Every finding on record at Faulkton Senior Living

Based on observation, interview, and policy review, the provider failed to ensure medications were securely stored and labeled for safe use according to professional standards to ensure:*One of two medication carts (the cart used by certified medication aide) were locked when unattended by one of one certified medication aide (F).*Insulin pens for three of eight sampled residents (11, 14, 43) were dated when opened to ensure they were used according to manufacturers' instructions.*One of one medication rooms was free from expired prescription medications and supplies. *One of one refrigerator in the medication room that contained a controlled medication (medication at risk for addiction) was locked. Findings include:1. Observation and interview on 12/11/25 at 8:15 a.m. with certified medication aide (CMA) F revealed: *She left the medication cart unlocked and unattended, went to the storeroom, and then returned to the cart with a medication. *She left the medication cart unlocked and unattended, went into a resident's room, and then returned to the cart.*Upon interview, she verified she should have locked the medication cart before leaving it unattended to ensure the medications were secured. *In the medication cart there was a Lantus insulin pen for resident 43 that did not have an open or expiration date written on it, to ensure it was used according to manufacturers' instructions. 2. Observation and interview on 12/11/25 at 9:57 a.m. with registered nurse (RN) E in the medication supply room, and of her assigned medication cart revealed: *In the medication room, there was a box of approximately 100 hypodermic needles that expired on 10/1/23. *In the medication room, there was a bottle of resident 13's 300mg gabapentin that expired on 9/11/25. *In the medication room, the unlocked emergency monoclonal antibody reaction kit contained oral Benadryl (a medication used when someone had allergy symptoms) that had expired on 3/25/23, an albuterol inhaler (an inhaled medication used when muscles in your breathing tubes tightened) that had expired on 2/2024, IV (intravenous) solumedrol (a medication given to reduce swelling and inflammation) that had expired on 6/7/25, an epinephrine pen (an emergency medication given when someone had a severe allergic reaction) that had expired in December 2023, and IV Benadryl that expired in April 2024. *RN E verified that expired medications may not be as effective if they were to be used for the residents. *RN E stated that the emergency kit had not been used for years, and the pharmacy was to remove it when the other emergency kits medications were exchanged. *The medication room was to be checked for outdated medications and supplies weekly, on the weekend, by a nurse or a medication aide. *The refrigerator had a lock on it that was unlocked. There was lorazepam (a controlled anxiety medication) inside of it.*In the medication cart assigned to RN E, there was a Basaglar insulin pen for resident 11 and a Humulin insulin pen for resident 14 that did not have an open or expiration date to ensure they were used according to manufacturers' instructions. 3. Interview on 12/11/25 at 11:45 a.m. with director of nursing (DON) B revealed:*She expected CMA F to lock the medication cart when it was unattended.*She expected insulin, a medication with a shortened expiration date (medication that, after opening, expired prior to the manufacturer's expiration date) to be dated when it was opened to know when it should be discarded or removed from the cart, so it was not available for use.*She expected the weekend night shift nurses to check the medication room for expired medications and supplies and to document when that check was completed. *She expected the refrigerator to be locked if there was a controlled medication inside of it to ensure it was secured properly. *The pharmacy was supposed to remove the emergency monoclonal antibody reaction kit from their facility because they no longer used it. 4. According to the Lantus manufacturer's instructions, the medication should be discarded after being open for 28 days, even if it still has insulin in it. 5. According to the Basaglar manufacturer's instructions, the medication should be discarded after being opened for 28 days. 6. According to the Humulin manufacturer's instructions, the medication should be discarded after being opened for 28 days. 7. Review of the provider's 12/3/25 Medication Administration policy revealed:* Identify expiration date. If expired, notify nurse manager. 8. Review of the provider's 11/18/25 Controlled Substances policy revealed:* NOTE: THE NARCOTICS SUPPLY IS TO BE KEPT UNDER TWO LOCKS AT ALL TIMES. THE LOCK ON THE MEDICATION CART AND THE LOCK ON THE NARCOTICS DRAWER ARE TO BE LOCKED AT ALL TIMES. IF THE CART IS KEPT IN A MEDICATION ROOM, THE MEDICATION ROOM IS TO BE LOCKED AT ALL TIMES.

Based on observation, interview, and policy review, the provider failed to account for the supply of the controlled medication (medication at risk for abuse and addiction), tramadol (controlled pain medication), according to the provider's policy for one of one resident (33):Findings include:1. Observation and interview on 12/11/25 at 8:34 a.m. with certified medication aide (CMA) F morning medication pass revealed:*Resident 33's medication card for her scheduled (given at a set time) dose of tramadol was empty. *The tramadol medication card being used for resident 33's scheduled tramadol dose was different from what she was used to seeing.*Resident 33's tramadol frequency of administration had changed, so they were using up those medication cards before getting new ones.*She was to administer resident 33's scheduled tramadol doses according to the dates labeled on the medication card. If the medication dose was missing, she would tell the nurse. *Resident 33's current tramadol card had dates written in marker by each medication bubble on the medication card that indicated when it was to be administered.*She did not need to sign anything after the scheduled doses of tramadol were given to verify the quantity of the medication count was accurate, but if the medication was given as am as needed (PRN) dose, then the nurse would have to give that dose and sign to verify the quantity of doses remaining in the card. * The night shift nurse and day shift nurse were to count the medications in the controlled medication box for the medication cart she used. At the end of her shift, she would count the medications in that controlled medication box with the day shift nurse to verify the counts of the controlled medications were accurate. 2. Observation and interview on 12/11/25 at 9:57 a.m. with registered nurse (RN) E revealed: *When scheduled tramadol was given to a resident, the dose was to be punched out of the medication card's bubble marked with the current date. Only PRN doses were counted on a controlled medication inventory sheet. The scheduled tramadol cards were not counted. *When looking at the empty tramadol card for resident 33 given to her from medication aide F, she was unsure how many tramadol pills were to be there since there was no controlled medication inventory sheet to indicate how many pills were administered and how many remained available for administration. *Resident 33's tramadol frequency changed on 11/22/25, and then the doses were renumbered on the bubble pack in marker. *There were two scheduled tramadol medication cards that had were partially used with some doses remaining in each of them, in the lock box in the nurses' medication cart for resident 33. She was unsure how many pills were in those cards when they were placed in the drawer and was not sure how many pills were supposed to be left in them that day (11/22/25) because there was no controlled medication inventory sheet for them.-One card had 4 pills left, and the other had 13 pills left. -She then made a controlled medication inventory sheet for the remainder of those pills and did not verify that count with another nurse.*She verified that those tramadol doses were not counted by two nurses at the change of shift because there was no controlled medication inventory sheet for those tramadol doses, but there should have been. 3. Interview on 12/11/25 at 11:45 a.m. with director of nursing (DON) B revealed:*She expected the CMAs and nurses to count the controlled medications and sign the controlled medication inventory sheet to indicate the count was verified when a scheduled and PRN tramadol dose was given. *She expected the tramadol in the nurses' medication cart lock box to have a controlled medication inventory sheet and for them to be counted at the change of shift to verify the count. 4. Review of the provider's 12/3/25 Medication Administration policy revealed:* If medication is a controlled substance, sign narcotic book. 5. Review of the provider's 11/18/25 Controlled Substances policy revealed: *Purposea) To complete a physical inventory of narcotics at each change of shift by two nurses to identify discrepancies and need for reconciliation and accountability. b) To assure controlled drugs are handled, stored, and disposed of properly.c) To assure proper record keeping for controlled drugs. *Procedurec) Narcotic records are reconciled by a physical count of the remaining narcotic supply at the change of each shift by the oncoming and outgoing licensed nurse/designee.f) After the supply is counted and justified, each nurse must record the date and his/her signature verifying that the count is correct.*Receiving Controlled Substancea) When the nurse receives the controlled medication, the nurse will need to fill out the top portion of the controlled drug administration record (information about the medication).c) Each time the medication is given the nurse should fill out the following columns: signature, date, time, amount on hand, amount administered, and amount remaining.

Based on interview, record review, and policy review, the provider failed to ensure complaints of potential abuse were investigated and reported to the facility leadership and the South Dakota Department of Health (SD DOH) for one of one sampled resident (7) who reported concerns of two different staff members (unidentified nurse and certified nursing assistant (CNA) H) handling her roughly during care. Findings include: 1. Observation and interview on 12/9/25 at 11:50 a.m. and 12/9/25 at 12:10 p.m. in resident 7's room revealed:*She was sitting in a broda wheelchair (a specialized wheelchair that can be reclined) applying lip gloss.*She reported that a travel staff member was rough with her, pushed her, and talked meanly to her when assisting her. She was unsure what that staff person's name was, but described her as having colored skin and said she put her to bed at night sometimes.*When asked if she told anyone she said the nursing home was short of help, so she did not think they would fire anyone, she did not want anyone to get mad at her, and her daughter did not believe her. 2. Review of resident 7's electronic medical record (EMR) revealed:*She was admitted on [DATE].*Her 10/20/25 Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated her cognition was moderately impaired. *She had diagnoses of unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities) and major depressive disorder (a serious mood disorder causing persistent sadness and loss of interest in activities, significantly impacting daily life). *Her 10/28/25 care plan indicated she required the assistance of two staff members to transfer into bed using a total body lift (a mechanical lift and sling used to lift a person's full body), the staff were to be patient with her as she talked quietly and slowly, and she was considered a vulnerable adult due to having dementia with poor decision-making abilities and the need for assistance with her activities of daily living.*There were progress notes that resident 7 refused medications and was aggressive with staff at times. *A 5/22/25 care conference note indicated resident 7's daughter, MDS coordinator/registered nurse (RN) G, and social worker (SW) C attended the meeting. Resident 7 had some behaviors with hitting and swearing, and did not have any cognitive changes. Resident 7's daughter reported concerns about a staff member who did not use a sling, picked up the resident, and set her down roughly. *An 11/6/25 care conference note indicated resident 7's daughter, MDS coordinator/RN G, SW C, activity staff, and dietary staff attended the meeting. The note indicated that the resident refused care, hit, bit, and kicked at staff members at times. The note indicated there was a complaint that resident 7 sat out in the dining room or solarium too long, it had been a regular complaint of hers, and it would be addressed with the staff. *There was no documentation that indicated any follow-up or discussion of the potential abuse allegations the residents' daughter reported during the 5/22/25 care conference occurred. 3. Interview on 12/10/25 11:40 a.m. with administrator A revealed:*If a complaint was reported, nursing staff would document it in the nursing notes in that resident's EMR, and if they were not able to correct the issue, then the grievance form would be filled out. *If a grievance form was filled out, it would be given to the charge nurse or the director of nursing (DON), and then it would be given to her for review. *No grievance forms had been filled out in the last six months. *If she found that there was a frequent complaint, she reported that to the interdisciplinary team (IDT) meeting for discussion. *Residents were educated on how to file a grievance at the resident council meeting and could share complaints at those meetings. 4. Interview on 12/10/25 at 2:05 p.m. with certified nursing assistant (CNA) I revealed: *Resident 7 had complained to her about a traveling staff member being rough with her around three weeks ago. At that time, she saw a red spot on resident 7's left side of her forehead, and CNA I thought that the staff person was travel CNA H.*CNA I explained that when CNAs repositioned resident 7 in bed, sometimes the residents head would bump on the wall if they were not careful due to how the resident was positioned. *She indicated that if the staff would not rush when working with resident 7, it would be better for the resident.*She reported resident 7's concerns and the red spot on her forehead to registered nurse (RN) J and licensed practical nurse (LPN) D right away.*No other residents had complained to her about a staff member being rough with them. 5. Interview on 12/10/25 at 2:08 p.m. with DON B revealed:*She had not heard any complaints about staff being rough with resident 7. She remembered resident 7 saying someone was rough with her, and recalled that an investigation was not warranted, and was unable to explain further. *DON B stated that resident 7 likes to be the boss and it's my way or the highway type of person. *DON B stated resident 7 had it out for a traveler [travel staff] staff member months ago, who was no longer working there. *She remembered a while ago that resident 7's daughter reported something about a staff member who left the residents pop out of her reach, but did not recall hearing anything about the staff member being rough. *If a resident made a complaint to a CNA, she expected that CNA to tell the charge nurse immediately.*She expected the charge nurse to make sure the resident was safe, reassign that CNA from working with residents, if warranted, and then to call her.*She reported she reviewed her daily staff clinical meeting notes, and she did not find any documented incidents regarding resident 7 and a staff member being rough with her in those notes.*There were no incidents or complaint reports filed regarding resident 7's complaints. *Staff had to assist resident 7 carefully; otherwise, she did not like it and would complain. *DON B called social worker (SW) C during the interview to see if she had heard of the incident of a staff member being rough with resident 7. SW C reported to DON B that resident 7's daughter reported a concern during a care conference that resident 7 was left in the dining room for a long period of time, but nothing about a staff member being rough with her. *DON B was unsure what was done to follow up on that complaint, as MDS coordinator/RN G attended the care conferences, and she must have looked into that complaint and did not find any reason to notify her of it. 6. Interview on 12/10/25 at 2:35 p.m. with MDS coordinator/RN G revealed:*Resident 7's daughter had reported to her in the past that a night shift staff member was rough with her, did not give her the name of that staff member, so they were not able to do anything about it.*Resident 7 had made accusations about a travel staff member who had colored skin in the past, around three to six months ago. Since then, during care conferences, she asked resident 7's daughter if resident 7 had reported any further instances of staff being rough with her. -There was no documentation that an investigation was completed.*She helped staff assist resident 7 with transfers several times, and the resident verbalized pain when transferred, even though the staff were being careful with her. 7. Interview and EMR review on 12/10/25 at 2:50 p.m. with SW C revealed:*She was the grievance counselor.*If a resident reported a complaint to a staff member, the staff member was to verbally tell her, their supervisor, the DON, the administrator, or the department head the complaint was related, or they could fill out the grievance form. *If someone reported a complaint to her, she would complete an assessment and make a progress note in the resident's chart.*If a grievance form was filled out, she would give it to the department manager it was related to, keep a copy of it, and it would then be scanned into the resident's chart.*She had not received any grievance forms since she started at the facility in March 2025.*At resident 7's last care conference, she thought resident 7's daughter complained about the resident being left in the dining room for a long period of time and about a wheelchair cushion. *She stated that the complaint during the 5/22/25 care conference, which SW C and MDS coordinator/RN G attended, was regarding a male nursing staff member whom resident 7 did not like. He picked her up without a sling and set her down roughly. The care conference note indicated that resident 7 stated, I don't want them mad at me, and the daughter reported that resident 7 feared retaliation. *The male staff member whom resident 7's complaint was about was talked to about the incident, and he no longer worked at the facility.*When reviewing resident 7's EMR, she was not able to find a progress note regarding what follow-up was done with the incident reported on 5/22/25 during the care conference.*The DON should have been notified about resident 7's complaint, since it had been regarding a nursing situation, and administrator A should have been notified. 8. Interview on 12/10/25 at 3:15 pm. with LPN D revealed:*Several weeks ago, CNA I reported to LPN D that resident 7 told her that a staff member was rough with her, and CNA I observed a red mark on the right side of the resident's forehead.*At the time CNA I reported that to her, she was busy, so she talked to resident 7 later that day. Resident 7 was not able to tell her anything about the incident, and LPN D did not observe a red spot on resident 7's forehead at that time. *LPN D stated that CNA I was good about reporting that kind of stuff.*LPN D did not report resident 7's complaint or CNA I's reported observation of a red spot on the residents forehead to anyone else since she did not see the red spot, and resident 7 was not able to recall the incident. *She thought she had charted her investigation in the residents' EMR.*She explained she thought resident 7's complaint was resident 7 being resident 7, and that resident 7 would say something and then later say something different. *If a CNA reported a resident's complaint to her, she would check on the resident and see what they said about it. If they reiterated the complaint to her, then she would notify the DON or the administrator about it. *She did not receive other reports or complaints about staff being rough with residents.*She had overheard other staff talking about travel CNA H being rough with residents during her last assignment to work at this facility, but not during CNA H's most current assignment. *She witnessed CNA H become upset with a confused resident. She asked her to step out of the room, and she found another CNA to take over the care of that resident. *After CNA H took a break, she was able to work with that resident again without issue. *She reported the incident regarding asking CNA H to leave the room to the DON a while ago.*CNA H currently worked at the facility.*She thought there was a communication issue between CNA H and the residents as her accent was difficult to understand, which frustrated the residents, and then she would get frustrated with them. She did not think CNA H was trying to be mean or rough with the residents. 9. Interview on 12/11/25 at 11:30 a.m. with travel CNA H in the day room revealed: *Resident 7 would tell her how she wanted things done for her. *She transferred resident 7 using a mechanical lift with two staff members.*Resident 7 was calm and cooperative when transferring her. *Sometimes, resident 7 would not want to get out of bed, so she would try again at a later time. *Sometimes, resident 7 would scream at her and another CNA when they helped her with her hygiene needs, and they would explain to her why they needed to help her with those care needs. If that did not calm the resident down, then she would leave the resident's room, give her time, and reapproach her later.*She would notify the nurse if the resident refused care and receive further direction from the nurse.*She was not aware of any staff member being rough with resident 7. *She has not accidently hit resident 7's head on the wall when repositioning her in bed. *She took care of resident 7 often. 10. Interview with administrator A and DON B on 12/11/25 at 11:52 a.m. revealed:*They were not aware of resident 7's concern with a male nurse who picked her up and set her down roughly without using the mechanical lift, or her concern regarding travel CAN H being rough with her. *They were not aware that LPN D had to remove CNA H from a resident's room after she became frustrated with that resident.*Since they were not made aware of the complaints, they would assume LPN D, SW C, and MDS coordinator/RN G resolved those issues with the resident and staff members. *They verified that if the resident's care plan was not followed, it could be considered neglect. *They expected LPN D to assess resident 7 right away(after CNA I reported the concerns with a red spot and staff being rough, instead of doing it later on that day.*They expected investigations regarding resident complaints to be documented in the residents' EMR, and if it was not documented, there was no supportive evidence that an investigation was initiated. *As far as they were aware, an investigation had not been done related to the staff members being rough. *They were responsible for completing the investigations. *They expected staff members to report complaints to them so they could determine if the event needed to be reported to the SD DOH. *They expected SW C and MDS coordinator/RN G to notify them of residents' complaints so they could determine if they needed to be reported to the SD DOH. *DON B did not agree with MDS coordinator/RN G's statement that nothing could be done if no one was named in the complaint and stated complaints would still need to be investigated, and education completed with the staff. *Their process for potential resident abuse or neglect reports from staff would be to not allow that staff member to work with that resident until an investigation was completed related to the event. *CNA H was working in the nursing home currently, so they planned to suspend CNA H from working, interview her, investigate the complaint, and report it to the SD DOH. *Administrator A expected reportable events to be reported to the state immediately and investigated, and the staff member not to work with that resident until the investigation was completed. * Administrator A was the grievance officer, not SW C. 11. Review of the provider's January 2023 Grievance Process policy revealed:* The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC [long term care] facility stay.* The resident has the right to, and the facility will make prompt efforts by the facility to resolve grievances.* The facility has established a grievance policy to ensure the prompt resolution of all grievances regarding the resident's rights.* The grievance official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility;.and coordinating with state and federal agencies as necessary in light of specific allegations. * As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated.* Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider, and as required by State law. 12. Review of the provider's 10/19/2022 Vulnerable Adult policy revealed:*.[the provider] supports Zero Tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of property.*In compliance with South Dakota regulations and the CMS [Centers for Medicare and Medicaid Services] and NF/SNF [nursing facility/skilled nursing facility] Requirements of Participation (2019).[the provider] has instituted the following policy and procedure on reporting of maltreatment of vulnerable adults. These regulations are intended to protect adults who are dependent upon others for their care. The requirements also assist health care providers to maintain a safe environment for their residents by requiring facilities and other mandated reporters to submit reports of suspected maltreatment or unexplained injuries for review and possible investigation. We believe all adult residents living or receiving services in.[the providers] are vulnerable and it is our policy to ensure the resident is free from abuse, neglect, mistreatment, misappropriation of resident property and exploitation.injuries of unknown source sustained by a vulnerable adult that is not reasonably explained immediately (as soon as possible).[The provider] will report any maltreatment of a vulnerable adult.*Mandated reporters employed by .[the provider] or providing services in our facility shall report abuse, neglect, mistreatment,.and injuries of unknown sources sustained by a vulnerable adult that is not reasonably explained immediately (as soon as possible) after the discovery of the incident.a) Identify Maltreatment: Compare the incident or event to the definitions of Accident, Abuse, Neglect,.and injuries of unknown source.b) Recognize Exception.c) Report: Review the Reporting procedures to find out where, how and when to report internally and externally.*Definitions.f) Maltreatment/Mistreatment 1) Mistreatment means inappropriate treatment or exploitation of a resident.g) Neglect 1) Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. h) Abuse (Abuse must be reported) 1) Abuse is the willful infliction of injury. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. ii) Conduct which produces or could reasonably be expected to produce pain or injury or emotional distress. Such conduct must not result from either an accident or therapeutic conduct. j) Injuries of Unknown Source/Unexplained Injuries 1) An injury should be classified as an injury of unknown source when both of the following conditions are met: i) Federal: a) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and b) The injury is suspicious because of the extent of the injury or location of the injury. ii) State: a) If a reporter has reason to believe that the vulnerable adult has sustained an injury which is not reasonable explained.* Internal Reporting Procedurea) During the shift that the alleged abuse/neglect or unexplained injury is first observed, a mandated reporter will immediately make an initial report to their Supervisor, after securing the resident's safety. Following the review of the situation, the Supervisor will immediately report to the Administrator and the Director of Nursing.b) Upon report to a Supervisor of the suspected abuse, the employees in question will be interviewed, re-assigned duties, placed under the direct supervision of a licensed nurse, assigned to non-resident related tasks or suspended pending investigation. This is for the protection of the resident.c) The Administrator or Director of Nursing shall determine if the incident/allegation meets the criteria for Reportable Incident. All incidents deemed reportable under SD statute are submitted to the appropriate agency within the expected timeline. d) The Supervisor, Director of Nursing or Administrator will immediately institute an internal investigation of the reported allegation or incident. The investigation may include: 1) Interviews of staff 2) Resident Interviews 3) Witness interviews. 5) Resident health status 6)Behavior review 7) Medication reviewe).Any incident deemed reportable will be reported not later than 2 hours after forming the suspicion, if the events that cause suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.f) If the Administrator or Director of Nursing determines the internal report does not meet the criteria for reporting under either state or federal guidelines, the Administrator or Director of Nursing will note that decision in writing on the Incident Report.*External Reporting Procedured) Any mandated reporter who observes or suspects abuse, neglect, mistreatment, misappropriation of resident property or physical injury not reasonably explained of a vulnerable adult may make an oral report to the SD Department of Health.e) The facility is responsible for submitting reports via the on-line system.*Identification/Investigationa) If events are identified as suspicious for abuse and neglect it is the responsibility of the employee, resident, or family to report their findings as soon as possible. 1) Residents and family or residents/patients may report verbally or may follow the grievance procedure written in the patients rights policy. 2) Employees will report findings, verbally and immediately to their supervisor. The supervisor will then immediately report to the Administrator and Director of Nursing Services. The Administrator or designee will initiate the investigation. An incident report will be completed. 3) Any findings will be acted upon immediately by the Administrator. 4) Any employee who witnesses or suspects abuse of a patient/resident and does not report such abuse is subject to disciplinary action.* Protection a) The individual identified as suspected for abuse/neglect will be removed from the situation. If the individual is an employee, they will be suspended pending the completion and outcome of the investigation.* Failure to Report-A person required by this section to report a suspected case of vulnerable adult abuse who knowingly and willfully fails to do so within twenty-four hours commits a simple misdemeanor.* No Retaliation:-The facility may not retaliate against an employee or individual for reporting a case of suspected crime.

Based on observation, interview, and policy review, the provider failed to ensure the privacy and confidentiality of resident electronic health records had been maintained by two of two staff (licensed practical nurse (LPN) C and certified nursing assistant (CNA) D, during medication administration. Findings include: 1. Observation and interview 7/30/24 from 8:50 a.m. to 9:00 a.m. of one medication cart computer in the dining room with LPN C revealed: *It was placed in the dining area and there were no staff within view of the medication cart. *The medication computer screen faced the wall, was open and displayed a resident's electronic medical record (EMR). *The unattended computer screen was visible to any resident, staff, or visitors that would have been passing by the medication cart. *It contained the following information: -The resident's name and room location. -Age and date of birth. -Gender. -Allergies. -Medical record number. *LPN C agreed the screen should not have been left open and should have been shut. *She thought since the screen was facing the wall no one would have looked at it. *She was not sure how to lock the screen. *She agreed it was a violation of Health Insurance Portability and Accountability Act (HIPAA). 2. Observation on 8/1/24 at 7:57 a.m. of one medication cart computer located in the dining room revealed: *CNA D had been in the dining area administering medications to a resident. *She had walked away from the medication cart. *The medication computer screen was open and displayed a resident's medication administration record (MAR). *The record had been visible to any resident, staff or visitors passing by the medication cart. 3. Observation and interview on 8/1/24 at 1:41 p.m. of one medication cart computer located in the 200-hallway with CNA D revealed: *The medication computer screen was opened and displayed a resident's EMR. *She had walked away from the medication cart and was in a resident's room. *She agreed she should not have left the medication cart with the screen open with the resident's information displayed on it. *She was not feeling well and was not doing her job 100%. *She only does medication pass once a month and feels it is like new every time she does it. *She stated she has not had re-training in [AGE] years. 4. Interview on 8/1/24 at 11:26 a.m. with director of nursing (DON) B regarding the above observations revealed she: *Would have expected all nurses to have locked the medication carts and the computer screen prior to leaving the medication cart unattended. *Agreed that if the computer screen was not locked when unattended resident's personal health information could have been viewed by anyone walking past that medication cart. 5. Review of provider's February 2019 Notice of Privacy Practice policy revealed: *How will this Facility protect my health information? - This Facility works hard to protect your health information. We use computer systems to store your health information. We have protections in place to keep your information from being seen by anyone that should not see it. *Electronic health records/ health information -This electronic health record is a secure system. This Facility and the providers using the system are trained to ensure your information is private.

Based on observation, interview, and policy review, the provider failed to ensure two of five mechanical lifts shared for multiple resident use were maintained in a clean and sanitary manner. Findings include: 1. Observation on 7/30/24 at 8:26 a.m. in the 300-hallway revealed: *The Volaro Full Body Lift had a torn and cover that left a non-cleanable surface area on the top of the lift. *There was rust and scratched paint on the top of the lift's legs. 2. Observation on 7/30/24 at 9:58 a.m. of the Volaro sit-to-stand aide lift in the 300-hallway revealed: *There was a buildup of food particles and dirt on the foot base. *The knee padding was worn and torn. *The foot base was missing several areas of paint with exposed rusted metal. *The right wheelbase of the lift had a large gouge in the rusted metal. 3. Interview on 7/31/24 at 10:42 a.m. with CNA E revealed: *She was unsure how to clean the damaged portions of the two lifts. *She was unsure if there was a policy on how to clean the lifts. 4. Interview on 8/1/24 at 11:26 a.m. with DON B revealed: *No one had informed her that the mechanical lifts were damaged and needed repair. *She would have expected all equipment would be in good working order and sanitized properly between each use. 5. Review of the provider's May 2024 General information Prevention and Control policy. *Procedure: -a. All items for resident care will be cleaned and disinfected and will be designated for the resident's use only. -i. Reducing and /or preventing infections through indirect contact requires the decontamination (i.e., cleaning, sanitizing, or disinfecting an object to render it safe for handling) for resident equipment, medical devices, and the environment. *Nursing Weekly Cleaning Tasks -Multiple use items will be cleanded and disinfected between each resident use: d. Mechanical lifts.

Based on observation, interview, record review, and policy review, the provider failed to assess fall prevention devices for 2 of 3 (15 and 18) sampled residents with devices. Findings include: 1. Observation and interview on 2/16/22 at 11:00 a.m. with resident 18 revealed: *She was seated in a reclining chair with her legs extended on the footrest and was using an oxygen concentrator. *She reported she had been in the hospital several times since she moved in and thought it was due to problems with her breathing. Observation and interview on 2/16/22 at 12:43 p.m. revealed: *Certified nursing assistant (CNA) J provided weight-bearing assistance while transferring resident 18 from her recliner to her wheelchair and then onto the toilet. *While the resident was seated on the toilet, CNA J moved an alarm pad from the seat of the recliner to the seat of the wheelchair. *The alarm sounded momentarily when the resident transferred off the recliner, and then when she sat down in her wheelchair. *CNA J explained the alarm sounds at times of transfer to confirm it is turned on and working, but staff received all other alarm sounds on their pagers when the resident was moving. Review of the progress notes in the electronic medical record (EMR) for resident 18 revealed: *On 11/30/21, she was admitted to the facility. *On 12/6/21, she was sent to the hospital with an injury that happened when the resident was rolling/sliding out of bed. *On 12/9/21, she returned to the facility, and a fall risk summary scored her as high risk. *On 12/10/21, a care conference noted a discussion of the resident's fall history and plans for fall prevention with multiple family members. *On 12/11/21, the resident was educated to use her call light but doesn't remember to use it at this point. She tends to yell .to get staff members attention. *On 12/14/21, a physical device evaluation noted the use of a hi-low bed in a low position was appropriate because the resident does not always remember to call for assistance, and she does not seem to want to get out of her [reclining] chair when her wheelchair and walker are not close enough to use. *On 1/23/22, the resident was found on the floor next to the toilet in her room with her bottom exposed and a bump on the back of her head. *On 1/24/22, a post-fall intervention was noted as Do not leave unattended in bathroom. Another note documented a conversation with the resident's power of attorney included: -Options to prevent falls, including moving her to a room closer to the nurse's station. -A discussion that most interventions are to prevent injuries as it is not feasible to expect we can prevent every fall. Review of the care plan, initiated on 11/30/21 and revised on 12/6/21, revealed: *At risk for falls r/t [related to] limited physical mobility and weakness. *An intervention for wide bed with pillow under sheet when in bed. Bed low to the floor. *Interventions added on 1/24/22 included: -Do not leave unattended in the bathroom. -Use an alarm pad under [resident] at all times in her bed, recliner, & w/c [and wheelchair]. Review of the physical device evaluation dated 2/1/22 revealed: *Locomotion devices included wheeled walker and wheelchair. *The Other option was not checked under the section for Other devices. Instead, None of the above was checked. *Medical symptoms and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Sensory and cognitive deficits, impaired judgment, unaware of boundaries, impulsive and self-injurious behavior, impaired mobility and weakness, and frequent falls. -Arthritis, stroke ([CONDITION(S)]), and dementia. *The section for Interventions was left blank. *The summary section indicated the device will be used for mobility, positioning, safety, resident preference. *There was no rationale documented for the use of the chair and bed alarms nor how the alarms could or did affect the resident's movement. Review of the 2/8/22 comprehensive Minimum Data Set (MDS) assessment revealed: *Bed and chair alarms were coded as not used. *The fall history noted that a fall occurred in the last month and in the last 2-6 months. *Resident 18's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *She needed extensive weight-bearing activities of daily living (ADL) assistance to transfer between surfaces. *Her mental status was cognitively intact, but she displayed behavioral symptoms that significantly interfered with the resident's participation in activities or interactions with others. Review of the 2/8/22 care area assessments (CAA) for the comprehensive MDS revealed: *The behavioral symptoms CAA noted resident 18 was disruptive and yelling out and had one episode of hallucinations/delusions that was associated with Sundowners. *The ADL functional potential CAA noted her functional abilities were impacted by her behavioral symptoms, recent falls due to the risk factors of weakness and poor balance. *The falls CAA noted a history of falls with several since admission with risks factors including weakness and dizziness from poor oxygenation. On 2/16/22, a written request form for documents, including the policies and procedures for fall prevention and physical restraints, was provided to administrator A. Review of the written request form and the documents provided revealed: *The fall risk and prevention guidelines, revised in February 2019, did not address the assessment of fall prevention devices. *The note, (Don't have one/[do not] use restraints) was written on the request form next to the requested restraint policy and procedure. Interview on 2/17/22 with MDS coordinator C did not occur as she was involved with the care conferences. Interview on 2/17/22 at 1:58 p.m. with director of nursing B revealed: *There were no documented assessments for the use of the chair and bed alarms because they had not restricted her movement. *She acknowledged they could have been addressed on the physical device evaluation. *The fall on 1/23/22 occurred when the resident impulsively tried to get up [from the toilet] when she was done [going to the bathroom]. *The fall could have been prevented if the CNA who had assisted the resident onto the toilet had not left her there to answer a call for help from another CNA. 2. Observation on 2/17/22 at 3:01 p.m. of resident 15 revealed: *She was lying on her bed that was low to the floor with a raised edge mattress. *She had both of her legs resting on top of the raised edge. *The resident was awake and spoke with a strongly tremulous (quivering) voice that made it very difficult to understand what she said. Review of the care plan, initiated on 1/23/20 and revised on 11/15/21, revealed the interventions for the resident's fall risk included: *Bed in low position at all times. *Lip mattress on bed. *Rocking w/c [wheelchair] for positioning and fall prevention. Review of the physical device evaluation dated 12/8/21 revealed: *Hi-low bed was the only bed device checked. Scoop type mattress was not checked. *Wheelchair was the only locomotion or chair device checked. The rocking wheelchair was not noted. *The Other option was not checked under the section for Other devices. Instead, None of the above was checked. *The section for Interventions was left blank. *The summary section indicated the device will be used for positioning, safety, and resident preference. Review of the 12/21/21 MDS revealed: *No physical restraint options were coded as used. *There had been no falls since the prior assessment. *She needed extensive weight-bearing activities of daily living (ADL) assistance to transfer between surfaces and was totally dependent for mobility in her wheelchair. *She had not wandered nor displayed any behavioral symptoms.

Based on observation, interview, record review, and policy review, the provider failed to follow the Centers for Disease Control and prevention (CDC) infection control guidelines regarding the coronavirus (COVID-19) pandemic including: *Screening of this surveyor coming into the facility. *Isolation precautions for a designated cohort unit currently housing eighteen positive COVID-19 residents (1, 2, 3, 4, 5, 6, 7 ,8 , 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) and two residents (25, and 26) who were negative for COVID-19. *Quarantine precautions for five residents (19, 20, 21, 22, and 23) considered presumptive positive due to close exposure to COVID-19. Findings include: 1. This surveyor entered the vestibule of the building on 10/28/20 at 3:00 p.m. *Introduction was made to community life employee C who had opened the door. *Community life employee C brought the surveyor into director of nursing B's office. -No screening questions were asked to assess for the possibility of having COVID-19 or exposure to COVID-19. -Temperature was not obtained. 2a. Observation on 10/28/20 at 3:19 p.m. of the 100 hallway revealed: *There was a set of double-doors. -One door was opened. *There were eleven resident rooms down the 100 hallway, and all doors were opened. *Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,18, 25, and 26 were located down the 100 hallway. - The business office was located inside the double-doors. --Office manager E and medical records employee F shared the business office; their door was opened. *Outside of the business office was a receptacle that housed personal protective equipment (PPE). *There was an a-frame dry erase board that let people know it was a cohort area, and they needed to wear PPE past the point of the dry erase board. *Across the hall from the PPE and board was resident 25 and 26's room. -Their door was opened. -They had not tested positive for COVID-19. *There were signs on some residents' doors that stated Infection control precautions were in place and to see the nurse before they entered. -One door had a sign that stated droplet precautions. -Two doors did not have a sign including the residents' door, who had tested negative for COVID-19. *There was a recliner and personal items in black trash bags located at the end of the hallway by the door. -According to the DON those items belonged to positive COVID-19 resident 24 who passed away. --They were in the hallway waiting for her family to pick them up. *Staff were removing their PPE outside of the two negative tested residents 25 and 26's opened door. *The breakroom for the staff working on the cohort hall was across from resident 25 and 26's opened door. b. Observation on 10/28/20 from 3:00 p.m. to 3:25 p.m. revealed one door of the set of double doors on the 100 hallway remained open. *Multiple staff that included the administrator A, DON B, community life staff person C, business office manager E, medical records staff person F and, environmental services director G passed through the door. -They had eye protection and N95 masks on but no gowns or gloves on. c. Observation on 10/28/20 at 3:30 of the 300 hallway revealed: *One side of that wing housed the presumptive positive residents 19, 20, 21, 22 and, 23. -They were roommates with residents who had tested positive for COVID-19. --All of their doors were opened. *Resident 22 was sitting in the hallway of the 300 wing wearing a surgical mask. -The DON asked her to go back to her room. *There was a three-drawered container that was used to house PPE. -There were no gowns in any of the drawers. *The DON asked staff development coordinator/infection control preventionist I to put gowns down in the 300 hallway. *A single gown was hung in the hallway outside of residents 19, 20, 21, 22, and 23's rooms. *The container that was used to discard soiled PPE was also in the hallway. d. Further observation on 10/28/20 at 3:40 p.m. on the 100 hallway revealed: *Registered nurse (RN) D standing in the doorway of the business office wearing full PPE waiting for someone to bring her spoons. *RN H who was assigned to another area in the facility was in the 100 hallway wearing an N95 mask and no eye protection, gown, or gloves. e. Observation on 10/28/20 at 5:19 p.m. of resident 3 revealed: *She walked passed the dry erase board, business office, opened door, and into the director of nursing's office. *She then walked into the main sitting area of the facility. *It was revealed she currently had COVID-19. -She did not have a mask on. f. Observation on 10/28/20 at 5:28 p.m. revealed: *Staff development/infection preventionist I removed a gray cart which was located inside the 100 hallway. *The cart was in the area by the dry erase board, in the COVID-19 positive hallway. -The cart had straws, with paper wrappers on them. --The cart and the straws were brought towards the kitchen. 3. Interview on 10/28/20 at 5:30 p.m. with DON B and administrator A revealed: *They had designated staff working cohort 100 hallway. -RN D was currently positive with the COVID-19 virus. *The cohort designated staff checked in at the front door and exited through the door at the end of the 100 hallway. -DON B was not sure if RN D came in through the front door or back door but she was good about wearing her N95 mask. 4. The following policies were requested from administrator A and DON on 10/28/20 at 4:00 p.m. to have by surveyor on 10/29/20 by 12:00 noon including: *Infection control and prevention policies. *Infection surveillance. *Any policies and procedures for caring for residents who were positive for COVID-19 and presumptive positive residents. *Policies and procedures to address residents/staff who refused testing. *Employee screening/visitor screening policies. *Emergency staffing policies. *On 10/29/20 at 1:26 p.m. the following was received: - Infection prevention procedures including surveillance. - Policies and procedures to address residents/staff who refused testing. - Gown and Facemask conservation. Review of provider's 4/27/17 Infection Surveillance policy revealed: To ensure a quality of surveillance the following elements must be incorporated. 1. A written list of infections to assist in organizing information about resident infections. The line list should be monitored and updated regularly to identify clusters, outbreaks and other unusual infection patterns. Cues for triggering a possible infection includes: a. Antibiotic starts-this is a trigger for a possible infection but is not in itself a determination of an infection. b. Resident signs and symptoms. *In regard to completing the Surveillance Line List: 1. The infection Line List is to be monitored and updated regularly to identify clusters, outbreaks and other infection patterns. *The policy did not address COVID-19 or monitoring for COVID-19 symptoms. Review of the provider's undated COVID-19 Emergency Declaration Conservation & Limited Re-use of Gowns Personal Protective Equipment revealed: Extended use of isolation gowns. Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same staff member when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. If the gown becomes visibly soiled, it must be removed and discarded as per infection control processes. Review of the provider's revised 11/2016 Infection Prevention and Control program revealed: .b. The IP (infection preventionist) shall develop, implement, comply with, and review at least annually, written policies and procedures regarding infection prevention and control which are consistent with the most up-to-date Centers for Disease Control and Prevention (CDC) publications, including but not limited to: i. Guidelines for Handwashing and Environmental Control. ii. Guidelines for Isolation Precautions. iii. Prevention and Control of [MEDICAL CONDITION] .d. The IP shall provide continuous collection and analysis of data, including determination of Healthcare Associated Infections (HAI), epidemics, clusters of infections, infections due to unusual pathogens or multiple antibiotic-resistant bacteria . Review of provider's 4/3/20 COVID-19 infection prevention guidelines revealed: .a. All visitors, admissions and employees who enter the community will be screened utilizing the appropriate COVID-19 Screening Form . Policies related to isolation precautions, transmission based precautions, and/or any policies related to caring for residents who had COVID-19 or presumptive positive for COVID-19 were requested again on 10/29/20 at 2:46 p.m. and at 4:14 p.m from administrator A and DON B. On 10/29/20 at 6:09 p.m. the following was received: *COVID-19 Infectious Disease initial actions, which stated: .Limit the exposure between those infected and the non-infected persons; consider isolation of ill persons *Surveyor did not receive policies on how staff should care for residents who have COVID-19 or have been exposed to COVID-19. Review of CDC 4/30/20 guidance for Responding to Coronavirus (COVID-19) in Nursing Homes for considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 revealed: .Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19, depending on facility capacity (e.g.(for example),staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms .

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (8 and 15): *Who required staff assistance with care had not developed a facility acquired pressure injury. *Pressure injuries had individualized interventions and implementations in place to prevent facility acquired pressure injuries. *Had received preventative care and treatment for [REDACTED]. Findings include: 1. Observation and interview on 11/06/18 at 12:00 noon with certified nursing assistant (CNA) A and CNA C regarding resident 8 revealed: *She had a pressure relieving air mattress on her bed. *Had a gauze dressing to her left hip. *Stated she liked to lay on her left side. *They would at times find her on her left side after she had been positioned on her right side. *There was a wedge cushion noted in her recliner that was used for positioning in bed. *No cushion was present in her wheelchair. *Stated it started out as a red spot but staff had not kept her off of her left hip, and she had developed a pressure injury. *They were not sure when the pressure injury had started. *They knew it had gotten bigger. Observation on 11/6/18 at 12:11 p.m. revealed resident 8 was seated in her wheelchair in the dining room. No pressure relieving cushion was in her wheelchair. *Prior to the above observation she had been seated in her wheelchair by the front lobby area for approximately twenty minutes before her meal. Observation on 11/6/18 at 2:14 p.m. she was assisted by CNAs A and C to use the toilet. She had not been repositioned since she had used the toilet before lunch. *She was placed in her recliner with the standing lift. There was no pressure relieving cushion in the recliner. *CNA C stated she preferred to sit in her recliner in the afternoon. Observation and interview on 11/07/18 from 8:20 a.m. through 8:28 a.m. with registered nurse (RN) B during a dressing change to the left hip revealed: *An approximately five centimeter (cm) round, two to three cm deep, with tunneling at about the two o'clock position pressure injury. *There was slough noted in the wound bed and edges had started to roll under. *She stated it had started out as a red area about a month ago. Staff had left her on her left side too much, and it had gotten worse. *The treatment was to place a dry four by four gauze piece in the wound, gauze in the tunneled area, and cover with dry gauze. Review of resident 8's last revised 8/27/18 care plan included: a.*Focus: (Resident name) has impaired skin integrity r/t (related to) immobility and incontinence aeb (as evidenced by) pressure ulcer on left hip and moisture associates (associated) skin alteration on buttocks. *Goal: Resident will be free from skin breakdown through the review date. The review date was 11/25/18. *Interventions: -Diligent peri cares, including barrier cream after incontinent episodes. -Dressings/treatments per orders. -Encourage repositioning q (every) 2-3 hours as needed. -Keep bed linens dry and wrinkle free. -(Resident's name) frequently rolls over to her left hip even after repositioning. Check frequently through the night and repo (reposition) appropriately. -Observe skin during cares. Report any changes to nurse. -Pressure relieving mattress on bed and cushion in chair for prevention of breakdown. *There were no specific interventions for pain related to her wound. b.* Focus: (Resident's name) has an ADL (activities of daily living) deficit r/t Alzheimer's and dementia with limited mobility. *Goal: Resident will maintain ability to feed herself with supervision through the review date. The review date was 11/25/18. *Interventions: -AMBULATION: Unable to ambulate at this time. -BED MOBILITY: Assist x (times) 1 (one staff person). -TRANSFER: Assist x 1. *Staff had assisted her with the standing lift to transfer on and off the toilet and to her recliner. *Staff had stated that she received comfort cares. c.* Focus: (Resident's name) has a potential Nutritional problem r/t history of unplanned/unexpected weight loss. *Goal: Weight will remain stable during the review date. The review date was 11/25/18. *Interventions: -Invite to activities that promote additional intake. -NIP (unknown) for added caloric intakes. -RD (registered dietician) to evaluate and make diet change recommendations PRN (as needed). -Provide, serve diet as ordered. Observe intake and record q meal. d. Review of resident 8's following weekly wound documentation records included: *On 8/6/18 and 8/14/18 a left hip pressure injury 0.5 cm long and 1 cm wide. With no depth or stage noted. -Small open area on left hip from pressure, surrounding skin is dark pink covering about the size of a golf ball, no drainage noted as wound bed is pretty dry, small maceration area on right buttock cheek, scant drainage noted, wound bed is dark pink and surrounding skin is normal in color. -Current treatment for [REDACTED]. *On 8/21/18 the left hip pressure injury measurements were 3 cm x 2 cm x 0.2 cm and a stage two. Left hip is larger with some slimy white drainage noted, wound bed is beefy res (red) granulation tissue however, surrounding skin is normal in color. No change in treatment. *The left hip pressure injury treatment from 8/2/18 through 9/25/18 remained the same, and the measurements decreased to 1.5 cm x 1.2 cm x 0.1 cm. *On 10/2/18 the pressure injury size had increased to 2.5 cm x 3 cm x 0.1 cm. The treatment was changed to [MEDICATION NAME] to wound bed and cover with Allevyn. *On 10/8/18 the pressure injury size had increased to 4 cm x .05 cm x 0.1 cm. Wound has become very moist under dressing and is getting bigger in size, moderate yellow/greenish drainage seen on Allevyn dressing, surrounding skin is pink in color, treatment will be changed as Allevyn appears to not be effective, dry to dry dressing BID (twice daily) is ordered now until wound resolves. *On 10/17/18 wound was 3.4 cm x 3.2 cm x 0.1 cm. with no change in treatment. *On 10/23/18 wound was 3.3 cm x 3.2. cm x 1 cm and was changed to unstageable. Wound has started tunneling on the upper lateral area, dark eschar present in middle of wound bed, moderate cloudy brown drainage noted on 2 x 2 dressing, surrounding skin is normal in appearance. Dressing changed back to Allevyn dressing changed every three days. *On 10/29/18 wound was 3.5 cm x 2 cm x 0.5 cm stage 4. Wound has a strong odor this week. More painful with dressing change and measurement. Actual depth is 0.5 cm but tunnels back towards gluteus 1.5 cm. No eschar noted, base of wound is white, unable to determine if it is bone, painful to touch. Dressing changed to calcium alginate with super absorbent dressing over top. Started this treatment a few days ago, too early to tell, however wound does not seem worse. *On 11/6/18 wound was 2.5 cm x 2 cm x 1.3 cm. Ulcer bed is beefy red with some white slough in the middle of the wound, tunneling underneath about 2.5 cm, heavy purulent drainage on dressing when removed. Dressing changed to dry-to-dry. 2. Observation and interview on 11/6/18 at 3:18 p.m. with CNAs A and C of resident 15 revealed: *She was laying in bed on her right side. *There was a pressure relieving cushion in her wheelchair, she had a low air loss bed, a urinary catheter, and she had bilateral elbow protectors on. *CNAs A and C stated she had pressure injuries on her coccyx and were not sure if she still had one on her elbow. *They thought those pressure injuries had been there a long time. *She was only up in her wheelchair for meals and when her son came to visit. Observation and interview on 11/07/18 from 8:30 a.m. to 8:40 a.m. with RN B revealed: *Resident was laying in bed on her left side. She had an incontinence product on. *On her right elbow she had bilateral padded elbow protectors on. -Had an approximately 5 cm round opened area with a minimal amount of slough and drainage present. -The area around her right elbow appeared swollen. *On her upper coccyx area she had an opened area. *RN B stated she had pressure injuries to her right elbow and her coccyx. *The treatment for [REDACTED]. *RN B stated They're not investing a lot of resources to help it heal, as she is on comfort care. Review of resident 15's last revised 10/10/18 care plan included focus, goals, and interventions including: a.*Focus: (Resident's name) has altered skin integrity related to limited mobility, physical decline and incontinence aeb current skin alterations being monitored. *Goal: Resident will show improvement in skin breakdown by review date. That date was 12/16/18. *Interventions: -Foley catheter to keep skin dry from incontinence r/t skin breakdown. Change and care per facility policy. -In w/c (wheelchair) for meals and back to chair/bed after done eating with frequent repositioning at a minimum of every 2 hours. -Keep bed no more than 30 degrees to reduce friction/shearing. -Keep linens dry, wrinkle free. -No incontinent product while in bed to keep area open to air. -Observe skin during cares. Report any changes to nurse. -Pressure reducing air mattress on bed and cushion in w/c. -Provide diligent perineal cares after incontinent episodes, including barrier cream. -Treatment as ordered. Update medical practitioner PRN. b.*Focus: (Resident's name) has an ADL self care performance deficit related to dementia and limited mobility as evidenced by need for assistance with ADL's daily. *Goal: Resident will accept assistance from staff with ADL's through the review date. That date was 12/16/18. *Interventions included: -BED MOBILITY: Dependent x 2 (staff). -Resident is on comfort care after care conference on 3/27/18 with family and Dr. (physician's name). -TOILET USE: Assist x 2 using the stand-up lift. Wears incontinent product when out of bed. c.*Focus: (Resident's name) has altered nutrition related to decline in condition as evidenced by weight loss and open wounds. *Goal: Resident will accept food based on her likes through the review date. That date was 12/16/18. *Interventions included: -NIP program for added caloric intake. -Resident will often refuse to eat or drink. She may respond better if you make it her idea to eat. Don't tell her what she has to eat, ask her 'What sounds better to you (resident's name)' and give her choices from her plate. d. Review of resident 15's weekly wound documentation records included: *The intergluteal cleft wound was documented as a shearing injury on 5/30/18. Measurements were 2 cm x 1 cm. The treatment was to apply [MEDICATION NAME] BID. *She also had moisture related maceration to her right buttock. *On 6/27/18 Nursing trial of Allevyn dressing for two days proved to be unsuccessful. 2 wounds on right buttock cheeks have met in the center creating one large wound and intergluteal cleft wound widened, surrounding skin is normal in color, will return to [MEDICATION NAME] treatment BID. The measurements were 2 cm x 2 cm for the intergluteal cleft wound. *The right elbow wound was discovered on 7/10/18. The initial measurements were 1 cm x 1 cm. New wound on right elbow present, began as a scrape and is now an open shallow ulcer, bed is pink, drainage is minimal, surrounding skin is pink in color. Treatment was Allevyn on the elbow. No staging was noted. *On 8/7/18 Right elbow is showing improvement, white wound bed, minimal drainage noted, surrounding skin is normal in appearance. Allevyn dressing to wound changed q 3 days and prn. Right buttock continues to show improvement, wound is dry with no drainage noted, light scab covering present and surrounding skin is normal in color, staff continue with [MEDICATION NAME] treatment bid. Intergluteal cleft continues to widen despite the OTA (open to air) treatment with [MEDICATION NAME], tunneling noted, wound bed has white slough in it and the wound walls are pink, light drainage noted, surrounding skin is normal in color, order to do wet to dry dressings tid (three times daily) obtained. It was still classified as a sheering injury. *On 8/14/18 the treatment to the intergluteal cleft wound was changed to Mycrocin and dry-to-dry dressing. *On 8/22/18 Right elbow is slightly larger with small amount of white/yellow drainage, Allevyn removed and elbow will be elevated on a pillow and left OTA. Intergluteal cleft continues to tunnel with white stringy tissue in the wound bed, surrounding skin is normal in color, Microcyn gel d/c'd (discontinued) and now doing regular dry to dry dressing. *On 9/4/18 Right elbow has a hard dry scab over it, staff are leaving it OTA and elevated on a pillow. Intergluteal cleft area continues to decline , wound bed is pink with white clumps of tissue in the wound, dressing is wet with dark creamy/green drainage that is foul smelling, this wound started out as a small area of sheering that is now a deep open ulcer. No changes in the treatments were done. *On 9/11/18 the right elbow pressure injury was changed to unstageable due to the eschar. The intergluteal cleft type was changed to vascular. *On 9/18/18 Right elbow scab fell off and new scab has formed down in the crater of the ulcer, area is dry and surrounding skin is normal in color intergluteal cleft remains a dark red open sore that is tunneling under all edges light red drainage noted on dry to dry dressing, surrounding skin is normal in appearance. *On 9/25/18 Elbow scab has opened back up this morning on her pillow, blood and light drainage present, surrounding skin normal in appearance, intergluteal cleft is beefy red in appearance, heavy yellow drainage noted on 2 x 2 dressing that is removed, tunneling has not worsened, surrounding skin is normal in appearance. *On 10/2/18 Intergluteal cleft presents as a beefy red deep open wound with tunneling around the edges, moderate clear blood tinged drainage noted, surrounding skin is normal in color. Elbow is a (has) come off again and light amount of blood tinged drainage present on sheets, new dressing of [MEDICATION NAME] is started with an Allevyn covering, elbow is slightly pink and very warm surrounding the area, possible infection and will be addressed on rounds in the morning. *On 10/16/18 Intergluteal cleft continues to tunnel, wound is dark red with blood emerging from walls, drainage is bloody and somewhat foul smelling, able to pack 6 2x 2 gauze into wound bed, surrounding skin is normal in color, treatment has been change to QID (four times daily). Elbow has moderate greenish-yellow drainage on dressing, wound bed is red and glossy and has grown some in size, treatment is changed to dry-to-dry QID. The intergluteal cleft was still classified as vascular. *On 10/23/18 the intergluteal cleft was a stage 3. The documentation for the type stated other (specify) and incontinent [MEDICAL CONDITION] was documented. The dressing was changed from dry-to-dry QID to dry-to-dry with [MEDICATION NAME]. *On 10/30/18 the intergluteal cleft was considered a stage 4 pressure injury. Intergluteal cleft/coccyx area is a deep beefy red ulcer with heavy creamy green drainage, smell is slightly foul. The wound is bout 1.5 cm deep, however has tunneled 7 cm upward and is undermining around all edges. Treatment changed back to dry to dry dressing QID. *On 11/6/18 Intergluteal cleft wound appears to have closed in some around the sides, tunneled area has decreased from 7 cm last week to 5.5 cm this week, wound bed is beefy red with large amounts of purulent drainage, surrounding skin is appropriate in appearance. right elbow wound has maintained about the same size in measurement, however has begun undermining around approximately 1/2 to 3/4 of the perimeter with a depth of approximately 2 cm, wound has moderate serosanguinous drainage on the dressing, surrounding skin is appropriate in appearance. Both pressure injuries treatments are dry to dry gauze dressing changed QID. 3. Interview on 11/8/18 at 9:00 a.m. with the Minimum Data Set (MDS) coordinator revealed she: *Had taken over the wound care measuring and documentation approximately nine months ago. *The director of nursing (DON) and the MDS coordinator had attended a wound care training two weeks ago. *Did not use the provider's recommended wound management guidelines. *Was not aware resident 8 did not have a cushion in her wheelchair or recliner. She was not sure when or how long the cushion had been missing. *Had no evidence based indications a dry-to-dry gauze dressing would have been an effective treatment. *Did not go on rounds with those residents' physician. The DON was the person who had gone on rounds with him. *Did not think resident 8's pressure injury was avoidable. Staff had not known she only liked to lay on her left side in bed. *Agreed resident 8 had been admitted on [DATE], and staff should have been aware of that preference. *Had no way to monitor if turning and repositioning for those above residents had been done according to the plan of care. *Stated the physician for resident 8 said the wound would not heal with any type of dressing. It would have to be debrided. Her family had decided against that plan. Interview on 11/8/18 at 11:00 a.m. with the DON revealed she: *Was the staff person who communicated residents 8 and 15's wound information to the physician when they did rounds. *Felt the wounds had gotten worse on the other dressings/treatments they had tried. *Had healed many wounds with dry-to-dry dressings. *Had no evidence based indications a dry-to-dry gauze dressing would have been an effective treatment. *Had no way to monitor if turning and repositioning for those residents had been done according to the plan of care. *Thought the wounds had improved with the dry-to-dry dressings. *Stated both residents 8 and 15 were on comfort care per their families and physician recommendations. Review of the provider's revised (YEAR) Pressure Injury Prevention policy included: *Standards of Practice: -The facility supports the goal of determining the risk factors associated with altered skin integrity so appropriate interventions can be implemented to prevent and/or resolve these areas. -An evaluation of the individuals (resident) needs for turning and repositioning based on individual risk factors and ability to effect meaningful independent position changes both in bed and in the chair for development of positioning programs if required. -The individualized care plan will reflect approaches to stabilize reduce or remove the individual's risk factors for Pressure Ulcer development and/or promote healing of existing Pressure Ulcers. Review of the provider's undated Recommended Wound Management Guidelines for pressure ulcers revealed recommendations including: *Stage 1: Protect and heal. Reduce or remove source of pressure. Apply skin protectant to area BID. Check area daily. *Stage 2: Manage exudate; prevent infection; heal notify MD (medical doctor) within 24 hours of uncomplicated Stage 2 ulcer. *Stage 3 and 4 wounds with slough/eschar: Notify MD ASAP (as soon as possible) prior to applying a dressing. Manage exudate; debride slough/eschar; prevent infection; fill cavity; heal. Debridement product including medical grade honey [MEDICATION NAME] Gel, autolytic, or enzymatic. Heavy exudate-Alginate and/or foam dressing. Frequent need for dressing changes may include ABD's (abdominal dressing) for added absorbency (Consider Super Absorbent Dressing). Light to moderate exudate-Foam dressing. (consider Barrier Island Dressing as secondary dressing over [MEDICATION NAME] or hydrogel). *Stage 2 and 4 wounds without slough or eschar: Notify MD ASAP. Manage exudate: prevent infection; fill cavity: heal ulcer. Heavy exudate-Alginate and/or foam dressing. Frequent need for dressing changes may include ABD's (abdominal dressing) for added absorbency (Consider Super Absorbent Dressing). Moderate drainage: Alginate base, fluffed gauze, cover with foam dressing. Light drainage: [MEDICATION NAME] Gel or hydrogel. (Barrier Island Dressing).

Based on observation, record review, interview, and guideline review, the provider failed to ensure 3 of 18 sampled residents' (8, 33, and 37) care plans matched the needs of the residents. Findings include: 1a. Review of resident 8's last revised 8/27/18 care plan included: *Focus: (Resident name) has impaired skin integrity r/t (related to) immobility and incontinence aeb (as evidenced by) pressure ulcer on left hip and moisture associates (associated) skin alteration on buttocks. *Goal: Resident will be free from skin breakdown through the review date. The review date was 11/25/18. *Interventions: -Diligent peri cares, including barrier cream after incontinent episodes. -Dressings/treatments per orders. -Encourage repositioning q (every) 2-3 hours as needed. -Keep bed linens dry and wrinkle free. -(Resident's name) frequently rolls over to her left hip even after repositioning. Check frequently through the night and repo (reposition) appropriately. -Observe skin during cares. Report any changes to nurse. -Pressure relieving mattress on bed and cushion in chair for prevention of breakdown. Interview on 11/8/18 at 10:00 a.m. with the Minimum Data Set (MDS) coordinator regarding resident 8 revealed she had not: *Made interventions specific to her regarding the turning and repositioning plan. *Included other staff shifts of the resident's always wanting to lay on her left side. *Included the use of the wedge and pillows for positioning. *Included where her actual pressure ulcers had been located. *Included pain interventions related to her impaired skin integrity. *Included what her comfort care included. Refer to F686 finding 1. b. *Focus: (Resident's name) has an ADL (activities of daily living) deficit r/t Alzheimer's and dementia with limited mobility. *Goal: Resident will maintain ability to feed herself with supervision through the review date. The review date was 11/25/18. *Interventions included: -AMBULATION: Unable to ambulate at this time. -BED MOBILITY: Assist x (times) 1 (one staff person). -TRANSFER: Assist x 1. -TOILET USE: Assist x 1. Grabs the assist bar and helps to transfer with cueing. -NURSING REHAB: AROM (active range of motion) Nu-step: level 3 for 15 minutes 6 days/week. GOAL: Build strength for safe transfers and ambulation with staff assistance. -NURSING REHAB: Walking-using gait belt, FWW (front wheeled walker), and 2 staff resident will ambulate in the hallway 150' (feet) for 15 minutes daily x 6 days/week. GOAL: ambulate safely with staff assistance at least part way to meals. During an observation on 11/6/18 at 2:14 p.m. of resident 8 revealed she was assisted from her wheelchair to the toilet with a standing lift. Interview on 11/8/18 at 10:00 a.m. with the MDS coordinator regarding resident 8 revealed she: *Was not aware the resident did not have a pressure relieving cushion in her wheelchair. *Had not been informed a standing lift was being used for transfers. c. *Focus: (Resident's name) has altered elimination related to advanced dementia, [MEDICAL CONDITION] bladder and functional loss as evidenced by incontinence and constipation. *Goals included: Resident will be free of moisture skin alterations due to incontinence through the review date. The review date was 11/25/18. *Interventions included: Foley catheter place per orders. Maintenance and cares per protocol. Update provider of any concerns. Interview on 11/8/18 at 10:00 a.m. with the MDS coordinator regarding resident 8 revealed she: *Was aware she did not have a urinary catheter. The catheter had been discontinued on 10/18/18. *Agreed there was no toileting plan in place after the catheter had been discontinued. 2. Review of resident 33's complete medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had recently been in the hospital with a [MEDICAL CONDITIONS]. -Had returned to the facility on [DATE]. *She had been on an anticoagulant. Review of resident 33's undated care plan revealed: a. Focus area of altered elimination related to constipation. *No interventions or tasks for bleeding risks due to being on anticoagulant therapy. b. No focus area of [MEDICAL CONDITION]. *No interventions or tasks of what to monitor or report. 3. Review of resident 37's complete medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He received [MEDICATION NAME] 6 milligrams (mg) daily. *On every Monday and Tuesday he received 0.5 mg in addition to the above dose. Review of resident 37's undated care plan revealed: a. Focus area of falls. *No interventions or tasks making staff or resident aware of increased risk of bleeding or bruising related to anticoagulant therapy. *No interventions or tasks on what to monitor or report. b. Focus area of altered elimination related to constipation. *No interventions or tasks for bleeding risks due to being on anticoagulant therapy. *No interventions or tasks for what to monitor or report. 4. Interview on 11/7/18 at 2:48 p.m. with the MDS coordinator revealed: *She typically completed residents' care plans. *The director of nursing would help her review and revise them. *She was still learning what all needed to be added to the focus area. *She agreed anticoagulant therapy and risks for bleeding were important issues and should be added to the care plan. Surveyor: Review of the provider's revised (MONTH) (YEAR) Person Centered Care Plan Guideline included: *Purpose: person-centered care planning focuses on the resident as the focus of control and supports the resident in making their own choices and having control over their daily lives. Person centered care planning is an on-going process which actively encourages the resident and/or the resident's representative to be an active participant in the care planning process and addresses the development and implementation of individualized person care. The Comprehensive Care Plan is comprised of but not limited to: NAR (narcotics administration record) Care Plan, MAR (medication administration record), TAR (treatment administration record), Flow sheets, P[NAME] (plan of care)/14 day ADL tracker documentation, Engage documentation, Engage documentation, Wound Rounds/Weekly wound documentation, and Physician orders. *Care plan should be clear and concise. It is acceptable and sometimes may be more appropriate to address multiple issues in one care plan segment. *Unavoidable areas included with appropriate focus. *Consistent with the Nursing Assistant Care Plan.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (3 and 6) who had pressure ulcers had received appropriate dietary interventions and services within a timely manner by one of one dietary manager and one of one registered dietitian. Findings include: 1. Observation on 8/7/17 at 6:20 p.m. of resident 3 revealed: *She had: -Been in a wheelchair (w/c) sitting in the dining room waiting for her supper. -Pressure relieving heel protectors on both of her feet. -Looked thin and frail. Observation on 8/8/17 at 8:10 a.m. of resident 3 revealed: *She had been: -Laying in her bed sleeping. -Laying on her back with the heel protectors on. *Her feet were off loaded with a heel lift cushion underneath of her legs. Review of resident 3's medical record revealed: *[DIAGNOSES REDACTED]. *She was alert, oriented, and had good memory recall. *On 7/9/17 she had fallen and fractured her left hip. *Prior to that fall she had been: -Independent with ambulating and all personal care. -Placed on a nutritional improvement plan due to loss of appetite and weight loss. *On 7/13/17: -She had been readmitted to the facility from an acute care setting. -The staff had completed an admission physical assessment of her skin and documented both of her heels were red, soft, and mushy. --Those areas of concern on her heels had progressed to stage two pressure ulcers on 7/23/17 and 7/25/17. -Her Braden pressure ulcer risk assessment score was fifteen. That score indicated she had been at moderate risk for developing pressure injuries. -A temporary care plan had been completed and pressure relieving measures had been put in place. --She had been noncompliant with those pressure relieving measures. *She had been dependent upon the staff to: -Assist her with all of her mobility needs for transferring from place-to-place, moving in bed, and activities of daily living (ADL). -Inform the physician and dietary department of any changes in her health condition. *On 7/23/17 she had acquired a stage two pressure ulcer to her left heel. -That change had occurred within ten days of her stay in the facility. *On 7/25/17: -She had acquired a stage two pressure ulcer to her right heel. That change had occurred within twelve days of her stay in the facility. -Verbal orders from the physician had been received for the resident to receive Vitamin C, Zinc oxide, and 2 Cal supplement twice a day. *On 7/26/17 the physician had been in the facility to assess the resident. -He had discussed the above pressure ulcers with the director of nursing with no new orders. *No documentation to support the dietary department had been notified of the wounds to both of her heels. Review of resident 3's nursing progress notes from 7/13/17 through 8/8/17 revealed: *Dietary notes had been completed by the dietary manager (DM) on 7/22/17 and 8/7/17. *No documentation to support: -The DM had been aware of the stage two pressure ulcers to both of her heels. -The registered dietician was notified of the stage two pressure ulcers. -Dietary interventions that had been put in place to promote healing for those pressure ulcers. Review of resident 3's 7/18/17 comprehensive care plan revealed: *Focus area: (Resident name) has a potential for alteration in nutrition: less than body requirement. *Goal and interventions for that focus area had no documentation to support stage two pressure ulcers to both of her heels. Interview on 8/9/17 at 9:55 a.m. with the director of nursing (DON) regarding resident 3 revealed: *She had not been aware the DM and RD were not aware of the wounds to the resident's heels. *She agreed the dietary department should have been informed of those wounds to ensure appropriate interventions had been put in place to promote healing. Interview on 8/9/17 at 12:55 p.m. with the DM regarding resident 3 revealed he: *Had been hired as the DM in March 2017. *Was in the process of completing his DM course. *Would have relied upon the nursing staff and interdisciplinary care team to inform him of any skin concerns. *Had not been aware of the: -Pressure ulcers located on the resident's heels. -Interventions put in place for the resident on 7/25/17. *Agreed he should have been informed of the pressure ulcers to her heels and what interventions had been put in place. 2. Random observations and interview on 8/8/17 every two hours from 8:00 a.m. to 2:35 p.m. of resident 6 revealed she: *Was in a different position each time. *Could walk with her walker with assistance. *Could reposition herself in a chair. *Was alert and could carry on a conversation with some occasional difficulty with word finding. Review of resident 6's medical records revealed: *Her 3/26/17 Brief Interview for Mental Status (BIMS) score was ten indicating a moderate cognitive impairment. *Her 3/26/17 Minimum Data Set (MDS) assessment showed she was independent with activities. *Her Braden skin assessment review revealed a score of twenty indicating minimal risk for pressure sores. *Weekly skin evaluations were being done. *She had a significant change MDS assessment done on 6/25/17. -Her BIMS exam revealed a score of five indicating severe cognitive impairment. -Her MDS assessment revealed she needed assistance for most activities. *She had some confusion. *She would sometimes refuse care. *She was now noted to be at risk for pressure ulcers, and pressure reducing devices had been added to her chair and bed. *Per physician's orders [REDACTED]. *On 7/2/17 she was noted to be mostly back to her normal self. *On 7/8/17 a blister was noted on her upper coccyx area. *On 7/10/17 it opened and was noted to be a stage 2 pressure ulcer. -The physician was notified and appropriate care initiated. Review of resident 6's weekly wound documentation from 7/10/17 through 8/1/17 revealed: *Healing that had stalled the last week in July, so new orders to change treatment were obtained and implemented. *On 7/10/17 dietary was notified of the pressure ulcer. Further review of resident 6's medical records revealed no dietary notes or interventions regarding the pressure ulcer. Interview on 8/9/17 at 9:30 a.m. with the DON regarding dietary notes and resident 6's pressure ulcer revealed: *There were not any dietary notes. *She had been unaware the dietary manager (DM) had not intervened. *She stated it was probably her fault and that she hadn't notified the DM of the pressure ulcer. *She agreed he should have done interventions. Interview on 8/9/17 at 4:00 p.m. with the dietary manager revealed: *He had started in March of this year and was currently taking his certification course. *He had not made any dietary recommendations for resident 6's pressure ulcer nor had he notified the registered dietician (RD) about that until 7/19/17. -That was nine days after the start of the pressure ulcer. *Afterwards he implemented the dietary changes that the RD had suggested . Review of the provider's undated Pressure Ulcer Nutritional Intervention policy and procedure revealed: *When a pressure ulcer is identified and defined (Stage 1-4), nursing will notify the DNS immediately and Dietary within 24 hours of discovery. Residents with a pressure ulcer will be added to the Nutrition Risk List. *Dietary will place the resident on the Nutritional Intervention Program(NIP). The condition of the resident will be monitored by nursing and dietary and discussed between the Dietary manager and the Director of Nursing at weekly meetings.

Based on record review, interview, and guideline review, the provider failed to continually monitor the nutrition intervention program (NIP) effectiveness for one of three sampled residents (5) with weight loss. Findings include: 1. Review of resident 5's 5/17/17 physician's progress note revealed she had a [DIAGNOSES REDACTED]. Review of resident 5's Minimum Data Set (MDS) assessments revealed: *The 3/12/17 quarterly MDS noted her weight as 120 pounds (lb). *The 5/30/17 quarterly MDS noted her weight as 112 lb, and a weight loss of 5 percent (%) or more in last month or loss of 10% or more in last six months. *Her weight loss from 3/12/17 to 5/30/17 was 6.6%. Review of resident 5's 4/24/17 care plan revealed: *Focus area: she had a nutritional deficit related to unplanned weight loss. *Goal: for her to maintain weight of 110 lb. *Interventions: included provide nutrition improvement program (NIP) for added caloric intake. Review of resident 5's Mini-Nutritional Assessments revealed: *Her score on 3/11/17 had been six, and she had been categorized as malnourished. *Her score on 5/24/17 had been nine, and she had been categorized as at risk for malnutrition. Review of resident 5's following progress notes revealed: *A 4/3/17 interdisciplinary team meeting noted she Is showing a 5# weight loss this week. She is on comfort cares and she doesn't eat well. We have decided to try Boost at all three meals to see if she will drink this when she doesn't eat. She is on the NIP program but this is not working as she does not eat well enough. *A 4/24/17 nutrition progress note by the registered dietitian (RD) noted she had been at nutrition risk related to current weight loss. -Plan was to continue current diet order, review with dietary manager if she had any food intake issues, and review foods/fluids that she would accept the best and offer as accepted by her. *There were no further progress notes documented related to her weight concerns. Interview on 8/9/17 at 9:30 a.m. with the dietary supervisor revealed: *The NIP added real food such as Karo syrup to residents' meals for additional calories. *He would consult with the RD for recommendations for supplements for residents with weight loss. *The RD visited monthly and was also available by phone. *Residents on the NIP would have been added to the Nutrition Risk List *Resident 5 was on the NIP but not on the Nutrition Risk List from April through July. *Resident 5 had not been on the 10:00 a.m., 3:00 p.m., or evening snacks list. *More interventions could have been in place for resident 5. Interview on 8/9/17 at 10:30 a.m. with the RD revealed if a resident had triggered for weight concerns she would have been notified. She had not been aware of concerns for resident 5. Resident 5 had not had any pressure ulcers, and her weight had been stable. Review of the provider's 3/24/16 Nutritional Risk Guidelines revealed: *The dietary supervisor would identify at risk residents including residents with significant weight loss or gain. *Residents determined to be at nutrition and hydration risk would be added to the Nutrition Risk List and monitored according to the care plan. *The RD would complete follow-up assessments each month for all residents on the Nutrition Risk List. *The dietary supervisor would meet with the director of nursing monthly concerning the Nutrition Risk List.

Based on record review and interview, the provider failed to ensure accurate documentation in the medical record of one of one sampled resident (2) with allergies [REDACTED].>1. Review of resident 2's medical record revealed: *An admission date of [DATE]. *A typed note in the front cover of the resident's chart stated allergies [REDACTED]. *An undated current care plan stated No Known allergies [REDACTED]. *The August 2016 Medication Administration Record [REDACTED] *The August 2016 Treatment record stated No Known allergies [REDACTED]. *A History and Physical from a hospital admitted d 05/17/16 with the following allergies [REDACTED].>Iron. [MEDICATION NAME]. [MEDICATION NAME]. Sulfa. Almonds. Strawberries. [MEDICATION NAME]. [MEDICATION NAME]. [MEDICATION NAME]. Patient is also sensitive to [MEDICATION NAME]. *An out of town clinic provider medication order dated 07/20/16 showed the following medication allergies [REDACTED]. The order was to give Injectafer (50 iron mg/mL), Solution 750 mg on 07/27/16. Further review of the resident's medical record revealed: *The facility Order Summary Report dated 7/5/16 showed the resident was receiving the following medications: [REDACTED] 1. [MEDICATION NAME] Patch 72 hour 12 MCG/HR Apply 2 patch [MEDICATION NAME] in the evening every 3 day(s) for Pain and remove per schedule. 2. [MEDICATION NAME] Tablet 15 MG Give 1 tablet by mouth every 6 hours for Pain [MEDICATION NAME] sulfate IR. 3. A local clinic referral/visit summary document showed the Injectafer infusion had been given 750 mg in 100 NS (normal saline) on 7/27/16. The consulting pharmacist's monthly visits dated 6/2/16 and 7/2/16 had not identified a discrepancy regarding resident 2's current medications and her allergies [REDACTED].>Interview on 08/02/16 at 3:30 p.m. with the Director of Nursing and administrator regarding the above for resident 2 revealed it was important the allergies [REDACTED]. They were aware the resident and physician had agreed the benefit outweighed the risk in regards to the use of the [MEDICATION NAME].

Based on interview, record review, and policy review, the provider failed to inform residents of resolutions to meal service grievances brought up in the resident council meetings from July 2015 through June 2016. Findings include: 1. Review of the resident council minutes from July 2015 through June 2016 revealed meal service grievances had been documented for eleven of twelve resident council meetings. Examples included: *On 7/4/15 Residents stated People at tables from the first group and evening meal is still being served late. *On 8/11/15 Confidential resident Wants something done about meals. *On 9/8/15 Confidential resident states Meal time is some what to late for resident and will continue to monitor the times of the meals and concerns. *On 12/8/15 Two residents Upset over dining experience and nothing is being done. *On 2/9/16 Second group did not start getting served until 6:50 PM and people from first group were still at some of the tables. *On 6/14/16 Table served at 1:15 PM and meal service continues to be an issue. *There had been no documentation regarding the resolutions to the above concerns. Confidential interview on 6/21/16 at 1:30 p.m. with a group of residents who requested to be unidentified revealed three residents had been concerned and unhappy with the meal service times. Residents from the first seating had been in the dining room when it was time for the second seating. The residents had also been concerned that nothing had been done regarding their concerns with meal service. Interview on 6/22/16 at 2:45 p.m. with the administrator revealed: *She had been aware of the residents' concerns with the lunch and supper meal services. *She had been exploring options and tweaking the system. *There was no documentation of grievance discussions or resolutions. Review of the provider's undated guideline for quality improvement form revealed: *It is the policy of this facility to respond to staff, resident/family in a timely and appropriate manner. *The Department Head or his/her designee will investigate the concern and record the findings of the investigation as well as the action plan for the resolution on the appropriate area on the Quality Improvement Form Follow Up. *The Department Head is responsible for contacting the person who initiated the quality input form and providing them with feedback on the resolution of the concern within 3 working days of receiving the concern.

Based on observation, interview, and policy review, the provider failed to ensure narcotics and medications were properly secured for two of two medication carts. Findings include: 1. Observation on [DATE] from 6:10 p.m. to 6:42 p.m. in the medication (med) room and nurses station area with registered nurse (RN) H revealed: *At 6:10 p.m. he had prepared insulin and left the insulin syringes on top of the cart. -That insulin stayed on top of the cart until 6:42 p.m. when he gave it to the resident. *During that time both med carts remained unlocked at the nurses station. *At 6:15 p.m. he unlocked the med room, gathered supplies, and upon leaving he left the door open. He continued to prepare for his shift in the nurses station. *At 6:20 p.m. he went back into the med room. *At 6:26 p.m. he walked out of the med room and into the nurses station leaving the med room door open. *At 6:32 p.m. he walked back into the med room and left the med delivery person in the med room while he returned to the nurses station. *He returned to the med room at 6:33 p.m. to continue to check in medications (meds) from the delivery person. *At 6:39 p.m. he returned to the nurses station leaving the med room door open. He locked the north cart. *At 6:42 p.m. the director of nursing (DON) stood in the doorway of the med room until RN H locked the door. Observation on [DATE] at 8:20 a.m. with RN F revealed: *Meds were crushed and prepared in applesauce. *The med included hydrocodone (narcotic pain med). *The unidentified resident who was to get those meds was not available. *RN F put the med in the top drawer of the med cart. *Meds were kept there until 8:42 a.m. with the narcotic being secured in a single-locked drawer. 2. Interview on [DATE] at 11:45 a.m. with registered nurse F revealed: *Fentanyl pain patches were changed during the day shift. *Patches were taken off by the day shift nurse and then signed for destruction when the night nurse began her shift. *Patches were kept in the top drawer of the med cart that was only single-locked. Interview on [DATE] at 6:00 p.m. with registered nurse G revealed the patches were routinely kept in the top drawer of the med cart awaiting destruction by two nurses. 3. Interview on [DATE] at 3:13 p.m. with the DON revealed: *Meds should not be kept on top of the med cart unattended. *Narcotics should always have been double-locked. Review of the [DATE] General Dose Preparation and Medication Administration policy revealed facility staff should not leave medications unattended. Review of the [DATE] Disposal/Destruction of Expired or Discontinued Medications policy revealed before destruction the facility should secure controlled substances under a double-lock at all times.

Based on observation, testing, interview, record review, manufacturer's instructions, and policy review, the provider failed to maintain sanitation with the potential of cross-contamination in the following areas: *One of one fan was blowing from a dirty to clean area in the dishwashing machine area. *Proper sanitizing of the wiping cloths during random observations in the kitchen for the food preparation area and residents' dining room tables. Findings include: 1. Observation on 6/20/16 from 3:25 p.m. through 3:55 p.m. in the kitchen revealed: *In the dish machine area: -There was a large fan mounted on the wall and located above the dirty end of the dish machine area. -That fan contained a moderate amount of gray, black, and tan spots with lint on the blades, was running on high, and oscillating. -It was moving air from the dirty end of the dish machine where dirty dishes and utensils were stored. -That same air was moving over the cleaned dishes and utensils stored on the clean end of the dish machine. *Testing with a napkin at the dish machine's dirty end and at the clean end counters revealed: -On the dirty end that same fan's air was blowing directly onto the dirty dishes and utensils stored there. -That same fan's air was then blowing directly onto the clean dishes and utensils on the clean end of the dish machine that were being stored there. *A green-colored bucket containing a liquid on the counter on the clean end of the three-compartment sink revealed: -There was a wet cloth located next to that bucket. -Using a Hydrion 40 test strip (a type of special paper), the liquid in the bucket tested at 600 parts per million (ppm). *Interview during the above time with cook A revealed she had used the liquid in the above bucket with the cloth to wipe down the food preparation areas. 2. Observation on 6/20/16 at 6:10 p.m. with dietary assistant B and on 6/21/16 at 11:15 a.m. with dietary assistant C revealed: *Both had been loading dirty dishes and utensils into the dish machine. *Both had been unloading clean dishes from the dish machine and placing them on the clean end of the dish machine. *The fan had been running on high and oscillating back and forth between the dirty and clean ends of the dish machine where those dishes and utensils were being stored. Record review on 6/22/16 of the provider's June 2016 Weekly Kitchen Cleaning List for cleaning the fan revealed: *It was scheduled for cleaning each Wednesday. *There was no documentation that showed the fan had been cleaned. 3. Observation on 6/20/16 at 6:05 p.m. in the kitchen revealed: *Two wet cloths located next to a green-colored bucket containing liquid on the dirty end of the three-compartment sink. *Those cloths were not in a sanitizing solution when not in-use. *Using a test strip, the liquid in the bucket tested at 600 ppm. Interview and observation on 6/20/16 at 6:15 p.m. in the kitchen with cook A and dietary assistant D revealed: *A red-colored bucket located on the a cart used to clean off the tables in the residents' dining room contained: -A liquid with a cloth. -Using a test strip, the liquid in the bucket tested at 800 ppm. *Dietary assistant D stated she used the bucket with the cloth to wipe down the residents' dining room tables. *Both stated the kitchen had both red and green-colored buckets that had contained cloths used for sanitizing the following areas: -Food preparation areas. -Residents' dining room tables. *Both stated the sanitizer had needed to have been 200 to 400 ppm for proper sanitizing. *Both confirmed the sanitizer had been at 800 ppm. *Both agreed the bucket containing the sanitizer with the wiping cloth had been mixed at too high of a concentration for proper sanitizing. Interview and observation on 6/21/16 at 11:15 a.m. in the kitchen with dietary assistant C and at 11:35 a.m. with dietary assistant I revealed: *A red-colored bucket located on the dirty end of the dishmachine contained a liquid and a cloth. -Using a test strip, the liquid in the bucket tested at 600 ppm. *Both stated they used the bucket with the cloth to wipe down the food production areas. *Both stated the kitchen had both red and green-colored buckets that had been used for sanitizing. *Both stated the sanitizer had needed to have been 200 to 400 ppm for proper sanitizing. *Both agreed the bucket containing the sanitizer with the wiping cloth had been mixed at too high of a concentration for proper sanitizing. Observation and testing on 6/21/16 at 11:35 a.m. with dietary assistants C and I revealed the sanitizer buckets were prepared using: *A dispenser attached to the wall located on the dirty end of the dishmachine. -That dispenser was attached to a tubing. -The tubing was connected to a five-gallon bucket marked with a label for VSS130 Disinfectant/Sanitizer. *Testing of the solution out of the dispenser revealed a level of 1000 ppm. *The label on the five-gallon bucket revealed: -For sanitizing non-porous surfaces that had included food countertops. -The level was to have been 200-400 ppm for proper sanitizing. Interview on 6/22/16 at 1:10 p.m. with cook E and dietary assistants C and B in the kitchen revealed: *There were a total of three sanitizing buckets used in the kitchen: -One was used on the residents' dining room tables. -Two were used on the food production counters in the kitchen. *They had been unsure of the proper dilution of the sanitizing buckets for proper sanitizing levels of the tables and the counters. *There had been no monitoring of the ppm levels of the sanitizing buckets containing the wiping cloths used on the above areas. 4. Interview on 6/21/16 at 5:30 p.m. and on 6/22/16 at 2:00 p.m. with the administrator regarding the above fan in the dish machine and the sanitizing buckets and cloths used in the kitchen for wiping down the food preparation areas and the dining room tables revealed she agreed: *The fan attached to the wall in the dish room was blowing over the dirty dishes to the clean dishes and utensils stored there. *The fan should not have been blowing from dirty to clean in the dish room. *The blowing fan had a potential for cross-contamination from dirty to clean areas. *Agreed the bucket that contained the wet cloths used to wipe down the residents' tables in the dining room and the kitchen food production counters needed to have been at 200-400 ppm according to manufacturer's instructions. *Agreed the sanitizer had not been mixed properly and the levels had not been monitored for the correct amount of sanitizer. Review of the provider's undated product specification document of the VSS130 Disinfectant/Sanitizer revealed it: *Could be used to sanitize hard, non-porous food contact surfaces such as tables and counters. *Was an effective sanitizer on food contact surfaces when used at 200 to 400 ppm active quaternary (quat). *Was to have been exposed to surfaces as a sanitizing solution for a period of at least one minute. Review of the provider's 2008 Kitchen Cloths policy revealed cloths that were used for cleaning purposes should have been stored in sanitizing solution between uses. Review of the provider's 2008 Handling Clean Equipment and Utensils revealed: *Clean equipment and utensils were to have been handled to prevent contamination. *Those items would be stored in a clean, dry location in a way that protected them from contamination.

Based on record review, interview, and policy review, the provider failed to maintain complete and accurate documentation of meals for three of three sampled residents (3, 8, and 9) with a history of weight loss. Findings include: 1. Review of resident 3's dietary intake records (amount of food eaten) revealed: *She had a ten pound weight loss from April 9, 2015 (98 pounds) to July 13, 2015 (88 pounds). *There were undocumented meals for: -Five meals in April. -Four meals in May. -Nine meals in June. -Three meals from July 1 through July 20. 2. Review of resident 8's dietary intake records revealed: *She had an eight and a half pound weight loss from March 12, 2015 (160.5 pounds) to April 9, 2015 (152 pounds). *Her historical weight on October 23, 2014 was 179 pounds. *There were undocumented meals for: -One meal in March. -Three meals in April. -Four meals in May. -Nine meals in June. -Three meals from July 1 through July 20. 3. Review of resident 9's dietary intake records revealed: *She had a 16 pound weight loss from June 11, 2015 (142 pounds) to July 21, 2015 (127 pounds). *There were undocumented meals for: -Three meals from July 1 through July 21. Interview on 7/22/15 at 2:20 p.m. with the dietary manager (DM) revealed: *The dietary staff were to have documented meal intakes for residents not needing assistance with meals. *The certified nurse aides (CNA) were to have documented meal intakes for residents they assisted with meals. *It was her responsibility to ensure the charting had been done. *The cook was responsible to ensure charting had been done on the days the DM was gone. *It was the facility's policy to document meal intakes for each resident, each meal, each day. *She agreed: -There were multiple meals not documented for the above residents. -Those residents had a history of [REDACTED]. -The staff had not been following their policy for documenting meal intake. Review of the provider's 2008 Recording Percent of Meal Consumed policy revealed the staff were to document the percentage of each meal consumed for each individual on a daily basis.

Based on record review, interview, and policy review, the provider failed to ensure restorative services and treatment had been offered to prevent further decline in activities of daily living for 1 of 11 sampled residents (7). Findings include: 1. Review of resident 7's medical record revealed she had [DIAGNOSES REDACTED]. Review of her Minimum Data Set (MDS) assessments had revealed: *Her ability to transfer between surfaces had declined from assistance of one staff to two staff assistance on the 2/1/15 MDS. *Her ability to walk had declined: -From limited assistance to extensive assistance of one staff on the 11/9/14 MDS. -From extensive assistance of one staff to only once or twice weekly with one assistance on the 2/1/15 MDS. -From once or twice weekly on 2/1/15 to not walking on the 4/26/15 and the 7/17/15 MDS. Interview on 7/22/15 at 1:50 p.m. with restorative aide A revealed: *She provided passive exercises to one resident. *Resident 7 had displayed declines in her status. *She had not provided passive or active exercises for resident 7. Interview on 7/22/15 at 3:15 p.m. with the MDS coordinator revealed: *She and the director of nursing worked together to implement restorative programs for the residents. *She agreed resident 7 had displayed gradual overall declines in her functioning over the last several months. *She had not offered restorative services to resident 7, because she had severe dementia and was expected to die. *She was not receiving hospice services. *Her functional abilities had changed day-to-day and were sometimes better, sometimes worse. *Restorative services were discussed in interdisciplinary team (IDT) meetings, but she had not known if it had been discussed with her family. *She had not known when an IDT discussion would have taken place. Interview on 7/22/15 at 4:15 p.m. with the director of nursing revealed: *She agreed the restorative services should have been offered when resident 7 had declines in functioning. *She had already identified an under-utilization of restorative services earlier in the week. Review of the provider's updated February 2013 Restorative Nursing Care policy revealed: *Mobility is critically important to our residents and functional decline can lead to depression, withdrawal, social isolation and complications. Restorative care programs might have been started upon admission, when restorative needs arose, or upon discontinuation of formal therapy.

Based on observation, interview, and policy review, the provider failed to ensure education and processes were in place for: *The handling and delivering of clean linens to the bathing room by one of one laundry aide (A). *Separating of soiled linens by one of one laundry aide (A). *The washing of linens in one of three washing machines by one of one laundry aide (A). *Disinfecting of a whirlpool bathing tub by one of one certified nursing assistants (CNA) (B). *Bathing of all residents with a catheter (tube inserted into the bladder to assist with draining) by one of one CNA (B). *Glove use and sanitizing between the residents' rooms by one of one housekeeper (E). *The use of a disinfectant per manufacturer's recommendations by one of one housekeeper (E). *Disposing of multiple treatment supplies in one of one medical supply room. *The storage for two of two biohazardous waste containers located in the medical supply room. *The storage of clean linens underneath a sink in one of two kitchen nook areas in the dining room. Findings include: 1. Observation on 5/20/14 at 2:20 p.m. of laundry aide A revealed: *She had been pushing a cart into the bathing room on 300 wing. *The cart had contained multiple clean linens. *She had removed multiple clean towels from the cart. *She held those clean towels next to her chest and abdomen while opening a cupboard in the bathing room. *She laid those towels on a shelf inside of the cupboard. Interview on 5/20/14 at the time of the observation with laundry aide A revealed the towels would have been used for all residents taking a bath. Interview on 5/21/14 at 11:45 a.m. with the director of nursing (DON)/infection control nurse confirmed the laundry aide should not have held the clean towels next to her body. That process had soiled the linens. 2. Interview on 5/21/14 at 10:10 a.m. with laundry aide A regarding the separating of soiled linens revealed: *After she had retrieved all the soiled linens from the three wings she would have separated them into bins. *She would not have used gloves while retrieving the soiled linens or while sorting them. Interview on 5/21/14 at 11:48 a.m. with the DON/infection control nurse confirmed the laundry aide should have worn gloves when retrieving and sorting of soiled linens. The provider's January 2010 Linen Handling policy and procedure had not mentioned glove use with soiled linens nor with delivery of clean linens. 3. Observation on 5/21/14 at 10:15 a.m. of the laundry room revealed: *Two commercial and one regular washers. *There had been two buttons located next to the regular washer. *One button had been labeled detergent and the other bleach. Interview on 5/21/14 at the time of the above observation with laundry aide A revealed: *The regular washer had been used to wash housekeeping and dietary linens and residents' linens exposed to infectious diseases. *She would have pushed the buttons located next to the washer for the detergent and bleach to be added to the wash water. *She had no knowledge of whether she needed to add bleach to the water or not. *She had no knowledge of the temperature of the water going into the washer. *She would not have used the bleach on the housekeeping linens as they already contained chemicals. *She would not have used the bleach on the residents' linens if they were colored. Interview on 5/21/14 at 11:50 a.m. with the DON/infection control nurse, administrator, and environmental services coordinator revealed: *They confirmed the washer had been used for dietary, housekeeping, and infectious disease linens. *They would have expected bleach to be added to all the linens during washing. *The water going into the regular washer was on the same system as the kitchen water. *The regular washer water temperature had not been tested seperately from the kitchen water. Review of the daily maintenance logs for April 2014 revealed the kitchen water temperature had been between 150 to 168 degrees Fahrenheit (F). The temperature had been over 160 degrees F ten times in a thirty day window of time. Review of the provider's undated Linen Laundry Temps and Germicidal Agents policy and procedure revealed: *"Purpose to destroy microorganisms in the laundry supply." *"Procedure for linen laundering temperatures is set above 160 degrees F for a 25 minute wash." *Water temperatures were to have been set between 71 and 77 degrees F when using bleach. 4. Observation on 5/20/14 at 2:40 p.m. of certified nursing assistant (CNA) B revealed: *She had been preparing to disinfect the whirlpool tub after bathing a resident. *She had not been wearing gloves. *With those ungloved hands she had: -Removed the the gel cushion from the whirlpool chair and placed it inside of the whirlpool tub for disinfecting. -Grabbed the handle on the whirlpool tub door and closed it. -Turned on several knobs to add the disinfectant and water to the tub. -Retrieved a large handled brush and scrubbed the interior of the whirlpool tub and chair. *She had not washed her hands after the above process. *With unwashed hands she had opened a clean linen cart containing residents' clothing. Interview on 5/20/14 at the time of the above observation with CNA B she confirmed she: *Should have worn gloves during the disinfecting process of the whirlpool tub. *Should have washed her hands prior to opening the clean linen cart. *She would not have always worn gloves during the disinfecting process of the tub. *The gloves and chemicals had caused irritation to her hands. Interview on 5/21/14 at 11:55 a.m. with the DON/infection control nurse revealed: *She had recently reviewed the whirlpool tub disinfecting process with the above CNA. *She would have expected CNA B to wear gloves. *She would have expected CNA B to wash her hands when done disinfecting the whirlpool tub. Review of the provider's undated manufacturer's recommendations for the whirlpool tub disinfecting process had not mentioned glove use. No other policy or procedure had been available from the provider. Surveyor: Preceptor: 5. Interview on 5/20/14 at 2:24 p.m. with CNA B revealed she: *Bathed residents with a Foley (urine) catheter submerged in a whirlpool tub. *Clamped the catheter tubing, so that it was closed off from the collection bag, then covered the collection bag with a plastic bag. She then humg it over the edge of the tub. *Had been taught that was an acceptable practice. Observation and interview on 5/21/14 at 10:00 a.m. with CNA F revealed she: *Had resident 1 who had a Foley catheter in the whirlpool tub. *Stated "I'm just going to give her a shower this time. Isn't that what you told us we should do?" *Normally had been giving resident 1 a submerged bath once a week. Interview on 5/21/14 at 12:00 noon with the DON revealed: *She agreed proper bathing technique had not been followed. *No policy or procedure existed for this. 6. Interview on 5/21/14 at 11:00 a.m. with housekeeping aide E revealed: *She had used a disinfectant to spray on all of the surfaces in the resident's bathrooms. *The disinfectant she had used was Bath Mate Acid-free washroom cleaner. *She would not have allowed the disinfectant to stay on the surfaces for any length of time. *She had worn gloves for the cleaning of all the residents' rooms. *She would not have changed her gloves until after she had cleaned "A few rooms." *She would not have sanitized or washed her hands when she had changed her gloves. Interview on 5/21/14 at 12:05 p.m. with the DON/infection control nurse, administrator, and environmental services coordinator revealed: *They had not been aware housekeeping aide E had not been allowing contact time for the disinfectant on all bathroom surfaces. *They had not been aware housekeeping aide E had not been changing her gloves and washing/sanitizing her hands between the cleaning of the residents' rooms. *Confirmed sanitary precautions had been broken, and there was potential for cross-contamination for any residents after the disinfecting and cleaning of their rooms. *The DON/infection control nurse had no audits available for the monitoring of the housekeeping department and the cleaning of the residents' rooms. Review of the Bath Mate Acid-free washroom cleaner manufacturer's recommendations revealed the disinfectant should have remained on all surfaces for five to ten minutes. Review of the provider's December 2011 Procedure for Handwashing revealed no process in place for the housekeeping department. 7. Observation on 5/20/14 at 1:45 p.m. of the clean medical supply room revealed: *Multiple treatment supplies was located inside of the cupboards. *There had been outdated treatment supplies in the cupboards. Those supplies had been: -Multiple boxes of abdominal gauze pad dressings dated 12/9/12. -Eight Allevyn (dressing for wounds) adhesive dated 2012. -One box of cotton tipped applicators dated August 2013. -Two full boxes of DuoDerm (dressing for wounds) dated October 2012. -One box of four by four gauze dressings dated November 2013. *Two large cardboard boxes with red biohazardous bags inside of the them. One of the boxes contained multiple containers for biohazard sharps (for used needles, lancets, and razors) wastes. Those containers had been full of sharps and were waiting for destruction. Interview on 5/21/14 at 12:10 p.m. with the DON/infection control nurse revealed: *The DON had not been aware of the outdated treatment supplies. *She had assigned two CNAs to clean the room and check for outdated supplies. *There was not a scheduled time for when the CNAs were to have cleaned the medical supply room. *She had not been aware the biohazardous containers should not have been located in the clean medical supply room. *She had agreed the biohazardous containers needed to be moved to a different area. 8. Observation on 5/20/14 at 10:40 a.m. in the dining room revealed a kitchen area with a sink. Underneath the sink were multiple clean towels. Interview on 5/21/14 at 12:15 p.m. with the DON/infection control nurse revealed she had not been aware the towels were being stored under the sink. She agreed the towels should not have been stored underneath the sink and had been a potential for cross-contamination. Review of the provider's January 2010 Infection Preventionist job description revealed: *"Consults on infection risk assessment, prevention, and control strategies including transmission based precautions and isolation." *"Implements evidence-based infection prevention and control practices including those mandated by regulatory and licensing agencies and guidelines from the Centers for Disease Control and Prevention." *"An essential element of the Facility Infection Control Program is the development and revision of written Policies and Procedures. The policies represent the foundation of the program and they must conform to current standards of practice and/or address specific facility concerns."

Based on observation and interview, the provider failed to: *Have a food expiration date system in place to ensure the safety of food stored in the resident use refrigerator in the dining room. *Ensure staff that assisted residents to eat did not touch ready-to-eat food with their bare hands. Findings include: 1. Observation on 5/20/14 at 4:45 p.m. of the resident use refrigerator in the dining room revealed the following unlabeled or outdated resident's personal food items had been saved to be eaten at a later date: *A covered plastic container with resident 9's name was written in ink on the lid, but no date was written in ink. When the container was opened it revealed a slice of carrot cake and a serving of cheesecake. The cheesecake was very moldy. *A white styrofoam container with resident 17's name written on it but no date. When the container was opened it revealed two chicken strips and a dinner roll. *A larger covered plastic container with resident 5's name written on it and the date of 5/16. That would be four days it had been in the refrigerator. It was not labeled as to what it was. When the lid was opened, it contained a large amount of what appeared to be chicken noodle casserole. Observation at the above time of the poster taped to the refrigerator revealed the following instructions: *Personal resident food items placed in this refrigerator MUST contain the following: -1. Resident's name. -2. Date it was placed there. *All food items must not exceed the expiration date. *The kitchen staff will dispose of any perishable items that are deemed unsafe for use or outdated due to Federal guidelines. *Signed by the food service director. Interview with the dietary manager (food service director) on 5/20/14 at 5:00 p.m. and a re-examination of each container revealed: *She was shocked there was any food in the resident use refrigerator that was old enough to have mold. *She checked resident 9's container and found a date of 4/20 scratched on the lid but not in ink. *She stated any food brought in and saved in that refrigerator were supposed to have been given to either the charge nurse or the kitchen staff for labeling and dating. *Her staff that delivered snacks to that refrigerator was supposed to have checked the food items in the refrigerator. *She had not assigned any specific position to be responsible to check the food items. *She had not assigned how often each day that refrigerator should have been checked for resident's food items. *She had not been in the habit of checking that refrigerator herself. *She did not have a defininte system in place for: -Who checked the food items in that refrigerator and how often. -Who the food items were to be given to before they had been placed in the refrigerator. -How the food was labeled when placed in the refrigerator. -How long the food was kept and was labeled with an expiration date. *She stated any cooked leftovers were not to be kept longer than three days. Review of the undated policy for Food From Outside Sources revealed: *Policy: "Food from outside sources is discouraged due to problems with food safety and infection control, as well as control of therapeutic diet orders." *Procedure: "All food brought in is checked by the charge nurse or the food service manager. It must be placed in a plastic ontainer with tight fitting lid. It is recommended that only enough food be brought in for that visit." *Procedure: "Food brought in should be labeled with the individual's name and dated if it must be stored." 2. Observation on 5/20/14 at 11:45 a.m. of activity assistant C revealed: *She had been assisting resident 16 with his meal. *He had a sandwich on his plate. *He had been unable to pick up the sandwich on his own. *She had picked up the sandwich multiple times to assist him to take a bite. *She had not been wearing gloves when handling his sandwich. Interview on 5/21/14 at 11:00 a.m. with activity assistant C confirmed she should not have touched the sandwich with her bare hands. She should have worn gloves or retrieved a knife to cut the sandwich into pieces. 3. Observation on 5/20/14 at 12:10 p.m. of CNA D revealed she: *Took a sandwich out of a baggie with her bare hands and put it on resident 14's place mat. *Picked up the sandwich off of the place mat with her bare hands and put it on a paper plate. Interview at that time with CNA D revealed she should have had gloves on before she handled the sandwich.

Based on observation, interview, and policy review, the provider failed to ensure: *Chemicals were stored appropriately in multiple areas (utility rooms, janitor rooms, exercise room, kitchen nook area in the dining room, and on the 300 wing). *Straight edge razors used to shave the residents' faces had been disposed of in an appropriate manner. Findings include: 1. Random observations from 5/20/14 through 5/21/14 revealed multiple areas where chemicals were not stored or secured properly and had created the potential for harm. Those areas and chemicals had been: *Multiple spray bottles of Hyro Kleen disinfectant, carpet spotter, Bath Mate acid-free disinfectant cleaner, and Virex II 256 quaternary disinfectant stored on a shelf in the utility and storage rooms of the 200 wing. -The doors had been left open. -There had been a sign taped between the two doors that read "Chemicals present. For the resident safety and protection it is mandatory that these doors be shut and locked at all times." -There had been several unidentified residents observed passing that area. *A plastic tub of Clorox germicidal wipes stored on a shelf in the utility room on 100 wing. The door had been left opened with no locking device attached to it or on the door handle. *Two spray cans of Zenatize disinfectant cleaner stored on a shelf in the janitor room on the the 100 wing next to multiple boxes of toothpaste, rolls of toilet paper, and a tube of body lotion. *A plastic tub of Clorox germicidal wipes stored in an unlocked cupboard in the exercise room. The room had been located off the dining room. There were no doors to the entrance area. An unidentified resident had been observed sitting at a table next to the entrance area multiple times. *A spray bottle stored under a sink in a kitchen nook area in the dining room. The spray bottle had been labeled Avery (bird) glass cleaner. The cabinet had been unlocked. There had been several unidentified residents observed passing that area. *A plastic tub of Clorox germicidal wipes stored in a holder attached to the vital sign machine in the commons area on 300 wing. There had been several unidentified residents who had passed by the vital sign machine. Interview on 5/21/14 at 11:45 a.m. during an environmental walk through with the environmental services coordinator, administrator, and director of nursing (DON) confirmed the above findings. They agreed the chemicals should have been stored in a secured/locked area and not with resident's personal care items. Review of the provider's undated Safe Storage of Cleaning Chemicals policy revealed "All chemicals should be locked up when not in direct sight of employee." 2. Interview on 5/20/14 at 2:50 p.m. with certified nursing assistant B revealed she: *Was one of the bath aides. *Had shaved the womens' faces with a straight edged razor. *Had disposed of the razor into the garbage can after shaving them. *Had realized that was an inappropriate procedure. *Confirmed the razors should have been disposed of in a sharps container (enclosed container for used syringes with needles or sharp devices). Interview on 5/20/14 at 11:50 a.m. with the DON confirmed the disposable razors should have been placed inside a sharps container for destruction.