Every finding on record at Cypress Cove Care Center

Based on observation, interview, and record review the facility failed to complete assessments for self-administration of medications for 2 (Resident #12 and Resident #75) of 3 residents. Findings include: 1. During an observation of Resident #75's room on 04/27/2026 at 10:13 AM, unsecured medications were present on bedside table. Resident #75 had 2 bottles of Chloraseptic spray. Review of physician orders dated 11/17/2025 for Resident #75 read, Cepacol Extra Strength Mouth/Throat Lozenge 15-2.6 MG (milligram) (Benzocaine-Menthol (Mouth-Throat) Give 1 lozenge by mouth every 8 hours as needed for cough. May Keep at bedside and self-administer. Review of physician orders for Resident #75 there was no order for Chloraseptic.Review of Resident #75's medical record documented no assessment completed self-administration of medications. 2. During an observation of Resident #12's room on 04/27/2026 at 10: 20 AM, unsecured medications were observed on the bedside table, a bottle of Thera Tears and a bottle of Tart Cherry capsules. Review of Resident #12's physician orders dated 11/7/2025 read, Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop in both eyes every 8 hours as needed for dry eyes may keep at bedside. Review of physician orders for Resident #12 documented no order for self-administration. Review of Resident #12 medical record documented no assessment completed to self-administer medications. During an interview with the Director of Nursing (DON) on 04/27/2026 at 11:23 AM she stated her expectations were that all meds [medications] should be secured and not at bedside. During an interview on 04/29/2026 at 1:00 PM the DON stated, The medication self - administration assessment was missing for both [Resident #12's name and Resident #75's name]. The nurse who initiated the orders for both residents should have completed an assessment for self-administration.Review of the facility policy titled, Resident Self- Administration of Medication Policy. approved on 02/18/2026, reads: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self- administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 4. The result of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.

Based on observation, interview and record review, the facility failed to properly secure medications in one of four halls observed for medications unsecured at the bedside. Findings include:During an observation on 04/27/2026 at 10:13 AM unsecured medications were present on bedside table in Resident #75's room. Resident #75 had 2 bottles of Chloraseptic spray.During an observation on 04/27/2026 at 10:20 AM unsecured medications were observed on the bedside table in Resident #12's room, a bottle of Thera Tears and a bottle of Tart Cherry capsules.Review of Resident #12 physician orders dated 11/07/2025, read, Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop in both eyes every 8 hours as needed for dry eyes may keep at bedside.During an interview on 4/27/2026 at 11:15 AM, Staff A, Licensed Practical Nurse (LPN) stated, I was not aware that the resident had medication at bedside, I did not see them.During interview with the Director of Nursing on 04/27/2026 at 11:23 AM, she stated that her expectations were that all meds [medications] should be secured and not at bedside.Review of the policy titled, Medication Storage Policy, approved on 2/18/2026, read, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.Review of the facility policy titled, Resident Self- Administration of Medication Policy. approved on 02/18/2026, reads: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self- administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.

Based on observation, interview, and record review the facility failed to ensure food was stored in a safe and sanitary manner in the main kitchen and in 2 of 2 nourishment rooms. Findings include: A tour of the main kitchen was conducted on 11/18/2024 beginning at 9:44 AM with the Certified Dietary Manager. There was a case of individual serving ice cream containers stored below meat products in the meat freezer. There was a plate of thawed nutritional drinks stored in the walk in refrigerator with no thawed on date inscribed on the individual supplement cartons. There was an undated bag of corn and an undated/unlabeled plastic bags of cookies stored in the walk in freezer. During an interview on 11/18/2024 beginning at 9:44 AM, the Certified Dietary Manager confirmed the individual serving ice cream containers should not be stored below meat products. She confirmed all food products should be dated and labeled. She acknowledged there was no thawed on date inscribed on the thawed nutritional supplements. A tour of Nourishment room [ROOM NUMBER] was completed on 11/18/2024 beginning at 9:59 AM with the Certified Dietary Manager. There were brown and black substances spattered on the interior upper surface of the microwave. There were brown and red substances pooled on the bottom of the refrigerator bins. During an interview on 11/18/2024 beginning at 9:59 AM, the Certified Dietary Manager stated the microwave oven and refrigerator bins needed cleaning. A tour of Nourishment room [ROOM NUMBER] was completed on 11/18/2024 beginning at 10:04 AM with the Certified Dietary Manager. There were brown and black substances spattered on the interior upper surface of the microwave. There was a yellow substance pooled on the bottom shelf of the refrigerator. During an interview on 11/18/2024 beginning at 10:04 AM, the Certified Dietary Manager stated the microwave oven and refrigerator needed cleaning. Review of the policy and procedure titled Food Receiving and Storage, last reviewed 1/17/2024, read 1. Food Services, or other designated staff, will maintain clean food storage areas at all times .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .13. Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits, vegetables and other ready to eat foods.

Based on interview and record review the facility failed to administered physician ordered medications in accordance with professional standards for 2 of 6 residents, Residents #10 and #18, reviewed for medication administration. Findings include: Review of Resident #10's Medication Administration Record (MAR) for November of 2024, the physician's order read, Insulin Glargine Subcutaneous Solution: 100 UNIT/ML (Insulin Glargine) Inject 12 unit subcutaneously at bedtime for diabetes mellites (DM). Start Date 09/19/2024 9:00 PM (2100). Review of Resident #10's physician orders did not provide parameters to hold the Glargine long-acting insulin. Review of the Resident #10's MAR for November 2024 documented the physician ordered Glargine Insulin was held on 11/15/2024 and 11/17/2024 and documented 4: Vitals outside of parameters for administration. Review of Resident #10's Care Plan documented Focus Area - [Resident #10's name] has a physician's order for insulin or hypoglycemic r/t [related to] DM. Goal - Resident will be free of adverse drug reactions from insulin administration through the next review date. Interventions - administer insulin as ordered. Monitor/document for side effects and effectiveness. Monitor and report blood glucose levels per physician's order. Date Initiated: 09/19/2024. Review of Resident #10's Progress Notes did not provide documentation on 11/15/2024 or 11/17/2024 of the blood sugar values at bedtime, notification to the physician when not administering the physician ordered Glargine long-acting insulin, and the reason for not administering the insulin. During an interview on 11/20/2024 at 2:15 PM, the Director of Nursing (DON) stated, For medications that do not have parameters, such as long-acting insulin, the expectation is that if they hold the medication, they notify the doctor. During an interview on 11/21/2024 at 8:40 AM, Physician A stated, I don't recall getting any calls about [Resident #10's name] or giving any orders to hold the long-acting insulin. Usually, we don't hold the long-acting insulin. It's the short-acting [insulin] that's usually the culprit [for dropping blood sugar levels]. If it was just a couple of days, there wouldn't be any significant harm. During an interview on 11/21/2024 at 8:50 AM, Physician B stated, I haven't gotten any calls about [Resident #10's name] insulin, and I did not give any orders to hold her long-acting insulin. If it was held a couple of times, it shouldn't have caused any harm. Review of Resident #18's Medication Administration Record (MAR) for October 2024 documented a physician order which read, Metoprolol Tartrate Tablet 25 MG [milligrams] - Give 1 tablet by mouth two times a day for HTN [hypertension] HOLD for SBP [systolic blood pressure] <110 [less than] OR HR [heart rate] <60 - Start Date 05/23/2020 1700 [5:00 PM]. Review of the documentation of the administration of the Metoprolol documented the medication was held, with a 4: vitals outside of parameters for administration, on 10/19/2024 at 9:00 AM, 10/23/2024 at 5:00 PM, and 10/26/2024 at 9:00 AM. On 10/26/2024 at 5:00 PM documented was 9. 9: Other/See progress notes. Review of Resident #18 vital signs when the medication was held documented on 10/19/2024 the B/P was 110/54; the HR/pulse was 73, dated 10/23/2024 at 4:10 PM B/P 110/50; HR/pulse 88, dated 10/26/2024 at 7:58 AM B/P 110/54; HR/pulse 73 and on 10/26/2024 at 3:33 PM B/P 119/69; HR 76. During an interview on 11/20/2024 at 1:15 PM, Staff C, RN stated, The aids do vital signs at the beginning of the shift. If the blood pressures are low, like with [Resident #18's name] they will let me know. If the reading is off, I will re-take it myself. The certified nursing assistants will tell me all of the vital signs. If [Resident #18's] blood pressure was 112/54 and her pulse rate was 64, I would hold her Metoprolol. I know her and know that she bottoms out. I would check her vital signs again. If it starts getting to be a routine, like three days in a row, I would go ahead and tell the doctor. During an interview on 11/20/2024 at 2:15 PM, the DON stated, The expectation for medications with parameters for metoprolol for example, that would have an order to hold for a [systolic] blood pressure of less than 110, if the blood pressure was below 110, they would hold the medication. If they are holding the medication [outside of the parameters] they will let the doctor know. During an interview on 11/21/2024 at 8:40 AM, Physician A stated, I don't recall getting any calls about [Resident #18's name]. I think we need to do some education with the nurses about Beta Blockers. For Beta Blockers we go with the heart rate, not the systolic blood pressure. We don't hold for B/P, it is the heart rate. If it was just a couple of days, there wouldn't be any significant harm. Review of the policy and procedure titled Medication Administration, last reviewed on 01/17/2024, read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 10. Ensure that the six rights of medication administration are followed: . c. Right dosage . f. Right documentation .

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a safe, secure, and orderly manner for 1 of 6 residents reviewed for medication (Resident #98). Findings include: During an observation on 9/11/2023 at 10:15 AM, a medication cup with four white round pills was on the bedside table in Resident #98's room. During an interview on 9/11/2023 at 10:16 AM, Resident #98 stated, That's just Tylenol. During an observation on 9/12/2023 at 8:03 AM, two medication cups were observed on Resident #98's over bed table. One cup contained 9 white round pills and the second cup contained one round yellow scored pill and a round pink pill. During an interview on 9/12/2023 at 8:03 AM, Resident #98 stated, The pill lady brought those pills to me this morning so I can take them with my breakfast. Review of the clinical record for Resident #98 showed no medication self-administration assessment, no resident-centered care plan related to medication or self-administration of medications and no physician's order for self-administration of medications. During an interview on 9/13/2023 at 10:20 AM, Staff A, Licensed Practical Nurse (LPN), stated, She does not have an order to have medications at her bedside, and that medication shouldn't be there. During an interview on 9/13/2024 at 10:25 AM, the Director of Nursing stated, Residents should not have medication at their bedside. Review of the policy and procedure titled Storage of Medications, last reviewed on 1/17/23, read, Policy Statement. The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, interview, and record review the facility failed to ensure respiratory services were provided in accordance with professional standards for 2 of 5 residents, Residents #89 and #76 reviewed for respiratory care in a total sample of 36 residents. Findings: 1) During an observation on 03/21/2022 at 10:17 AM, Resident #89 was observed in her room lying in bed. Oxygen was being administered to the resident at 2.5 liters via nasal cannula. Review of Resident #89's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/23/2022 at beginning 8:06 AM, Staff A, RN (Registered Nurse) stated she could not find a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #89 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) During an observation of Resident #76 on 3/21/2022 at 9:45 AM the resident was resting in bed with oxygen being administered at 3.5 liters per minute via nasal cannula. During an observation of Resident #76 on 3/24/2022 at 10:00 AM, the resident was resting in bed with oxygen infusing at 3.5 liters per minute via nasal cannula. (Photographic evidence obtained) Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Staff B, RN on 3/24/2022 at 10:10 AM she verified Resident #76 has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, The oxygen concentrator should be set at 2 liters per minute and is currently running at 3.5 liters per minute. During an interview with Staff C, Licensed Practical Nurse (LPN) on 3/24/2022 at 10:15 AM she verified Resident #76's oxygen concentrator was set at 3.5 liters per minute. During an interview with the Director of Nursing (DON) on 3/24/2022 at 10:30 AM she stated it is her expectation that the nurses on the floor would follow the physicians' orders related to oxygen therapy. Review of the policy and procedure titled Administering Medications Last Reviewed: 03/10/2022 read: Facility standard of practice 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review the facility failed to ensure food was stored in a safe and sanitary manner in 1 of 2 nourishment rooms, Station 2. Findings: An observation of the Station 2 nourishment room was completed with the Certified Dietary Manager on [DATE] at 9:30 AM. There were three individual containers of pudding stored in the refrigerator with expiration dates of [DATE]. There was brown speckled debris covering the interior bottom of the refrigerator. During interview on [DATE] at 9:30 AM, the Certified Dietary Manager confirmed the pudding in the three individual containers had expired on [DATE]. She confirmed that there was brown speckled debris covering the interior bottom of the refrigerator and that the refrigerator needed to be cleaned. Record review of the facility policy titled Food Safety for Your Loved One Last Reviewed: [DATE] read: The facility standard of practice Foods or beverages that have past the manufacturer's expiration date should be thrown away. Record review of the facility policy titled Refrigerators and Freezers Last Reviewed: [DATE] read: The facility standard of practice 8. Refrigerators and freezers will be kept clean, free of debris, and wiped with sanitizing solution on a scheduled basis and more often as necessary.

Based on observation and interview, the facility failed to maintain proper sanitation and standards in the food production area and serving kitchen. This has the potential of affecting the entire 93 resident population. (Photographic Evidence). Findings include: During a tour of the kitchen with the Kitchen Manager on 11/2/2020 at 9:25 AM, an opened, undated and unlabeled meat item, was observed, in the walk-in cooler. The item was not in a manufacturer's bag, but a baggie. Review of the item showed approximately five pounds of chicken parts. The bag was thawed in a metal container with a red liquid filling the bag and the pan. During an interview with the Kitchen Manager on 11/2/2020 at approximately 9:45 AM she stated did not know it was there and she did not know how long it was unfrozen. She stated she did not know the plan for the chicken or why it was thawed. She verified there was no labeling or date on the bag or pan. Review of the facility policy for labeling opened foods including meats revealed under #8 All foods stored in the refrigerator or freezer will be covered, labeled and dated.

Based on observation, interview, and policy and procedure review, the facility failed to ensure residents' rights related to dignity for 2 of 4 residents, Residents #37 and #5 in a total of 8 residents with indwelling Foley catheters by not applying privacy covers over the drainage collection bag. Findings include: During an observation 11/03/2020 beginning at 4:16 PM of Resident #37 during medication administration it showed, Resident #37 has an indwelling Foley catheter drainage bag hanging on the right side of the bed closest to the hallway door. The privacy curtain between the two beds was open and the indwelling Foley catheter drainage bag was visible from the hallway. The residents indwelling Foley catheter drainage bag was not covered with a privacy bag. During an interview on 11/03/2020 at 4:18 PM with Resident #37 she stated, I did not know that my catheter bag could be covered by a privacy bag. No-one ever told me. During an interview on 11/03/2020 at 5:08 PM with the resident's primary Licensed Practical Nurse (LPN), Staff A, she stated, I do not know why the resident's indwelling Foley catheter drainage bag is not covered with a privacy bag. The indwelling Foley catheter drainage bag should be covered with a privacy bag, During an interview on 11/03/2020 at 5:28 PM with the resident's primary Certified Nursing Assistant (CNA) Staff B, stated, I put the resident back to bed at the beginning of my shift at 3:00 PM and forgot and left the indwelling Foley catheter drainage bag cover on the resident's chair. I did not cover the residents indwelling Foley catheter drainage bag with a privacy bag after I put her back to bed. I should have replaced the privacy bag after I put the resident back to bed. Review of Resident #37's facility medical record revealed the resident is a [AGE] year old that was admitted to the facility on [DATE]. The record showed the resident's BIMS (Brief Interview for Mental Status) score of 13 (intact cognitive response). During an observation on 11/03/2020 beginning at 5:10 PM of Resident #5 during medication administration it showed Resident #5 has an indwelling Foley catheter drainage bag hanging on his walker which is located closest to the hallway door. The resident's indwelling Foley catheter drainage bag was not covered with a privacy bag. During an interview on 11/03/2020 at 5:16 PM with Resident #5 he stated, What covering, what are you talking about. I have never had a covering for my catheter bag. I have not had a covering since I have been in this facility. During an interview on 11/03/2020 at 5:27 PM with the resident's primary Certified Nursing Assistant (CNA) Staff C she stated, I don't see a privacy bag for this resident. I don't know where his bag is. Review of Resident #5's facility medical record revealed he is [AGE] years old. He was admitted to the facility on [DATE] with a BIMS score of 15 (intact cognitive response). A review of the policy and procedure titled, Quality of Life - Dignity last revised 02/2020 reads - helping the resident to keep urinary catheter bags covered.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care to maintain the highest possible level of functioning and well-being to prevent possible infection of [MEDICAL CONDITION] for 1 (Resident #55) of 2 residents reviewed for skin conditions and to provide foot and/or podiatry care for 1 (Resident #67) of 2 residents reviewed for care out of a total of 36 sampled residents. Findings include: 1. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #55 was observed on 11/2/20 at 1:41 PM. The resident was sitting in his room in a wheelchair. Resident was observed to have three scabbed areas on the right side of his face. One to the right of his right eye, one in the middle of the right cheek and one on the right side of his neck. Residents fingernails of both hands were long, jagged and had dark debris under the nail bed. Resident was observed scratching and picking at the scabs on his face. Resident #55 was observed on 11/3/20 at 3:56 PM. Resident was up in wheelchair in hallway, His fingernails were long, jagged and had dark debris under the nail beds. Resident #55 was observed on 11/4/20 at 8:38 AM. Resident was in wheelchair in his room, picking at the scabs on his face. Residents nails were long and jagged and had dark debris under the nails. Resident continued to pick at his face while observed for approximately 12 minutes. Resident was pleasant and had a calm manner. An interview was conducted with Resident #55's Power of Attorney for healthcare on 11/3/20 at 10:40 AM. She stated that the resident always picks at his skin and the facility doesn't cut his fingernails. An interview was conducted with Staff F, Certified Nursing Assistant (CNA) on 11/4/20 at 8:46 AM. She stated she provides ADL care which includes making bed, getting the resident up and assisting with personal hygiene. Resident #55 was up this morning when she arrived to work. She stated he has some behaviors like abusive language but she just talks to him nicely to keep him calm. She does not usually have any problems with him when providing care. An interview was conducted with Staff G, Registered Nurse (RN) on 11/4/20 at 8:55 AM. She confirmed the resident's nails were long, jagged and had dark debris under the nail beds. She confirmed that he was picking at the scabs on his face. She stated that sometimes he is moody, sometimes he has behaviors, and sometimes he refuses care. She stated this is documented in the resident's clinical record. An interview was conducted with the Director of Nursing (DON) on 11/4/20 at 9:04 AM. She confirmed that the resident's nails were long, jagged and dark debris under the nail beds. She asked the resident if she could cut his nails and he stated ok. An interview was conducted with the DON on 11/4/20 at 1:41 PM. She stated that the resident's picking behavior is monitored. She confirmed that nail care is not documented whether being completed or being refused by the resident. An interview was conducted with the DON on 11/4/20 at 3:10 PM. She stated that the resident's behaviors are monitored each shift. She confirmed that the documentation on behaviors for the last three months revealed that the resident was not having any behaviors which includes his picking behavior and refusal of care. She stated that this is not accurate documentation as the resident has picking behavior all the time. An interview was conducted with Staff H, CNA on 11/5/20 at 9:19 AM. He stated that he cares for Resident #55 often and will tell you no. When that happens, he stated he will reapproach the resident later. He stated that 90% of the time when the resident is reapproached, they can successfully carry out the care that is needed. He provides any ADL care the resident wants. He stated the resident will tell him that when he picks, it is itchy. He will remind him not to pick at his skin. He stated when care was refused or the resident had behaviors it is put in the point of care system. He will report this behavior to the nurse. He stated there is no place to document nail care or refusal of nail care. A review of the task sheet completed at the point of care system by the nursing assistants revealed that from 10/6/20 to 11/30/20 the resident used abusive language on three different occasions, kicking/hitting on one occasion, and yelling/screaming on one occasion. A review of the physician orders [REDACTED]. Check Y if monitored and none of the behaviors observed. Check N if monitored and any of the behaviors are observed and select other/see nurses notes and progress note findings three times a day for behaviors. A review of the Medication Administration Records (MAR) from 8/1/20 through 11/3/20 revealed no documentation of any behaviors by the resident to include refusing care or picking at skin. The documented MAR indicated [REDACTED]. There was no nursing note related to the documentation made by the nursing assistants on their task sheet. A review of Resident #55 progress notes revealed no behavior notes related to refusal of nail care or behavior related to picking at his skin. A review of the Minimum Data Set (MDS) Annual Comprehensive assessment dated [DATE] revealed the resident requires extensive assistance with one person physical assist for personal hygiene. A review of the written plan of care for Resident #55 revealed the resident has a skin tear/bruises potential for fragile skin, 4/2/19 [DIAGNOSES REDACTED]. Interventions include: 10/8/20 Encourage and assist resident with keeping fingernails trimmed and smooth. 10/8/20 Redirect resident when noted that he is scratching self. Monitor skin for rashes or skin irritation. Encourage resident to keep fingernails trimmed and smooth and provide nail care. A review of the Annual Care Plan Review dated 9/18/20 revealed the following: continues in a terminal condition and comfort measures continue. Is helped in all areas as needed and accepts this fact. Makes needs known and aware of conditions, forgetful, and confused at times. 2. Is able to cooperate and tolerate all care and he is neatly groomed and clean as he liked in the past. Does what he can for himself. Is accepting of all interventions, will continue. 7. Goal and interventions address the potential for skin tears and bruises due to his overall medical conditions and fragile skin and he is closely watched and monitored. #2. During an observation on 11/02/20 at 11:19 AM, Resident #67's toe nails were seen as long, discolored with some nails curling around her toes (photographic evidence). During an interview on 11/03/20 at 3:45 PM, Resident #67 confirmed she can perform her own hand nail care, but is unable to care for her toenails. Resident said her toe nails need to be cut and too long. Resident has not been offered any assistance with her toe nails. She also stated concerns about her foot and toe nail care because of her diabetes. A record review of Resident #67's orders revealed an admission order for a podiatry consult as needed. Resident has a care plan for activities of daily living (ADL) started on 10/15/2020. The ADL care plan revealed for bathing that Resident can wash upper body, needs assistance from one staff member for lower body, and set up of supplies for personal hygiene with assistance from staff if needed. During an interview on 11/04/20 at 03:14 PM, Staff I (Licensed Practical Nurse) confirmed she has been caring for Resident over past couple weeks. Staff stated the Certified Nursing Assistants (CNAs) are helping with bed baths in the quarantine unit. Staff confirmed CNAs should be giving head to toe care for skin and notifying nurse of any concerns including long toe nails. Staff confirmed that no CNA had reported Resident #67's long toe nails and had not observed them herself.

Based on observation, interview, and record review, the facility failed to accurately document behaviors and refusals of care related to skin care for 1 of 2 residents reviewed for skin conditions in a total sample of 36 residents. Findings include: A review of the facility policy titled Requesting, Refusing and/or Discontinuing Care or Treatment dated revised May 2017, annually reviewed on 1/15/20 reads Policy Statement: Residents have the right to request, refuse and/or discontinue treatment prescribed by his or her healthcare practitioner, as well as care routines outlined on the resident's assessment and plan of care. Policy Interpretation and Implementation. 1. Residents/representatives will be informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment and plan of care. 11. Detailed information relating to the request, refusal or discontinuation of care and treatment will be documented in the resident's medical record. 12. Documentation pertaining to a resident's request, discontinuation or refusal of treatment shall include at least the following: a. the date and time the care or treatment was attempted; b. the type of care or treatment; c. the resident's response and stated reason for request, discontinuation or refusal; 4. the name of the persona attempting to administer the care or treatment; e. the resident was informed of the purpose of the treatment and potential outcome of not receiving the medication/or treatment; f. The resident's condition and any adverse effects due to the request; g. the date and time the practitioner was notified as well as the practitioner's response; h. all other pertinent observations; and i. the signature and title of the person recording the data. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #55 was observed on 11/2/20 at 1:41 PM. The resident was sitting in his room in a wheelchair. The resident was observed to have three scabbed areas on the right side of his face. One to the right of his right eye, one in the middle of the right cheek and one on the right side of his neck. The resident's fingernails of both hands were long, jagged and had dark debris under the nail bed. The resident was observed scratching and picking at the scabs on his face. Resident #55 was observed on 11/3/20 at 3:56 PM. The resident was up in a wheelchair in the hallway. His fingernails were long, jagged and had dark debris under the nail beds. Resident #55 was observed on 11/4/20 at 8:38 AM. The resident was in a wheelchair in his room, picking at the scabs on his face. The resident's nails were long and jagged and had dark debris under the nails. The resident continued to pick at his face while observed for approximately 12 minutes. An interview was conducted with Staff F, Certified Nursing Assistant (CNA) on 11/4/20 at 8:46 AM. She stated she provides ADL (activities of daily living) care which includes making beds, getting the residents up and assisting with personal hygiene. Resident #55 was up this morning when she arrived to work. She stated he has some behaviors like abuse language, but she just talks to him nicely to keep him calm. She does not usually have any problems with him when providing care. An interview was conducted with Staff G, Registered Nurse (RN) on 11/4/20 at 8:55 AM. She stated that sometimes he is moody, sometimes he has behaviors, and sometimes he refuses care. She stated this is documented in the resident's clinical record. An interview was conducted with the Director of Nursing (DON) on 11/4/20 at 1:41 PM. She stated that the resident's picking behavior is monitored. She confirmed that nail care is not documented whether being completed or being refused by the resident. An interview was conducted with the DON on 11/4/20 at 3:10 PM. She stated the resident's behaviors are monitored each shift. She confirmed that the documentation on behaviors for the last three months revealed that the resident was not having any behaviors which includes his picking behavior and refusal of care. She stated that this is not accurate documentation as the resident has picking behavior all the time. An interview was conducted with Staff H, CNA on 11/5/20 at 9:19 AM. He stated that he cares for Resident #55 often and he will tell you no. When that happens, he stated he will reproach the resident later. He stated that 90% of the time when the resident is reproached, they can successfully carry out the care that is needed. He provides any ADL care the resident wants. He stated the resident will tell him he picks because it is itchy. He will remind him not to pick at his skin. He stated when care was refused, or the resident had behaviors it is put in the point of care system. He will report this behavior to the nurse. He stated there is no place to document nail care or refusal of nail care. A review of the task sheet completed at the point of care system by the nursing assistants revealed that from 10/6/20 to 11/30/20 the resident used abusive language on different occasions, kicking/hitting on one occasion, and yelling/screaming on one occasion. A review of the physician orders revealed dated 10/15/19 Monitor behaviors including and refusing care. Check Y if monitored and none of the behaviors observed. Check N if monitored and any of the behaviors are observed and select other/see nurses notes and progress note findings three times a day for behaviors. A review of the Medication Administration Records (MAR) from 8/1/20 through 11/3/20 revealed no documentation of any behaviors by the resident to include refusing care or picking at his skin. The documented MAR indicated [REDACTED]. There was no nursing note related to the documentation made by the nursing assistants on their task sheet.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible spread of infection. The facility failed to prevent the possible cross contamination in the handling of the soiled linen from the clean linen in the laundry room, and failed to ensure the staff donned the required Personal Protective Equipment (PPE) for resident care on the COVID-19 Dedicated Unit, for Resident #32 and Resident #71, in a total sample of 36 residents. Findings include: 1. The initial observation of the laundry room on 11/04/2020 beginning at 9:14 AM, showed no staff present in the laundry room. The door between the soiled laundry and the clean laundry areas was propped open with an uncovered trash can containing soiled items. An observation of the laundry room on 11/04/2020 beginning at 9:15 AM when the Laundry Supervisor and Staff D, Laundry Aide, arrived to the laundry room, showed two of two washing machines loaded and washing. An orange rolling container with no lid or top was stationed next to a washing machine. The door between the washing machine and the soiled linen area was propped open with an uncovered trash can, filled with trash. The door had a sign which read, Keep door closed at all times. There were two dryers engaged with linen inside. There was clean linen folded and hanging in the dryer area. There was an uncovered rolling container of clean linen parked in the doorway between the soiled and clean linen areas. There was a large portable fan moving at full speed, about five feet from the doorway to the soiled linen room. (Photographic Evidence) During an interview on 11/04/2020 at approximately 9:20 AM, Staff D, Laundry Aide, stated they move the soiled linens to the washing machine from the carts in the soiled linen room. The rolling container of clean linen would be contaminated by the soiled linen when they put the soiled linen in the washing machine. She added that the rolling clean linen container was placed there because they had no other room for it. Review of the facility policy for Infection Control and Prevention, under Linens read, . must handle, transport, process, and store all contaminated linens in a manner that prevents the spread of infectious organisms to another individual or surface. This will include preventing contact between your skin, mucous membranes, and clothing and contaminated linens. The Policy titled Departmental (Environmental) Laundry and Linen, under Standard Precautions, #1, reads, Separate soiled and clean linen at all times and under Washing Linen and other Soiled Items #6, Keep soiled and clean linen and their respective hampers and laundry carts, separate at all times, #7. Clean linen will remain hygienically clean, through measures designed to protect it from environmental contamination, such as covering clean linen carts. During an interview with the Laundry Supervisor and Staff D, Laundry Aide, on 11/04/2020 at 9:35 AM, they confirmed the door between the soiled and clean laundry areas was propped open and should be closed at all times to prevent cross contamination. 2. An observation of the COVID-19 Dedicated Unit on 11/02/2020 at 10:50 AM, showed isolation signs were hung in doorway thresholds, which read, DROPET PRECAUTIONS - Attention: Family, visitors, and Associates, before entering please carefully review the instructions below. (door may remain open). Personal Protective Equipment Requirements, beneath this it showed pictures of, two people wearing gowns and masks, a picture of a mask, a picture of a person with a face shield, and a picture of a person wearing a gown and gloves. Beneath the pictures it showed, Mask, Gown, Eye protection, Gloves. (Wear gown upon entering the room if substantial contact with the resident or their environment is anticipated). Equipment - beneath this was pictures of a sphygmomanometer (blood pressure cuff), a thermometer, and a stethoscope. Beneath the pictures it read, Disposable or dedicated to Resident. Clean and disinfect all equipment before leaving this room. Hand Hygiene - Upon entering and leaving the Resident's room wash/sanitize your hands; Remove gloves and gown, then perform hand hygiene. (Photographic Evidence) During an observation of the COVID-19 Dedicated Unit on 11/02/2020 at 12:40 PM, Staff K, Certified Nursing Assistant (CNA), was observed entering Resident #32's room to answer their call light but did not put on gloves. Staff K adjusted the linens covering Resident #32 with bare hands. Review of Resident #32's records revealed the resident was on droplet precautions. During an observation on the COVID-19 Dedicated Unit on 11/02/2020 at 12:57 PM, Staff J, CNA, was feeding Resident #71 without gloves on. Review of Resident #71's records revealed the resident was on droplet precautions. Review of the facility's policy titled Disaster Preparedness, last revised on 09/30/2020, read, 39. The facility will make every effort to comply with the new guidance issued by CMS (Centers for Medicare and Medicaid Services) on 04/03/2020 in regards to Full PPE should be worn per CDC (Centers for Disease Control and Prevention) guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. If COVID-19 (Coronavirus Disease 2019) transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED]. During an interview on 11/04/2020 at 10:13 AM, the Infection Preventionist (IP) stated, When caregivers enter a resident's room on the COVID-19 Dedicated Unit, they need to wear gown, gloves, mask, and face shield or goggles if providing any care. The IP confirmed staff were not following droplet-based precautions appropriately when they failed to wear gloves when touching linens and feeding residents on the COVID-19 Dedicated Unit.

Based on observation, interview and facility policy, the facility failed to ensure food was served at the appropriate temperatures established by Food Code Standards (hot food at or above 135 degrees Fahrenheit (*F) and cold foods at or below 41*F), and in maintaining sanitary standards for the prevention of food borne illness, affecting the entire 113 resident population. Findings: An observation of the main tray line service area was conducted on 5/08/2019 beginning at 7:16 AM. The observation was conducted with the facility Food Services Director/Certified Dietary Manager (FSD/CM). A calibrated digital thermistor thermometer was utilized for the observation and temperature validation. All hot food items served as well as a selection of cold items were checked for temperature validation to ensure Food Code Standards were being adhered to, hot foods at or above 140*F and cold foods at or below 41*F. Sanitation technique was also observed during the observation. Areas of concern identified included: a.) The staff person taking the temperatures initially sanitized the thermometer with an alcohol wipe before starting, however she used an up and down swiping motion, running the alcohol pad back and forth over the probe, recontamination with each swipe. The probe was then placed into the pan of oatmeal. Once the temperature was obtained, she removed the thermometer and using the same wipe she used initially, wiped the thermometer, using the up and down motion again for cleaning the thermometer. She then placed the thermometer into the next pan of fortified oatmeal. She failed to utilize a sanitized thermometer between pans. After the temperature of the pureed sausage was obtained, she used a new alcohol wipe, wiping it back and forth, contaminating the thermometer. This back and forth motion when wiping the thermometer was observed with each of the nine pans checked. She reused the same wipe on three (3) separate pans of food in the steam table, which included the fortified oatmeal, scrambled eggs and mechanical sausage. b.) The temperature of the sausage links was checked. She initially speared down through multiple pieces instead of going into the middle of individual portions of meat in order to obtain the internal center temperature of the pieces. When the pieces were checked individually, through the middle of the sausage, the temperatures failed to meet the minimum 135*F standard for hot foods. The temperatures read 109*F, 115*F and 110*F, all well below the 135*F standard. The pieces were checked at different layers of the pan. c.) The temperature of a selection of cold food items was checked. The 4 ounce cup of Yogurt, when checked at 7:35 AM was 52.6*F or well above the standard of at or below 41*F. Each of the observations found out of compliance was discussed with the Food Services Director. The actions as observed were confirmed as occurring. A review of the facility policy and procedures was conducted, specific to the areas identified. The policy, Holding Hot and Cold Potentially Hazardous Foods included: Purpose: To prevent food borne illness by ensuring that al potentially hazardous foods are held under the proper temperature. Instructions: Hold hot foods at 140*F or above. Hold cold foods at 41*F or below. Monitoring: If the temperature does not maintain 140*F or above, the food must be reheated to 165*F for 15 seconds; food can only be reheated once. All cold potentially hazardous foods should be 41*F or below for meal service.

Based on observation, interview and record review, the facility failed to ensure a baseline care plan was implemented specific to renal restrictions for 1 (Resident #424) of 3 baseline care plans reviewed. Findings: A review of the medical record for Resident #424 revealed she was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. During an observation on 5/07/2019 at 8:10 AM, Resident #424 was observed receiving a tray which included a 6 ounce glass of orange juice. During the same observation, the resident was observed drinking the orange juice from the tray. Review of the diet slip for the resident revealed the resident was on a special diet which consisted of a fluid restriction of 1200 ml, Low Concentrated Sweets (LCS), no added salt (NAS), no potato, tomato, banana, orange juice or oranges. The resident's Baseline care plan (dated 05/06/2019) includes the relevant interventions concerning the focus area listed below: 1) The resident is at nutritional risk related to [MEDICAL CONDITIONS]. Interventions included: Diet as ordered: LCS (Limited Concentrated Sweets), NAS (No Added Salt), chopped meat texture, no bananas, oj (orange juice), oranges, potatoes, tomato products; RD (Registered Dietitian) to evaluate and make recommendations PRN (as needed). An interview was conducted on 05/08/2019 at 8:47 AM. The resident stated she drank the entire glass of orange juice after her breakfast received the day before. An interview with the Consultant Dietitian conducted on 05/08/2019 at 9:21 AM, confirmed the resident is on a special diet and should not have been served orange juice with her breakfast. She also added the resident had physician's orders [REDACTED]. That order would have been put into effect immediately. A review of the Consultant Dietitian's nutritional assessment dated [DATE] confirmed the resident was on a LCS, NAS, no bananas, orange juice, oranges, potatoes, tomato diet.

Based on observation, record review and interview, the facility failed to ensure resident-specific Care Plans were implemented for 1 of 5 residents reviewed for Unnecessary Medications and 1 of 3 residents for nutrition, Resident #104. Findings: 1.) A review of the medications Resident #104 was prescribed included an order initiated on a telephone order blank (TO) dated 4/12/2019. The order specified, [MEDICATION NAME] 0.25 mg 1 PO (by mouth) BID (twice daily) PRN (as needed) for 14 days only. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) confirmed the medication has been administered as needed, however the order was still active as of 5/08/2019 and exceeded the 14-day ordered timeframe, with day 14 being 4/26/2019. The medication was administered during the first 5 days of May. A review of the resident's Care Plans included: 1.) Resident yells out frequently throughout the day. She also throws objects. Family stated she has a history of these behaviors and that she believes it is attention seeking. Interventions include: Administer meds as ordered, monitor/document for side effects and effectiveness. An interview was conducted with the Director of Nursing on 5/08/2019 at 10:50 AM. The order in the medical record, paper chart was reviewed as were the computerized Medication Administration Records (MARs). The records were reviewed for (MONTH) and (MONTH) 2019 confirming the medication was still active in May, having been administered 4 times prior to the 5/08/2019 interview with staff. A follow up interview with the Director of Nursing was conducted at approximately 12:55 PM. A copy of the resident's Care Plan was provided by the Director of Nursing. The intervention of administration was confirmed. A follow up interview was conducted with the facility Consultant Pharmacist on 5/08/2019 at 12:48 PM. She confirmed there had not been a stop date identified when the order was written on 4/12/2019 with the medication not being stopped per the order after the 14 days, but continued to be adminstered. 2.) A review of the medical record for Resident #104 revealed the resident has a history of significant behavioral issues, poor PO (by mouth) consumption and very erratic eating patterns. The resident was admitted to the facility on [DATE]. The resident has a limited concentrated sweets (LCS), no added salt (NAS) mechanical soft texture, nectar thickened liquids. A review of the resident's weight history included: 03/04/2019: the resident weighed 153.0 # on admission, 3/06/2019: 153.2# 3/11/2019: 153.6# 4/10/2019: 138.4# 4/23/2019: 130.2# 5/01/2019: 32.6 pounds which is a -13.33 % Loss in less than 6 months. An observation of the resident's breakfast was conducted on 5/08/2019 at 7:56 AM. She was fed by a staff Certified Nursing Assistant (CNA) who confirmed the resident is in a very good mood this morning, and ate well for her. Areas of concern were identified on her tray. They included: Health Shake x1 4 ounce: 75% consumed. (Two (2) shakes are ordered, not 1). Sausage links x 2 cut up in 1/2 inch pieces by staff: 5% consumed (not mechanically altered). A salt packet observed on tray when observed with the Registered Dietitian (RD) at 8:07 AM. She confirmed the salt should not be on the tray. An interview was conducted with the CNA who fed her at 8:10 AM. She confirmed the tray came from the kitchen with the salt packet on it. A review of the resident's Care Plan included: 1.) Resident is at nutritional risk related to decreased PO intake and dementia. Receives a mechanical soft, low concentrated sweets, no added salt diet with nectar thick liquids related to [DIAGNOSES REDACTED]. Potential for weight fluctuations related to changes in [MEDICAL CONDITION] and diuretic use; recent significant weight decline. Diet as ordered. Monitor weekly weights. Supplements as ordered; sugar free med pass 120 cc's PO TID Sugar Free shakes x 2 with meals. (Revised 5/07/2019). It was confirmed the Care Plan developed for the resident specific to the weight monitoring weekly, the diet as ordered and use of supplements was not implemented as written.

Based on record review and interview, the facility failed to ensure a [MEDICAL CONDITION] medication ([MEDICATION NAME]) scheduled for PRN (as needed) use, was limited to the identified order of 14 days with follow-up and renewal ordered for 1 of 5 residents reviewed for the Unnecessary Medication review, Resident #104. Findings: A review of the medications Resident #104 was prescribed included an order initiated on a telephone order blank (TO) dated 4/12/2019. The order specified, [MEDICATION NAME] 0.25 mg 1 PO (by mouth) BID (twice daily) PRN (as needed) for 14 days only. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) confirmed the medication has been administered as needed, however the order was still active as of 5/08/2019 and exceeded the 14-day ordered timeframe, with day 14 being 4/26/2019. The medication was administered during the first 5 days of May. An interview was conducted with the Director of Nursing on 5/08/2019 at 10:50 AM. The order in the medical record, paper chart was reviewed as were the computerized Medication Administration Records (MARs) reviewed for (MONTH) and (MONTH) 2019 confirming the medication was still active in May, having been administered 4 times prior to the 5/08/2019 interview with staff. A follow up interview was conducted with the facility Consultant Pharmacist on 5/08/2019 at 12:48 PM. She confirmed there had not been a stop date identified when the order was written on 4/12/2019 with the medication not being stopped per the order after the 14 days, but continued to be adminstered

Based on observation record review and interview, the facility failed to ensure medication administration and storage for one (Resident #65) of 28 residents reviewed. The findings included: An observation of Resident #65 on 3/26/18 at approximately 9:40 AM revealed he was laying on his side, in his bed, facing the wall. A medicine cup with five (5) pills was on the over bed table to the side of his bed. There were no staff in the room. Registered Nurse (RN)/Staff A was down the hall and was asked to observe the medications on the over bed table. She picked up the medications cup and Resident #65 grabbed them out of her hand. He refused to take them or give them back. He suddenly moved very close to the nurse and raised his voice, stating he would take them when he was ready. RN/Staff A moved back out of the room. At approximately, 9:55 AM, during an interview Resident #65 stated the nurses always administer the medications in two visits. He stated they give him the big pills first. When he has swallowed those, they give him the second medication cup with the smaller pills. He stated they leave them on his table. He stated he does not like the nurses watching him take the medications and he does not have to tell them when he takes them. He stated he does not let the medications out of his sight. He stated all of the nurses pass his medications in this manner. An observation of Resident #65's room at approximately 10:30 AM revealed an empty medication cup on the over bed table. It was unknown what happened to the medications. He refused to say he took the medications. A review of the locked box in his bedside drawer revealed chest rub, two bottles of rubbing alcohol and one bottle [MEDICATION NAME]([MEDICATION NAME]). During an interview with RN/Staff A and floor nurse to Resident # 65 on 3/26/18 at 9:50 AM, she stated he refuses to take the medications when she hands them to him. She stated he takes the first cup, then she brings the second cup and he insists she leave them on the table. She had no information as to how she determines if he takes them. She confirmed she did not see him take the medications. She stated this is typical behavior for this resident. She stated the bottle [MEDICATION NAME] in the locked box in his nightstand, was a 24 count. She counted the pills left in the bottle, with a result of two. She stated she did not know the medications were in the locked box. During an interview with the Social Services Director (SSD) on 3/27/18 at 10:00 AM, she had no other available phone numbers for Resident #65's family, to discuss the possibility they brought the bottle [MEDICATION NAME] put it in Resident #65's locked box. Two messages were left for the family at the phone numbers available. Review of Resident #65's record revealed the (MONTH) (YEAR), Medication Administration Record (MAR) revealed a Physician's order for bedside medications for rubbing alcohol and chest rub, only. Nurses, meaning the medications were taken by Resident #65, initialed the boxes. The [MEDICATION NAME] and [MEDICATION NAME] were initialed by RN/Staff A as administered by the nurse on 3/26/18 at 9:00 AM. The MAR did not list the [MEDICATION NAME] as a bedside medication. The [MEDICATION NAME] is a PRN medication. There were no initialed boxes signifying any [MEDICATION NAME] was taken during the months of (MONTH) (YEAR), or (MONTH) (YEAR). There was no documentation for monitoring the locked boxes by the nurses. Review of Resident #65's record revealed a Safety Screen for Self Administration of Medication dated 2/23/2018. It determines the Resident may self-administer medications unsupervised. The only medications authorized were rubbing alcohol and chest rub. There was no approval for [MEDICATION NAME]. His Minimum Date Set dated 2/12/18 notes he has a Brief Interview for Mental Status (BIMS) score of 15, which means cognitively intact and aware. Review of Resident #65's Care Plan dated 1/29/18 directs the resident to communicate to the nurse the times the medications were taken. Under the Focus it states he does not like to be asked if and when he has used the medications and becomes angry when asked. Says he will let us know. Under #5, it directs the med nurse to document on med mars and in progress notes when med was used, time used, frequency, side effects and effectiveness. Further, it directs, med nurse will not ask resident if med was used during time frame between med passes and for what reasons. He becomes angry and wants to let us know when he uses them. Review of Resident #65's record revealed the following Progress Notes: 3/26/18 9:05 AM refused to take the pills while nurse in the room, raised his voice stating he would take them when he was ready and they could not be removed from the room. 3/10/18 resident yelling at the nurse when she tried to explain his pills, another nurse called to intervene and MD notified 3/6/18 resident yelling, using profanities, threatening staff due to a medication, staff tried to explain, notified MD, medication reinstated and given to resident ([MEDICATION NAME]). 2/19/18 Plan of Care Note under #2 states impaired cognitive function/dementia or impaired thought processes, short term memory loss and helped in all areas with cognition and decision making. Family notified and agreed to room change. 1/22/18 the Registered Nurse writes she observed resident attempting to inflict physical blow onto roommate. She intervened and stopped action. He started explicit language to writer. She removed the roommate and placed him in another area for safety. 1/22/18 subsequent to the above entry, the Social Services Director (SSD) wrote he denied hitting or trying to hit anyone. He stated he had a problem with the facility not his roommate. He refused to go to another facility. 1/29/18 the resident was provided a bigger medication lock box for bedside medications (rubbing alcohol and chest rub), stated resident does not want nurses asking him if he had used his bedside medications, he said he will tell the nurses if he uses them. His family will provide the medications. 12/3/17, 12/4/17, 12/6/17, 12/7/17, 12/11/17, 12/12/17, 12/13/17, 12/14/17, 12/16/17, 12/17/17, 12/18/17, 12/20/17, 12/23/17, RN/Staff A wrote refuses to tell staff when he uses medications, Becomes agitated when asked and begins to yell. Review of Resident #65's MAR for (MONTH) (YEAR) revealed orders for the following medications: [REDACTED] [MEDICATION NAME] 250 milligrams (mg) every (Q) 8 hours as needed (PRN), [MEDICATION NAME] 60 mg every day (QD), [MEDICATION NAME] 12.5 mg QD, [MEDICATION NAME] 40 mg Q AM, [MEDICATION NAME] 5 mg twice a day (BID), [MEDICATION NAME] 81 mg QD. For Bedside Medications the order is for the chest rub and the rubbing alcohol. Review of the facility policy for Medication Administration under #21, it stated remain with the resident until all medications have been taken and under #1, will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. The Policy for Self Administration stated under #9, staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration During a telephone interview on 3/27/18 at 9:05 AM, the Registered Nurse Practitioner stated the Physician was out of the office for the week. She did not have knowledge of the medications left at Resident #65's bedside yesterday, his refusal to cooperate with the nurses when taking the medications nor his aggressive behavior. She confirmed the medications should not be left at bedside as well as the nurse not observing the resident taking the medications. She confirmed the resident might not be a good candidate for self-administration of medications. During interviews with Licensed Practical Nurses (LPN)/Staff B, C and D, floor Nurses, on 3/27/18 beginning at 8:15 AM, they stated if the resident refused the medications then they document it in the MAR and notify the physician the resident did not take the medications on this date. They denied giving residents medications without ensuring they took them. During an interview with the Director of Nursing (DON) and the Risk Manager on 3/27/18 at 11:00 AM, the DON confirmed RN/Staff A told her she left the medication cup at bedside for Resident #65. The DON confirmed RN/Staff A did not observe the resident take his medications. DON confirmed RN/Staff A did not inform the DON about the bottle [MEDICATION NAME] in the locked box in Resident #65's room. The DON confirmed he does not have an order for [REDACTED]. The DON confirmed the resident does not cooperate with communicating to the nurses about the medications he takes. The DON confirmed there had been no reassessment for Self Administration of Medications after [MEDICATION NAME] found. The DON confirmed their present form of assessment is not reflective of Resident #65's lack of cooperation with the nurses. During an interview on 3/28/18 at 12:00 PM, the Pharmacist confirmed the nurse needed to observe the medication was ingested. She confirmed the nurse should not have left the medications in the room.

Based on observation, interview and record review, the facility failed to store, prepared and serve food in a safe and sanitary manner. Findings: 1. During the initial tour of the Kitchen on 5/1/2017 beginning at 9:45 AM, An observation of the large reach in refrigerator revealed no thermometer was present inside the refrigerator. An interview was conducted with the cook, Staff A on 5/1/2017 at 9:55 AM. She confirmed she recorded the temperature this morning on the temperature log. She confirmed she used the thermometer on the outside of the refrigerator for the temperature reading. An interview with the Certified Dietary Manager (CDM) on 5/1/2017 at 9:55 AM confirmed no thermometer was present inside the refrigerator. A review of the facility policy entitled Refrigerator/Freeezer Temperatures dated 1/1/16 reads under #2 Record temperatures using the inside thermometer only in the morning and evening. 2. During the initial tour of the Kitchen on 5/1/2017 beginning at 9:45 AM an observation of the large walk in refrigerator revealed 8 cups of pineapple chunks and 6 cups of chocolate pudding were undated. An interview with the CDM on 5/1/2017 at 9:55 AM confirmed 8 cups of pineapple chunks and 6 cups of chocolate pudding were undated. She further stated that every item in the refrigerator should be dated. During the initial tour of the kitchen on 5/1/2017 beginning at 9:45 AM an observation of the reach-in cooler revealed 13 whole sandwiches of which 8 whole sandwiches were not dated (photographic evidence obtained). An interview with the CDM on 5/1/2017 at 10:00 AM confirmed the undated sandwiches. A review of the facility policy entitled Food Receiving and Storage dated ' revised December 2008 ' reads under #7 All foods stored in the refrigerator or freezer will be covered, labeled and dated opened or prepared date. 3. During the initial tour of the kitchen on 5/1/2017 beginning at 9:45 AM 2 muffin pans were observed with built up brown and black substances on the outside and the inside of the muffin pans (photographic evidence obtained). An interview with the cook, Staff A, on 5/1/2017 at 10:00 AM confirmed the muffin pans needed to be cleaned. 4. During the initial tour of the kitchen on 5/1/2017 beginning at 9:45 AM, a 3-tiered rolling cart was observed with clean plate covers on it. The 3-tiered cart had spilled debris on the 1st and 2nd tiers of the cart (Photographic evidence obtained). An interview with the CDM on 5/1/2017 at 10:00 AM confirmed the 3-tiered cart has spilled debris on the 1st and 2nd tiers of the cart. 5. An observation of the trayline and lunch service was conducted on 5/3/2017 beginning at 10:52 AM. The cook, Staff B, was observed removing plates from the plate warmer by reaching into the area where the plates are stacked, putting her hand on sides of plates extending her thumbs into the center of the plates in order to pull them up from the plate warmer. An interview was conducted with Staff B on 5/3/2017 at 11:30 AM. She stated she did not know any other way to get the plates out. She stated she thinks that the spring in the warmer that is suppose to raise the plates up, is on order. She confirmed she put her thumbs in the eating area of the plates. Further observation of Staff B during lunch service revealed she picked up 2 clean bowls with her fingers extended inside of each of the bowls then served a side of vegetables in each bowl. An interview was conducted with Staff B on 5/3/2017 at 11:30 am. She confirmed she put her fingers into the bowls touching the eating area of the bowls while serving lunch. An interview was conducted with the CDM on 5/3/2017 at 11:40 AM. She confirmed Staff B should not have put her fingers on the eating area of the plates and bowls.

Based on interview and record review, the facility failed to implement the plan of care for a resident who self-administers topical pain medications for 1 (Resident #169) of 3 reviewed for pain of 26 sampled residents. Findings: Resident #169 was admitted in the facility on 4/6/16 with a [DIAGNOSES REDACTED]. A record review of the physician's orders [REDACTED]. Further review revealed an order dated 1/5/17 for [MEDICATION NAME] Sodium Gel 1%, apply to lower extremities and hands topically every 6 hours as needed for pain, patient may keep it at bedside. Review of the care plan revealed a focus dated 6/14/16 reads Wants to self administer sombra and keep at bedside and dated 11/18/16 [MEDICATION NAME] Sodium Gel 1% apply to lower extremities topically every 6 hours as needed for pain (Patient can keep it at bedside). The care plan goal reads Will be able to safely store and self-administer desired meds per order as deemed able by Doctor, Nurses and Interdisciplinary Team (IDT). Will be able to verbalize indications for use, frequency of use and any potential side effects when asked every day, 7 times a week. The care plan interventions included the following: Med nurse to ask resident if med was used during time frame between med passes and for what reason. A review of the Medication Administration Record [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 05/04/2017 at 10:21 AM . She stated she was unaware that the nurses were not asking if the PRN topical medications Resident #169 was self administering were being used and she stated she was unaware they were not recording the information on the MAR. She stated that without the information from Resident #169 regarding his use of self-adminstered topical pain medications, the facility does not know whether the treatment is effective or whether it is time to reorder the medication. She confirmed there was no way of knowing if he was using the medication as prescribed.

Based on observation and interview, the facility failed to maintain essential kitchen equipment in a safe operating condition, specifically the plate warmer. Findings: An observation of the trayline and lunch service was conducted on 5/3/2017 beginning at 10:52 AM. The cook, Staff B, was observed removing plates from the plate warmer by reaching into the area where the plates are stacked, putting her hand on sides of plates extending her thumbs into the center of the plates in order to pull them up from the plate warmer. An interview was conducted with Staff B on 5/3/2017 at 11:30 AM. She stated she did not know any other way to get the plates out. She stated she thinks that the spring in the warmer that is suppose to raise the plates up is on order. She confirmed she put her thumbs in the eating area of the plates. An interview was conducted on 5/4/2017 at 11:25 AM with Staff B. She stated the plate warmer is still not working correctly. The plates still will not raise up as the plates are lifted off. She stated maintenance came in and worked on it yesterday and said the spring in it needs to be replaced. An interview was conducted on 5/4/2017 at 11:45 AM with the CDM. She stated the plate warmer is still not working and a spring needs to be ordered.