Every finding on record at Farmington Wellness & Rehabilitation

Based on observation and interview, the facility failed to promote care with dignity and respect for 16 residents observed during a random dining observation when the facility did not serve breakfast at the same time to all the residents seated at the same dining table. This deficient practice could likely result in residents feeling frustrated and disappointed. The findings are:A. On 05/05/26 at 7:16 am, a breakfast observation in the dining room revealed the following:1. Two residents sat at the same table waiting for breakfast to be served:a. The first resident was served their meal at 7:37 am and the second resident watched the first resident ate their meal.b. The second resident was served their meal at 7:53 am. 2. Four residents sat at the same table waiting for breakfast to be served:a. The first resident was served their meal at 7:35 am and the other three residents watched as the first resident ate their meal.b. The second resident was served their meal at 7:39 am and the other two residents watched as the first and second residents ate their meals.c. The third resident was served their meal at 7:52 am and the last resident watched as the other three residents ate their meals.d. The fourth resident was served their meal at 7:57 am and the first resident had completed their meal. 3. Three residents at the same table waiting for breakfast to be served:a. The first resident was served their meal at 7:41 am and the other two residents watched as the first resident ate their meal.b. The second resident was served their meal at 7:43 am and the last resident watched the first two residents eat their meals.c. The third resident was served their meal at 7:58 am. B. On 05/05/26 at 7:52 am, during an interview, R #41 stated she would prefer to have her meal served at the same time as everybody else at the table. She stated she doesn't like to watch everyone else eat.C. On 05/05/26 at 8:33 am, during an interview, the son of R #15 stated they always have to wait so long for food to be served.D. On 05/08/26 at 9:36 am, during an interview, the Dietary Manager (DM) stated residents having to wait twenty-two minutes after another resident is served at the same table is too long. She stated her expectation is to have residents seated at the same table to be served at the same time or within a few minutes of each other.

Based on record review and interview, the facility failed to create accurate baseline care plans (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 4 (R #7, R #18, R #38, and R #39) of 7 (R #3, R #5, R #6, R #7, R #18, R #38, and R #39) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care upon admission and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition. The findings are: R #18 A. Record review of R #18's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Major depressive disorder (a common and debilitating mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), 2. Profound intellectual disabilities (a condition in which individuals experience significant limitations in intellectual (reasoning and understanding) functioning and adaptive behavior, affecting their ability to communicate, learn, and perform everyday tasks independently), 3. Other disorders of psychological development (neurodevelopmental (process when brain forms) conditions characterized by developmental delays or abnormalities that do not fit into more specific categories), 4. Developmental disorder of speech and language (conditions where a child's ability to communicate effectively is significantly impaired). B. Record review of R #18's baseline care plan revealed it was completed on 04/22/26 (five days after admission). C. On 05/08/26 at 9:08 am, during an interview with the Assistant Director of Nursing (ADON), she confirmed that R #18's baseline care plan should have been completed within 48 hours, and it was not. R #7 D. Record review of R #7's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Fracture of the neck (part of the bone that connects to its shaft or long portion of the bone) of the left femur (thigh bone), 2. Essential (primary) hypertension (HTN: high blood pressure), 3. Lobar pneumonia (an acute bacterial infection that affects one or more lobes of the lung), 4. Age-related osteoporosis (bones become extremely porous and are subject to fracture and slow healing) with current pathological fracture (bone break that occurs due to an underlying disease or condition), 5. Unspecified fall, subsequent encounter. E. Record review of R #7's baseline care plan revealed it was completed on 04/14/26 (four days after admission). F. On 05/08/26 at 8:59 am, during an interview with the ADON, she confirmed that R #7's baseline care plan should have been completed within 48 hours, and it was not. R #38 G. Record review of R #38's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Displaced fracture (bone break where pieces of the bone have moved out of alignment) of medial condyle (the larger, rounded part of the inner end of the femur) of left femur, 2. Liver cell carcinoma (a type of liver cancer that originates in the main liver cells), 3. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 4. Acute kidney failure (a condition that occurs when the kidneys suddenly stop working), 5. Morbid (severe) obesity (overweight). H. Record review of R #38's baseline care plan revealed it was completed on 04/01/26 (five days after admission). I. On 05/08/26 at 9:03 am, during an interview with ADON she confirmed that R #38's baseline care plan should have been completed within 48 hours, and it was not. R #39 J. Record review of R #39's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Inflammatory disorders of scrotum (conditions that cause swelling, pain, or tenderness to the scrotum due to infection, trauma, or other causes), 2. Peripheral vascular disease (PVD; poor circulation), 3. Essential hypertension (HTN; high blood pressure), 4. GERD (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining), 5. Esophageal obstruction (a blockage in the esophagus that prevents food and liquids from passing normally from the throat to the stomach), 6. Benign prostatic hyperplasia benign prostatic hyperplasia (BPH; enlarged prostate) without lower urinary tract symptoms, 7. Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. K. Record review of R #39's admission evaluation dated 04/07/26 revealed the following: 1. R #39 utilized a foley catheter (a thin, sterile tube inserted into the bladder to drain urine) upon admission to the facility. 2. R #39 has a scrotal abscess (a painful collection of pus in the scrotum) with dressing intact. L. Record review of R #39's baseline care plan revealed the following: 1. The care plan was completed on 04/11/26 (four days after admission) 2. R #39's foley catheter use is not indicated. 3. R #39's need for wound care is not indicated. M. On 05/08/26 at 9:07 am, during an interview with the ADON she confirmed that R #39's baseline care plan did not indicate R #39's foley catheter use or need for wound care and it should have. ADON stated she expects all baseline care plans to be accurate according to the residents' needs and be completed within 48 hours, and it was not.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis 2 (R #3 and R #18) of 5 (R #3, R#5, R #6, R #18, and R #40) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are:R #3 A. Record review of R #3's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Major depressive disorder (a common and debilitating mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. End stage renal disease (ESRD; chronic irreversible kidney failure),4. Morbid obesity (severely overweight). B. Record review of R #3's physician's orders, revealed the following: 1. An order dated 04/21/26 for mirtazapine (antidepressant) 15 milligrams (mg) at bedtime for appetite stimulant.2. An order dated 04/27/26 for trazadone (antidepressant and sedative) 50 mg, three tablets to be given every 24 hours as needed for obstructive sleep apnea for 14 days.3. An order dated 04/28/26 for omeprazole (a medication used to reduce stomach acid and treat condition such as heartburn, GERD, and ulcers) 20 mg to be given daily for End Stage Renal Disease (ERSD). C. On 05/08/26 at 9:20 am, during an interview, the Assistant Director of Nursing (ADON), she confirmed the following: 1. Mirtazapine is an antidepressant and appetite suppressant is not an appropriate diagnosis for use of mirtazapine. 2. Trazadone is an antidepressant and obstructive sleep apnea is not an appropriate diagnosis for the use of trazadone. 3. Omeprazole is an acid reducer for the stomach and ERSD is not an appropriate diagnosis, and resident does not have a diagnosis of acid reflux (stomach acid overflows into esophagus (tube connecting the throat to the stomach)).4. Medications should be indicated to be used as they relate to the resident's diagnoses, and these do not. #18D. Record review of R #18's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Major depressive disorder,2. Profound intellectual disabilities (a condition in which individuals experience significant limitations in intellectual (reasoning and understanding) functioning and adaptive behavior, affecting their ability to communicate, learn, and perform everyday tasks independently),3. Other disorders of psychological development (neurodevelopmental (process when brain forms) conditions characterized by developmental delays or abnormalities that do not fit into more specific categories),4. Developmental disorder of speech and language (conditions where a child's ability to communicate effectively is significantly impaired). E. Record review of R #18's physician's orders revealed the following:1. An order dated 04/21/26 for mirtazapine 15 mg to be given at bedtime for sleep management.2. An order dated 04/17/26 for quetiapine fumarate (antipsychotic) medication 50 mg to be given twice daily for behaviors.3. An order dated 04/17/26 for quetiapine fumarate 100 mg to be given twice daily for behaviors.4. An order dated 04/17/26 for melatonin (a medication that helps regulate your sleep-wake cycle) three mg to be given every 24 hours as needed for insomnia. F. On 05/08/26 at 9:20 am, during an interview, the ADON, she confirmed the following:1. Mirtazapine is an antidepressant and sleep management is not an appropriate diagnosis for use of mirtazapine.2. Quetiapine fumarate is an antipsychotic medication, and behavior management is not an appropriate diagnosis for the use of quetiapine fumarate.3. Melatonin is a synthetic (man-made) hormone (chemical messenger sent out in the body to other glands or tissues in the body) used for insomnia, and R # 18 does not have a diagnosis for insomnia.4. Medications should be indicated to be used as they relate to his diagnoses and these do not.

Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions when staff:1. Prepared food and plated the food without wearing a beard restraint.2. Got ice from the ice machine without wearing a hair restraint.3. Failed to sanitize hands while consistently touching the apron he was wearing while plating the food.4. Plated the food while the paper meal ticket was on the plate.This deficient practice is likely to affect all 32 residents listed on the resident census list provided by the Administrator on 05/04/26 and is likely lead to foodborne illnesses in residents if food is not being stored properly. A. On 05/05/26 at 11:08 am, an interview and observation of the kitchen revealed the following:1. The cook was not wearing a beard restraint while cooking and plating food.2. The Dietary Manager (DM) confirmed the cook should be wearing a beard restraint.3. The receptionist did not wear a hair restraint and entered the kitchen, opened the ice machine, and filled a container full of ice.4. The cook wore a black apron that had what appeared to be splatters of dried food on it and a glove on his left hand. The cook used his left hand to touch the food. Each time the cook used his gloved left hand to touch food, he would then wipe his gloved hand off on his apron. The cook did not utilize sanitizer or change his glove each time he wiped his hand on his apron.5. The paper meal ticket would be placed on top of the plate, then the food would be plated. The paper meal ticket would then be removed from under the food and placed on the plastic meal tray. B. On 05/08/26 at 9:30 am, during an interview with the DM she confirmed:1. All staff entering the kitchen should wear a hair restraint and a beard restraint if the person has a beard.2. Staff should wash or sanitize their hands anytime they touch a dirty item such as an apron.3. The paper meal tickets should not be placed on the plates. The paper meal tickets should not be touching the food.

Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1(R #56) of 2 (R #6 and R #56) when staff failed to: 1. Ensure proper Personal Protective Equipment (PPE) was worn during wound care.2. Ensure proper hand hygiene practices are followed during wound care. 3. Ensure good infection control practices when staff wiped hands on pants during wound care.If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: A. On 05/04/26 at 1:16 pm, during an observation of wound care for R # 56:1. Enhance Barrier Precaution sign was noted outside R #56's door with Personal Protective Equipment (PPE) hanging on the outside R #56's door.2. Licensed Practical Nurse (LPN) #1 did not put on required gown prior to dressing change.3. LPN #1 applied sanitizer to hands, blowing on them prior to putting on gloves to perform the dressing change.4. Upon removing first set of gloves and washing hands with soap and water, LPN #1 dried hands with paper towels and then rubbed her hands on her pants prior to putting on gloves to complete the wound care. B. On 05/04/26 at 1:35 pm, during an interview with LPN #1, she confirmed she should not have blown on her hands after application of alcohol-based hand sanitizer, she also confirmed she should not have wiped her hands on her pants after removal of gloves. C. On 05/08/26 at 8:27 am, during an interview with Assistant Director of Nursing (ADON), she stated her expectations are:1. Appropriate PPE to include a gown should be worn through the entire process of completing wound care.2. Proper use of an alcohol-based cleanser is to allow hands to air-dry for 15-20 seconds and not to blow on them to dry.3. Maintaining infection control practices by washing and drying hands appropriately and not wiping hands-on pants.

Based on record review and interview, the facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) to 1 (R #20) of 3 (R #20, R #60, and R #61) residents reviewed for beneficiary notices. If residents or their representatives are not provided with the beneficiary notices, then they may not make an informed decision about the services provided to them and could likely result in a decline in health and function. The findings are:A. Record review of R #20's admission Record revealed he was originally admitted to the facility on [DATE].B. Record review of R #20's End of Part A MDS assessment (an assessment that is required when a resident's Medicare Part A stay ends but they remain in the facility), dated 04/01/26, revealed R #20's end date for his most recent Medicare stay was on 03/23/26.C. On 05/07/26 at 2:40 pm, during an interview, the Administrator (ADM) stated the facility has no evidence of R #20 receiving a NOMNC for the stay that ended on 03/23/26. The ADM stated his expectation was for staff to give residents or their representatives a copy of the NOMNC at least three to five days before the end of their Medicare Part A coverage so they could make informed decisions regarding the residents' care.

Based on observation and interviews, the facility failed to safeguard resident's medical record information for 1 (R #59) of 3 (R #3, R #15, and R #59) residents reviewed for privacy and confidentiality of records when the staff left Private Health Information (PHI) in plain view on a computer screen, where unauthorized people had ability to access it. This deficient practice could likely lead to residents feeling embarrassed and ashamed. The findings are:A. On 05/08/26 at 8:13 am, during an observation of the unit medication cart located on the west hall, revealed an unattended computer screen with R #59's name, vital sign [body temperature, pulse rate, respiration rate (rate of breathing), oxygen saturation (amount of oxygen in the blood), and blood pressure] information, and information pertaining to his medications on and facing the hall.B. On 05/08/26 at 8:36 am, during an interview, the Licensed Practical Nurse (LPN) #1, stated the unattended computer screen contained PHI and was left visible on the medication cart. LPN #1 stated she should have locked the computer screen prior to walking away and did not.

Based on record review and interview, the facility failed to develop an accurate, comprehensive care plan within seven days of the completion of the comprehensive assessment for 1 (R #39) of 3 (R #3, R #5, and R #39) residents reviewed for care plans. This deficient practice could likely result in residents not getting the most appropriate interventions and treatments needed. The findings are:A. Record review of R #39's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Inflammatory disorders of scrotum (conditions that cause swelling, pain, or tenderness to the scrotum due to infection, trauma, or other causes),2. Peripheral vascular disease (PVD; poor circulation),3. Essential hypertension (HTN; high blood pressure),4. Gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining),5. Esophageal obstruction (a blockage in the esophagus that prevents food and liquids from passing normally from the throat to the stomach),6. Benign prostatic hyperplasia benign prostatic hyperplasia (BPH; enlarged prostate) without lower urinary tract symptoms,7. Encounter for surgical aftercare following surgery on the skin and subcutaneous tissueB. Record review of R #39's admission evaluation dated 04/07/26 revealed the following:1. R #39 utilized a foley catheter (a thin, sterile tube inserted into the bladder to drain urine) upon admission to the facility.2. R #39 has a scrotal abscess (a painful collection of pus in the scrotum) with dressing intact.C. Record review of R #39's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 04/10/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 12, moderately impaired.2. R #39 utilizes an indwelling catheter.3. R #39 has an active wound infection.4. R #39 has a surgical wound and requires surgical wound care (medical instructions and ongoing management of a wound to promote healing) to include application of nonsurgical dressings, ointments, and medications.D. Record review of R #39's comprehensive care plan revealed it was completed on 05/04/26 (24 days after completion of the MDS assessment).E. On 05/08/26 at 9:07 am, during an interview, the Assistant Director of Nursing (ADON) stated R #39's comprehensive care plan was not completed timely. The ADON stated this does not meet her expectations because the care plan should be person-centered, accurate and implemented within seven days of the MDS assessment being completed and this care plan was not.

Based on observation, record review, and interview, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #7) of 3 (R #3, R #15, and R #40) residents reviewed for nutrition and weight management when the facility failed to:1. Assist R #7 with her meal as required.2. Notify the physician of R #7's 12.5% (percent) weight loss.These deficient practices could likely lead to residents suffering from malnutrition which could exacerbate (make worse) other medical conditions. The findings are:A. Record review of R #7's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Fracture of the neck (part of the bone that connects to its shaft or long portion of the bone) of the left femur (thigh bone),2. Essential (primary) hypertension (HTN: high blood pressure),3. Lobar pneumonia (an acute bacterial infection that affects one or more lobes of the lung),4. Age-related osteoporosis (bones become extremely porous and are subject to fracture and slow healing) with current pathological fracture (bone break that occurs due to an underlying disease or condition,5. Unspecified fall, subsequent encounter.B. Record review of R #7's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 04/13/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 09, moderately impaired.2. R #7 requires setup or clean-up assistance with all meals.C. Record review of R #7's care plan dated 04/14/26 revealed:1. R #7 is at risk for malnutrition and has a goal in place to maintain adequate nutritional status as evidenced by maintaining weight within five percent (%) of baseline and should consume 75% of at least two meals daily.2. R #7 needs a calm, quiet setting at mealtimes and prefers to sit in the dining room to eat.3. Staff are to monitor and report to the physician any signs or symptoms of malnutrition including significant weight loss.D. On 05/04/26 at 1:51 pm, an observation of R #7 in her room revealed R #7 sleeping in her bed. There was a full meal tray, containing R #7's lunch sitting on the dresser in her room.E. Record review of R #7's list of weights revealed the following: 1. R #7 weighed 113.6 pounds on 04/10/26.2. R #7 weighed 99.4 pounds on 04/26/26.3. R #7 had a 12.5% weight loss in 16 days.F. Record review of R #7's Documentation Survey Report dated April 2026 revealed 17 of 21 days that R #7 was admitted to the facility during that month where she did not eat more than 75% of meals.G. Record review of R #7's electronic health record revealed no documentation of R #7's physician being notified of the 12.5% weight loss.H. On 05/08/26 at 8:59 am, during an interview, the Assistant Director of Nursing (ADON) stated her expectation for any resident that required setup or clean up assistance for meals to be assisted in setting up the meal. The ADON stated the facility staff should never just drop a meal off, even if the resident is asleep. The ADON stated the physician was not notified of R #7's weight loss and should have been.

Based on observations and interviews, the facility failed to properly store medical supplies and medications when staff failed to ensure:Ensure the medication and supply room was locked and secured,Failed to dispose of expired blood collection tubes.These deficient practices are likely to affect all 32 residents residing in the facility according to the census provided by the Administrator on [DATE] and could result in resident having unauthorized access to medications, supplies and inaccurate lab results by using expired blood collection tubes. The findings are: A. On [DATE] at 12:00 pm, during a random observation of the west hall, revealed the medical storage room was found unlocked.B. On [DATE] at 12:09 pm, during an interview with the Assistant Director of Nursing (ADON), she stated the medical room door should be locked. She stated it does not meet her expectations because residents should not have access to anything in the room.C. On [DATE] at 1:50 pm, during an observation of the [NAME] Hall medical storage room, revealed the following:1. Sixty-three blue top blood collection tubes expired on [DATE],2. One hundred green top blood collection tubes expired on [DATE],3. One hundred gray top blood collection tubes expired on [DATE].D. On [DATE] at 1:58 pm, during an interview, the Licensed Practical Nurse (LPN) #2 stated the blood collection tubes had expired and should have been thrown away.E. On [DATE] at 2:05 pm, during an observation of the East Hall medical storage room, revealed two gray top blood collection tubes that expired on [DATE].F. On [DATE] at 2:06 pm, during an interview, the LPN #1 stated the blood collection tubes had expired on [DATE] and should have been thrown away.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) for 1 (R #15) of 1 (R #15) residents reviewed during medication administration, when staff administered two out of 28 medications late, which resulted in a medication error rate of 7.14%. If medications are administered late, then residents are likely to experience less than optimal results from their medication regimen. The findings are: A. Record review of R #15's Physician Orders, dated 03/05/25, revealed the following: - Capsaicin external cream 0.075 % (medicated pain reliever cream.) Apply a small amount to painful areas topically at 7:30 am. - Erythromycin base oral tablet (antibiotic), 250 milligrams (mg.) Give one tablet by mouth for gastroparesis (when stomach is slow to empty of food) at 7:30 am. B. On 03/05/25 at 8:50 am during observation of a medication pass, Certified Medication Aid (CMA) #1 administered the following morning medications to R #15: - Capsaicin external cream 0.075 %. - Erythromycin base oral tablet, 250 mg. C. On 03/05/25 at 8:53 am, during an interview, CMA #1 stated she administered the morning medications for the East Hall late, because her manager asked her to cover for a Certified Nursing Assistant (CNA) who called out in [NAME] Hall. D. On 03/05/25 at 11:06 am, during an interview, the Director of Nursing Services (DNS) stated she expected CMA #1 to administer R #15's morning medications within a two-hour period, one hour before to one hour after the time stated on the resident's orders.

Based on observations, interviews and record review, the facility failed to ensure Nurses and Certified Medication Aids (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) vials and discarded them within 28 days of opening date for 1 (R #20) of 1 (R #20) resident reviewed. This deficient practice is likely to result in R #20 receiving medications that are less effective or expired in the facility. The findings are: A. On [DATE] at 10:04 am, during observation of the East Hall medication cart, a Humulin R insulin (a short-acting insulin),100 units/milliliter (ml) multiple-dose vial was opened and dated [DATE]. The insulin vial belonged to R #20. B. Record review of the manufacturer's instructions for Humulin R insulin multiple dose vial, dated 2023, revealed staff were instructed to throw away all opened vials after 28 days of use, even if there was insulin left in the vial. C. Record review of R #20's Physician Orders, dated [DATE], revealed R #20 had an active order to receive Humulin R insulin. D. On [DATE] at 10:04 am, during an interview, CMA #1 stated she should have discarded the opened Humulin R insulin vial within 28 days of the opening date. E. On [DATE] at 10:20 am, during an interview, the Director of Nursing Services (DNS) stated staff must date the opened Humulin R insulin vial and discard it within 28 days of the opening date.

Based on observations, record reviews, and interviews the facility failed to: 1. Ensure all medications were kept in their original packaging. 2. Ensure all expired supplies were not kept with unexpired supplies. 3. Document daily medication refrigerator/ freezer/ medication room temps. These deficient practices are likely to result in all 22 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication or improperly temperature-controlled medication that may have lost their potency or effectiveness. The findings are: Findings for ensuring all medications are kept in their original container. A. On [DATE] at 2:26 pm during an observation of the east medication cart, a small medication cup sat in the top drawer of the cart and held one pill. The cup had the name of a resident written on it with a sharpie. The pill was peach in color, oblong, and was not in its original container. B. On [DATE] at 2:27 am, during an interview with Registered Nurse (RN) #1, she stated the medication belonged to a resident who discharged a week ago, and she did not know why the medication was in the drawer. The RN said the pill should not be in the medication cart. Ensure all expired supplies were not kept with unexpired supplies. C. On [DATE] at 2:30 pm, during an observation of the east medication cart, two boxes of expired of Even Care Proview [solution that tests the high and low in a glucometer (a device that checks blood) to ensure the readings are accurate]. They expired on [DATE], and staff did not remove them from the medication cart. One box of the Even Care Proview solution was opened. D. On [DATE] at 2:32 pm, during an observation, the east medication storage room revealed: 1. Four boxes of Even Care Proview solution had an expiration date of [DATE] and sat on the shelf. 2. An auto lancelet device [device where a lancet (a small needle) can be placed and used to poke the finger] with an expiration date of [DATE]. E. On [DATE] at 3 :24 pm, during an interview with RN #1, she stated these things were expired and should not be in the medication room. Documented daily medication refrigerator/freezer/ Medication room temps. F. During record review of the medication, refrigeration, and freezer temperature logs for the East Hall, staff did not maintain the temperature logs. The logs did not contain documentation of the temperatures for the refrigerators, freezers, and medication room from [DATE] through [DATE]. G. On [DATE] at 3:30 pm, during an interview with Infection Preventionist (IP), she confirmed staff did not maintain the temperature logs like they should. She confirmed the logs were missing many temperatures.

Based on observation, interview, and record review, the facility failed to: 1. Discard opened, refrigerated food when it met its seven day shelf life or appeared to be decomposed; 2. Date food with received dates and use by dates, as required by Food and Drug Administration (FDA) Food Code and facility policy. These deficient practices are likely to affect all 22 residents listed on the census provided by the Director of Nursing (DON) on 12/04/23. These deficient practices could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. Review of the FDA Food Code, dated 2022, revealed the following guidance regarding the storage of food: -Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, - Food prepared on premises and held cold, - (A) Refrigerated, ready-to-eat, time/temperature controlled for food safety, food prepared and held in a food establishment shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. - Food commercially processed, opened, and held cold: - (B) Ready-to-eat, time/temperature controlled for food safety, food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and: - The day the original container is opened in the food establishment shall be counted as Day 1; - The day or date marked by the food establishement may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. - Section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, - A food specified in paragraph 3-501.17(A) or (B) shall be discarded if it: - Is in a container or package that does not bear a date or day. B. Record review of the facility's policy titled Refrigerator and Freezers, last revised November 2022, revealed the following: - All food appropriately dated to ensure proper rotation by expiration dates. - Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. - Expiration dates on unopened food are observed; - Use by dates are indicated once food is prepared or opened. C. On 12/05/23 at 6:48 am, during a kitchen observation, the following items were observed: 1. Refrigerated items: a. Two pitchers of milk opened and undated; b. One pitcher of orange juice opened and undated; c. One bag of heavy whipping cream undated; d. One bag of shredded cheese undated; e. One bag of celery undated and appeared soggy; f. One bag of carrots undated appeared soggy; g. One package of green grapes undated and appeared brown and soggy; h. One package of grape tomatoes undated and appeared molded; i. One package of Romaine lettuce, undated and appeared soggy. j. One package of opened raw bacon dated 11/21 and not discarded; k. One package of ham opened, dated 11/26, and not discarded; l. Two packages of turkey, opened, dated 11/26, and not discarded; m. Five packages of strawberries undated and appeared molded; n. One package of pastry filling, strawberry flavor undated; o. One package of pastry filling, cream flavor undated; p. One package of pastry filling, apple pie flavor undated; q. One container of green chili, dated 11/19 and not discarded; r. One container of beef flavored base (about 3/4 full) opened and undated; s. One 14 ounce container of dried tomato and garlic pesto (about 1/4 full) undated and expiration date of 10/22/23. t. Twenty-four packs of individual yogurt containers, expiration date 12/01/23. u. Thirty-six packs of individual yogurt containers, expiration date 11/28/23. v. One open container of salsa undated; w. One container of barbeque sauce undated; x. One container of Italian dressing undated; y. One container of heavy duty mayonnaise undated; z. One container of dill pickle relish undated; 2. Dry storage items: a. One box of gelatin packets undated and without an expiration date; b. One container of Kitchen Bouquet Browning and Seasoning sauce, expiration date 03/23. c. One gallon of cooking white wine undated; d. One container of cooking wine [NAME] undated; e. One package of spaghetti undated; f. One package of orzo pasta undated; g. One container of teriyaki sauce marinade opened and undated. The label stated should be refrigerated after opening. h. One container of soy sauce opened and undated; The label stated should be refrigerated after opening. i. One container of pure sesame oil undated; j. One package of sliced bread undated; k. One package of buns undated; l. One package of English muffins undated; m. One package of potato buns undated; n. One package of [NAME] rolls undated; D. On 12/05/23 at 6:48 am, during an interview, the Dietary Manager confirmed staff should have documented a use by date on the open items in the refrigerator and dry storage area. She also explained: a. The opened ham, turkey, and bacon have a shelf life of seven days after opening, and staff should have discarded them. b. Staff should have discarded the fresh fruit and vegetables that appeared to be decomposed. c. Staff should have discarded items past the expiration date. d. Staff should discard food items that have been stored longer than the five to seven day shelf life. 47899

Based on observation, record review, and interview, the facility failed to properly date oxygen tubing and place the facemask in a plastic bag when not in use for 2 (R #120 and R #123) of 2 (R #120 and R #123) residents reviewed for respiratory care by not properly dating the oxygen tubing and not placing the facemask in a plastic bag when not in use. These deficient practices could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (process where water vapor becomes liquid) or becoming dirty leading to reduced flow of oxygen. The findings are: A. Record review of Wellbrook's Departmental Respiratory Therapy- Prevention of Infection policy, revised November 2011, Infection Control Consideration Related to Medication Nebulizers/Continuous Aerosol directed staff to do the following: - Obtain equipment [administration set-up (tubing, mask), plastic bag, gauze, sponges.] - Store the facemask in the plastic bag, marked with the date and residents name, between uses. - Discard the administration set-up every 7 days. Findings for R #120 B. Record Review of R #120's physician's orders, dated 11/20/23, for albuterol sulfate (used to treat wheezing and shortness of breath caused by breathing problems) nebulization (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) solution, 2.5 milligram (mg) /3 milliliter (ml), 0.083 percent (%). Inhale the contents of the vial via nebulizer every six hours as needed for shortness of breath (SOB). C. On 12/04/23 at 4:06 pm, during an observation in R #120's room, a face mask laid on the table beside the bed. The face mask was not in a plastic bag, and it was not dated anywhere on the tubing or the face mask. D. On 12/04/23 at 4:07 pm, during an interview, Registered Nurse (RN) #1 confirmed there was not a date on the tubing, and the mask should be in a plastic bag. Findings for R #123 E. Record review of R #123 's physicians orders, dated 11/30/23, for albuterol sulfate nebulization solution, 2.5 mg/3 ml, 0.083%. Inhale four times daily a day for miner's lung (caused by long-term inhalation and deposition of coal dust in the lungs and the consequent lung tissue's reaction to its presence.) F. On 12/05/23 at 10:47 am during an observation in R #123's room, a face mask laid on the table near the bed, and it was not in a plastic bag. The face mask was not dated, and the tubing was not dated. G. On 12/05/23 at 10:50 am, during an interview, RN #1 confirmed the tubing did not have a date, and the mask was not in a plastic bag.

Based on record review and interview, the facility failed to ensure documents were complete and accurate for 1 (R #125) of 1 (R #125) residents who were reviewed for documentation when they failed to accurately document: 1. A resident came out the straps used to keep her wheelchair in place when being transported. 2. Assessments staff completed on that day. 3. A physician was informed. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the documents. The findings are: A. Record review of R #125 face sheet revealed she was admitted into the facility on [DATE]. B. On 12/05/23 at 1:35 pm, during an interview with R #125, she stated she went to an appointment at the spine clinic that morning. The resident said the wheelchair she sat in came out of the two front straps used to hold it down, and it threw her back in the van. R #125 stated it hurt the back of her head, and the facility was sending her out to do x rays to make sure she did not break a bone. R #125 stated the driver drove down hill and immediately came back up a hill. The driver stopped at a stop sign and then pushed on the gas pedal. R #125 stated the chair floated in place for a moment before jolting her backwards. She said she hit her head on the back of the wheelchair. C. Record review of the progress note, dated 12/05/23, revealed staff did not document the incident. D. On 12/06/23 at 9:30 am during an interview with the Transportation driver, she stated she drove R #125 to a spine provider appointment the morning of 12/05/23. She said she put the resident into the vehicle and buckled her into place. The driver stated there were four straps she hooked onto the frame of the resident's wheelchair and a lap belt that went around the resident's lap. The driver stated once the straps were in place, she turned the little things on the straps back and forth until she did not hear a cranking noise. She said when the cranking noise stopped then she knew the straps were in place. The driver stated when they were on a hill and she pressed the gas, the top two straps came off of the resident's wheelchair. This indicated too much slack in the straps. The driver said stopped and checked the resident out, and she called the facility. The driver said when they got back to the facility after the resident's spine appointment, the physician ordered X-rays, and the resident went to the emergency room (ER) for those. E. On 12/06/23 at 12:16 during a phone interview, the Physician verified the facility called him, and he ordered X-rays for R #125. He stated he would expect the nurses to document the information in the chart. F. On 12/07/23 at 8:36 am, during a phone interview with the DON, she stated R #125's chart did not contain documentation regarding the incident. She said there was some documentation in the Risk Management System, but staff did not complete an assessment or document anything in the nursing progress notes. The DON stated staff should have documented the incident.

Based on record review and interview, the facility failed to develop Baseline Care Plan that included documentation for a 30-day event heart monitor (small portable device that records the electrical activity of the heart) placed on the resident for 1 (R #1) of 3 (R #1-3) resident reviewed for baseline care plans. This deficient practice could likely result in resident not receiving the appropriate care, services, and monitoring needed upon admission to the facility. The findings are: A. Record review of R #1's face sheet revealed admitted [DATE] and Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] heart disease (hardening of the arteries), falls, [MEDICATION(S)] (inflammation of the bladder), fracture of nasal bones, hypertensive urgency (marked elevation in blood pressure without evidence of organ damage), [CONDITION(S)] (chronic disease that causes joint pain, stiffness, swelling and decreased movement of the joints), benign neoplasm of cerebral meninges (a tumor that forms on membranes that cover the brain and spinal cord just inside the skull), laceration of left eyelid, contusion of other part of head (bleeding and swelling inside of the brain), abnormal levels of serum enzymes (an inflamed or damaged liver), headache, dizziness and giddiness (a sensation of whirling and a tendency to fall or stagger), chronic obstructive pulmonary disease ([CONDITION(S)] lung disease that causes obstructed airflow from the lungs), [CONDITION(S)] (abnormally high concentration of fats or lipids in the blood), [CONDITION(S)] (a disturbed state of mind that results in confused thinking), coronary angioplasty implant and graft (treatment used to widen and open up narrowed or blocked arteries supplying your heart muscle). Cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), muscle weakness (lack of strength in the muscles), unsteadiness on feet (unable to stand or walk easily) and limitation of activities (restriction in the performance of activities resulting from disease, injury, or environmental restrictions). B. Record review of R #1's hospital medical records dated 08/30/22, stated, Have placed (on residents body) a 30-day event (heart) monitor. C. Record review of R #1's Nursing Progress Notes dated 08/30/22 stated, Clinical admission evaluation: [name of product] (heart) monitor placed by [name of hospital]. D. Record review of care plan dated 08/31/22, revealed, no documentation stating a 30-day event [name of product] heart monitor is placed on the resident. E. On 11/08/22 at 10:45 am, during an interview with Director of Nursing (DON) confirmed that the 30-day event [name of product] heart monitor is not documented on the base line care plan.

Based on observation, and interview, the facility failed to: 1) Ensure that expired medications were not stored with unexpired medications inside of the medication room refrigerator. 2) Ensure that (2) insulin (a hormone produced in the pancreas, which regulates the amount of glucose/sugar in the blood) injectable pens stored in the medication room refrigerator were labeled with resident specific identification. These deficient practices could likely affect all 38 residents identified on the facility census list provided by the Director of Nursing on 09/06/22. If residents are administered expired medications or medications not prescribed for them, they may likely suffer adverse effects and/or fail to achieve their optimal level of well-being. The findings are: A. On 09/06/22 at 2:04 pm, during observation of the medication storage room [ROOM NUMBER], observed in the medication refrigerator: 1. One box of Influenza (a disease caused virus infecting the respiratory tract) Vaccine, containing one closed 5mL (milliliter) multi-dose vial of [MEDICATION(S)] (a brand of influenza vaccination that protects against 4 types of influenza) which had expired on 06/01/22. 2. Two unlabeled, with resident specific identification, single-patient-use, prefilled injectable insulin pens found in a bag on the top shelf of the medication refrigerator: -[MEDICATION(S)] Insulin [a long-acting insulin used to improve blood sugar control in people with diabetes mellitus] Injectable Pen containing 100 units(U) per milliliter (mL) with a total of 300 units (3mL) of insulin for Diabetes Mellitus (DM) [a metabolic disorder in which the body has high sugar levels for prolonged periods of time]. -[MEDICATION(S)] Insulin [a fast-acting mealtime insulin that works to control blood sugar when you eat] Injectable Pen containing 100 units(U) per milliliter (mL) with a total of 300 units/ (3mL) of insulin injectable pen. B. On 09/06/22 at 2:04 pm, during an interview with the Licensed Practical Practical Nurse (LPN) #1, she confirmed that the Influenza vaccine vial found in the medication storage refrigerator was expired. She also confirmed that the two insulin injectable pens were not labeled with patient specific identifiers and that they should have been.

Based on observation and interview, the facility failed to store and serve food under sanitary (clean) conditions by not ensuring kitchen staff have their hair covered while working in the kitchen. This deficient practice is likely to affect all 24 residents listed on the resident census list provided by the Administrator on 05/24/21, and could likely lead to foodborne illnesses (illness caused by eating contaminated food) in residents if food handling practices are not adhered to. The findings are: A. On 05/24/21 at 12:02 pm during random observation of facility kitchen, Culinary Assistant (CA)#1 and Cook #1 were observed to be preparing food without hair restraints/covering (hair nets). B. On 05/24/21 at 12:05 pm during interview Cook #1 confirmed she is in charge of the kitchen at this time and hair restraints are required for anyone who enters or works in the kitchen.

Based on observation, interview, and record review, the facility failed to maintain proper infection prevention measures by: 1. Failing to screen (a series of questions asked to determine a person's risk for COVID-19) the survey team for COVID-19 (an acute respiratory illness in humans caused by a coronavirus capable of producing severe symptoms and in some cases death) symptoms and facility staff self screening for COVID-19 prior to entering the facility. 2. Facility staff failing to properly wear Personal Protective Equipment (PPE- protective clothing, facemasks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection)) as required. 3. Facility staff holding used gowns against their body as they dispose of them. Failure to adhere to an infection control program is likely to cause the spread of infections and illness to all 24 residents listed on the census as provided by the Director of Nursing (DON) on 05/24/21. The findings are: 1. Screening: A. On 05/25/21 at 8:10 am, the survey team entered the facility. A Facility Receptionist (FR) asked the surveyors to sign in, but she [facility receptionist] did not ask the surveyors the required screening questions until the Director of Nursing (DON) approached her and reminder her to do so. The surveyors temperatures were also not taken until the survey team requested their temperatures be taken. The FR confirmed the survey teams temperatures should have been taken automatically and stated, I forgot. B. On 05/26/21 at 7:05 am, when the survey team entered the facility, Certified Nursing Assistant (CNA) #2 opened door and stated, You guys [survey team] were here yesterday, right? Just sign in. CNA #2 walked away without properly screening either surveyor. C. On 05/26/21 at 7:34 am during an interview with the Director of Admissions (DOA), she stated that every employee screens themselves when entering the facility and the temperature book is then reconciled to make sure no employee entered the facility with an elevated body temperature above normal degrees. D. On 05/26/21 at 7:36 am during a random observation, the Director of Staff Development/ Infection Preventionist (DSD/IP) is observed screening herself in, and taking her own temperature when entering the facility. E. On 05/26/21 at 7:42 am during an interview with the DSD/IP, she stated all staff screen themselves in, and staff has been doing this for a year. DSD/IP also stated that screening questions are to be asked for visitors and vendors, and it is not her expectation that non employees screen themselves in. DSD/IP confirmed CNA #2 did not follow the correct process. F. On 05/27/21 at 12:58 pm during an interview with the DSD/IP, she stated, They're [staff]supposed to come into the building, self temp (temperature), answer the questions, and if they [staff]have a a temp or anything, they report to me. 2. PPE: F. On 05/26/21 at 12:44 pm during a random observation, Registered Nurse (RN) #1 was observed wearing a KN95 mask (a type of respirator which removes particles from the air that are breathed through it) below her nose. G. On 05/26/21 at 1:21 pm during an observation and interview with RN #1, she was observed to be still wearing her KN95 below her nose and walking through the RM (room) #101-111 hallway. RN #1 stated, It [KN95] won't stay up. We [staff] weren't fitted for them [KN95] and that's the problem. H. On 05/26/21 at 4:43 pm during a random observation, RN #1 was observed still wearing her KN95 under nose and talking to CNA's at nursing station in the RM #101-111 hallway. I. On 05/27/21 at 12:59 pm during an interview with the DSD/IP, she stated, They [staff] should make sure they should be covering their nose [with an N95 mask]. I am aware of it [RN #1 not wearing N95 properly] and she [RN #1] has been reprimanded and written up for it. 3. Gown Disposal: J. On 05/25/21 at 3:41 pm during an interview with R #13, no gown disposal bin was present in or near R #13's room [RM #114]. Nursing staff is observed carrying used gowns against their bodies down the hall to a linen closet. K. On 05/25/21 at 3:43 pm during an interview with CNA #6, she stated, We have a cart [for used gowns] and it's [gown disposal cart] in the soiled linen closet. We [staff] turn the gowns inside out and carry them there. CNA #6 confirmed no gown disposal in or near isolation rooms. L. On 05/26/21 at 5:27 pm during a random observation, staff was observed carrying their used gowns down the hall to the linen closet in the RM #101-111 hallway. M. On 05/27/21 at 12:59 pm during an interview with the DSD/IP, she stated, They [staff] shouldn't be holding them [used gowns] next to their body and they [staff] should be holding it out [away from each staff members body when carrying used gowns]. DSD/IP confirmed staff should be carrying used gowns away from their body to prevent contamination.