Every finding on record at Covington Post Acute

Based on facility policy review, medical record review, the facility's shower schedule review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering and personal hygiene care for 3 of 4 (Resident #2, #8 and #67) sampled residents reviewed for ADLs. The findings include: 1. Review of the facility's policy titled, Activities of Daily Living.,dated 3/2018, revealed .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living.Residents who are unable to carryout activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.hygiene [bathing, dressing, grooming.]. Review of the undated facility's policy titled, Resident [NAME] of Rights, revealed .It is designed to ensure that residents receive care that respects their dignity.Each Resident shall have the right to.The right to receive the services and/or items included in plan of care.The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Mild Cognitive Impairment, Other Lack of Coordination, and Muscle Weakness with Need for Assistance with Personal Care. Review of the Care Plan dated 12/17/2025, revealed Resident #2 had an ADL Self Care deficit and required staff assistance with ADLs. Review of the significant change Minimum Data Set (MDS) assessment dated 12/24/2025, revealed Resident #2 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. The MDS revealed it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Resident #2 required partial to moderate assistance with showering and required supervision to touch assistance with personal hygiene. Review of the facility's Shower Schedule revealed Resident #2 was scheduled to receive a shower on every Monday, Wednesday and Friday on the 6:00 AM- 6:00 PM shift. Review of the Follow Up Question Report (a sheet that showed documentation of showers received) dated December 2025, revealed Resident #2 did not receive a shower on the following scheduled dates:a. 12/19/2025 b. 12/21/2025 c. 12/26/2025 d. 12/28/2025 e. 12/30/2025 Review of the Follow Up Question Report dated January 2026, revealed Resident #2 did not receive a shower on the following scheduled dates:a. 1/2/2026 b. 1/5/2026 c. 1/7/2026 d. 1/10/2026 e. 1/14/2026 f. 1/16/2026 g. 1/21/2026 h. 1/23/2026 i. 1/26/2026 j. 1/28/2026 k. 1/30/2026 Review of the Follow Up Question Report dated February 2026, revealed Resident #2 did not receive a shower on the following scheduled dates: a. 2/2/2026 b. 2/4/2026 c. 2/6/2026 d. 2/9/2026 e. 2/11/2026 f. 2/13/2026 g. 2/16/2026 h. 2/28/2026 i. 2/20/2026 j. 2/23/2026 k. 2/25/3026 l. 2/27/2026 Review of the Follow Up Question Report dated March 2026, revealed Resident #2 did not receive a shower on the following scheduled dates: a. 3/2/2026 b. 3/4/2026 c. 3/6/2026 d. 3/9/2026 e. 3/11/2026 f. 3/13/2026 g. 3/16/2026 h. 3/18/2026 i. 3/20/2026 j. 3/23/2026 Review of Resident #2's shower documentation revealed, the resident only received 4 showers from 12/17/2025 - 3/25/2026. During an interview on 3/23/2026 at 10:13 AM, Resident #2 stated, .I have not received a shower but about 4 times since I've been here. When asked if he had spoken to anyone regarding the concern, the resident stated, I told a Nurse, but no one has done anything. During an interview on 3/24/2026 at 11:56 AM, Resident#2 stated that he requested a shower today and was also waiting on the Certified Nursing Assistant (CNA) to assist. During an interview on 3/24/2026 at 3:22 PM, Resident #2 was asked if he had received his shower that was requested. Resident #2 stated, I haven't. I spoke with the Nurse down there and she act like she didn't know what I was talking about.I would still like my shower today. During an interview on 3/25/2026 at 8:49 AM, CNA A stated that she is responsible for performing a shower on Resident #2. CNA A explained that on most days she does not have enough time to complete her assigned showers. CNA A was asked how many times he was to receive a shower. CNA A stated, I think two times a week. CNA A proceeded to review assignment packet and noted that Resident #2 was noted three times a week. When asked the last time Resident #2 received a shower, CNA A stated, I have to be honest, the last time I gave him a shower was about 3 weeks ago. During an interview on 3/25/2026 at 9:33 AM, the Administrator and Director of Nursing (DON) confirmed bed baths are done daily when they don't receive a shower. Residents are to receive a shower 3 days a week. The DON and Administrator were asked if residents should receive showers on their assigned shower days. The Administrator stated, Yes, absolutely. The Director of Nursing stated, I agree. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Dysphagia, Malnutrition, Seizures, and Gastrostomy (a feeding tube placed into the stomach for nutritional supplements or medication administration) status. Review of the Care Plan dated 5/12/2025, revealed .The resident needs total assist for bathing . Review of the significant change MDS assessment dated [DATE], revealed Resident #8 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Resident #8 was dependent on staff with activities of daily living (ADLs). Review of the facility's Shower Schedule revealed Resident #8 was scheduled to receive showers on day shift every Tuesday, Thursday, and Saturday. Review of Resident #8's ADL bathing task dated 1/2026, revealed Resident #8 did not receive a bath or shower on the following dates scheduled: a. 1/6/2026 b. 1/10/2026 c. 1/13/2026 d. 1/15/2026 e. 1/20/2026 f. 1/24/2026 g. 1/27/2026 Review of Resident #8's ADL bathing task dated 2/2026, revealed Resident #8 did not receive a bath or shower on 2/21/2026 as scheduled. Review of Resident #8's ADL bathing task dated 3/2026, revealed Resident #8 did not receive a bath or shower on the following dates as scheduled: a. 3/6/2026 b. 3/8/2026 c. 3/17/2026 During an observation and interview in the resident's room on 3/23/2026 at 10:57 AM, Resident #8 was resting in bed watching television with bed in lowest position, blinds closed, a strong foul body odor was noted in the resident's room. Resident #8 was asked if he gets his showers/baths like he is scheduled. Resident #8 stated, No. During an observation in Resident #8's room on 3/23/2026 at 2:13 PM, revealed Resident #8 was asleep in bed with bed in lowest position and a strong foul body odor noted in the resident's room. 4. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Traumatic Brain Injury, Malnutrition, and Dementia. Review of the Care Plan dated 7/9/2025, revealed .The resident needs mod [moderate] to max [maximum] for bathing . Review of the annual MDS assessment dated [DATE], revealed Resident #67 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. Resident #67 was dependent on staff with ADLs. Review of the facility's Shower Schedule revealed Resident #67 was scheduled to receive showers on day shift every Tuesday, Thursday, and Saturday. Review of Resident #67's ADL bathing task dated 1/2026, revealed Resident #67 did not receive a shower or bath on 1/13/2026 as scheduled. Review of Resident #67's ADL bathing task dated 2/2026, revealed Resident #67 did not receive a shower or bath on 2/21/2026 as scheduled. Review of Resident #67's ADL bathing task dated 3/2026, revealed Resident #67 did not receive a shower or bath on the following scheduled dates. a. 3/12/2026 b. 3/17/2026 c. 3/20/2026 During an observation and interview in Resident #67's room on 3/23/2026 at 9:39 AM, revealed Resident #67 resting in bed. Resident stated, I do not get 3 baths a week, sometimes I only get one a week. Resident #67 was asked if she had mentioned to anyone about her not receiving her baths as scheduled. Resident #67 stated, Yes, but it didn't matter. During an interview on 3/25/2026 at 8:03 AM, the DON was asked what days Resident #8 and Resident #67 are scheduled to get showers. The DON stated, On day shift every Tuesday, Thursday, and Saturday. The DON was asked if the residents are scheduled to get their scheduled showers on those days should they get them and should it be documented. The DON stated, Yes, but they could have refused. The DON was asked if the resident refused should the documentation not reflect the resident's refusal instead of not applicable or activity did not occur without explanation. The DON stated, Yes, if the resident refused the documentation should reflect refusal and NA is not appropriate documentation.

Based on the American Council on Aging Website, financial document review, medical record review, and interview, the facility failed in their responsibility in maintaining assets under $2,000 for the 2026 Tennessee Medicaid allowance for 7 of 55 (Resident #12, #14, #30, #37, #50, #78, and #84) sampled residents. The findings include: 1. Review of the American Council on Aging Website, Tennessee Medicaid (TennCare) Income & Asset Limits for Nursing Homes & In-Home Long Term Care, dated 3/4/2026, revealed .In 2026, single Medicaid Nursing Home applicant in Tennessee must meet the following criteria.Assets under $2,000. 2. Review of medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, and Atrial Fibrillation. Review of the Resident Statement Landscape, dated 3/2/2026 revealed Resident #12's balance was $10,975.19, which was $8,975.19 over the $2,000.00 limit. 3. Review of medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Anxiety, Alzheimer's, and Bipolar. Review of the Resident Statement Landscape, dated 3/13/2026 revealed Resident #14's balance was $8,106.10, which was $6,106.10 over the $2,000.00 limit. 4. Review of medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Dementia, Epilepsy, and Depression. Review of the Resident Statement Landscape, dated 3/13/2026 revealed Resident #30's balance was $2,808.26, which was $808.26 over the $2,000.00 limit. 5. Review of medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Diabetes, Anemia, and Dementia. Review of the Resident Statement Landscape, dated 3/13/2026 revealed Resident #37's balance was $2,542.12, which was $542.12 over the $2,000.00 limit. 6. Review of medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses including Kidney Disease, Seizures, and Hypertension Review of the Resident Statement Landscape, dated 3/3/2026 revealed Resident #50's balance was $5,639.36, which was $3,639.36 over the $2,000.00 limit. 7. Review of medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Dementia, Osteoarthritis, and Chronic Pain. Review of the Resident Statement Landscape, dated 3/13/2026 revealed Resident #78's balance was $3,348.96, which was $1,348.96 over the $2,000.00 limit. 8. Review of medical record revealed Resident #84 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, and Anxiety Review of the Resident Statement Landscape, dated 3/13/2026 revealed Resident #84's balance was $4,764.38, which was $2,764.38 over the $2,000.00 limit. During an interview on 3/25/2026 at 10:35 AM, with the Business Office Consultant (BOC), was asked can you tell me the limit a resident can have in their account. The BOC stated, $2,000. During an interview on 3/25/2026 at 3:55 PM, with the Administrator, the Administrator was asked how much money is the maximum that should be in the resident trust. The Administrator stated .$2,000 should be the max.

Based on facility policy review, medical record review, facility's Situation Background Assessment Recommendation (SBAR) Note review, observation, and interview, the facility failed to notify the physician for 1 of 3 (Resident #81) sampled residents reviewed for falls. The findings include: 1. Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 2/2021, revealed .Our facility notifies the resident, his or her attending physician.of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's attending physician or physician on call when there has been a (an).accident or incident involving the resident.significant change in the resident's physical/emotional/mental condition.need to alter the resident's treatment significantly.need to transfer the resident to a hospital/treatment center. 2. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Malnutrition, Hypertension, and Depression. Review of Physician's Order dated 10/9/2025, revealed Eliquis [used as a blood thinner].5 MG [milligram].Give 2 tablet by mouth two times a day. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #81 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Resident #81 was dependent on staff with activities of daily living (ADLs). Review of the facility's SBAR Note dated 3/14/2026, .Resident rolled over from her bed to the floor while she was being changed .Was the fall witnessed .Yes .Date and time of Fall: 3/14/2026 [at]10:30 AM .What was resident doing just prior to the fall .Resident was being changed in her bed .Vital Signs: BP [Blood Pressure]108/75, Pulse: 64 bpm [beats per minute] .Does the resident exhibit or complain of pain related to the fall .No .Location of injury: bruise to forehead, skin tear to left elbow .Note any injury to the head, extremities, or trunk .Swelling, Bump, Bruising .Alert Charting Notes .CNA [Certified Nursing Assistant] was changing resident when the resident rolled herself over the edge of the bed and onto the floor. CNA called nurse to bedside. Resident helped back to bed and assessed for injuries. Resident able to move all extremities as is her normal .Skin tear to left elbow and a bruised bump noted to forehead. Skin tear cleansed with normal saline. Xeroform and dry dressing applied. A second CNA was called to the room to prevent the resident from slipping over the edge of the bed while the resident was finished being changed. Review of the Nurse Practitioner (NP) Note dated 3/16/2026 at 7:51 PM, revealed Provider was not notified of patient fall that reportedly occurred on 3/14/2026 at the time of incident. Provider became aware of fall today 3/16/2026 upon review/discussion with nursing staff. On assessment today, patient noted to have left forehead hematoma and complaints of left hip pain. Patient is currently on Eliquis, increasing risk for bleeding complications. Given anticoagulation status and current findings, patient was sent to the emergency department for further evaluation and imaging. During an observation and interview in Resident #81's room on 3/23/2026 at 9:22 AM, Resident #81 was resting in bed with a hematoma (a swollen bruised area under the skin) to her forehead and a large bluish-yellow bruise in color from forehead to mid jawline to the left side of the resident's face, a gauze dressing to her left forearm with purple bruising noted under dressing. Resident #81 pointed to her left hip and complained of pain. Resident #81 was asked what happened. Resident #81 stated, had a fall a week ago Friday. During an interview on 3/24/2026 at 11:06 AM, Licensed Practical Nurse (LPN) B was asked about Resident #81's fall on 3/14/2026. LPN B stated [named CNA C] came to the entrance of the resident's room and waved me down.I entered the resident's room and saw the resident on her back on the floor with her head towards the head of the bed with her head tilted to the left side. LPN B was asked if the resident had any injuries. LPN B stated, She a skin tear to her left elbow that I went ahead and dressed and bruising to her face. LPN B was asked if she notified anyone. LPN B stated, I called her son. LPN B was asked if she notified the physician or NP. LPN B stated, No, I don't think so. She [NP] was made aware a couple of days later. LPN B was asked if the physician or NP should have been notified considering the resident was taking Eliquis and hit her head. LPN B stated, I realize later the resident's fall should have been reported to the provider the same day. During an interview on 3/24/2026 at 2:05 PM, the NP was asked when she was made aware of Resident #81's fall on 3/14/2026. The NP stated, I was made aware when I was rounding at the facility on 3/16/2026 and I heard the resident calling out from her room.When I entered the resident's room I noticed a bruise to her face and hematoma to her forehead.I asked her nurse what happened and was told that the resident had a fall over the weekend.I went to ask the Director of Nursing [DON] if she was aware of the resident had fallen over the weekend. The NP was asked what she expects the facility staff to do when a resident has a fall. The NP stated, Report it to me or the on call especially if the resident is on Eliquis which is a concern.The resident could have a bleed and will need CT [Computed Tomography] and should be assessed for acute findings. The NP was asked would you expect staff to notify the provider the same day in this case. The NP stated, Yes, I do. During an interview on 3/24/2026 at 2:43 PM, the DON asked when she was made aware of Resident #81's fall on 3/14/2026. The DON stated, I was made aware the same day the NP was notified. She came and got me. The DON was asked what staff should do when a resident has a fall with injury. The DON stated, Call the provider and notify them of the fall.

Based on policy review, observation, kitchen sanitation logs, and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when opened, undated, and expired food items were found, the 3 compartment sink sanitation system was not working properly, kitchen sanitation logs were incomplete, and carbon build up was observed on cookware. The facility had a census of 76, and 76 of those residents received a meal tray from the kitchen. The findings include: 1. Review of the facility policy titled, Dietary Cleaning, dated [DATE], revealed .the CDM [Certified Dietary Manager] /Kitchen Supervisor is responsible for maintaining a cleaning schedule to indicate which equipment and areas to be cleaned and at what frequency .Cleaning surfaces, equipment or utensils involves the use of hot water and detergents .Sanitizing can occur by applying heat and/or chemicals for enough time to reduce bacterial count on .dishware, utensils .pots and pans .the weekly cleaning schedule shall be used to document when a cleaning assignment is completed .the CDM/Kitchen Supervisor shall audit the cleaning schedule for completeness .shall conduct sanitation/safety inspections/kitchen observations . Review of the facility policy titled, Dietary Food Storage, dated [DATE], revealed .food shall be stored in accordance with professional standards for food service safety .leftover food items are stored in appropriate containers .they are covered, labeled, and dated .used within three days .opened food items in dry storage should be stored in a closed container to prevent contamination .all stored items should have an expiration date .refrigerated, ready-to-eat, potentially hazardous food .prepared and packed by a food processing plant shall be clearly marked at the time the original container is opened . Review of the facility policy titled, Dietary: Manual Ware Washing-3 Compartment Sink, dated [DATE], revealed .a three-compartment sink is used to manually wash, rinse, and sanitize cookware to prevent the spread of bacteria that may lead to food borne illness .Procedure .fill with hot water .or use chemical sanitizer .detergent chlorine at ,d+[DATE] PPM [Parts Per Million] .Confirm appropriate temperature or concentration at least 30 seconds .the sanitizing sink should be monitored for the proper temperature .for proper chemical concentration if chemical sanitization is used . 2. During an observation and interview in the Kitchen at the 3 compartment sink on [DATE] at 8:53 AM, revealed the Dietary [NAME] washed pans in the first compartment, rinsed them in the second compartment, and sanitized them in the third compartment. The Dietary [NAME] performed the sanitation test of the 3 compartment sink with the test strip remaining white/gray in color, indicating there was no sanitation solution in the water. The Dietary [NAME] confirmed the sanitizer in the three-compartment sink was not working, and stated, .it had not been working for about a month . The Dietary [NAME] confirmed the Dietary Supervisor and Maintenance Supervisor were aware the sanitation was not working. 3. Review of the Ware Washing/Three Compartment Sink sanitation logs dated ,d+[DATE] and ,d+[DATE], revealed that the sanitation of the 3 compartment sink was to be tested every Morning, Afternoon, and Evening with a chemical strip. The sanitation logs had multiple blank areas without initials for the schedules provided. The following dates staff failed to perform the sanitation test on the 3 compartment sink: a. [DATE] no morning or afternoon chemical strip test completed. b. [DATE], no morning or afternoon chemical strip test completed. c. [DATE], no evening chemical strip completed. d. [DATE], no morning or afternoon chemical strip test completed. e. [DATE], no morning or afternoon chemical strip test completed. f. [DATE], no morning or afternoon chemical strip test completed. g. [DATE], no morning chemical strip test competed. 4. Observation in the kitchen on [DATE] at 8:55 AM, revealed the following: a. 3 stock pots (2 with handles) and 1 large cooking pot on the lower shelf below the microwave was noted to have carbon buildup to the bottom and sides of the pans. b. 1 cast iron skillet on the lower rack of the three-tiered wire rack had a large amount of carbon build up on sides and bottom of the skillet. 5. Observation in the walk-in cooler on [DATE] at 8:58 AM, revealed: a. 1 undated stainless-steel bowl of yellow gelatin b. 1 undated metal sheet pan containing an unfrosted cake c. 2 opened packages of expired sliced ham dated [DATE] 6. Observation in kitchen, in the dry storage area on [DATE] at 9:02 AM, revealed 1 opened, unsecured box of dried pinto beans opened to air, dated of [DATE]. 7. Observation at the nurse's station in the nutritional refrigerator on [DATE] at 11:09 AM, revealed 8 individual cups of orange sherbet with an expiration date of [DATE]. During an interview on [DATE] at 4:51 PM, the Dietary Supervisor confirmed that all foods should be labeled and dated, expired food should be discarded by the expiration date, cookware should not have black carbon build up. The Dietary Supervisor confirmed that she is responsible for ensuring that the sanitization logs are completed every morning, afternoon, and evening. The Dietary Supervisor confirmed that she is responsible for maintaining the food/drinks in the nourishment refrigerator. During an interview on [DATE] at 5:43 PM, the RD (Registered Dietician) confirmed that she, along with the Dietary Supervisor and Administrator, are responsible for ensuring the cleaning logs/sanitation logs are completed in a timely manner.

Based on policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 17 of 47 (Rooms 110, 300, 301, 302, 303, 304, 305, 308, 312, 400, 401, 402, 403, 404, 408, 409, and 411) resident shared bathrooms observed and for 1 of 1 (400 hall) ice machines observed. The findings include: 1. Review of the facility policy titled, Interim Life Safety Measures, dated 1/28/2024, revealed .To provide a safe environment for patients, visitors, and staff .The implementation of Interim Life Safety Measures shall be determined by Administration, QAPI (Quality Assurance Performance Improvement) Committee, and all staff continuously monitoring and reporting any real or potential Life Safety Code deficiencies. Monitoring shall include .Routine environmental tours .Buildings and/or structures .Updates are done routinely and as needed . Review of the facility policy titled, Dietary: Ice Storage, dated 10/25/2023, revealed .Ice shall be maintained and served to patients in a sanitary manner .Ice containers and scoops shall be kept clean and shall be stored and handled in a sanitary manner . 2. Observation on the 100 hall in the shared bathroom of room [ROOM NUMBER] on 11/4/2024 at 10:24 AM, and on 11/7/2024 at 10:13 AM, revealed areas of dark black spots coming down the wall from under the ceiling trim in various areas. 3. Observation on the 300 hall in the shared bathroom of room [ROOM NUMBER] on 11/5/2024 at 2:02 PM, and 11/7/2024 at 8:52 AM, revealed dark black spots on the ceiling and descending down the wall in various areas of the bathroom. 4. Observation on the 300 hall in the shared bathroom of room [ROOM NUMBER] on 11/5/2024 at 10:44 AM, and on 11/7/2024 at 10:07 AM, revealed dark black spots on the wall under the ceiling trim. 5. Observation on the 300 hall in the shared bathroom of room [ROOM NUMBER] on 11/5/2024 at 2:02 PM, and 11/7/2024 at 8:52 AM, revealed dark black spots on the ceiling and descending down the wall in various areas of the bathroom. 6. Observation on the 300 hall in the bathroom of room [ROOM NUMBER] on 11/4/2024 at 10:49 AM, and on 11/7/2024 at 10:05 AM, revealed dark black spots on the wall and descending down the wall in various areas of the bathroom. 7. Observation on the 300 hall in the shared bathroom of room [ROOM NUMBER] on 11/5/2024 at 2:02 PM, and 11/7/2024 at 8:52 AM, revealed dark black spots on the ceiling and descending down the wall in various areas of the bathroom, and bathroom vanity with cracked caulking down entire sink. 8. Observation on the 300 hall in the shared bathroom of room [ROOM NUMBER] on 11/4/2024 at 10:46 AM, revealed dark black spots on the ceiling and descending down the wall in various areas of the bathroom. 9. Observation on the 300 hall in the shared bathroom of room [ROOM NUMBER] on 11/5/2024 at 2:02 PM, and 11/7/2024 at 8:52 AM, revealed dark black spots on the ceiling and descending down the wall in various areas of the bathroom, and bathroom vanity with cracked caulking down entire sink. 10. Observation on the 300 hall in the shared bathroom of room [ROOM NUMBER] on 11/5/2024 at 2:02 PM, and 11/7/2024 at 8:52 AM, revealed dark black spots on the ceiling and descending down the wall in various areas of the bathroom. 11. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] on 11/4/2024 at 9:32 AM, 12:04 PM, and 2:23 PM, and on 11/7/2024 at 12:04 PM, revealed dark black spots descending down from underneath the ceiling tile on the wall behind the toilet, extending down the wall and in the corner over the sink and vanity. 12. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] on 11/4/2024 at 9:20 AM, 12:06 PM, and 2:21 PM, and on 11/7/2024 at 12:04 PM, revealed dark black spots on the door frame of bathroom door, and dark black spots descending down from under the ceiling tile down the wall behind the toilet. 13. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] on 11/4/2024 at 9:37 AM, 12:08 PM, and at 2:24 PM, 11/5/2024 at 8:13 AM, and on 11/7/2024 at 12:04 PM, revealed dark black spots descending down from underneath the ceiling tile down the wall on the left side of the toilet. 14. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] at 11/04/2024 at 9:28 AM, 12:07 PM, and 2:25 PM, 11/5/2024 at 7:52 AM, and 12:52 AM, and on 11/7/2024 at 12:04 PM, revealed dark black spots descending down from underneath the ceiling tile down the wall behind the toilet. 15. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] at 11/4/2024 at 9:48 AM, and 2:28 PM, and on 11/5/2024 at11:53 AM, 11/6/2024 at 10:53 AM, and on 11/7/2024 at 12:04 PM, revealed dark black spots descending down from underneath the ceiling tile down the wall inside the bathroom on the left side of the bathroom entrance, and on the wall above the bathroom sink and vanity, and inside of bathroom door frame. 16. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] at 11/04/2024 at 10:02 AM, 12:13 PM, and on 11/5/2024 at 7:59 AM, and 12:00 PM, 11/6/2024 at 7:20 AM, and 11:00 AM, and on 11/7/2024 at 12:04 PM, revealed dark brown and black discoloring on the wall and around exposed pipes underneath the sink, on the assist bar / handrail next to toilet, and around the base of exposed pipes underneath the toilet, and dark black spots descending from underneath the ceiling tiles extending down the wall in the of the bathroom corner over the sink. 17. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] at 11/04/2024 at 9:53 AM, and 12:09 PM, and on 11/5/2024 at 12:17 PM, and on 11/6/24 at 7:17 AM, and 2:18 PM, and on 11/7/2024 at 12:04 PM, revealed dark black spots descending down from underneath the ceiling tiles down the wall behind the toilet, coming from the ceiling tile down the wall behind the toilet. 18. Observation on the 400 hall in the shared bathroom of room [ROOM NUMBER] at 11/4/2024 at 9:59 AM, 12:10 PM, 2:30 PM, and on 11/5/2024 at 7:20 AM, 12:20 PM, and on 11/7/2024 at 8:20 AM and at 12:04 PM, revealed the bathroom vanity top loose and separating from wall with cracked caulking, dark black spots descending down from underneath the ceiling tiled down the wall in the corner of the bathroom over the toilet. 19. Observation at the 400 hall ice machine on 11/4/2024 at 9:16 AM, and 10:00 AM, revealed the ice machine was unlocked, with dark black substance on the upper inside rim of the ice machine, dust particle build up on the ledge of the ice machine and the filter of ice machine, with ice scoop resting in water in the scoop holder on the wall. 20. Review of the facility document titled Work History Report, revealed, .Due Date .10/31/2024 .Ice Machines/Ice Bins .Check filters .clean coils, sanitize interior, delime as necessary .Task Completion .Marked done on time by [Named Maintenance Supervisor] .on 10/21/2024 . Observation at the 400 hall ice machine on 11/4/2024 at 12:02 PM, revealed the ice machine was unlocked with dark black substance on the upper inside rim of the ice machine, dust particles build up on the ledge of the ice machine and the filter and the ice scoop resting in water in the scoop holder on the wall. 21. During observation and interview on the 300 hall on 11/7/24 beginning at 10:05 AM, the Maintenance Supervisor was shown room [ROOM NUMBER], 301, 302, 303, 304, 308 and 312 bathrooms. The Maintenance Supervisor was asked what the black spotty areas on ceiling and walls were in the bathrooms. The Maintenance Supervisor stated, It is mildew from the ventilation fan issues we are having, I am currently working to get this fixed . The Maintenance Supervisor was asked should the caulking adhesive holding the sink be cracked and coming off on the sink. The Maintenance Supervisor stated, No. During observation and interview on 11/7/2024 at 10:13, the Maintenance Supervisor confirmed that mildew was found in room [ROOM NUMBER], #301, and #303. During observation and interview on the 300 hall on 11/7/2024 at 12:02 PM, the Maintenance Supervisor was shown room [ROOM NUMBER] and was asked what the black substance on the bathroom wall near the ceiling. The Maintenance Supervisor confirmed that the black substance was mildew. During observation and interview on the 400 hall on 11/7/2024 beginning at 12:04 PM, the Maintenance Supervisor, was shown the dark black spots descending down from the ceiling tile down the walls in resident rooms 400, 401, 402, 403, 404, 408, 409, and 411, and was asked what those dark black spots were. The Maintenance Supervisor confirmed he was unaware of the spots until 11/4/2024 when it was brought to his attention by State Agency staff and the areas were tested and it was found to be mildew. The Maintenance Supervisor was asked what caused the mildew. The Maintenance Supervisor confirmed it was caused by a malfunction fan and that the 400 hall was the hall that it was found in almost every resident shared bathroom. The Maintenance Supervisor confirmed that there should be no mildew found in any resident room or bathroom. The Maintenance Supervisor confirmed that he checks rooms on each hall randomly on a weekly basis but was unaware of mildew in the resident's bathrooms. The Maintenance Supervisor was shown the dark black substance on the inside of the ice machine, dust particles on the ledge of the ice machine, and the dust on the filter and was asked should the black substance be inside of the ice machine, should the dust be on the ledge of the ice machine and should the filter contain dust particles. The Maintenance Supervisor confirmed he is unsure of what the black substance was on the inside of the ice machine, but confirmed he checks and cleans the ice machine at least every six months. The cleaning of the ice machine consists of wiping down the outside, changing the filter and cleaning the inside of the machine. 47835 50408 50611

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 staff (Licensed Practical Nurse (LPN #A) failed to perform hand hygiene during an incontinent care and failed to follow enhanced barrier precautions during Percutaneous Endoscopic Gastrostomy (PEG) site care for 2 of 3 (Residents #48 and #72) sampled residents. The findings include: 1. Review of the facility policy titled, Hand Hygiene, revised 3/28/2024, revealed .Staff involved in direct resident contact shall perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is indicated and shall be performed under the conditions listed in, but not limited to, the attach hand hygiene table .use clean/dry towel to turn off the faucet .After handling contaminated objects .Before and after handling clean or soiled dressings, linens .Before performing resident care procedures .After handling items potentially contaminated with blood, bodily fluids, secretions, or excretions . Review of the facility policy titled, Transmission Based Precautions, revised 4/1/2024, revealed .To provide guidance on taking appropriate precautions to prevent transmission of infectious agents .Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .An order for enhanced barrier precautions shall be obtained for residents with any of the following .Wounds and/or indwelling medical devices even if the resident is not known to be infected .Make gowns and gloves available which may include near or outside of the resident's room .face protection may also be needed if performing activity with risk of splash or spray .PPE [Personal Protective Equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room . 2. Review of the medical record review revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis of the Vertebra, Lumbar Region, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Heart Failure, and Sepsis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating Resident #48 had severe cognitive impairment and a Stage 2 pressure ulcer. Review of the Physician's Telephone Orders dated 11/4/2024, revealed .Zinc Oxide Paste 1 Time Daily .(L) [Left] Buttock}: Clean area with Normal Saline. Apply Zinc Oxide and .Zinc Oxide Paste 1 Time Daily . [Coccyx]: Clean area with Normal Saline. Apply Zinc Oxide. Observation during wound care on 11/6/2024 beginning at 10:19 AM, revealed LPN A was at Resident #48's bedside wearing gloves preparing to perform wound care. LPN A unfastened Resident #48's brief and started to pull it down, stopped, repositioned the brief to cover Resident #48's buttocks, looked at LPN B and stated, She [Resident #48] is going to have to be changed . Registered Nurse (RN) C entered the room and was asked for a towel and brief by LPN A. RN C brought a towel and brief to the room and handed them to LPN A. LPN B stated, You might want to wet that. LPN A took the towel to the bathroom and without removing the gloves or performing hand hygiene, turned on the faucet, wet the towel, turned off the water, returned to Resident #48's bedside and began performing incontinent care. During an interview on 11/7/2024 at 10:17 AM, the Director of Nursing (DON) was asked should staff wear soiled gloves they had used while providing care to a resident to use the sink, wet linen, and then to perform incontinent care to a resident. The DON stated, Probably not .They should remove their gloves, perform hand hygiene, and put on new gloves. 3. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Cerebrovascular Accident, Seizure Disorder, Dysphagia, and Gastrostomy status. Review of the Physician's Order dated 6/5/2024, revealed .G-Tube [Gastrostomy Tube] Site Care One Time Daily .[clean] with soap and water. Monitor for signs and symptoms of infection Review of the quarterly MDS dated [DATE], revealed a BIMS score of 3, which indicated Resident #72 was severely cognitively impaired, assessed for an indwelling foley catheter and a feeding tube. Observation during peg site care on 11/06/2024 at 9:43 AM, revealed LPN A entered the Resident's room and placed barrier on the over the bed table, performed hand hygiene, donned gloves, and performed G-Tube site care without applying a gown for PPE. LPN A discarded trash in biohazard bag and exited Resident's room. During an interview on 11/6/2024 at 9:43 AM, LPN A was asked if she should have worn a gown for PPE when performing site care. LPN A stated, Yes . During an interview on 11/6/2024 at 2:09 PM, the DON confirmed that staff should wear a gown for PPE when performing Peg/G-tube site care. 50408

Based on policy review, observation, and interview, the facility failed to ensure food was stored and distributed in a manner to prevent the spread of infection when 3 of 14 staff members (Certified Nursing Assistant (CNA) #1, Dietary Aide #1, and #2) failed to wear appropriate Personal Protective Equipment (PPE) and perform proper hand hygiene when delivering meal trays, and failed to perform hand hygiene in the Kitchen and Dining Room. This had the potential to affect the 64 of the 71 residents residing in the facility. The findings include: Review of the facility's policy titled, Transmission Based Precautions effective 3/2020, revealed .Contact Precautions .Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves .Donning personal protective equipment .upon room entry .Droplet Precautions .Healthcare personnel wear a mask or a mask with a shield, gown and gloves . Review of the facility's policy titled, Dietary-Mechanical Dish Washing dated 10/2020, revealed .if the same person is loading and unloading the racks, hands must be washed or sanitized before touching the clean surfaces . Review of the facility's policy titled, Dietary: Handwashing Techniques dated 10/2020, revealed Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations .After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes . Dining observation on the 100 hall on 7/12/2021 at 12:38 PM, revealed a sign posted on Resident #168's entry door, STOP SPECIAL DROPLET/ CONTACT PRECAUTIONS .Everyone Must: including visitors, doctors & [and] staff .Wear eye protection (face shield or goggles) Gown and glove at door . Dining observation on the 100 Hall at 7/12/2021 at 12:38 PM, revealed CNA #1 entered Resident #168s room without wearing a face shield/googles or gloves and delivered Resident #168's meal tray. Dining observation on the 100 Hall on 7/12/2021at 12:39 PM, revealed CNA #1 entered Resident # 32's room, delivered a meal tray, performed tray set up, entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. dining observation on the 100 Hall on 7/12/2021 at 12:40 PM, revealed a sign posted on Resident #44's entry door, STOP CONTACT PRECAUTIONS .PROVIDERS AND STAFF MUST .Put on gloves before room entry . Dining observation on the 100 Hall on 7/12/2021 at 12:40 PM, revealed CNA #1 entered Resident #44's room, delivered a meal tray, performed tray set up, entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation on the 100 Hall on 7/12/2021 at 12:51 PM, revealed CNA #1 entered Resident #164's room, delivered a meal tray, performed tray set up, entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation on the 100 Hall on 7/12/2021 at 12:54 PM, revealed Resident #167's entry door had a sign posted, STOP CONTACT PRECAUTIONS .PROVIDERS AND STAFF MUST .Put on gloves before room entry . Dining observation on the 100 Hall on 7/12/2021 at 12:54 PM, revealed CNA #1 entered the Resident #167's room without wearing gloves, delivered a meal tray, performed tray set up, entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation on the 100 Hall on 7/12/2021 at 12:56 PM, revealed Resident #170's entry door had a sign posted, STOP CONTACT PRECAUTIONS .PROVIDERS AND STAFF MUST .Put on gloves before room entry . Dining observation on the 100 Hall on 7/12/2021 at 12:56 PM, revealed CNA #1 entered Resident #170's room without applying gloves, placed a meal tray on the overbed table, raised the head of the bed and performed tray set up, without performing hand hygiene, CNA #1 entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation on the 100 Hall on 7/12/2021 at 12:58 PM, revealed CNA #1entered Resident #172's room and placed a meal tray on the overbed table, raised the head of the bed, placed Resident #172's arm on top of the bed linens, performed tray set up without performing hand hygiene. CNA #1 entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation on the 100 Hall on 7/14/2021at 8:15 AM, revealed CNA #1 entered Resident #32's room, entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation on the 100 Hall on 7/14/2021 at 8:20 AM, revealed CNA #1 entered Resident #44's room, delivered a meal tray, performed tray set up, entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation on the 100 Hall on 7/14/2021 at 8:25 AM, revealed CNA #1 entered Resident #164's room, delivered a meal tray, performed tray set up, then entered the bathroom, performed hand hygiene, and failed to turn off the faucet with a clean paper towel. Dining observation in Resident #165's room on 7/14/2021 at 8:25 AM, revealed CNA #1 entered the room, delivered a meal tray, moved a wheelchair, performed tray set up without performing hand hygiene, went to the bathroom and washed her hands, dried her hands with a paper towel, then turned off the faucet with the same paper towel. Dining observation on the 100 Hall on 7/14/2021 at 8:26 AM, revealed Resident #170's entry door had a sign posted, STOP CONTACT PRECAUTIONS .PROVIDERS AND STAFF MUST .Put on gloves before room entry . Dining observation on the 100 Hall on 7/14/2021 at 8:26 AM, revealed CNA #1 entered Resident #170's room without applying gloves. Observation in the Kitchen on 7/13/2021 at 9:50 AM, revealed Dietary Aide #1 placed the dirty dishes from the meal cart into the dish machine tray, sprayed the dishes off with a sprayer, placed the tray into the dish machine and then pulled the tray of clean dishes out of the clean side and touched the clean dishes with her bare hands. Dietary Aide #1 failed to wear gloves or perform hand hygiene between the dirty and clean dishes. Observation in the Kitchen on 7/13/2021 at 10:58 AM, revealed Dietary Aide #1 did not apply gloves or perform hand hygiene while preparing the lunch trays for the residents. Observation in the Dining Room on 7/13/2021 at 11:47 AM, revealed Dietary Aide #2 disposed of trash into the trash can, pulled 2 Styrofoam plates from a cabinet and placed them on the counter next to the food on steam table, without performing hand hygiene. During an interview on 07/15/2021 beginning at 2:17 PM, the Registered Dietician (RD) was asked should the dietary staff working in the dish machine room perform hand hygiene. The RD stated, .yes should perform hand hygiene between dirty and clean . The RD confirmed after dietary staff disposed of trash in the trash can, the dietary staff member should wash their hands. During an interview on 7/15/2021 at 5:00 PM, the Director of Nursing (DON) confirmed staff should wear gloves when entering Contact Isolation rooms and should wear gloves and a face shield or googles when entering Droplet/Contact Isolation rooms. The DON was asked if staff should use the same paper towel to dry hands and then turn off the faucet. The DON stated No, ma'am. The DON confirmed after any contact with wheelchairs, bed linens, remote controls, the staff should perform hand hygiene before performing tray set up.

Based on policy review, medical record review, and interview, the facility failed to ensure the mandatory personnel attended the interdisciplinary care plan meetings for 17 of 18 sampled residents (Resident #2, #4, #8, #14, #19, #21, #32, #38, #43, #44, #49, #53, #54, #57, #62, #164, and #167) reviewed for care plan meetings. The findings include: Review of the facility's policy titled, Care Planning-Resident Participation, dated 10/2020 revealed .This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care) .will notify resident and /or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care .The facility will encourage and assist the resident and /or resident representative to participate in choosing care and treatment options .The facility will honor requests for care plan meetings and acknowledge requests for revisions to the person centered plan of care . Review of medical record, revealed Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 3/26/2021, revealed the only staff member in attendance of the meeting was the Minimum Data Set (MDS) Coordinator. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 1/6/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Dietary Services, Activities Director, and Social Worker. Review of Resident #4's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 4/8/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Dietary Services, Activities Director, Social Worker, and Rehabilitation (Rehab) Services. Review of Resident #4's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 7/7/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Dietary Services, Activities Director, Social Worker, and Rehab Services. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 10/14/2020, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Activities Director, Nursing Services, Dietary Services, Social Worker, and Rehab Services. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 10/28/2020, revealed the only staff members in attendance of the meeting were the MDS Coordinator and Activities Director. Review of Resident #14's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 1/20/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Dietary Services, Rehab Services, and Activities Director. Review of the medical record, revealed Resident #19 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 1/29/2021, revealed the only staff member in attendance of the meeting was the MDS Coordinator. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 11/25/2020, revealed the only staff members in attendance of the meeting were Nursing Services, Dietary Services, and Activities Director. Review of Resident #21's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 5/10/2021, revealed the only staff members in attendance of the meeting were Nursing Services and Activities Director. Review of the medical record, revealed Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 1/2/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator and Nursing Services. Review of the medical record, revealed Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 6/4/2021, revealed the only staff members in attendance of the meeting were Nursing Services and Activities Director. Review of the medical record, revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility could not provide an Interdisciplinary Team care plan review form for Resident #43. During an Interview with MDS Coordinator #1 on 7/15/2021 at 8:40 AM, MDS Coordinator #1 confirmed Resident #43 did not have an Interdisciplinary Team care plan review form. Review of the medical record, revealed Resident #44 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 12/8/2020, revealed the only staff members in attendance of the meeting was the MDS Coordinator. Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 3/17/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Dietary Services, Activities Director, Social Worker, and Rehab Services. Review of Resident #49's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 6/16/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Dietary Services, Activities Director, Social Worker, and Rehab Services. Review of the medical record, revealed Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 6/28/2021, revealed the only staff member in attendance of the meeting was Nursing Services. Review of the medical record, revealed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 1/13/2021, revealed the only staff member in attendance of the meeting was Nursing Services. Review of Resident #54's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 3/31/2021, revealed the only staff members in attendance of the meeting was Nursing Services, Dietary Services, Activities Director, and Rehab Services. Review of Resident #54's INTERDISPCIPLINARY TEAM CARE PLAN REVIEW dated 5/26/2021, revealed the only staff members in attendance of the meeting were Nursing Services, Dietary Services, Activities Director, and Rehab Services. Review of the medical record, revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 8/11/2020, revealed the only staff member in attendance of the meeting was the MDS Coordinator. Review of Resident #57's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 8/24/2020, revealed the only staff members in attendance of the meeting were the MDS Coordinator and Nursing Services. Review of Resident #57's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 9/10/2020, revealed the only staff members in attendance of the meeting were the MDS Coordinator and Nursing Services. Review of Resident #57's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 3/24/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Nursing Services, and Activities Director. Review of Resident #57's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 6/16/2021, revealed the only staff member in attendance of the meeting was the MDS Coordinator. Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 3/23/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Nursing Services, and Social Worker. Review of Resident #62's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 6/16/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator, Nursing Services, and Social Worker. Review of the medical record, revealed Resident #164 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #164's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 6/25/2021, revealed the only staff members in attendance of the meeting were the MDS Coordinator and Nursing Services. Review of the medical record, revealed Resident #167 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Acute Respiratory Failure, and [CONDITION(S)]. Review of Resident #167's INTERDISCIPLINARY TEAM CARE PLAN REVIEW dated 5/3/2021, revealed the only staff members in attendance of the meeting were Nursing Services and Activities Director. During an interview on 7/14/2021 at 1:26 PM, MDS Coordinator #1 was asked who should attend the care plan meetings. MDS Coordinator #1 confirmed that a representative from MDS, a floor nurse, the Activities Director, Therapy Services, Social Service Director, the physician, a Certified Nursing Assistant, and a family member/responsible party should attend the meetings. MDS Coordinator #1 confirmed not all disciplines were present at the meetings as they were required.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 1 of 14 staff members (Certified Nursing Assistant (CNA) #2) failed to knock and/or announce herself before entering residents' rooms (Resident #5, #12, #24, #47, #53, and #265) during dining observations. The findings include: Review of the facility's policy titled, Promoting /Maintaining Resident Dignity Policy, dated 5/24/2021, revealed .It is the Practice of the facility to protect and promote resident rights and treat each resident with respect and dignity .all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights . Observation on the 400 Hall on 7/12/2021 beginning at 12:19 PM, revealed CNA #2 delivered meal trays to Resident #5, #12, #24, #47, #53, and #265. CNA #2 failed to knock and/or announce herself prior to entering the residents' rooms. During an interview on 7/15/2021 at 12:09 PM, the Director of Nursing confirmed that staff should knock and announce themselves when entering a resident's room.

Based on resident trust account procedure manual, medical record review, review of resident trust funds, and interview, the facility failed to refund the residents funds within 30 days of death or discharge for 4 of 6 sampled residents (Resident #217, #218, #219, and #220) reviewed for trust funds. The findings include: Review of the facility's manual titled, RESIDENT TRUST ACCOUNT PROCEDURES MANUAL dated ,d+[DATE], revealed .all refunds must be made within 30 days of discharge or expiration . Review of the medical record, revealed Resident #217 was admitted on [DATE] and expired on [DATE]. Review of the trust funds revealed a check was not issued until [DATE](6 months after Resident #217 expired). Review of the medical record, revealed Resident #218 was admitted on [DATE] and expired on [DATE]. Review of the trust funds revealed a check was not issued until [DATE] (6 months after Resident #218 expired). Review of the medical record, revealed Resident #219 was admitted on [DATE] and expired on [DATE]. Review of the trust funds revealed a check was not issued until [DATE] (6 months after Resident #219 expired). Review of the medical record, revealed Resident #220 was admitted on [DATE] and expired on [DATE]. Review of the trust funds revealed a check was not issued until [DATE] (3 months after Resident #220 expired). During an interview on [DATE] at 3:04 PM, the Social Worker confirmed that the residents' refund should be refunded within 30 days of discharge or death.

Amended 8/10/2021 Based on policy review, observation, and interview, the facility failed to ensure opened medications were properly labeled and dated, external and internal medications were not stored together, and medications were not stored past their expiration date after opened in 4 of 7 medication storage areas (100 Hall Medication Cart, 300 Hall Medication Cart, 400 Hall Medication Cart, and Medication Room). The findings include: Review of the facility's policy titled, Medication and Biological Storage, Night/Emergency Box and Backup Pharmacy dated 10/2020, revealed .All medications are stored in designated areas which are sufficient to ensure proper sanitation .the medications are to be labeled in accordance with accepted professional principles .disinfectants and drugs for external use are stored separately from internal .Whenever a seal of a multidose vial is broken it must be initialed and dated by the Nurse with an open date . Observation of the 300 Hall Medication Cart on 7/12/2021 at 10:20 AM, revealed the following: a. 1 open undated [MEDICATION(S)] 200 mcg [micrograms]-25 mcg inhaler b. 1 open undated [MEDICATION(S)]-[MEDICATION(S)] HFA 160 mcg-4.5 mcg inhaler c. 1 open undated [MEDICATION(S)] 160 mcg-4.5 mcg inhaler d. 1 open undated [MEDICATION(S)] 2.5 mcg-2.5 mcg inhaler e. 1 open undated Incruse Ellipta 62.5 mcg inhaler Observation of the 300 Hall Medication Cart on 7/12/2021 at 10:25 AM, revealed one bottle of [MEDICATION(S)] 1.5 enteral feeding lying on top of a bucket of disinfectant wipes, 2 packs of adult wash clothes, and 1 box of alcohol swabs. Observation of the 400 Hall Medication Cart on 7/12/2021 at 10:52 AM, revealed the following: a. a medication cup with a large white pill in the second drawer from the top of the medication cart b. 1 open and undated Incruse Ellipta inhaler During an interview on 7/12/2021 at 10:25 AM, the Staffing Coordinator confirmed when medications are opened, the staff should record open dates on the medications. The Staffing Coordinator confirmed that internal and external medications should be stored separately in the medication carts. Observation of the 100 Hall Medication Cart on 7/12/2021 at 11:03 AM, revealed a white pill in a medication cup in the top drawer of the medication cart. During an interview on 7/12/2021 at 11:03 AM, Registered Nurse #1 confirmed that the medication should have been wasted in the medication room. Observation in the Mediation Room on 7/12/2021 at 11:11 AM, revealed a multi dose vial of [MEDICATION(S)] vaccine with an open date of 6/3/2021. During an interview on 7/13/21 at 7:50 AM, the Director of Nursing (DON) confirmed internal and external medications should not be stored together in the medication cart. The DON confirmed that an open date should be recorded when a medication is opened. The DON confirmed that loose medications should not be stored in medication cups in the medication carts. The DON confirmed that a multi dose vial of [MEDICATION(S)] vaccine expires 30 days after it is opened.

Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 4 of 6 (Resident #2, 27, 68, and 76) sampled residents reviewed for transfer/discharge requirements. The findings included: 1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Clinical Notes Report dated 5/20/18 documented, .orders to have resident sent to hospital for evaluation .Ambulance arrived and resident left facility at 9:45 am . The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. 2. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Treatment/Order Update/Change in Condition form dated 4/25/18 documented, .Transfer to (Named Hospital) . The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. 3. Medical record review revealed Resident #68 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Treatment/Order Update/Change in Condition form dated 5/25/18 documented, .transfer to (Named Hospital) . The Treatment/Order Update/Change in Condition form dated 7/8/18 documented, .Transfer to (Named Hospital) . The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE] and on 7/8/18. 4. Medical record review revealed Resident #76 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Treatment/Order Update/Change in Condition form dated 3/24/18 documented, .Transfer to (Named Hospital) . The Treatment/Order Update/Change in Condition form dated 5/12/18 documented, .Transfer to hospital . The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE] and on 5/12/18. Interview with the Administrator in the Orientation room on 8/14/18 at 2:21 PM, the Administrator confirmed these residents were not listed on the Emergency Transfers from Facility form sent to the Ombudsman and stated, .were doing it one way, then the Ombudsman said were doing wrong and only wanted these (residents that did not return from the hospital back to the facility) on the form . Interview with the Business Office Manager on 8/14/18 at 2:48 PM, in the Orientation room, she stated .were notifying of everything (all discharges), then Ombudsman said only wanted to know the hospitalization s. The Business Office Manager was asked about the Residents that were not listed on the Emergency Transfers from Facility form that was sent to the Ombudsman. The Business Office Manager stated, I don't remember seeing these being on our ADT (Admission Discharge Transfer) report, not sure why they were not on this report .

Based on policy review, medical record review, observation, and interview, the facility failed to notify the physician of a change of condition for 1 of 18 (Resident #25) sampled residents. The findings included: 1. The facility's Notification of Change policy dated 9/30/17 documented, .The Community promptly .consults the resident's physician .when .A significant change in the resident's physical .condition .Acute condition .Exacerbation of a chronic condition . 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Clinical Notes Report documented, .8/5/2018 .Res (Resident) exhibiting redness to both eyes and eye lids, when questioned Res admits to rubbing his eye stating that they were itching . Observations in Resident #25's room on 8/13/18 at 10:05 AM and 11:47 AM, 8/14/18 at 11:56 AM, and 8/15/18 at 8:30 AM, revealed Resident #25 had redness with thick greenish-yellow drainage to both eyes. Interview with Resident #25 on 8/15/18 at 8:31 AM, in Resident #25's room, Resident #25 was asked if his eyes bothered him. Resident #25 stated, Yes. They need to be cleaned out and put some drops in them. Interview with Licensed Practical Nurse (LPN) #1 on 8/15/18 at 8:35 AM, in Resident #25's room, LPN# 1 confirmed the redness and drainage to Resident #25's eyes. LPN #1 was asked what she should do for the eye redness and drainage. LPN #1 stated, He has that problem off and on. His eyes run, get red, and he rubs his eyes a lot. Interview with Certified Nursing Assistant (CNA) #1 on 8/15/18 at 8:38 AM, on the 400 hall, CNA #1 was asked if she noticed any redness or drainage to Resident #25's eyes. CNA #1 stated, .He does have drainage sometimes. CNA #1 was asked when she had last reported Resident #25's eye redness and drainage to the nurse. CNA #1 stated, It has been a long time . Interview with the Director of Nursing on 8/15/18 at 10:45 AM, in the Orientation room, the DON confirmed the nursing staff should have notified the physician of Resident #25's eye redness and drainage. The facility was unable to provide documentation the physician was notified of Resident #25's change in condition until 10 days later on 8/15/18.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a tube feeding was administered according to the physician's orders [REDACTED].#25) sampled residents reviewed for tube feeding. The findings included: 1. The facility's Enteral (Tube) Feedings policy dated 4/20/18 documented, .Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice .The nurse will .Obtain the physician's orders [REDACTED].Will be adjusted based upon the needs of the resident . 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #25 was moderately cognitively impaired, was totally dependent on staff for eating, had a weight gain of 5 percent (%) or more in the last month or 10% or more in the last 6 months, was not on a physician-prescribed weight-gain regimen, and required a feeding tube. The Care Plan dated 6/6/18 documented, At risk for compromised nutritional status related to .receiving tube feedings .Interventions .feeding as ordered with flushes as ordered .NPO (Nothing by Mouth) .has a (an) unplanned weight gain . The physician's orders [REDACTED].Enteral Feedings .[MEDICATION NAME] 1.2 @ (at) 60cc/hr (cubic centimeters per hour) . The Clinical Notes Report documented, .RD (Registered Dietician) Review .6/24/2018 .currently on [MEDICATION NAME] 1.5 continuous feedings at 60ml/hr (milliliters per hour) .CBW (Current Body Weight) 145# (pounds) .has a 6.6% wt (weight) gain x (times) 90 days .no .[MEDICAL CONDITION] .RD Review .7/20/2018 .currently on [MEDICATION NAME] 1.2 continuous feedings at 60 ml/hr .CBW 148# .has 3# wt gain x30days .no .[MEDICAL CONDITION] .RD Review .8/6/2018 .currently on [MEDICATION NAME] 1.2 continuous feedings at 60 ml/hr .CBW 152# .has 4# wt gain x30 days, and 11# wt gain x90 days .no [MEDICAL CONDITION] .Needs reassessed d/t (due to) wt gain . Observations in Resident #25's room on 8/13/18 at 10:05 AM, 11:47 AM, and 2:47 PM, 8/14/18 at 11:56 AM, and 8/15/18 at 8:30 AM and 9:45 AM, revealed [MEDICATION NAME] 1.5 infusing per gastrostomy pump at 60ml/hr per pump. Interview with Certified Nursing Assistant (CNA) #1 on 8/15/18 at 9:46 AM, in Resident #25's room, CNA #1 confirmed the enteral formula infusing was [MEDICATION NAME] 1.5. Interview with the Staff Development Coordinator (SDC) on 8/15/18 at 9:46 AM, at the nurses' station, the SDC was asked what enteral formula was ordered for Resident #25. The SDC stated, .[MEDICATION NAME] 1.2 . Interview with the Director of Nursing (DON) on 8/15/18 at 10:45 AM, in the Orientation room, the DON in was asked if she expected the nursing staff to administer enteral feedings as ordered by the physician. The DON stated, Yes .we're out of the 1.2 ([MEDICATION NAME] 1.2) .we got an order from the doctor today to use the 1.2 until the 1.5 ([MEDICATION NAME] 1.5) comes in . Interview with the Registered Dietician (RD) on 8/15/18 at 10:47 AM, in the Orientation room, the RD was asked who ordered the enteral feedings. The RD stated, The doctor. The RD was asked if she expected the nursing staff to follow the physician's orders [REDACTED].

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #2) nurses properly disposed of a topical medication patch during medication administration. The findings included: 1. The facility's DESTRUCTION OF MEDICATIONS policy dated 2/16/18 documented, .Medications .must be wasted properly. These medications must be disposed of in the sharps container or by flushing down sink or commode . 2. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 0.4 mg/hr (milligrams per hour) [MEDICATION NAME] 24 hour patch, apply 1 patch QD (everyday) .Remove [MEDICATION NAME] nightly . Observations in Resident #20's room on 8/13/18 at 3:41 PM, revealed LPN #2 removed a [MEDICATION NAME] 0.4 mg/hr topical patch from Resident #20's upper chest, then removed her gloves, placed the used [MEDICATION NAME] inside the gloves, and discarded it in the regular trash in Resident #20's bathroom. Interview with the Director of Nursing (DON) on 8/15/18 at 10:45 AM, in the Orientation room, the DON was asked how she expected the nursing staff to dispose of medications. The DON stated, .they can put them in the sharps container .or .flush down the commode or sink . The DON was asked if it was acceptable to throw a used topical medication patch in the trash in a resident's bathroom. The DON stated, No.

Based on medical record review, observation and interview the facility failed to follow the plan of care and provide personal hygiene care for 1 of 3 (Resident #1) sampled residents to ensure the resident's skin was properly cleansed during 1 of 2 observations of incontinence care. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set significant change assessment dated [DATE] revealed the resident was cognitively severely impaired, non-ambulatory, dependent to extensive assist of staff for: bed mobility, transfer, dressing, eating, hygiene and bathing, and always incontinent of bowel and bladder. The plan of care (P(NAME)) dated 8/15/17 documented, .(Named Resident #1) is always incontinent of bladder .change if wet/soiled. Clean skin with mild soap and water . The Care Area assessment dated [DATE] documented, .Will continue with P(NAME) to meet toileting needs and keep resident clean, dry, and odorfree . Observations in Resident #1's room on 10/18/17 beginning at 9:25 AM, revealed Certified Nursing Assistant (CNA) #1 provided incontinence care for the resident during which time the incontinence pad under the resident was noted to be wet with urine. The CNA did not wash the resident's back where it had come in contact with the wet incontinence pad. Interview on 10/18/17 in Resident #1's room at 9:45 AM with CNA #1, when asked who's responsibility it was to make sure the resident didn't have urine left on her skin, stated, .It's mine . Interview on 10/18/17 in the Administrator's office at 12:45 PM, the Minimum Data Set nurse, Registered Nurse (RN) #1, confirmed the resident's incontinence and toileting plan of care which was to be followed by facility staff.

Based on medical record review, observation and interview the facility failed to provide personal hygiene care for 1 of 3 (Resident #1) sampled residents to ensure the resident's skin was properly cleansed during incontinence care. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set significant change assessment dated [DATE] revealed the resident was cognitively severely impaired, non-ambulatory, dependent to extensive assist of staff for: bed mobility, transfer, dressing, eating, hygiene and bathing, and always incontinent of bowel and bladder. Observations in Resident #1's room on 10/18/17 beginning at 9:25 AM, revealed Certified Nursing Assistant (CNA) #1 provided incontinence care for the resident during which time the incontinence pad under the resident was noted to be wet with urine. The CNA did not wash the resident's back where it had come in contact with the wet incontinence pad. Interview on 10/18/17 in Resident #1's room at 9:45 AM with CNA #1, when asked who's responsibility it was to make sure the resident didn't have urine left on her skin, stated, .It's mine .

Based on policy review, medical record review, observation and interview, the facility failed to ensure the dignity/privacy was maintained when 1 of 14 (Certified Nursing Assistant (CNA) #1) staff members referred to Residents #69 and 30 as feeders. The findings included: The facility's Resident Rights policy documented, .Employees must treat all patients with .kindness, respect and dignity . The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 for Resident #69, indicating cognitively intact. Interview with Resident #69 on 5/15/16 at 11:15 AM, in Resident #69's room, Resident #69 was asked if the staff treated her with dignity and respect. Resident #69 stated, .they call us feeders . Observations in the 100 hallway, on 5/15/16 at 11:36 AM, revealed Resident #69 and Resident #30 sitting in wheelchairs, with CNA #1 standing beside them. Interview with CNA #1 in the 100 hallway, on 5/15/16 at 11:37 AM, CNA #1 was asked why Resident #69 and Resident #30 were not in the dining room. CNA #1 stated, They are feeders. Other staff members and residents were present in the hallway. Interview with the Director of Nursing (DON) on 5/17/16 at 12:21 PM, in the DON office, the DON was asked if the staff should call residents feeders. The DON stated, No.

Based on medical record review and interview, the facility failed to accurately assess residents with diuretics for 1 of 13 (Resident #25) sampled residents reviewed of the 25 residents included in the Stage 2 review. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #25 received a diuretic 3 days of the last 7 days. Review of the Medication Administration Record [REDACTED]. Interview with MDS Coordinator #1, on 5/16/16 at 4:55 PM, in the MDS office, MDS Coordinator #1 was asked about the MDS which stated the resident received a diuretic 3 days of the past 7 days, and the MARS which documented the resident received [MEDICATION NAME] daily from 4/29/16-5/5/16. MDS Coordinator #1 confirmed the MDS was inaccurate, and stated, Can I just say OK .OK .

Based on policy review, observation, and interview, the facility failed to ensure food was served in a sanitary manner when 1 of 14(Certified Nursing Assistant (CNA) #2) staff members did not perform hand hygiene between residents while serving trays and touched resident's food bare handed. The findings included: The facility's Hand Hygiene policy documented, Hand hygiene must be performed at a minimum .Before and after each patient contact . Observations in the 100 hall, on 5/15/16 beginning at 12:45 PM, revealed CNA #2 entered Resident #66's room with a meal tray, touched the bedside table, served Resident #66 the meal tray, and did not perform hand hygiene. CNA #2 then returned to the meal tray cart, obtained a meal tray and entered Resident #103's room, moved the bedside table, raised the head of the bed, touched the covers at the foot of the bed, and then served the tray to Resident #103. CNA #2 then went to Resident #23's bedside, touched the bed linens, touched Resident #23's chest, raised the head of the bed, moved the bedside table, and returned to the cart and obtained a meal tray. CNA #2 then began to serve the meal tray to Resident #23. CNA #2 touched the baked potato with her bare hand and cut it open, then continued to hold it bare handed while she placed butter and sour cream on it. CNA #2 did not perform hand hygiene during this time period. Interview with the Director of Nursing (DON) on 5/17/16 at 12:25 PM, in the DON office, the DON was asked what should staff do between serving residents trays. The DON stated, Wash their hands. The DON was asked if staff should touch the residents food with bare hands. The DON stated, No.