Every finding on record at Crestview Rehabilitation Center, LLC

Based on observations, interviews and record reviews, the facility failed to follow physician orders and maintain infection control practices for 1 of 3 residents observed for direct care. (Resident #64)The findings Include:On 08/18/25 at approximately 4:15 PM, an observation of Resident # 64 was made. He was noted sitting in his wheelchair at the nurses' station in front of the medication cart. Nurse A, a Licensed Practical Nurse (LPN), was kneeling in front of the resident applying Diclofenac External Gel 1% (a topical medication used to treat pain) to the left knee with her bare hand. Nurse A then squeezed the gel into her bare hand and applied it to the resident's right knee and finally squeezed gel into her bare hand again and applied it to the resident's right shoulder. Nurse A then replaced the lid onto the medication and laid the medication on top of the medication cart and performed hand hygiene. The Director of Nursing (DON) was also present during the observation. On 08/18/25 at approximately 4:20 PM, an interview was conducted with Nurse A, who indicated that applying the medication without gloves would be considered an infection control issue. Nurse A further indicated that the medication was over the counter and she placed the tube into her uniform pants pocket. She stated that she liked to do her treatments as she goes down the hall with her residents. Nurse A was asked to clarify if the same tube of medication was used on multiple patients. Nurse A indicated that, because the medication was over the counter, it was not signed out to individual residents and further indicated that she should have dispensed the medication into a medication cup to use on multiple residents instead of her hand.The box that the medication came in had no open date and no resident room number to indicate single resident use. Nurse A was asked where for the dispensing card (pre-marked plastic card used for measuring the appropriate dosage) for the medication. She indicated that she was not aware of a dispensing card. Upon reviewing the medication box, the dispensing card was located inside the box, attached to the pharmaceutical insert in the box.The physician orders on the electronic treatment administration record (ETAR) revealed that the order for the Diclofenac Sodium External Gel 1% was to apply 2 grams to the left knee twice daily, apply 2 grams to the right knee twice daily, and 2 grams to the left shoulder twice daily for arthritis, not to exceed 16 grams in 24 hours. Nurse A confirmed that she did not follow the physician's order by applying the medication to the right shoulder not the left shoulder, Nurse A further indicated that the resident refuses to have the medication to the left shoulder but requests the medication for the right shoulder. When asked if she had contacted the physician to have the order clarified, Nurse A stated that she should have contacted them prior to applying the medication. On 8/18/25 at approximately 4:32 PM, an interview was conducted with the DON, who indicated that the expectation is that the nurse follows the physician orders, to contact the physician if the order needs to be clarified, and to use proper technique, such as gloves and dispensing card, to administer the medication. The facility's policy states, Policies and Practices-Infection ControlPolicy StatementThis facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and ImplementationThis facility's infection control policies and practices apply equally to all personnel, consultants, contractors, resident, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, [NAME] or veteran status, or payor source.The objectives of our infection control policies and practices are to:a. Prevent, detect, investigate, and control infections in the facility;b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; etc .3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall establish, review, and revise infection control practices, and help department heads and managers ensure that they are implemented and followed.4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of the employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on observation, interviews, and record reviews, the facility failed to provide medications in a timely manner for 2 of 5 residents sampled for medication administration. (Residents #85 and #30) The findings include: On 3/1/23 at approximately 9:30 AM, an observation was made of Resident #85's medication administration by Nurse F, a Licensed Practical Nurse (LPN). Nurse F was scheduled to administer a Vitamin B-12 injection, 1000 micrograms subcutaneously, but could not as it was not available from pharmacy. Nurse F stated she would notify the Nurse Practitioner and the pharmacy to have this medication delivered from the back-up pharmacy. On 3/1/23 at approximately 2:00 PM, an observation was made of Nurse D, a Registered Nurse. Nurse D was scheduled to administer the medication Urecholine 10 milligrams to Resident #30 but could not as it was not available from the pharmacy. The nurse stated she would notify the physician or Nurse Practitioner and the pharmacy and have the medication delivered. On 3/1/23 at approximately 2:10 PM an interview was conducted with Nurse B, a Registered Nurse and Unit Manager. Nurse B stated that the medications should be re-ordered when the current supply was down to one week's supply to ensure medications are received in a timely manner. Nurse B was observed to re-order the missing medications while the surveyor observed. Nurse B confirmed that the empty medication card had not been pulled to be faxed to the pharmacy for a refill. On 3/1/23 at approximately 5:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that it was her expectation that all medications should be reordered from pharmacy when the medication is down to one week's supply in order to receive the refill medications from the pharmacy in a timely manner. The DON stated that the Vitamin B-12 injection for Resident #85 was incorrectly listed as on hand in the medication record, which is why it was not delivered from the pharmacy. The DON confirmed that Resident #30's Urecholine had not been re-ordered electronically until today at 2:00 PM. On 3/2/23, a review was conducted of the Policy titled,4.5 Reordering, changing, and Discontinuing Orders (last revised January 1, 2022). Under procedure number 2, it states Reorder/Refill Orders: Facilities are encouraged to re-order medications electronically or by fax whenever possible. On 3/2/23 at approximately 12:41 PM, a follow up interview was conducted with the DON and the Corporate Nurse concerning the time frame for re-ordering medications. The DON confirmed that the policy 4.5 did not state what time frame to re-order medications, but stated that the nurses are trained during orientation on when to re-order medications.

Based on observation, record review, staff interviews, and facility policy review, the facility failed to provide appropriate treatment to prevent further decrease in range of motion for 1 of 2 residents reviewed for limited range of motion. (Resident #69) The findings include: An observation of Resident #69 was conducted on 2/27/23 at 12:46 PM. The resident was in bed and contractures were observed to the upper and lower extremities. A review of the quarterly minimum data set, with an assessment reference date of 12/23/22, revealed the resident had functional limitation in range of motion to upper and lower extremities on both sides. The occupational therapy discharge summary, dated 10/24/22, revealed the resident had contractures to bilateral upper extremities. Review of the resident's electronic medical record revealed a current plan of care dated 11/10/22 for a passive range of motion restorative nursing program. The interventions included passive range of motion with stretching at the end of the range on shoulder flexion, elbow extension as tolerated, to be completed every day 4 days per week. Review of the documentation of passive range of motion (PROM) for the time period of 1/31/23-2/28/23 revealed the PROM had been completed a total of 7 times on the following dates: 2/5/23, 2/6/23, 2/9/23, 2/13/23, 2/20/23, 2/26/23, and 2/27/23. An interview was conducted with Employee C (Restorative Licensed Practical Nurse) on 3/1/23 at 10:06 AM. Employee C stated she has trouble with restorative therapy getting completed because the staff are pulled to the floor. She stated, It has been a constant battle since I took over the position, and, if the restorative aid is pulled to the floor, I try to complete the range of motion or restorative ordered. She confirmed that any zeros entered on the documentation meant the task was not completed. She stated the resident does not usually tolerate the range of motion well and her contractures have worsened in the last few months. She states that Resident #69 had been referred back to therapy for an evaluation on 2/3/23. An interview was conducted with the Rehabilitation Director on 3/1/23 at 10:30 AM. She stated the resident declined and contracted really fast. She was last discharged from therapy on 12/9/22. She did not recall the resident being referred backed to therapy by restorative staff in the last 30 days. An interview was conducted with the Director of Nursing (DON) on 3/1/23 at 10:55 AM. The DON stated she was aware that staff get pulled to the floor from restorative, but she was not aware restorative tasks were not being completed. Review of the facility policy for Restorative Nursing Program (SHCRC 3006.01) revealed it is the policy of the center to assist each Resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance to State and Federal Regulations. The center's restorative program will include, but not be limited to, hygiene, mobility, elimination, dining-eating, and communication. The programs will be documented on the center's designated restorative care forms/tools in the resident's electronic medical record.

Based on observation, record review, staff interview, and policy review, the facility failed to provide treatment and care in accordance with professional standards and facility policy for 1 of 2 residents sampled for non-pressure related skin conditions. (Resident #27) The findings include: An observation of Resident #27 was conducted on 2/27/23 at 1:54 PM. The resident was observed to have an undated dressing on her left lower arm. Another observation of Resident #27 was conducted on 3/1/23 at 12:38 PM in the presence of Employee A (licensed practical nurse). The undated dressing remained on the resident's left lower arm. The nurse removed the dressing and a small (approximately 1/2 inch) clean skin tear was observed under the dressing. The resident was not able to state how the skin tear occurred. The nurse stated she was not aware the dressing was on the resident's arm and was not sure how the resident received the skin tear. She confirmed the dressing she removed was not dated. A review of Resident #27's electronic medical record revealed no documentation of the skin tear, no physician orders for care of the skin tear, and no documentation of how the skin tear occurred. An interview was conducted with employee B (Registered Nurse Unit Manager) on 3/1/23 at 12:47 PM. Employee B stated she did not know where the dressing came from and was not aware of the skin tear on Resident 27. She stated staff should obtain physician orders for the dressing, let the physician know about the skin tear, and let the wound care nurse know about the skin tear so they can follow the area. An interview was conducted with the Director of Nursing (DON) on 3/1/23 at 1:49 PM. The DON confirmed the resident record contained no physician orders for the dressing or record of how the skin tear occurred. Review of the facility policy Skin Tear Management (SHCRC20001.04, revised 10/24/22) revealed, Skin tears are managed by focusing on prediction and prevention. When a skin tear does occur, the goal is to promote prompt healing and minimize the risk of infection. Occurrence of a skin tear is reported and is investigated by the clinical team. Follow physician's orders for treatment. In the progress notes, record: evaluation and cause of the skin tear, physician and family notifications, the treatment ordered and initiated, and progress or lack of progress in healing.

Based on observation, interview and record review, Memory Care Unit staff failed to provide a safe and sanitary environment by failing to perform hand hygiene when indicated according to their Hand Washing/Hygiene Policy (Staff member D, F, and K) The findings include: On 9/29/2020 at approximately 6:15 PM, dinner tray pass was observed on the Memory Care Unit. CNA D was observed to bring a tray table into Resident #59's room and position it in front of the resident. CNA D did not perform hand hygiene after exiting the room. She returned to the tray cart and delivered a tray to Resident #26. CNA D repositioned the resident's wheelchair and tray table, removed the resident's lap safety belt, opened the milk carton and sat beside the resident to assist with the meal. CNA D exited the room and resumed passing trays to other rooms. No hand hygiene was observed. On 9/29/2020 at 6:33 PM, an interview was conducted with CNA D. The surveyor asked how she performs hand hygiene and she replied that she washes her hands in the residents' rooms. The surveyor pointed out that alcohol-based hand rub was not observed in resident care areas and asked if she'd been provided a personal size alcohol-based hand rub by the facility. CNA D confirmed that she had. The surveyor then asked if she had it on her and she replied, No, it's in my bag. The surveyor pointed out to the CNA that she'd been observed at dinner time passing meal trays, assisting with meal setup, moving tray tables, repositioning wheelchairs, and removing lap safety belts without performing hand hygiene in between. CNA D confirmed what the surveyor observed. The surveyor asked if it was realistic for her to wash her hands each time it was indicated during meal tray pass and she replied, No. On 10/1/2020 at approximately 7:45 AM, breakfast tray pass was observed on the Memory Care Unit. CNA F delivered a tray to Resident #77 and repositioned the tray table closer to the resident. She exited the room and grabbed another tray from the cart and repositioned the tray table for Resident #18 who occupied the B bed and then adjusted the pillows for Resident #45 who occupied the A bed. She exited the room and made two more trips to the meal cart to deliver trays to Resident #119 and Resident #22. CNA F closed the door to their room for a moment and then returned back to the cart and delivered a tray to Resident #12 who occupied the A bed. Resident #12 was reclined in bed so CNA F used the remote control to raise the head of the bed. She returned to the tray cart on the hall and then delivered a tray to Resident #128 who occupied the B bed. CNA F provided the same assistance with raising the head of the bed. CNA F returned to the cart and then delivered a tray to Resident #14 and repositioned the tray table closer to the resident. No hand hygiene was performed at any time during the observation period. On 10/1/2020 at approximately 8:00 AM, an interview was conducted with CNA F. The surveyor informed her of observed concerns regarding not performing hand hygiene after coming into contact with residents and/or their physical environments. CNA F acknowledged that she does not carry hand sanitizer around with her and said that she should. On 10/1/2020 at approximately 11:45 AM, lunch tray pass was observed on the Memory Care Unit. CNA K delivered a tray to Resident #12, who occupied the A bed, and positioned the tray table closer to the resident. CNA K did not perform hand hygiene after she exited the room. She then went back to the tray cart on the hall and delivered a tray to Resident #128 who occupied the B bed. After setting the lunch tray down on the tray table, she used the remote control to raise the head of the resident's bed. CNA K then positioned the bedside tray table over the resident's lap. Then, CNA K went back to Resident #12 in the A bed and positioned the plate on the tray closer to the resident. She then proceeded to cut Resident #12's food into bite size pieces. CNA K exited the room, handed a tray from the meal cart in the hall to another CNA and pushed the meal cart down the hall to pass trays on the opposite end. No hand hygiene was observed to be performed in between residents after coming into contact with residents' physical environment. On 10/1/2020 at 11:54 AM, an interview was conducted with CNA K. The surveyor asked when she was trained to perform hand hygiene during meal tray pass and she replied, Every three trays. The surveyor asked who told her that and received no answer. CNA K then asked the surveyor, After every tray?. The surveyor informed CNA K of her observations regarding not performing hand hygiene when indicated during meal tray pass. She stated she's usually in the dining room where she's not coming into contact with the resident's environment. The surveyor asked if she had a personal hand sanitizer on her and she replied no, but that she uses the one at the nurse's station or medication cart. The surveyor informed CNA K again that she was not observed to do that during the observation 10 minutes earlier. 10/1/2020 at 11:18 AM, an interview was conducted with Staff Development. The surveyor asked if she conducts random hand hygiene observations and she replied yes. The surveyor asked if she had identified a specific area in the building where she had to provide re-education due to identified concerns and she stated, No, not in a particular area. The added that the issue she sees most is staff not using a fresh paper towel to turn off the faucet. The surveyor asked if she had conducted any of these hand hygiene observations during meal tray pass and she stated, Not in awhile. She stated that staff are educated to wash their hands prior to passing trays. The surveyor asked when else staff are trained to perform hand hygiene. She stated if they don't touch the resident then they aren't required to perform hand hygiene in-between passing trays to rooms. The surveyor asked what about when they come into contact with the resident or the resident's environment and she replied, Yes, they should then. They surveyor asked if it's realistic for staff to wash their hands in-between resident rooms and she said, No, but alcohol rub, yes. The surveyor informed her that the DON and CNAs on the Memory Care Unit all stated that personal hand sanitizers were provided, but that staff didn't have them on them to be utilized. Staff Development stated that she'd provide re-education. On 10/1/2020 at 12:19 PM, an interview was conducted with the Memory Care Unit Manager. The surveyor asked if he'd identified any issues with hand hygiene during tray pass and he stated that there has been ongoing confusion among staff regarding when to perform hand hygiene and he doesn't know where staff are getting this idea of every three trays. He stated that he educated staff to perform hand hygiene any time they come into contact with anything besides the tray. He stated that he's conducted no formal education at this point. Review of the facility's Hand Washing/Hygiene Policy revised 6/5/2019 revealed the following: - This facility considers hand hygiene the primary means to prevent the spread of infections . - Hand hygiene products and supplies .shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. - Alcohol-based hand rub may be used for hand hygiene opportunities when soap and water is not indicated. Hand hygiene opportunities include: prior to caring for a resident, after contact with the resident environment, before and after assisting a resident with meals, upon and after coming in contact with a resident's intact skin (lifting a resident), among others.

Based on observation and staff interview the facility failed to ensure that expired narcotics were removed for the medication cart for 1 of 3 medication carts observed (100 Wing Cart). The findings include: On [DATE] at approximately 8:20 AM, a review of the 100 Wing medication cart was conducted in the presence of Staff member A, a Licensed Practical Nurse (LPN). The narcotic drawer was opened by the LPN and Resident #90's medication, [MEDICATION NAME] 50 mg (a narcotic used for non-acute pain) was reviewed. The expiration date on the back of the medication was [DATE] and there were 5 pills remaining. A review of the sign out sheet revealed the last time the medication was administered to resident #90 was on [DATE]. (Photographic evidence obtained). At the time of the observation Staff member A, LPN, stated Yes, I see it is expired. I will remove it immediately.

Based on observation, and staff interview the facility failed to perform proper hand hygiene during wound care for 1 of 2 residents observed (#84) . The findings include: On 9/30/2020 at 9:35 AM, a dressing change was observed for resident #84. The wound care Medical Doctor (MD) and wound care Licensed Practical Nurse (LPN) were both in the room. Before entering the room, the MD told the LPN she wanted to use calcium alginate sheet (an absorbent dressing that can be placed in open and/or deep wounds). The LPN removed the calcium alginate sheet from the treatment cart and placed it on the clean overbed table, with normal saline, collagen powder, and a foam pad covering. Resident #84 was positioned on her right side for the wound care. The MD and LPN washed their hands and donned clean gloves, a certified nursing assistant (CNA) assisted with positioning. The MD then debrided the wound. She finished and told the wound care nurse to irrigate the wound with normal saline. The MD remained in the room to observe LPN with the rest of the dressing change. During the dressing change Resident #84 had a bowel movement and was cleaned by the LPN and CNA. The resident was then repositioned on her left side for the LPN to complete the dressing change. The LPN washed her hands and donned clean gloves. The LPN irrigated the area with normal saline. Once the area was irrigated the LPN removed the calcium alginate sheet from the overbed table. She then reached into her pocket with her left hand and removed a pair of scissors. She then proceeded to cut the calcium alginate sheet in a circular motion. She failed to clean the scissors or re-wash her hands. She then put most of the calcium alginate in the wound, cut the unneeded section off with the scissors. She covered with foam dressing dated for 9/30/2020. An interview was conducted with the LPN on 9/30/2020 at 9:40 AM. She was asked if she removed the scissors from her pocket. She said, Yes. She was asked if she washed her hands after putting her hands in her pocket, and she said I will not lie, No, I did not.

Based on resident interview, staff interview, and record review, the facility failed to provide discharge orientation for 1 of 3 residents reviewed (#1) to ensure a safe and orderly discharge. The findings include: Resident #1 was admitted to the facility on [DATE] for short term rehabilitation. He was sent to another long-term care facility on 3/10/2020. A telephone interview was conducted with the Administrator, Director of Nursing (DON), and the Social Services Director on 7/6/2020 at 12:30 PM. They said resident #1 came to the facility for short term rehabilitation and was scheduled to return to an assisted living facility (ALF). The resident told us he could not go back to ALF. We told him we had not long-term beds available for him our facility. His insurance required he have a semi-private room and he was in a private room according to the Administrator, so he was discharged . The social worker was asked how he was prepared for the discharge to another facility on 7/6/2020 at 12:30 PM . She was asked to read her progress note regarding the preparation. She said she had not documented any discussions with him about his discharge to another facility. She then stated, I guess I should have but I did not. A telephone interview was conducted with Resident #1 on 7/7/2020 at 11:00 AM. He said he was told they were discharging him unless he paid $36.00/day for the private room where he was staying. He said I could not pay that. He then said he was told they had no room for him without the extra charges. He said he did not want to leave the facility and he did not ask to leave. He denied being giving a 30-day notice of transfer/discharge. He denied any discharge orientation. He then said, I was told I was dumped here.

Based on resident interview, staff interview, and record review, the facility failed to provide a 30 day notice of transfer/discharge for 1 of 3 residents reviewed (#1) for transfer/discharges. The findings include: Resident #1 was admitted to the facility on [DATE] for short term rehabilitation. He was sent to another long-term care facility on 3/10/2020. A telephone interview was conducted with the Administrator, Director of Nursing (DON), and the Social Services Director on 7/6/2020 at 12:30 PM. They said resident #1 came to the facility for short term rehabilitation and was scheduled to return to an assisted living facility (ALF). The resident told us he could not go back to an ALF as he needed more care than an ALF could provide. We told him we had no long-term beds available for him in our facility. His insurance required he have a semi-private room and he was in a private room according to the Administrator, so he was discharged . The social worker was asked how he was prepared for the discharge to another facility. She was asked to read her progress note regarding the preparation. She said she had not documented any discussions with him about his discharge to another facility. She then stated, I guess I should have but I did not. The Administrator said he had talked to the Ombudsman about discharging him. They were then asked about resident #1's cognitive ability and he said that resident #1 was cognitively intact. The Administrator was then asked if he saw anything wrong with discharging him to another facility without issuing a transfer/discharge notice and he said, I guess I do. The Administrator then said he did sign a notice of Medicare non-coverage even though we did need him to sign, and the DON said he also signed his discharge summary. A telephone call was placed to Resident #1 on 7/7/2020 at about 10:00 AM. A voice message was left. An interview was conducted with the Ombudsman on 7/7/2020 at 10:45 AM when the resident could not be contacted. She said the resident felt he had to leave because he could not pay an extra $20-30 per night to stay in private room and there were no long-term care beds available in the facility when he was not going to therapy. Resident #1 returned the call on 7/7/2020 at 11:00 AM. He said he was told they were discharging him unless he paid $36.00/day for the private room where he was staying. He said I could not pay that. He then said he was told they had no room for him without the extra charges. He said he did not want to leave the facility and he did not ask to leave. He asked to remain in or near Crestview so that friends could visit. He denied being giving a 30-day notice of transfer/discharge. He then said he did sign some type of notice and left shortly after that (this was the notice of Medicare Non-Coverage). He said he was unable to participate in therapy due to his legs being numb and tingling and could not stand without assistance. I was sent to this facility. He then said, I was told I was dumped here. An onsite visit was made to the facility on [DATE]. An interview was conducted with the Administrator at 9:45 AM. He was asked if resident #1 initiated the discharge. He said that resident #1 initiated the discharge when we told him there were no long-term care beds in our facility available. At that time he said he would go and we sent out packets to other long term care facilities. We tried to find him a place in Crestview, but were unable. A facility in Fort Walton Beach accepted him. The social services director was interviewed on 7/8/2020 at 10:24 AM. She said the resident was told we did not have any long-term care bed for him and that if he wanted to stay in the facility, he would have to pay the difference for the private room he had. Resident #1 told me he could not pay that and would have to go to another facility. She was then asked if he was aware he was not required to leave. She said she did not remember specifically telling him he could stay.

Based on observations and interviews, the facility failed to serve food at safe temperatures for 1 of 2 observed meals. Findings included: On 3/11/19 at approximately 11:03AM, during an observation of the kitchen, temperatures were verified for the lunch meal items. Staff C measured the temperatures of the food items, showing the mashed potatoes to be 131 degrees, ground beef 146 degrees, and pureed roast beef 147 degrees. In an interview on 3/11/19 at 11:26AM, the Dietary Manager stated the ground beef should be heated to 155 degrees and mashed potatoes above 140 degrees. The manager directed staff to reheat the items and recheck the temperatures. At that time, the mashed potatoes were 132 degrees, pureed roast beef 127 degrees, and ground beef 140 degrees. A plate with ground beef was prepared and set to be served. After pointing this out, staff B directed staff to pull the plate from service. Staff B stated that reheated foods in the microwave must reach a temperature of 165 degrees. At 11:46 AM temperatures were again obtained after reheating of food items. The pureed roast beef had been reheated on the stove to 156 degrees, the mashed potatoes reheated on the stove to 145 degrees and the ground beef reheated in the microwave to 136 degrees. The ground beef was placed back in the microwave and at 11:53AM was rechecked and measured 177 degrees. While observing food removed from microwave by staff B, observed the cover removed and temperature taken immediately upon removing food from microwave. When questioned about the process for checking temperatures after microwave heating, Staff B admitted the food needed to be stirred upon removal from the microwave, and before taking the temperature of the food. Staff made no mention of the need to allow the food item to sit covered prior to rechecking the food's temperature. On 3/13/19 at 11:17 AM, during an observation of the kitchen, food temperatures for the lunch meal were noted. Staff D measured the ground chicken and chopped chicken at 153 degrees. Staff D confirmed the temperatures and proceeded to prepare food for service. The dietary manager was called over and removed the chopped and ground chicken for reheating. On 3/13/19 at 11:32AM, while preparing a plate which required chopped chicken, Staff D took a plate to where staff B was reheating the meat and attempted to obtain chopped chicken that had not yet been reheated. The administrator was in the kitchen and observed this and verbally directed staff D to stay on the serving line and allow staff B to reheat the meat. The ground chicken was reheated in the microwave to 191 degrees and the chopped chicken was reheated to 167 degrees. Staff B was observed to remove the items heated in the microwave and immediately remove their covers, stir and measure temperatures without allowing the food items to sit for two minutes covered. A review of policy titled Holding Foods, with an effective date of 2/21/2017, contained a page titled Food Code Temperatures with a copyright date of 2014. The policy indicated that ground meats including beef, pork, injected and mechanically tenderized meats, other meats or fish were to be at 155 degrees for 15 seconds, 150 degrees for 1 minute, and 145 degrees for 3 minutes. Poultry or stuffed fish/meat/pasta/poultry was to achieve a temperature of 165 degrees for 15 seconds. Food cooked in a microwave oven was to be held covered for 2 minutes and had to reach 165 degrees.

Based on record review, staff interview and facility policy review, the facility failed to provide appropriate care and services in accordance with resident's plan of care by failing to demonstrate assessment of bruit and thrill for the arteriovenous (AV) shunt used for [MEDICAL TREATMENT] for 1 of 1 sampled resident (#115). The findings include: Review of the electronic record from (MONTH) 2019 through (MONTH) 2019 was conducted for Resident #115 and revealed no documentation of assessment of bruit or thrill in the AV shunt located in the resident's right arm. There was also no physician's order to check bruit or thrill for the resident. The resident's plan of care for [MEDICAL TREATMENT] therapy indicated the nurse should monitor bruit and thrill. The facility policy for [MEDICAL TREATMENT] (SHCRC .15) stated the AV graft or fistula should be monitored daily for positive bruit and thrill and that if bruit and thrill were absent, staff should notify the nephrologist and [MEDICAL TREATMENT] center. An interview was conducted with employee A (Licensed Practical Nurse) on 3/13/19 at 11:56 AM. Employee A stated they should document checking the bruit and thrill on the medication record and stated there was normally an order to do so, but was unable to find any such documentation for Resident #115. An interview was conducted with the Director of Nursing (DON) on 3/13/19 at 12:31 PM. The DON stated the nurses were expected to assess bruit and thrill at least daily and it should be documented on the medication record daily. After review, he stated the resident had gone to the hospital in (MONTH) (YEAR) and the order had not been put back in the resident's orders when she was readmitted .

Based on observations, record review, staff interviews and policy review, the facility failed to develop and implement an effective quality assurance (QA) plan to address identified concerns with their steam table holding temperatures. The findings include: During two separate kitchen inspections, conducted 3/11/19 and 3/13/19, issues were discovered with foods being on the tray line that were not at appropriate temperatures, and staff improperly reheating food items and not verifying holding temperatures of the food items prior to putting them on the tray line for use during meal service for residents. (See F804). An interview was conducted with the Administrator on 3/14/19 beginning at 12:54 PM. She stated the facility had a current and ongoing QA plan to address tray line steam table food holding temperatures. The plan was initiated 11/1/18. She stated the staff did not temp the final cooking temperatures before they moved the food to the tray line. The facility produced documents indicating a quality assurance corrective action plan dated 11/1/18 and 1/31/19 with goals to include meals will be held to maintain proper temperature and all foods will be acceptable temperature prior to being placed on the tray line and during tray line service. The facility produced 3 audits of final cooking temperatures and steam table holding temperatures dated 11/1/18, 12/27/18 and 1/31/19. The facility was not able to to produce further evidence of audits or review/revision of the plan. The facility Quality Assurance Performance Improvement (QAPI) policy (SHCP .08) revealed the facility would identify areas of concern and improvement opportunities; develop QAPI plans with set goals, analyze the data, decide whether to continue monitoring or initiate a more focused study if further study was indicated and monitor data measures for changes and sustained improvement.

Based on interview, observation, record review, the facility failed to follow facility policy to prevent the spread of infections for resident #140 and #131. The findings are: Resident #140 Review of the medical record for resident #140 indicated she had been admitted with [DIAGNOSES REDACTED]. Review of physician orders indicated to have strict contact isolation, and the resident's plan of care, dated 3/1/18, indicated resident to be in contact isolation. Observation of the resident's room on 3/12/18 at 9:56 am, 3/13/18 at 9:20 am, 3/14/18 at 9:30 am and 1:30 pm found no sign on the resident's door to inform staff, family or visitors of precautions and the room did not have biohazard waste barrels or linen barrels. Interview with the unit manager on 3/12/18 at 2:25 pm found the resident was on contact isolation for [MEDICAL CONDITION]. Interview with director of nursing on 3/15/18 at 9:51 am indicated there should have been a sign on the door and barrels in the room for linen and biohazard waste that according to facility protocol. Resident #131 Observation on 03/13/18 at 9:20 am, 3/14/18 at 9:30 am and 1:45 pm of resident #131 found a suction bottle, half-full of cloudy water with mucus. Interview with resident #131 on 3/13/19 at 9:30 am revealed the nurses use the suctioning machine 2-3 times a week, but had not used it that week, and the liquid in the container had been there since last week. Interview with the unit manager on 3/14/18 at 1:45 pm said the suction container should be cleaned after each use. Review of the facility policy indicated the suction container should be emptied at the end of each shift and at least daily.

Based on observation, record review and staff interview, the facility failed to implement the plan of care related to the treatment of [REDACTED].#77). The Findings Include: Review of the medical record for resident #77 revealed a plan of care related to the resident's self-care deficit. The plan of care indicated resident #77 was dependent on staff for all care needs, and was not able to turn or reposition himself and revealed an intervention for staff to turn and reposition resident #77 every 2 hours. On 03/12/18 at approximately 02:55 PM an interview was conducted with a family member of resident #77. During the interview, the family member indicated staff were not turning and repositioning the resident #77 often enough, and that he should have been turned and repositioned at least every 2 hours as he had a pressure ulcer on his coccyx. Observation of resident #77 on 3/13/18 at approximately 5:04AM, showed the resident to be in bed with his eyes closed. He was positioned on his right side. Observation at approximately 7:43AM revealed the resident was in the same position. Continued observations at approximately 8:00AM, 8:10am, 8:41AM and again at 9:15AM revealed the resident to be in the same position, turned onto his right side. His position did not change until observation at 9:33 AM when the resident was observed to be on his left side. On 3/13/18 at 11:06AM an interview was conducted with the wound care physician for resident #77. The physician confirmed the resident should be turned and repositioned at least every two hours by staff. The physician did indicate that there had been no decline in the resident's wound status since he was admitted to wound care services in (MONTH) (YEAR) and that the area was slowly improving. On 3/15/18 at 10:27AM an interview was conducted with the facility's director of nurses (DON) with review of the surveyor's 3/13/18 observations. During the interview, the director of nurses confirmed that residents who could not turn and reposition themselves should have this service provided by staff at least every two hours, and stated this was especially important to prevent and help heal wounds for dependent residents. The DON also confirmed that the care plan related to the provision of activities of daily living (ADLs) for resident #77 had not been followed based on surveyor observations.

Based on record review, observations and interview, the facility failed to provide necessary care and services to promote healing of pressure ulcer, by failing to turn and reposition the resident in accordance with the resident's plan of care and standards of practice, for 1 of 3 residents reviewed for pressure ulcer care (#77). The findings are: Review of the medical record for resident #77 revealed a plan of care related to the resident's self-care deficit. The plan of care indicated resident #77 was dependent on staff for all care needs, and was not able to turn or reposition himself and revealed an intervention for staff to turn and reposition resident #77 every 2 hours. On 03/12/18 at approximately 02:55 PM an interview was conducted with a family member of resident #77. During the interview, the family member indicated staff were not turning and repositioning the resident #77 often enough, and that he should have been turned and repositioned at least every 2 hours as he had a pressure ulcer on his coccyx. Observation of resident #77 on 3/13/18 at approximately 5:04AM, showed the resident to be in bed with his eyes closed. He was positioned on his right side. Observation at approximately 7:43AM revealed the resident was in the same position. Continued observations at approximately 8:00AM, 8:10am, 8:41AM and again at 9:15AM revealed the resident to be in the same position, turned onto his right side. His position did not change until observation at 9:33 AM when the resident was observed to be on his left side. On 3/13/18 at 11:06AM an interview was conducted with the wound care physician for resident #77. The physician confirmed the resident should be turned and repositioned at least every two hours by staff. The physician did indicate that there had been no decline in the resident's wound status since he was admitted to wound care services in (MONTH) (YEAR) and that the area was slowly improving. On 3/15/18 at 10:27AM an interview was conducted with the facility's director of nurses (DON) with review of the surveyor's 3/13/18 observations. During the interview, the director of nurses confirmed that residents who could not turn and reposition themselves should have this service provided by staff at least every two hours, and stated this was especially important to prevent and help heal wounds for dependent residents. The DON also confirmed that the care plan related to the provision of activities of daily living (ADLs) for resident #77 had not been followed based on surveyor observations.

Based on observation, record review and staff interview, the facility failed to provide appropriate care and services related to the use of an indwelling catheter, by failing to secure the catheter tubing to prevent injury in accordance with facility policy, for 1 of 2 sampled residents with catheters (#121). The findings are: Review of the medical record for resident #121 revealed the presence of an indwelling catheter that had been placed almost a year prior due to [MEDICAL CONDITION] with [MEDICAL CONDITION]. Catheter care for resident #121 was observed being performed by certified nursing assistants (CNAs) staff N and satff O on 3/14/18 at 1:45 PM. During observation of resident care, the catheter tubing was observed to not be secured to the resident, and was observed being pulled taunt as the CNAs turned the resident from side to side for care. A red mark, the width and length of a pencil, was noted to the resident's right upper inner thigh. The resident did not know she had the mark, and the CNAs indicated the mark had not been present last Thursday. Review of the resident's most current plan of care, dated 3/11/18, indicated resident #121 had an indwelling catheter with interventions to monitor for urinary tract infections, and change catheter as needed. The care plan lacked interventions to secure the catheter tubing to prevent complications. Interview with the facility's Director of Nursing on 3/15/18 at 10:30 AM indicated the catheter strap should have been secured to the resident to prevent possible complications. Review of facility policy found catheter tubing should be secured to the resident's thigh.

Based on record review and staff interview, the facility and consultant pharmacist failed to address the use of as needed (PRN) [MEDICAL CONDITION] medications for 3 of 5 residents sampled for unnecessary medications (#105, #62 and #27). Findings Include: Resident #62 Review of physician orders [REDACTED]. Further review of the resident's medical record failed to reveal any justification by the physician for continuing an as needed [MEDICAL CONDITION] medication beyond the 14 day time limit for these medications. There were also no consultant pharmicist recommendations for the resident. An interview with the Director of Nursing (DON) was conducted on 3/15/18 at 10:00 am. He confirmed there was no physician justification in the record for continued use of the PRN [MEDICAL CONDITION] medication. On 3/15/18 at 3:14pm, an interview was conducted with the consultant pharmacist in which he stated that he was aware of the 14 day limit on as needed [MEDICAL CONDITION] medications. Resident #27 Review of physician orders [REDACTED]. Review of the resident's medication administration records from 11/9/17 until current found the resident had been receiving an average of 10 doses of the medication per month. There was no physician justification documented in the resident's chart for the continued use of the [MEDICAL CONDITION] medication and there were no pharmacist recommendations for the resident. Interview with the DON on 3/15/18 at 3:15 PM indicated they had not completed audits of resident records who were receiving as needed [MEDICAL CONDITION] medications since requirements changed on 11/28/17. Review of pharmacy visits found he reviewed the resdent's medications every month from (MONTH) (YEAR) through (MONTH) (YEAR). During that time, the pharmacist made no recommendations. Resident #105 Review of the physician orders [REDACTED]. A review of the resident's Medication Administration Record [REDACTED]. An interview with the licensed practical nurse (LPN), Staff I, caring for this resident on 3/14/2018 at 9:20AM revealed resident #105 received this medication on most days, sometimes multiple times per day, for acting out behaviors. Review of the Medication Administration Record [REDACTED]. Further record review failed to provide documentation that this order had been reviewed by the ordering provider within 14 days. The order had not been changed or cancelled since initiated and there was no documented justification by the provider that would provide for continued use of the [MEDICAL CONDITION] medication past the 14 day time limit. A review of pharmacy consultative reports documented a gradual dose reduction (GDR) request on 4/18/17, GDR considerations documented on 3/22/17 with new order from physician on 4/12/17, and GDR considerations documented on 11/28/17. Pharmacist documentation demonstrated GDR considerations approximately every 6 months. On 3/15/2018 at 8:15AM a review of the Medication Administration Record [REDACTED]. An interview with Staff I occurred at this time and confirmed that the medication order was changed due to the resident's frequent need for the PRN medication to be administered for behaviors. An interview with the Director of Nursing (DON) on 3/15/18 at 10:00AM confirmed that no documentation from the ordering provider concerning a review or recommendation for continued use of the PRN order of Klonopin could be located in either the electronic or paper records. The DON left to determine if there were records that had not yet been filed in the record and returned a short time later with notes dated 1/3/2018, 1/15/2018, and 1/24/2018 written by the mental health services consultant which stated that continued use of Klonopin was recommended, but did not include a duration of use. A telephone interview with the consulting pharmacist on 3/15/18 at 3:14PM confirmed that the pharmacist was aware of the 14 day limitation for PRN [MEDICAL CONDITION] medications. The pharmacist went on to explain that his interpretation of this regulation is that the 14 day limitation is to be addressed by the ordering provider and only applies to the initial 14 day period after a medication is ordered. The pharmacist said there is not a requirement to review PRN medications active more than 14 days. The pharmacist stated that he included the PRN medications in the GDR recommendations and that he looks for documentation from the provider to ensure that the ordering provider has reviewed the PRN medications. The pharmacist stated that he leaves a note for the provider if he notices that there are PRN medication orders active for more than 14 days. (No evidence of this could be found during record review.) The pharmacist stated that a practitioner can't review the medication every 14 days; it only has to be done 14 days post initiation of a drug. The pharmacist further stated that he is only in the facility once every month and can't review the medications every 14 days.

Based on record review and interview, the facility failed to provide physician documentation of rationale and medication duration over the 14 day time limit for as needed (PRN) [MEDICAL CONDITION] MEDICATION ORDERS FOR [REDACTED]. The findings were: Review of the MEDICATION ORDERS FOR [REDACTED]. Review of the medical record for resident #62 failed to reveal any justification by the physician for continuing an as needed [MEDICAL CONDITION] medication beyond 14 days and failed to show a duration for the use of the medication. An interview with the Director of Nursing (DON) was conducted on 3/15/18 at 10:00 am. At that time he confirmed that the chart lacked the documentation to continue the as needed order beyond 14 days. Review of physician orders [REDACTED]. There was no identified stop date for the medication Review of the medical record for resident #27 failed to reveal any justification by the physician for continuing an as needed [MEDICAL CONDITION] medication beyond 14 days and failed to show a duration for the use of the medication. Review of physician orders [REDACTED]. A review of the resident's Medication Administration Record [REDACTED]. An interview with the LPN (Staff I) caring for this resident on 3/14/2018 at 9:20AM revealed that the resident receives this medication on most days, sometimes multiple times per day for acting out behaviors. The Medication Administration Record [REDACTED] Review of the medical record for resident #105 failed to reveal any justification by the physician for continuing an as needed [MEDICAL CONDITION] medication beyond 14 days and failed to show a duration for the use of the medication. Interview with DON on 3/15/18 at 3:15 pm indicated the facility had not completed audits of resident records who were receiving as needed [MEDICAL CONDITION] medications since the regulations changed in (MONTH) (YEAR).

Based on observation and interviews, the facility failed to store drugs and biologicals under proper temperature controls and failed to store a schedule IV medication in a separately locked, permanently affixed compartment in 1 of 2 medication rooms reviewed (200 hallway). Findings include: On 3/15/18 at approximately 2:30PM, a review of the medication room on the 200 hallway was conducted with an RN (Staff H) who entered the locked room using a key. A refrigerator temperature log was posted for (MONTH) (YEAR) and was up-to-date as of 3/15/18. Temperatures were documented on the log in the range of 44-46 degrees. Upon inspection of the refrigerator, there were two themometers. The temperature reading on one of them was 50 degrees, and the temperature on the other themometer showed 48 degrees as observed by surveyor and confirmed by Staff H. Two boxes of [MEDICATION NAME] (a schedule IV controlled substance) were in the refrigerator and not secured in a locked compartment; however, a locked and secured container was observed inside the refrigerator where another box of [MEDICATION NAME] was located. Staff H was able to secure one of the boxes of [MEDICATION NAME] inside the locked drawer, but there was not room to fit the other box of [MEDICATION NAME] in it. On 3/15/2018 at 2:42 PM, the Director of Nursing (DON) accompanied the surveyor to the medication room in the 200 hallway and verified that two thermometers were in the refrigerator reading 52 degrees and 48 degrees at that time. The DON removed one of the thermometers and stated that he had ordered a more accurate replacement. He stated the expected temperature range for the refrigerator was between 33 and 46 degrees. The DON also confirmed that a box of [MEDICATION NAME] was in the refrigerator and not secured in a separate locked compartment.

Based on observations and interviews, the facility failed to properly store food items by failing to label prepared stored in a walk-in cooler with preparation or discard dates, failing to prepare foods in a sanitary manner, and failing to maintain appropriate cold storage temperatures for 3 of 3 pantry refrigerators (100 Hall, 200 Hall and 300 Hall). The findings are: On 3/12/18 at 10:30 AM, an initial tour of the kitchen was conducted. The walk-in cooler was observed to contain a tray with 7 small bowels of prepared salad on the second shelf on the left side. The bowels were observed to have no preparation or discard date on them. (Photographic evidence was obtained). Also during the initial kitchen tour, an observation was made of staff F rinsing cooking utensils at the sink located in back of the kitchen. Located directly next to the sink, was a cart containing a pan of cooked carrots and an open container of white colored powder. Water from the shaking of the utensils was observed to splash onto the cart and on the items on the top of the cart. When asked about the powder, staff F stated the powder in the container was a thickener, a powder used to thicken liquids for consumption. When asked if the thickener was in use, staff F stated she was about to use it to add to the pureed foods. (Photographic evidence was obtained of liquid resting on the items on the cart). On 3/12/18 at approximately 11:00 AM, an interview was conducted with the kitchen manager. While speaking with the manager, staff F approached and with the manager present, proceeded to pick up the open container of thickener with four fingers grasping the inside of the container, exposing the powder to her ungloved, visibly dripping wet hand. On 03/15/18 at approximately 2:46 PM, an interview was conducted with the kitchen manager. The manager stated all food items should be labeled with a preparation date when placed in the refrigerator, especially prepared foods because they had to be thrown out after 48 hours and you wouldn't know when that was if there was no date. The manager also confirmed that they had discarded the contaminated container of thickener. Review of the facility's policy, Food Storage Principles, last updated 8/23/16 stated each package, box, can, etc. should be labeled with the expiration date, date of receipt or date of preparation. On 3/15/18, between 11:00 AM and 11:30 AM, temperature checks on the refrigerators in the facility's three nourishment rooms was conducted. The 100 hall temperature was 42 degrees(°) Fahrenheit (F), 200 hall temperature was 48°F and the 300 hall was at 46°F. On 3/15/18 at approximately 11:20 AM, an interview was conducted with staff G, an LPN, who stated the night shift staff were responsible for checking, recording and reporting the refrigerator temperatures. When asked what was done when the temperature was out of range, staff G responded she did not know because they don't check the temperatures during the day, only night shift checks. On 3/15/18, a review of the facility's policy, Storing Refrigerated Foods, last updated 9/28/15, was conducted. The policy stated refrigerators must consistently register between 35 and 41 degrees Fahrenheit for proper food storage. On 03/15/18 at approximately 1:49 PM, an interview with the 200 hall Unit Manager (UM) was conducted. The UM stated the temperature log should show what interventions, if any, were done if the temperatures were out of range. Review of the logs with the unit manager confirmed all the recorded temperatures for the month of (MONTH) (YEAR) had been out of range Review of the facility policy, Cold Food Storage Areas, last updated 8/23/16 stated the temperature should be checked twice daily and should be below 41 F.