Every finding on record at Courville at Manchester

Based on interview and record review, the facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used a resident's insulin pen to administer insulin to another resident. (Resident identifier is #1.)Findings include:Interview on 5/1/26 at approximately 11:30 a.m. with Resident #1 revealed he/she received someone else's insulin a week or two ago and was admitted to the hospital. Review on 5/1/26 of Resident #1's medical record revealed a hospital Discharge summary, dated [DATE], that stated .Accidentally Received Lispro 19 units and Trulicity 1.5 mg. Further review of the hospital discharge summary revealed no lab results for bloodborne pathogens. Further review of Resident #1's medical record revealed no orders for blood borne pathogen lab work before or after hospitalization.Interview on 5/5/26 at 2:30 p.m. with Staff F (Licensed Practical Nurse) confirmed that on 4/20/26 they had administered to Resident #1 insulin from another resident's open Lispro pen. Interview on 5/1/26 at approximately 10:45 a.m. with Staff C (Director of Nursing) confirmed that Resident #1 received Resident #2's used Lispro insulin via multidose pen on 4/20/26. Staff C revealed that no bloodwork for bloodborne pathogens had been performed on Resident #1 or Resident #2. Resident #1's Durable Power of Attorney for Health Care had not been notified of the risk for transmission of bloodborne pathogens as a result of receiving insulin from another resident's used insulin pen.Review on 5/1/26 of the Lispro pen manufacturer's instructions revealed .Do not share your needles or syringes with other people, even if the needle is changed. You may give other people a serious infection or get a serious infection from them.Review on 5/1/26 of the facility policy titled Medication Administration and Storage, effective 9/8/2022, revealed .Use needles, cannulas and syringes for only one resident.Multidose insulin pens are to be clearly labeled for the resident and used only for the resident ordered. Review on 5/1/26 of the Centers for Disease Control and Prevention (CDC) website titled, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/24, retrieved 5/1/26, from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=medications%20in%20pockets.-,Insulin%20administration,Training%20and%20oversight revealed: .Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. These devices permit self-injection, but healthcare providers may also use them to administer insulin. Each pen is designed to be safe for just one patient to use multiple times with a new, fresh needle for each injection. Pens must never be used for more than one patient because blood may be present in the pen after use

Based on interview and record review, the facility failed to ensure residents are free from significant medication errors which resulted in a resident requiring intervention and hospitalization for multiple nights for 1 of 3 medication errors reviewed. (Resident identifier is #1.)Findings include:Interview on 5/1/26 at approximately 11:30 a.m. with Resident #1 revealed he/she had received someone else's insulin a week or two ago and was admitted to the hospital.Review on 5/1/26 of Resident #1's medical record revealed a hospital history and physical, dated 4/20/26, that stated .CHIEF COMPLAINT: Accidental medication overdose, nausea and vomiting .- Aspirin 81 mg The patient was found to be hypoglycemic over here with blood sugars in the low 60s. [Pronoun omitted] was symptomatic with nausea and vomiting . Further review of Resident #1's medical record revealed a hospital Discharge summary, dated [DATE], that stated .ASSESSMENT AND PLAN: .Monitor on telemetry overnight .Antiemetics . Blood glucose every 2 hours overnight, D5WNS [Dextrose 5 percent with Normal Saline] overnight, Aspiration and seizure precautions . Interview on 5/1/26 at approximately 10:00 a.m. with Staff B (Unit Manager) revealed that on 4/20/26 Resident #1 had received multiple medications that were intended for Resident #2 in error during the morning medication pass.Review on 5/1/26 of Resident #2's April 2026 Medication Administration Record revealed the following medications were dispensed for Resident #2 with the morning medication pass:Atenolol (antihypertensive) 25 mg (milligrams), Insulin Lispro 19 units, Trulicity (GLP-1)1.5 mg, Allergy relief nasal suspension, Omeprazole 40 mg, Jardiance 25 mg, Furosemide (diuretic) 20 mg, Donapezil 10 mg, Namenda 10 mg, buspirone (anxiolytic)10 mg, metformin (antihyperglycemic) 1000 mg, Gabapentin (anticonvulsant) 300 mg, Norco (Opioid analgesic) 5-325 mg, Biofreeze Gel 5 % (percent), Visine Dry eye ophthalmic solution, Vitamin C 500 mg, Lactaid 3000 Unit, Calcium Carbonate- Vit D 600-400 mg-unit, Aspirin 81 mg.Interview on 5/1/26 at approximately 10:45 a.m. with Staff C (Director of Nursing) confirmed the above medications intended for Resident #2 were given to Resident #1 in error on the morning of 4/20/26 which resulted in Resident #1 being admitted to the hospital.

Based on observation, interview, and record review, the facility failed to ensure resident medications were labeled in accordance with currently accepted professional principles, medications were not removed from use after expiration, and failed to keep medications stored securely for 2 of 3 medication carts observed. (Resident identifiers are #3 and #6.)Findings include:Observation on 5/1/26 with Staff A (Licensed Practical Nurse) of the first floor medication cart revealed Resident #3's open Glargine (Lantus) insulin pen with no open date or open use by date. Further observation revealed Resident #3's Lispro insulin Kwikpen with an open date of 4/1/26 and a discard date of 4/29/26. Both insulin pens had a pharmacy sticker that read discard 28 days after opening. Review on 5/1/26 of the Lantus (insulin glargine) pen manufacturer instructions for use revealed .After 28 days throw your open Lantus pen away- even if it still has insulin in it. Review on 5/1/26 of the Lispro Kwikpen manufacturer instructions for use revealed .Do not use your pen past the expiration date printed on the label or for more than 28 days after you first start using the pen. Interview on 5/1/26 at approximately 8:30 a.m. with Staff A confirmed the above findings. Observation on 5/1/26 at approximately 8:15 a.m. revealed a second floor medication cart with a clear plastic medicine cup containing pills on top of the cart. There were no nurses in view of the medication cart. Further observation revealed Licensed Nursing Assistants pushing residents by the cart and visitors walking down the hall. Interview on 5/1/26 at approximately 8:15 a.m. with Staff E (Registered Nurse) confirmed that they left the medications unattended on the medication cart and revealed that they were for Resident #6. Review on 5/1/26 of Resident #6's April 20, 2026 Medication Administration Record revealed the following signed morning medications: furosemide (diuretic) 40mg (milligrams),Lisinopril (antihypertensive) 20mg,metoprolol succinate (beta blocker) extended release 100mg, metoprolol succinate extended release 25mg, Pepcid (proton pump inhibitor) 20mg, Risperdal 0.25mg (antipsychotic), sertraline (antidepressant) 150mg, Eliquis (anticoagulant) 5mg, and senna plus 8.6-50mg. Interview on 5/1/26 at approximately 8:30 a.m. with Staff E (Registered Nurse) confirmed the above listed medications were the medications that were left unintended on the medication cart. Review on 5/1/26 of facility policy titled Medication Administration and Storage, effective date 9/8/2022, revealed .Medications are locked in a clean cart, medication room, or refrigerator.Confirm medications are labeled, dated and expired medications are removed.

Based on observation, interview, and policy review, it was determined that the facility failed to remove expired food, label thawed items, properly store thawing meats, and maintain clean cooking equipment and microwaves for 1 of 1 kitchen and 2 of 3 kitchenettes observed. Findings include:KitchenObservation on 2/17/26 at approximately 8:00 a.m. with Staff B (Food Service Director) of the kitchen's revealed the following expired food items and unlabeled thawed items in the small refrigerator:Thirteen quarts of half and half milk product with an expiration date of 2/10/26;Three thawed Mighty Shakes (nutritional supplement) without a thaw or use by date;Six half gallons of whole milk with an expiration date of 2/4/26; andOne half gallon of whole milk with an expiration date of 2/14/26. Further observation in the kitchen revealed the following expired and unlabeled food items in the walk-in refrigerator:One defrosted frozen orange juice concentrate dated 2/2/26;Further observation in the kitchen revealed the following thawed meats stored in thawing racks in the walk-in refrigerator:Salisbury steak defrosting on the tray above the spanakopita;Hamburger defrosting on the tray above the coleslaw. Further observation in the kitchen revealed the following food items and food debris on pellet warmers in the food preparation area:An opened grape jelly container with no date of opening or expiration, containing multiple white substances;Ten yogurts near the food line that were warm to the touch; andFood debris adhered to the inside of the pallet warmer used for clean plates. Further observation in the kitchen revealed the following expired and unlabeled food items in the refrigerator under the food preparation area:One package of swiss cheese, labeled with an open date of 1/7 Further observation in the kitchen revealed two flat top cooking griddles with dried food remnants adhered to them, stored on a rack that was in contact with a trash barrel. The knife holder on the wall near the stove had a thick layer of dust and dirt. Burnt, blackened food debris was also observed on the bottom interior surface of the kitchen stove. KitchenettesObservation on 2/17/26 at approximately 8:20 a.m. with Staff B of the second floor microwaves revealed dried food adhered to the inside side walls, top of the inside and the bottom of the inside.Observation on 2/17/26 at approximately 8:25 a.m. with Staff B of the third floor microwaves revealed dried food adhered to the inside side walls, top of the inside and the bottom of the inside. Interview on 2/17/26 at 8:30 a.m. with Staff B confirmed the above findings. Review on 2/17/26 of the facility policy titled, Date/Dating, undated, revealed: Please date everything before putting in walk-in, . Dispose of any item that is out of date. Review on 2/17/26 of the Mighty Health Shake container revealed: Use thawed product within 14 days . Review on 2/17/26 of the facility policy titled, Guidelines for Food Safety and Use By dates, undated revealed, 4. All items opened, must have a Use By date applied. The Use By date or expiration date is the last day an item I to be served. The following guidelines will serve as Use By Date. All cheeses . 1 month, . Dressings, . 1 month. Review on 2/17/26 of the facility's policy titled, [NAME] Meat Thawing Policy, Review Date 11/1/25, revealed, 4. Approved Thawing Methods, A. Refrigerator Thawing (Preferred Method), . Place meat in a leak-proof container or on a tray to prevent cross-contamination. Store on the lowest shelf to prevent drips onto ready-to-eat foods. 7. Cross-Contamination Prevention, . Store raw meat below ready-to-eat foods at all times.

Based on observation, interview, and record review, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for choices in a final sample of 17 residents. (Resident identifier is #6.)Findings include:Observation on 2/17/26 at approximately 9:11 a.m. revealed that Resident #6 had a medicine cup containing two large white pills on their meal tray. There were no staff present at that time.Interview on 2/17/26 at approximately 9:15 a.m. with Resident #6 revealed that he/she self-administers their medications with their breakfast.Review on 2/17/26 of Resident #6's assessments revealed that there was no assessment for the self-administration of medications. Review on 2/19/26 of the Resident #6's Medication Administration Record revealed that Resident #6 received the following prescribed medications with breakfast: one capsule of Saccharmyces Boulardii +MOS (probiotic) 250 mg (Milligrams)/200mg, one soft gel of Vitamin D3 5000 UI (International Unit) with coconut oil, and one tablet of Turmeric Forte Herbal Supplement Tablet.Interview on 2/19/26 at approximately 9:31 a.m. with Staff F (Unit Manager) confirmed that Resident #6 did not have a self- administration assessment.Review on 2/19/26 of the facility's policy Self -Administration of Medications, revised February 2021, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so 3. If it is determined safe and appropriate ., this is documented in the medical record and the care plan.

Based on observation, record review, and interview, the facility failed to keep residents free from physical restraints for 1 of 1 residents reviewed for physical restraints in a final sample of 17 residents (Resident identifier is #17).Findings include:Observation on 2/18/26 at approximately 8:49 a.m. revealed Resident #17 sitting in his/her wheelchair wearing a seat belt.Interview on 2/18/26 at approximately 12:59 p.m. with Resident #17 revealed that he/she wore the seat belt because he/she has fallen out of the wheelchair in the past. Review on 2/18/26 of Resident #17's fall care plan revealed an intervention to apply the seat belt while in the motorized wheelchair for fall prevention per family request. Further review revealed that there were no interventions to release the seat belt and reposition the resident periodically while using the seat belt.Review on 2/18/26 of Resident #17's social service note (late entry) dated 6/17/25 revealed that a care planning meeting occurred on 6/13/25 that indicated that social services reviewed with the family that the seat belt would be considered a restraint.Review on 2/18/26 of Resident #17's medical record revealed no restraint assessment or order for the seat belt use.Interview on 2/18/26 at approximately 2:11 p.m. with Staff F (Unit Manager) confirmed that there was no restraint assessment or physician's order for seat belt use. Further interview with Staff F revealed that Resident #17 was unable to self-release his/her seatbelt. Review on 2/19/26 of the facility's Use of Restraints policy Revised April 2017 revealed the following: . Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls 6 .there shall be a pre-restraining assessment and review to determine the need for restraints 9. Restraints shall only be used upon the written order of a physician .13. e. Restrained residents must be repositioned at least every two (2) hours on all shifts 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s) but the underlying problems that may cause the symptom(s).

Based on interview and record review, the facility failed to follow physician orders for 1 of 1 resident reviewed for dialysis and 1 of 5 residents reviewed for unnecessary medications in a final sample of 17 residents (Resident Identifiers are #2 and #8). Findings include:[NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Resident #2 Review on 2/18/26 of Resident #2's January 2026 and February 2026's MAR (Medication Administration Record) revealed the following physician's order: Norvasc Oral Tablet 5 mg (milligrams) (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN (Hypertension) Hold for SBP (Systolic Blood Pressure) less than 130, Start Date 1/22/26. Further review revealed the following dates and corresponding SBP results for which Norvasc was administered: 1/25/26 SBP 92; 1/26/26 SBP 116; 2/3/26 SBP 113; 2/9/26 SBP 90. Interview on 2/18/26 at approximately 11:45 a.m. with Staff C (Director of Nursing(DON)) confirmed the above findings. Resident #8 Review on 2/18/26 of Resident #8's January 2026 and February 2026's MAR revealed the following physician's order: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (milliliters) Inject 10 unit subcutaneously one time a day for T2DM (Type 2 Diabetes Mellilitus), Hold for CBG (Capillary Blood Glucose) < (less than) 110, start date 7/10/25. Further review revealed the following dates and corresponding CBG results for which Insulin Glargine was administered: 1/25/26 CBG 109; 1/26/26 CBG 82; 2/3/26 CBG 86; 2/9/26 CBG 86; 2/18/26 CBG 95. Interview on 2/18/26 at approximately 2:45 p.m. with Staff C confirmed the above findings. Interview on 2/19/26 at approximately 9:45 a.m. with Staff D (Nurse Practitioner) revealed that the above medications should not be given outside the ordered parameters. Review on 2/18/26 of the facility policy titled, Administering Medications, Revision Date 9/12/22, revealed: 4. Medications are administered in accordance with prescriber orders, . 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 21. Medications may not be left at the resident bedside unless the resident has been deemed capable to self-administer medications by evaluation by staff and or medical provider. In addition to general evaluation of decision making capacity, the staff and or medical provider will perform a more specific skill assessment to determine capacity and capability to self-administer medications.

Based on record review and interview, the facility failed to adequately monitor for adverse consequences for anticoagulant medication for 2 residents in a final sample of 17 residents (Resident identifiers are #5 and #7).Findings include:Resident #7Review on 2/19/26 of Resident #7's Medication Administration Record (MAR) revealed a physician's order dated 11/3/25 for Apixaban, (anticoagulant) for treatment of atrial fibrillation. Further review revealed no indications of monitoring for signs and symptoms of bleeding and bruising on the MAR.Review on 2/19/26 of Resident #7's comprehensive care plan revealed that no specific interventions to monitor or manage the risk of bleeding and bruises Resident #5, who was receiving anticoagulant therapy. Interview on 2/19/26 at approximately 2:51 p.m. with Staff C (Director of Nursing) confirmed the above findings.Resident #5Review on 2/19/26 of Resident #5's Medication Administration Record (MAR) revealed a physician's order dated 10/24/23 for Apixaban, anticoagulant) for treatment of atrial fibrillation. Further review revealed no evidence of monitoring for signs and symptoms of bleeding and bruises associated with the administration of the medication in the MAR.Review on 2/19/26 of Resident #5's comprehensive care plan revealed that no specific interventions to monitor or manage the risk of bleeding and bruises for Resident 5, who was receiving anticoagulant therapy. Interview on 2/19/26 at approximately 2:24 p.m. with Staff C confirmed the above findings.

Based on record review, it was determined that the facility failed to ensure that residents do not receive PRN (as needed) orders for psychotropic drugs that are limited to 14 days unless the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days and indicate the duration for the PRN order for 1 of 4 residents reviewed for unnecessary medications (Resident Identifier is #71). Findings include: Review on 1/17/25 of Resident #71's medical record revealed an order, dated 12/26/24, for Lorazepam (anti-anxiety) Oral Tablet 0.5 mg (milligram) Give 1 tablet by mouth every 4 hours as needed for moderate anxiety and 2 tablets by mouth every 4 hours as needed for severe anxiety with no duration indicated. Further review of Resident #71's medical record revealed an order, dated 12/26/24, for Haloperidol lactate (anti-psychotic) Oral Concentrate 2 mg/ml (milliliter) Give 0.25 ml by mouth ever 4 hours as needed for moderate agitation, nausea, vomiting and give 0.5 ml by mouth every 4 hours as needed for severe agitation, nausea and vomiting with no duration indicated. Review on 1/17/25 or Resident #71's Medication Administration Record (MAR) for January 2025 revealed that Resident #71 received 7 doses of as needed Lorazepam and 5 doses of as needed Haloperidol after 1/8/25 (14 days after start date of 12/26/24). Review on 1/17/24 of Pharmacy Consultation report, dated 12/27/24, revealed that Resident #71 .has a PRN order for an antipsychotic without a stop date: haloperidol . A recommendation to .add a stop date that does not exceed 14 days from initiation . Recommendation was reviewed by provider and declined with the following written statement Pt [patient] is hospice-respite stable on current regime. Review on 1/17/25 of Pharmacy Consultation report dated 12/27/24 revealed that Resident #71 .has PRN orders without a stop date: lorazepam . A recommendation was present to .add a stop date that is less than 14 days from initiation . Recommendation was reviewed by provider and declined with the following written statement Pt [patient] is hospice-respite stable on current regime. Review on 1/17/25 of facility policy titled Psychotropic Medication Use, revision date 9/15/24, revealed .6. PRN order for psychotropic medications should be limited to no more than 14 days .6.1 If the physician/prescriber believes that it is appropriate for a PRN psychotropic order (excluding antipsychotics) to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of use .

Based on interview and record review, it was determined that the facility failed to ensure that required in-service training was conducted and maintained, including the required annual minimum 12 hours for nurse's aides and addressed areas of weakness as determined in nurse aides' performance reviews and the facility assessment for 1 of 1 Licensed Nursing Assistant (LNA) reviewed. Findings include: Review on 1/17/25 of the facility assessment, dated 8/2024, revealed: .Staff training/education and competencies: 3.4 . Required in-service training for nurse aides, In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year .Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff . Review on 1/17/25 of Staff M's (LNA) personnel and in-service training records for revealed that Staff M had started at the facility in 2022 and had approximately 8 hours of in-service training for dementia, abuse, and facility policies on infection control practices for 2024. Interview on 1/17/25 at 11:33 a.m. with Staff G (Staff Development) confirmed the above findings. Interview on 1/17/25 at 2:47 p.m. with Staff C (Administrator) revealed that they had not been doing performance reviews for LNA's every 12 months and therefore areas for weakness determined in performance reviews were not addressed. Review on 1/17/24 of facility policy titled, Education, revised 5/2019, revealed: .Nur 403.02 Continuing Education Requirements for LNA. Each applicant for renewal, reinstatement, or endorsement of an LNA license shall complete at least 12 contact hours per year of workshops, conferences, lectures, or in-service education offerings that are designed to enhance nursing assistant knowledge, judgment, and skills. Successful completion of a state nursing assistant examination may be used to fulfill such continuing education requirements .

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Transmission Based Precautions (TBP) to prevent the potential spread of infection for 1 of 1 residents on TBP in a final sample of 19 residents. (Resident identifier is #31). Findings include: Resident #31 Observation on 1/15/25 at approximately 9:30 a.m. revealed that Resident #31 had a sign posted on the wall, in their room stating Contact Precautions and what to wear for PPE (staff and visitors to wear gown and glove prior to entering the room). Review on 1/15/25 of Resident #31's medical record revealed that Resident #31 had a urinalysis culture with VRE (Vancomyocin-Resistant Enterococi) identified on 1/11/25. Observation on 1/15/25 at approximately 9:40 a.m. revealed Staff F (Licensed Practical Nurse) entered Resident #31's room without donning PPE. Interview on 1/15/25 at approximately 9:40 a.m. with Staff F revealed Staff F was not aware that Resident #31 was on contact precautions. Review on 1/17/25 of the facility policy, Isolation-Categories of Transmission-Based Precautions, Revision Date September 2022, revealed: .Contact Precautions .7. Staff and visitors wear gloves (clean, non-sterile) when entering the room [ROOM NUMBER]. Staff and visitors wear a disposable gown upon entering the room .

Based on interview and record review, it was determined that the facility failed to complete a performance review at least once every 12 months for 1 of 1 Licensed Nurse Assistant (LNA) reviewed. Findings include: Review on 1/17/25 of the facility assessment, dated 8/2024, revealed: .Staff training/education and competencies: 3.4 . Required in-service training for nurse aides, In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year . Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff . Review on 1/17/25 of Staff M's (LNA) employee records revealed an employment start date of November 2022. Further review revealed there has been no evidence of a performance evaluation completed for 2023 and 2024. Interview on 1/17/25 at 2:47 p.m. with Staff C (Administrator) confirmed that the facility had not been doing performance reviews every 12 months for LNA's.

Based on observation, interview, and record review, it was determined that the facility failed to provide supervision at meals for 1 of 1 resident reviewed for ADL's (Activities of Daily Living) in a final survey sample of 19 residents. (Resident identifier is #60). Findings include: Observation on 1/15/25 at approximately 9:40 a.m. revealed a sign posted above Resident #60's bed: ASPIRATION PRECAUTIONS 1:1 [One on One] ASSIST W/FEEDING [with feeding] (SLOWLY ALTERNATE BITES/SIPS). Observation on 1/15/25 at approximately 12:10 p.m. to 12:15 p.m. revealed that Resident #60 was sitting on his/her bed eating lunch with no staff present. Observation on 1/16/25 at approximately 12:10 p.m. to 12:15 p.m. revealed that Resident #60 was sitting on his/her bed eating lunch with no staff present. Review on 1/16/25 of Resident #60's Nutritional Care Plan, dated 12/30/24, revealed: . Interventions .Resident to eat all meals in supervised area. Encourage small bites; encourage frequent small sips of fluid between bites Interview on 1/16/25 at approximately 12:15 p.m. with Staff F (Licensed Practical Nurse) revealed that they were unaware that Resident #60 needed to eat in a supervised area. Review on 1/17/25 of Resident #60's Health Status Notes, dated 10/12/24 at 12:32 p.m., revealed: .Resident found choking at lunch by another resident .New order to place resident on aspiration precautions . Review on 1/17/25 of Physician order, dated 10/12/24, revealed . Resident to eat all meals in supervised area

Based on observation, interview, and record review, it was determined that the facility failed to follow physicians orders for 1 out of 1 residents reviewed for bowel/bladder incontinence in a final sample of 19 residents. (Resident identifier is #31). Findings include: Standards: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 1/16/25 of Resident #31's physician's orders revealed the following orders: Offer 120 ml (milliliters) of prune juice by mouth for 3 days without a bowel movement on 7-3 shift. As needed for no bowel movement for 3 day, Start Date 12/5/24; M.O.M. (Milk of Magnesia Concentrate Suspension) (Magnesium Hydroxide) Give 30 ml by mouth as needed for constipation for a day 3 without a bowel movement on 3-11 shift, Start Date 12/5/24. Review on 1/15/25 of Resident #31's Bowel Continence Record for December 2024 and January 2025 revealed that Resident #31 had no bowel movement recorded for the following consecutive time frames: December 15-17 (3 days); December 20-22 (3 days): January 5-7 (3 days): January 9-11(3 days). Review on 1/16/25 of Resident #31's December 2024 and January 2025's MAR (Medication Administration Record) revealed that Resident #31 did not receive as needed Prune Juice or M.O.M. per physicians orders for the above listed time periods. Interview on 1/16/25 at approximately 12:30 p.m. with Staff D (Unit Manager) confirmed the above findings. Review on 1/17/25 of the facility policy titled, Bowel Management, Effective Date 6/05, revealed: .if there is no BM [bowel movement] by the second night, give the ordered laxative or a glass of prune juice. If there is no BM by the third day, give a rectal suppository or enema (with MD [Doctor of Medicine]) orders

Based on interview and record review, it was determined that the facility failed to report an allegation of neglect to the administrator for 1 of 1 resident reviewed for abuse in a final sample of 19 (Resident Identifier is #21). Review on 1/17/25 of Resident #21's medical record revealed a progress note, dated 12/6/24, stating that Resident asked to use the bathroom this evening around 4:40 p.m. Resident appeared to still have the bed pan underneath of [pronoun omitted] bottom from the morning shift as LNA's [Licensed Nursing Assistant] stated. Resident appeared to have a red bottom . Interview on 1/17/25 at approximately 9:30 a.m. with Staff I (Licensed Practical Nurse) revealed that he/she had reported to Staff J (Nursing Supervisor (3-11 Shift)) on 12/6/24 that they found Resident #21 on a bedpan for an undetermined amount of time and that their bottom was red. Interview on 1/17/25 at approximately 9:30 a.m. with Staff J revealed that he/she had not reported the incident to the Administrator or the Director of Nursing that Resident #21 had potentially been left on the bedpan since the morning.

Based on interview, record review, and policy review, it was determined that the facility failed to implement the facility's abuse policy for 1 out of 1 residents reviewed for abuse in a final sample of 19 residents. (Resident Identifier is #21). Review on 1/17/25 of Resident #21's medical record revealed a progress note, dated 12/6/24, stating that Resident asked to use the bathroom this evening around 4:40 p.m. Resident appeared to still have the bed pan underneath of [pronoun omitted] bottom from the morning shift as LNA's [Licensed Nursing Assistant] stated. Resident appeared to have a red bottom . Interview on 1/17/25 at approximately 9:30 a.m. with Staff I (Licensed Practical Nurse) revealed that he/she had reported to Staff J (Nursing Supervisor (3-11 Shift)) on 12/6/24 that they found Resident #21 on a bedpan for an undetermined amount of time and that their bottom was red. Interview on 1/17/25 at approximately 9:30 a.m. with Staff I (Licensed Practical Nurse) revealed that he/she had reported to Staff J (Nursing Supervisor (3-11 Shift)) on 12/6/24 that they found Resident #21 on a bedpan for an undetermined amount of time and that their bottom was red. Interview on 1/17/25 at approximately 9:30 a.m. with Staff J revealed that he/she had not notified the Administrator or the Director of Nursing that Resident #21 had potentially been left on the bedpan since the morning. Review on 1/17/25 of facility policy titled Resident Abuse Prevention and Investigation Policy, reviewed on 8/28/24, revealed . If staff or resident makes an allegation of abuse, mistreatment, neglect .the administrator or DON [Director of Nursing] will be notified by the supervisor immediately and follow their recommendations .

Based on record review and interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 4 of 19 residents in a final sample of 19 residents (Resident Identifiers are #18, #68, #72, and #73). Findings include: Resident #18 Review on 1/16/25 of Resident #18's social service note, dated 12/27/24, revealed that Resident #18 had an unplanned transfer to the hospital and was anticipated to return to the facility. Review on 1/16/25 of Resident #18's MDS, with Assessment Reference Date (ARD) of 12/27/24, revealed under section A0310: Type of Assessment: 10: Discharge assessment - return not anticipated was coded indicating that Resident #18 was not anticipated to return to the facility. Interview on 1/16/25 at 12:29 p.m. with Staff L (Director of Social Services) confirmed that Resident #18 had planned to return to the facility after being transferred to the hospital on 12/27/24. Resident #72 Review on 1/17/25 of Resident #72's Discharge - return not anticipated MDS, with an ARD of 11/22/24, revealed under section A0301G: Type of Discharge: Unplanned was coded. Review on 1/17/25 of Resident #72's social service note, dated 11/22/24, revealed that Resident #72 was a planned discharge to home. Interview on 1/17/25 at 8:31 a.m. with Staff L confirmed that Resident #72 was a planned discharge to home on 11/22/24. Resident #73 Review on 1/16/25 of Resident #73's progress note, dated 11/7/24, revealed that Resident #73 was being discharged to home. Review on 1/16/15 of Resident #73's Discharge - return not anticipated MDS, with an ARD date of 11/7/24, revealed under section A2105: Identification Information: Discharge Status: 04: Short-Term General Hospital was coded indicating that Resident #73 was discharged to the hospital. Interview on 1/17/25 at 8:46 a.m. with Staff K (MDS Coordinator) confirmed that Resident #73 was discharged to home and not to the hospital. Interview further revealed that the MDS was coded incorrectly for Resident #18, #72 and Resident #73. 48515 Resident #68 Review on 1/17/25 of Resident #68's Entry Record, dated 8/30/24, and the Admission Assessment, dated 9/3/24, revealed that Resident #68's name in Section A-Identification Information of the MDS was spelled incorretly. Review on 1/17/25 of final validation report for Resident #68's IPA assessment, dated 9/17/24, Submission ID: 32647423 and dated 9/20/24, revealed: Message Number: -1027 Message Type: Warning Message: A new resident record was created in the iQIES System with the information submitted in this MDS record. Verify that the new information is correct. Interview on 1/17/25 at approximately 2:00 p.m. with Staff K confirmed the above findings and that because Resident #68's name had been entered incorrectly, it created a seperate record.

Based on observation, interview, and record review, it was determined that the facility failed to ensure the dishwasher was reaching proper temperatures and chemical sanitization in the main kitchen, failed to ensure food was served in a sanitary environment on 1 of 3 units (First Floor Unit), and failed to ensure use of facial hair restraints when serving food from the kitchen to the main dining area on 1 of 3 units observed for meal service (First Floor Unit). Findings include: Main Kitchen - Dishwasher Logs Observation on 2/13/24 at approximately 8:10 a.m. with Staff B (Cook) of the Dish Room logs for December 2023, January 2024, and February 2024 revealed the parts per million (PPM) test results were missing for the following days for the low-temperature, chemical dishwasher: 12/2/23, 12/3/23, 12/9/23, 12/21/23, 12/30/23, 12/31/23, 1/6/24, 1/13/24, 1/19/24, 1/20/24, 1/21/24, 1/25/24, 1/28/24, 2/8/24, 2/10/24, and 2/11/24. Interview on 2/13/24 at approximately 9:15 a.m. with Staff D (Food Services Director) confirmed the above findings and stated that the PPM is to be filled out for each mealtime cleaning cycle to ensure appropriate PPM is reached for sanitization. Review on 2/14/24 of the facility's policy titled [NAME] Dish Machine Policy with an effective date of 1/13/24, revealed: .Procedure: The [NAME] at [NAME] staff will adhere to the following steps to ensure that the [NAME] Dish Machine is working correctly and that the chemical agent is at the correct mixing level to sanitize all dishware that is fed through .5. Note the temperatures for both wash and rinse cycles on the log sheet hanging on the wall .7. Run the strip along the rack rail inside the machine .9. It MUST read between 50-100 PPM .11. Record the PPM reading on the log sheet hanging on the wall and note any actions required . First Floor Main Dining Room Food Service Area Observation on 2/13/24 at approximately 8:15 a.m. with Staff B of the first floor main dining room revealed the food service area had countertops with 3 areas of missing laminate approximately 6 to 12 inches in length exposing porous wood and creating an uncleanable surface, a wall that had wallpaper peeling up approximately 12 inches exposing sheet-rock with food stains on the wall, and a wooden countertop with chipped wood and paint exposing porous wood approximately 2 feet in length where napkins and silverware were stored. Interview on 2/13/24 at approximately 11:00 a.m. with Staff E (Administrator) confirmed the above findings. Review of the facility's policy titled Food Preparation and Service last revised 11/2022, revealed: .6. Prep surfaces shall be clean and surfaces shall be in good repair without breaks . Review on 2/16/24 of the U.S. Food and Drug Administration Food Code, dated 2022, retrieved from: https://www.fda.gov/media/164194/download, revealed: . 4-602.13 Nonfood Contact Surfaces Nonfood contact surfaces or equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues First Floor Unit Main Dining Room Lunch Meal Service Observation on 2/13/24 at approximately 12:00 p.m. of Staff C (Dietary Aide) revealed he/she was handling uncovered plates with food on them in the kitchen and serving the meal plates to the residents in the first floor unit main dining room with a full beard that was over an inch long and was not covered. Interview on 2/13/24 at approximately 12:20 p.m. with Staff C revealed he/she does not normally wear a covering over his/her beard in the kitchen and during meal service. Interview on 2/13/24 at approximately 12:30 p.m. with Staff D revealed that kitchen staff with beards need to wear a covering, and confirmed the finding. Review of the facility's policy titled Food Preparation and Service last revised 11/2022, revealed: .Food Distribution and Service .8. Food and nutrition services staff wear hair net restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents received treatments that were ordered for 1 out of 2 residents reviewed for pressure ulcers in a final sample of 22 (Resident Identifier is #41). Findings include: Review on 2/15/24 of Resident #41's offsite wound care progress notes dated 11/29/23, revealed that Resident #41 received wound care services offsite for a Stage II pressure ulcer on left buttock and a deep tissue injury on his/her right buttock. Further review of the section titled Wound Orders revealed the following order: PT [Physical Therapy] evaluation for modified chair cushion. Review on 2/15/24 of Resident #41's offsite wound care progress note, dated 12/6/23, revealed that Resident #41 was being followed for a Stage II pressure ulcer on left buttock and a deep tissue injury to right buttock. Further review revealed the section titled Wound Orders on 12/6/23 revealed the following order: PT evaluation for modified chair cushion. Observation on 2/15/24 at 12:40 p.m. revealed Resident #41 sitting up in a reclining chair in his/her room with two bed pillows under his/her buttock. Interview on 2/15/24 at 12:40 p.m. with Resident #41 revealed that he/she had not used a chair cushion since admission. Further interview revealed that Resident #41 sits and sleeps in the recliner all or most of the time and that his/her buttock was sore. Interview on 2/15/24 at 2:15 p.m. with Staff F (Licensed Practical Nurse) revealed that the pillows observed under Resident #41 were not a pressure relieving device. Staff F also stated that Resident #41 is in the reclining chair all or most of the time. Interview on 2/15/24 at 3:30 p.m. with Staff H (Director of Nursing) confirmed the above findings.

Based on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible regarding the storage of chemical cleaning solutions on 1 of 3 units observed (First Floor Unit). Findings include: Observation on 2/13/24 at approximately 8:15 a.m. with Staff B (Cook) of the main dining serving area revealed an unlocked cabinet below the sink that contained 3 cans of Clean Force Stainless Steel Cleaner and Polish, 1 bottle of Comet Cleaner With Bleach, 1 container of ECOLAB Foam Hand Sanitizer, and 3 bottles of Surface Cleaner Sanitizer. Interview on 2/13/24 at approximately 10:30 a.m. with Staff H (Director of Nursing) revealed there are 2 residents identified at risk for wandering/elopement. Observation on 2/13/24 at approximately 11:00 a.m. with Staff E (Administrator) of the main dining serving area revealed an unlocked cabinet below the sink that contained 3 cans of Clean Force Stainless Steel Cleaner and Polish, 1 bottle of Comet Cleaner With Bleach, 1 container of ECOLAB Foam Hand Sanitizer, and 3 bottles of Surface Cleaner Sanitizer. Interview on 2/13/24 at approximately 11:00 a.m. with Staff E confirmed the above findings and revealed that residents can access the dining room at any time. Review on 2/14/24 of the facility's policy titled Policy to Ensure Safety of Residents with Regards to Poisonous Products with an effective date of 1/13/24, revealed: .Policy: Poisonous and toxic materials shall be stored in areas away from the food service area .Procedure: Each department will keep potentially hazardous materials out of direct reach of the resident and stored per the recommendation of the manufacturer .When not in use, the poisonous and toxic materials will be stored on shelves that are used for no other purpose or stored in a place outside the food storage, food preparation, and cleaned equipment and utensil storage . Review on 2/14/24 of Safety Data Sheets revealed: Clean Force Stainless Steel Cleaner and Polish - Section 11. Toxicological Information - Inhalation: Intentional misuse by deliberate inhalation may be harmful or fatal. P&G Professional Comet Cleaner with Bleach - Ready to Use - 11. Toxicological Information - Serious eye damage/eye irritation - Irritating to eyes. ECOLAB Digisan E Foam Hand Sanitizer - Section 11. Toxicological Information - Acute Inhalation toxicity: 4 h [hours] Acute toxicity estimate: > [greater than] 200 mg/l [milligrams per liter] .Acute oral toxicity: Dodecylbenzenesulfonic Acid. Clean Force Surface Cleaner Sanitizer - Section 11. Toxicological Information - Eyes: Causes eye irritation.