foot/heel directly on the bed. No pillows/cushions/ or protective footwear was visible in the room, other than the pillows supporting Resident #48's head. On 10/8/19 at 4:45 p.m., when asked what interventions would be put in place for a resident with a heel pressure ulcer, Wound Care RN M stated, Elevate, elevate, elevate. When asked if Resident #48 had elevation of his right heel in the care plan interventions, RN M stated, I got him a (Name Brand) mattress. It is top of the line. When asked if that prevented pressure to his heel if lying in bed, RN M stated, No. On 10/9/19 at 11:31 a.m., when asked what assistance was provided to Resident #48 to related to his pressure injuries, Certified Nurse Aide (CNA) P stated, (Resident #48) likes a pillow underneath his left amputated (foot) leg when he is in bed .We have a brace for his right foot, with his shoe - I am not sure what that is for .He just like one pillow underneath his amputated leg. CNA P said Resident #48 did not have a protective boot or use pillows or cushions to elevate his right heel off the bed to prevent/reduce pressure. On 10/9/19 at 11:36 a.m., related to care for Resident #48, CNA L stated, He needed to be positioned often, because of his amputated (left) leg. With the right leg (foot) he can push up his heel to get up (higher) in bed .The amputated leg needs to be a little elevated. We put it on a pillow sometimes .No, he didn't need to have the other leg (right) leg elevated because he usually had it bent anyway (with pressure on the right heel) . On 10/10/19 at 10:45 a.m., a copy of Resident #48's Kardex (CNA care guide) was received from RN Q that included interventions pertaining to elevating the right heel and elevating heels while in bed with cushion. Review of Resident #48's care plan, received on 10/10/19 at 11:00 a.m., revised 10/8/19 by RN M, found the following new interventions: Education provided to (Resident #48) on the importance of elevating right heel while in bed related to pressure injury .Date Initiated 10/8/19 .Elevate heel while in bed as tolerated with provided cushion. Revision on 10/8/19 . Neither of these interventions were present on Resident #48's care plans received on 10/8/19 from RN O. On 10/10/19 at 7:45 a.m., the Nursing Home Administrator (NHA) was informed of the concern related to observation of Resident #48's right heel in direct contact with the bed, lack of specific interventions to prevent delayed healing/worsening of the pressure injury, staff reports of the resident using his right heel to boost himself up in bed, and lack of elevation or protective footwear to reduce pressure to the right heel. The NHA expressed understanding of this Surveyor's concern with deficient practice related to pressure ulcer care. On 10/10/19 at 8:55 a.m., when asked about the lack of protection, interventions, and/or measure to prevent worsening or delayed healing of Resident #48's right heel pressure injury, the Director of Nursing (DON) stated, I think we are doing all those things. I just think it is a care plan issue. When informed Resident #48's right heel had been observed in direct contact with the bed during all observations while in bed, the DON stated, Oh.

Based on observation, interview, and record review, the facility failed to protect and maintain residents' private room accommodations to ensure residents privacy from unannounced visits by other residents, for three residents (Resident #C-3, #C-4, and #C-5) of six residents reviewed for resident rights. This deficient practice resulted in residents reporting a non-homelike environment, lacking privacy and dignity, and the potential for psychosocial harm. Findings include: Review of Resident #C-3, #C-4, and #C-5's Minimum Data Set (MDS) assessments, reference dates in 2019, revealed the Brief Interview of Mental Status (BIMS) assessment showed all three were 'cognitively intact'. During an observation on 10/07/19 at 1:49 p.m., Resident #39 was observed wheeling her manual wheelchair into a male resident's room next to her room. Review of Resident #39's progress notes revealed: 10/07/19 at 2:44 p.m.: .Exit seeking and attempting to go into other rst (resident) rooms multiple times during shift . 10/05/19 at 15:18 (3:18 p.m.): Resident up ad lib (on her own) in her wheelchair, wandering in and out of other resident's rooms . 10/03/19 at 2:14 p.m.: Resident was very agitated and appeared anxious .Attempted to go into other resident rooms, and staff was unable to redirect rst (resident) without rst becoming agitated and aggressive, yelling 'No, I want to go into this room . 9/29/19 at 4:51 a.m.: Resident has had the usual behaviors this evening. Going in and out of people's (residents) rooms . 9/27/19 at 1:45 a.m.: Rst (resident) appeared anxious .attempted to go into rooms of other residents .continued behavior for many hours throughout shift . Review of Resident #39's Care Plan, revised 9/11/19, revealed: .When distress (sic), (Resident #39) gets more confused rummage (sic) .everyone (sic) belongings and roving around the facility .Observe wandering behavior and attempt diversional interventions when wandering into inappropriate locations such as other resident rooms when not invited . During the confidential group meeting on 10/08/19 at 2:30 p.m., Resident #C-3 reported, Residents are wandering into my room, (at) all times, all hours of the day and night. (Resident #39) does it day and night; (Resident #39) will come into my bathroom. I put my clothes in the bathroom for the next day, and one day (Resident #39) moved my clothes, a couple months ago. (Resident #39) comes in and wakes me up all the time .I don't like to be woken up .(having other residents in my room) frustrates me sometimes . During an interview on 10/08/19 at 2:40 p.m. during the confidential group meeting, Resident #C-4 reported, (Resident #37) comes into my room but doesn't focus on anything. I usually get her to sit on my bed. (Resident #C-4's roommate) starts screaming and gets upset. I don't like a [AGE] year-old (resident) upset; she (Resident #C-4's roommate) is scared and she yells for them (staff) to get her out and she is afraid things are going to get broken. Neither one of them understands . This Surveyor asked if Resident #37 leaves when she is asked. Resident #C-4 replied, No, not usually .As a resident, it frustrates me .It bothers some of the families. They are short-staffed on the weekends .The girls (staff) are running. (Resident #39) comes into my room. I have to try to get her back into her chair (wheelchair). They need one of them (staff/aides) in the hallway with these residents .The one time it bothered me is when (Resident #37) tried to get in bed with (Resident #C-4's roommate). I grabbed her shirt by the tail , I tugged on it and she looked at me. I use my light (call light) now .If the bed is empty, she goes in, and they have to get her out of the bed; she refuses most of the time . During an interview on 10/08/19 at 3:57 p.m., after the confidential group meeting, Resident #C-5 asked to see this Surveyor privately, and reported, .It's hard when they don't have enough people working . Some of them has (sic) Alzheimer's (dementia disease) and they (residents) don't know where their room is .I'm awake late. They come (in at) all times, anytime. One is (Resident #37); she is the worst one of all. I say, 'This is not your room.' It's been for me at nighttime; she (Resident #37) hides behind the door of my room. She crawls on the floor so the staff couldn't (sic) see her; that was a while ago. (Name of Resident #C-5's roommate) is scared of her .(Resident #37) takes things. I have seen her in my closet . During an interview on 10/09/19 at 7:39 a.m., Laundry Supervisor/ Staff I, was asked about residents wandering in and out of rooms and taking items. Staff I responded, I know (Resident #37) does I see her (Resident #37) sometimes walking down the hall with someone else's (resident's) clothes on. One time there was a missing blanket .(Resident #37) does go into other people's (residents) rooms and leaves things and takes things . This Surveyor asked what is being done. Staff I stated, I don't know what is being done .they (other staff) take care of that, the aides or social services .We tell the aide she (Resident #37) has so and so's (a residents) clothes on .She changes a million times a day. We usually keep her roommates' clothes in her roommate's drawer, so she doesn't take them . During an interview on 10/09/19 at 8:37 a.m., Certified Nurse Aide (CNA) K was asked about residents wandering into other residents' rooms. CNA K responded, Our main wanderers are (Resident #37) and (Resident #39). (Resident #39) gets lost; she thinks it is her room .I see (Resident #37) take tissue boxes; she shoves spoons up her shirt. I have seen her wearing other people's clothes .Sometimes she grabs people's headbands. With her, she does have violent behavior sometimes .We get the clothes back and put them in the wash . During an interview on 10/09/19 at 8:25 a.m., Nursing Manager/ Registered Nurse (RN) M was asked about residents wandering into other resident rooms. RN M stated, (Resident #37) is observed at times in other residents' rooms .she was in (other Resident Room number) this week, and it was difficult to get her out of there . During an observation on 10/09/19 at 1:30 p.m., Resident #37 was observed entering (Resident #C-4's) room; CNA L saw a Surveyor stop at the doorway, and directed Resident #37 out of the room. Resident #C-4 had her back to the door, and did not appear to see Resident #37 in her room. During an interview on 10/10/19 at 8:23 a.m , the Social Services Designee/ Staff J, was asked if she was aware of Resident #37 and Resident #39 entering other residents' rooms. Staff J responded, Both of them go around room to room .I found out one time (Resident #37) was holding the clothing (of another resident) and changing into a t-shirt she grabbed from another resident. Her former roommate complained so we did a room change .If she sees an item that is familiar to her, she thinks it belongs to her .(Resident #39) is fidgety; most of the time she goes around . looking for a bathroom. She likes to grab tissues: she tucks them in her wheelchair or bed .It's (Resident #37 and Resident #39) who are going in the resident rooms at night. I have heard about it .Most of the time we find her (Resident #37) laying on someone else's bed . The policy, Resident Rights and Responsibilities, revised 5/2017, provided by the Nursing Home Administrator (NHA) in the admission packet on 10/07/19, revealed, Resident Rights .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of .quality of life, recognizing each resident's individuality. E. Respect and Dignity. The resident has a right to be treated with respect and dignity, including .Privacy and confidentiality. The resident has a right to personal privacy .

Based on interview and record review, the facility failed to report an unwitnessed fall with major injury for one Resident (#23) of six residents reviewed for falls. This deficient practice resulted in a [MEDICAL CONDITION] for Resident #23, and the potential for future lack of reporting. Findings include: Review of Resident #23's Minimum Data Set (MDS) assessment, dated 8/7/19, revealed the following active Diagnoses: [REDACTED]. Resident #23 scored 00 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of severely impaired cognition. Review of Resident #23's Incident and Accident Report, signed by Registered Nurse (RN) G on 9/28/19, revealed Resident #23 was found lying on the floor in her bathroom at 7:00 p.m. RN G documented Resident (#23) was complaining of left hip pain. Resident #23 was transferred to the emergency department (ER) with a subsequent transfer to an acute care hospital for evaluation. Resident #23's ER Progress note, dated 9/28/19, revealed Resident #23 had sustained an intertrochanteric [MEDICAL CONDITION] femur (left [MEDICAL CONDITION]). During an interview on 10/10/19 at 10:37 am, the Nursing Home Administrator (NHA) was asked what his understanding of the reporting requirements were for reporting to the State Agency an injury of unknown origin (unwitnessed fall with major injury) with the need to investigate potential abuse/neglect. The NHA acknowledged injuries of unknown origin .should be reported within two hours. When asked why the unwitnessed incident involving Resident #23, which resulted in a fracture of her left hip, was not reported, the NHA replied understanding of the incident was based on the recreation of the event conducted by the Director of Nursing (DON), which showed there was no deficient practice on the part of the facility and therefore, did not need to be reported. Review of the facility Abuse Prohibition Policy, revised 3/2014, revealed in part: 1. The staff will report any allegations or suspicions of mistreatment, abuse, neglect . and injuries of unknown source to the Administrator and DON immediately. 2. The administrator or designee will notify .any State or Federal agencies of allegations per state guidelines.

Based on observation, interview, and record review, the facility failed to maintain clean oxygen concentrators for three Residents (#17, #33, and #43), of eight residents reviewed for respiratory care. This deficient practice resulted in the potential for decreased oxygen supply, exacerbation of respiratory condition, and transmission of infectious organisms. Findings include: On 8/1/18 at 12:00 p.m. an observation of Resident #33's oxygen concentrator outside filter showed it contained dust and debris. During an interview at that same time, Resident #33 reported using the oxygen concentrator the previous night. A second observation on 8/2/18 at 1:40 p.m. found dust and debris still present on the external filter. Heavy dust and debris was visible on the louvers on the outside of the concentrator, directly underneath the external filter. On 8/2/18 at 7:00 a.m. Resident #17's oxygen concentrator was observed to have debris on the back of the outside filter. During an interview on 8/2/18 at 2:15 p.m., Maintenance Director (Staff) D stated, .Nursing (staff) cleans the filters Maintenance doesn't touch (oxygen) concentrators . Staff D confirmed the facility had a contract with an oxygen supply company for oxygen and rental/maintenance of the oxygen concentrators, including internal cleaning and filter change. On 8/2/18 at 2:30 p.m. the Director of Nursing (DON) observed the eight oxygen concentrators, actively in use by residents within the facility, with this Surveyor. Observations and interviews at this time included: room [ROOM NUMBER]: Resident #33's oxygen concentrator's inside filter was dirty and dated 4/25/18. The inside compartment, housing the filter, was layered with dust and debris. room [ROOM NUMBER]: Resident #17's oxygen concentrator's inside filter was dirty and dated 7/18. Thick dust was clearly visible on the louvers near the inside filter. room [ROOM NUMBER]: Resident #43's oxygen concentrator's inside filter was dirty and dated 4/21/18, with thick dust visible in the inside compartment housing the filter. The DON stated, That is dirty too . Review of the facilitie's Use of Oxygen policy, revised 6/2016, read, in part: The following guidelines will be observed in oxygen administration .The O2 (oxygen) equipment should be cleaned regularly .The filter on the concentrator should be checked at least every month and cleaned as needed . On 8/2/18 at 3:14 p.m. the DON reported she had notified the company, contracted by the facility to maintain the oxygen concentrators, of the dirty filters. The DON stated, .Those oxygen concentrators were dirty, and it shouldn't have been that way. Review of the contract regarding oxygen concentrators, dated 8/1/2017, revealed the following agreement, in part: (Company Name) will be responsible for changing the internal filters and performing scheduled maintenance according to manufacturer's Guidelines .The Facility will be responsible to: Clean the external filter on the concentrator weekly . On 8/2/18 at 3:17 p.m. the oxygen supply company owner F was interviewed, by telephone. Owner F stated, .Once a year the inside filter is changed .Our protocol was that we put a date (on the inside filter of the oxygen concentrator). If we did it (cleaned machine and replaced the inside filter) today, we would put 8/2/19 (date of next filter change). When asked about the 4/18 and 7/18 dates found on the inside filters of the dirty oxygen concentrators, Owner F stated, .We could have missed (failed to clean) the machine(s) .

Based on observation and interview, the facility failed to provide a sanitary environment for residents, staff and the public, as evidenced by the lack of back flow and back siphonage protection on the water supply line for the hair wash sink in the beauty shop and not ensuring an air gap existed between the drain line from the bin type ice machine and the overflow rim of the drain into the sanitary sewer. This deficient practice has the potential to affect all 59 residents in the facility if there was back flow of contaminants into the drinking water supply or back siphonage of sewage into the hopper of the ice machine. Findings include: On 5/9/17 at 9:00 a.m., it was observed that the hair wash sink was equipped with a hose type faucet sprayer. The water supply connection was then observed to have been installed totally circumventing the atmospheric vacuum breaker type back flow device. At 9:58 a.m., an interview was conducted with Maintenance Staff A in the presence of the sink who confirmed the water line connection was not directed through the back flow protection device. On 5/9/17 at 10:15 a.m., the drain from the ice machine, located in the dining room, was observed terminating 1 below the over flow rim of the catch funnel, located in the kitchen under the drain boards for the mechanical dish machine. This drain from the ice machine traveled through the wall of the dining room, into the kitchen space, where it terminated at the drain, and was confirmed with an interview with Staff A at 10:20 a.m.