Every finding on record at Cloverdale Healthcare Center

Based on observation, interview and record review, the facility failed to ensure that controlled drug (medications that the use and possession of are controlled by the federal government) records were documented in sufficient detail to enable accurate reconciliation for three out of 19 sampled residents when count discrepancies were found for Resident 23, Resident 66, and Resident 32 controlled drugs. This failure has the potential to cause medication errors or diversion of controlled medication.Findings:During a concurrent observation and interview on 12/18/2025 at 11:31 a.m. during and inspection of a medication cart at the North Hall, Licensed Nurse (LN) 2 confirmed the following discrepancies in controlled medications (drugs regulated by the government due to their potential for abuse, misuse, or dependence): The controlled substance count sheet of Resident 23's Tramadol (a synthetic opioid medication used to treat pain) 50 milligram (mg- unit of measure) tablet indicated 18 tablets should be remaining. LN 2 showed Resident 23's Tramadol 50 mg tablet package had 17 tablets remaining (one missing/unaccounted for). The controlled substance count sheet of Resident 66's Oxycodone (an opioid medication used to treat pain) 5mg tablet indicated 16 tablets. LN 2 showed Resident 66's Oxycodone 5mg tablet package had 15 tablets remaining (one missing/unaccounted for). The controlled substance count sheet of Resident 32's Tramadol 50mg tablet indicated 9 tablets should be remaining. LN 2 showed Resident Tramadol 50mg tablet package showed 8 tablets remaining (one missing/unaccounted for).During the interview on 12/18/25 at 1:56 PM, LN 2 stated the danger of not accounting and reconciling controlled medication could lead to administration of extra doses and overdose.During an concurrent interview and record review on 12/18/25 at 1:46 p.m. with the Director of Nursing (DON), the facility policy titled Inventory Control of controlled substances, last revised 8/1/24, was reviewed. The DON acknowledged the facility policy indicated, the facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled substance verification/shift count sheet to the medication administration record.

Based on observation, interview and records review, the facility failed to ensure medication and supplies were stored in accordance with professional principles for all residents of the facility when:1. 19 dressing change sets (sterile kits containing supplies to change wound dressings), one safety infusion set (sterile medical device used for administering fluids, drugs or drawing blood), one continue-Flo solution set (sterile tubing used for administering fluids and medications into a vein), three 10 ml syringes (medical device used to inject and withdraw fluids from the body), and 19 continuous ambulatory delivery device administration-sets (CADDs- specialized tubing used to deliver fluids and medications at controlled rates) were expired but kept with ready to use supplies in the medication room.2. Two bottles of Aspirin with illegible expiration dates were kept in medication carts.3. An expired allergy relief medication in a plastic container was kept in the South medication cart; and4. 15 loose unidentified pills were left scattered in the top drawer of the South medication cart.These failures can lead to use of medication and supplies with reduced effectiveness or with compromised packaging which can further threaten the frail condition of the residents in the facility.Findings:1. During an observation on [DATE] at 9:13 AM, with Licensed Nurse 1 (LN 1), during an inspection of the medication room, LN 1 confirmed the presence of the following items stored with other ready to use supplies: 19 dressing change kits which have expired on the following dates: three expired on [DATE], two expired on [DATE], one expired on [DATE], five expired on [DATE], and eight expired on [DATE]. One safety infusion-set which expired on [DATE] One continue-Flo solution set which expired on [DATE] Three 10 ml syringes which expired on [DATE] 19 CADD administration-sets which expired April and [DATE], and five expired in 2024.During a concurrent interview and record review on [DATE] at 10:14 a.m., with the Infection Preventionist (IP) Resource, the facility's policy titled, Equipment and supplies, revised 11/2019, was reviewed. The IP Resource stated she was aware of the presence of expired supplies in the medication room and that the facility's policy indicated that expired supplies needed to be removed from storage. The IP Resource stated the facility should ensure that expired supplies are not available for resident use, to ensure the best level of patient care. 2. During an observation on [DATE] at 8:47 AM at the North Hall, LN 2 confirmed the presence of an Aspirin bottle with illegible expiration date in the medication cart.During an observation on [DATE] at 8:57 AM at the South Hall, LN 3 confirmed the presence of an Aspirin bottle with illegible expiration date in the medication cart.During an interview on [DATE] at 10:50 AM, the Director of Nursing (DON) acknowledged the Aspirin bottles found in the medication carts had illegible expiration dates.3. During an inspection of the medication cart at the South Hall on [DATE] at 11:51 AM, A white plastic bottle of allergy relief medication (Loratadine) 10 mg tablets had expired on 10/2025.4. During an inspection of the medication cart at the South Hall on [DATE] at 11:51 AM, LN 3 confirmed the presence of 15 loose pills of various sizes and colors littered the top drawer of the cart.During a concurrent interview and record review on [DATE] at 1:19 p.m. with the Director of Nursing (DON) the facility policy titled, Storage and expiration dating of medication, biologicals, syringes and needles was reviewed. The DON acknowledged the policy indicated, the facility should ensure medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The DON confirmed the policy also indicated that the facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions.

Based on interview and records review, the facility failed to provide the Office of the State Long term Care Ombudsman (Ombudsman- an advocate for residents of nursing homes, board and care centers, and assisted living facilities) a copy of the Notification of discharge for one of three sampled closed records (Resident 61) when Resident 61 was transferred to the hospital on [DATE]This failure can result in inappropriate and unsafe discharge and deprive Resident 61 of access to an advocate who can provide information of her options and rights. Findings:A review of Resident 61's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated she was admitted to the facility in 11/2025 with diagnosis of above the knee amputation of the left leg.A review of Resident 61's Nursing Progress Notes, dated 12/3/25 at 9:45 AM, indicated the Facility Physician saw Resident 61, determined the resident's leg amputation (stump) looked infected on the underside with a foul smell, and ordered the resident to be sent to the hospital. A review of Resident 61's facility to hospital Transfer form indicated she was transferred to the acute hospital on [DATE].During an interview on 12/18/2025 at 3:52 PM, with the Social Services Director (SSD), the SSD stated she has not yet faxed the copy of notification of discharge to the Office of the State long-term Care Ombudsman because she had been busy.A review of the facility's undated facility policy title, Notice to Long-Term Care Ombudsman indicated, the facility shall provide a timely written notice of all involuntary transfers and discharges to the Long-term care Ombudsman. Timing of Ombudsman notification is at the same time the 30-day notice is issued to the resident and representative or in the case of emergency transfer/discharge, should be as soon as practicable following the transfer.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two out of 19 sampled residents (Resident 66 and Resident 48) when:1. there was no order for Resident 66's continuous oxygen therapy (provides extra oxygen for peoples whose bodies cannot get enough from the air) at 2- Liters-Per-Minute (LMP, a unit of measurement) via nasal cannula (NC, a common comfortable device with two small prongs that fit into the nostrils to deliver supplemental oxygen or increased airflow for respiratory support).2. Resident 48 was administered insulin Lispro (a rapid-acting, human-made version of human insulin used to manage blood sugar levels) after breakfast.These failures had the potential to risk the health and wellbeing of the affected residents.Findings:1. A review of Resident 66's face sheet indicated admission to the facility in 12/2025 with a diagnosis that included Acute and Chronic Respiratory Failure (a condition where the lungs cannot exchange enough oxygen) with Hypoxia (low blood oxygen occurs when the lungs can't get enough oxygen into the blood), and Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that makes it hard to breathe due to inflamed, narrow airways and damaged air sacs called alveoli).A review of Resident 66's physician order summary report, dated 12/18/25, indicated there was no documented evidence that Resident 66 had an order for continuous oxygen therapy.A review of Resident 66's care plan, dated 12/12/25 to 12/17/25, did not include a care plan specifically for oxygen therapy.A review of Resident 66's Medication Administration Record (MAR), dated 12/1/2025 to 12/31/25, indicated there was no documented evidence for administration of oxygen therapy.During an observation and concurrent interview on 12/18/25 at 12 p.m., Resident 66 was wearing a NC and her oxygen concentrator was set at 2 liters (L, a unit of measurement) of oxygen. Resident 66 stated she always had to wear her oxygen because of her respiratory problems. During a concurrent interview and record review on 12/18/25 at 12:20 p.m., with Licensed Nurse 2 (LN 2), Resident 66's Physician order summary, dated 12/18/25, were reviewed. LN 2 stated Resident 66 was on 2 L of continuous oxygen. During a review of Resident 66's physician orders, LN 2 confirmed there was no order for Resident 66's oxygen therapy.During a review of the facility policy and procedure titled, Physician Orders, Revised 02/2025, indicated, It is the policy of this facility that drugs or biological shall be administered only upon written order of a person duly licensed and authorized to prescribe such drugs.Orders for mediations must include.Name and strength of the drug.Quantity or specific duration of therapy.Dosage and frequency of administration.During a review of the facility policy and procedure titled, Oxygen Therapy, revised 11/2007, indicated, Plan of Care: the resident's plan of care should be addressed.That oxygen is to be administered.When and how often oxygen is to be administered.The type of oxygen device to use.Any special procedures or treatment to be administered.2. During an observation on 12/18/25 at 8:57 a.m., Licensed Nurse (LN) 1 administered Insulin Lispro 10 units (measurement for insulin) injection on the left upper outer arm of Resident 48. LN 1 asked Resident 48 if she had eaten her breakfast and Resident 48 nodded and confirmed she did.A review of Resident 48's physician order summary, for 11/2025, indicated the resident was ordered, Insulin Lispro Injection Solution . Inject 10 unit subcutaneously before meals .During an interview on 12/18/25 at 10:48 a.m. LN 1 confirmed Resident 48 had already finished eating breakfast when she administered the Lispro insulin injection. LN 1 confirmed the physician ordered the insulin Lispro to be administered to Resident 48 before meals.During a concurrent interview and record review on 12/18/25 at 1:19 p.m., with the Director of Nursing (DON) the facility's policy titled, General dose preparation and medication administration, last revised 11/15/24, was reviewed. The DON acknowledged the policy indicated, .medication should be administered within timeframes specified by facility policy or manufacturer's information.

Based on interviews and record reviews, the facility failed to notify a Responsible Party (RP, a person appointed to make healthcare decisions for a person who is unable) for one resident (Resident 1) of three sampled residents when Resident 1 fell . This failure resulted in Resident 1's RP not knowing Resident 1's pain was a result of the fall. Findings: A review of Resident 1's Admission Record indicated admission to the facility in January 2025 with diagnoses which included cerebral infarction due to embolism (the lack of oxygen to the brain due to a blockage in a blood vessel from a blood clot) and cognitive communication deficit (difficulty communicating caused by brain injury). The admission record also indicated Resident 1's wife was his, Emergency Contact #1. A review of a facility document titled Facility Verification of Informed Consent dated 1/23/25, indicated, [Resident 1] .DOES NOT [check marked as option] have the capacity to understand and consent .If not, see name and phone number of resident's surrogate .[Resident 1's RP signed the document] .Date 1/23/25 .[Physician also signed the document] .Date 1/24/25 . A review of Resident 1's Progress Notes dated 2/14/25 at 1:31 a.m., indicated, COC [Change of Condition] Day 1 Fall: Resident [Resident 1] was found by a CNA [Certified Nursing Assistant] trying to get out of bed, when resident fell against the standing pole next to his bed .causing an abrasion to his forehead, right side and shoulder right side .after helping him back to bed .had a C/O [complained of] 7/10 [severe pain on a pain scale out of 10] pain to his right shoulder .DON [Director of Nursing] was contacted as well as [the Physician]. This progress note did not indicate nursing staff notified Resident 1's RP of Resident 1's fall. During a concurrent record review and interview on 3/5/25 at 4:20 p.m., the DON verified the licensed nurse did not complete a Situation, Background, Appearance, Review and Notify (SBAR) Communication Form for Resident 1's fall. The DON reviewed Resident 1's progress dated 2/14/25 at 1:31 a.m. and confirmed the progress note did not indicate Resident 1's RP was notified of the fall. The DON stated the licensed nurse was expected to have notified Resident 1's RP of the fall and have documented it. A review of a facility policy and procedure titled Change of Condition Reporting dated 2/2025 indicated, Acute Medical Change .The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken .All nursing actions will be documented in the licensed progress notes .Routine Medical Change .Document resident change of condition and response in nursing progress notes .All attempts to reach the .responsible party will be documented in the nursing progress notes. Documentation will include time and response.

Based on observation, interview, and document review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 14 (room [ROOM NUMBER], room [ROOM NUMBER]. Rooms 7 through 14, and Rooms 19 through 22) of 22 resident rooms in the facility. Findings included: The Client Accommodations Analysis, dated 01/08/2025, revealed the facility had 14 rooms (Rooms 1-2, 7-14, and 19-22) with an approved capacity of four beds that each measured 307.8 sq ft, which yielded a total 76.95 sq ft for reach resident. On 01/08/2025 at 10:02 AM, the Maintenance Supervisor measured the following rooms and confirmed the following dimensions: - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. During an interview on 01/09/2025 at 8:37 AM, the Director of Nursing (DON) stated the minimum requirement was based on square footage in residents' rooms and she did not know what the exact minimum requirement was. The DON stated she expected residents' rooms to have enough space for their belongings, care to be provided, and mobility in and around the room. During an interview on 01/09/2025 at 8:42 AM, the Operations Manager (OM) stated the facility did not have a room size policy, but private room had to measure 100 sq ft and rooms with multiple residents had to measure 80 sq ft for each resident. The OM confirmed the facility had 14 rooms that housed four beds in each room. According to the OM, he expected residents' rooms to meet the minimum requirements.

Based on observation, interview and record review, the facility failed to ensure the environment was safe for residents and visitors, when a known tripping hazard, located in the parking lot, was not repaired timely. Facility staff were aware of the tripping hazard for more than two months, had purchased asphalt for its repair, and did not execute the repair until after a visitor tripped and fell . This failure: 1) Caused potential for resident falls, and subsequent injury, for one unidentified resident know to wheel himself (in a wheelchair) outside independently (without supervision), 2) Caused potential for resident falls, and subsequent injury, for eight sampled residents (Resident 25, Resident 144, Resident 29, Resident 16, Resident 8, Resident 36, Resident 28, and Resident 39) and six Unsampled residents (Resident 27, Resident 17, Resident 9, Resident 34, Resident 55, and Resident 56), known to ambulate with physical therapy staff inside and potentially outside, the building, and 3) Caused one Confidential Visitor (CV) to trip, fall and sustain injuries while walking through the parking lot. Findings: During an observation on 10/17/22 at 1:25 p.m., a Confidential Visitor (CV) to the facility was walking to their car in the parking lot. The CV tripped (and subsequently fell ) on a three-to-four-inch-deep drop in the pavement. The surrounding pavement (next to the drop) was cracked; the area was located near a corner of the building, near the physician's designated parking spot. Pictures were taken of the uneven, cracked pavement. During an observation and concurrent interview on 10/17/22 at 1:35 p.m., the three-to-four-inch-deep drop in the pavement (and visitor fall) was reported to the Director of Nursing (DON). The DON and the CV went to the uneven pavement site (where the fall occurred), and the DON stated she had not been aware of the uneven pavement and stated the area was, large. Director A was nearby and stated the cement had, shifted. During an observation on 10/17/22 at 2:10 p.m., the CV and three of their confidential coworkers were walking in the parking lot toward their cars. As the CV and their coworkers approached the uneven pavement site, the DON, Administrator and Director A were standing there. A bag of asphalt was on the ground, and Director A was using a shovel to fill in the three-to-four-inch-deep drop with asphalt. During a telephone interview on 10/20/22 at 10:43 a.m., the Activity Director (Director B) was asked about types of activities offered to residents at the facility. Director B stated the facility offered multiple activities including walking. Director B stated a, couple of residents, participated in morning or after meal walks. Director B stated approximately three residents were able to walk independently, but they ambulated with supervision (of staff). Director B stated Physical Therapy (staff) would walk additional residents. When asked where residents walked outside of the building, Director B stated residents could walk on the sidewalk, from one side of the building to the other. Director B stated the sidewalk had a railing, and the parking lot was on the other side of the railing. When asked if residents walked on the other side of the railing (in the parking area), Director B stated, Yes, it depends. Director B was asked if residents walked near the physician's parking space (near the visitor fall site), and she stated she did not like them to walk there but if they asked to walk around the entire building (which included walking in the parking lot), Director B stated, We would take them. During a telephone interview on 10/20/22 at 11:01 a.m., Physical Therapy Assistant C (PTA C) stated his job duties included assisting residents with Ambulation Goals (Physical Therapy targeting improvement of ambulation/walking). PTA C stated residents who had Ambulation Goals as part of their therapy program, were assisted by Physical Therapy staff with walking. PTA C stated twenty-five residents currently received Physical Therapy services at the facility, and north of (more than) 80% of them (approximately twenty residents) had Ambulation goals (indicating they walked with Physical Therapy staff). During the same telephone interview on 10/20/22 at 11:01 a.m., PTA C was asked where therapy staff took residents to ambulate. He stated PT staff walked residents inside and outside the building, and the location could depend on the resident's goals and the type of terrain (stretch of land, especially its physical features) needed to achieve those goals. PTA C stated indoor terrain (inside the facility) provided a more even surface for walking. He stated outdoor terrain had some smooth pavement but also had bumpy and rough surfaces (for more challenging walking surfaces). He stated, We have a parking lot that is bumpy, and areas outside with rougher asphalt. When asked what he would do if he encountered a tripping hazard with a resident, PTA C stated, We would navigate away from it. PTA C stated the facility had had tripping hazards in the parking lot in the past. PTA C stated, if the tripping hazard needed to be fixed, he would report it to Director A and stated they were good about fixing issues. When asked if he was aware of any (outside) tripping hazards that needed repair lately, PTA C stated, No. During a telephone interview on 10/20/22 at 11:29 a.m., the Director of Plant Management (Director A) was asked about the uneven, three-to-four-inch-deep drop in pavement located in the parking lot. Director A stated the facility had fixed the concrete (in the parking lot) in 2012, and at some point the, concrete shifted. Director A stated the shifting concrete caused a, lip to occur. When asked when the lip occurred, Director A stated it was, more than a couple of months (ago), but less than, a year. When asked why the lip had not been repaired if the facility was aware of its existence for at least a couple of months, Director A stated the facility had identified the hazard and had purchased asphalt to repair it, but the visitor had tripped and fallen over the site before he fixed it. During the same telephone interview on 10/20/22 at 11:29 a.m., Director A was asked about the repair work he had done on the uneven pavement after the visitor fall on 10/17/22. Director A stated he used the asphalt the facility had onsite to make the repair (a patch). When asked if the asphalt patch was a cold patch (filling a pothole with asphalt material without heating it), Director A stated the repair was a cold patch and confirmed it was a temporary fix. He stated he could grind down the cement to create a permanent fix, but he did not have a cement grinder. Director A stated the facility was working on a permanent fix, and he would need to consult with the corporate owners (regarding the permanent fix). During the same telephone interview on 10/20/22 at 11:29 a.m., Director A was asked if he was aware of any other visitors falling in the parking lot in the past years. Director A stated he was working at the facility (years ago) when a visitor had fallen in the parking lot and broken her wrist. Director A stated that past fall (resulting in the broken wrist) was not related to the cement, lip, but was due to a, loose bolt on metal in the driveway, which was removed after the fall. During a telephone interview on 10/20/22 at 3:34 p.m., the Director of Nursing (DON) was asked if she was aware residents ambulated in the parking lot, and she stated, Yes she was aware. The DON stated residents usually used the sidewalk (adjacent to the parking lot) and walked along the fence; she stated they did not usually walk where the cars parked. The DON stated residents were, mostly supervised, and stated one wheelchair-bound resident independently went outside and wheeled around. The DON stated residents went outside and looked at the flowers, used the sidewalk area, and did not wheel around the driveway. During the same telephone interview on 10/20/22 at 3:34 p.m., the DON was asked to provide a list of residents whose Physical Therapy included ambulation goals and walking around the facility. Review of multiple resident medical records (provided by the DON) titled, Physical Therapy, subtitled, PT Recert, Progress Report & Updated Therapy Plan, indicated approximately fourteen residents currently had Ambulation Goals as part of their Physical Therapy treatment program. Residents 25, 144, 27, 17, 29, 34, 55, 16, 8, 36, 28, 9, 39, and Resident 56 each had documented ambulation goals ranging from 10 - 200 feet of walking around the facility. Review of facility policy titled, Nursing, subtitled, Resident Assessment, subtitled, Fall Management System, further subtitled, Standard (undated) indicated, This facility is committed to .providing an environment that remains as free of accident hazards as possible . Policy and procedures for Environment and for Safety were requested from facility leadership; the requested policies and procedures were not provided during the survey.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services to meet the needs of each resident when: 1. The facility pharmacist failed to identify a risk for a potential medication administration error for one resident, Resident 144. The medication label on a controlled medication, [MEDICATION(S)] ([MEDICATION(S)] is used as a pain reliever. [MEDICATION(S)] is two to eight times more potent than [MEDICATION(S)] but shorter duration and greater sedation), was not the indication for use as written by Resident 144's physician. This failure had the potential to result in ineffective pain management or overdosing that could adversely affect the health and safety of Resident 144; and, 2. The facility failed to implement a system to consistently and accurately reconcile its inventory of [MEDICATION(S)] Patches (a potent opioid pain medication that is given and absorbed through the skin), which had the potential to result in medication diversion going unnoticed for an extended amount of time. Findings: 1. During a review of Resident 144's, Order Summary Report, dated 10/21/22, at 10:54 a.m., the report indicated Resident 144 had medical diagnoses that included Secondary Malignant Neoplasm of Bone (Secondary [CONDITION(S)] refers to a cancer that has started in another part of the body and has spread (metastasized) to the bone via the bloodstream or lymph nodes). The report indicated Resident 144's Physician wrote an order for [MEDICATION(S)] HCL ([MEDICATION(S)]) 4 mg, give 1 tablet by mouth every four hours as needed for Moderate Pain and [MEDICATION(S)] HCL 1.5 tablets (6 mg) by mouth every four hours as needed for Severe Pain. During an observation on 10/19/22, at 11:32 a.m., inside Resident 144's room, Resident 144 was sitting in his wheelchair, and a physical therapist came in to get him ready for Physical Therapy. Resident 144 screamed in pain as he was getting repositioned in his wheelchair. During a review of Resident 144's, Care Plan, for pain, the care plan indicated Resident 144 had pain related to left total knee replacement and left femur (thigh bone) replacement on 8/1/22. The care plan indicated Resident 144 had a history of cancer that metastasized to his left femur. The goal for the care plan was Resident 144 would not have an interruption in normal activities due to pain. The care plan indicated one of the interventions was to follow the pain scale and to medicate as ordered. Another intervention on the care plan indicated, Serious, life threatening, or fatal respiratory depression may occur with the use of [MEDICATION(S)]. Monitor for respiratory depression, especially during initiation of [MEDICATION(S)] or following a dose increase. During a concurrent observation and interview on 10/20/22, at 3:58 p.m., with Licensed Staff O, a blister pack (A blister pack is a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) for Resident 144's [MEDICATION(S)] HCL 4 mg tablets, indicated on the label, take 1(4 mg) to 1.5 (6 mg) tablets by mouth every 4 hours as needed for pain. It was shown to Licensed Staff O that the medication label did not indicate when to give 1 tablet or 1.5 tablets. Licensed Staff O was asked, when she would administer 1 tablet and when would she administer 1.5 tablets, because it was not specified on the label. Licensed Staff O stated she would ask Resident 144, and if his pain was moderate (level 4-6), she would administer 1 tablet and give 1.5 tablets if Resident 144's pain was severe (level 7-10). The blister pack for the [MEDICATION(S)] HCL had a written warning that this medication was an opioid: (Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as [MEDICATION(S)], and pain relievers available legally by prescription). Risk of overdose and addiction. During a review of Resident 144's, Medication Administration Record (MAR) for October 2022, the MAR indicated, Resident 144 was being monitored for pain every shift, pain level 0 was no pain, 1-3 was mild pain, 4-6 was moderate pain, and 7-10 was severe pain. On 10/11/22, at 11 p.m., Licensed Staff P assessed Resident 144's pain level at 6, moderate pain, and he was administered [MEDICATION(S)] HCL 1.5 tablets (6mg). On 10/18/22, at 7 p.m., Resident 144's pain level was 5, moderate pain, Licensed Staff P administered [MEDICATION(S)] HCL 1.5 tablets (6mg). The Physician's Order on the Order Summary Report, transcribed to the MAR, indicated [MEDICATION(S)] HCL 4 mg, 1.5 tablets (6mg) would be administered as needed every 4 hours for severe pain, not for moderate pain. On 10/11/22, at 3:54 p.m., Resident 144's pain level was assessed at 7, severe pain, Licensed Staff P administered [MEDICATION(S)] HCL 1 tablet (4mg). On 10/14/22, at 12:37 p.m., Resident 144's pain level was assessed at an 8, Licensed Staff Q administered [MEDICATION(S)] HCL 1 tablet (4mg). The MAR indicated, if Resident 144's pain was severe, per Physician's Order, he should have received [MEDICATION(S)] HCL 1.5 tablets (6mg). During an interview on 10/21/22, at 11:31 a.m., with the facility Pharmacist, she stated she had reviewed Resident 144's medication regimen and was not concerned about how the label was written for [MEDICATION(S)]. During a review of the, Consultation Report, dated 10/10/22, by the facility Pharmacist, the report indicated, Based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my judgement that at such time, the resident's medication contained no new irregularities. During an interview on 10/21/22, at 11:49 a.m., with the Director of Nursing (DON), the DON stated she was not concerned about the medication label for [MEDICATION(S)]. The DON stated Resident 144 had a pain monitoring scale on the MAR and that was what the nurses followed in assessing Resident 144 for his pain. During a concurrent observation and interview on 10/21/22, at 5:01 p.m., with Resident 144 was lying in bed, in his hospital gown. When Resident 144 was asked how he was feeling that day, he stated he may need to be transferred to the hospital because he was not tolerating his Physical Therapy. When asked if he got his pain medication when he needed it, he stated he got them but sometimes it helped with the pain and sometimes it did not. A facility document titled, LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual, dated 4/5/19, indicated, Facility should request that Pharmacy perform a routine nursing unit inspection for each station in facility to assist facility in complying with its obligations pursuant to applicable law relating to the proper storage, labeling, security, and accountability of medications and biologicals. 2. Controlled Medications, are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. Disposition, is the process of returning and/or destroying unused medications. Diversion of medications, is the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use, as adapted from the Uniform Controlled Substances Act. During a Medication Administration Cart (Med Cart) inspection and concurrent interview with Licensed Nurse M (LN M), on 10/17/22, at 12:51 p.m., there was a drawer in the cart that had a separate lock which required a key in order to access the drawer. LN M stated controlled medications were stored in the double locked drawer. LN M unlocked the drawer and pulled the drawer open for inspection. In the drawer were two boxes with labels indicating they contained [MEDICATION(S)] patches. The prescription label on the boxes indicated an old patch would be removed and replaced every 72 hours. LN M stated she was the nurse normally responsible for applying and removing the patches. LN M was asked to describe, in detail, the steps taken from administration to eventual discontinuance of the medication. During an interview with LN M, on 10/17/22, at 12:55 p.m., she described the facility process of handling used [MEDICATION(S)] patches. LN M stated she wore gloves and removed the old patch from the resident. LN M stated she folded the old patch to ensure both sticky sides were touching each other. LN M stated she put the folded patch into a thick plastic sleeve used to hold tablets that needed to be crushed. LN M stated she took the sleeve and smashed it with the pill crusher. LN M stated she put the plastic sleeve into the sharps container attached to her Medication Administration Cart (Med Cart). LN M stated that was the entire process for used [MEDICATION(S)] patches. LN M confirmed she carried out this procedure by herself every 72 hours. LN M stated there was no documentation requirement for this process. LN M stated she remembered a different process that required a second nurse as a witness and a signature page for used patches, but that process had not been used in a very long time. During an interview, on 10/19/22, at 2:10 p.m., with the Pharmacist Consultant (PC), she stated the facility had a new policy for [MEDICATION(S)] Patches that had gone into effect this year. The PC stated used [MEDICATION(S)] patches did not require any documentation and could be thrown in the regular trash bin on the Med Cart. When asked to provide a professional reference for her statement, the PC stated she would get back with the information. During an interview, on 10/20/22, at 3 p.m., with the Director of Nursing (DON), she stated she was responsible for medication disposition in the facility. The DON stated medication that was no longer needed should be removed from the Med Cart. The DON stated the facility expectation for controlled medication was to remove the medication and the corresponding Drug Count Sheet from the Med Cart and pass them to the DON for storage prior to destruction. The DON stated she and the Pharmacist Consultant (PC) reviewed all controlled medications and documentation at least once a month to destroy the controlled medications. During an interview, on 10/20/22, at 3:05 p.m., with the DON, she stated the facility had a procedure in place all Licensed Nurses were expected to follow if a controlled medication was removed from its packaging and not given to the resident. The DON stated the medication needed to be wasted. The DON stated two Licensed Nurses had to verify the controlled medication was removed and sign the Drug Count Sheet with the phrase, wasted. The DON stated the medication was disposed of into a container designed to store pills safely until they could be destroyed. During an interview, on 10/20/22, at 3:10 p.m., with the DON, she stated the facility had a procedure for the disposal of used [MEDICATION(S)] Patches. The DON stated the Licensed Nurse was expected to fold the used patch so that the sticky sides adhered to each other. The DON stated the patch would be put into a plastic sleeve, and the sleeve would be crushed with the pill crusher. The DON stated the plastic sleeve was disposed of into the sharps container on the Med Cart. The DON confirmed there was no Drug Count Sheet to document or monitor the disposal of used [MEDICATION(S)] patches. The DON confirmed the facility did not require a second Licensed Nurse to witness the disposal of the used [MEDICATION(S)] patch. When asked how did she know the used patches were going into the sharps container and not being diverted into someone's pocket, the DON stated she did not know. During a review of the facility policy and procedure titled, 3.12 Prescribing, Administration and Disposal of [MEDICATION(S)] Systems, dated 1/22, the policy indicated this was a new policy for the facility and would be in effect 4/1/22. The policy indicated, 14. [MEDICATION(S)] Disposal: Used transdermal system should be folded so that the adhesive side of the system adheres to itself, or per applicable state or local regulations. 14.1. Dispose in trash receptacle on cart in such a way to restrict access by staff, residents and visitors. Remove trash receptacle immediately after each medication pass, or 14.2. Make the patch unusable by mixing the folded patch with an undesirable substance such as kitty litter or wet coffee grounds and place in trash, or 14.3. Place folded patch in commercially available disposal kit and dispose per package directions, or 14.4. Store used and unwanted systems securely until facility ships to a DEA approved reverse distributor or 14.5. Place used and unwanted systems in a DEA approved mail-back program and ship via U.S. Mail NOTE: [MEDICATION(S)] patches are not biohazard waste. [MEDICATION(S)] patches are not considered hazardous pharmaceutical waste by the U.S. EPA. 15. Any unused systems should be removed from their pouch folded so that the adhesive side of the system adheres to itself before disposal/destruction. 16. Facility staff should routinely reconcile the inventory of [MEDICATION(S)] systems by comparing the countdown sheets, to the number of systems on hand, to medication administration records. A document request was made for the professional guidance used to create the new policy titled, 3.12 Prescribing, Administration and Disposal of [MEDICATION(S)] Systems, dated 1/22. At the time of exit no documentation was provided. During a review of the Food and Drug Administration's (FDA) recommendations titled, Safe Medicine Disposal Options, reviewed on 11/10/22, indicated the disposal method for used medication patches. The recommendation indicated, To dispose of a drug patch, carefully remove it by the edges and avoid touching the used medicine pad; then fold the patch in half, sticky sides together . [MEDICATION(S)] patches should be flushed immediately. During a review of the document titled, Federal Register Vol. 79, No. 174, dated 9/9/14, the Rules and Regulations section indicated clarification was needed for the proper procedures of dealing with transdermal patches in an institutional setting. The document indicated after administration, if some of the medication was left on the transdermal patch but could not be further utilized; such remaining substance must be properly recorded, stored, and destroyed in accordance with Drug Enforcement Administration (DEA) regulations and all applicable Federal, State, tribal, and local laws. During a review of the Code of Federal Regulations (CFR) Title 21 Chapter II titled, Drug Enforcement Administration, Department of Justice, last updated 10/25/22, indicated part 1317 Disposal contained Subpart C Destruction of Controlled Substances which included section 1317.95 Destruction Procedures. This section indicated the destruction of any controlled substance shall be in accordance with the following requirements, (d) If the controlled substances are destroyed at a registrant's registered location utilizing an on-site method of destruction, the following procedures shall be followed: (1) Two employees of the registrant shall handle or observe the handling of any controlled substance until the substance is rendered non-retrievable; and (2) Two employees of the registrant shall personally witness the destruction of the controlled substance until it is rendered non-retrievable.

Based on observation, interview, and record review, the facility failed to implement its medication labeling and medication storage policies and procedures, when: 1. One vial and two boxes of medication, which had no prescription labels attached to them, were found among the active supply (current prescription) of medications in the Medication Storage Refrigerator. This failure had the potential to result in administration of the wrong medication to the wrong resident; and, 2. Three liquid medications, which had been previously opened, did not have a label to indicate the date opened and/or any changes to the medication use-by date. These failures had the potential to result in administration of deteriorated medications and increased risk for ineffective treatments, resulting in residents' lower quality of life. Findings: 1. During a Medication Storage Room inspection and concurrent interview with the Infection Prevention Nurse (IP), on 10/17/22, at 10:48 a.m., the IP stated the refrigerator inside the Medication Storage Room was used to store temperature-sensitive medications. The IP opened the refrigerator door, inside the refrigerator there were several blue plastic bins filled with insulin pens, boxes, bags, and vials of various medications. During a Medication Storage Room inspection and concurrent interview with the IP, on 10/17/22, at 10:53 a.m., inside the Medication Storage Refrigerator there was a glass vial with a green label. The IP read the label on the vial and stated the medication was [MEDICATION(S)] (a man-made long-acting insulin used to control high blood sugar in adults and children with diabetes) for injection, 100 U/mL 10 ml total volume. The label on the vial indicated the medication expired 3/21/24. The vial had no prescription information attached to it. The vial had no indication of who's medication it was. The IP stated she was not sure who was prescribed the vial she was holding. There were several other insulins located in the refrigerator, the vials were all secured inside a cardboard box package. The cardboard box outer packaging had prescription stickers attached to them. The IP stated she did not know why the vial was stored with no prescription information. During a Medication Storage Room inspection and concurrent interview with the IP, on 10/17/22, at 10:56 a.m., inside the Medication Storage Refrigerator there were two white boxes, approximately 3 inches by 3 inches by 1 inch tall. The IP read the label on the boxes, and stated the medication was [MEDICATION(S)] (an injectable form of human growth hormone important for the growth of bones and muscles). There was no prescription information on either box. The IP stated she would have to look through the Medication Administration Reports (MAR) to figure out whose medication it was. During a review of the facility policy and procedure titled, Storage and Expiration Dating of Medications, Biological, last revised on 7/21/22, the policy indicated the facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels. 2. During a Medication Administration Cart (Med Cart) inspection and concurrent interview with Licensed Nurse M (LN M), on 10/17/22, at 12:41 p.m., there was one open bottle of liquid [MEDICATION(S)] (a medication approved to prevent and control partial seizures, relieve postherpetic neuralgia after shingles and moderate-to-severe [CONDITION(S)]) in the cart. LN M inspected the label on the bottle, and stated there was no open date documented on the bottle. LN M stated the only date on the bottle was the expiration date on the manufacturer's label During a review of the medication insert titled, Package Leaflet: Patient information, last revised 5/19, the document indicated [MEDICATION(S)] had specific storage instructions. The document indicated the medication should be discarded 30 days after opening. During a Med Cart inspection and concurrent interview with LN M, on 10/17/22, at 12:43 p.m., there was one open bottle of liquid [MEDICATION(S)] Solution (a medication used to treat certain conditions of the stomach and intestines) in the cart. The label on the bottle indicated the medication expired on 9/23. LN M read the label, and stated there was no open date on the bottle. LN M stated the medication was good until 9/1/2023. During a review of the medication insert titled, Package Leaflet: Patient information, last revised 5/22, the document indicated [MEDICATION(S)] Solution had specific storage instructions. The document indicated the medication should be used within one month of opening the bottle. During a Med Cart inspection and concurrent interview with LN M, on 10/17/22, at 12:44 p.m., there was one open bottle of liquid [MEDICATION(S)] (used to treat [CONDITION(S)] disorders, mental/mood conditions, and to prevent migraine headaches. The medication works by restoring the balance of certain neurotransmitters (natural substances) in the brain) in the cart. The label on the bottle indicated the medication expired on 4/24. LN M read the label, and stated there was no open date on the bottle. LN M stated the medication was good until 4/1/2024. During a review of the medication insert titled, Package Leaflet: Patient information, last revised 1/22, the document indicated liquid [MEDICATION(S)] had specific storage instructions. The document indicated after first opening, discard any unused medication after 50 days. During a review of the facility policy and procedure titled, Storage and Expiration Dating of Medications, Biological, last revised on 7/21/22, the policy indicated once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. The policy indicated the facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication had a shortened expiration date once opened or opened.

Based on observation, interview and record review, the facility failed to follow food safety requirements during food prep and food storage, when: 1. The facility stored flour in the bag it was delivered in, opened in a plastic tub; 2. One Cook, Cook E, was not wearing a beard cover for two days; 3. The North nursing unit resident refrigerator contained 15 expired Nutritional supplements; and, 4. The South nursing unit resident refrigerator contained an employee lunch bag in the freezer and an unlabeled/undated pink water pitcher. These failures put residents at risk for consuming food prepared with contaminated flour, hairs falling into resident food, risk for consuming expired nutritional supplements, which could lead to dyspepsia (Dyspepsia is another word for indigestion. People with indigestion often report feelings of stomach pain, over-fullness and bloating during and after eating. Other common symptoms include acid reflux, heartburn, and excessive burping), as well as infection control concerns. Findings: 1. During a tour of the dry storage on [DATE] at 10:35 AM, flour, still in the bag it was delivered in, was opened and stored inside plastic tub with a id. In a concurrent interview, the DFS (Director of Food Services) confirmed the bag was the original shipping bag which would not have been protected from dirt or dust during transportation. The facility policy and procedure titled, Storage of Food and Supplies, dated 2020, indicated in item #6. Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. 2. During a kitchen tour on [DATE] at 10:05 AM, Cook E was wearing a surgical mask which did not cover the hairs on his neck. During a kitchen tour on [DATE] at 9:46 AM, Cook E was again wearing a surgical mask which did not cover the hairs on his neck. During an observation and interview with the DFS on [DATE] at 2:30 PM, it was noted there was a sign on the kitchen door displaying a picture and indicating hair covering was mandatory. When the DFS was asked about the expectation, relative to beard covers related to Cook E, she stated, It is usually covered with a mask. The facility policy and procedure titled, Dress Code for Dietary Staff, not dated, indicated, Purpose: Appropriate dress in the Food and Nutrition Department; under Clothing: 7. Beard cover for facial hair, if applicable. 3. During a review of the resident refrigerator on the South side nurses' station on [DATE] at 8:51 AM, there were 15 expired nutritional supplements in the refrigerator. This was verified with Licensed nurse L on duty. 4. During a review of the resident refrigerator on the North side on [DATE] at 10:30 AM, the freezer contained a black canvas bag labeled, nurse. Inside was a foil wrapped food. There was no name or date on the bag. In addition, a pink water pitcher, with no name or date, was located in the freezer. The refrigerator and freezer were not clean. During an interview with Licensed Nurse M on [DATE] at 10:34 AM, when shown the nurse's bag and water pitcher in the freezer, she stated, That is not mine. That is a water pitcher we give residents water. I don't know why it is in there. It is the kitchen who stocks the refrigerator. During an interview with the DFS on [DATE] at 11 AM, when shown the nurse's bag and the water pitcher, she stated, It is not the kitchen's responsibility to clean the refrigerator, it is housekeeping. During an interview with Director A on [DATE] at 11:15 AM, he stated he was aware of what the surveyor found, his staff was cleaning the refrigerator now, and the housekeeping staff were to wipe down the refrigerator daily. The facility policy and procedure titled, Food for Residents From Outside Sources, dated 2018, indicated: Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, nursing station refrigerator or in the residents' personal refrigerator. In the food service department, the policy on food storage will apply. Otherwise, if unopened, refrigerated, or frozen items will be disposed of by the expiration date on the container.

Based on observation, interview and record review, the facility failed to follow professional standards of practice for one Resident (Resident 41) when: 1) there was no formalized process for nursing to communicate with the RD to provide assessments for residents who had pressure or diabetic ulcers; and, 2) there was lack of inclusion of the RD in relevant patient care committees, in accordance with the approved job description. Resident 41 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in a nutritional assessment not being completed, which had the potential to contribute to the wound not healing. Findings: It is estimated that up to 50% of hospitalized patients are malnourished. Malnutrition can lead to longer hospital stays, altered immune function, and impaired skin integrity and wound healing. Malnutrition has been found to be a significant factor influencing pressure injury (PI) risk and wound healing. While PI prevention requires multidimensional complex care using a variety of evidence-based strategies, hospitalized patients benefit from interventions that focus on improving oral nutrition to reduce PI risk and enhance wound healing. Unfortunately, malnutrition is often under-recognized and inadequately managed in hospitalized patients and this can lead to higher rates of complications such as PI. Recent Advances: Recent studies suggest that nutritional care has a major impact in PI prevention and management. Strategies, including early identification and management of malnutrition and provision of specially-formulated oral nutritional interventions to at-risk patients, optimization of electronic health record systems to allow for enhanced administration, monitoring, and evaluation of nutritional therapies, and implementation of protocol-based computerized decision support systems, have been reported to improve outcomes. Optimizing Nutrition Care for Pressure Injuries in hospitalized Patients. (2019) Advances in wound care, 8(7), 309-322.https://doi.org/10.1089/wound.2018.0925 During a review of Resident 41's clinical record, indicated Resident 41 had an acute care hospital office visit and saw a Doctor of Podiatry Medicine (DPM) on 3/1/22. The following issues were addressed: Diabetes Type 2 with peripheral [CONDITION(S)], Diabetes Type 2 with Diabetic Ulcer of right heel, and pressure ulcer of the right heel Stage 3. During a further review of the clinical record, it indicated Resident 41 had a diet order of CCHO (Consistent Carbohydrate Controlled) diet for diabetics. Resident 41 needed 75g protein for wound healing. Review of Documentation of Survey Report v2, dated 10/19/22, indicated Resident 41's average meal intake for August, September and October 2022, Resident 41's average intake was 56% of her meals. Her caloric needs were 1678-1845 Kcals. If she was only eating 939.68 kcals and 42g protein, she was not meeting her caloric needs. During an interview with the RD on 10/19/22 at 11:28 AM, she stated she started in 2019. Apparently, it was missed by me. I wasn't notified of that change. I don't attend the meetings. The Interdisciplinary Team is nursing, DFS (Director of Food Services) The Care planning and weight committee is limited to DFS and nursing. During an interview and concurrent record review with the RD on 10/20/22 at 10:30 AM, showed the baseline care plan, dated 9/25/17, which documented a recommended intervention for the RD to do an assessment. The RD stated she did not know why she was not notified. During an interview with DFS on 10/21/22 at 1:38 p.m., when asked how the RD was notified of residents, she stated change of condition, onsite, weekly weights, staff can reach out, all new admissions. During a review of the job description for the Registered Dietitian, not dated, it indicated the RD was hired on 3/13/20. The primary purpose of the job position was to, .plan, organize, develop, and direct the overall operation of the Dietary Department . to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. It further indicated the RD assist the Quality Assessment and Assurance committee in developing and implementing appropriate plans of actions to correct dietary deficiencies. The RD serves on, participates in, and attends the various committees of the facility (i.e. Infection Control, Policy Advisory, Pharmaceutical, Budget, Quality Assessment and Assurance, etc.) as required, and as appointed by the Administrator. The facility policy and procedure titled, Quality of Care - Skin Management System, dated 5/2019, indicated, It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventative measures taken to ensure that the resident does not develop pressure ulcers. It further indicated the Registered Dietitian would provide nutritional support when appropriate. The facility policy and procedure titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, not dated, indicated under, Treatment and Management: a. Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcers. b. Beyond trying to maintain a stable weight and providing approximately 1.2-1.5 gm/kg protein daily, there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer. The facility policy was not reflective of accepted standards of professional practice. It was also noted that the policy did not indicate a professional reference for the practice statement discounting the benefit of nutritional interventions in wound healing.

Based on observation, interview, and record review, one of two sampled Diet Aides was not able to verbalize or demonstrate how to properly test the chemical strength of the sanitation bucket in the kitchen. This failure had the potential for this Diet Aide not to have the correct concentration and would potentially result in ineffective sanitization of food service equipment. Findings: During an observation and concurrent interview on 10/18/22 at 3 PM, Diet Aide H was scooping ice cream. Upon completion of the task, Diet Aide H was asked to describe how surfaces were sanitized. Diet Aide H could not verbalize or demonstrate proper test procedure. The Director of Food Services (DFS) intervened and assisted Diet Aide H to find the correct measuring strips. Diet Aide H stuck the test strip in the solution in the red bucket for 10 seconds, read the strip on the back of the bottle of test strips, which showed Test 400. During a review of the department document titled, Verification of Job Competency-Cooks, dated 9/2/22, for Diet Aide H, it showed she was able to verbalize sanitizing solution; test concentration and record results and when to replace the solution. The competency was signed/verified by the Director of Food Services (DFS). During a review of the Job Description for Dietary Aides, not dated, indicated to assist in daily or scheduled cleaning duties, in accordance with established policies and procedures.

Based on observation, interview and record review, the facility failed to puree two food items per the recipe. This failure caused one puree item not to hold its shape and the other to taste grainy. Findings: The International Dysphagia Diet Standardization (IDDSI) Framework July 2019, provides a common terminology to describe food textures. Foods are measured from Levels 3 - 7. Level 4 Pureed Usually eaten with a spoon (a fork is possible) o Cannot be drunk from a cup because it does not flow easily o Cannot be sucked through a straw o Does not require chewing o Should be smooth and can be piped, layered or molded because it retains its shape, but should not require chewing if presented in this form o No lumps o Not sticky o Liquid must not separate from solid. Cohesive enough to hold its shape on a spoon. During a tray line observation on 10/17/22 at 11:40 AM, Cook E was pureeing meatballs. Cook E stated he could add chicken broth or beef broth if he needed to. He pureed just the meatballs with nothing added. A taste test was conducted, based on surveyor observation of pureed food production practices, on 10/17/22 at 12:36 PM, and the pureed meatball did not hold its shape. The pureed meatball looked like ground beef and fell apart in the surveyor's mouth. It tasted like ground meat. The DFS tasted the pureed meatball and stated, It is crumbly because it didn't have any gravy. The DFS confirmed the meatball was crumbly. A test tray, in the presence of the Director of Food Service (DFS), was conducted on 10/18/22 at 8:33 AM, based on resident concerns. The test tray included an evaluation of pureed items. It was noted the pureed eggs tasted grainy and bland. Review of the Recipe: Pureed Meats, not dated, indicated the Cook should puree on low speed to a paste consistency before adding any liquid. Gradually add warm liquid (low sodium broth or gravy). Starting with the smaller amount and adding more as needed to achieve the desired consistency. Puree should reach a consistency slightly softer than whipped topping. During a review of the Recipe: Pureed Eggs, not dated, indicated the Cook should puree on low speed to a paste consistency before adding any liquid. Gradually add warm milk. Starting with the smaller amount and adding in more as needed to achieve the desired consistency. Puree should reach a consistency slightly softer than whipped topping.

Based on observation, interview, and a review of documents, a safe and effective practice for preventing infection was not implemented, when one of four staff members failed to demonstrate an appropriate practice for the routine cleaning and disinfection of a non-critical patient-care medical device (e.g., a blood pressure cuff). This failure placed all residents at potential risk for infection from a contaminated medical device. Findings: On 5/22/20 at 9:35 a.m., Staff A was observed to take a non-dedicated sphygmomanometer machine (a machine used to take a blood pressure measurement) from the nurse station and into a resident's room. Staff A took the resident's blood pressure and returned the equipment to the nurse station. The machine was not cleaned before or after being used on the resident. Staff A was asked to describe the facility's process for cleaning the equipment. Staff A stated, We wipe it down with an alcohol wipe pad if the patient is known to have, or suspected to have, an infection. Otherwise we don't do anything. On 5/22/20 at 9:42 a.m., Staff B was asked to describe the facility's process for cleaning blood pressure equipment. Staff B stated, We have a sanitizer spray, and I use it before and after I take a resident's blood pressure. When asked if this was only done if the resident had or was suspected to have, an infection, Staff B stated, No, I like to do it with all of my residents. On 5/22/20 at 9:45 a.m., Staff C was asked to describe the facility's process for cleaning blood pressure equipment. Staff C stated, I wash my hands before and after, and I sanitize the equipment before and after each use. On 5/22/20 at 10:05 a.m., Administrative Staff D was asked to describe the facility's process for cleaning blood pressure equipment. Staff D stated the process was to use either a sanitizing spray or a cloth wipe from, the purple-top lid container, and it should be done, between each patient use. A facility policy titled, Infection Control Prevention and Control Program (dated 9/2017), indicated on Page 2, C., Prevention of Infection Policies, procedures and aseptic practices are followed by personnel in performing procedures, linen handling and disinfection of equipment. Based upon observation and interview, the facility's practice for disinfection of equipment was inconsistent. A facility policy titled, Cleaning and Disinfection of Environmental Surfaces (dated August, 2019), indicated on Page 7, c., Non-critical items are those that come in contact with intact skin but not mucous membranes. Section 2 on Page 7 indicated, Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. This policy did not differentiate between equipment used on (a) an infected or suspected-infected resident and (b) a non-infected or non-suspected resident. The Centers for Disease Control and Prevention (CDC) document titled, Disinfection and Sterilization: Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), indicated on page 3 of 14, Section 4. b., Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. Section 4. c. indicated, Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). The facility did not have a process in place to ensure noncritical patient-care devices (e.g., blood pressure cuffs) were consistently being disinfected according to CDC guidance.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet, per resident, in 8 of 21 sampled resident rooms (Rooms 07, 08, 09,10,12,13, 20, and 22), and bathroom availability was difficult for residents who must share bathrooms between two rooms. These failures caused residents to complain of feeling uncomfortable, cramped, unable to maneuver equipment, and to not have sufficient space to move about in their living spaces. Findings: During an initial tour and concurrent interview on 12/2/19 at 10:00 a.m., Resident 202 complained bathrooms were always in use since the bathroom was shared between two rooms, and she was particular how clean the toilets were with all the use. I prefer my own commode. Resident 202 also stated one concern she had was when staff left the commode full for a long period of time, It smells. During Resident Council Meeting on 12/3/19 at 10:09 a.m., Resident 23 stated he was in a room with four beds, and the other room had four beds, with eight people using the same bathroom. It created long periods of waiting to get his turn in the bathroom. During an interview on 12/3/19 at 11 a.m., Resident 30 complained the room was cramped with all the medical equipment. My wheelchair and bed are oversized and then you have the residents' equipment, it's very tight. The bathroom is always in use, we must share between two rooms. During an interview on 12/4/19 at 11 a.m., Resident 2 complained the bathroom was always full, and he had a Suprapubic catheter which needed to be drained often. The bathroom was always in use, we must share between two rooms. I pull the curtain when I need privacy. During an interview on 12/4/19 at 1:44 p.m., Resident 22 complained there was not enough room to walk around her bed, and privacy was an issue when the closets were inches from her bed. Resident 22 stated she must pull the curtain and take out her hearing aids, when residents' and staff were over by the closets, because of the noise. During an interview on 12/5/19 at 12:30 p.m., the Plant Supervisor was asked to measure Resident rooms [ROOM NUMBERS]. The measurements for room [ROOM NUMBER] was 16' by 19' with each resident area measuring 8' X 9'. There was 18 between the closets and Resident 204's bed. room [ROOM NUMBER]'s measurements were also 16' by 19', 8' x 9' for each resident area, with 20 between the closets and Resident 22's bed. These measurements resulted in <76 (less than) square feet of living space, per resident. During an interview on 12/6/19 at 9:57 a.m., Unlicensed Staff E, stated some residents had complained the rooms felt crowded. When questioning Unlicensed Staff E, what she did to reduce the feeling of crowding in residents' rooms, she stated she cleaned up the room and sometimes rearranged the furniture, when possible.

Based on interview and record review, the facility failed to complete the Pre-Admission Screening and Resident Review (PASARR) accurately for two out of fifteen sampled residents (Resident 34 and 49). This failure resulted in the prevention of further evaluation to identify any specialized services required to meet individual needs in a population of residents with mental illness. Findings: During an interview on 12/3/19, at 4:03 p.m., with The Minimum Data Set Coordinator (MDS Coordinator), she stated she completed the PASARR assessments for every resident in the facility. The MDS Coordinator stated she submitted the Level 1 Screening Documents during the admission process, when a resident had a significant change in their health condition, when a resident had a change in medical diagnosis, and annually. During review, Resident 34's Admission Record, dated 12/4/19, indicated Resident 34 had active medical [DIAGNOSES REDACTED]. During a concurrent interview and record review, on 12/4/19, at 4 p.m., with the MDS Coordinator, Resident 34's PASARR Level 1 Screening Document, dated 5/7/19, was reviewed. The document indicated, Resident 34 did not have serious difficulty communicating needs as a result of a cognitive deficit. The MDS Coordinator stated the question had been marked based on Resident 34's ability at the time of assessment. The MDS Coordinator stated Resident 34's ability to communicate varied from day to day. The MDS Coordinator confirmed Resident 34 did have times where she had serious difficulty communicating needs. The MDS Coordinator stated the question should have been answered yes, to indicate Resident 34 had serious difficulty communicating needs as a result of a cognitive deficit. During a review of Resident 49's Admission Record, dated 12/4/19, indicated Resident 49 had active medical [DIAGNOSES REDACTED]. During a concurrent interview and record review, on 12/4/19, at 3:16 p.m., with the MDS Coordinator, Resident 49's PASARR Level 1 Screening Document, dated 8/26/19, was reviewed. The document indicated Resident 49 did not have any neurocognitive disorders, which included Dementia. The MDS Coordinator stated the question was answered incorrectly. The MDS Coordinator stated the question should have been marked yes, to indicate Resident 49 had Dementia. During a review of the facility's policy and procedure titled, PASARR, dated 8/19, indicated the facility would ensure each resident was properly screened using the state specific PASARR.

Based an interview and record review, the facility did not meet professional standards of practice when the intravenous (IV) medication for one of one resident's, receiving IV medications (Resident 153) was not documented on the Medication Administration Record (MAR) clearly. This error made it appear Resident 153 was not getting his IV medication, as ordered. Findings: During a review of Resident 153's clinical record, the Order Summary Report, dated 12/6/19, documented Resident 153 was admitted on [DATE], with the [DIAGNOSES REDACTED]. The orders included care of the IV line, the use of the CADD pump, (device to control the flow of IV fluids) and [MEDICATION NAME] (antibiotic) 2 grams intravenously, three times a day for infection, until 12/25/19. During further review of the clinical record, the (MONTH) 2019, MAR listed CADD Pump: Change Bag and Tubing every night shift, between 0400 and 0600 (4 a.m. and 6 a.m.), ordered 11/26/19; this was documented as done each night. The MAR also listed CADD Pump: Monitor Pump and ensure infusing every shift, ordered 11/14/19. This line was missing several signatures for day and evening shift, indicating the monitoring was not always done. Resident 153's 12/2019, MAR listed [MEDICATION NAME] 1 gram, use 2-gram IV three times a day for infection, with times listed as 0300, 1100, and 1900 (3 a.m., 11 a.m. and 7 p.m.). The 0300 dose was documented each day. The 1100 and 1900 doses were not all documented as given every day. During an interview and concurrent observation on 12/4/19 at 11:30 a.m., the DON stated Resident 153's medication is on a CADD pump and is always connected. She stated the CADD pump bag and tubing were changed by an RN every morning, and the pump was programmed for 24-hour dosing. The CADD pump settings were looked at, and it was set to go at 83 ml an hour over 30 minutes, and the next dose was for 1900 (7 p.m.). The CADD pump was set by the pharmacy, based on the doctor's order for the IV medication. The Pharmacy prepared a 24-hour bag and tubing for the facility. During an interview on 12/4/19 at 11:30 a.m., the DON stated the MAR listed the CADD pump bag and tubing to be changed every night, and the [MEDICATION NAME] IV medication to be given at 0300, 1100, and 1900. The DON acknowledged that the three doses were contained in the bag and tubing which was changed by the nurse at one time. The DON stated the medication and the CADD pump orders had to be listed out separately on the MAR. The DON stated she was responsible for documentation of the 1100 dose and monitoring the CADD pump when she worked, and stated she did not get to the MAR each day (to document). During an interview on 12/4/19 at 11:30 a.m., the DON stated the documentation was the responsibility of the RN's, not the LVN's, who had the resident assigned to them. The DON stated the facility did not have RN coverage 24 hours a day, 7 days a week. The facility made sure an RN was available to change the CADD pump each day, and an RN was available by telephone.

Based on interview and record review, the facility failed to prevent the development of a pressure ulcer (area of damaged skin caused by staying in one position for too long; they commonly form where the bones are close to the skin) to the sacrum, (the triangular bone at the base of the spine), for one of fifteen sampled residents. Resident 46 developed a Stage 3 pressure ulcer to her sacrum, requiring surgical interventions. Findings: During an observation on 12/5/19 at 9:29 a.m., Resident 46 was lying on her right side. She stated the nurse had just cleaned up the sore on her bottom. During an interview 12/5/19 at 12:20 p.m., at nurse's station, Licensed Staff [NAME] stated she had changed Resident 46's dressing. She stated the dressing changes were done daily. She described the wound as healing, appeared covered with a layer of fragile skin. During a review of Resident 46's clinical record, the Order Summary Report, dated 12/6/19, documented Resident 46 was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. During continued review of Resident 46's clinical record, the Initial Admission Record, dated 11/7/19, documented Resident 46 was, noted to have dark blanch-able redness to coccyx and bilateral buttocks, no open areas noted. (Blanch-able, discolored skin turns white when pressed down and returns to regular color when released. Skin which doesn't lighten to the touch is a sign of a pressure injury.) The initial care plan, dated 11/7/19, included: At risk for skin breakdown related to impaired mobility and incontinence. Interventions were to encourage repositioning every two hours, and as needed, to prevent skin breakdown, pressure reducing mattress to bed, and skin check two times a week and as needed. Resident 46's clinical record included the CNA Kardex, a report listing the care the resident needs, dated 12/6/19. The section titled, Skin, instructed low air loss mattress, the, Pain, section instructed positron for comfort, and under, Other, was the directive: Position Resident with proper body alignment for optimal breathing pattern. Review of the documentation of, Tasks (items CNA's were to do) for Resident 46, included the question: Did you turn and reposition resident? This question did not specify turn every two hours. The response consisted of a check mark for each shift. The date, 11/10/19, did not have any notation for night shift. Day staff documented the task was done for 11/8 through 11/10/19. The task was documented as not applicable for the day shift for the dates, 11/11/19, through 11/14/19, and no documentation was present for day shift on 11/15/19. The task with the question about urinary continence, indicated Resident 46 was incontinent of urine on 11/10/19, in the evening and incontinent during the night on 11/11/19 through 11/15/19. The question about bowel continence, indicated Resident 46 was incontinent of bowel once on 11/8/19, 11/9/19, 11/11/19, and 11/13/19 through 11/15/19. The task question for Resident 46, was what type of bathing activity was completed. This was marked as not applicable for 11/8 through 11/13/19; indicating six days without any type of bath. On 11/14/19 at 12:10 p.m., a check mark indicated a shower was given at this time. Resident 46's clinical record showed a first notation of a skin problem was the, Change of Condition, Progress Note, dated 11/15/19, and timed at 11:15 p.m. This indicated, Res has open area to right buttock. Barrier cream applied, dressing applied, all needs met. Turned q (every) 2 hours as allowed Clinician was notified on 11/15/19, at midnight. Resident 46's Treatment Administration Record (TAR) documented Barrier Cream to buttocks every shift, ordered by Clinician on 11/15/19, and administrated, as ordered, on 11/15/19 to 11/18/19. Resident 46's Surgical Consult was done 11/18/19. This documented a wound located on the right sacrum and called a Pressure Injury/Ulcer. The tissue type in the wound bed was 80% Granulation (the formation of minute, rounded, fleshy connective tissue projections on the surface of a wound) and 20% Necrotic (dead) tissue. The consultant debrided (removed) the devitalized (devoid of life) tissue of an estimated 8 millimeters (mm) by 8 mm by 1 mm deep. Resident 46's second Surgical Consult, dated 12/2/19, documented a wound on the right sacrum caused by a Pressure Injury/Ulcer which had devitalized tissue. The consultant preformed muscle tissue debridement by excision of devitalized subcutaneous, muscle, fascia, and tendon tissue for a total of 4 mm by 4 mm by 1 mm deep, excised. (Stage 3 involves the full thickness of the skin and may extend into the subcutaneous tissue layer. At this stage, there may be undermining that makes the wound much larger than it may seem on the surface. Stage 4 pressure ulcers are the deepest, extending into the muscle, tendon or even bone.) During review, Resident 46's Nursing Care Plan, dated 11/22/19, documented, Focus: Has Stage 3 pressure injury to right sacrum. Interventions included: Administer treatments as ordered, monitor for effectiveness, Assess and document wound size, give nutritional supplements for wound healing, low air loss mattress to bed and others. During an interview on 12/6/19 at 10 a.m., the MDS coordinator stated the wound was found on 11/15/19, and was seen by the specialist on 11/18/19. The staging of pressure injury/ulcers was done by the facility's wound care specialist. On 11/18/19, the specialist ordered: Clean wound with normal saline, pat dry, cover with foam dressing daily. On 11/22/19, the Skin Committee met and decided to add oral supplements for wound healing and a low air loss mattress. The low air loss mattress was put on Resident 46's bed 11/22/19. During an interview on 12/6/19 at 10:30 a.m., the DSD (Director of Staff Development) stated the wound was found by the nurse when she was giving Resident 46 an enema on 11/15/19. The wound bed was necrotic, and the skin around the area was inflamed/red. The wound care specialist, who came on Mondays, assessed and treated the wound and wrote wound care orders on 11/18/19. The DSD stated she saw the wound, with the specialist, and documented on Resident 46's Skin Pressure Ulcer Weekly Report, using the information from the specialist report on the wound. The facility's procedure, Skin and Wound Management Care Guidelines, dated 8/25/16, instructed to implement guidelines on Pressure Injury Prevention and Treatment, as indicated, such as, Preventive Skin Care, Nutritional Support for Pressure Injury, Educate Resident and Encourage Repositioning guidelines to prevent and manage Pressure Injury .

Based on food storage observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by: 1) freezer and refrigerator products were not sealed, 2) a vendor entered the kitchen without wearing a hair net, and 3) a food production staff member touched her sleeves with her non-gloved hands while assisting with tray line and touched the food scooper ends of the serving scoopers. Failure to ensure effective dietetic services operations which prevent foodborne illness may result in compromised medical status and in severe instances may result in death. Findings: 1. During the initial tour of the kitchen on 12/04/17 at 6:55 a.m.: a. A large bag of frozen zucchini and a large bag of frozen bacon (stored in their original delivery box) located in the freezer were not sealed, and b. Opened bag of celery located in the refrigerator was stored in an open plastic container. During an interview on 12/04/17 at 5:00 p.m., when the Dietary Supervisor was asked if opened bags of food products stored in the refrigerator and freezer should be tied tightly or sealed, she stated the opened food products stored the refrigerator and the freezer should be sealed tightly or placed in airtight containers. During a concurrent observation and interview on 12/06/17 at 8:00 a.m. an open bag of frozen biscuits located in the freezer was not sealed. When the Dietary Supervisor was shown the opened bag of frozen biscuits, the Dietary Supervisor stated, the frozen biscuits were going to be cooked eventually, so what was the issue? The surveyor requested a policy/procedure from Dietary Supervisor regarding refrigerator and freezer food products needing to be sealed tightly once opened, but the facility was unable to provide a policy/procedure. 2. During an observation and interview on 12/07/17 at 8:22 a.m., a vendor delivering kitchen rags entered the kitchen by way of the north bound kitchen door (considered the dirty side door; door had sign posted to be used only by kitchen staff) without wearing a hair net, and left the kitchen after leaving the kitchen rags in the janitors closet through the south bound kitchen door (considered the clean side entrance door). When Dietary Staff I was asked if the delivery people and maintenance walk into the kitchen without a hair net, Dietary Staff I hesitated, but then stated maintenance usually entered the kitchen through the clean side door, which was nearest the hand washing sink and left by way of the same door, but delivery people and maintenance may forget to wear a hair net when they come into kitchen on occasions. During an interview on 12/07/17 at 10:32 a.m., Dietary Supervisor stated if maintenance and/or delivery people entered the kitchen, they should have put on a hair net prior to entering the kitchen and should have entered the kitchen through the door nearest the hand washing sink, which was the south bound entrance. Dietary Supervisor stated the north bound kitchen entrance was considered the dirty side and only dietary staff were to use the north bound kitchen door. Dietary Supervisor stated anyone entering the kitchen through the south bound kitchen door entrance and went past the red line needed to wear a hair net. Dietary Supervisor stated maintenance and vendors were aware they needed to enter the kitchen through the clean kitchen door and needing to wear a hair net if they went past the red line. The facility policy/procedure titled, Dress Code for Women and Men, undated, indicated personal hygiene and appropriate dress are very important part of the total appearance of the Dietary Department. Appearance is very important in maintaining a high standard of food service. The following recommendations are made including a hair net or hat which completely covers hair. 3. During an observation on 12/06/17 at 11:30 a.m., Dietary Staff N, who was assisting the AM Cook during tray line was observed touching the food scooper ends (the end of a serving scooper which touched the food) as she moved food scoopers into a pile on the steam table. Dietary Staff N then touched the food scooper end of a serving scooper as she placed the scooper back into the kitchen drawer. Dietary Staff N was not wearing gloves. Dietary Staff N was then observed pulling the ends of her pink long sleeve shirt over the palms of her hands as she was waiting for the AM Cook to call out directions. Dietary Staff N did not have gloves on nor did she wash her hands after touching her clothing. Dietary Staff then retrieved a sandwich from the refrigerator and prepared two bowls of soup. During an interview on 12/08/17 at 10:54 a.m., when Dietary Staff N was asked if she thought it was okay to touch the ends of her shirt sleeves with the palm of her hands while assisting with tray line, Dietary Staff N stated she could see it being an issue due to the ends of the shirt sleeves could be dirty. The surveyor requested a policy/procedure from Dietary Supervisor regarding dietary staff touching clothes with bare hands while assisting with tray line, but the facility was unable to provide one.

Based on observation, interview, and record review, the facility failed to ensure residents' rights and dignity for 4 of 20 sampled residents (Residents 2, 18, 38, and 101) and one of six confidential residents when: 1. Staff did not provide supervision or cueing when Resident 38 performed oral hygiene, which resulted in Resident 38 having difficulties and confusion in brushing his teeth and not being able to brush teeth properly. 2. The information on the communication board for Resident 101 was not updated and not within the resident's sight, which resulted in Resident 101 not knowing the date and the nurse and CNA (certified nursing assistant) names and asking her family member every day for those information. 3. Staff did not answer call light in a timely manner for Resident 2, 18, and one of six confidential residents, which resulted in residents not receiving care timely. These failures also resulted in the potential to decline residents' rights and dignity, potentially compromise residents' physical and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 12/4/17, at 9:32 a.m., in Resident 38's room, Unlicensed Staff B was helping another resident in the room. Resident 38 was in bed and awake. When Resident 38 was asking about the plastic box he took from the nightstand, Unlicensed Staff B came over and took out a toothbrush from the plastic box and gave the toothbrush to Resident 38. When Resident 38 was holding the toothbrush, Unlicensed Staff B put some toothpaste into the toothbrush and gave Resident 38 a basin and three paper towels for brushing his teeth. After Unlicensed Staff B gave Resident 38 the toothbrush with toothpaste, the basin, and the paper towels, Unlicensed Staff B left the room. Resident 38 brushed his teeth. Resident 38 did not use water to rinse his mouth before or after brushing his teeth. After Resident 38 brushed his teeth, he stated usually the toothbrush was cleaned two to three days after use and asked where to put the toothbrush. Resident 38 was holding his toothbrush and searching on the bedside table where a cup of water near the basin on the table. When prompted about a cup of water on the table, he asked Do you want me to rinse my mouth? Resident 38 then rinsed his mouth with one sip of water. Resident 38 repeated saying a couple times about what should he do with the paper towels and this was the first time they gave him the paper towels. When prompted if he used the call light for assistance, Resident 38 looked for a call bell and stated he could not find it. When prompted about a white cord near him, he finally found the call bell and put on the call light. Unlicensed Staff B came and cleaned up the toothbrush and the basin. Unlicensed Staff B placed the toothbrush and basin back to its place and left the room. During an interview on 12/7/17, at 11 a.m., Unlicensed Staff B stated Resident 38 required limited assistance (requires staff provide guided maneuvering of limbs or other non-weight-bearing assistance) for brushing teeth. Unlicensed Staff B stated she set up the tooth brushing supplies for the resident, checked back on the resident later or came back when the resident turned on the call light. Resident 38's activities of daily living (ADL) flow sheet dated 12/4/17, morning shift 6:30 a.m. to 2:30 p.m., indicated Resident 38 required supervision (oversight, encouragement or cueing) for personal hygiene including brushing teeth. During a concurrent interview and record review of Resident 38's ADL flow sheet dated 12/4/17, on 12/8/17, at 2:22 p.m., when reviewed and asked what was supervision and cueing meant, the RN Resource (a corporate staff covering for the Director of Staff Development who was on leave) stated that somebody provided oversight and cueing to the resident. When mentioned to her about the observation on 12/4/17 on how Resident 38 brushed his teeth, the RN Resource stated she understood that the resident needed supervision and cueing for brushing his teeth properly. RN Resource stated they needed to educate the staff. The RN Resources stated that Resident 38 might not have rinsed out all the toothpaste by one sip of water. The facility's policy and procedure titled ADL, Services to carry out, revised 11/2016, indicated It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. 2. During a concurrent observation and interview on 12/5/17, at 9:14 a.m., in Resident 101's room, a white board on the wall above the nightstand near the head of the bed. The white board contained information headings including date, nurse, CNA, diet, precaution, and notes. The date on the board was 12/4/17. All other areas under the headings were blank. Resident 101 stated she could not see the board. Resident 101's family member stated Resident 101 could not see the board and did not know the date, the name of the nurse and CNA. Resident 101's family member stated Resident 101 asked the family member every day for the date. Resident 101's family member stated he had told a nurse that Resident 101 could not see the board due to its location and a nurse agreed. Resident 101's family member stated the nurse stated she (a nurse) could not do anything because it was how it set up. Resident 101 and the family member both stated they wished if the board was placed where the resident could see it. During a concurrent observation and interview on 12/6/17, at 10:21 a.m., in Resident 101's room, the white board contained a date of 12/4/17 and the name of the nurse and CNA. Licensed Staff A stated the white board was a communication board. Licensed Staff A stated the board contained incorrect date, nurse, and CNA names. Licensed Staff A also acknowledged the other areas of the board were blank. Licensed Staff A stated the CNA should have updated the information in the morning. Licensed Staff A stated the resident could not see the communication board. She stated if the resident could not see it and the board contained incorrect information, it would not be effective communication. Licensed Staff A stated she already knew the board up there where resident could not see the information on the board. Licensed Staff A stated the maintenance personnel put the board up. During an interview on 12/7/17, at 2:19 p.m., the Director of Nursing (DON) stated the communication board in the resident's room was for communication among the team including the resident, family, and staff. The DON stated the resident was the main part of the team. When mentioned to her the communication board was placed where the resident was not able to see it, the DON stated they would have to move the board to a place where the resident could see it. When mentioned that the communication board contained incorrect date, nurse and CNA names, and the other areas of the board were blank, the DON stated they needed to update the board so the team including the resident knew what is going on. 3. During an interview on 12/4/17 10:06 a.m., when asked how staff response to call light, Resident 18 stated, not, very soon. After breakfast, I need to go to the bathroom; I could not find anybody. During an interview on 12/4/17 10:10 a.m., Resident 2 stated the response when she use the call light was not very fast. During a confidential resident group interview on 12/5/17, at 10:02 a.m., one of six residents stated the resident had to wait for 15 minutes for the staff after the resident put on the call light. The resident stated 15 minutes wait time was too long for the resident. During an interview on 12/7/17, at 12:30 p.m., regarding Call Lights Answer, the DON stated staff should answer call lights as soon as possible based on resident needs. Also, the DON stated answering call lights was every staff's responsibility. During an interview on 12/8/17 11:17 a.m., Unlicensed Staff B stated the reasonable response for call light, I think it's 2 minutes but I try to quickly answer as soon its (call light) turned on. Unlicensed Staff B stated pretty much anyone could answer the call light if the Certified Nursing Assistants (CNAs) assigned to the resident calling was busy; other CNAs and nurses could help answer the call light. During an interview on 12/11/17 9:45 a.m., Unlicensed Staff C stated Resident 18 would always comes out and ask to use the bathroom, she uses the call light. She's really good at communicating her needs to me. The facility's policy and procedure titled Call Light/Bell, revised 05/2016, indicated .Answer the light/bell within a reasonable time based on resident needs . The facility's policy and procedure titled Dignity and Respect, Revised 05/2007, indicated It is the policy of this facility that all residents be treated with kindness, dignity and respect.