Every finding on record at Four County Health and Rehabilitation

Based on observations, staff interviews, and review of the facility's policy titled, Food Safety for External Sources, the facility failed to properly store, label, date, and discard food items in the kitchen. The deficient practice created a potential risk of foodborne illnesses for 64 of 67 residents who received an oral diet from the kitchen.Findings Include: Review of facility provided document titled, Receiving dated 08/2025 documented, All items: LABEL PRESENTReceive dateExpiration date or utilize the package dateIf removed from the original box or package, label must state the common name and mfg {manufacturer} date; along with receive and expiration dateWe follow FIFO {First in first out}If expiration date is not located on the item, the expiration date should be from the mfg date, not the receive dateExpiration may be located on the product, not the box containerMfg dates are located on {Food Supplier Name} website.During the initial kitchen tour on 08/07/2026 at 7:43 AM, revealed in the dry storage area, 20 white potatoes with expiration date 07/28/2026, 100 red potatoes with expiration date 07/28/2026, three 24 ounce (oz) packages of gelatin mix with an expiration date of 07/08/2026, and eight 24.5 oz. packages of flour tortillas with an expiration date of 07/29/2026, one 1.36 liter (L) apple juice nectar consistency with expiration date 07/08/2026. Observation in the kitchen revealed yellow rice 16 quart (qt) container with expiration date of 08/05/2026. One 12 qt. container with puree rice with the expiration date 07/21/2026, and one 16 qt. container of puree corn with expiration date 08/01/2026.The walk-in cooler/refrigerator was inspected and revealed one opened 80 oz. bag of parmesan cheese with expiration date 08/06/2024. The Dietary Manager (DM) confirmed all expired, unlabeled, and undated food items.Observation on 08/07/2026 at 12:51 PM, above the preparation table and between the steamtable revealed a liquid substance dripping from ceiling and air unit onto pots and pans.On 08/09/2026, at 11:38 AM, an interview with the DM revealed that all kitchen staff were responsible for verifying food labels, expiration dates, and the dates for opening and discarding items. The Dietary Manager confirmed the liquid substance had been a concern since she started in June.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Self-Administration of Drugs, the facility failed to ensure one of 32 sampled residents (R) (R30) did not have unauthorized, unsecured medications at the bedside. This deficient practice had the potential for unauthorized access to medications by other residents and visitors in the facility.Findings include:Record review of the facility policy titled, Self-Administration of Drugs dated 2020 documented, Intent: It is the intent to promote safe medication administration practices for patients that choose to self-administer medications. Documented in Procedure: Should the patient wish to self -administer his or her own drugs or medications, the patient should be permitted to do so. Drugs and medications should be stored in a safe and secure place designated by the Director of Nursing Services. The care planning team should assess each patient's mental, physical, and visual ability to determine if the patient is capable of self-administration of drugs and medications. Should the care planning team determine that the patient is unable to carry out this responsibility, due to safety concerns, the patient should not be permitted to self-administer his or her drugs or medications. A review of electronic health record (EHR) for R30 revealed the following diagnoses, but not limited to, unspecified atrial fibrillation, essential (primary) hypertension other hyperlipidemia, type 2 diabetes mellitus without complications, heart failure, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, unspecified, unspecified systolic (congestive) heart failure, and chronic kidney disease, stage 3.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R30 presented with a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairments.An observation on 08/07/2026 at 9:40 AM of R30's room revealed the following over the counter/prescription medications sitting in a 3-tier clear plastic container and on the resident bedside table. All the medications were visible to staff and visitors entering the resident room. The medications included the following: a jar of VapoRub cough cold medication, a tube of Fluorouracil cream 5% (percent), cough drops, a bottle of 1 ounce nasal spray pump mist, a bottle of magnesium glycinate 200mg capsules, a bottle of Equate hair, skin, nails gummy vitamin pills, a bottle of Women 's 50 multi fruits and vegetables dietary supplement pills, four tubes of Equate menthol vapor nasal inhaler, bottle of Rolaids, bottle of Tums, a tube of Pimecrolimus cream 1%, an inhaler , and a box of Mucinex DM pills.During an interview with R30 at the time of the observation on 08/07/2026 at 9:44 AM, R30 confirmed that she was not approved to keep medication in her room. R30 verified she did not receive any education or training from staff and that she took her medications as needed.A review of clinical records for R30 revealed an omission of a completed assessment to determine whether the resident was capable of self-administration of medications.A review of R30's care plan revealed no focus area for self-administration of medications.During an interview and observation in the room of R30 on 08/07/2026 at 4:22 PM with the Director of Nursing (DON), the DON confirmed the medications were in the resident's room. The DON stated that R30 could not self-administer the medications without supervision. She stated that staff were aware of prior incidents where R30 had unauthorized medications in her room.

Based on record review, staff interviews, and review of the facility policy titled, Best Practices for PASRR, the facility failed to ensure that one resident (R) (R61) was evaluated for level two PASRR (Preadmission Screening and Resident Review) specialized services by the appropriate state-designated authority. The deficient practice increased the potential that R61 would not meet the highest practicable psychosocial well-being.Findings include:Review of the undated facility's document titled, Best Practices for PASRR, documented including, but not limited to the following: There are two areas a person can be a PASRR patient: SMI (Significant Mental Illness or ID/DD Intellectual Disability/Developmental Disability). In each of these areas there is a subcategory: Requires Services or Does Not Require Serv (Often says: Lesser intensity services, or no services needed) The SSD should maintain an active, ongoing, and current list of PASRR patients. The list should contain at a minimum, the Patient's Name, SMI or ID/DD, if they require Services or Do Not Require Services.In addition, documented on the second page, There are times a patient is admitted to our Centers with a level 1 that does not include all Mental health diagnoses. As we learn more about our patients and provide care, new diagnoses may develop that were not on the Original Level 1s. and When you work the monthly audit, you may discover the need to resubmit a level 1 . Review of the clinical record revealed R61 was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses included, but not limited to, dependence on renal dialysis, chronic obstructive pulmonary disease, and chronic diastolic (congestive) heart failure. On 12/05/2025, R61 was diagnosed with major depressive disorder. On 05/03/2026, R61 was diagnosed with bipolar disorder.Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], documented R61 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Review of the Care Plan for R61 dated 07/09/2026 documented a Care Area: Mood disturbance/change in mood. Goal: Patient will have/report decreased episodes of anxiety through the review period. Interventions: Social Service referral.During record review of the Preadmission Screening/Resident Review (PASRR) Level two list updated 07/29/2026 revealed R61 was not listed.Record Review of PASRR Level one dated 10/18/2023 revealed the Level one was approved with physician signature.Record Review of PASARR Level one dated 08/08/2026 revealed pending.During an interview conducted on 08/08/2026 at 12:32 PM, the Social Service Director (SSD) stated that she has not received training from the regional office concerning the completion of the PASRR.On 08/08/2026, at 12:34 PM, the Minimum Data Set (MDS) Director indicated that she is responsible for the submission of PASRR until SSD coverage is established. The MDS Director confirmed R61 had a diagnosis of bipolar disorder and major depressive disorder, but a new Level one was not submitted.An interview held on 08/08/2026, at 1:27 PM with the Administrator revealed that a new PASRR Level one to be screened for Level two services had not been submitted. The Administrator confirmed R61's diagnoses and stated that she was admitted to the facility in 2023, noting that her qualifying diagnosis was absent. The Administrator indicated that a follow-up should have been provided by the previous social worker, who was not clinical and thus overlooked this matter. The new social worker is not familiar with the procedure for submitting PASRR applications. The Administrator stated that a new PASRR Level one has been submitted with the updated qualifying diagnosis.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled ADL Plan of Care, the facility failed to provide Activities of Daily Living (ADLs) care pertaining to showers and/or bed baths for two of 17 sampled residents (R) (R35 and R54). The deficient practice increased the risk to compromise the dignity and psychosocial well-being for R35.Findings include: A review of the facility policy titled, ADL Plan of Care review dated 12/27/2025, documented under Intent: Develop and communicate patient needs for assistance with ADLs. 1. A review of the clinical record for R35 revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including, but not limited to, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4, orthostatic hypotension, heart failure, chronic pain syndrome, primary insomnia, seborrhea capitis, benign prostatic hyperplasia with lower urinary tract symptoms, major depressive disorder. The record review of R35 revealed quarterly Minimum Data Set (MDS) assessment dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 13, which indicated little to no cognitive impairment. Section GG documented R35 was dependent for toileting hygiene, shower/bathe self, put on/take off footwear, lower and upper body dressing. A review of R35's care plan initiated on 07/29/2025 and updated on 08/08/2025, documented in care area Self-care deficit needs assistance with all functional ADLs. Goal: Resident will receive appropriate level of assistance with ADLs and needs will be met throughout the review period. Interventions: Assist with ADLs as needed. Provide cues as needed. In addition, documented in care area Skin breakdown: at risk for/actual Seborrhea Capitis. Interventions: Inspect skin during care and bathing and report any changes to charge nurse. A review of R35's physician orders dated 01/09/2026, ketoconazole 2 % (percent) Shampoo (KETOCONAZOLE) 1 Shampoo topically Tuesday, Friday on Night Shift Shampoo scalp, beard, behind ears, and any other scaly plaque areas twice weekly during routine bath. Dx: Seborrhea capitis. A review of R35's electronic health chart regarding bathing and physical functioning instructions, dated 08/07/2026, recorded in the 'task' section indicated that Certified Nurse Assistant (CNA) FF did not document any bathing or showering activity. A review of R35's shower sheets dated for the last three months revealed two shower sheets for June and July dated 06/10/2026, 06/24/2026, 07/11/2026, and 07/25/2026. No shower sheets were provided for the month of August. During the initial screening interview on 08/07/2026 at 10:02 AM, R35 disclosed that he does not take showers. An interview conducted with the Director of Nursing (DON) on 08/08/2026, at 1:59 PM, confirmed that R35's Hall was scheduled for showers on Tuesday and Friday. The DON indicated that the CNA FF recorded the functional abilities and skin assessment for R35 on 08/07/2026, which suggested that CNA FF had completed the bathing process. The DON confirmed that CNA GG was assigned to R35 on the scheduled shower/bath day. The DON stated that if it was not documented it was assumed that it did not happen. A follow-up interview was held on 08/08/2026, at 2:26 PM, with R35 and he indicated that he did not receive his scheduled shower for Friday night. He was aware that he was supposed to have a shower, but no alternative was offered, nor did he decline his shower. On 08/08/2026, at 2:32 PM, an interview with CNA FF confirmed that she did not provide R35 a shower nor bed bath as he received service with night shift CNAs. A phone interview conducted on 08/09/2026 at 7:10 AM with CNA GG confirmed she was assigned to R35 on 08/07/2026, during which she did not provide a shower or bed bath. CNA GG stated that she did not offer any bathing options and could not provide a reason for this omission. She stated that she gave R35 a shower on 08/04/2026 but failed to document it on the shower sheet or in the electronic system due to a malfunction. 2. Review of the Quarterly MDS assessment dated [DATE], revealed R54 had a BIMS score of 15, which indicated little to no cognitive impairment. Section GG revealed R54 required substantial/max assist with bathing. Interview with R54 on 08/07/2026 at 8:55 AM revealed, she did not get a shower the past Tuesday as scheduled, and it happened frequently. She stated she preferred a shower in the afternoon after she has a bowel movement. R54 stated that when she missed a shower, she had to wait until the next scheduled shower day to get a shower. Record review revealed the only documentation of showers was on 06/26/2026 and 07/10/2026. Interview with the DON on 08/08/2026 at 2:30 PM confirmed there was no additional documentation that showers were given. Interview with CNA CC on 08/09/2026 at 9:32 AM revealed that she gave the resident showers if it fell on her shift and R54 had never refused any care that she offered.

Based on observations, record review, staff interviews, and review of facility policy titled, Assessment and Treatment of Pressure Ulcers/Injuries, the facility failed to identify a change in wound condition for one resident (R) (R10) of three residents with pressure ulcers. The facility's failure placed the resident at risk for wound deterioration and delayed necessary modifications to the treatment plan.Findings include:Review of the facility policy titled, Assessment and Treatment of Pressure Ulcers/Injuries, dated 12/27/2025 revealed it is the intent of the facility to provide a comprehensive assessment of the resident's clinical condition to identify potential risk for pressure ulcer/injuries (PU/PI) development and implement a plan of care to prevent pressure ulcer/injury development unless the resident's medical condition demonstrates that it was unavoidable and that the facility provides care and services consistent with professional standards of practice including but not limited to:A resident having a PU/PI will receive necessary treatment and services to promote healing, prevent infection and prevent PU/PI from developing if consistent with overall clinical condition and individualized goals of care.The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented R10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. R10 diagnoses including, but were not limited to, diabetes mellitus and malnutrition. Section M: Skin Conditions documented that R10 had one stage 2 pressure ulcer and one stage 3 pressure ulcer that was not present on admission.Review of the Physician Orders dated 05/29/2026 revealed foam on Tuesday, Friday day shift, clean feet with normal saline. Pat dry. Apply foam heel protectors for protection only.Observation of the treatment on 08/07/2026 at 2:30 PM revealed Licensed Practical Nurse (LPN) BB removed the dressings from each heel separately, cleaned with normal saline, and applied new dressing. Each heel was done separately. No open wound was noted to the right heel, and an open area was noted to left heel with drainage. During the treatment, LPN BB confirmed there was no open wound to right heel, and there was an open wound to the left heel. LPN BB took no further action related to the open wound on the left heel. R10 refused to wear heel protectors.Review of the clinical record revealed there was no weekly wound documentation since 05/29/2026, when the wound to left heel was noted to be resolved.Review of weekly Skin Data assessment dated [DATE], documented no wounds. However, Skin Data assessment dated [DATE] documented location of wounds, left and right heels.Interview with the Director of Nursing (DON) on 08/08/2026 at 2:30 PM revealed that they do not currently have a wound nurse. She stated the floor nurses do the treatments, and the LPN Supervisor conducts the weekly wound assessments. She stated she expected the floor nurses to notify the LPN Supervisor or DON of new wounds or changes in the condition of the wound. Interview with the LPN Supervisor AA on 08/08/2026 at 2:45 PM revealed that the wound was resolved in May 2026 and immediately assessed the heels when informed of the new open area on the left heel. Interview with LPN Supervisor AA on 08/09/2026 at 9:45 AM revealed the floor nurse should have done a COC (change of condition) form at that time the wound was observed and notified the physician.Review of the Weekly Wound Report completed 08/08/2026 revealed the wound to the left heel was a stage 2 measuring 2.3 centimeters (cm) x 2.5 cm x 0.1 cm.

Based on observations, staff interviews, record review, and review of the facility's policies titled Medication Administration-General, Controlled Substance Medication Accountability, and Insulin Administration, the facility failed to ensure medications and biologicals were stored securely on three of six medication carts (100 Hall, 200 Hall, and 300 Hall), failed to ensure controlled medications were signed out at the time of administration on one of six medication carts, and failed to ensure medications were labeled when opened on one of six medication carts. These deficient practices created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals, had the potential to place residents at risk of receiving inaccurate dosages of medications, and had the potential to place residents at risk of receiving incorrect medications. Findings include: Review of the facility's undated policy titled Medication Administration-General, documented Intent: To facilitate that medications are administered as prescribed, in accordance with good nursing principles. Review of the facility's undated policy titled Controlled Substance Medication Accountability documented Intent: To establish a method for accountability and reconciliation of controlled medications. Guidelines: Controlled medications are tracked from the time they are received in the center through administration, discontinuation, discharge, and/or destruction. Procedure: When a routine controlled medication is administered, the licensed nurse administering the medication will promptly enter the following information on the Medication Administration Record (MAR) and the Controlled Drug Record Sheet (count sheet sent from the pharmacy): Date and time of administration. Amount administered. Initials of the nurse administering the dose. Review of the facility's undated policy titled Insulin Administration documented Intent: To administer correctly and safely administer insulin. Insulin is a high-alert medication that can be associated with significant patient harm when used/administered in error. Guideline: Nursing should double-check all insulin therapy before administering and be certain that the correct insulin is identified and used. Date insulin bottles and pens with date of first puncture or date removed from refrigerator. Depending on the manufacturer's recommendations, insulin MUST be replaced 10 to 56 days after first use. Administration as follows: Patient name and drug order is checked and double-checked. 1. Observation on 4/30/2025 at 8:54 am revealed Certified Medication Assistant (CMA) CC left a medication cup with five tablets on the medication cart unattended for two minutes when he went to ask a nurse about medication for a resident. Observation further revealed there were residents ambulating along the 200 Hall, and they passed closely to the medication cart with the medication cup on top, containing the tablets. In an interview on 4/30/2025 at 8:56 am, CMA CC confirmed he left a medication cup with five tablets in the cup on the medication cart on the 200 Hall unattended when he went to ask a nurse about medication for a resident. He stated he should not have done that because a resident could pick up the pills and take them. In an interview on 4/30/2025 at 3:13 pm, Unit Manager (UM) BB stated that medications should not be left unattended on medication carts or anywhere in the facility. She stated that the nurses and CMAs were responsible for ensuring medications were secured. UM BB further stated that the residents could take the medications off the cart and experience adverse reactions to the medications. In an interview on 4/30/2025 at 3:20 pm, the Director of Nursing (DON) stated her expectations were for the nurses and CMAs to ensure medications were not left unattended on medication carts. She stated that a negative outcome would be that the residents could take the medications and be affected negatively, such as having a decline in their condition. 2. During a concurrent observation and interview on 4/30/2025 at 1:20 pm, during review of the 200 Hall Nurse's Medication Cart, observation revealed an open glucometer strip vial with no open date. The label on the glucometer strip bottle documented Discard any remaining test strips over three months after first opening the vial. Licensed Practical Nurse (LPN) DD was present during the review, and she confirmed there was no open date on the glucose strip vial. She stated there should be an open date because the strips will not be good after a certain time after the vial was opened. Observation on 4/30/2025 at 1:39 pm during review of the 300 Hall Medication Aide Cart revealed one opened vial of glucometer strips with no open date. Observation on 4/30/2025 at 1:54 pm during review of the 100 Hall Medication Aide Cart revealed one opened vial of glucometer strips was found with no open date. In an interview on 4/30/2025 at 1:31 pm, UM BB stated glucometer strip vials should have open dates because after opening them, they were not to be used after 90 days from when they were opened. UM BB further stated that a negative outcome could be that the residents could have false blood sugar readings, and the residents could be overmedicated. In an interview on 4/30/2025 at 1:52 pm, CMA EE confirmed the glucometer strip vial did not have an open date on the vial. She stated the vial should have an open date when it was opened, and she was responsible for placing the date on it, but she did not. CMA EE further stated that when there was no open date on glucose strips, it meant that if the strips were used, they could give a wrong reading, and it would not be effective for the residents, and the residents' blood sugar could be inaccurate. In an interview on 4/30/2025 at 3:21 pm, the DON stated her expectations were for the opened glucometer strip vials to have opened dates. She stated the strips were discarded 30 days after they were opened, so an open date was needed. The DON further stated that if the strips were used on the residents, there could be false readings. 3. Review of the Physician's Notes dated 7/27/2021 for R30 documented included but not limited to Hydrocodone 5 mg (milligrams)-acetaminophen 325 mg tablet (hydrocodone bitartrate/acetaminophen) one tablet by mouth three times per day. Review of the Physician's Notes dated 4/14/2023 for R9 documented included but not limited to Lacosamide 10 mg/ml oral solution (lacosamide) 20 mg/ml by mouth two times per day. Observation on 4/30/2025 at 1:23 pm during review of the controlled substance book on the 200-Hall Nurse's Cart revealed there were two missing signatures. LPN DD was present during the review, and she stated she did not sign the narcotics book today after she administered narcotics to two residents between 9:30 am and 10:00 am this shift. LPN DD confirmed it was almost four hours since she administered the medications, and she stated she should have signed the narcotic sign-in sheets immediately after administering the medications to the residents. LPN DD stated that because she did not sign, the residents could get additional doses of the narcotic because the nurse may think she had not given the narcotic already and give it again. She also stated the narcotic count could be off, and the oncoming nurse may not be able to account for it. Record review of the facility's Control Drug Record revealed no signature for LPN DD for narcotics administered on 4/30/2025 for R9 and R30. In an interview on 4/30/2025 at 1:23 pm, UM BB stated that after the narcotics were taken out of the packet, the nurse should have signed the narcotic book because narcotics were controlled substances and the count would be inaccurate. In an interview on 4/30/2025 at 3:22 pm, the DON stated her expectations were for the nurses to immediately sign in the narcotic sign-out sheet when they administer narcotics to the residents or sign as soon as possible. She stated a resident could receive a double dose if a medication was not signed out. 4. Observation and interview on 4/30/2025 at 1:54 pm revealed one open insulin pen was without a resident name, label, or open date. CMA EE confirmed the insulin pen had no name, and no open date was in the medication cart. She stated she was responsible for ensuring the insulin pen had a resident's name and open date on it. She stated she should have removed it from the cart. In an interview on 4/30/2025 at 2:05 pm, UM BB stated insulin pens should be labeled with the resident's name and have an open date. She stated it was the responsibility of the nurses and CMAs to ensure insulin pens were labeled with the resident's name and open date. UM BB stated some insulin pens are not effective after 28 days of opening such as the short acting insulin pens and not effective after 42 days after opening such as the long acting insulin pens so not having an open date means no one would know when it was opened and it won't be effective to the resident if it was administered. UM BB also stated it would be an infection control issue because insulin pens are for personal use, and if more than one resident shared the pen, there could be cross-contamination, and the residents could get an infection. In an interview on 4/30/2025 at 2:54 pm, the DON revealed her expectations were for the Nurses and the CMAs to ensure the name of the resident and the open date were on the insulin pens. She stated this would prevent the use of another resident's insulin pen. She also stated it was an infection control issue if insulin pens were shared, and that could cause infection in the residents. The DON stated that if there was no open date, no one would know when it was open, and the strength of the insulin may become ineffective.

Based on observation, staff interviews and review of the facility's policies titled Medication Administration-General, Hand Hygiene and Infection Prevention and Control Program, the facility failed to practice hand hygiene by not sanitizing hands between residents during medication administration. This deficient practice had the potential to cause infection to the residents. Findings include: Review of the facility's undated policy titled Medication Administration-General revealed, Intent: To facilitate tat medications are administered as prescribed, in accordance with good nursing principles. Review of the facility's policy titled Hand Hygiene reviewed 12/27/2024 revealed, Intent: It is the intent of this facility to promote and facilitate appropriate hand washing as set forth by the guidelines of CDC. Purpose: Hand Hygiene is the single most important means of preventing the spread of infection. Guideline: Associates should use alcohol-based hand rub or wash hands with soap and water for the following indications: .After touching a patient or the patient's immediate environment. Review of the facility's policy titled Infection Prevention and Control Program reviewed 12/27/2024 revealed, Intent: Each center will 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. Observation on 4/30/2025 at 8:54 am revealed, the Certified Medication Assistant (CMA) CC did not sanitize his hands after he administered medication and left a resident's room, before proceeded to prepare medications for other residents. Interview on 4/30/2025 at 8:54 am with CMA CC confirmed and verified that he did not sanitize his hands after he administered medication and left a resident's room, and before he proceeded to prepare medications for other residents. He stated he should have sanitized his hands, and he did not. He further stated the residents would get infections when he did not sanitize his hands. Interview on 4/30/2025 at 3:12 pm with Unit Manager (UM) BB revealed the nurses were expected to hand sanitize between administering medications to each resident. She stated it was in infection control issue and if it was not done, the residents could get germs and get infections. Interview on 4/30/2025 at 3:20 pm with the Director of Nursing (DON) revealed she stated her expectations were for the staff to ensure hand hygiene was performed between residents. She stated that infection could be carried from one resident to another and cause a decline in the resident's medical status.

Based on staff interview, record review, and review of the policy titled Changes in a Patient's Condition, the facility failed to ensure that the Responsible Party was notified of a decline in a pressure ulcer for one resident (R) R#1) from a total sample of three residents. Findings include: The facility had a Changes in a Patient's Condition policy, dated 12/4/21. The policy included that nursing services should be responsible for notifying the patient, next-of-kin, or responsible party/patient representative of changes to a patient's plan of care or treatment plan. However, facility nursing staff failed to notify Resident (R)#1's responsible party of a change in a pressure ulcer in a timely manner. Review of R#1's clinical record revealed that a stage II pressure ulcer to the right lateral ankle was identified on 6/23/22. Further review of the clinical record, including the Weekly Wound documentation revealed that the pressure ulcer was assessed weekly. On 8/3/22, the weekly wound assessment documented a change in the pressure ulcer from a stage II to a stage III. Registered Nurse (RN) BB documented in an 8/3/22 note that the pressure ulcer had progressed to a stage III with light bloody drainage and slough present in the wound bed. The note further included that the physician was notified with new orders received. However, there was no evidence that R#1's responsible party was notified of the decline in the pressure ulcer and new treatment plan. During an interview on 10/18/22 at 4:10 p.m., the Director of Nursing (DON) stated that she did not see R#1's responsible party was notified of the change in the pressure ulcer on 8/3/22.

Based on observation and staff interviews the facility failed to ensure that trash was not placed in the self-extinguishing can that cigarette butts were disposed of on three of three days of smoking observations. Findings include: During an observation of smoke breaks on 9/20/2022 at 10 a.m., 9/21/2022 at 10:20 a.m., and 9/22/2022 at 10:05 a.m. It was noted that there was trash (soda cans, empty cigarette packs, paper cups, and paper) observed in the red can which specifically stated, for ashes only in addition to cigarette butts. An interview conducted on 9/21/2022 at 10:15 a.m. with Licensed Practical Nurse (LPN) AA revealed that no one really checks the red can daily, but he is responsible for it. LPN AA stated that one of the residents must have placed these items in the red can without his knowledge. LPN AA acknowledged that nothing should be in the red can except cigarette ashes and cigarette butts. During an interview and observation on 9/22/2022 at 10:05 a.m. with Environmental Service BB revealed Maintenance and Environmental Service staff are responsible for making sure the red can is free of trash and dumped. Environmental Service BB revealed staff assigned to smoke breaks are responsible for making sure residents do not put trash in the red can with the sign that says, no trash. Environmental Service BB confirmed trash mixed with cigarette butts were in the red can. An interview and observation were conducted on 9/22/2022 at 10:10 a.m. with the Maintenance Director who revealed he was responsible for making sure the red can was free of trash and dumped. He further revealed the red can had been dumped the prior day. Maintenance Director further reported that residents continue to put trash despite the no trash sign. He verified trash mixed with cigarette butts were in the red can. An interview conducted on 9/22/2022 at 10:15 a.m. with the Administrator revealed Housekeeping and Maintenance staff are responsible for making sure residents do not put trash in the red cans and keeping it clean. The Administrator revealed he expected staff to make sure the red can is free of trash to prevent any accidents. He denied that there have been any residents burned while smoking and denied that there have been any fires in the red containers.

Based on interviews and record review, the facility failed to ensure that one resident (R) (R#3) was free from abuse, from a total sample of 13 sampled residents. Findings include: Record review revealed that R#3 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of personnel records revealed that Certified Nursing Assistant (CNA) FF was employed at the facility from 8/31/21 through 1/12/22. A review of in-service education information revealed that CNA FF had received abuse-related training. CNA FF had completed courses on Anger Management (9/30/21), Customer Service Essentials Self-Paced (8/31/21), The Elder Justice Act Self-Paced (8/31/21), Hand in Hand Module 5: Preventing and Responding to Abuse v2.0 (9/1/21), and Understanding Abuse and Neglect Self-Paced (9/1/21). A review of facility reported incidents revealed a Facility Incident Report Form, dated 1/11/22, that documented an allegation of staff to resident abuse. The form included that the allegation involved R#3 and CNA FF. A further review of the form revealed that R#3 had no injuries noted and that the physician, responsible party, and police were notified. CNA FF was also suspended pending the final investigation. A review of the accompanying investigation that included staff witness statements, police report, and a five-day summary conclusion revealed that the allegation of abuse was substantiated, and CNA FF was terminated on 1/12/22. Review of R#3's clinical record revealed a Skin Data form completed on 1/12/22 that documented no abnormal findings. Licensed Practical Nurse (LPN) GG documented in a statement that she was sitting at the nursing station and witnessed CNA FF grab R#3, pull his face mask on his face, and tell him to go to his room. After R#3 would not go to his room, CNA FF pushed the resident in his back and stood as if she was going to fight him. LPN GG documented that she yelled at CNA FF to stop and that she could not put her hands on him, and the CNA began walking down the hallway using profanity. LPN GG's statement documented that she immediately called the Administrator, who gave instructions to send CNA FF home, and the CNA left the building. Temporary Nurse Assistant (TNA) HH documented in a statement that she was standing by the nurses' desk and witnessed CNA FF walk up to R#3 and they were arguing. The statement documented that CNA FF hit R#3, and R#3 hit CNA FF back. TNA HH further documented in her statement that LPN GG told CNA FF that she could not hit R#3. During an interview on 3/29/22 at 2:35 p.m. the Administrator confirmed that he was notified of the incident between CNA FF and R#3 on 1/11/22 and instructed LPN GG to send CNA FF home. He also stated that he came to the facility and met with the police officer. The Administrator also confirmed that CNA FF was terminated the following day on 1/12/22. During an interview on 3/29/22 at 2:50 p.m., law enforcement officer II stated that warrants were issued for CNA FF. A review of the State Warrant and Mittimus documentation revealed that the charges on the warrants for CNA FF were misdemeanors and included simple assault, disorderly conduct, and cruelty to elderly. Following the substantiated abuse allegation from 1/11/22, the facility provided in-service education on abuse and residents' rights on 1/20/22.

Based on observations, staff interviews, and review of the policy titled, Skilled Inpatient Services-Housekeeping Services the facility failed to maintain a clean, sanitary environment, in the bathrooms of the following rooms 207, 211, 212, 213, 214, 215, 207, 211, 212, 213, 214, and 215 on one of three halls (200 hall). The facility census was 79 residents. Findings include: Review of a policy provided by the maintenance supervisor titled, Housekeeping Services, revealed routine cleaning of horizontal surfaces in resident care areas would be done daily, and more frequently if visible soiling occurred. Observations on 3/3/19 from 12:03 p.m. until 2:16 p.m. and observations on 3/4/19 from 9:04 a.m. until 12:18 p.m. revealed that the following bathrooms had a heavy buildup of dust on the bathroom ceiling vents or vent grates: 207, 211, 212, 213, 214, 215, 207, 211, 212, 213, 214, and 215. Interview on 3/5/19 at 10:56 a.m. with the Housekeeping (HK) Aide BB revealed he worked 7 a.m. to 3:00 p.m. HK BB revealed the floor technicians were responsible for pressure washing wheelchairs, changing and cleaning privacy curtains, taking trash to dumpsters, waxing floors, and deep cleaning, which included vents. Interview and observations on 3/6/19 at 9:39 a.m. with HK BB confirmed that the ceiling vents had a heavy buildup of dust. Interview at that time revealed HK BB cleaned the surface of the vent whenever they noticed they were dirty, and they called maintenance for deep cleaning jobs, vents were considered deep cleaning. Interview and observation on 3/6/19 at 9:45 a.m. of rooms 206, 212, 214, and 215 with the Maintenance Supervisor confirmed ceiling vents (grates) had a heavy buildup of dust. Interview at that time revealed vents were surface cleaned by housekeeping with a long-handled, hand held duster. Interview on 3/6/19 at 2:26 p.m. with the Administrator revealed he knew dust accumulated, and some build up was inevitable, but he did not expect vents to have a heavy coating of dust.

Based on record review, resident and staff interviews the facility failed to provide the Ombudsman with notification of transfer to the hospital for one resident of 35 residents (R#40). Findings include: Review of the resident's [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS) listing documented a discharge assessment for 12/8/18 and a reentry assessment for 12/10/18. Interview on 3/3/19 at 1:08 p.m. with R40 revealed that in (MONTH) he became sick and had to be sent to the hospital and was subsequently admitted to the hospital. review of the resident's medical record revealed [REDACTED]. Interview on 3/5/19 at 4:19 p.m. with the Director of Nursing (DON) revealed that the Social Service Director (SSD) had not been notifying the Ombudsman AA of hospitalization s. The DON stated that Ombudsman AA had notified the Social Service Director with a memo from the Centers for Medicare/Medicaid Services (CMS) that documented the requirements for notification of transfers. The DON also stated that apparently the SSD read the flier wrong and did not understand that the Ombudsman was to receive notification of hospitalization s. Interview on 3/5/19 at 4:48 p.m. with Ombudsman AA revealed that the facility had not been sending notices to her of residents that were transferred to the hospital. Interview on 3/6/19 at 2:03 p.m. with the DON revealed that they had did not have a policy for transfer or discharge requirements.

Based on observation and staff interview the facility failed to properly handle kitchen utensils when checking food temperatures on the steam table. The Census was seventy six (76) with twelve (12) tube fed residents. Findings include: Observation on 6/3/15 at 8:25 a.m. of stream table temperatures with dietary staff person DD revealed that during the steam table temperature checks dietary staff person DD did not wash their hands before calibrating the thermometer then placed the thermometer into the pureed eggs. Dietary staff person DD then took an alcohol prep and wiped of the food particles, opened the trash can lid with his/her bare hands and placed the alcohol prep in the trash can then again touching the lid of the trash can he/she then handled the utensil to stir the grits on the steam table, placed the thermometer in the grits, wiped it off with a alcohol prep, opened the trash can, touching the trash can lid with bare hands. Dietary staff person DD continued this practice with six (6) prepared items on the steam table. An interview at this time with dietary staff person DD revealed that before touching the thermometer and utensils staff should wash their hands and after touching the trash can lid, you should wash your hands. Continued interview with dietary staff person DD at this time confirmed that he/she should have washed their hands, then put on gloves and should not have touched the trash can lid and then touch the utensils on the steam table. An interview on 6/3/15 at 8:25 a.m. with the Dietary manager, confirmed that dietary staff DD should not touch the serving utensils on the steam table and then touch the trash can or trash can lid without washing hands their hands in between.

Based on record review, staff interview, and observation the facility failed to provide personal hygiene for one (1) resident #29 of nineteen (19) sampled residents. Findings include: Review of the facilities Minimum Data Set (MDS) annual assessment dated [DATE] revealed the resident is rarely understood and requires total assistance with all activities of daily living including personal grooming. [DIAGNOSES REDACTED]. Review of the residents Care Plan dated 8/8/14 revealed that resident #29 requires extensive to total assistance with activity of daily living (ADL's) always incontinent of bladder and always incontinent of bowel, is not a candidate for bladder training or scheduled toileting due to decreased cognition and difficulty with transfers and walking and is fed by staff. An observation on 6/1/15 at 2:21 p.m. resident #29 was observed sitting up in a high back chair in their room, hair uncombed and fingernails on both hands with dark black/brown substance underneath all nails. An observation on 6/2/15 7:58 a.m. resident #29 was sitting up in bed and a certified nursing assistant CNA was at bedside, feeding resident breakfast. Observed the resident's finger nails, of both hands, dirty with dark black/brown substance underneath nails. An observation on 6/2/15 at 1:18 p.m. of the resident sitting up in straight back chair in room with hands in his/her lap. The surveyor asked to see the bracelet he/she had on the left arm and he/she raised both arms and the finger nails on both hands had dark brown/black substance under the nails. Certified nursing assistant( CNA) AA was making the B bed in the room stated that she fed the resident lunch today and that resident #29 did not eat to much because he/she had eaten good at breakfast. An observation on 6/2/15 at 3:33 p.m. resident #29 was sitting up in a straight back chair in the room, was eating a little Debbie cake, finger nails remain dirty with dark black/brown debris under nails on both hands. An observation on 6/3/15 at 8:09 a.m. resident #29 was sitting up in bed with a CNA sitting at bedside feeding resident. Observed residents hands in lap and fingernails on both hands have dark/brown substance under all nails on both hands. An interview on 6/2/15 at 9:15 a.m. with Licensed Practical Nurse (LPN) EE revealed that the certified nursing assistants (CNAs) know what care to provide for their residents by calling into their headsets and once the CNA provides the care it is recorded into the head set where it is documented as being done. An interview on 6/3/15 at 9:29 a.m. with Licensed Practical Nurse (LPN) CC on the 200 Hall revealed residents have showers twice weekly and if the residents do not have a shower they would have a bed bath, which includes personal care. An interview on 6/3/15 at 9:39 a.m. with CNA AA revealed that he/she was assigned to the resident yesterday and today. The CNA further revealed that the resident is total care, is fed by staff in the room and that he/she had given the resident a shower the day before, 6/2/15. Continued interview with CNA AA revealed that resident is a two (2) person transfer, and can not communicate his/her needs, the staff has to anticipate the resident's needs. An interview on 6/3/15 at 9:45 a.m. with Registered Nurse (RN) BB revealed that personal care includes bathing, dressing, toileting, mouth care, nail care, and perineal care. During an interview on 6/3/15 at 10:21 a.m. RN BB revealed that the Director of Nursing (DON) does compliance rounds daily for personal grooming after which the form is shred. The DON could not provide any proof that the resident had received any nail care.

Based on record review and staff interview, it was determined that the facility failed to obtain a physician's order in a timely manner for [MEDICAL CONDITION] care and suctioning as needed for one (1)resident (#88) with a [MEDICAL CONDITION] from a total sample of twenty-seven (27)residents. Findings include: Record review of the 1/15/14 admission nursing assessment for resident #88 revealed the resident had a [MEDICAL CONDITION] that was capped on admission to the facility. Record review of the 1/15/14 admission physician's orders revealed there were no orders for [MEDICAL CONDITION] care or suctioning until eleven (11) days later on 1/26/14. The 1/26/14 physician's order instructed to provide [MEDICAL CONDITION] care everyday and as needed and to suction as needed. Review of the Medication Administration Record [REDACTED]. An interview with Licensed Practical Nurse "AA" on 3/13/14 at 12:50 p.m. revealed that they thought the resident had admitting orders for [MEDICAL CONDITION] care and suctioning but was unable to provide that documentation. She stated if a resident is admitted with a [MEDICAL CONDITION] and did not [MEDICAL CONDITION] care and suction orders then staff would have to call the physician for orders. An interview with the Director of Nursing on 3/13/14 at 10:45 a.m. she confirmed the resident should have had physician orders on admission for [MEDICAL CONDITION] care and suctioning as needed.

Based upon observation and staff interview the facility failed to ensure that insulin was discarded, once opened, after twenty eight (28) days per policy on one (1) of three (3) medication carts on one (1) of three (3) halls. Census was eighty four (84) Findings include: During observation of the medication cart for the 200 hall with Licensed Practical Nurse (LPN) "BB" on [DATE] at 5:45 p.m. revealed three (3) bottles of Lantus insulin which, per the facility policy, expires in twenty eight (28) days after opening. 1. Two bottles of Lantus had an opened date of [DATE] and should have been discarded on [DATE]. 2. One bottle of Lantus had an expiration date on the label of [DATE] During an interview with LPN "BB" she confirmed that all three (3) insulin vials had expired and should have been removed from the cart twenty eight (28) days after being opened. Interview with Registered Nurse (RN) "CC" on [DATE] at 2:20 p.m. revealed that Lantus insulin expires twenty eight (28) days after being opened and that the expired Lantus should not have been on the medication cart. A telephone interview with the dispensing pharmacist "CC" on the same day at 2:40 p.m. confirms the pharmacy and facility policy is that Lantus insulin expires after twenty eight (28) days once opened. Review of the Elder Care Pharmacy "Multi-dose packages of medication storage conditions and expiration dates reveal that all insulin, except Levemir, expires twenty eight (28) days after being opened.

Based on observation, record review, staff interview, and resident interview, the facility failed to ensure that the call light was in reach for one resident (# " A " ) from a sample of six residents. Findings include: Resident "A" had been assessed, on the current Minimum Data Set assessment, as having a BIMS score of 15 and as being able to communicate well. The resident's current ADL Plan of Care documented the resident was incontinent of both bowel and bladder, and was totally dependent on staff for activities of daily living activities such as toileting and transfers. During an observation conducted on 04/01/2013 at 4:00 p.m., the entrance door to the room of Resident "A" was almost closed and the resident could not be seen from the hallway. The surveyor knocked and requested to enter the room, and the resident acknowledged, stating that it was alright for the surveyor to enter. Upon entering the room, the resident was observed to be up in a Geri-chair which was positioned on the left side of the resident's bed. The resident was observed to be able to use her hands and arms, but could not get up from the Geri-chair without assistance. The call light had been placed by staff on the upper quarter rail on the right side of the bed and well out of reach of the resident. During an interview conducted at the time of the observation referenced above, Resident "A" stated that she uses the call light a lot and felt that was why staff had placed the call light out of reach. She requested for the surveyor to put the call light closer to her. On 04/01/2013 at 4:10 p.m., Nurse "BB" was observed to be in the hallway and was requested to observe Resident "A". This nurse acknowledged that she observed a problem with the call light being way out of reach of the resident.

Based on observation, record review, staff interview, and resident interview, the facility failed to provide the necessary care to maintain good grooming for two (2) residents ("A" and #2) from a total survey sample of six (6) residents. Findings include: 1. Resident "A" was observed on 04/01/2013 at 4:00 p.m. to have the left third finger with the fingernail being long and jagged, with a dark substance underneath. Also, the fingernails on the fourth and fifth fingers of the left hand and the first, second, third and fourth fingers of the right hand were all long and had a dark substance underneath. The resident also had dried matter between the right eyelids. During an interview with Nurse "BB" conducted on 04/01/2013 at 4:10 p.m., Nurse "BB" acknowledged that Resident "A"'s fingernails were dirty and too long, and acknowledged the dried matter between the resident's right eyelids. During an interview with Resident "A" conducted on 04/01/2013 at 5:35 p.m., the resident stated that she would not refuse nail care if offered. Review of the resident's ADL Plan of Care revealed that the resident was totally dependent on staff for bathing, and that before bathing, staff were to check the resident's entire body. However, further review of this ADL Plan of Care and accompanying documentation revealed no evidence of recent nail care being done for the resident 2. Record review for Resident #2 revealed the April 2013 physician's orders [REDACTED]. However, Resident #2 was observed on 04/01/2013 at 4:20 p.m. to have a dark substance underneath all of her fingernails. During an interview with the Director of Nursing (DON) conducted on 04/01/2013 at 5:35 p.m., the DON stated that all nail care for any diabetic resident should be done by licensed staff or a physician. Further record review revealed no record of the resident being assisted with any nail care for the last two weeks of March, 2013.

Based on observation and record review, it was determined that the facility failed to properly discard two expired vials of Lantus insulin on one (100 hall) of three medication carts. Findings include: According to the Nursing 2012 Drug Handbook, opened vials of Lantus insulin should be discarded after 28 days. The American Diabetes Association's insulin storage guidelines documented that, even though each insulin was stamped with an expiration date, a loss of potency might occur after the vial had been in use for more than 30 days. On [DATE] at 9:40 a.m., there were two vials of expired Lantus insulin stored in the 100 Hall medication cart. There was a label attached to each vial stating the vial expired 28 days after first use. The vials were dated as first used on [DATE] (39 days after opening) and [DATE] (37 days after opening).

Based on record review, it was determined that the facility failed to ensure that the attending physician wrote progress notes at each visit for 11 (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, and #12) residents from a sample of 16 residents. Findings include: 1. According to the nursing notes, the physician visited residents #1, #3, #4, #6, #8, #9, #10, #11, and #12 on 4/29/10 and 6/7/10. However, the most recent progress notes for each of those residents was dated 3/31/10. There were not any physicians' progress notes for those visits until 6/16/10, after surveyor inquiry. 2. According to the nursing notes, the physician visited resident #2 on 4/29/10. However, the most recent progress note was dated 3/31/10. There was not a physician's progress note for that visit until 6/16/10, after surveyor inquiry. 3. According to the nursing notes, the physician had visited resident #7 on 6/7/10. However, there was not a physician's progress note for that visit.