Every finding on record at Clinton Manor Living Center

Based on interview and record review, the facility failed to follow the manufacturer's recommendations by ensuring the sling for a mechanical lift was secure, prior to transfer, for 1 of 3 residents (R2) reviewed for incidents/accidents, in the sample of 5. Findings include: R2's Care Plan dated 4/20/23 documents R2 is transferred via a mechanical lift with the assistance of two staff. It further documents R2 is at risk for falls and the goal is for R2 to be free of falls. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired and requires extensive assistance from two staff members for transfers. On 11/30/2023 at approximately 11:45 AM, V10, Certified Nursing Assistant (CNA) stated, (V7, CNA) and I were transferring (R2) to bed after lunch. I was on (R2's) left side and (V7) was on the right side. We hooked the top and bottom two straps. I swore I pulled down on the sling to make sure it locked into place. I went to raise the machine and (V7) pulled the chair out (from under R2). It happened out of nowhere (R2 falling). (V7) went to the floor to catch (R2's) head and I caught her back/hip area. We lowered her to the floor. The plastic piece from the sling was off. We've had problems with these machines before with other residents. She did have a small little bump on the back side of her head. The front of her leg was bad. It had 3 or 4 shears. (R2's) leg was hanging in the sling. (R2) has paper thin skin. On 11/30/2023 at 1:11 PM, V11, Registered Nurse/Physical Therapy Assistant stated, I have been going around observing the staff using the lift. They are supposed to ensure the sling is hooked in all the way and raise the resident above the surface and then move the chair. I am thinking one of the straps wasn't correctly hooked and became un-hooked during the transfer. On 11/30/2023 at 1:32 PM, V12, R2's daughter, stated R2 fell from the lift during a transfer and added, It could have been really bad if (V7) hadn't caught her (R2's) head. She fell from 4 or 5 feet in the air. On 12/4/2023 at 10:23 AM, V3, Registered Nurse (RN) stated, When I entered the room, (R2) was on the floor and the top left side of the sling was unlatched and hanging down. It was fine when they started to lift her up and pulled the wheelchair out from under her. She fell from a pretty high height, so we sent her to the ER (emergency room ) for x-rays. On 12/4/2023 at 10:45 AM, V7, CNA stated, (V10) was on the left and I was on R2's right side. We hooked her up and as she was going up, I pulled the wheelchair out. Next thing you know, I saw her going down. It was the top left part of the sling. It happened so fast. It was just loose and not hooked all the way. Normally we double check by pushing down on them. It wasn't all the way fastened. It was a complete accident. I did see blood on her legs. Her skin is so thin. R2's Progress Notes dated 11/24/2023 at 4:06 PM documents, This nurse was notified by other nurse that pt (Patient) fell out (mechanical) lift. This nurse went to room and noted pt laying on floor supine (on her backside) head was on pillow and pt was laying on back . Nurse assess pt- neuro (neurological) checks - WNL (within normal limits). VS (Vital Signs)- 98/58, P- 98, R- 20, spo2 97% 97.0F. R2's Progress Notes further documents R2 sustained multiple skin tears to her left thigh and lower legs and was sent to the local emergency room for evaluation. The Facility's Untitled document dated 11/24/2023 documents the mechanical lift hook came undone or was not latched all the way. The Facility's Untitled Document dated 11/24/2023 documents, I immediately went to her (R2's) room where she was laying on the floor with a pillow under her head. (Mechanical lift) was above and only 3 hooks were attached. This document was signed by V6, Licensed Practical Nurse (LPN). The Facility's Untitled Document dated 11/24/2023 documents, (V6) came and told me the (R2) fell out of the (mechanical lift). I went to check on her to find out why this happened. (R2) was laying on the floor on her back. She had skin tears to her legs and (V4) was taking pictures of all the wound obtained from the sling when her feet slid out going down. The (mechanical lift) was still in the air above bed level. The left top latch to the sling was hanging down. The latch was no defective or broken. It was strong and intact. (V10) and (V7) said that the top latch came off and (V7) went to the ground to try and protect her head while (V10) caught her mid-section and lowered her to the floor. This document was signed by V3, Registered Nurse (RN). The Facility's Untitled Document dated 11/24/2023 documents, Around 1 PM after lunch, (V10) and I took (R2) back to her room to lay her down. (V10) was on the left side of her and I was on the right. (V10) lowered the (lift) down close enough to hook the pad to (the lift). We then hooked the top first then lowered more to fasten in between the legs. (V10) then lifted the (lift) enough to where she pulled the (pad) out and I pulled back the wheelchair. As (R2) was being lifted and chair was being moved, she stared sliding out from the left side (top). It further documents V4 and V6 provided wound care. It continues to document, I believe the hook on the left side was not all the way fastened causing (R2) to slide out of the lift pad. I am always very careful to check to make sure all hooks are tightly fastened. This document was signed by V7, CNA. The Facility's Untitled Document dated 11/24/2023 documents R2 was observed on the floor underneath the mechanical lift laying on her back and slightly to the left. It further documents V7 and V10 stated the lift hook slipped off. It continues to document, I questioned if it was double checked and both CNAs stated they thought they did. This nurse re-educated CNAs on importance of both staff to check all equipment prior to using. This document was signed by V4, LPN. The Facility's Untitled Document dated 11/24/2023 documents, I was getting the machine up in the air so the (V7) could move the wheelchair out from the (lift). As I was raising the sling a bit more and was ready to move the (lift), I just so happened to see the left should of the sling drop to the floor. This document was signed by V10, CNA. The Facility's Performance Skill-Transfer Using a Mechanical Lift document, undated, documents staff should ensure they are using the appropriate lift for the resident, applying the correct sling, attaching the sling to the lift and to check to ensure all 4 hooks are completely latched. It continues to document, Staff must verbally confirm that each hook is latched properly before beginning the transfer. The two staff pull down on the sling for a triple check that the hooks are completely slipped into position before raising the (full body mechanical lift). On 12/4/2023 at 2:16 PM, V2, Director of Nurses (DON) stated the incident was user error and she would expect staff to follow the manufacturer's instructions for the mechanical lift. On 12/4/2023 at 2:34 PM, V1, Administrator stated the piece to the sling wasn't completely in place and that V3 checked to ensure the sling wasn't torn and the plastic was in good condition. The Facility's Hoyer Lift Sling Safety undated, documents, Two staff must check all four hooks to make sure they are completely latched. Two staff must make sure the hooks are in the correct position (must be touching and in the top curve pictured below). Two staff must verbally confirm that each hook is latched properly before beginning transfer. Two staff are to pull down on sling for a triple check that the hooks are completely slipped into position before raising lift. Two staff then raise resident using the lift above the surface transferring from before moving away from the surface. Do not pull the wheelchair away before raising the lift. The Manufacturer's Information for the mechanical lift documents, (Mechanical lift) must always be handled by a trained care giver and in accordance with the instructions outlined in this manual. Failure to understand and follow these instructions may result in injury to yourself and others. It continues to document, Caution: Always check that all the sling attachment clips are fully in position before and during the lifting cycle and in tension as the patient's weight is gradually taken up.

Based on observation, interview, and record review, the facility failed to assess and treat 1 of 4 residents (R22) in the sample of 23. This failure resulted in the resident sustaining a significant weight loss of over 24 lbs. (approx. 15%) in 2 months. Findings include: R22's Face sheet documents, an admitted [DATE]. Diagnosis includes: Fracture of Unspecified Part of Neck of Left Femur, Displaced Oblique Fracture of Shaft of Humorous Right Arm, Atherosclerotic Heart Disease, Chronic Kidney Disease. R22's Minimum Data Set, MDS, dated [DATE] documents, R22 has no cognitive impairments. MDS dated [DATE] documents, R22 had no issues with eating, drinking, or choking. No recent weight loss and no special diet order documented. R22's Care Plan dated 6/8/2023 documents, Nutrition, Interventions include: Registered Dietician to monitor per protocol. R22 chooses to wear clothing protector. Monitor per protocol. High calorie supplement twice daily and health shakes three times daily. R22's admission weight dated 6/2/2023 documents 161#, (pounds). R22's weight dated 6/4/2023 documents 162.8#. R22's weight dated 6/23/2023 documents 152.6#. A steady decline in R22's weight is documented throughout. R22's 8/4/2023 weight 142.2#. R22's weight on 8/10/2023 138.2#. R22's order sheets dated 8/8/2023 documents, health shakes three times daily. R22's order sheets dated 8/8/2023 documents, Magic cup bid, (twice daily), ordered. R22's order sheets dated 8/9/2023 document, Remeron Oral Tablet 15 MG (Mirtazapine) give 0.5 tablet by mouth at bedtime. R22's Progress Notes dated 7/23/2023 at 1:44AM documents, local hospital called for an update and per staff nurse, (R22) has mild malnutrition and has nasogastric, (NG), tube providing feedings at this time until (R22) can reach 50% meal consumption. On 8/9/2023 at 2:00PM V2, Director of Nursing, DON, stated, We just had a care plan meeting for R22 and just started high calorie drinks and Remeron to stimulate her appetite. R22 has been in and out of the hospital and had pancreatitis and gall stones. She just hasn't had an appetite. On 8/10/2023 at 10:15AM V6, Minimum Data Set Coordinator, stated, (R22) gets full fast and will complain of nausea. She needs a lot of encouragement. On 8/10/2023 at 10:20AM V14, Resident Assistant, stated, (R22) needs a lot of encouragement when eating, to keep eating. She does not usually eat well. On 8/10/2023 at 10:40AM, V15, Registered Dietician, stated, I just reviewed (R22)'s case yesterday. We started the high calorie supplements three times daily, and the facility was going to start Remeron. (R22) had been in and out of the hospital with pancreatitis. Facility Nutrition Assessment policy dated 10/2017 states, As part of the comprehensive assessment, a Nutritional Assessment, including current nutritional status and risk factors for impaired nutrition shall be conducted for each resident. The Dietician, in conjunction with the Nursing staff and Healthcare Practitioners, will conduct a nutritional assessment for each resident upon admission with current baseline assessment time frames and as indicated by a change in condition that places the resident at risk for impaired nutritional. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.

Based on observation, interview, and record review, the facility failed to store, prepare and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 21 residents living in the facility. Findings include: On 08/08/23 at 11:20AM V5, Cook, was removing items from the standing refrigerator. One container was labeled mechanical ham and was dated 07/31/23. On 08/08/23 at 11:22AM in the walk-in refrigerator there was an opened bag of mozzarella cheese that was sealed with plastic wrap but was not dated. On 08/08/23 at 11:24AM in the walk-in freezer there was a plastic bag containing round slices of meat, each approximately two inches in diameter. The bag was dated 07/13 but was not labeled. There was a plastic bag of corn on the cob that was sealed but was not labeled or dated. There was a bag of breaded meat that was sealed, but not dated or labeled. There was an unknown cylindrical shaped item wrapped in brown paper and plastic wrap that was not dated or labeled. On the top shelf of the freezer, there was a fifteen-pound box of chicken breasts, a twelve-pound box of panko shrimp and three boxes of breaded catfish. The lower levels of shelving below contained various types of foods, including vegetables and mozzarella cheese sticks. V5, Cook, stated, the items on the top shelf are not pre-cooked. On 08/08/23 at 11:30AM, V4, Dietary Manager, stated, items can be arranged any way in the freezer because they are frozen. On 08/08/23 at 11:44AM the resident refrigerator in the dining room held a container of diced fruit with no label or date. There was a half empty container of blackberries with no date. There was a plastic bag containing half a cucumber and another plastic bag with a whole cucumber, neither of which were labeled or dated. There was an opened eight-ounce carton of chocolate milk that was not resealed, labeled with resident information, or dated. There was a container with a name written in black marker, but the contents inside were not labeled or dated. There was a foam container labeled R22 with no food item label or date. There was stack of sliced white cheese approximately one inch thick and a stack of sliced yellow cheese approximately two inches thick that were wrapped in plastic wrap. The dates written in black marker were not legible, and there were no item labels. On 08/08/23 at 11:47AM the freezer in the resident dining room had ice crystals on the shelves that were approximately one-half inch thick. There were four waffles in a plastic package that was not resealed after opening. The waffles were open to air and were not labeled or dated. There was a plastic bag containing several square breaded items with no label or date. On 08/08/23 at 12:05PM, V5, Dietary Manager, (DM), poured a can of tomato soup into a bowl, placed bowl in the microwave, and began heating. On 08/08/23 at 12:07PM, V5, DM, removed soup from the microwave and placed on the meal cart to be served. V5 did not check the temperature of the soup. On 08/08/23 at 12:11PM, V5, DM, stated, Soup is more of a side item, so we normally don't check it (for temperature). I don't know if we should be, but we try to get it nice and hot. On 08/08/23 at 12:13PM, temperatures were obtained from the steamtable after the last resident tray was served using a metal calibrated thermometer. The pureed pork measured 134 F (Fahrenheit), the pureed turnip greens measured 127 F, and the mechanical soft pork measured 125 F. The Facility's Diet Type Report dated 08/09/23 documented, R1, R10, and R12 were on pureed diets, and R3, R7, R8, R14, and R22 were on mechanical soft diets. On 08/10/23 at 3:43PM V1, Administrator, stated, she expects staff to follow food service policies. The Facility's Food Receiving and Storage revised October 2017 documents, Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in refrigerator or freezer will be covered, labeled and dated (use by date). Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Beverages must be dated when opened and discarded after twenty-four (24) hours. Other opened containers must be dated and sealed or covered during storage. Partially eaten food may not be kept in the refrigerator. The Facility's Food Preparation and Service revised April 2019 documents, The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135 F. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 F for at least 15 seconds. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. The Facility's Resident Census and Condition of Residents Form CMS-672 dated 08/08/23 documents there are 21 residents living in the facility.

Based on interview and record review the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practices in the facility. The facility staff also failed to utilize appropriate Personal Protective Equipment, (PPE), when entering a COVID-19 rooms. This has the potential to affect all 21 residents living in the facility. Findings Include: 1. The facility's Antibiotic Surveillance Tracking Form for the month of January documents, R6 was given Cipro for a Urinary Tract Infection, (UTI) from 1/23/23 through 1/30/23, and no culture was ordered. The Antibiotic Surveillance Tracking Form did not document the organism causing the infection. R6 Physician Order Sheet, (POS), dated 1/23/23 documents, Cipro 250mg, (milligrams), BID, (twice daily), for bladder pain related to, benign Prostatic Hyperplasia for 7 days. 2. The facility's Antibiotic Surveillance Tracking form for the month of May documents R15 was treated from 5/16/23 through 5/23/23 for a UTI. R15 was on hospice and was treated for signs and symptoms. A Culture and Sensitivity, (C/S), was not completed. The resident (R15) was on Macrobid. R15's POS dated 5/16 through 5/23 documents, R15 was on Macrobid 100mg BID, related to UTI. The Antibiotic Surveillance form did not document the organism causing this infection. 3. The facility's Antibiotic Surveillance Tracking Form for the Month of April documents, R16 was placed on Cipro and a culture was not completed. The organism causing the infection was not found on the form. R16's POS dated 4/9/23 through 4/16/23 documents, R16 was on Cipro 500mg BID for 7 days related to, a personal history of UTI. 4. The facility's Antibiotic Surveillance Tracking Form for the month of April documents R176 was on Macrobid. The Antibiotic Surveillance Tracking Form did not document the organism causing the infection. R176's POS documented, R176 was ordered Macrobid 100mg twice daily from 4/19/23 to 4/21/23 for a UTI. The Antibiotic Surveillance Tracking Form for the month February documented, that R176 was placed on Bactrim DS 800mg /160mg BID for urinary tract infection for 6 doses, on 2/14/23. The Antibiotic Surveillance Tracking form did not document the organism for this UTI. The Antibiotic Surveillance Tracking Form For the month of February also documented, that R176 was ordered Bactrim DS 800mg/160mg BID x, (times), 10 days on 2/24/23. The Antibiotic Surveillance Tracking form did not document the organism for this UTI. 5. On 08/09/23 at noon, V12 Certified Nursing Assistant, (CNA), entered the room of R9 and R19 who are on contact and droplet precautions for being symptomatic for COVID-19. V12 CNA donned gloves, gown, and goggles but, did not put on a N95 mask. V12 entered the room wearing a surgical mask. 6. On 8/9/23 at 1:00 PM V13 CNA donned PPE, (Personal Protective Equipment), and entered the room of R14 and R11. R11 and R14 are both positive for COVID-19. V13 CNA took a sit to stand machine into the room. V13 wiped down the sit to stand with a bleach wipe and rolled it out of the room. V13 then took the sit to stand sling that was used in the room and placed it on top of the sit to stand that was in the hallway. On 8/9/23 at 1:30 PM V13 CNA stated, I don't know why I did that. I was going to put it in the laundry, because they already have one in their room. On 8/11/23 at 12:08 PM V2 Director of Nursing stated, Yes we do, we are going to make sure all hospice residents get a UA/culture before starting ABT, (antibiotics), and we are addressing/stopping the prophylactic ABT we have with family and doctor. It isn't working anyway. The facility policy Infection Prevention and Control Program dated October 2018 documents surveillance tools are used for recognizing the occurrence of infections recording their number and frequency detecting outbreaks and epidemics monitoring employee infection monitoring adherence to infection control practices and detecting unusual pathogens with infection control implications. Prevention of Infections: educating staff and ensuing that they adhere to proper techniques and procedures. The Facility's Resident Census and conditions Form dated 8/8/23 documents the facility had a census of 21 residents.

Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R6, R17, R15, and R176) reviewed for antibiotic stewardship in the sample of 23. Findings include: 1-The Facility's Antibiotic Surveillance Tracking Log for the month of January 2023 documents, No culture ordered for R6's urinary infection. R6's Order Summary Report printed 8/11/23 documents the order, Cipro Oral Tablet 250 mg (Ciprofloxacin HCl) - Give 1 tablet by mouth related to benign prostatic hypertrophy with lower urinary tract infection symptoms for 7 days until finished with Start Date of 1/23/23 and End Date 1/30/23. R6's MAR for January 2023 documents R6 received 14 doses of Cipro. On 8/9/23 at 4:15 PM, culture for R6's January 2023 UTI, (Urinary Tract Infection), was requested from V2, Director of Nursing, (DON). On 8/11/23 at 10:00 AM, no C&S was received from the Facility. 2-The Facility's Antibiotic Surveillance Tracking Log for the month of April 2023 documents, N/A for organism identified and UTI prophylaxis as site of R17's urinary infection. R17's Order Summary Report printed 8/9/2023 documents, ordered Bactrim DS 800-160 MG, (milligram), (Sulfamethoxazole-Trimethoprim) - Give 1 tablet by mouth one time a day related to urinary tract infection, site not specified with Start Date of 5/4/23 and no End Date listed. R17's Medication Administration Record, (MAR), for May 2023 through August 9, 2023, documents R17 received 98 doses of the antibiotic Bactrim DS. On 8/9/23 at 12:55 PM, culture for R17's UTI was requested from V2, DON. On 8/11/23 at 10:00 AM, no C&S was received from the facility. 42834 3-Facility's Infection Control log dated 5/16/2023 documents, R15 prescribed Macrobid 100mg 1 capsule by mouth twice daily given 5/16/2023-5/23/2023. No culture and sensitivity, (C&S), ordered. Facility was asked for culture and sensitivity on 8/9/2023. No results given. R15's Order sheet dated 5/16/2023 Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day related to Urinary Tract Infection, (UTI), for 7 days. R15's Medication Administration Sheets, (MAR), dated 5/1/2023-5/31/2023 documents, Macrobid Oral Capsule 100 MG. Give 1 capsule by mouth two times a day related to UTI. MAR documents dated administered 5/16/2023-5/23/2023. R15's Nurse's Notes dated 5/16/2023 documents, hospice nurse returned phone call, new order for Macrobid 100 mg two times daily x 7 days. Hospice nurse stated, if we see not see improvement within 48 hours to notify hospice. 4-Facility's Infection Control log dated 2/14/2023 documents, R176 ordered Bactrim DS and started on 2/14/2023-2-17/2023. UA and culture done at radiation appointment. No results obtained by facility. Facility's Infection Control log dated 2/24/2023 documents, R176 was ordered Bactrim DS which started on 2/24/2023-3/1/2023. No growth noted on culture. Antibiotic started based on initial UA results. R176's February 2023 medication administration sheets, (MAR), document Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole Trimethoprim). Give 1 tablet by mouth two times a day related to UTI. MAR documents, dates administered 2/14/2023-2/17/2023, 2/24/2023-3/1/2023. R176's Progress Notes dated 2/14/2023 at 5:38PM documents, R176 returned from radiation with a bottle of 6 Bactrim DS pills for a UTI that was found while at radiation. First dose to be given this evening. R176 is alert and able to make needs known. Vitals are within normal limits and in chart. Skin is warm and dry and bowel sounds are present. Respirations are even and nonlabored. Medications taken without difficulty. R176's Progress Notes dated 2/16/2023 at 11:33AM documents, Antibiotic for UTI. R176 has no signs and symptoms noted from antibiotic for UTI. Denies burning or discomfort. R176's Progress Notes dated 4/17/2023at 6:00PM documents, R176 reported burning upon urination and suprapubic discomfort when up to restroom. Will plan to obtain UA with culture and sensitivity per clean catch as per standing orders of Physician. R176 sitting up in bedside chair with call light in reach. R176's order sheets dated 4/18/2023 document, Macrobid Oral Capsule 100 MG (Nitrofurantoin Macro) Give 1 capsule by mouth two times a day related to UTI. R176's Progress Notes dated 4/18/2023 at 7:52PM, Physician in this evening and addressed residents UA. Received verbal orders from Physician to start Macrobid 100mg twice daily x 10 days. R176's Progress Notes dated 4/19/2023 at 12:51PM documents, Urinalysis results came back with preliminary culture which states there was no growth in 1 day. R176 on Macrobid 100mg by mouth twice daily. UA and preliminary sent to physician. R176's Progress Notes dated 4/21/2023 at 6:45AM document, Received UA with C&S with no indication of infection. Push PO fluids and cranberry juice. Update provider if symptoms arise or do not resolve. R176's Progress Notes dated 4/21/2023 at 1:36PM Note Text: Discontinued antibiotic. Urine culture came back and showed no signs of infection. Facility infection control log documents, on 4/21/2023 R176's antibiotic discontinued due to no UTI. No infection present. R176's MARS dated 4/1/2023-4/30/2023 documents; Macrobid Oral Capsule100 MG (Nitrofurantoin Macro) Give 1 capsule by mouth two times a day related to UTI. Start Date04/19/2023 0900-D/C Date04/21/2023. MARS document, dosage administered from 4/19/2023-4/21/2023. Facility policy dated 12/2016 states, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Appropriate indications for the use of antibiotics include: Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending. When a culture and sensitivity is ordered, it will be competed, and Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotics therapy should be started, continued, modified, or discontinued.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin in 1 of 1 resident (R4) reviewed for abuse in the sample of 23. Findings include: R4's Face Sheet documents, R4 was admitted to the facility on [DATE] and has diagnoses including chronic kidney disease stage 3; schizoaffective disorder, bipolar type; bipolar disorder; type 2 diabetes mellitus without complications; anxiety disorder; and pain, unspecified. R4's Minimum Data Set, (MDS), dated [DATE] documented, R4 was cognitively intact, required extensive two or more-person physical assistance with bed mobility and transfer, and had no documented skin conditions. R4's Care Plan, undated, does not address risk of abuse. The Facility's Unusual Occurrence Reports/Quality Assurance Review Log for the month of July 2023 documents R4 had a bruise to her left forearm on 07/12/23 that could have happened during transfer. The Date IDPH (Illinois Department of Public Health) Notified column documented, N/A. The Facility's Unknown Injury Report dated 07/12/23 documents, Nursing Description: Resident has a dark purple bruise measuring 2.5 x 3 on her left forearm as well as two small dark purple bruises under her watch. Resident Description: Resident states, she has no idea what happened to cause the bruises. MD, (Medical Doctor), POA, (Power of Attorney) and Admin, (Administrator), Nurses informed. There are no documented witness statements. The Notes added on 07/21/23 document, Could have been during transfer. R4's Progress Note dated 07/12/23 at 11:31 AM documents, Note Text: Resident called this nurse to her room and showed me a bruise to her left forearm. Bruise is located on her left forearm and is 2,4 x3 cm, (centimeters), color is dark purple. Resident states it is not painful but itches. R4's Progress Note dated 07/12/23 at 2:03 PM documents, Bruise remains dark purple in color. No pain reported with bruise. Resident states it kind of itches. On 08/10/23 at 9:47 AM, R4 stated, she thinks the bruising on her forearm last month was probably just from scratching. On 08/10/23 at 10:35 AM, V13, Certified Nurse Assistant, (CNA), stated, she remembers the bruising on R4's forearm. She said R4 didn't remember what happened but said she had been bruising a lot easier. V13 stated she and R4 both reported it to V16, Licensed Practical Nurse, (LPN). On 08/10/23 at 10:00 AM, V2, Director of Nursing, (DON), stated V16, LPN, was on leave from the Facility due to illness. On 07/12/23 at 1:55 PM, V6, MDS Coordinator, stated there were no witnesses to explain what happened to R4's forearm. On 08/09/23 at 2:30 PM, V2, DON, stated the bruise of unknown origin to R4's forearm was not reported to IDPH. On 08/10/23 at 3:43 PM, V1, Administrator, stated she always reports injuries of unknown origin, but she did not report R4's bruise. The Facility's Abuse Investigation and Reporting Policy revised July 2017 documents, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) or Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin in 1 of 1 resident (R4) reviewed for abuse in the sample of 23. Findings include: R4's Face Sheet documents R4 was admitted to the facility on [DATE] and has diagnoses including chronic kidney disease stage 3; schizoaffective disorder, bipolar type; bipolar disorder; type 2 diabetes mellitus without complications; anxiety disorder; and pain, unspecified. R4's Minimum Data Set, (MDS) dated [DATE] documented R4 was cognitively intact, required extensive two or more-person physical assistance with bed mobility and transfer, and had no documented skin conditions. R4's Care Plan, undated, does not address risk of abuse. The Facility's Unusual Occurrence Reports/Quality Assurance Review Log for the month of July 2023 documents R4 had a bruise to her left forearm on 07/12/23 that could have happened during transfer. The Date IDPH (Illinois Department of Public Health) Notified column documented N/A. The Facility's Unknown Injury Report dated 07/12/23 documents, Nursing Description: Resident has a dark purple bruise measuring 2.5 x 3 on her left forearm as well as two small dark purple bruises under her watch. Resident Description: Resident states she has no idea what happened to cause the bruises. MD (Medical Doctor), POA (Power of Attorney) and Admin (Administrator) Nurses informed. There are no documented witness statements. The Notes added on 07/21/23 document, Could have been during transfer. R4's Progress Note dated 07/12/23 at 11:31 AM documents, Note Text: Resident called this nurse to her room and showed me a bruise to her left forearm. Bruise is located on her left forearm and is 2,4 x3 cm, (centimeters), color is dark purple. Resident states it is not painful but itches. R4's Progress Note dated 07/12/23 at 2:03 PM documents, Bruise remains dark purple in color. No pain reported with bruise. Resident states it kind of itches. On 08/10/23 at 9:47 AM, R4 stated she thinks the bruising on her forearm was probably just from scratching. On 08/10/23 at 10:35 AM, V13, Certified Nurse Assistant, (CNA), stated she remembers the bruising on R4's forearm. She said R4 didn't remember what happened, but R4's watch was tight on her risk near the location of the bruise. V13 stated she told V16, Licensed Practical Nurse, (LPN) and stated, Any time there is an injury of unknown origin we are supposed to do a write up. On 08/10/23 at 10:00 AM, V2, Director of Nursing, (DON), stated V16, LPN, was on leave from the Facility due to illness. On 07/12/23 at 1:55 PM, V6, MDS Coordinator, stated, That (the unknown origin report) is the investigation. There were no witnesses so it must have happened during transfer. So, am I just supposed to write down their names and say they didn't know anything about it? Should I start making them a skin injury instead of an unknown origin? On 08/09/23 at 2:30 PM, V2, DON, stated she would expect the investigation to include statements from staff. On 08/10/23 at 3:43 PM, V1, Administrator, stated she expects the Facility to conduct an investigation for all injuries of unknown origin. The Facility's Abuse Investigation and Reporting Policy revised July 2017 documents, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident.

Based on observation, interview and record review, the facility failed to provide residents properly cooked food for 1 of 20 residents (R20) reviewed for food temperatures in the sample of 18. Findings include: R20's Care Plan dated 2/29/2020 documents, Regular Diet, Mechanical Soft texture, thin consistency. On 6/22/2022 at 11:32 AM, during the lunch service V8, Dietary Aid, prepared a plate of mechanical meat for R20 and it was served to her at the dining room table. On 6/22/2022 at 11:28 AM, the mechanical meat temperature was taken with a metal, calibrated thermometer and registered 121.1 degrees Fahrenheit (F). On 6/22/2022 at 11:27 AM, during the lunch service the lid to the mechanical meat was not hot to the touch. On 6/22/2022 at 11:00 AM, the Food Log Temperature Book was reviewed and does not document any temperatures were taken for the mechanical meat. The area was blank. On 6/23/2022 at 9:35 AM, V7, Dietary Manager, stated, After we talked (V8) went and added the temperature to the mechanical meat food log book. I was there with you and it was blank and not filled out when you asked to see it. I am not sure where she got that temperature but I know it was not correct. On 6/22/2022 at 11:30 AM, V8, Dietary Aid, stated, I did not take a temperature on the mechanical meat, only the regular meat, and it was within range. The area was blank because I did not take it for the mechanical soft meat. On 6/22/2022 at 11:32 AM, V7, Dietary Manager, stated, I expect all food on the steam table to be at least 135 degrees (F) or higher. The mechanical meat should have been at a higher temperature and the temperatures should have been taken. On 6/23/2022 at 1:45 PM, V14, Dietician, stated, On 6/23/2022 at 2:01 PM, V14, Dietician stated, I would expect all of the food on the steam table to be held at 135 degrees Fahrenheit (F) or higher. If a food item temperature is lower than 135, I would not expect it to be served to the residents. When the food is under 135 F, it can be a danger zone/hazardous. The danger zone is an ideal environment for bacterial growth. On 6/22/2022 at 3:31 PM, V2, Director of Nursing (DON), provided a list of residents on pureed and/or mechanical texture diets and the following residents were documented: R3, R14, R17 and R20. The Facility Food Preparation and Service Policy with a revision date of 4/2019 document, Food and Nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. Potentially hazardous food include meats. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees F during preparation or they are reheated to 165 F for at least 15 seconds.

Based on observation, interview and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 29 residents living in the facility. Findings include: On 8/20/19 at 9:44 AM in the walk-in cooler (refrigerator) there was a metal rack to the right which had a large plastic bag of chicken sitting on it. There was no label and no date on this item. On 08/20/2019 at 9:45 AM, on the rack across from the kitchen is large metal rack and on the middle shelf is a large industrial box of oranges. The box is sitting next to a pan of thawing meat (hamburger) and blood is on the bottom of the pan. Above the oranges the shelf was storing lunch meats, hams and bacon. The fresh oranges are not being stored above uncooked and raw animal products. On 08/20/2019 at 9:45 AM, V4, Dietary Manager stated. Yes, I expect everything to be labeled and dated. That bag has chicken in it. I don't know why that box of oranges is being stored with the meats. I will throw it out immediately. The oranges and fresh produce should never be stored next to meat. I think someone accidentally put it on the wrong shelf. The Facility's Food Receiving and Storage Policy dated (MONTH) (YEAR) documents in part, Foods shall be received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by date'). 13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and ready-to-eat foods. The Facility's Resident Census and Conditions of Residents form dated 08/28/2019 documented the facility had a census of 29 residents.

Based on interview and record review the facility failed to ensure food was palatable, attractive and in safe temperatures for 6 out of 12 residents (R8, R11, R12, R13, R16, and R17) reviewed for food tasting in the sample of 24. Findings include: During the group meeting on 8/21/2019 at 9:00 AM, R8, R12, R13, R16, and R17 all stated that food is usually cold. We have talked to (V4, Dietary Manager). (V4) told us he would look into it, but nothing really changed. We really would like food that is at the right temperatures. We complain and complain, and nothing ever happens. Our food is always cold especially when dietary staff are running late. On 08/20/2018 at 11:55 AM, the food was sitting on the steam table in the front dining room and the following temperatures were taken with a calibrated thermometer and were below 135 degrees Fahrenheit (F), ham 121.0 F, and French fries 116.0. On 08/20/2019 between 11:56 AM and 12:13 PM, R8, R12, R13, R16, and R17 were all served the ham and French fries with temperatures below 135 F. On 08/21/2019 at 1:46 AM, V4, Dietary Manger stated I know some of the residents complained about the food being cold and I always tell residents staff will always reheat a plate if the food is cold. Yes, I am aware that there have been several complaints from the resident council meeting minutes. I am not sure what else to do. I expect staff to check the food temperatures multiple times throughout the service. Resident Council Minutes Pink Notes Plus dated 06/27/2019 at 11:23 AM, 'Food not being up to temperature will be addressed by cooking food and it being placed in warm when complete instead of an open steam table.' On 08/21/19 at 11:41 AM in the back-dining room and on a plate was a single mechanical meat patty labeled (R11) the meat patty temperature was taken with a calibrated thermometer and registered 109.0F. V5, cook stated I already took the temperatures in the kitchen and I will not take any more temperatures again until 30 minutes have passed. On 08/21/2019 at 1:46 AM, V4, Dietary Manger stated I know some of the residents complained about the food being cold and I always tell residents staff will always reheat a plate if the food is cold. Yes, I am aware that there have been several complaints from the resident council meeting minutes. I am not sure what else to do. I expect staff to check the food temperatures multiple times throughout the service. The (MONTH) (YEAR) Food Preparation and Service Policy documents in part, Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. 1. The 'danger zone for food temperatures is between 41 degrees F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 3. The longer foods remain in the 'danger zone' the greater the risk for growth of harmful pathogens. Therefore, Potentially Hazardous Food (PHF) must be maintained below 41 F or above 135 F. Food Services/Distribution, 3. The temperatures of foods held in steam tables will be monitored by food and nutrition services staff.

Based on record review and interview, the facility failed to operationalize their abuse policy and procedure for 1 of 12 residents (R7) reviewed for abuse in the sample of 24. Findings include; The facility's policy and procedure, dated as revised 10/2011 and entitled, People are Free of Abuse and Neglect and documents in part, Agency Value Statement, People are free from abuse and neglect. People deserve the physical and psychological freedom from all forms of abuse and neglect. The people our agency provides support to deserve the physical and psychological freedom from abuse and neglect in all its forms. Our agency addresses all allegations of abuse and/or neglect regardless of the source. After the individual has been attended to and notifications has been made to the physician, family administrator, local Public Health department and the police, if necessary, the agency will continue conducting its own investigation, unless instructed by the local authorities that they will continue the investigation. At any time the administrator believes it is necessary they may expand the questioning to include others who might know the person(s) involved or who have worked with them in the past. On 8/22/2019 at 1:15 PM, V1 stated, I wrote the policy and never really thought about putting the resident interviews in the policy. ` The facility's abuse investigation for R7, dated (MONTH) 3, 2019 completed by V3, Assistant Director of Nursing, (ADON), documents, in part, that R7 reported to V9, COTA, (Certified Occupational Assistant), that another therapy staff member (V10, COTA), hit her in the right buttock/hip region while walking during a therapy session on (MONTH) 1, 2019. There was no injury. The investigation included witness statements from, V9 COTA, V11 Physical Therapy Assistant (PTA), V12, Certified Nursing Assistant (CNA), V13, PTA, V14,V15,V16, CNA's, V17 and V18 Licensed Practical Nurses (LPN). Their statements document all the staff interviewed were unaware of the incident. The final Investigation Report dated 6-10-2019, completed by V1, Administrator, concludes that the allegation could not be substantiated. The final report failed to include any statements from any other residents. On 8-20-2019 at 1:54 PM, VI reported no resident interviews were completed for R7's investigation. V1 stated, No, I was on vacation when this happened. On 8/21/19 at 2:00 PM, V2 DON, (Director of Nursing), stated there were no other residents interviewed for this investigation. DON reported the V20, Physician, was not notified of the alleged abuse. At that time, review of the clinical record had no documentation V20 was notified of the alleged abuse.

Based on record review and interview, the facility failed to do a complete investigation for 1 of 12 residents (R7) reviewed for abuse in the sample of 24. Findings include; The Minimum Data Set ((MDS) dated [DATE] documents R7 has a BIMS (Brief Interview Of Mental Status) score of 10, which indicates moderate impairment with cognition. R7's Electronic Health Record (EHR) documents a diagnoses, in part, of Schizo-affective Disorder, [MEDICAL CONDITION] Disorder, and Anxiety, placing her at a high risk for abuse. The facility's abuse investigation for R7, dated (MONTH) 3, 2019 completed by V3, Assistant Director of Nursing (ADON) documents, in part, that R7 reported to V9, COTA (Certified Occupational Assistant) that another therapy staff member (V10, COTA) hit her in the right buttock/hip region while walking during a therapy session on (MONTH) 1, 2019. There was no injury. The investigation included witness statements from, Certified Nursing Assistant (CNA), V9 COTA, V11 Physical Therapy Assistant (PTA), V12, CNA, V13, PTA, V14, V15, V16, CNA's, V17 and V18 Licensed Practical Nurses (LPN). All the staff interviewed were unaware of the incident. The final Investigation Report dated 6-10-2019, completed by V1, Administrator, concludes that the allegation could not be substantiated. The final report failed to include any statements from any other residents. On 8-20-2019 at 1:54 PM, VI reported no resident interviews were completed for R7'sinvestigation. V1 stated, No, I was on vacation when this happened. On 8/21/19 at 2:00 PM, V2 DON (Director of Nursing) stated there were no other residents interviewed for this investigation. DON reported the V20, Physician was not notified of the alleged abuse. At that time, review of the clinical record had no documentation V20 was notified of the alleged abuse. On 8/22/2019 at 1:15 PM, V1 stated, I wrote the policy and never really thought about putting the resident interviews in the policy.

Based on observation, interview and record review the facility failed to provide pressure relief to prevent the formation of pressure ulcers and failed to assess when the pressure ulcer was found for 1 of 3 residents (R23) reviewed for pressure ulcers in the sample of 24. Findings Include: R23's Minimum Data Set (MDS), dated [DATE], documents R23's cognitive skills are modified independence for decision making with some difficulty in new situations only. R23's MDS also documents R23 does not have any pressure ulcers/ injuries. R23's MDS further documents R23 needs extensive assistance for transfers and bed mobility. R23's Care Plan, dated 07/03/19, fails to document a turning and positioning schedule. R23's Care Plan also documents float my heels on pillows anytime I'm in the recliner or in bed. R23's Care Plan documents this intervention was initiated on 07/24/19. R23's Braden Scale assessment for pressure ulcer risk, dated 07/07/19 documents R23 is at risk for pressure ulcers. R23's Progress Note, dated 7/07/19 at 5:28 PM documents R23 returned from the hospital after surgical repair of her broken left hip and leg and no skin breakdown to heels or other bony prominences were documented. R23's Progress Note, dated 7/13/19 at 8:46 PM, documents R23 complained of her left heel hurting and was assessed as measuring 4.0 X 3.0 cm (centimeter) and not open. The Progress Note documents V21, Physician ordered, keep heels elevated and off pressure. Start skin prep to left heel daily. R23's Progress Note, dated 7/20/19 at 12:39 PM documents, (R23) has discoloration to her bilateral heels. (R23's) bilateral heels are discolored reddish/purple as they were last weekend. (R23's) heel is not mushy. There was no documentation on the measurements of the heels. R23's Skin and Wound Evaluation, dated 07/21/19, documents R23 has pressure and deep tissue injury to her left heel. The skin and wound evaluation describes her left heel as new, in house acquired, measuring length 3.0 cm in length and 4.2 cm in width. R23's left heel wound was actually discovered on 07/13/19, but the wound was not measured on that date. R23's Skin and Wound Evaluation, dated 07/25/19 documents R23 has pressure and deep tissue injury to her right heel measuring 1.6 cm in length and 1.8 cm in width. R23's right heel wound is characterized as in house acquired and new. However, the discoloration of bilateral heels was mentioned in a Progress note on 07/20/19. R23's right heel was not measured until 7/25/19. R23's Point Click Care Form, dated 8/01/19 documents, R23's right heel wound measures 1.11 cm in length and 1.25 cm in width. The surrounding tissue is dark reddish brown and intact. R23's Skin and Wound Evaluation form, dated 08/17/19 documents R23's right heel is a deep tissue injury is persistently non blanchable with deep red, maroon, or purple discoloration. R23's right heel wound measures 1.6 cm in length and 1.8 cm in width. R23's Skin and Wound Evaluation form dated 08/20/19 documents R23 has a deep tissue injury to her right heel measuring 2.9 cm in length and 2.8 cm in width. R23's Point Click Care Form dated 08/01/19 documents R23 has a wound to her left heel measuring 1.26 cm in length and 2.35 cm in width. R23's Skin and Wound Evaluation Form dated 08/17/19 documents R23 has a deep tissue injury in house acquired. R23's left heel wound measures 3.0 cm in length and 4.2 cm in width. R23's Skin and Wound Evaluation Form dated 08/20/19 documents R23 has a deep tissue injury it her left heel measuring 2.0 cm in length and 2.1 cm in width. On 08/20/19 at 12: 30 PM R23 is lying in bed on her right side with a wedge between her legs and pressure reducing booties to her right and left foot. R23's heels was not floated and were resting directly on a pillow. On 08/21/19 at 10:27 AM, V6 Registered Nurse (RN) rolled her treatment cart in the room. V6, RN washed her hands and donned gloves. V6 removed R23's pressure relieving boot from her right foot. R23 has a nickel size open area. V6 sanitized her hand and donned new gloves. V6 cleansed R23's right heel with a wound cleanser. V6 then sanitized her hands and donned new gloves, and applied skin prep to her right heel. V6 sanitized her hands and donned new gloves. V6 placed R23's pressure relieving boot onto her right foot. V6 removed R23's pressure relieving boot from her left foot. V6 sanitized her hands and applied gloves. V6 cleansed R23's left heel with wound cleanser. R23's left heel had a nickel size, purple area with a scab hanging half way off. V6 sanitized her hands and donned gloves, and applied cream to her left heel. On 08/21/19 at 10:35 PM, V6 stated,(R23) had to go back to surgery, because her pin came out of her hip. She has to be on bed rest for 30 days. On 08/21/19 at 4:19 PM, V2, Director of Nursing (DON) stated, When (R23) came back from the hospital the Admission Nursing Assessment did not have any documentation of anything being on (R23's) heels. On 08/22/19 at 12:30 PM V2, DON stated, We didn't measure (R23's) heels until the 21st. The facility policy, entitled Pressure Ulcer/Injury Risk Assessment and dated 7/2017, documents risk factors that increase a resident's susceptibility to develop or not to heal pressure ulcers including but are not limited to impaired/decreased mobility and decreased functional ability. Cognitive Impairment. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition.

Based on interview, observation and record reviewed, the facility failed to ensure food was palatable, attractive and safe with maintaining temperatures. This has the potential to affect all 31 residents living in the facility. Findings include: During the group meeting on 09/26/2018 at 9:30 AM, R10, R18 and R23 stated that sometimes the breakfast food was cold. On 09/25/2018 at 9:01 AM, the cook stated, Yes, I am still serving breakfast until 9:30 AM. The steam table was cold to the touch and the table is not hot. In the main dining room the steam table was set up for breakfast and V23 does not notice and continues to serve food off the steam table. On 09/25/2018 at 9:11 AM, the following temperatures were taking with a calibrated thermometer: Hard boiled eggs 93.0 degrees Fahrenheit (F), scrambled eggs 99.0 F, mechanical hard boiled eggs 93.0 F, mechanical sausage 92.2 F, oatmeal 109.0 F, pureed oatmeal 99.0 F, pureed sausage 98.0 F, bacon 87.9 F, and pureed eggs 94.5 F. On 09/25/18 at 10:46 AM, V22, Dietary Manger stated she expects all food on the steam table to be held at least 140 degrees F. The Preventing Foodborne Illness Food Handling Policy with a revision dated of (MONTH) 2014 documents in part, Food will be stored, handled and served so that the risk of foodborne illness was minimized. 6.) Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. 7.) Potentially hazardous foods held in the danger zone (41 F - 140 F) for more than 4 hours will be discarded. The Facility's Resident Census and Conditions of Residents form dated 09/25/2018, documented the facility had a census of 31 residents.

Based on observation, interview and record review the facility failed to ensure food is stored safely and prepared in a manner which prevents potential contamination. This has the potential to affect all 31 residents living in the facility. Findings include: On 09/25/2018 at 10:32 AM, in the refrigerator were 2 large industrial clear bags of meat product. The bags were not closed or tied shut and the meat was exposed to the air and the bags have no date or label. There are approximately 15-20 pieces of meat in each bag. On 09/25/2018 at 10:33 AM, V22, Dietary Manager stated, I expect all food to be covered. I think staff must have been in a hurry and did not get all of the bags closed. The one bag was chicken and not sure what the other bag was. On 09/25/2018 at 10:34 AM, in the main kitchen above the stove the hood was shining, greasy in appearance with particles of dust stuck on it. On 09/25/2018 at 10:35 AM, V22, stated, I am not sure when the last time the hood was cleaned I will make sure the hood gets cleaned. The Food Receiving and Storage Policy with a revision dated, of (MONTH) (YEAR) document in part, Foods shall be received and stored in a manner that complies with safe food handling practices. 8.) All foods stored in the refrigerator or freezer will be covered, labeled and dated.

Based on interview and record review the Facility failed to identify and track organisms for antibiotic stewardships. This has the potential to affect all 31 residents living in the facility. Findings include: During review of the Infection Control Logs for 3 months the residents name with onset and end date, infection, and antibiotics was documented. There was no organism documented on the log even when residents were returned from the hospital. The antibiotic was documented on the Log but no organism was documented on the Infection Control Log. On 09/26/2018 at V2, Director of Nursing (DON) stated, No, we do not have another form or documentation related to the type of culture or organism for the Infection Control Log. On 09/27/2018 at 12:42 PM, V2 stated, Yes, I expect organisms should be listed on the Infection Control Log. I am not sure I communicated that well to (V26). On 09/27/2018 at 9:28 AM. V26, Registered Nurse (RN) and Infection Control Nurse stated, Yes I am in charge of infection control and I am the only one at this time in charge of it. No, there is no documentation when a resident comes back from the hospital related to an organism being listed on the Infection Control Log. I do not call the hospital for the organism or the cultures. No, I am not adding any of the organisms to the Infection Control Log. I look at documentation and symptoms of the residents to know if an antibiotic drug is effective and the symptoms are resolving. I do not have the culture and sensitivity and without that I cannot ensure or determine if the residents who require antibiotics are getting the optimal treatment addressing the infections with the current indication, dose and duration. The (Facility) Antibiotic Stewardship, with a revision date of (MONTH) (YEAR) documents, The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The same document goes on to say, When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. A document titled (Facility) Antibiotic Stewardship - Orders for Antibiotics, with a revision date of (MONTH) (YEAR) states: Appropriate indications for us of antibiotics include: a.) Criteria met for clinical definition of active infection or [MEDICAL CONDITION]; and b.) Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture pending.) The Facility's Resident Census and Conditions of Residents form dated 09/25/2018, documented the facility had a census of 31 residents.

Based on interview and record review, the facility failed to notify resident representatives in writing of hospital transfers for 6 of 6 residents (R6, R7, R14, R19, R21, and R29) reviewed for hospitalization s in a sample of 17. Findings Include: 1. R21's Resident Face Sheet documents R21 was admitted to the facility on [DATE]. This document lists V17 (Family member) is the responsible party for R21, with V18 (Physician) being listed as her Attending Physician. Primary [DIAGNOSES REDACTED]. On 07/18/18, R21's Progress Notes documents R21 was sent to the emergency roiagnom on [DATE] due to weeping, [MEDICAL CONDITION] to bilateral lower extremities. R21's Hospitals Discharge Summary documents an admitted to the hospital of 07/18/18 with a [DIAGNOSES REDACTED]. On 07/29/18, R21's Hospitalist History and Physical documents R21 was sent to the emergency room for evaluation due to a fall R21 sustained in the nursing home. [DIAGNOSES REDACTED]. No indication of the resident family representative being notified in writing was found in the clinical record. 2. R6's Resident Face Sheet documents R6 was admitted to the facility on [DATE]. This document lists V19 (Family member) is the responsible party for R6, with V20 (Physician) being listed as her Attending Physician. Primary [DIAGNOSES REDACTED]. On 07/09/18, R6's Hospitalist History and Physical documents R6 was sent to the emergency roiagnom on [DATE] for evaluation due to dark brown / black coffee ground emesis. [DIAGNOSES REDACTED]. On 09/09/18, R6's Progress Notes documents R6 was sent to the emergency roiagnom on [DATE] due to an emesis, and oxygen saturation levels in the upper 80's. R6's Hospital Discharge Summary documents an admitted to the hospital as 09/09/18 with the [DIAGNOSES REDACTED]. No indication of the resident family representative being notified in writing was found in the clinical record. 3. R7's Resident Face Sheet documents R7 was admitted to the facility on [DATE]. This document lists V21 (Family member) is the responsible party for R7, with V20 being listed as her Attending Physician. Primary [DIAGNOSES REDACTED]. On 10/11/17, R7's Hospitalist History and Physical documents R7 was sent to the emergency room for evaluation due to a fall R7 sustained in the nursing home. [DIAGNOSES REDACTED]. On 12/31/17, R7's Patient Transfer Form documents R7 was sent to emergency room for evaluation due to weakness and unresolved [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. On 07/20/18, R7's Hospitalist History and Physical documents R7 was sent to the emergency room for evaluation due to shortness of breath. [DIAGNOSES REDACTED]. No indication of the resident family representative being notified in writing was found in the clinical record. 4. R19's Resident Face Sheet documents R19 was admitted to the facility on [DATE]. This document lists V24 (Family member) is the responsible party for R19, with V20 being listed as her Attending Physician. Primary [DIAGNOSES REDACTED]. On 03/31/18, R19's Hospitalist History and Physical documents R19 was sent to the emergency room for evaluation due to abdominal pain. [DIAGNOSES REDACTED]. On 04/13/18, R19's Hospitalist History and Physical documents R19 was sent to the emergency room for evaluation due to right upper quadrant abdominal pain. [DIAGNOSES REDACTED]. On 05/02/18, R19's Hospitalist History and Physical documents R19 was sent to the emergency room for evaluation due to abdominal pain, nausea and vomiting. [DIAGNOSES REDACTED]. On 07/20/18, R19's Hospitalist History and Physical documents R19 was sent to the emergency room for evaluation due to increased shortness of breath, nonproductive cough, and decreased appetite. [DIAGNOSES REDACTED]. No indication of the resident family representative being notified in writing was found in the clinical record. 5. R14's Resident Face Sheet documents R14 was admitted to the facility on [DATE]. This document lists V25 (Family member) is the responsible party for R14, with V20 being listed as her Attending Physician. Primary [DIAGNOSES REDACTED]. On 04/10/18, R14's Hospitalist History and Physical documents R14 was sent to the emergency room for evaluation due to left sided weakness, numbness, and pain. [DIAGNOSES REDACTED]. On 07/08/18, R14's Hospitalist History and Physical documents R14 was sent to the emergency room for evaluation due to chest pain, and shortness of breath. [DIAGNOSES REDACTED]. On 07/12/18, R14's Hospitalist History and Physical documents R14 was sent to the emergency room for evaluation due to drooping to the right side of her face, slurred speech, and confusion. [DIAGNOSES REDACTED]. No indication of the resident family representative being notified in writing was found in the clinical record. On 09/25/18 at 02:37 PM, V2 (Director of Nursing, DON) states resident representatives are notified prior to, or at the time of the resident's hospital transfer via phone. V2 states nothing in writing is provided to the resident representative regarding the resident transfer. 6. R29's Physician Face Sheet document R29 was re-admitted to the facility on [DATE]. V29 was documented as the responsible party for R29 with V18, Physician being listed as his Attending Physician. R29's Physician order [REDACTED]. R29's Progress Notes dated 07/25/2018 at 7:40 AM, document R29 had a fall and was sent out to the hospital for evaluation and treatment. There was no documentation present documenting R29's representative was notified of the discharge in writing. On 09/27/2018 at 10:44 AM, V 2, Director of Nursing (DON) stated, No discharge letter was sent out for discharges to families of R29. A document titled, (Facility) Transfer or Discharge Notice, with a revision date of (MONTH) (YEAR) states, Our facility shall provide a resident and / or the resident's representative (sponsor) with a thirty (30) - day written notice of an impending transfer or discharge. Included in this same document it states under the circumstances that the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the notice will be provided as soon as it is practicable.

Based on observation, interview and record review the facility failed to serve and store food in a sanitary manner. This has the potential to affect all 30 residents living in the facility. Findings include: 1. On 10/17/2017 at 9:18 AM, the two ice machines in the main kitchen both had clear hoses which were attached to the ice storage bin drain. The clear drainage hoses were attached to the ice storage bin drain spout then were lying directly on the floor for three feet under the ice machine and adjacent three compartment manual washing sink, then protruded into the sewage drain more than 1/2 inch. On 10/17/2017 at 9:18 AM, E10, Certified Dietary Manager stated We use the ice from these ice machines for all the resident drinks at meals and for all drinks in the resident's rooms. The drain from both of the ice machines go into the floor (sewage) drain. The facility's Ice policy dated 7/00, documents in part, It is the policy of this agency that ice be maintained and served to individuals in a sanitary manner. 1. Ice will be handled, transported, and stored in such a manner as to be protected against contamination. The facility's Food Storage policy, dated 7/00, documents in part, It is the policy of this agency that food storage areas be maintained in a clean, safe, and sanitary manner. All foods will be stored not subject to sewage or wastewater backflow or contamination. 2. On 10/17/2017 at 11:25 AM during the service of the lunch meal, 12 resident's lunch meals were served on chipped or cracked plates. On 10/19/2017 at 10:15 AM, E10 stated We have more plates. We can trade out the chipped plates that happens from time to time. The facility's Sanitation policy, dated 7/00, documents in part, It is the policy of this agency that the food service area be maintained in a clean and sanitary manner. 3. Plastic ware, china, and glassware that cannot be sanitized or are hazardous because of chips, cracks, or loss of glaze shall be discarded. 3. On 10/17/2017 at 11:25 AM in the refrigerator in the main dining room, was a bowl covered with plastic wrap of meat patties, and two carafes of colored liquid which were not labeled or dated. On 10/19/2017 at 10:18 AM, in the main dining room refrigerator, there were 2 carafes with color liquid with no label and no date. On 10/17/2017 at 9:05 AM, E10 stated We label and date everything in the refrigerator and throw it away in 5 days. On 10/17/2017 at 12:00 PM, E13, Cook stated That meat is sausage patties from breakfast. They prepare breakfast in the dining room. On 10/19/2017 at 10:18 AM, E10 stated The red juice is cranberry and the other is apple juice. We use these for breakfast every day. The facility's Food Storage policy, dated 7/00, documents in part, It is the policy of this agency that food storage areas be maintained in a clean, safe, and sanitary manner. 4. The Resident Census and Conditions of Residents, CMS 672, dated 10/16/2017, documents there are 30 residents living in the facility.

Based on observation, interview and record review, the Facility failed to provide complete incontinent care and assist residents with activities of daily living for 4 of 8 residents (R1, R3, R7, and R9) reviewed for assistance with activities of daily living in the sample of 10. Findings include: 1. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 has a [MEDICATION NAME] and requires extensive assist of 1 staff member for hygiene. On 10/17/17 at 10:00 AM, E9, Certified Nurse Aide (CNA), assisted R1 with positioning in bed. R1 requested E9 to take off R1's pants. R1 has a [MEDICATION NAME] bag which has a port at the bottom of the bag that the urine drainage tubing connects into. R1 held the [MEDICATION NAME] bag and unlocked the port so E9 could unhook the drainage tubing to remove R1's pants. Once R1's pants were off, the drainage tubing was reconnected to the [MEDICATION NAME] bag and R1 locked the port. E9 did not offer to assist R1 with hand hygiene before E9 left the room. 2. R7's MDS dated [DATE] documented R7 required extensive assist of 1 staff member for hygiene. R7's October 2017 Physician order [REDACTED]. On 10/17/17 at 9:30 AM, E11 CNA, assisted R7 with toileting. R7 sat on the toilet and voided. E11 assisted R7 with pulling up his pants and ambulating to bed. E11 failed to offer to assist R7 with washing his hand or encourage R7 to wash his hands. On 10/19/17 at 10:15 AM, E2, Director of Nurses (DON), stated, I do expect staff to assist residents with hand hygiene after toileting, and staff should assist (R1) with hand hygiene after he handles his [MEDICATION NAME] bag. The facility policy and procedure Handwashing dated 8/01/01 does not address resident hand washing. 3. R3's MDS dated [DATE] documented R3 required extensive assistance with toileting, and personal hygiene, had a [MEDICAL CONDITION] and was incontinent of bladder. On 10/16/17 at 2:43 PM, E14 and E15, both CNAs, provided incontinent care to R3 in bed. E14 used 2 washcloths wet with no rinse periwash and 2 dry washcloths. E14 and E15 removed R3's heavily saturated incontinent brief. E14 cleansed R3's exposed tip of his penis with wet washcloth in a circular motion using the two wet washcloths. Then E14 wiped the tip dry with one dry washcloth. E15 assisted R3 to turn to his left side. E14 wiped R3's rectal area with the second dry wash cloth. E14 and E15 put on clean incontinent briefs and pad underneath R3. E14 stated they were finished with incontinent care. E14 did not wash R3's groin area, shaft of the penis, scrotal area, both inner thighs and both buttocks and any other area that came in contact with the heavily saturated incontinent brief. The Facility Policy on Giving Perineal Care dated 11/7/14 documents, For a male resident: Continue to wash the perineal area including the penis, scrotum and inner thighs. The Policy further documents, i. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. 4. R9's MDS dated [DATE] documented R9 requires cueing and supervision with eating. On 10/16/17 at 11:55 AM, R9 sat in her wheelchair in the main dining room with her lunch in front of her. R9 was staring into space. There was no cueing provided for R9 to start eating. At 12:11 PM, R9 took a butter knife and fed herself with mashed potatoes using the knife to feed herself. At 12:15 PM, E11, CNA, sat next to R9 to assist R17 with feeding on the same table. R9 continued to stare into space. E11 did not attempt to provide any cueing or prompting to R9. At 12:31 PM, R9 continued to stare into space. No cueing or prompting was provided by staff. At 12:46 PM, E9 drank from her now empty glass which contained a brown colored beverage 3 times without any staff asking her if she wanted another serving of the drink. At 12:49 PM, R9 took a mouthful of mashed potatoes using her butter knife. R9 did not eat anything else from her plate which had an untouched sandwhich. At 12:57 PM, E11 took away R9's plate without asking her if she wanted something else.

Based on observation, interview and record review, the facility failed to perform hand hygiene to prevent the spread of infection for 3 of 9 residents (R1, R3, R4) reviewed for infection control practices in the sample of 10 and 1 resident (R11) in the supplemental sample. Findings include: 1. On 10/16/17 at 2:43 PM, E14 and E15, both Certified Nursing Aides (CNAs), provided incontinent care to R3 in bed. E14 and E15 were not observed washing their hands or sanitizing prior to donning gloves at the start of care. E14 washed R3's peri area, changed gloves before moving to the back without any form of hand hygiene.E14 and E15 put on clean incontinent briefs and pad underneath R3. E14 stated they were finished with incontinent care. E14 and E15 took off their gloves and exited R3's room without any form of hand hygiene. 2. On 10/17/17 at 1:33 PM, E11 and E16, both CNAs, provided incontinent care to R4 in bed. E11 and E16 reported R4 just had a bowel movement using the bed pan and that her incontinent brief was wet with urine when they removed it. E11 used no rinse periwash and water to cleanse R4. E11 washed R4's groin area, and across the vaginal area. E11 washed R4's left buttock, then replaced her gloves without any prior hand hygiene. E11 replaced the incontinent pad and put clean briefs on R4. E11 and E16 removed their gloves, put on clean gloves without any hand hygiene between glove changing. E11 and E16 straightened R4's clothes and stated they were done with pericare. E11 and E16 left R4's room without washing their hands after removing their gloves. 3. On 10/17/17 at 9:08 AM, E18, Registered Nurse (RN), entered the dining room during breakfast, donned gloves without hand hygiene first and performed a blood glucose monitoring test on R11. With the same gloves E18 gave R11 2 insulin injections in the upper right arm. 4. On 10/17/17 at 10:00 AM, E9 CNA, transferred R1 from his wheelchair to bed with the use of a mechanical lift. During this procedure E9 changed gloves without hand hygiene between glove changes. Once R1 was in bed, E9 changed gloves with no hand hygiene, donned a new pair of gloves, unhooked R1's urine drainage tubing from R1's [MEDICATION NAME] bag, removed R1's pants, reattached the urine drainage tubing to the [MEDICATION NAME] bag, positioned R1 onto his left side, covered R1 up, E9 then removed his gloves and then pushed the mechanical lift out of R1's room down the hall. On 10/19/17 at 8:35 AM, E2, Director of Nurses (DON), stated that staff should wash hand before care, before donning gloves, between glove changes and after removing the gloves. The facility policy and procedure Handwashing dated 8/1/01 documents, in part, Appropriate thirty second hand washing must be performed under the following conditions: 2. Whenever hand are obviously soiled; 4. Before handling medications; 5. After prolonged contact with a resident; 7, After contact with blood, oral secretions, mucous membranes, broken skin. 12. Upon completion of a duty. This policy does not address the need to wash hand before donning gloves. The facility policy and procedure Using Gloves dated 9/20/15 documents, in part, 5. Wash hands after removing gloves. This policy does not address the need to wash hand before donning gloves.