Every finding on record at Fayetteville Healthcare Center

Based on record review and staff interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments. This deficient practice had the potential to affect one (1) of three (3) closed records reviewed during the survey process. Resident Identifier: #60. Facility Census: 57. Findings included:a) Resident #60 Review of Resident #60's discharge return not anticipated Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/16/26, coded the resident's discharge destination as a short-term general hospital.According to a nursing note, written on 01/16/26 at 3:28 PM, Resident #60 was discharged home with home health. On 03/10/2026 at 3:05 PM, the Director of Nursing (DON) confirmed Resident #60 was discharged home and the discharge MDS was incorrectly coded regarding discharge destination.

Based on record review and staff interview, the facility failed to honor a resident's Physician's Orders for Scope of Treatment (POST) form indicating the resident did not want cardio-pulmonary resuscitation. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the closed record category of death. This was determined to be past non-compliance beginning on [DATE] and ending [DATE]. Resident Identifier: #61. Facility Census: 57. Findings Included:a) Resident #61 The facility's policy titled Emergency Procedures, with no implementation or revision dates given, stated cardio-pulmonary resuscitation (CPR) would not be provided for residents having a valid physician order to withhold CPR per the resident's or resident's representative's request. Review of Resident #61's medical records showed the resident was admitted to the facility on [DATE]. The resident, who had the capacity to make his own medical decisions, completed a [NAME] Virginia Physician's Orders for Scope of Treatment (POST) form on [DATE]. The resident indicated he wanted no cardio-pulmonary resuscitation (CPR) in the event he had no pulse and was not breathing. The resident had a Do Not Resuscitate (DNR) order.Further review of Resident #61's medical records showed the following nursing note, written on [DATE] at 9:10 AM, This Unit Manager was notified by LPN [licensed practical nurse] that [resident] had collapsed in the floor. Upon assessment resident was cyanotic; pupils were fixed and dilated, no pulse detected. CPR was initiated, and 911 was notified, upon EMS [emergency medical services] arrival, code status was verified to be DNR and life-saving measures were discontinued and resident was pronounced dead by EMS at 9:02am. [Physician] and [resident's next of kin] were notified.During an interview on [DATE] at 9:00 AM, the Administrator stated education was provided to staff on [DATE] regarding ascertaining residents' correct code status prior to initiating CPR. She stated the matter was also brought before the Quality Assurance Performance Improvement [QAPI] committee in an ad hoc meeting on [DATE]. The ad hoc QAPI meeting held on [DATE] identified the root cause as an inexperienced nurse who had the incorrect electronic health record open when checking the resident's code status. A Performance Improvement Plan (PIP) was developed to include education and mock codes. The record of Inservice Training dated [DATE] had the following summary of inservice, Before initiating CPR, verify the resident's code status in the electronic medical record by checking the header. Ensure that you are looking at the correct resident's medical record. The Emergency Procedures and [NAME] Virginia Code Status Procedures are attached. Review the attached policies. All nursing and nurse aide staff received the inservice training in person or by telephone on [DATE] and [DATE]. Mock codes were documented from [DATE] through [DATE]. The mock codes were on-going. The mock codes were performed on all shifts and 23 mock codes had been conducted so far. On [DATE] at 9:00 AM through 9:15 AM, staff members were interviewed regarding steps to be taken when residents were found without pulses or respirations. Licensed Practical Nurse (LPN) #2 and LPN #67 identified checking the correct electronic health record to determine the residents CPR status before beginning resuscitative efforts. They identified the resident's CPR status as being contained in the banner on the first page of the resident's electronic health record and on the resident's electronic medication administration record (MAR). These could be accessed on computers on medication carts or at the nursing desk. Nursing Assistant NA #11 and NA #44 also identified checking the correct electronic health record to determine the residents CPR status before beginning resuscitative efforts. They identified the resident's CPR status as being contained on the resident kardex which could be accessed on kiosks in the hallway. They also identified the resident's CPR status as being contained in the banner on the first page of the resident's electronic health record which could be accessed on computers at the nursing desk.

Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to resident hand sanitation before meals. This was true for Resident #53 and Resident #6. Facility census: 57. Findings included:a) Lunch Meal on 03/10/26 At 12:12 PM on 03/10/26, the State Agency (SA) observed Nurse Aide #65 passing lunch trays to Resident #53 and Resident #6. Nurse Aide #65 set up trays for both residents, who share the same room, without first offering hand sanitation to either resident. The nurse aide then exited the room and walked back to hallway. At 12:15 PM, the SA interviewed Nurse Aide #65 and inquired if she had provided hand sanitizing care. She replied, Um ., um. The nurse aide then walked over to the cart, grabbed some hand wipes, walked back into resident's room, and asked if they had eaten yet and if they would like to wipe their hands. When she exited the room she reported to this surveyor in the hallway, They hadn't eaten yet. The Facility Policies and Standard Procedures, Subject: Standard Precautions directs on page 3, Section II when to perform hand hygiene: Before eating/before feeding or assisting in dining room tray pass.

Based on record review and staff interview, the facility failed to revise the resident's comprehensive care plan to reflect the resident's choices of long term care goal. This had the potential to affect one (1) of 30 residents reviewed in the Long-Term Care Survey Process. Resident Identifier: #6. Facility Census: 57. Findings Included:a) On 03/11/26 at 10:15 AM, a document review revealed resident's care plan stated the following: Page one (1), Patient with plans to discharge to home when there is an overall improvement in abilities. Date Initiated: 02/08/19Revision on: 02/08/19 Page 14, Resident has no plans for discharge secondary to long term care placement in the facility. Date Initiated: 08/28/24 Revision: 08/28/24 b) Interview with Social Worker, on 03/11/26 at 10:18 AM, who reported the initial focus should have been resolved but continues to show up on care plan as active. c) Interview with Administrator and Director Of Nursing, at approximately at 10:25 AM on 03/11/26, who acknowledged the care plan had both plans to return to the community and for long-term care on his care plan and that the care plan needed to be revised.

Based on observation and staff interview, the facility failed to maintain an infection control program for removal of dirty dishes, old food and drinks from the dining room for Resident #31 and storage of the oxygen cannula and tubing and a soiled bath basin for Resident #47. These were random opportunities for discovery. Resident Identifiers: #31 and #47. Facility Census: 57.Based on observation and staff interview, the facility failed to maintain an infection control program for removal of dirty dishes, old food and drinks from the dining room for Resident #31 and storage of the oxygen cannula and tubing and a soiled bath basin for Resident #47. These were random opportunities for discovery. Resident Identifiers: #31 and #47. Facility Census: 57. Findings Include: a) Resident #31 Upon arrival to facility on 07/01/25 at 3:15 AM, an observation of dirty dishes from the evening meal with old food and drinks which included: tea, milk, macaroni and cheese with bread stuffed into a bowl, which had Resident #31's meal ticket under the dinner plate. Also, a styrofoam cup with lid and straw with no name or room number was observed sitting randomly on dining room table. On 07/01/25 at 3:20 AM, Licensed Practical Nurse (LPN) #7 and #24 were notified. LPN #24 removed the dishes from the dining room. b) Resident #47 On 07/01/25 at 3:28 AM, an observation was made in Resident #47's room. The observation found an oxygen cannula and tubing laying in the floor by the bed as well as a used pink bath basin. The resident was noted with confusion and could not answer questions regarding the items in the floor. On 07/01/25 at 3:31 AM, Nurse Aide (NA) #43 was notified and removed the tubing and bath basin from the floor. On 07/01/25 at 3:40 AM, the Director of Nursing (DON) was notified and stated, the resident may have threw the items in the floor.

Based on observation and staff interview, the facility failed to provide a dignified experience during activities of daily living (ADL) care for Resident #55. This was a random opportunity for discovery. Resident Identifier: #55. Facility Census: 57. Findings Include: a) Resident #55 On 07/01/25 at 3:25 AM, an observation of Resident #55 sitting in a wheelchair with no shirt on and brief on in front of the bathroom with the door to the hallway was open. Nurse Aide (NA) #15 was emptying the urinary catheter bag. Resident #55 was interview at this time. The resident was asked, are you getting the assistance you need? The resident stated, she is getting my catheter emptied and getting ready to put me on the pot. On 07/01/25 at 3:40 AM, the Director of Nursing (DON) was advised of the observation. The DON confirmed the door to the hallway should have been closed.

Based on record review and staff interview, the facility failed to complete discharge planning and permit Resident #58 to return to the facility after an acute care transfer. This was true for one (1) of one (1) residents reviewed under the care area of transfers/discharges. Resident identifier: #58. Facility census: 57.Based on record review and staff interview, the facility failed to complete discharge planning and permit Resident #58 to return to the facility after an acute care transfer. This was true for one (1) of one (1) residents reviewed under the care area of transfers/discharges. Resident Identifier: #58. Facility Census: 57. Findings Include: a) Resident #58 On 07/01/25 at 5:00 AM, a review of a facility-reported incident (FRI) dated 12/27/24 was completed. The review found Resident #58 had been admitted to the facility on [DATE]. The resident was noted with a Brief Interview for Mental Status (BIMS) score of 14 on 11/29/24. The score of 14 indicates the resident is cognitively intact. The resident was noted with capacity for medical-decisions on 09/06/24. The resident was listed with the following diagnoses: peripheral vascular disease, chronic obstructive pulmonary disease, chronic respiratory failure, history of falling, congestive heart failure, unspecified dementia, unspecified severity, with agitation and behavioral disturbance, difficulty in walking, atrial fibrillation, hyperlipidemia, hypertensive retinopathy, radiculopathy, lumbar region, unsteadiness on feet, major depressive disorder, unspecified, unspecified mood (affective) disorder, hypokalemia, constipation, cognitive communication deficit, abnormal posture, benign prostate hypertropy, age-related nuclear cataract, bilateral, presbytopia, insomnia, muscle (generalized) weakness, and essential (primary) hypertension. The review found the resident was noted with multiple instances of inappropriate sexual behaviors, as well as physical and verbal behaviors to staff members as well as other residents. The resident was noted with inappropriate sexual behavior on 12/27/24. The resident was sent to an acute care facility for this behavior. The resident did not have discharge planning in place and was not allowed to return to the facility. The facility had worked on transferring the resident to other facilities; however, no other facility would accept the resident or did not have a bed available. The referrals were sent out in 07/2024. No further indication of any other referrals were made after 07/2024. Although, the resident was medically cleared in the acute care facility, including a psychiatric evaluation, the resident was not allowed to return to the facility. An interview was held with the Director of Nursing (DON) on 07/01/25 at approximately 8:00 AM. The DON denied making any statements to the acute care facility regarding the resident being a dump. The DON stated, the resident had multiple incidents with other residents and staff members, including sexual inappropriate behaviors .we sent him out and the facility decided the resident could not return to the facility. The DON was then asked, why wasn't the resident allowed to return to the facility on one-on-one supervision like in the past until another facility was found? The DON responded, the decision was made and the resident was not allowed to return to the facility. The DON did not answer the question regarding the one-on-one supervision. The DON was, also, asked, why was this incident of behavior different than the previous behaviors noted in the past? The DON did not answer this question. The DON did confirm the resident did not have active discharge planning in place and the resident was not permitted to return to the facility. An interview was held with the Administrator on 07/01/25 at approximately 9:00 AM. The Administrator stated, I reported this to the proper State agencies when it happened, the behavior of the resident made the other residents unsafe.

Based on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #58. This was true for one (1) of nine (9) residents reviewed during the survey process. Resident Identifier: #58. Facility Census: 57. Findings Include: a) Resident #58 On 07/02/25 at 8:40 AM, a record review was completed for Resident #58. The review found the resident had been transferred to an acute care facility on multiple occasions. The transfer form dated 02/02/23 was incorrect and the correct date was 03/26/24. An additional transfer form dated 03/26/24 was incorrect and the correct date was 08/09/24. On 07/02/25 at 8:55 AM, the Director of Nursing (DON) was notified regarding the incorrect dates on the transfer forms. The DON confirmed the dates were incorrect. The DON stated, sometimes the nurses get in a hurry and do not review the transfer form dates.

Based on observation and staff interview the facility failed to ensure hallways were free from clutter and allowed resident a direct access down the hallway. This was a random opportunity for discovery and had the potential to affect a minimal number of residents residing in the Long-Term Care Facility. Facility census: 57 Findings include:During the initial our of the facility on 07/01/25 at 3:20 AM surveyor observed wheelchairs, geri chairs, and mechanical lifts parked on the right side of the hall along with a large portable Air Conditioning unit. On the left side of the hall was a linen cart and a geri chair, this blocking a direct path up or down the hallway.On 07/01/25 at 3:30 AM Licensed Practical Nurse ( LPN) #7 confirmed the hall did not have a direct path for residents to easily get through.

Based on record review and staff interview the facility failed to implement their antibiotic stewardship program. Resident #44's attending physician received the urine culture results which indicated the resident's infection was resistant to Macrobid. However, the physician ordered Macrobid to treat the urinary tract infection (UTI). The resident did not improve and when questioned the facility reviewed the culture again and discovered the wrong antibiotic was ordered. This resulted in actual harm for Resident #44. Her UTI symptoms persisted and she was later hospitalized with sepsis. This was discovered during the completion of the infection control task during the long term care survey process. Resident Identifier: #44 Facility Census: 56 Findings Included: a) Resident #44 On 08/21/24 a record review found Resident #44 had a urinalysis and culture and sensitivity performed on a urine sample collected at the facility on 04/11/24. On 04/15/24 at 6:03 PM the urine culture and sensitivity showed the bacteria identified in the urine culture was providencia stuartii. Each antibiotic was listed and identified as the bacteria being resistant (meaning it will not kill the bacteria) or susceptible (meaning it will kill the bacteria) to each antibiotic. The bacteria was identified as being resistant to Nitrofurantoin (Macrobid). The in house physician ordered Macrobid 100 mg twice a day for seven (7) days. The resident received the seven (7) days prescribed. On 04/27/24 documentation shows the .family requested an increase in the dose of Macrobid as the symptoms were not resolving. Review of the labs demonstrated that the organism was resistant to Macrobid so, changed to susceptible abx - Bactrim. Renal function reviewed. acceptable. Full dose for 5 dose . The resident then received Bactrim 800-160 mg one capsule twice a day X five (5) days. The resident received the five (5) days as prescribed. Record review shows Resident #44 was sent out to the local hospital on 05/09/24 at 10:31 AM with an admitting diagnosis from the hospital as Sepsis: The discharge diagnosis is documented as: Sepsis, Metabolic Encephalopathy secondary to Urinary tract infection (UTI), Acute kidney injury (AKI) secondary to sepsis versus urinary retention and acute urinary retention. She was hospitalized for nine (9) days and returned to the facility on [DATE]. According to the facility Antibiotic Stewardship Plan Policy and Procedure: .the facility participates in an Antibiotic Stewardship program to protect residents and reduce the threat of antibiotic resistance in this setting . .The Infection Preventionist Nurse will have expertise and date to inform strategies to improve antibiotic use. This includes but not limited to: 1) using evidence based published criteria during the evaluation and management of treated infections 2) Reviewing antibiotic resistance patterns in the facility . .support the antibiotic stewardship program in the facility. This includes but no limited to 1) timely and appropriate ordering of antibiotics 2) reviewing culture data . On 08/21/24 at 1:55 PM the Director of Nursing stated the Physician read the culture wrong and ordered the wrong antibiotic. When the family questioned why the resident was not improving they re-addressed the lab culture and discovered the organism was resistant to the antibiotic the physician had ordered. He was contacted and gave new orders for a new antibiotic. On 08/21/24 at 2:28 PM during an interview with the Infection Preventionist #12 she stated the day the urine culture in question came back, the physician came in her office about the same time the culture came in. She showed him, he looked at it and he verbally ordered Macrobid 100 mg BID X 7 days. She placed the culture in the box to be scanned and ordered. She had no reason to pull the culture again and follow up on it or to question the physician's original order. The Infection Prevetionist said her normal process would be when she gets the culture back she emailed the physician with the resident name, the culture results and which medications are resistant or susceptible. The culture goes in a box on her desk until she gets a return email from the physician with an order. If she does not get a response within 24 hours, she reaches out again. She felt this was missed due to the time frame the culture came in, the physician placed the order and her filing the culture away. Under normal circumstances, she would look at a culture several times.

Based on observation and staff interview the facility failed to dispose of garbage and refuse properly by not ensuring the lid on the dumpster was closed. This was found while completing the facility task of the Kitchen and has the potential to affect all residents currently residing in the facility. Resident Census: 56. Findings include: a) Dumpster An observation of the facility's dumpster on 08/21/24 at 1:40 PM with the Nursing Home Administrator (NHA) present found the lid to the dumpster was opened. When looking into the dumpster it was noted there was a bag trash inside the dumpster. The NHA confirmed the dumpster lid should have been closed.

Based on observation and staff interview the facility failed to ensure the safe food handling practices was used. A glass was held barehanded by the rim during mixing for a thickened diet. This was a random opportunity for discovery identified during the long term care survey process and had the potential to affect a limited number of residents. Facility Census: 56. Findings include: a) Thickened drink. On 08/20/24 at 08:15 AM during an observation of the dining room breakfast prep it was observed that Certified Nursing Assistant (CNA) #45 was mixing thickened juice drink for a resident. It was further observed that CNA #45 was holding the glass with her bare hand. She had placed her pointer finger and thumb on the top rim of the glass as she stirred the liquid with the opposite hand. When asked if the resident would be drinking from the rim of the glass she stated yes and that she would re-mix another drink. During an interview with the Clinical Manager Registered Nurse (CM RN) #12 on 08/20/24 at approximately 8:19 AM, CM RN #12 stated that the CNA's know better than that and CM RN #12 disposed of the drink.

Based on observation and staff interview the facility failed to provide a homelike environment. This was true for two (2) of fifty-six (56) residents observed during the long term care survey process. Resident Identifiers: #21, #112 Facility Census: 56 Findings include: a) Resident #21 On 08/19/24 at 9:23 AM observation of Resident #21's wardrobe found the face of the drawer in the bottom of the wardrobe was missing. This was confirmed with Registered Nurse Unit Manager #76 on 08/19/24 at 9:45 AM. b) Resident #112 On 08/19/24 at 9:23 AM observation of Resident #112's room found there were three (3) curtain hooks missing from the privacy curtain between the entrance door and the bed. This caused the curtain to hang down on one corner. This was confirmed with the Registered Nurse Unit Manager #76 on 08/19/24 at 9:45 AM.

Based on record review, family interview, observation and staff interview the facility failed to develop a comprehensive care plan for Resident #44 related to diet restrictions associated with a medical condition. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: # 44. Facility Census: 56. Findings Include: a) Resident #44 Observation of the noon time meal on 08/21/24 at 12:47 PM found Resident #44 was sitting in the dining room. She was served her meal and on her plate was a serving of corn. Resident #44 immediately stated, I can not eat corn, they know that. She then pushed her plate to the side. A few minutes later Resident #44's family member entered the dining room and said, oh we can just take that corn off your plate. She then helped Resident #44 remove the corn from her plate. An interview with Resident #44's family at this time found, the facility always gives her stuff she should not eat due to her ileostomy. A review of Resident #44's tray ticket found she was supposed to be served the alternate vegetable instead of the corn. A record review of Resident #44's care plan found the care plan to be void of any special diet restrictions related to Resident #44's ileostomy. An interview with the Registered Dietician on 08/21/24 at 1:00 PM found the resident should not have been served corn. She stated, there are foods she should avoid and corn is one because it could cause a blockage related to her ileostomy. An interview with the Director of Nursing (DON) in the afternoon of 08/21/24 confirmed Resident #44's care plan was void of any diet restrictions related to her ileostomy.

Based on record review and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for Resident #60 upon discharge. This was true for one (1) of one (1) residents reviewed for discharge during the survey process. Resident identifier: 60. Facility census: 56. Findings include: a) Resident #60 At approximately 9:15 AM on 08/20/24, during a record review for Resident #60, the following note, entered by the Social Worker (SW) was discovered (typed as written): 7/1/24 14:56 Social Services Note: Note Text: (Resident #60's name)'s family would like (Resident #60's name) to discharge on 7/3/24 related to progress made on goals. They plan on picking her up sometime after 4:00p.m. No equipment needs. Home health will be arranged with (Home Health Provider). Per daughters the family all take turns staying with (Resident #60's name) and she has 24 hour care at home. According to the discharge summary provided by the facility, Resident #60 was discharged home on 07/03/24. Upon review of the discharge MDS Assessment completed by the facility, specifically section A completed and signed by the SW, the discharge location for Resident #60 was entered as Short-Term General Hospital (acute hospital, IPPS) instead of Home/Community. At approximately 2:26 PM on 08/21/24, an interview was conducted with the SW regarding the MDS for Resident #60 upon discharge. The SW acknowledged the mistake on the MDS and stated It must have just been a typo. I was probably looking at where she came from, which was a short-term hospital, and just entered that into the discharge location by accident.

Based on record review and staff interview, the facility failed to report an alleged incident of resident to resident abuse involving Resident #3 and an unknown resident. This was true for one (1) of three (3) residents reviewed for abuse during the survey process. Resident identifier: #3. Facility census: 56. Findings include: a) Resident #3 At approximately 2:15 PM on 08/20/24, a review of Resident #3's progress notes was conducted, related to behaviors the resident exhibited. It was noted on 03/18/24, Resident #3 was witnessed throwing a cup of water in the face of another resident who was not identified. Upon review of the incidents and reportables logs supplied by the facility, it was determined the incident was not listed on either log. At approximately 3:15 PM on 08/20/24, a copy of the reportable incident and investigation, if available, was requested from the Administrator. At approximately 3:45 PM, the Administrator confirmed the incident was not reported and an investigation was not started. Review of Resident #3's care plan discovered a note under the focus area pertaining to behaviors stating, Resident has thrown water at staff/residents.

Based on medical record review and staff interview the facility failed to formulate an advance directive by not obtaining the signature of the Medical Power of Attorney. This was true for one (1) of four (4) residents whose advanced directives were reviewed during the long term care survey process. Resident identifier: Resident #10. Facility Census: 56. Findings include: a) Resident #10 During a medical record review on 08/19/24 at 2:33 PM a review of the [NAME] Virginia Physician Order for Scope of Treatment (WV POST) form for Resident #10 it was identified the facility obtained a verbal confirmation of agreement from the residents Medical Power of Attorney (MPOA) on 06/09/22. It is further identified the signature of the MPOA had not been obtained. In review of the WV Post Using the Post Form Guidance for Health Care Professionals it is identified on page 20 the verbal confirmation of agreement from the patient's MPOA representative can be obtained and the form should then be signed at the earliest available opportunity. During an interview with the Assistant Director of Nursing (ADON) on 08/20/24 at 11:29 PM, the ADON agreed the signature had not been obtained as required.

49650 Based on medical record review and staff interview the facility failed to update the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PASARR) with new qualifying diagnoses of major depressive disorder. This was true for two (2) of three (3) residents whose PASSARR's were reviewed during the long term survey process. Residents identifiers: #34, #39. Facility Census: 56. Findings included: a) Resident # 34 During a medical record review [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PASSARR) on 08/21/24 at 12:00 PM, it was identified the PASSARR was completed on 11/25/22. During a further medical record review it was identified on 03/20/24 the resident was diagnosed with Major Depressive disorder. An updated PASSARR could not be found for this new diagnosis. During an interview with the Social Worker (SW) #77 on 08/21/24 at 12:21 PM, SW #77 agreed that the PASSARR should have been updated at the time of the new diagnosis of major depressive disorder on 03/20/24. b) Resident #39 At approximately 8:30 AM on 08/20/24, a record review for Resident #39 was conducted. During this review, it was noted the resident was admitted to the facility on [DATE]. During the resident's stay at the facility, 08/09/23, he was diagnosed with major depressive disorder. Review of the PASSAR for Resident #39 indicated there was not a new one completed to reflect the new diagnosis of major depressive disorder. At approximately 12:37 PM on 08/20/24, an interview was conducted with the Social Worker. The SW confirmed she was responsible for submitting the PASSARs at the facility. The SW confirmed there was no new PASSAR for Resident #39 following the diagnosis and stated We are working on redoing the PASSARs for residents that need them.

Based on record review and staff interview the facility failed to ensure a Preadmission Screening and Review (PASARR) form had the appropriate diagnoses present. This was true for one (1) of three (3)PASSr's reviewed during the long term care survey process. Resident Identifier: #20 Facility Census: 56 Findings Include: a) Resident #20 On 08/20/24 at 10:29 AM record review of the transfer PASARR provided by Social Worker #77, dated 04/15/24 found that the only diagnosis listed was dementia. A review of Resident #20 medical diagnosis found the following diagnosis: Dementia, upon admission Bipolar, upon admission Depression, upon admission Generalized Anxiety Disorder, upon admission On 08/20/24 at 3:10 PM this was confirmed with Social Worker #77 who agreed all the listed diagnosis should be on the PASARR.

Based on a review of the facility policy and procedure for Abuse, Neglect and Misappropriation, facility record review, medical record review and staff interview the facility failed to implement and ensure actions were in place to prevent further potential abuse. This was a random opportunity of discovery during the long term care survey process. This had the ability to affect a limited number of residents. Resident Identifier: Resident #34. Facility Census: 56. Findings include: a) Resident #34 During a review of the facility policy and procedure for Abuse, Neglect and Misappropriation it was identified on page 6 (six) of 20, (written as typed); In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with the state law. If the alleged violation is verified, appropriate corrective actions will be taken by the facility. On 08/21/24 at approximately 10:30 AM during a facility record review of a facility reported incident dated 07/17/24, Resident #34 allegedly inappropriately attempted to move the hand of a another resident to Resident #34 groin area. At the time of the incident there were staff witnesses confirming the allegation. It is further identified through Resident #34 medical record review that the facility had initially placed Resident #34 on 1:1 (one on one) supervision. However, at the time of the incident the attending physician was in the building and it was noted that the attending physician stated the resident did not need 1:1 supervision at this time. It was further identified the physician order for 1:1 supervision was not entered until 07/18/24 at 7:00 PM. A review of the Treatment Administration Record (TAR) identifies that the 1:1 supervision started the night shift of 07/18/24. During an interview with the Director of Nursing (DON) on 08/21/24 at approximately 12:55 PM the DON stated she felt they had continued the 1:1 supervision but was not able to provide any documentation to support her belief. She agreed without the 1:1 supervision the residents in the facility including the victim of the incident was not provided protection from further potential abuse from the time the staff was aware of the initial abuse incident at 11:30 AM on 07/17/24 through 07/18/24 at 7:00 PM.

Based on observation, record review and staff interview the facility failed to ensure food was stored and prepared in a manner to prevent the spread of food borne illnesses. The facility failed to ensure food served from the kitchen was cooked thoroughly to an adequate temperature before serving it to residents. In addition, the facility failed to ensure the kitchen was clean and food was stored in the kitchen in a safe and sanitary manner. There were multiple items which were either not labeled or remained available for service past use by dates. Ensuring all food is cooked to an adequate temperature is critical to prevent the spread of food borne illnesses. The state agency found the failure to cook food items to the appropriate temperature placed all 55 residents currently residing in the facility in an immediate jeopardy (IJ) situation. At which time serious harm and/or death could occur immediately if the facility did not correct this failure. The facility was notified of the IJ at 3:43 PM on 03/12/24. The SA accepted the plan of correction (POC) at 5:30 PM on 03/12/24. On 03/13/24 after observation of the noontime meal it was determined the facility had implemented their plan of correction and the IJ was abated at 12:45 PM. After the IJ was abated it was determined a deficient practice remained at F812 due to the facility's failure to ensure food was stored safely and discarded when past the expiration date and they failed to ensure the kitchen was clean. Because a deficient practice remained the scope and severity were decreased from a L to a F. The IJ began on 02/15/24 which is the first date the state agency identified the facility failed to cook food to the appropriate temperature. The IJ continued until it was abated by the state agency on 03/13/24 at 12:45 PM. These failed practices had the potential to affect all residents currently residing from the facility because all residents receive meals from the facility's kitchen. Facility Census: 55 Findings Include: a) Meal Preparation The facility utilizes a Service Line Checklist that indicates the item names and temperatures for all hot and cold food. The temperatures should be obtained before placing food on the steam table to ensure the food was cooked to the appropriate temperature to avoid potentially spreading food borne illnesses. An observation of the noontime meal on 03/11/24 found Employee #19 a facility cook was preparing Chicken Pot Pie for the noontime meal. At approximately 12:30 PM Employee #19 took the temperature of the chicken pot pie mixture. The temperature was 143 degrees Fahrenheit (F). She removed the mixture from the convection oven and placed it onto the steam table and the meal service began at approximately 12:45 PM. Between 12:30 PM and 12:45 PM Dietary Employee #91 who was visiting from a sister facility spoke with the surveyor. The surveyor advised her that the chicken pot pie mixture was cooked to 143 degrees F. Employee #91 said, It should have been 165 degrees F. However, Employee #91 did not stop Employee #19 from serving the chicken pot pie to the residents. A review of the service line checklists from 02/12/24 to 03/12/24 on 03/12/24, found on the following dates food items were not cooked to the appropriate temperature: - 02/15/24 - Pureed rancher chicken was 162 degrees F and should have been 165 degrees F. -- 02/16/24 -- Jambalaya was 164 degrees F and should have been 165 degrees F. -- 02/21/24 - Turkey was 156 degrees F, the ground Turkey was 156 degrees F, and the pureed turkey was 160 degrees F. The menu indicated 165 was the appropriate temperature. --02/24/24 - Hot Dogs and pureed hot dogs were heated to 73 degrees F and 70 degrees F respectively. The menu indicated 165 was the appropriate temperature. An interview with Employee #90 who is a Certified Dietary Manager (CDM) from a sister facility on 03/12/24 at 2:43 PM confirmed the items listed above should have been cooked to 165 degrees F. Review of the menus for the above-mentioned food items found each recipe indicated the item needed to be cooked to a minimum temperature of 165 degrees F for 15 seconds. b) Facility's Plan of Correction The facility's POC read as follows: Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of 42 CFR 405.1907 and State Regulations. 1. An assessment was conducted with all residents currently residing within the center by director of nursing/designee on 3/12/24 to determine if any residents reported or exhibiting signs and/symptoms that could be related to food borne illness resulting in no concerns reported. 2. All center residents will be monitored each shift for 24 hours for new onset food borne illness symptoms. 3. The center administrator/designee provided all available dietary staff education on 3/12/24 on the Food: Preparation Policies, which includes the requirement to take appropriate temperatures and record them on the Service Line Checklist to ensure food is prepared and held at a safe temperature to prevent the spread of food borne illness prior to serving food from the service line with post-test to validate understanding. All dietary staff not available for education and training will be re-educated upon return to work. 4. An ongoing audit will be conducted by the interim food services manager\ designee, starting immediately, for each meal x 3 months and randomly thereafter to ensure appropriate temperatures as determined by food service production logs, are obtained, and recorded on the Service Line Checklists prior to the service of meal. Food outside of required temperatures will not be served. Audits will be reviewed weekly with the ED or designee and submitted for review to the Quality Assurance Committee monthly x3 and then when random audits are completed. c) Initial Tour of Kitchen An initial tour of the kitchen beginning at 9:06 AM on 03/11/24 with the Nursing Home Administrator (NHA) found the following storage and sanitation issues: 1) Reach In Refrigerator: -- Staff members personal drinking cup in the reach in refrigerator. -- Four (4) bowls containing a piece of cake which were not labeled or dated. -- One (1) bowl containing applesauce which was not labeled or dated. -- One (1) bowl containing a pumpkin dessert which was not labeled or dated. -- One (1) bowl pudding which was not labeled and dated. -- Seven (7) bowls of pears which were not labeled or dated. -- One (1) bowl of pureed peaches which was not labeled or dated. -- One (1) bowl of vanilla pudding with a prepared date of 03/05/24 which should have been discarded on 03/08/24. -- Two (2) bowls of salad with a prepared by date of 03/07/24 which should have been discarded on 03/10/24. -- One (1) bowl of pineapples prepared by date of 03/06/24 which should have been discarded on 03/09/24. -- Four (4) bowls of peaches with a prepared by date of 03/07/24 which should have been discarded on 03/10/24. -- One (1) 46-ounce container of Grove Pineapple juice which had a manufactured stamped expiration date of 02/26/24. This juice was open, and the dietary aide indicated it had been opened a few days ago. -- One (1) container of V8 juice which was opened but was not labeled as to when it was opened. The NHA was present during this tour and agreed all items needed discarded. 2) Walk in Cooler -- Two (2) five (5) pound containers of sour cream which had a manufacture stamped expiration date of 02/24/24. -- Five (5) bowls of chocolate pudding which were not labeled or dated as to when they were prepared. -- One (1) container of what appeared to polish sausage was not labeled or dated to indicate when it was prepared. -- One (1) Large mixing bowl containing a salad mixture which should have been discarded on 03/10/24 but was still available for use on 03/11/24. -- One (1) container of hamburger which should have been discarded on 03/10/24 but was still available for use on 03/11/24. -- 35 individual bowls of deluxe fruit salad (Peaches, marshmallows, and whipped cream mixed) which were not labeled or dated to indicate when they were prepared. -- 14 individual bowls of apricots which were not labeled or dated as to when it was prepared. -- One (1) Ziploc bag containing turkey which was dated for 03/07/24 and should have been discarded on 03/10/24. -- One (1) container of mashed potatoes which was dated 03/02/24 and should have been discarded on 03/05/24. -- One (1) container of chili which was dated 03/03/24 and should have been discarded on 03/05/24. The NHA was present during this tour and agreed the items needed discarded. 3) Dry storage -- Six (6) 46-ounce containers of pineapple juice which had a manufacture stamped expiration date of 02/26/24. -- A bag of walnuts which had been opened and were not properly closed and were left open to air. -- Six (6) cans of Fired Roasted green chili's which had a manufactured stamped expiration date of 03/08/24. -- One opened bag of brown sugar which was stored directly on the floor. The NHA was present during this tour and agreed all items needed discarded. 4) Cleanliness -- The microwave was covered with food particles on the inside. -- The bottom shelves on the steam table were covered with debris, sticky substances and water. Stored on the shelves face down were multiple serving bowl/pans. -- The floor was not clean and contained debris and spilt food. -- The convection oven, steamers, and the oven/stove were covered with baked on food and debris. A review of the facility's cleaning schedule found the kitchen had not been cleaned since 03/08/24. When asked how often the kitchen should be cleaned the NHA indicated it should be done daily.

Part I -- Based on family interview, medical record review, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injuries for one (1) of thirty-four (34) Stage II sample residents. Record review revealed Resident #48 fell from her bed on the morning of 01/31/11 and sustained a compression fracture of the T-4 vertebra and a facial bone fracture. Further review of the record revealed she had sustained two (2) previous falls from her bed (on 08/23/10 and 11/07/10) with no injuries; however, the interdisciplinary team did not revise the resident's care plan after these falls to include interventions that would serve to either prevent the resident from falling out of bed and/or reduce the likelihood of serious injury from such a fall. The care plan interventions for falls remained essentially unchanged since 08/30/10, with a reliance on the use of bed and chair alarms to alert staff to unassisted self-transfers. The use of bed bolsters and floor mats was not added to her overall plan of care until after the 01/31/11 fall. Resident identifier: #48. Facility census: 55. Findings include: a) Resident #48 1. When interviewed on 03/07/11 at approximately 2:00 p.m., Resident #48's daughter stated she did not understand why the facility had not initiated the use of more safety devices (such as fall mats in her mother's room) after Resident #48 fell in November 2010. The resident had subsequently sustained a fall with injuries in January 2011. -- 2. Record review revealed Resident #48 was an [AGE] year old female originally admitted to the facility on [DATE], with her most recent admission occurring on 06/29/10. According to her most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 02/06/11, Resident #48 scored 4 on the Brief Interview for Mental Status (BIMS); a resident scoring between 0 and 7 is considered to have severe cognitive impairment. In Section C1300 (Signs and Symptoms of Delirium), the assessor noted the resident exhibited inattention ("2 - Behavior present, fluctuates"). In Section C1600 (Acute Onset Mental Status Change), the assessor noted there was no evidence of an acute change in mental status from the resident's baseline. In Section G (Functional Status), the assessor noted the resident required the extensive physical assistance of two (2) or more persons for bed mobility, transfer, and toilet use. In Section G0300 (Balance During Transitions and Walking), the assessor coded 2 for moving from a seated to a standing position, moving on and off the toilet, and making surface-to-surface transfers (transfer between bed and chair or wheelchair), with 2 meaning the resident was "Not steady, only able to stabilize with human assistance". In Section G0400 (Functional Limitation in Range of Motion), the assessor noted the resident had impairments in range of motion of upper and lower extremities on both sides. In Section I (Active Diagnoses), the assessor noted the following [DIAGNOSES REDACTED]., Parkinson's disease, seizure disorder, anxiety, depression, and a psychotic disorder other than schizophrenia. Additional [DIAGNOSES REDACTED]. In Section J1800, the assessor noted the resident had experienced falls since admission or since the prior assessment. In Section 1900, the assessor noted the resident had one (1) fall with a major injury. -- 3. Review of the resident's current care plan (last reviewed by the facility on 02/15/11) found the following problem statements (quoted below as recorded in the record): - "ADL (activities of daily living) performance requires extensive assist, Parkinsons, tremors." The goal was: "Patient will maintain adequate level of function." Interventions included: "Fall Risk." (These were all dated as having been initiated on 09/13/10.) - "(PATIENT has experienced an actual fall with compression fx (fracture), injury to her face 01/31/2011 risk for further fall/injury." The goal was: "Patient will resume usual activities without further complication through the review date." The interventions were: "RISK OF INJURY FROM FALL:alarms to bed and w/c (wheelchair) to alert staff she needs assistancebed in lowest position when in bed bed bolsters on bed, falls matts by the bed non skid cushion in w/c. "Continue interventions on the at-risk plan. Monitor / document / report to physician for s/sx (signs / symptoms): Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. HIGH FALL RISK: Anticipate and meet patient's needs." (The last intervention was noted to have been initiated on 01/06/11, while the problem statement, goal, and other interventions were noted to have been initiated on 11/09/10, even though the fall with injury occurred after this date on 01/31/11. Please also note no "at-risk plan" was found elsewhere in the comprehensive care plan.) -- 4. Review of the resident's nursing notes revealed the resident sustained [REDACTED]. A nursing note, dated 01/31/11 at 10:10 a.m. (quoted verbatim), stated:"... Alerted to resident's room resident lying on floor on stomach looking towards bed. Blood noted on floor from resident's face. ... Bleeding controlled, Resident remained on stomach not moved. 911 phoned, Daughter notified. ... " A subsequent nursing note, dated 02/01/11 at 1:01 a.m. (quoted verbatim), stated: "... resident has returned from (name hospital) with facial fracture .alert talking re: (regarding) her fall today able to move all extremities .noted bil. (bilateral) bruising to eyes and across nose also swelling ... bed alarm on call light given to pt. inst (instructed) not to get oob (out of bed) call for help bed down to low position. ..." A nursing note, dated 02/03/11 at 8:00 a.m., stated: "... Follow up to fall ... Floor mats and bed bolsters ordered." A nursing note, dated 02/04/11 at 12:41 a.m. (quoted verbatim), stated:"... follow up to fall. ... Has weak grips but that is normal for this resident. Bruising noted to nose and eyes. ... Bed in lowest position, bed alarm remains on and falls mat to side of bed. ..." A nursing note, dated 02/05/11 at 5:14 p.m. (quoted verbatim), stated: "... Nursing Assessment: Eyes are black, broken nose, T-4 fracture. ... " Review of the resident's physician orders [REDACTED]. The order stated: "Bed Bolsters while in bed for positioning and to facilitate a tactile barrier to provide a sense of bed boundaries." -- 5. According to her nursing notes, Resident #48 previously sustained a fall from her bed on the early morning of 11/07/10: "Resident found sitting on bottom in the floor beside floor. Resident stated 'I want to use the commode.' 'I'm not hurt.' " A nursing note, dated 11/08/10 at 4:10 a.m. (quoted verbatim), stated:"... Resident fall on 11/07/10 2300-700 (11:00 p.m. to 7:00 a.m. shift). ... Resident resting with eyes closed. No acute distress not=ed (sic) ... No complaints voiced. No grimacing noted. Communication of concern or assessment to physician: None at this time. Physician Response or Order given: None at this time. Physician Response or Order given: None at this time. Communication of physician's response or order: None at this time. Patient / Health Care Decision Maker Notification: None needed at this time." A subsequent nursing note, dated 11/09/10 at 4:01 a.m. (quoted verbatim) stated: "... Previous fall. ... Resident resting quietly at present, with eyes closed. Bed in decreased position with call light within reach. 0 s/s of distress observed. 0 pain verbalized thus far this shift. ... Continue to observe. Bed alarm present and active. CNA monitoring q1hr (every hour). Redirection to use call bell when needing assistance and ambulation for any reason. ..." -- 6. Review of her previous MDS, a comprehensive assessment for a significant change in status, with an ARD of 11/14/10, revealed the BIMS was not completed, as the resident, at that time, was rarely / never understood. In Section C0700, the assessor noted the resident had problems with both short and long-term memory, she was oriented to person only, and her cognitive skills for daily decision-making were moderately impaired. In Section C1300, the assessor noted she exhibited inattention and disorganized thinking (both encoded 2, meaning "Behavior present, fluctuates"). The assessor also noted, in Section C1600, that this represented in acute change in her mental status from the resident's baseline. In Section G, the assessor noted the resident required the extensive physical assistance of one (1) person for bed mobility and two (2) or more persons for transfers and toilet use. In Section G0300, testing for balance could not be completed, and in Section G0400, the assessor noted the resident had impairments in range of motion of upper and lower extremities on both sides. In Section I, in addition to the previously stated diagnoses, the assessor also noted the resident's current functional status was affected by the following Diagnoses: [REDACTED]. In Section J1800, the assessor noted the resident had experienced falls since admission, and in Section J1900, the assessor noted the resident had one (1) fall with no injury. In Section V0200, the assessor indicated that falls would be addressed on the resident's care plan. -- 7. Review of the care plan that had been reviewed / revised after the 11/14/10 MDS (and after the 11/07/10 fall) revealed the following (quoted below as recorded in the record) the following problem statements: - "ADL (activities of daily living) performance requires extensive assist, Parkinsons, tremors." The goal was: "Patient will maintain adequate level of function." Interventions included: "Fall Risk." (These were all dated as having been initiated on 09/13/10.) - "(PATIENT has experienced an actual fall with no injury noted at the time." The goal was: "Patient will resume usual activities without further complication through the review date." The interventions were: "RISK OF INJURY FROM FALL:alarms to bed and w/c staff she needs assistance. Continue interventions on the at-risk plan. Monitor / document / report PRN (as needed) x 72h (72 hours) to physician for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation." (These were all dated as having been initiated on 11/09/10. No "at-risk plan" was found elsewhere in the comprehensive care plan.) -- 8. Further review of the resident's medical record revealed [REDACTED]. A nursing note, dated 08/23/10 at 2:30 a.m. (quoted verbatim), stated, "Residents bed alarm sounded - two CNA's (nurse aides) and a nurse went to check on resident. Resident found on (R) (right) side of bed in floor, head was under chair and (L) (left) arm was under residents back. Resident states she doesn't recall what happened or how she fell in floor. (R) side of cheek is reddened and (L) elbow has small bruise on it. ... Moves all extremities freely. Residents POA (power of attorney) notified - (name of daughter) @ 225 AM (2:25 a.m.). Dr. (name) notified @ 215 A (2:15 a.m.) Will cont (continue) to monitor ..." The next consecutive nursing note, dated 08/23/10 at 4:45 a.m., stated: "Resident resting /c (with) eyes closed. Has attempted to get up /c out assistance - redirected resident to use call bell when wanting to get out of bed for any reason ... " -- 9. Review of the care plan developed after the fall on 08/23/10 revealed the following problem statement (which was created on 08/30/10): "Has fallen with risk of further falls due to weakness, confusion, transfers without help." The goal was: "Resident will be free from falls with fx (fracture) or injury requiring a hospital visit through this review." The interventions were: "Transfer with 1 assist to w/c with no skid matt. Therapy to work with resident for safety, transfers, mobility and ambulation as well as simple grooming. nursing monitor for any med (medication) changes for cognitive changes, dizziness, lethargy. bed alarm and chair alarm to alert staff assistance is needed." The following intervention was handwritten on the care plan after it had been printed, although the entry was not dated: "Special pressure sensitive call light / nursing. " -- 10. Resident #48 participated in physical therapy in the summer of 2010. According to Employee #88 (physical therapist), the resident's original goal consisted of rehabilitation and then returning home. However, she had declined, and the goal changed. The physical therapist said the therapy department had Resident #48 on their case load in the summer of 2010 but stopped working with her around September 2010. She had made progress and walked some with a walker at that time. However, that progress did not last as she declined after discharge from therapy. After September 2010, Resident #48 received speech and occupational therapy to work on positioning in her wheelchair and on positioning during meal time. The physical therapist said her department did not screen the resident following the 11/07/10 fall, because she was not currently on their case load at that time. -- 11. On 03/09/11 at approximately 1:00 p.m., the clinical care supervisor (Employee #78) reviewed the resident's medical record and stated she was not sure why the facility had not ordered floor mats for the resident after the 11/07/10 fall from bed. She stated she thought the family had said they did not want the mats, because they were afraid they would trip over them while visiting with her. However, no documentation of this statement attributed to the family was located in the resident's medical record or on the facility's 24-hour daily report. -- 12. Resident #48's active [DIAGNOSES REDACTED]. She required extensive physical assistance from staff with her activities of daily living due to the tremors associated with her Parkinson's disease. She had periods of confusion and disorientation and chronic pain. When she sustained a fall from bed without an injury on 08/23/10, her care plan was revised to include treatment by therapy staff to address safety, transfers, mobility, and ambulation. Her care plan also referenced the use of bed and chair alarms and the provision of a pressure sensitive call light. Resident #48 sustained a second fall from her bed on 11/07/10. In the months prior to this fall, the resident had been discharged from physical therapy. After the fall occurred, no interventions were added to her care plan that would prevent falls from bed and/or reduce the likelihood of injuries from such falls. On 01/31/11, Resident #48 sustained the third fall from her bed, which resulted in fractures of her T-4 vertebra and facial bones. After this third fall, which resulted in major injuries, the facility implemented the use of bed bolsters and floor mats. The resident has not fallen from bed since the bed bolsters were initiated. -- Part II -- Based on observation and staff interview , the facility failed to provide a resident environment as free as possible of accident hazards. Unlocked storage cabinets located in common bathing areas contained hazardous materials, including razors, medications, and hygiene supplies labeled for external use only. The unrestricted access of these items posed the potential for more than minimal harm to more than an isolated number of residents (especially residents who were independent in locomotion with impaired cognition). Facility census: 55. Findings include: a) Resident central shower areas 1. During the initial tour of the facility on 03/06/11, the following potentially hazardous items were observed in the common shower areas on C-hall: a. In the women's shower area in an unlocked cabinet (the cabinet was equipped with a lock): - A bottle of Nystop (Nystatin) powder labeled for external use only. The medicated powder was a prescription item and had a pharmacy label indicating it was for Resident #36. - Two (2) boxes of ten (10) Dawn Mist Disposable 3 Blade Razors. - Bottles of Selsun blue shampoo and Rugby anti-dandruff shampoo which bore manufacturers' labels for external use only. - b. Among the many things stored in the Century tub, located between the men's and women's central shower areas, were two (2) bottles of Rugby anti-dandruff shampoo (blue formula) labeled for external use only. - c. In the men's shower area in an unlocked cabinet (the cabinet was equipped with a lock): - Three (2) boxes of razors, Selsun Blue shampoo, and one (1) ounce bottles of after shave. - A bottle of Ammonium Lactate 12% with a prescription label for Resident #6. The bottle was labeled for external use only. -- 2. On 03/09/11 at 1:15 p.m., the shower areas were again checked accompanied by the life safety surveyor and Employee #84 (the facility's environmental coordinator). The cabinets were again found unlocked. The bottle of Nystop (Nystatin) powder was still in the cabinet. Employee #84 agreed the medication should not be in the shower room. She took the bottle to the director of nursing's office immediately. By virtue of the medicated powder being in a common area in an unlocked cabinet, it could be accessed by ambulatory residents, could be applied to someone for which it was not ordered, and did not meet the requirements for storage of medications. (See also citation at F431.) The other items, previously noted on 03/06/11, were also still found in the cabinets, with the exception of the Ammonium Lactate for Resident #6. -- 3. On 03/15/11 at 12:27 p.m., the shower rooms were again checked. The non-prescription items found on previous visits remained in unlocked cabinets. On this occasion, a bottle of Nizoral Shampoo labeled for external use only and bearing a prescription label for Resident #62 was also found. -- 4. On 03/15/11, at 12:50 p.m., the administrator was informed of these findings. She locked the cabinets at that time. .