Every finding on record at Coral Gables Nursing and Rehabilitation Center

Based on observations, record review and interview the facility failed to maintain good grooming and personal hygiene for one resident (Resident #62) out of 24 residents sampled, as evidenced by observations of dirt under Resident #62's fingernails. There were 74 residents residing in the facility at the time of survey. The findings included: On 07/08/24 at 9:30 AM Resident #62 was observed lying in bed awake alert, nonverbal and used left upper extremity to gesture. Dirt was observed under Resident # 62's fingernails on the left hand. On 07/11/24 at 8:35 AM Resident #62 was observed lying in bed awake alert and dirt was observed under the fingernails of left hand. Record review of demographic sheet for Resident #62 revealed an admitted [DATE] with diagnosis that included Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Record review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 6/3/2024 Section C for cognitive status revealed a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. Section GG for functional abilities and Goals revealed dependent for personal hygiene care. Section E for behaviors revealed no indicators of psychosis. Record review of a Care Plan started on 9/18/23 and revised on 6/5/24 for Resident #62 revealed total care was required to maintain personal hygiene. The interventions included: Aid with oral care, washing, drying face hands, and perineum. Record review of physician orders revealed an order dated 10/25/2023 to check that fingernails are clean and trimmed every day. On 07/11/24 at 8:35 AM, Registered Nurse (RN) Unit Manager acknowledge Resident #62's fingernails are dirty and should have been cut and cleaned. The schedule indicates that residents' nails are to be cut and cleaned on Sundays on the evening shift; the schedule is kept in the CNA's (Certified Nursing Assistants) binder. Record review of a Policy entitled, Giving a Bed bath revised October 2010 revealed Purpose: The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. 15. Arms and Hands: d. Check the resident's fingernails, nail beds, and between the fingers. Provide nail care only when instructed.

Based on observations, record review and interview facility failed to ensure that one (Resident #46) out of 24 sampled residents received adequate support services as evidenced by dry and scaly skin on Resident # 46's legs. There were 74 residents residing in the facility at the time of survey The findings include. On 07/08/24 at 8:56 AM Resident #46 was observed lying in bed, the skin of bilateral lower extremity appeared dry and scaly. The resident was constantly rubbing one leg against the other in an up and down motion. On 07/10/24 at 9:55 AM Resident #46 was seated in a wheelchair in the Main dining area, for activities. No distress or rubbing of legs noted. Record review of the demographic sheet revealed Resident #46 was admitted on [DATE] with diagnosis that included: Rash and other nonspecific skin eruption. Review of the Quarterly Minimum Data Set (MDS) with assessment reference date of 5/6/2024 Section C for Cognitive Status revealed a Brief Interview for Mental Status (BIMS) score was 13, out of a scale of 00-15, indicating intact cognition. Section GG for Functional abilities and Goals revealed partial/moderate assistance for eating/oral hygiene/transfer and dependence for toileting/shower. Section M for skin revealed no skin problems. Record review of Care Plan started on 2/2/2024 and revised on 5/8/2024 revealed Resident #46 is at risk for pressure ulcers and skin impairments related to impaired mobility and decline in function. Interventions included: Use moisture barrier (Vitamin A & D Ointment) product as indicated. Report any signs of skin breakdown (sore, tender, red, or broken areas) and Podiatry/Wound care consults as needed. Record review of Electronic Health Record revealed a progress note dated 07/07/2024 that indicated Resident #46's skin was warm and dry to touch, signed by licensed nurse. Further review of Electronic Health Records revealed Certified Nursing Assistant with dates 7/08/24, 7/09/24, and 7/10/24 indicated no skin issues. Record review of Electronic Health Record revealed physician orders dated 2/01/2024: Facility skin care protocol and Skin check every shift during care and report any unusual findings to nurse and 4/12/2024: Weekly skin check once a day on Sundays. On 07/11/24 at 8:44 AM Surveyor asked Staff A, Registered Nurse, (RN) to observe skin of lower extremities of R#46. Staff A, RN brought Resident #46 into the room and evaluated resident's skin. On 07/11/24 at 8:54 AM Staff A, RN stated: I completed a visual skin assessment on [Resident #46] legs and observed dryness, no swelling, and no open area. [Resident #46] denied itching. I will inform the physician. There are no current physician orders pertaining to [Resident #46] legs. The facility protocol is to assess the skin every week for the nurse and the Certified Nursing Assistants (CNA) are to do a daily inspection and to report any change to nursing. Record review of Policy, Pressure Ulcer and Skin Assessment revised September 2013 Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: 1. Review the resident's care plan to assess any special needs of the resident. Assessment: Monitoring: a. Staff will perform routine skin inspections (with daily care).

Based on interview and record review, it was determined the facility failed to ensure residents, their representatives and families were notified by 5:00 pm, the next calendar day following the occurrence of a single confirmed infection of COVID 19 with a staff member. The findings included: On May 8, 2020, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule titled, Medicare and Medicaid Programs, Basic Health Program, and Exchanges: Additional Policy and Regulatory Revisions in Response to the COVID 19 Public Health Emergency and Delay of Certain Reporting Requirements for Skilled Nursing Facility Quality Reporting Program. Included in this final interim rule was the facility requirement to Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19. This information must: (i) Not include personally identifiable information; (ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and (iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. During an interview with the facility's Infection Preventionist/Director of Nurses (DON)/Staff A, on 7/14/2021 at 11:20 am, it was reported that the last COVID 19 positive case in the facility was on 06/18/2021. The documentation to demonstrate that the facility's residents and their families were notified was requested. Staff A reported, Social Services notified residents and families by phone about the COVID 19 positive case. On 7/14/2021 at approximately 1:30 pm, the requested information was brought to the conference room by the Social Services Director, Staff B. During a review of the information, it was noted that the information titled, Resident Contacts and written at the top of the list was Call log positive 6-18-21. The list was 21 pages and included resident names, with the residents' emergency contact, family member, responsible representative, and/or their legal guardian. The list included a date of June 2021, but the day on the list was illegible. Information documented on the list included: Key West. Birthday, monthly, no visit, Sunday, California, daily, Georgia, no answer confirm. When, notified person, guardian notified and days of the week. Staff B, also brought in a blank log used to schedule family visits. During an interview with Staff B, the Social Services Director on 7/15/2021 at 2:30 pm, Staff B was asked to explain the information that was provided on 7/14/2021. Staff B was asked, how we would confirm she had notified the residents and families related to the 6/18/21 positive COVID 19 case. Staff B reported, she documented the completion of the notification by documenting, completed 6/20/21 [her initials]. There was no information to confirm the date and time each resident or family member was notified and the information provided during the phone calls. At approximately 2:45 pm on 7/15/2021, Staff B brought an email copy of the positive employee's notification of the positive COVID 19 results that was dated 6/19/2021 at 9:03 pm. The email was presented to demonstrate the facility did not know about the employee's results until 6/19/2021 and that they were in compliance because they documented the notification was completed on 6/20/2021. After Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of the facility's Infection Prevention and Control Program, with an effective date of 2016 and revised on 11/2020 revealed, The Infection Prevention and Control Program shall be conducted in accordance with all applicable federal and state rules and regulations .Including evidenced-based guidelines and recommendations .Centers for Medicare and Medicaid Services (CMS).

Based on observations, interviews and record reviews the facility failed to 1.) Treat residents with dignity or maintain resident's quality of life during dining experience by not providing enough tables in the Station one dining area and keeping Resident#24 and Resident#64 away from the dining tables during dining times for two residents (R#24 and R# 64) in one dining room (Station one) out three dining areas . 2)Ensure dignity was maintained for residents requiring assistance with eating from staff on Station one and Station two as evidenced by staff assignment boards included the terminology feeding for thirteen residents along with their room numbers listed on Station one and thirteen residents with their room numbers also listed on Station two out of a sample size of twenty-one residents. There were fifty-nine dependent residents out of seventy-eight residents in the facility during the time of the survey. The findings included: 1.) Review of residents listed on Station one revealed it included R#24 and R#64 who were identified sitting away from the tables during dining. Record review of face Sheet for resident # 24 revealed admitted s 02/21/2017 and the last admission was on 11/23/2018. The [DIAGNOSES REDACTED]. Record review of Quarterly, Minimum Data Set (MDS) for resident # 24 dated 05/21/2019 in section C for Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating resident is severely impaired cognitively. Section G for functional status on the MDS for eating was coded for R#24 as total assistance and one person assistance. Record review of R#24's Care Plan dated 02/08/2018, revised on 05/27/2019 revealed that the facility did not address the resident's preferences with eating in the care plan. Resident # 24 was cared planned for being severely impaired related to his condition, Psychosocial well-being, and Activities for Daily Living (ADLs). The Care Plan did not address any preferences for resident # 24 seating during dining. Record review of R#24's Care Plan Conference meeting dated 05/27/2019 revealed that the facility did not address R#24's preferences for dining. Record review of Care Plan Meeting Sign in Sheet dated 08/01/2019 revealed that the facility completed a conference call with R#24's responsible party and discussed previous preference requests for R#24 to eat outside of the room. The facility did not address the issue of not having enough space to accommodate R#24's wheelchair next to the table on Station one. Record review of Psychologist consult dated 06/11/2019 for resident # 24 revealed recommendations for therapeutic interventions for maintaining routine and reduction of environmental changes to reduce mood symptoms. Record review of face sheet for resident # 64 revealed a date of admission of 06/19/2019. The [DIAGNOSES REDACTED]. Record review of Resident #64's Admission MDS dated [DATE] revealed the BIMS score was blank. Section G of the MDS for functional status for R # 64 for eating was coded as Extensive Assistance and one person assistance. Record review of R#64's Care Plan dated 06/20/2019, revised on 07/29/2019 revealed that the facility did not address R#64's preferences with eating in the care plan. Resident # 64 was cared planned for being severely impaired related to the cognition, Psychosocial well-being and ADL Care. The care plan did not address any preferences for resident # 64 during dining. Record review of R#64's Care Plan Conference meeting dated 07/01/2019 revealed that the facility did not address R#64's preferences for dining. Record review of the Meeting Sign in Sheet dated 08/01/2019 revealed the facility's Interdisciplinary team (IDT) met with R#64's responsible party and discussed the plan of care, preferences, physician orders, and resident's progress. It was documented that previous requested preferences for R#64 included to eat outside his room. The facility did not address the issue of not having enough space to accommodate R#64's wheelchair next to table on the Station 1. Observation on 7/29/2019 at 12:29 PM of Station 1's dining room revealed there were three residents (R#64, R#24 and R#42) eating their meals while seated in their wheelchairs positioned by the wall and away from the dining tables. There were two tables with six residents all in need of total assistance with eating. There were five CNAs assisting five residents and a family was assisting the other resident. There was a total of eight residents eating their food by themselves and only four residents were sitting at the table. Observation on 07/31/2019 at 11:30 AM of Station 1's dining room revealed residents were sitting in the dining room while staff were performing tasks to have everything ready for lunch. There were six residents in need of total assistance with eating sitting at two tables (3 residents at each table). There were five staff ready to help those residents with eating and one family member who visited daily to assist his relative with eating. There were two residents (R#24 and R#42) sitting by themselves by the wall and away from the dining room tables waiting for their meal. R#24 was sitting in a mobile recliner type of chair and R#42 was sitting in a high back sized wheelchair. Both residents had individual tray tables positioned in front of their wheelchair where the State Agency Representative observed staff served the meal trays. Observation on 07/31/2019 at 12:00 PM revealed that staff started passing the meal trays to the residents in the same place where they were sitting. Staff passed the meal trays and placed them on the tray tables positioned in before residents (R#24, R#42 and R#31), who were all sitting by themselves away from the tables and started eating by themselves. Interview on 07/31/2019 at 12:10 PM with Staff H, Licensed Practical Nurse (LPN) revealed that the reason resident R#24, R#42 and R#21 were sitting by themselves was due to lack of space at the tables to accommodate them. Staff H, LPN stated that she believed the facility was not able to add a new table to Station one dining area, because the facility would have problems with space when all residents are sitting there during the day time. Staff H, LPN noted that those residents were eating by themselves, because there were not enough tables. Interview with Staff I, Registered Nurse (RN) Supervisor on 07/31/2019 at 12:15 PM revealed that for residents R#24 and R#64 Station one did not have enough tables to accommodate all residents to eat by themselves, so they served their meals on the tray table which was placed in front of them. Staff I, RN Supervisor noted that Station one had three tables, two tables were used to accommodate the residents in need of total assistance with eating and the other table was used to accommodate residents that could eat by themselves. Staff I, RN Supervisor explained that on Station one there were eight residents who were able to eat by themselves and there was only one table where they could accommodate four of those eight residents. Staff I, RN Supervisor noted that they preferred four residents on one table that could eat by themselves, interact and socialize with other residents during meal times. Staff I, RN Supervisor reported that two of the residents were able to eat by themselves (R#42 and R#31) and preferred to eat alone. The other two residents (R#24 and R#64) who were not able to voice their preferences and were not sitting at a table, because they did not have more tables in that area. Staff I, RN Supervisor stated that she did not believe that adding another table on Station one would be possible, because they had a fire egress and it would be a problem if they needed to evacuate the residents in case of an emergency. Interview with Staff J, Certified Nursing Assistant (CNA) on 07/31/2019 at 12:20 PM revealed R#24 started eating by himself very recently. Staff J, CNA noted regarding R#64 that he will be assisted with eating later today. R#64 was in bed and liked to get up to eat and go back to bed. Interview on 07/31/2019 at 03:30 PM with Maintenance Director revealed that his Department oversaw repairs and provided maintenance, but that they did not decide the number of tables in the dining rooms. Interview on 07/31/2019 at 03:35 PM with Food Service Director revealed she had nothing to do with the number of tables in the dining room or the residents being served their meals on the overhead tables. Interview on 07/31/2019 at 3:40 PM with Director of Social Services (SSD) revealed that the reason not all the residents were sitting at the tables in the dining room on Station one was because there was no space to add new tables and due to the residents' preferences. The Director of Social Services explained about the two residents sitting by themselves away from the tables, the SSD looked in the record and stated that R#24 could communicate and made himself understood, but he was cognitively impaired. R # 24 BIMS score was 3 out of 15. R#64 could barely be understood and was severely impaired with a BIMS score of 3 out of 15. Interview on 07/31/2019 at 3:50 PM with Administrator revealed that not all residents were sitting at the tables during dining was not due to lack of space, but depended on the residents' condition at times. The Administrator mentioned as an example that a tube feeding resident was not sitting at the table during dining with other residents, because the facility respected residents' dignity. Administrator noted that they were not able to place more dining room tables on Station one, because they would be in the middle of the fire egress area which cannot be blocked. Administrator showed one side (the rear) where there was a fire egress and in the other direction led to the entrance of the facility and there was a fire egress through the gym. Administrator stated they did not change the table configuration on Station one dining area. Administrator noted that they had the same number of tables and did not take any tables out or added any tables. Interview on 08/01/2019 at 02:38 PM with Staff M, LPN revealed that she was not aware that R#24 and R#64 or their responsible parties had preferences for them to receive their meal away from the dining table. Staff M, LPN explained that R#24 started eating by himself very recently. Resident # 24 required total assistance with eating and at times needed some assistance, it depended on the day. Staff M, LPN noted that Resident #64 could eat by himself. Staff M, LPN reported that R#24 and R#64 both ate in their wheelchairs away from the dining room tables. Staff M, LPN explained that staff noticed R#64 when he was sitting with other residents at the table , after he had finished his meal attempted to grab another residents' food. Staff M, LPN stated they were in the process of observing and adjusting R#64 to the table. Staff M, LPN mentioned that R#64 was sitting alone and after he finished, staff would ask him if he wanted something else and tried to work with him. Staff M, LPN stated R#24 was sitting by himself, because the facility only had 3 tables on Station one. Staff M, LPN explained there was one table (the first table) which was used to accommodate residents to eat by themselves. The other two tables in the back were used to seat and assist residents who need total assistance with eating. Staff M, LPN stated that the facility had no space for any other tables on Station one in the dining area. Interview on 08/1/2019 at 3:50 PM with Director of Nursing (DON) revealed that the facility's seating arrangements in Station one was re-evaluated frequently. The DON showed the seating charts as far back as (MONTH) 2019. The DON explained that they revised the seating chart based on different factors (capability, assistance needed for residents, space and availability around the table). while showing the seating chart for (MONTH) 2019, the DON explained that as an example of that month on Station one they had the same number of tables and there were seven residents who were sitting by themselves. The DON explained that they did not want to eat inside the room and the space on Station one would not let them place any other tables; and that the administrator would be able to explain more about the space. The Administrator was present during the interview and noted that there was not enough space to place extra tables. The Administrator explained that it was not just the tables, but the space for the wheelchairs to fit at the tables. The DON then showed the seating chart evaluation that they had conducted, where they evaluated the resident's needs. They had decided so that they were able to communicate with the kitchen to make decisions about when the trays came out. The DON explained that there were still residents eating inside their room. The DON noted that R#64 was a new admission and R#24 was in the facility for a while, and that both residents were cognitively impaired. Record review of seating chart for Station one during the dining times revealed that there were three tables, two tables had three residents each and one table with four residents. There were four other residents who were identified on the chart that were observed sitting by themselves away from the tables. 2.) Observation on 07/30/2019 at 9:17 AM revealed that there was a large staff assignment board dated 07/30/2019 in the common activity / dining area next to the Station two nurse's Station that was visible to residents and visitors that contained the nursing and Certified Nursing Assistance (CNA) assignments with the resident room numbers, showers with resident room numbers, monitoring times. There was a total of thirteen residents room numbers next to the terminology feeding. A photo of the staff assignment board on Station two was taken as evidence. Observation on 07/31/2019 at 11:41 AM of the staff assignment board on Station two revealed that there was the terminology feeding for thirteen resident rooms numbers. The staff assignment board on Station two was next to the common area for activities and dining. There were eighteen residents in that activity / dining area. Observation on 07/31/2019 at 5:50 PM of Station one staff assignment board revealed that the word feeding with thirteen resident room numbers was noted. The staff assignment board was in the common area next to the dining area that had fifteen residents during the time of the observation. Interview on 08/1/2019 at 10:25 AM with staff D, Licensed Practical Nurse (LPN) revealed that she reviewed the staff assignment board with the word feeding and room numbers on Station two and noted: Feeding is for breakfast. At lunch everyone is here. Some residents are in their rooms for lunch. Feeding means, give the food. Staff D, LPN explained that she did not have a concern with the terminology feeding with resident room numbers on the Station two assignment board, since this meant that residents could not eat by themselves. Interview on 08/1/2019 at 11:07 AM with staff F, Registered Charge Nurse (RN) regarding the word feeding with resident room numbers on the Station two staff assignment board revealed that residents needed the Certified Nursing Assistant help with food and could not eat the food by themselves. Staff F, RN Charge nurse noted that she did not have a concern with the word feeding on the staff assignment board on Station two, since they placed residents next to the tables with other staff. Interview on 08/1/2019 at 11:17 PM with staff G, Certified Nursing Assistant (CNA) regarding the word feeding with resident room numbers on the Station two assignment board revealed that the staff assignment board was for breakfast and lunch and sometimes her side had many residents for feeding. Staff G, CNA noted that: It is good that the CNAS have the same feeding, it is divided. Observation and interview on 08/1/2019 at 11:29 AM with the Director of Nursing (DON) regarding the word feeding with resident room numbers on the Station two staff assignment board revealed that this meant that the CNA's gave assistance to the residents. DON noted that she did not have an issue with the staff assignment board with the word feeding with resident room numbers, since this was to inform staff which residents to assist with meals. Record review of the facility policy for dignity, dated (MONTH) 2009 revealed: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall always be treated with dignity and respect . Staff shall speak respectfully to residents at all times including addressing the residents by his or her name of choice and not labeling or referring to the resident by his or her room number, [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to follow a seafood allergy noted on meal ticket and did not include ham allergy for one resident (resident#35) out of twenty-one residents sampled out of sixty-eight residents who ate orally during the time of the survey. There were seventy-eight residents in the facility during the time of the survey. The findings included: Record review of the face sheet and the Medication Administration Record [REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] for Section C Cognitive Patterns revealed Brief Interview for Mental Status (BIMS) of 15 out 15 indicating no cognitive impairment. In the Section K Swallowing / Nutritional Status revealed that resident #35 had no weight loss or weight gain reported. The resident was on a Mechanically altered diet and Therapeutic diet. Record review of the Nutrition Care Plan last reviewed on 06/11/2019 revealed that resident #35 was on a Mechanically Soft, No Added Salt (NAS) diet (no orange juice and no seafood). The same information was observed on the tray's meal ticket on 07/29/2019. Record review of the Medical orders for (MONTH) 2019,revealed resident # 35 dietary order for Mechanical Soft Diet / NAS, thin liquids (no seafood). Observation on 07/29/2019 at 12:02 PM revealed resident #35 requested a food substitute and Staff A, Certified Nursing Assistant (CNA), brought a tuna sandwich for resident # 35 who had a seafood allergy. Resident # 35 asked more than once what kind of sandwich it was, and was informed that it was a tuna sandwich. Resident # 35 was upset, because she could not eat tuna and the meal tray ticket indicated no seafood and yet it was placed close to the resident's plate. Interview on 07/29/2019 at 1:20 PM with resident # 35 revealed that today at lunch she got an alternate, because she did not like a lot of fat, and she did not want the stuffed peppers with tomato sauce. Resident # 35 stated They gave me the sandwich and I touched it to see what type of sandwich is was. It was tuna and I am allergic to fish and shellfish. I asked the nurse what it was, and she said tuna. It was good that I did not eat this, or I would go to the hospital. I was not hungry anyway, they gave me bread with butter, this was what I had wanted. This had never happened to me before. They never gave me fish. There was a paper they put on the table and it listed everything that I did not eat including the Seafood. Interview on 07/31/2019 at 9:58 AM with Staff A, CNA, revealed that in case a resident requested a food substitute, she would ask the resident what food she or he wanted to eat based on the options of the day. Staff A, CNA checked the meal ticket and she asked the nurse what food resident # 35 could eat. On Monday on 7/29/2019 staff A noted that she was in the dining room during lunch and was taking care of the residents. Staff A, CNA asked the nurse if resident #35 could eat tuna. Staff A, CNA checked the diet for resident #35 on the meal ticket on the tray and resident # 35 had a regular diet. Staff A, CNA noted that she did not check if resident # 35 had food that was not recommended on the meal ticket. Staff A, CNA stated that after she offered the tuna sandwich to resident #35, resident # 35 had stated that she wanted another option. Staff A, CNA asked the nurse what food resident # 35 could have and she brought bread with butter for the resident according to her request. Interview on 07/31/2019 at 3:25 PM with Staff B, Registered Nurse (RN) revealed that in the dining room, the staff had to read the meal ticket that came with the food tray. Staff B, RN noted that she took the meal tray, checked the food on the plate to make sure that it matched the food on the meal ticket. Staff B, RN mentioned that if it was not matching then the nurse returned it to the kitchen. In the case of resident # 35 who had requested a food substitute, the CNA and Nurse should check the meal ticket on the tray. Staff B, RN stated that resident # 35 was oriented and alert time to name, place and time. Resident #35 had restrictions in her diet, and she had an allergy to some foods and medications. Staff B stated that the son of resident #35 had brought a ham sandwich to resident # 35 and she ate it without any complications. Staff B, RN noted that on 07/29/2019 during lunch time Staff A, CNA asked resident #35 if she wanted a substitute. The substitute was a ham and cheese sandwich or a tuna sandwich resident # 35 had noted that she wanted a tuna sandwich. Staff B, RN remembered that resident #35 was asking what kind of sandwich it was after she had received the tuna sandwich. Staff B, RN asked resident #35 what kind of sandwich she wanted and resident # 35 asked for a bread with butter sandwich. Staff B, RN threw the tuna sandwich away and brought the food substitute requested by resident # 35. Staff B, RN stated that maybe resident # 35 was allergic to Seafood but not fish. Interview on 07/31/2019 at 3:51 PM with the Food Service Director revealed that when residents first came into the facility they had an initial evaluation to check the resident's food preference and reviewed the medical records for any food allergies. They talked with residents regarding any food allergies and preferences and the information was updated as needed or on a quarterly basis. Every staff could access this information regarding resident allergy in the Medication Administration Records (MAR) and checking the meal ticket. All staff received training to check this information in the meal ticket. The kitchen staff checked the meal ticket when they were doing the tray line, the nurses checked the meal ticket for food allergies as well. The CNA's double checked it before they offered food to the residents. If the meal ticket specified no seafood it included no fish, no shrimp and nothing that came from Ocean. If a resident only had a Shrimp allergy for example, it was specified as Seafood and not shrimp. The Food Service Director stated that resident #35 had an allergy to iodine, ham and seafood. Food Service Director stated that on the meal ticket for resident #35, no Seafood and no ham was not included. The Food Service Director explained that regarding resident # 35 ham allergy, resident #35 ate ham sometimes without reactions. Interview on 08/01/2019 at 4:05 PM with Registered Dietitian, revealed that she confirmed that the residents were screened for food allergies and the information regarding allergies was on the meal ticket. If the meal ticket read no Seafood then the resident should not receive any food from the sea. If a resident had a specific allergy for fish, for example, then the meal ticket should be specified with resident had an allergy to fish, but could eat shrimp, for example. Interview on 08/01/2019 at 3:40 PM with resident #35 revealed that resident # 35 had an allergy to seafood, including fish. Resident # 35 stated that she had a bad reaction to seafood years ago and she stopped eating it. Resident # 35 noted that she had allergy to ham. Her son used to bring turkey and Swiss cheese instead for her and she loved it. Record review of the facility Food Allergies and Intolerance's Policy revealed: Residents with food allergies and /or intolerance's will be identified upon admission and steps will be taken to prevent exposure to the allergens(s). In the Section Assessment and Interventions included the information but not limited to Residents will be assessed for a history of food allergies and intolerance's upon admission. All residents who reported food allergies and intolerance's will be documented in the assessment notes and incorporated into the resident's care plan. Residents with food intolerance's and allergies will be offered appropriate substitutions for foods that they cannot eat.

Based on observation, interview and record review the facility failed to ensure garbage and refuse was disposed of properly as evidenced by failure to maintain all waste in closed containers. The findings included: Observation on 7/30/2019 at 12:10 PM on unit one revealed one gray covered trash bin in the hallway. The bin contained soiled linens. There was no soiled utility room located on unit one. Interview on 7/30/2019 at 12:15 PM with the Director of Housekeeping revealed that: There is usually a white bin used for disposable of trash. When the staff bring the resident trash from the rooms, they place it into sealed bags in the rooms and then carry it to the bags in the white covered bins. The white trash bin is not on the unit now, it was removed from the unit, because we are serving lunch. There is no soiled utility room on unit one, so we keep the trash and linen bins in the hall. The biohazard waste is taken to the biohazard room near the laundry for unit one. The trash is taken from unit one and placed in a cart outside of the building. Observation on 7/30/2019 at 12:20 PM revealed a large open cart outside the exit door near unit one. The cart was uncovered and overflowing with bags of resident trash including personal care supplies and briefs. Interview on 07/30/2019 at 12:20 PM with the Director of Housekeeping revealed that trash was placed outside in this cart at about 10:00 AM this morning and it would be placed into the dumpster about 2:00 PM. The Director of Housekeeping noted: The trash is taken out there every few hours and when the cart is empty we take it to the dumpster. Interview on 7/30/2019 at 1:35 PM with the Director of Housekeeping revealed that he went out to the storage area and he found a cover for the cart used outside for the trash. He stated that the cart was now covered. Observation outside the exit door on unit one revealed the cart outside of the building used for trash disposal. There was a hinged lid on the cart but, it was half open exposing the trash bags stored inside the cart. Interview on 7/31/2019 at 4:20 PM with the Director of Nursing and Infection Control Nurse revealed that they had spoken to the Housekeeping Director about the trash outside not being covered. They always told him it had to be covered or taken directly to the dumpsters. After it was observed uncovered he located a lid for the cart and started to check every two hours. We instructed him to check it every hour to ensure the trash was contained and covered. Review of the facility policy titled: Infection Control and Environmental Services, revised 3/1/2017 revealed: All trash receptacles shall have water proof liners to confine any organism that may be on trash surfaces. When removing trash from rooms tie plastic bag and place in a bin to be transported to the dumpster.

Based on observation, interview and record review the facility failed to implement appropriate infection control and prevention measures by failure to ensure garbage and refuse was disposed of properly as evidenced by failure to maintain all waste in closed containers. The findings included: Observation on 7/30/2019 at 12:10 PM on unit one revealed one gray covered trash bin in the hallway. The bin contained soiled linens. There was no soiled utility room located on unit one. Interview on 7/30/2019 at 12:15 PM with the Director of Housekeeping revealed that: There is usually a white bin used for disposable of trash. When the staff bring the resident trash from the rooms, they place it into sealed bags in the rooms and then carry it to the bags in the white covered bins. The white trash bin is not on the unit now, it was removed from the unit, because we are serving lunch. There is no soiled utility room on unit one, so we keep the trash and linen bins in the hall. The biohazard waste is taken to the biohazard room near the laundry for unit one. The trash is taken from unit one and placed in a cart outside of the building. Observation on 7/30/2019 at 12:20 PM revealed a large open cart outside the exit door near unit one. The cart was uncovered and overflowing with bags of resident trash including personal care supplies and briefs. Interview on 07/30/2019 at 12:20 PM with the Director of Housekeeping revealed that trash was placed outside in this cart at about 10:00 AM this morning and it would be placed into the dumpster about 2:00 PM. The Director of Housekeeping noted: The trash is taken out there every few hours and when the cart is empty we take it to the dumpster. Interview on 7/30/2019 at 1:35 PM with the Director of Housekeeping revealed that he went out to the storage area and he found a cover for the cart used outside for the trash. He stated that the cart was now covered. Observation outside the exit door on unit one revealed the cart outside of the building used for trash disposal. There was a hinged lid on the cart but, it was half open exposing the trash bags stored inside the cart. Interview on 7/31/2019 at 4:20 PM with the Director of Nursing and Infection Control Nurse revealed that they had spoken to the Housekeeping Director about the trash outside not being covered. They always told him it had to be covered or taken directly to the dumpsters. After it was observed uncovered he located a lid for the cart and started to check every two hours. We instructed him to check it every hour to ensure the trash was contained and covered. Review of the facility policy titled: Infection Control and Environmental Services, revised 3/1/2017 revealed: All trash receptacles shall have water proof liners to confine any organism that may be on trash surfaces. When removing trash from rooms tie plastic bag and place in a bin to be transported to the dumpster.

Based on observations, interviews, and record reviewed, the facility failed to ensure the proper handling and disposition of medications that belonged to one resident (R#80) out of six residents whose medications were reviewed during the survey. The findings included: Record review of the medical Face Sheet revealed, resident #80 (R#80) was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Observation on 4/23/2018 at approximately 6:45 AM, in room [ROOM NUMBER] revealed, a small medicine cup sat at the bedside table for bed A. The cup contained a small pink pill. At 7:19 AM, the medicine cup remained by the bedside table, but it was empty. Record review of the Comprehensive Minimum Data Set (MDS) for resident #80 dated 10/11/2017 revealed, the resident had a score of 12 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was able to verbalize her needs and was not cognitively impaired. Record review of the Care plan for resident #80 revealed, problem start date 3/15/2018 {R#80} takes more than 3 medications at a time on any medication pass. Does not want to take crushed medications one at a time. At times, she prefers to have all her meds crushed. The goals included, Will have no adverse consequences of having crushed meds given together. The Approaches included: Give mediations as ordered and observe for adverse reactions of medications: [REDACTED] Further clinical record review revealed, no evidence that the resident was assessed or care- planned for the option to self-medicate. Interview on 04/25/2018 at 12:12 PM with Staff A, a Registered Nurse(RN) revealed, the RN routinely administered medications to R#80, during the 7:00am - 3:00pm shift. The RN reported, she was very familiar with this resident and her medications. According to the RN, R#80 refused to take some of her medications at times, and other times, the resident insisted that the nurse leave the medicine by her bedside. Staff A explained, she never left resident's medications in their rooms, unsupervised. The RN did not notice any medications left by the bedside on Monday, 4/23/18, but she had seen this done previously, at least once. After describing the above-mentioned observation, the RN deducted that the pink pill must have been the resident's antacid, [MEDICATION NAME], which the resident was supposed to take at the end of the previous shift, before breakfast, at 6:30AM. Interview on 04/25/18 at 12:54 PM, with resident #80 revealed, the resident explained she knows her medications and presented a notebook with documented details of the different types of medications that she was taking. R#80 explained, she asked and insisted that her nurse, staff B, an RN, leave her antacid by the bedside table. The resident preferred to take the medication with her breakfast. Interview on 4/25/2018 at 1:51 PM with staff B revealed, the RN stated, she never left medications on the resident's bedside table. Staff B reported, The policy is, if the resident does not want to take the med when offered, you take the med back with you and come back at a later time to offer the med again. The RN stated, she made sure resident #80 took her medicine in the morning, before she left the room. During an interview on 04/26/2018 at 10:11 AM, staff C, a Certified Nurse Assistant (CNA) reported, she often cared for resident #80 during the morning shift. The CNA stated, she had often seen the above-mentioned pill on the bedside table and the resident took it with breakfast in the mornings. Interview on 04/26/18 at 11:24 AM with staff D, an RN Supervisor revealed, it was not the policy for staff to leave meds by the bedside. The supervisor stated, If a patient insists, we educate them on the policy {for med administration} and safety. We let them know that we can not leave meds by the bedside but, will come back at the time they might be ready. We understand, we have alert and oriented residents, but they might still may have periods of confusion.

Based on observation, interview and record review the facility failed to prepare food in a method to conserve nutritive value and palatability as evidenced by preparation of food items scheduled to be served for the lunch meal prior to 6 AM potentially having a negative effect on the nutritive value, taste and palatability of the food served due to prolonged cooking times. This has the potential to affect seventy five resident who eat orally out of a total of eighty one residents residing in the facility. The findings included: Observation during the breakfast service on 3/29/17 beginning at 6:05 AM revealed the following concerns: -Observation at 6:50 AM revealed a third pan stored in the left well of the steam table contained a smooth brownish colored food item. During interview with the morning cook (staff E) on 3/29/17 at 6:50 AM, he said the item was pureed meat for lunch. The temperature of the item registered 120 degrees F. Staff E stated he would be putting it back in the oven after he served breakfast. He said I do not have room for it on the stove right now, so I am leaving it in the steam table. -Observation at 6:42 AM revealed a large pan of Ropa Vieja (shredded beef) sitting on the grill top. The grill top was cool to touch. During interview with staff E, he said this meat was just shredded and had to be cooked more before lunch. The temperature of the Rope Vieja registered 120 degrees F and remained on the grill top through the entire breakfast service. At 6:42 AM, a pan of ground Ropa Vieja was observed cooking on the stove top. There was also a pan of sliced carrots boiling on the stove top at 6:42 AM. The ground meat and carrots continued to cook throughout the entire breakfast service which ended at 7:30 AM. There was a second pan of sliced carrots observed in the lower oven. The carrots were partially frozen. The oven was not turned on at the time of the observation. There was a pan of chicken soup boiling on the stove top at 6:20 AM. There were two cold cooked meat patties in the lower oven with the carrots. During interview with staff E, he said the meat patties were left over from yesterday and they should not be in the oven. Staff E stated he had to start to prepare lunch early. I am responsible for cooking breakfast and lunch and I have to do the dishes pointing towards the three compartment sink. The pureed meat was removed from the steam table and placed into the oven at 7:45 AM. The Rope Vieja was removed from the grill top and placed on the stove top to begin cooking at 7:45 AM. The temperature of both items were 110 degrees F at the time of this observation. Review of the meal time schedule provided, indicated lunch service started at 11:45 AM. During interview with the Food Service Director (FSD) on 03/30/2017 at 2:44 PM, revealed that she was responsible to oversee the kitchen operation to ensure all tasks were being performed according to standards. Basically, I fluctuate my time schedule so I am available to make rounds in the kitchen daily and observe all meals served. I have made observations and responded with training as indicated. The cook that was working yesterday generally does not prepare the food for the lunch meal early in the morning. In reference to food production, the cook should never cook lunch that far in advance. The cook should not put the food into the steam table until thirty minutes prior to service. During interview with the consultant Registered Dietitian (RD) on 03/30/2017 at 2:51 PM revealed that she came to the facility on a weekly basis and spot checked the tray line, food production, temperature monitoring, dish washing. I ask question to test the knowledge of the staff to assess practices. On a monthly basis I do a complete sanitation inspection. I observe the tray line to make sure the menu is followed, food is palatable, and food temperatures are correct. As far as food production, the cooks generally do not prepare the food ahead of time to be held for extended periods of time, especially items such as vegetables which may lose vitamins when held for long periods of time. The food is generally not placed on the steam table until about thirty minutes ahead of service. Review of the facility policy titled Food Preparation and Service (undated) revealed steam tables were never used to reheat food. Review of the morning cooks work schedule revealed 9:00 AM review: The lunch menu and begin preparing lunch, 11:00 AM place lunch items on the steam table. Review of the evening cooks work schedule revealed 10:30 AM assist AM cook with lunch menu. Prepare pureed entrees, pureed vegetables, blenderized meals and chopped or ground meat items.

Based on observation, interview and record review the facility failed to store and serve food under sanitary conditions as evidenced by storage of expired food in the walk-in refrigerator, failure to maintain food preparation equipment in a clean, sanitary condition, failure to hold food items in a manner to ensure temperature control, and failure to practice sanitary food handling techniques and appropriate hand hygiene during the tray line service. This has the potential to contaminate the food served resulting in food bourne illness. This has the potential to affect seventy five residents who eat orally out of a total of eighty one residents residing in the facility at the time of the survey. The finding included: Observation during the initial kitchen tour on 3/27/2017 beginning at 9:01 AM revealed the following concerns: -A partial case of individual 4 ounce yogurts were stored in the walk in refrigerator. The use by date on the yogurt was 3/18/2017. -The bench can opener blade was corroded. The integrity of the metal blade was compromised potentially resulting in metal shaving contaminating the food. The base of the can opener contained a black substance. During interview with the morning cook (staff E) at 6:10 AM, he said I just used the can opener. Observation revealed an opened can of food sitting next to the can opener. Observation during the breakfast service on 3/29/2017 beginning at 6:05 AM revealed the following concerns: -Upon entrance to the kitchen at 6:05 AM, observation revealed breakfast food items on the tray line which included scrambled eggs, boiled eggs, pureed scrambled eggs and pureed muffins. There were two third pans of food in each of two steam table wells leaving a gap in one-third of each well which allowed steam and heat to escape. -Observation revealed the hot cereal and steamed milk held on the stove with the gas burners off at the time of the observation. These items were served directly from the stove throughout the breakfast meal and never placed into the steam table wells. The gaps in the steam table were not covered allowing steam and heat to escape during the entire breakfast service. -Observation at 6:15 AM revealed the morning cook preparing to check food temperatures on the breakfast line. The thermometer was initially sanitized before use, but the cook was observed placing the thermometer deeply into each food item. The thermometer case which was not sanitized prior to use touched each food items directly. -Observation at 7:13 AM revealed the holding temperature of the steam milk registered 108 degrees Fahrenheit (F). The steamed milk remained on the stove top with no heat source. -Observation at 6:50 AM revealed a third pan stored in the left well of the steam table contained a smooth brownish colored food item. During interview with the morning cook (staff E) on 3/29/2017 at 6:50 AM, he said the item was pureed meat for lunch. The temperature of the item registered 120 degrees F. Staff E stated he would be putting it back in the over after he served breakfast. He said I do not have room for it on the stove right now, so I am leaving it in the steam table. -Observation at 6:42 AM revealed a large pan of Ropa Vieja (shredded beef) sitting on the grill top. The grill top was cool to touch. During interview with staff E, he said this meat was just shredded and had to be cooked more before lunch. The temperature of the Rope Vieja registered 120 degrees F and remained on the grill top through the entire breakfast service. At 6:42 AM, a pan of ground Ropa Vieja was observed cooking on the stove top. There was also a pan of sliced carrots boiling on the stove top at 6:42 AM. The ground meat and carrots continued to cook throughout the entire breakfast service which ended at 7:30 AM. There was a second pan of sliced carrots observed in the lower oven. The carrots were partially frozen. The oven was not turned on at the time of the observation. There was a pan of chicken soup boiling on the stove top at 6:20 AM. There were two cold cooked meat patties in the lower oven with the carrots. During interview with staff E, he said the meat patties were left over from yesterday and they should not be in the oven. Staff E stated he had to start to prepare lunch early. I am responsible for cooking breakfast and lunch and I have to do the dishes pointing towards the three compartment sink. The pureed meat was removed from the steam table and placed into the oven at 7:45 AM. The Rope Vieja was removed from the grill top and placed on the stove top to begin cooking at 7:45 AM. The temperature of both items were 110 degrees F at the time of this observation . -Observation at 6:40 AM revealed staff E wearing gloves while serving the breakfast line. He was observed wiping his brow with the gloved hands and then he continued to serve the line without hand washing or changing his gloves. While serving the line he touched the eating portion of each plate. When placing plastic plate guards onto multiple plates he was observed using the same gloves to touch in interior portion of the plate guards. He also touched the entire interior eating surface of the plates while placing the plate guards onto the plates. He was observed touching the handle of the lower oven with his gloved hands. At 7:04 AM, staff E was observed reaching for serving tongs. He touched the portion of the serving utensil which was used to pick up the food items. The tongs were used to serve muffins. He was observed during the service touching the handle of the oven with the same gloves, then removing sandwiches from the oven touching each one directly with the gloves. This practice was repeated each time a sandwich was removed from the oven. He used his foot to kick the oven door closed each time. He used a knife that was sitting on a soiled cutting board to cut the sandwiches. The sandwiches were being touched directly with the same gloves each time one was cut in half. At 7:10 AM, staff E touched his face with the same gloves and wiped the sweat from his brow. After being prompted by the Food Service Director (FSD), he washed his hands and changes his gloves, but then laid the soiled paper towel used to dry his hands on the tray line. At 7:13 AM, he removed a soiled rubber spatula from on top of a cardboard box. He used the spatula to stir the scrambled eggs. At 7:21 AM, he left the breakfast line, used his gloved hands to stir the soup touching the utensil handle, then opened the oven door touching the handle. He then placed his fingers directly inside three insulated coffee mugs before filling them with steamed milk. At 7:28 AM, he touched his face again with gloved hands, touched the knob on the stove to adjust the temperature and then continued to serve breakfast without washing his hands or changing his gloves. During interview with the FSD on 03/30/2017 at 2:44 PM, revealed that she was responsible to oversee the kitchen operation to ensure all tasks were being performed according to standards. Basically, I fluctuate my time schedule so I am available to make rounds in the kitchen daily and observe all meals served. I have made observations and responded with training as indicated. The cook that was working yesterday generally does not prepare the food for the lunch meal early in the morning. The cooks are responsible for checking the dates on the food. I also check dates of food stored in the kitchen. The diet aids and all staff are encouraged to do this daily. The staff informed me that the yogurt was past the use by date the first day of the survey. This should have been checked by the staff and disposed of if not used by that date. In reference to food production, the cook should never cook lunch that far in advance. The food should also be placed in the steam table for service. The cook should not put the food into the steam table until thirty minutes prior to service. I cannot explain why the oatmeal or the steamed milk was held on the stove without heat instead of placing all of the items on the tray line. During interview with the consultant Registered Dietitian (RD) on 03/30/2017 at 2:51 PM revealed that she came to the facility on a weekly basis and spot checked the tray line, food production, temperature monitoring, dish washing. I ask questions to test the knowledge of the staff to assess practices. If I see something that is not correct I review concerns immediately on the spot with the staff. I have the staff do return demonstration after meeting with them to determine understanding. On a monthly basis I do a complete sanitation inspection. I observe the tray line to make sure the menu is followed, food is palatable, and food temperatures are correct. When I do my comprehensive assessment I check the dates and labels on all the food and also spot check weekly. As far as food production, the cooks generally do not prepare the food ahead of time to be held for extended periods of time, especially items such as vegetables which may lose vitamins when held for long periods of time. The food is generally not placed on the steam table until about thirty minutes ahead of service. When setting up the steam table the cooks are trained to make sure all wells are used or to use an extra empty pan in any spaces to make sure the heat does not escape. I demonstrate with the staff related to glove use. I make them put one glove on and leave one off. After they touch anything I ask them which hand is cleaner so they understand the glove is as soiled as the bare hand once contaminated. I discouraged the use of gloves unless the food is being handled directly. Review of the facility policy titled Food Preparation and Service (undated) revealed: Steam tables are never used to reheat food. Bare hand food contact is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and / or soiled and must be changed between tasks. Review of the morning cooks work schedule revealed 9:00 AM review the lunch menu and begin preparing lunch, 11:00 AM place lunch items on the steam table. Review of the evening cooks work schedule revealed 10:30 AM assist AM cook with lunch menu. Prepare pureed entrees, pureed vegetables, blenderized meals and chopped or ground meat items.

Based on observation, record review and staff interview the laundry staff failed to store clean linen and clean resident clothing in the laundry room appropriately. The laundry staff failed to maintain all doors in the laundry room closed. The facility failed to utilize impervious Personal Protective Equipment in order to prevent cross contamination. The findings included: Observation of the laundry room on 03/30/2017 at 10:00 AM with the Housekeeping Director and Laundry Staff C, noted there was a box that contained latex gloves, and a box of plastic aprons located on the wall next to the Personal Protective Equipment Supplies. An interview conducted with Laundry Staff C on 03/30/2017 at 10:10 AM revealed she utilized a plastic apron and latex gloves to sort soiled linen. Observation of the folding area on 03/30/2017 at 10:15 AM noted Laundry Staff D was folding linen on the folding table. Observation of the two linen carts revealed they contained folded clean linen observed uncovered. Observation of the resident's personal clothing revealed they were uncovered and hanging from a clothing rod. There was a box, which contained folded blankets observed to be uncovered. There was a shelf with folded blankets, which were also uncovered. An interview conducted with Laundry Staff D on 03/30/2017 at 10:20 AM revealed the clean linen located in the linen carts, shelf, and a box were uncovered. The laundry staff stated the residents clothing hanging on the rod was also clean and uncovered. An interview conducted with the Housekeeping Director on 03/30/2017 at 10:25 AM confirmed that the laundry staff was utilizing a plastic apron and latex gloves to sort soiled linen. The Housekeeping Director confirmed the clean linen and resident clothing were uncovered. Observation of the laundry area on 03/30/2017 at 4:05 PM revealed the door leading to the dryer area was open. The dryer area had a screen door, which contained lint. Observation of the dryer area revealed two clothing carts with clean clothing observed to be uncovered. An interview conducted with laundry staff D on 03/30/2017 at 4:10 PM revealed she had the door open because she was in the laundry room. The Infection Control Nurse on 03/30/2017 at 4:20 PM confirmed that the clean linen and the clean resident clothing were uncovered. The laundry room door was open. The staff was not wearing impervious Personal Protective Equipment in order to prevent cross contamination. Review of the facility Policy and Procedure for Departmental (Environmental Services) -Laundry and Linen noted: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. General or washing linen must wear a gown and gloves. Standard precautions. 3. Consider all soiled linen to be potentially infectious and handle with standard precautions. Sorting soiled linen. 1. Employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected. 2. Use heavy-duty rubber gloves for sorting laundry. Always wash hands after completing the task and removing gloves. Washing linen and other soiled items. 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.

Based on interview and record review, the facility failed to follow care plans for: 1) one (resident #55) out of five sampled residents whose medication regimens were reviewed related to the facility not monitoring a medication that was used for [MEDICAL CONDITION], and 2) not accurately assessing one (resident #90) out of three residents reviewed for dental status and services involving the fitting of a lower dental prosthesis, out of fifteen residents whose care plans were reviewed. The Findings included: 1.) Record review of the medical facesheet for resident #55 was originally admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Record review of the physician order sheet (POS) for resident #55 revealed that on 08/11/2016 the resident was prescribed five milligrams (5mg) of [MEDICATION NAME], a hormone, to be given at bedtime for [MEDICAL CONDITION]. Record review of the care plan for [MEDICAL CONDITION] dated 01/20/2016, recently reviewed on 03/28/2017, revealed that resident #55 was care planned for receiving medications related to her inability to sleep at night. The goal included that resident #55 would not exhibit signs of drug related sedation or [MEDICAL CONDITION] with a target date of 06/24/17. The approaches included, but were not limited to, observe / record effectiveness of drug treatment. Record review of the medication administration records (MARs) for the months of January 2017 to March 2017 revealed that resident #55 received 5mg of [MEDICATION NAME] at bedtime daily. There was no documentation to indicate that the resident was being monitored for the inability of sleep, or the effectiveness of the medication in the behavior monitoring section. Record review of the nursing notes for the months of January 2017 to March 2017 revealed no notation that resident #55 was being monitored for sleep disturbances, or if the [MEDICATION NAME] medication was effective and if there were any side effects. Interview with the Registered Nurse (Staff A) on 03/29/2017 at 10:39 am, via telephone, revealed that she worked with resident #55 during the 11 pm to 7 am shift. Staff A did not provide the [MEDICATION NAME] medication to the resident, however, she checked on the resident while she slept; the resident had no problems with sleeping. She said that if there was a problem with the resident sleeping she would have documented it in the nursing notes. Interview with the Registered Nurse (Staff B) on 03/29/2017 at 12:30 pm, via telephone, revealed that she worked the 3 PM to 11 PM shift. She administered the [MEDICATION NAME] medication to resident #55, and before the end of her shift she would make her rounds and check on the resident to make sure that she was fine and sleeping. Staff B said that she would document in nurses' progress notes, and on the behavior monitoring sheets, how the resident was sleeping and if the medication was effective. Interview with the Director of Nursing (DON) on 03/29/2017 at 1:03 pm revealed that the nursing staff should be monitoring for the effectiveness of the medication, and if the medication was not effective it should be documented in the nursing notes and followed up as necessary. The DON said that even though there was no documentation in the nursing notes and on the MARs, nursing staff were monitoring resident #55 for the inability to sleep. 2.) Record review of the face sheet revealed that resident # 90 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Physician Order Sheet (POS) for resident # 90 for March 2017 revealed the following diet order: Regular, No Concentrated Sweets (NCS), No added Salt (NAS) with thin liquids. Record review of the Minimum Data Set (MDS) for resident # 90 dated 1/16/2017 revealed section L (Oral / Dental Status) no natural teeth or tooth fragments - edentulous was checked. Broken or loosely fitting full or partial dentures was not checked. Record review of the nutrition quarterly review dated 1/16/2017 for resident # 90 revealed resident remained stable this quarter. Tolerating current diet well. No chewing or swallowing problem noted. Resident with upper and lower dentures. Preferred to wear upper only. No discomfort noted. Able to chew without difficulty. Record review of the dental consult note for resident # 90 dated 4/1/2016 revealed comments: Patient presented for a screening. Patient had no existing upper or lower natural teeth. Patient was asymptomatic to pain. No follow up needed. Patient was not interested in dentures at this time. Signed by Staff G, dentist. Record review of the dental consult note for resident # 90 dated 5/6/2016 revealed patient presented for jaw and a bite registration. Measurements were taken accordingly. Next visit wax try in. Signed by Staff G, dentist. Record review of the dental consult note for resident # 90 dated 6/20/2016 revealed patient presented for a wax tray in of lower complete dentures. All went comfortable. Will deliver at next visit. Signed by Staff G, dentist. Record review of the dental consult note for resident # 90 dated 07/25/2016 revealed patient presented for a lower completed denture delivery. Denture was adjusted accordingly and denture care instructions were given. All went comfortable. No follow up needed. Record review of the dental consult note for resident # 90 dated 1/23/2017 revealed comments: Patient presented for a screening. Patient had no existing natural teeth. Patient was asymptomatic to pain. Patient had an existing set of complete dentures that were functional and stable. No follow up needed. Dental hygienist was authorized to treat patient. Signed by Staff G, dentist. Record review of the dental care plan for resident # 90 revised on 3/29/2017 revealed problem: Dental Care. Resident # 90 was at risk for oral problems and was edentulous, with dentures in use. At times when she preferred, refusing to wear them occasionally. Goal: Resident will be free from inflamed gums, swollen or bleeding gums and oral abscess. Approach: Observe condition of oral cavity, tongue, lips. Observe mouth for excessive bleeding, sores, or [MEDICAL CONDITION]. Notify Medical Doctor. Observe resident's dentures for proper fitting. (Certified Nursing Assistant and Nursing). Obtain dental consult as needed. Provide assistance for oral hygiene. Record review of the social services note for resident # 90 dated 3/30/2017 at 3:16 PM revealed as per Interdisciplinary team (IDT) member report, resident stated that she preferred not to wear her bottom dentures because they did not feel comfortable to her and that she had not made mention previously. Record review of the social services note for resident # 90 dated 3/30/2017 at 3:30 PM revealed update to resident's dental service: Received a telephone call from Dental group, dentist will be in the facility on Monday morning, April 3, 2017 prior to noon. IDT made aware. Interview with resident # 90 on 3/28/2017 at 11:08 am with Spanish translation by Staff H revealed that resident # 90 noted that her dentures were uncomfortable when she wore them. Resident # 90 explained that she had seen the dentist and the dentures did not fit. Resident # 90 noted that she told a dentist that the dentures did not fit but did not tell the staff. Interview on 3/29/2017 at 3:57 PM with Staff B, Registered Nurse (R.N.) regarding resident # 90 revealed she ate with a plate guard and was set up for lunch. Staff B said that resident # 90 could eat on her own and noted that she had dentures. Resident # 90 never told her that the dentures didn't fit. Staff I, Certified Nursing Assistant (CNA) noted through Spanish translation that resident # 90 had a stroke. Staff I mentioned that resident # 90 cleaned the dentures herself. Staff I, Certified Nursing Assistant stated that resident # 90 never told her about her dentures not fitting right. Observation on 3/29/2017 at 4:05 PM of resident # 90 with Staff B, RN and Staff I revealed that she had upper dentures in her mouth and was not wearing lower dentures. Interview on 3/29/2017 at 4:05 PM with resident # 90 via Spanish translation by Staff B, RN and Staff I was also in the room of resident # 90 revealed that sometimes, a long time ago when she didn't wear the dentures her gums were sore. Resident # 90 noted that her lower dentures did not fit okay. Resident # 90 stated that she told the dentist. Resident # 90 mentioned that her lower dentures were in her drawer. Observation on 3/29/2017 at 4:18 PM revealed that Staff I, CNA had obtained the lower dentures for resident # 90 from her drawer in her room. The lower dentures of resident # 90 were in a sealed denture cup. Staff B, RN was also present. Interview on 3/29/2017 at 4:18 PM with resident # 90 via Spanish translation by Staff B, Registered Nurse and Staff I, Certified Nursing Assistant (CNA) was also present in her room revealed that resident # 90 noted that the lower dentures were too big for her and she confirmed that the dentures were in the drawer since they didn't fit right. Staff B and staff I mentioned that this was the first time they had heard of the lower dentures not fitting right. Resident # 90 said that a dentist took the measurements of her teeth which was one or two years ago. Resident # 90 noted that she informed the dentist at that time, but the dentist stated that the dentures were okay. Resident # 90 said that was why she did not tell the staff here. Resident# 90 replied when asked about her lower dentures that did not fit: If she saw the dentist, she would like lower dentures that fit and she would use them. Interview on 3/30/2017 at 12:52 PM with staff F, Minimum Data Set (MDS) coordinator revealed that she completed the dental section of the MDS and social services dealt with the dental consults. Staff F noted that she would assess the oral cavity and made sure that the dentures fit. If the resident was alert she would ask if they had oral discomfort. She would also check for missing or broken teeth. Staff F noted that she also filled out the dental care plan at the time of the MDS and then updated as needed. The dental services would assess the resident's oral cavity. The hygienist would come inhouse to complete the cleaning and evaluate if a resident needed dentures or not. They would evaluate the dentures for proper fitting. Staff F noted that in January 2017 the MDS was completed and nothing was checked for loose or not fitting dentures since this was not appropriate at the time. Staff F noted that resident # 90 sometimes refused to wear her dentures but never told her that the dentures didn't fit right. Interview on 3/30/2017 at approximately 1:30 pm with staff F revealed that she would speak to social services about getting a dental consult as soon as possible so they could re-assess her for lower dentures according to her preferences if she decided to wear them. Interview on 3/30/2017 at 4:05 PM with staff I, Certified Nursing Assistant (CNA) through Spanish translation by Staff J, Registered Nurse regarding resident # 90 revealed that it depended on the resident. If the resident needed total assistance then she would complete total mouth care which would involve: Cleaning of the dentures and soaking the dentures in the solution. If the resident were alert she would ask the resident if the dentures were okay. If the resident was not alert and there might be facial grimacing then she would report this to the nurse. Staff I noted that resident # 90 sometimes refused to wear the lower dentures because they were blue. Staff I confirmed that she never had helped resident # 90 insert her dentures. Record review of the facility policy for care plans dated 08/2006 revealed: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation. 1. Our facility's Care Plan / Interdisciplinary team, in coordination with the resident, his / her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's Comprehensive Care Plan has been designed to: A. Incorporate identified problem areas. B. Incorporate risk factors associated with identified problems. C. Build on the resident's strength. D. Reflect treatment goals and objectives in measurable outcomes. E. Identify the professional services that are responsible for each element of care. F. Aid in preventing or reducing declines in the resident's functional status and or functional levels and G. Enhance the optional functioning of the resident by focusing on a rehabilitative program. Record review of the facility dental service policy statement not dated revealed: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Oral health services are available to meet the resident's needs. Nursing Services is responsible for notifying Social Services of a resident's need for dental services.

Based on interview and record review, the facility failed to provide documentation to indicate adequate monitoring for the use of a medication ordered for [MEDICAL CONDITION] for one (resident #55) out five sampled residents for medication regimen. The Findings included: Record review of the facility's policy and procedures titled, Behavioral Assessment, Intervention and Monitoring, undated, revealed, The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. If the resident is being treated for [REDACTED]. Record review of the medical facesheet for resident #55 was originally admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Record review of the physician order [REDACTED].#55 revealed that on 08/11/2016 the resident was prescribed five milligrams (5mg) of [MEDICATION NAME], a hormone, to be given at bedtime for [MEDICAL CONDITION]. Record review of the medication administration records (MARs) for the months of January 2017 to March 2017 revealed that resident #55 received 5mg of [MEDICATION NAME] at bedtime daily. There was no documentation to indicate that the resident was being monitored for the inability of sleep, or the effectiveness of the medication in the behavior monitoring section. Record review of the nursing notes for the months of January 2017 to March 2017 revealed no notation that resident #55 was being monitored for sleep disturbances, or if the [MEDICATION NAME] medication was effective and if there were any side effects. Interview with the Registered Nurse (Staff A) on 03/29/2017 at 10:39 am, via telephone, revealed that she worked with resident #55 during the 11 pm to 7 am shift. Staff A did not provide the [MEDICATION NAME] medication to the resident, however, she checked on the resident while she slept; the resident had no problems with sleeping. She said that if there was a problem with the resident sleeping she would have documented it in the nursing notes. Interview with the Registered Nurse (Staff B) on 03/29/2017 at 12:30 pm, via telephone, revealed that she worked the 3 pm to 11 pm shift. She administered the [MEDICATION NAME] medication to resident #55, and before the end of her shift she would make her rounds and check on the resident to make sure that she was fine and sleeping. Staff B said that she would document in nurses' progress notes, and on the behavior monitoring sheets, how the resident was sleeping and if the medication was effective. Interview with the Director of Nursing (DON) on 03/29/2017 at 1:03 pm revealed that the nursing staff should be monitoring for the effectiveness of the medication, and if the medication was not effective it should be documented in the nursing notes and followed up as necessary. The DON said that even though there was no documentation in the nursing notes and on the MARs, nursing staff were monitoring resident #55 for the inability to sleep.

Based on observation and interview, the facility failed to ensure a portable fan used in a resident's room was adequately cleaned for 1 of 35 residents (Resident #52) whose rooms were observed. Findings include: An observation of Resident #52's room was made on 04/25/2016 at 11:18 am. A small portable box fan was observed on a night stand. The box fan was not on at this time and was observed with an accumulation of gray dust along the edges of the fan blades and on the inner cord component. A second observation of Resident #52's room was made on 04/26/2016 at 09:33 am. The fan was in use at this time. A third observation of Resident #52's room was made on 04/27/2016 at 12:12 pm. The small portable box fan was again observed on the night stand. The box fan was not on at this time and was observed with the accumulation of gray dust along the edges of the fan blades and on the inner cord component. Interview and observation of Resident #52's room was made on 04/28/2016 at 10:27 am with the Director of Maintenance and Maintenance Consultant. The box fan was observed on the night stand with the same accumulation of gray dust along the edges of the fan blades and on the inner cord component. The Maintenance Director stated Resident #52's family requested the fan and it is used by Resident #52 and sometimes by her roommate. The Maintenance Consultant stated that if a fan is dusty, it should be cleaned and this fan should have been cleaned, like the other fans. He stated housekeeping was responsible for cleaning, but the maintenance department would also clean.

Based on observation, record review and interview the facility failed to update a visual function comprehensive care plan for 1 (Resident #107) of 3 residents sampled for vision out of 50 residents with lack of corrective action for visual problems to include the use of corrective glasses. Findings include: Observation of resident #107 on 04/27/2016 at 9:45AM revealed the resident was in bed watching TV. A pair of bifocal glasses were observed on the resident. Interview with resident #107 on 04/27/16 at approximately 9:46AM revealed he needs glasses to watch TV and read. He said he had bifocal glasses to see near and far. Record review of resident #107's clinical record revealed the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of resident #107's Nursing Admission Evaluation dated 01/28/16 showed the resident's vision patterns as impaired-sees large print, but not regular print in newspapers/book. Corrective lenses was marked as no. Review of resident #107's Inventory of Personal Effects on file dated 1/29/16 revealed Glasses & Cases: 1 pair. Review of resident #107's care plans revealed the resident had a care plan on file for problem impaired vision, initiated on 02/05/16. Approaches not limited to eye consult as ordered; keep call light within reach; observe eyes for secretions/redness and report to the doctor. There was no mention of the resident wearing glasses on the care plan. Review of most recent comprehensive, admission, minimum data set (MDS) with assessment date 02/04/16 revealed the resident was triggered for Visual Function and it was okay to proceed to care plan. Review of the Care Area Assessment (CAA) Detail Worksheet revealed Vision was triggered. CAA Triggers: vision impairment is indicated. Review of Indicators of Visual Function: decreased visual acuity. Use of visual appliance is marked as none of the above. Analysis of findings: (resident name) vision is impaired no visual complications noted at this time. Interview with MDS/Care plan coordinator on 04/27/26 at 3:45PM reports she saw resident #107 with glasses a couple of days ago. Resident was in bed watching TV with his glasses on. She is not sure when the family brought him those glasses. Interview and observation with the MDS/Care plan coordinator at the residents room on 04/27/2016 at 3:59PM. Resident #107 had glasses on and he was watching TV. Resident reported he brought his glasses with him when he got here. Those glasses were lost. About 4 months ago, his family brought him the pair he was wearing, which he had at his sister's house. Resident then said his glasses did not go missing, they broke. Interview with social services director (SSD) on 04/27/2016 at 4:17PM with MDS/care plan coordinator present, revealed resident #107 was admitted to the facility with glasses. Resident had a fall, the glasses broke and the family brought him another pair which were the ones he was wearing. The fall happened on 03/29/16. Both MDS coordinator and SSD said the resident was interviewed on 02/04/16 for the admissions MDS. At that time, he did not have his original glasses with him. On admission, the resident had a pair of glasses that had a tape around them and his son, who was visiting here for New York, took them for repairs. A family member brought him a new pair not too long ago. MDS coordinator explained that if a patient is alert and oriented times three an interview, in addition to observations, was done with the resident about the glasses. She also reviews the nurses' admission assessment. The resident was admitted with glasses but they broke before the MDS assessment was done and the family recently brought a new pair. On 04/28/16 at 11:39PM SSD presented this surveyor with a progress note dated 04/28/16 stating Social worker (SW) spoke to son upon resident's admission. At that time son stated that resident's glasses were broken and had been taken for repair. His cousin would bring new glasses. SW spoke to cousin in regards to the glasses. (cousin's name) stated that she had brought (resident's name)'s glasses and other personal items prior to his hospital discharge. But had not informed any of the staff at that time. SSD said even though this conversation happened at time of admission she entered the documentation today. She also presented this surveyor with a Vision care plan with a note by MDS/Care plan coordinator dated 04/28/16 stating Resident has a pair of glasses that was brought by family upon admission his glasses were broken and were taken by family for repair. SSD said MDS coordinator entered that note today, 04/28/16. Interview with MDS coordinator on 04/28/2016 at 11:47AM revealed she updated resident #107's vision care plan today. She updated the problem area of the care plan to say eye glasses in use and the approaches were updated as well to say assure that the lenses of the glasses are clean and in good repair She acknowledged the use of eyeglasses should have been documented on the resident's care plan. She said the resident is due for a quarterly MDS soon so the use of eyeglasses will be captured then. Telephone interview with resident #107's niece (contact person on resident's facesheet) on 04/28/2016 at 4:47 PM reports the resident owns three pairs of glasses, which he prefers her to keep at home. She said the resident called her to ask her to bring him a pair of glasses. She said she does not remember the exact date when she brought him the glasses but it was not too long after he was admitted here. She brought him some clothes, his wallet and the pair of glasses. At that time the resident was assigned to a different room. Record review of physician orders [REDACTED].

Based on record review and interview, the facility failed to ensure a resident's care plan was followed related to monitoring and to medication administration for constipation for 1 of 5 sampled residents (Resident #52) whose medication regimens were reviewed. This is related to lack of evidence of attempts to administer an as needed laxative as ordered and to lack of documentation that signs of constipation were being monitored by nursing staff. Findings include: A review of Resident #52's clinical record was conducted beginning on 04/27/2016. Review of Resident #52's comprehensive care plans revealed Resident #52 had a a care plan dated 10/16/2013 for Problem: (Resident #52) at risk for constipation related to decreased mobility, use of [MEDICAL CONDITION] medications. Goal: Resident will have bowel movement once every 3 days. Some of the Approaches listed included: 10/16/2013-Administer medications per Medical Doctor order. Observe effectiveness and side effects. and 10/16/2013-Monitor for signs of constipation (abdominal pain/distention). Review of Resident #52's bowel monitoring log showed the log was completed by certified nursing assistants and indicated the date and time of the data entry and whether Resident #52 had a small, medium, or large bowel movement or none to indicate no bowel movement. Resident #52's bowel monitoring log showed she had a large bowel movement on 03/13/2016 during the 3pm-11pm shift. One entry was found for 03/14/2016 which indicated none for Bowel Movement. Three entries were found for 03/15/2016 for 03:48 am, 10:06 pm, and 10:06 pm which indicated none for bowel movement. One entry was found for 03/16/2016 which indicated none for bowel movement. One entry was found for 03/17/2016 which indicated none for bowel movement (which totaled four consecutive days of no bowel movements). One entry was found for 03/18/2016 at 07:32 pm which indicated a large bowel movement. The bowel monitoring log was not used to document any additional information. Review of Resident #52's current Physician's Order sheet showed an order beginning on 03/05/2016 for '[MEDICATION NAME] solution 20 gram/30 milliliters give 30 milliliters by mouth daily as needed if no bowel movement times 2 days'. Review of Resident #52's March 2016 Medication Administration Record (MAR) showed a section for '[MEDICATION NAME] 20 grams/30 milliliters administer 30 milliliters as needed for a [DIAGNOSES REDACTED]. Review of Resident #52's Progress Notes showed a nurse's note was written on 03/13/2016 at 03:40 pm which indicated Resident #52 was alert and did not display signs or symptoms of pain or discomfort. The next nurse's note was written on 03/18/2016 01:16 pm which indicated Resident #52 was alert with no signs or symptoms of pain or discomfort but did not address Resident #52's bowel status or use of [MEDICATION NAME]. No nurse's notes were found for the days of 03/14/2016, 03/15/2016, 03/16/2016, and 03/17/2016 and no further information was found that indicated the [MEDICATION NAME] was administered or that indicated what monitoring was completed during this time for signs of constipation. An interview was conducted with Licensed Practical Nurse (LPN) A on 04/28/2016 at 02:43 pm. LPN A confirmed she takes care of Resident #52 on the 7am-3pm shift. She confirmed Resident #52 had an as needed order for [MEDICATION NAME] to be given if Resident #52 does not have a bowel movement after two days. LPN A reviewed Resident #52's bowel movement log and confirmed that according to the documentation, Resident #52 did not have a bowel movement on 03/14/2016, 03/15/2016, 0316/2016, and 03/17/2016. LPN A reviewed Resident #52's March 2016 MAR and confirmed there was no indication that [MEDICATION NAME] had been given during that time. She stated it would have been given on the 16th. An interview was conducted with the Director of Nursing (DON) on 04/28/2016 at 03:24 pm. The DON stated certified nursing assistants are responsible for documenting bowel movements on the bowel movement log and reporting to nurses. The DON confirmed the physician's order did not specify which shift it should be given. During this interview, the DON summoned LPN A and asked her to try to remember the reason Resident #52 did not receive the [MEDICATION NAME] during this time period. LPN A paused and stated that Resident #52 refuses medications and must have refused the [MEDICATION NAME]. When asked, LPN A was unable to recall how many attempts she made to encourage Resident #52 to take the [MEDICATION NAME] and confirmed she did not contact Resident #52's primary care physician to report that Resident #52 refused the [MEDICATION NAME] after over two days without having a bowel movement. LPN A confirmed she did not document any of this information in her nurse's notes. LPN A confirmed that the Physician's Order did not specify that the [MEDICATION NAME] should only be administered on the 7am-3pm shift. The DON attempted at this time to contact Resident #52's 3pm-11pm nurse, Registered Nurse (RN) A, via telephone. A second interview was conducted with the DON on 04/28/2016 at 05:10 pm. The DON stated that if Resident #52 refused to take the [MEDICATION NAME], it should have been documented in the nurse's notes and the primary care physician should have been notified of the refusal. A telephone interview was conducted with RN A on 04/28/2016 at 05:46 pm. RN A stated that sometimes Resident #52 refuses medications if she wants to sleep or if its something she does not like. RN A stated sometimes she documents the refusals.

Based on observation, interview and record review the facility failed to protective measures to ensure that the suction machine for resident number eighteen (R#18) was maintained in a sanitary manner for one of five residents (R#18) ordered suctioning and with the potential to affect all residents with care equipment. There were a total of 77 resident residing in the facility at the time of this survey. The findings include: Record review of the Annual Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 12-07-14 had the following [DIAGNOSES REDACTED]. According to the face sheet the resident was originally admitted to the facility on [DATE] with the latest return noted as 12-19-13. Observation of R#18 conducted on 02-02-15 at 11:40am, revealed that the suction machine located on the night stand was not covered. There was a bright green sticker on the base of the machine which had the dates of 3/14 and 3/15 handwritten on it. There was a heavy layer of dust coating entire areas of the top and outer surfaces of the suction machine's clear canister, blue canister lid, metal section of the machine and the bright green sticker. The tubing attached to the suction machine and black cords plugged in the double wall socket were also coated with dust on the upper surface areas. During a closer observation conducted on 02-02-14 at 4:20pm revealed that all of the items on the night stand were covered with a heavy visible layer of dust on the outer surfaces. This included the Vac Assist Suction Unit, the Pure Air Humidifier, a small glass vase with yellow artificial flowers, a white ceramic vase holder and a 32 ounce size bottle of Skin Repair Cream. The night stand was located directly under the wall Air Conditioning (AC) unit. The AC Unit was coated with a heavy layer of dust on the outer surface areas of the front panel grid. Observation of the Vac Assist Suction Unit conducted on 02-03-15 at 9:33am revealed that it remained uncovered and coated with heavy layer of dust on the outer surface area of the canister, blue lid, metal base, tubing and black electrical cord. During an observation of the Vac Assist Suction Unit conducted with the Unit-1 Registered Nurse (RN) on 02-03-15 at 1:30pm, she instantly stated that the suction machine should be covered. She also confirmed that the surface area of the Vac Assist Suction Unit and parts was dusty. She stated that she would check to see if the Vac Assist Suction Unit belonged to the resident (R#18). An interview and record review of the electronic Physicians Order Sheet (POS) with the Unit-1 Registered Nurse (RN) conducted on 02-03-15 at 1:40pm, she stated that R#18 had orders for suctioning which were dated since September 29, 2014. During an interview with the Director of Nursing (DON) on 02-03-15 at 1:43pm, she said the facility currently have five residents with orders for suctioning. This order is usually prescribed for residents when they have excessive secretions. A record review of the nurses' notes dated 09-29-14 at 11:00pm revealed, "the resident observed with excess oral/respiratory secretions. Suctioning provided PRN as ordered, with effective results, respiration even and unlabored. No s/s of pain or discomfort observed. HOB (head of bed) elevated. Safety/comfort measures maintain at all times. Aspiration precautions maintain at all times. Will continue to monitor. Record review of the nurses notes dated 09-30-14 at 06:46am revealed the resident in bed asleep with HOB up. Enteral feedings and H2O (water) flushes tolerated well. No Secretions noted at this time. Resident kept clean and dry by staff. The ABT's (antibiotics) is in progress via IV (intravenous). Afebrile skin, warm and dry (w/d) to touch. No s/s of hyper or [DIAGNOSES REDACTED]. Bed is low. Call light in reach." Record review of the PRN (as needed) Medication Administration History dated from 01-01-15 to 01-31-15 revealed that the order for suctioning of respiratory/oral secretion/as needed. Start date is 09-29-14 and end date noted as open ended. During an observation on 02-03-14 at 1:48pm conducted with the DON and the RN, the DON confirmed that the Vac Assist Suction unit should be covered. When the DON saw the coating of dust, she instructed the attending nurse to clean and cover the suction machine, the items on the night stand and the top of the night stand. The DON stated that she would have maintenance come to clean the Air Conditioning unit. An observation of the Vac Assist Suction Unit on 02-03-15 at 2:42pm revealed that the machine was covered with a large plastic semi-clear bag. The machine is inside the bag with a knot tied on the end. The night stand table, flowers, vase and air humidifier machine are clean to sight on the surface areas. During an interview with the RN on 02-03-14 at 2:45pm she stated that the suction machine, the night stand and other items were cleaned by the maintenance staff. She stated that the Nurse Supervisor accompanied the maintenance worker while the cleaning was done. During an interview with the Maintenance worker on 02-03-15 at 2:48pm, he confirmed that he was instructed to clean the suction machine, the flowers, the air humidifier, the top of the night stand and the air conditioning unit in room 205. During a brief visit to the resident's room, the maintenance worker showed the area and items that needed to be thoroughly cleaned. During an interview with the DON on 02-04-15 at 8:15am she was asked to submit the facility's policy on the proper storage of the resident's care equipment. On 02-04-15 at 10:07am the DON presented the facility's policy titled "Cleaning Medical Equipment". There was no date noted on the policy. The policy's Purpose: "the purpose of this procedure is to prevent cross contamination when using medical equipment between residents when continuous use is needed. Medical equipment will be disinfected after each use. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: 1. Facility approved disinfectant solutions 2. Gloves 3. Personal protective equipment as needed The Steps in the Procedure In the absence of the manufacturer's specific care and maintenance instructions, clean the equipment using the following procedures: 1. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Put on clean gloves. 4. Examine medical equipment for damages. Report damaged equipment to your supervisor. 5. Using firm pressure, clean medical equipment in a circular motion. 6. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 7. Return the equipment to its designated storage area. 8. Discard disposable equipment and supplies in designated containers. 9. Wash and dry your hands thoroughly. 10. For medical equipment that is in use on a continuous basis, equipment will be checked weekly by the designated nurse and as needed to make sure that it is clean and functioning properly." A record review of the policy conducted with the DON on 02-04-15 at 10:10am revealed that the policy does not directly address the proper storage of resident's care equipment. The DON stated that she would check to see if there was a policy that was applicable to the proper storage of the resident's care equipment but at this time the only one she was aware of was the "Cleaning Medical Equipment" policy. On 02-04-15 at 11:02am the DON presented the facility's policy titled "Storage of Medical Equipment". The policy does not have a noted effective date. The policy's Purpose is to ensure that medical equipment is clean and ready for use. The policy's Procedures noted are: the Durable Medical Equipment (DME) at bedside shall be stored in a plastic bag when not in use. A record review of the electronic Physician order [REDACTED]. The Order Description: "Suctioning of Respiratory/Oral secretions, as needed dated 09-27-14 Frequency: As needed Times/Shifts: PRN Description: PRN 1, PRN 2 and PRN 3. Repeat: Every Day Category: Treatments Flow Sheet: PRN Medications Ordered by the MD (Medical Doctor) Created and Verified Date: 09/29/2014 10:56pm Start Date: 09/29/2014 End Date: Open Ended." On 02-05-15 at 7:20am the DON presented a print out of the electronic nurses' notes dated from 9-30-14 to 10-02-14. A record review of the nurses notes dated 09-29-14 at 11:00pm reveal the resident observed with excess oral/respiratory secretions. Suctioning provided PRN as ordered. Effective results. Respiration even and unlabored. No s/s of pain or discomfort observed. HOB (head of bed) elevated. Safety/comfort measures maintain at all times. Aspiration precautions maintain at all times. Will continue to monitor. Nurses notes dated 09-30-14 at 06:46am, "resident in bed asleep with HOB up. Enteral feedings and H2O flushes tolerated well. No Secretions noted at this time. Kept clean and dry by staff. ABT in progress via IV (intravenous). Afebrile skin w/d to touch. No s/s of hyper or [DIAGNOSES REDACTED]. Bed low. Call light in reach." On 02-05-15 at 7:32am interview with the housekeeping staff revealed that she cleans room 205. During an observation of room 205, the 'housekeeping staff explains that she will clean all the surface area of the furniture including the night stand, picture frames, overhead light fixture, bed head and foot board, air humidifier and the upper and front panels of the air conditioner. She cleans the resident's bathroom, floors, closet doors and anything else needed. She presented a large container of Germicidal Bleach Wipes which is used for cleaning. Se says the rooms are cleaned every shift and as needed. Record review of the hard copy medical record reveal the doctor visited the resident on 01-02-15, 12-02-14, 11-24-14, 11-02-14, 10-14-14 and 09-24-14 according to the doctors progress notes. On 09-24-14 and 10-28-14 the notes have dated that the residents' lungs are clear. The doctor notes dated for 11-02-14, 12-02-14 and 01-02-15 indicate no wheezing. Review of the labs done reveal that they were done 09-22-14, 10-13-14, 11-03-14, 12-15-14, 01-12-15 and 02-02-15. All results were reported to the MD.

Based on observation, interview and record review the facility failed to provide housekeeping services to ensure that the residents rooms (Room #205) were maintained in a sanitary manner by keeping the air conditioning unit and furniture dust-free. This has the potential to affect three out of 77 residents residing in the facility at the time of the survey. The findings include: Observation conducted on 02-02-14 at 4:20pm revealed that the surface area of the items located on the night stand was covered with a heavy visible layer of dust. This included the Vac Assist Suction Unit, the Pure Air Humidifier, a small glass vase with yellow artificial flowers, a white ceramic square shaped vase holder and a 32 ounce size bottle of Skin Repair Cream. The night stand was located directly under the wall Air Conditioning (AC) unit. The AC Unit was coated with a heavy layer of dust on the outer surface areas of the front panel and grid Observation of the conducted on 02-03-15 at 9:33am revealed that the surface area of the Vac Assist Suction Unit, night stand, flowers, vase, vase holder and bottle of cream remained coated with dust. Observation of the night stand and items located on it was conducted with the Unit-1 Registered Nurse (RN) on 02-03-15 at 1:30pm, she confirmed that area was dusty. Observation on 02-03-14 at 1:48pm conducted with the DON and the RN, the DON instructed the attending nurse to clean the suction machine, the items on the night stand and the top of the night stand. The DON stated that she would have maintenance come to the room to clean the Air Conditioning unit. During an interview with the RN on 02-03-14 at 2:45pm she stated that the suction machine, the night stand and other items were cleaned by the maintenance staff. During an interview with the Maintenance worker on 02-03-15 at 2:48pm, he confirmed that he was instructed to clean the suction machine, the flowers, the air humidifier, the top of the night stand and the air conditioning unit. During a brief visit to the resident's room at this time, the maintenance worker showed that the area and items had been thoroughly cleaned. On 02-04-15 at 3:15pm the DON was asked for the facility's policy relating to housekeeping services for the cleaning of resident's room. On 02-04-15 at 3:50pm the DON submitted a four page policy titled "Environmental Services " with the revision date of 03-01-2012 and reference number #4025. The policy's Purpose noted was to "control the spread of infection within the facility by maintaining a thoroughly clean and safe environment. The Responsibilities are: Sanitation within the facility environment depends upon cleaning thoroughness and frequency. There shall be procedures for cleaning walls, floors, windows, beds, furniture, draperies, carpets, waste containers, bathrooms, equipment, stairs, special resident care departments and other nonresident areas. Resident Rooms/Activity Areas/Beauty Shop: All upward facing horizontal surfaces shall be damp cleaned daily. EQUIPMENT: All equipment including electrical cords and wheels, shall be wet-cleaned. The cleaning equipment for specialty areas are not interchangeable." Interview with the housekeeping staff on 02-05-15 at 7:32am revealed that she was the person that cleaned room 205. She explained that she when she cleans the residents rooms it includes cleaning all the surface areas of the furniture (including the night stand), picture frames, overhead light fixture, bed head and foot board, air humidifier and the upper section and front panels of the air conditioner. She also cleans the resident's bathroom, sweep and mop the floors, wipe closet doors and clean any other items as needed. She presented a large container of Germicidal Bleach Wipes which was the product used for cleaning. She said the rooms are cleaned every shift and as needed.

Based on observation, interview and record review the facility failed to store, prepare and distribute food under sanitary conditions as evidenced by improper food storage, failure to maintain sanitary conditions in areas where food was prepared and clean dishes were being stored, and failure to distribute food under sanitary conditions during dining. These practices have the potential to result in contamination of the food and potentially effect 68 residents who eat orally. The census at the time of the survey was 80. Findings include: Observation during the initial kitchen tour on 1/27/14 beginning at 6:57 am revealed the following areas of concern: -46 ounce container of apple juice that was opened and not dated -46 ounce container of orange juice opened and not dated. -One case of food thickener stored directly on the floor in the dry storage room. The box flaps were open as well as the interior plastic bag. The food product was exposed. -A bulk storage bin containing rice was observed with the lid partially opened exposing the food product. -A light fixture was observed to have an accumulation of dust between the two fluorescent bulbs. The light was directly above the meal carts that were pre-set with placemats, glasses, condiments and bread for the breakfast meal. -Three knives stored on a agnatic knife rack were observed to had food debris on the blades. The wall directly behind the knife rack was soiled and the wall tiles were damaged. Interview with the morning cook during observation revealed all items stored in the walk in must be dated after they are opened. Observation on 1/29/14 beginning at 11:15 pm revealed the following concerns: -The bench can opener blade and base had a heavy accumulation of food build up. -The hood vents above the stove and deep fryer had a heavy accumulation of grease and dirt. The AM cook stated they were supposed to be removed every Sunday to be taken outside and cleaned. -The am cook was observed preparing and serving food. He had facial hair and was observed without a hair restraint over the facial hair. Review of the cleaning schedule provided did not include the hood vents. Interview with the Food Service Director on 1/29/14 at 11:20 am revealed the can opener should be cleaned after each use. She instructed the staff that the can opener and base needed to be cleaned. She also reported that all items stored in the walk in refrigerator should be dated after they are opened. Observation on 1/3013 at 2:15 pm revealed -The overhead fluorescent light fixture near between the steam table and the clean side of the dish room area had an accumulation of black dust at the end of the fixture. The flood light above the clean dish processing area dusty along with the shelf below the lights. The light fixtures and shelf were directly above the clean side of the dish machine and the clean dish storage and dome storage racks. -Clean dishes are stored on the soiled side of the dish room area on a shelf above where the staff scrapes and pre rinses the soiled dishes. Interview with the Consultant Registered Dietitian on 1/31/13 at 11:00 am revealed she was not sure if the facility had a policy to address the use of hair restraints, but anyone with a beard or facial hair should wear a mask or beard cover. Observation on 1/31/14 at 11:20 am revealed: -46 ounce container of Silk soy milk opened and not dated -The bulk storage bin used for rice again was observed with the lid open and the food exposed. -The bench can opener blade and base still had a heavy accumulation of food build up. -The emergency water supply was stored outsize in a storage room. There were 12 milk crates each containing 4 gallons of water that were stored directly on the concrete floor of the storage room. They were not stored at least 6 inches off the floor and not free potential contamination. Interview with the Director of Maintenance on 1/31/14 at 11:20 am revealed maintenance is responsible for cleaning the hood vents and the light fixtures monthly. If the cooks have time they can also clean them. He stated he checked the lights monthly and keeps a log. Review of the maintenance log provided for use in the kitchen revealed the light fixtures were not included on the log. Review of a Policy and Procedure titled "Employee Hygiene and Sanitary Practices" revealed 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contaminating exposed food, clean equipment, utensils, and linens.

Based on observation and interview, the facility failed to ensure that staff members promoted and enhanced the dignity of each resident during dining. This was evidenced by staff members standing to feed/hydrate 2 random residents (RR#1, RR#2) out of 81 residents currently residing at the facility. Findings include: Observation of the breakfast meal in the unit 2 common dining area on 1/27/14 at 7:24 am revealed a Certified Nursing Assistant (CNA) began to feed a resident (RR#1) while standing up to the resident's right. During a second dining observation, conducted on 12/29/14 at 11:40 am during lunch in the unit 2 common dining area, staff distributed juice to the residents in the dining room. At 11:44 am, a nurse was observed standing to the left of a resident (RR#2), holding the resident's drink and assisting her with consuming juice. Interview with the Director of Nursing on 1/31/14 at 10:59 am revealed she confirmed that staff members should not be standing to feed/hydrate the residents but should be seated while doing so.