Every finding on record at Franke Health Care Center

Based on review of the facility policy, observations, and interviews, the facility failed to ensure foods were stored appropriately, and temperatures were monitor in the walk in cooler in one of one main kitchens. Findings include: Review of the facility policy titled, Food Storage, states: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 10. Food should be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall with adequate space on all side of stored items to permit ventilation. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Review of the facility policy titled, Refrigerators and Freezers, states: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 1. Acceptable temperature ranges are 35 degrees to 40 degrees for refrigerators and less than 0 degrees Fahrenheit for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. 4. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. 5. The supervisor will take immediate action if temperatures are out of range. Actions are necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. An observation on 04/17/2025 at 10:15 AM during initial tour of the facility main kitchen, revealed the following: 1) One partially eaten, opened, snack cake was observed lying on a can in the dry storage area. It was then removed by the Dietary Manager. 2) No temperature logs kept for the reach in cooler. 3) In the walk-in-cooler food in boxes was stacked less than 18 inches from the ceiling. During an interview on 04/17/2025 at 10:20 AM with the Dietary Manager, she confirmed the findings and stated she would look for the reach in cooler temperature logs. These were not provided by the end of the survey.

Based on the facility policy, observations and interviews, the facility failed to ensure one of two dumpsters were not leaking and further failed to ensure the grease trap was clean and free from spillage and an accumulation of old grease and fried food debris. Findings include: Review of the facility policy titled, Food-Related Garbage and Refuse Disposal, states: Food-related garbage and refuse are disposed of in accordance with current state laws. The Policy Interpretation and Implementation, states: 1. All food waste shall be kept in containers. 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food wastes will be stored in manner that is inaccessible to pests. 6. Storage areas will be kept clean at all times, and shall not constitute a nuisance. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. An observation on 04/15/2025 at 10:25 AM with the Dietary Manager of the dumpsters and the grease trap revealed: 1) One of two dumpsters were observed with a liquid running from under the dumpster and onto the cement surface. 2) The grease trap, was on a non-porous surface and had a large build-up of old grease that had ran down the outside and fried food particles around the lid. During an interview on 04/15/2025 at 10:26 AM with the Dietary Manager, she confirmed the findings and stated she was not aware of the liquid coming from the dumpster and stated she would have to call the company concerning the old grease and food particles left around the opening of the grease trap.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure expired and outdated medications and biologicals were removed from storage and not currently in use in 2 of 2 medication carts, 2 of 2 treatment carts and 1 of 1 med storage rooms. Findings include: Review of the facility policy titled, Storage of Medication, states: Medications and biological's are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. An observation on [DATE] at 07:50 AM of the skilled rehab medication cart revealed: Biscodyl EC 5 milligram (mg) tablets with Lot #P933476, 24 tablets was expired on ,d+[DATE]. During an interview on [DATE] at 08:00 AM with Registered Nurse (RN)1 confirmed the findings. An observation on [DATE] at 08:19 AM of the skilled treatment cart revealed: One bottle of Skin Tegrity Wound Cleanser, manufactured by Medline, 16 ounces with Lot #70238 was expired on ,d+[DATE]. One box of Hypafix measuring 5 centimeters by 10 centimeters by 2 inches by 11 yards with Lot #94751230 was expired on ,d+[DATE]. One box of Hypafix measuring 5 centimeters by 10 centimeters by 2 inches by 11 yards with Lot #93540230 was expired on ,d+[DATE]. One box of Hypafix measuring 5 centimeters by 10 centimeters by 2 inches by 11 yards with Lot #74931230 was expired on ,d+[DATE]. One box of Hypafix measuring 5 centimeters by 10 centimeters by 2 inches by 11 yards with Lot #74222230 was expired on ,d+[DATE]. One box of Hypafix measuring 5 centimeters by 10 centimeters by 2 inches by 11 yards with Lot #74640230 was expired on ,d+[DATE]. One box of Hypafix measuring 5 centimeters by 10 centimeters by 2 inches by 11 yards with Lot #93930230 was expired on ,d+[DATE]. One box of Hypafix measuring 10 centimeters by 10 centimeters by 4 inches by 11 yards with Lot #41230 was expired on ,d+[DATE]. The expired biologicals on the treatment cart were confirmed by the Director of Nursing (DON). Review on [DATE] at 08:55 AM of the long term care treatment cart revealed: One bottle of Nystop, 30 grams with Lot #2228099 was expired on [DATE]. The expired medication was confirmed by the DON. An observation on [DATE] at 09:12 AM of the one medication room for the unit revealed: One prefilled syringe of the Hepatitis B Vaccine, Engeix B 20 micrograms with Lot #D23D3 was expired on [DATE]. The medication was confirmed as expired by the DON. Review on [DATE] at 09:30 AM of the long term care medication cart revealed: One bottle of Alacone Double Strength Antacid, 12 fluid ounces with Lot #ADN022 was expired on ,d+[DATE]. This was confirmed by Licensed Practical Nurse (LPN)1. Further review of the long term hall medication cart revealed: Senna - Time, 8.6 milligram tabs, with Lot #,d+[DATE], manufactured by Time, 18 tablets were expired on [DATE]. The DON confirmed at this time, the expired tablets. An additional observation revealed: Senna - Time, 8.6 milligram tabs, with Lot#,d+[DATE], manufactured by Time, 27 tablets were expired on [DATE]. The expired tablets were confirmed by the DON.

Based on interviews, record reviews, and facility policy reviews, the facility failed to ensure that one out of one resident, (Resident 14), had a signed copy of their Power of Attorney form on Resident (R) 14 records. Additionally, the facility failed to assure an accurate code status for R20. Findings Include: Review of R14's electronic health record (EHR) revealed she was admitted on [DATE] with a diagnosis of Neurocognitive disorder with Lewy Bodies, Major Depressive Disorder, Anxiety Disorder Review of R14's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicates R14's C1000 Cognitive Skills for Daily Decision-Making Score of 3: Severely Impaired - Never/rarely made decisions. Review of R14's EHR on [DATE] 03:10 PM, R14 has an advanced directive on file Do Not Resuscitate Form (DNR) signed by her daughter. After further review of R14's EHR, no documentation on file of R14's Power of Attorney (POA) form or Decisional Capacity Form. Additional review of the EHR on [DATE] at 11:00 AM, no POA form or Decisional Capacity form found on resident's EHR. Additional review of the EHR on [DATE] 09:23 AM revealed no POA form or Decisional Capacity form on file for resident. Interview with Director of Nursing at approximately 9:00 AM at [DATE], DON states that facility attempted to contact the Hospice service to get a copy of the resident's POA form and attempt was unsuccessful as the Hospice company stated that the resident daughter had the form. Facility attempted to get a copy of the POA form from the resident's daughter, but DON states the daughter is away in the mountains with limited service. DON states that it is possible that the facility may not be able to produce R14's POA form to survey team by end of day. Interview with Director of Social Services (DSS) on [DATE] 11:58 AM, indicates that the facility screens residents on admission for their advance directives. Facility will review any pertinent documentation in regard to patient advanced directives and if properly completed facility will then upload documents to resident EHR. If residents and families need assistance with filling out Advance directive paperwork, the facility will help assist with this process. 2. Review of the undated Admission Record, provided by the facility, revealed R20 was readmitted to the facility on [DATE] with the diagnosis of hypertension, and dementia. Review of R20's admission MDS with an ARD of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating R20 was severely cognitively impaired. Review of R20's DNR Order located under the Attachments tab in the EHR revealed a DNR order dated [DATE]. Review of R20's baseline care plan dated [DATE] revealed under Code Status CPR (Full Code). During an interview on [DATE] at 12:36 PM, the DON stated, [R20] came to us from our assisted living and transferred to long term care. It [DNR] would be the same DNR that she had there [assisted living] . During an interview on [DATE] at 1:57 PM, Licensed Practical Nurse (LPN)2 stated, It [DNR] wasn't available to me when I did this care plan, and it wasn't given to me. I didn't ask the nurse I was helping. During an interview on [DATE] at 2:11 PM, the DSS stated, The DNR should be in the computer when the nurses do the admission. R20 has been here before and was a DNR then too. That information would carry over from that admission for staff to see the entire record of the previous admission. During an interview on [DATE] at 2:36 PM, the DON stated, [R20] was in long term care previously and the DNR would have been accessible to any nurse to refer back to when [R20] was admitted this time.

Based on record review, interview, and policy review, the facility failed to provide a notice of bed hold to the resident for one of three residents (Resident (R)27) reviewed for hospitalization s in a total sample of 15 residents. This failure increased the risk of residents not knowing their rights to request and the cost of a bed hold. Findings include: Review of the facility policy Bed-Holds and Returns, dated March 2022, revealed Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. the rights and limitations of the resident regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan (Medicaid residents); c. the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. the details of the transfer (per the notice of transfer) . Review of the undated Admission Record, provided by the facility, revealed R27 was readmitted to the facility on [DATE] with the diagnosis of sepsis, urinary tract infection, and diabetes mellitus. Review of R27's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15, indicating R27 was cognitively intact. Review of R27's electronic medical record (EMR) revealed R27 was discharged to the hospital on 01/13/24. There was no documentation of a bed hold notification given to the resident and/or responsible party prior to R27's transfer to the hospital on 01/13/24. During an interview on 03/05/24 at 1:30 PM, R27 stated he did not remember receiving a bed hold notice when he was sent to the hospital on 01/13/24. During an interview on 03/05/24 at 12:17 PM, the Director of Nursing (DON) stated, The nurses would document it in the nurses' notes, or they have a form that they can fill out and place in the attachments. I don't see where they documented this anywhere.

Based on record review and staff interview, the facility failed to develop an accurate baseline care plan for one of three residents (Resident (R)285) reviewed as new admissions out of a total of 15 sampled residents. This failure increased the risk for incomplete and/or inaccurate care being provided to the residents. Findings include: 1. Review of the undated Admission Record, provided by the facility, revealed R285 was admitted to the facility on [DATE] with the diagnosis of pneumonia and respiratory failure with hypoxia (low oxygen levels). Review of R285's nursing assessment, provided by the facility and dated 02/20/24 at 9:09 PM, revealed resident .alert and oriented to person, place, time, and situation with confusion . Review of R285's physician orders, provided by the facility, revealed an order for Oxygen continuous at 2 l/min [liter per minute]. This order was dated 02/20/24. Review of R285's baseline care plan completed by the Director of Nursing (DON) on 02/20/24 revealed under Respiratory Room Air. During an interview on 03/05/24 at 12:14 PM, the DON stated, I must had hit the wrong button by mistake. The DON confirmed oxygen should had been included on the baseline care plan instead of it reflecting room air.

Based on review of the facility policy, observations, interviews, and record review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure 2 of 2 residents received the proper respiratory care for R187 and R285. This failure has the potential to cause respiratory and other communicable infections/complications. Findings include: Review of the facility's Oxygen Administration Policy, revised October 2010;n revealed: Preparation-Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of R187's clinical record revealed the admitted [DATE] and the diagnoses included but not limited to; other pulmonary embolism, acute respiratory failure with hypoxia, and dementia. Review of R187's Physician Orders included: 02/29/24-Oxygen (O2) at 2 L/min continuous. Review of R187's Care Plan dated 02/29/24 revealed Care Plan: Problem: Resident is at risk for alteration in breathing pattern, Goal: Resident will have adequate air exchange as evidenced by O2 sats and no signs and symptoms of resp distress. Interventions: Meds as ordered, O2 as ordered. Review of R187's Medication Administration Record (MAR) revealed staff did not document the assessment of Oxygen saturation. Observation on 03/03/24 at 11:33 AM revealed R187 sleeping in bed, O2 was underneath R187's chin. Observation on 03/03/24 at 12:54 PM revealed R187 sleeping in bed, O2 was underneath R187's chin. Observation on 03/03/24 at 1:41 PM revealed R187 alert and eating her dessert, O2 not administered. Observation on 03/03/24 at 2:38 PM revealed R187 has a raddling cough. At this time, the Administrator went to get the nurse and the Director of Nursing (DON) came into room to check on the resident. Observation on 03/04/24 at 12:39 PM revealed R187 eating her lunch in dining room and started coughing, Certified Nursing Assistant (CNA)1 suggested R187 drink some tea or water. R187 stated, Do you think that will help?, Observation revealed the cough subsided. O2 not administered. Observation on 03/04/24 at 3:15 PM revealed R187 sitting in her room in her wheelchair watching television, O2 not administered. Observation on 03/05/24 at 8:11 AM revealed R187 being rolled down the hall by her CNA, no O2 administered. Observation on 03/05/24 at 11:44 AM revealed R187 sitting in the common area with other residents, no O2 present. During an interview on 03/05/24 at11:44 AM with R187 revealed that she did not have her oxygen on today, but she had it on last night. During an interview on 03/05/24 at 10:07 AM with Licensed Practical Nurse (LPN)2, revealed she is assigned to R187. LPN2 was told by the night nurse, the oxygen was PRN (as needed). LPN2 stated the procedure when administering medication is to pull up physician's orders in the medical record and to always follow the orders. LPN2 stated she had not looked at R187's orders at the time of the interview. LPN2 pulled up orders and verified the orders are O2-2L a minute and says continuous. During an interview on 03/05/24 at 10:14 AM, LPN3 revealed that she didn't see any orders for oxygen for R187; LPN3 stated 03/04/24 was her first day providing services for R187. LPN3 stated the night nurse verbally told her R187 was admitted the night before with a respiratory issue and a chronic cough. LPN3 stated when residents have orders for oxygen, the computer system is supposed to pull it over to the treatment section of the chart, however LPN3 stated R187 did not have oxygen in the treatment section. During an interview on 03/05/24 at 12:48 PM the DON confirmed R187 physician's orders for Oxygen (O2) at 2 L/min continuous. The expectation of the nurse is to follow the physicians' orders. 28306 2. Review of the undated Admission Record, provided by the facility, revealed R285 was admitted to the facility on [DATE] with the diagnosis of pneumonia and respiratory failure with hypoxia (low oxygen levels). Review of R285's nursing assessment, dated 02/20/24 at 9:09 PM and provided by the facility, revealed resident .alert and oriented to person, place, time, and situation with confusion . Review of the physician orders, provided by the facility, revealed an order for Continuous Positive Airway Pressure (CPAP) at hour of sleep (Starting 03/04/24 8:00 PM [sic] .Assist resident with CPAP at bedtime . Review of the comprehensive care plan, provided by the facility, revealed under Problem [R285] is at risk for alteration in breathing patterns r/t [related to] pneumonia, acute respiratory failure .wears CPAP during sleep. Under Interventions revealed .Assist resident with CPAP every bedtime . Observations were made on 03/03/24 at 1:38 PM and on 03/04/24 at 12:42 PM of the CPAP mask sitting on the bedside table not stored in a plastic bag. During an interview on 03/04/24 at 1:10 PM, Licensed Practical Nurse (LPN)4 stated, That's a CPAP mask and it should be stored in a plastic bag. During an interview on 03/04/24 at 2:54 PM, the Director of Nursing (DON) stated they do not have a policy that speaks to the storage of a CPAP mask but We treat and manage them like any other oxygen supply that isn't in use. We put it in a respiratory bag.

Based on observations and interviews, the facility failed to assure that a medication belonging to Resident (R)22 was properly stored and secured in the room of R30 for 1 of 12 residents observed during initial tour. Findings include: The facility policy on Storage of Medications, revised November 2020, states: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. , 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. and 3. The nursing staff is responsible for maintaining storage and preparation areas in a clean, safe, and sanitary manner. R30 had been admitted to the facility on [DATE] with diagnoses including, but not limited to dementia and R22 had been admitted to the facility on [DATE] with diagnoses including, but not limited to ulcerative colitis. On 3/3/24 at approximately 11:16 AM, during initial tour of R30's room, one orange, oblong pill, unlabeled as to drug content and imprinted 435 on one side was found in a clear medicine cup labeled with a sharpie type pen with the name of R22 atop the chest of drawers, located on opposite side of the room from bed. On 3/3/24 at approximately 11:23 AM, Licensed Practical Nurse (LPN)1 was asked by Surveyor to come to R30's room, where she confirmed the finding and stated R30 was not her resident and she had not been in the room today. On 3/3/24 at approximately 11:27 AM, Registered Nurse (RN)1 stated she was the nurse caring for R30 and confirmed the finding while stating that the medication was Mesalamine and belonged to R22, not R30. RN1 further stated that she had given R22 her morning dose of mesalamine earlier in the morning and that she did not place the unlabeled drug in R30s room. On 3/3/24 at approximately 11:38 AM, the Surveyor identified the orange pill imprinted 435 as Mesalamine DR (Delayed Release) 800 mg (milligram) and review of R22's March 2024 medication administration record revealed that RN1 had administered the 3/3/24-8:00 AM dose to R22.

Based on observation, interviews, and review of the facility policy titled, Catheter Care, Urinary, the facility failed to follow a procedure to prevent infection during Foley catheter care for Resident (R)23 for 1 of 1 resident reviewed for catheter care. Findings include: The facility admitted R23 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 5/4/22 at 2:15 PM of foley catheter care for R23 revealed the following: The Unit Manager, Licensed Practical Nurse (LPN)2, Certified Nursing Assistant (CNA)1 and the surveyor entered R23's room after asking permission. CNA1 explained the procedure and provided privacy. CNA1 and LPN2 washed their hands and applied gloves. The supplies were already set out on the over bed table. CNA1 then removed the bed covers and pulled down R23's pants and his brief. CNA1 then unhooked the drainage bag from R23's right leg, then she took a wipe and cleaned around the insertion site several times and using the same wipe, she continued to wipe different areas of the penis. After using the same wipe multiple times, CNA1 discarded the wipe and took another wipe and wiped over the same areas again. CNA1 then removed her gloves and washed her hands and took a wipe and wiped down the tubing 4 times, changing the wipe each time. CNA1 then removed her gloves and washed her hands and then applied gloves and took a wipe and wiped down the left and right side of the scrotum. CNA1 then removed her gloves and washed her hands and applied gloves and then applied a clean brief, and reattached the leg bag to R23's right leg, after emptying it. She then pulled up his pants and made him comfortable. On 5/4/22 at 2:35 PM, during an interview with LPN2, she was informed that CNA1 was observed using the same wipe to clean more than one area during R23's catheter care. LPN2 did not offer comment. On 5/4/22 at 2:40 PM during an interview with CNA1, she was informed that the surveyor had observed her using the same wipe to wipe several areas and some of the same areas already wiped. CNA1 did not offer comment. Review on 5/4/22 at 2:45 PM of the facility policy titled, Catheter Care, Urinary, number 16 states, Males-Using left hand, grasp penis, with right hand wash from meatus outward down the side closest to you and discard in a bag. Number 17 states, Using a clean disposable washcloth, wash from the meatus outward. Number 18 states, Repeat washing using a clean disposable washcloth each time, until all areas are clean. Number 19 states, Gently slide fingers to grasp the tube and using a clean disposable washcloth, wash down the tube about 4 inches.

Based on record review and interview, the facility failed to ensure each Certified Nursing Assistant (CNA) received the required 12 hours of annual inservice training based on their hire date for of all CNA's employed by the facility. The findings included: Review on 2/27/2019 at approximately 9:09 AM of the facility documented 12 hours of required inservice training for CNA's based on hire date indicated that all CNA's employed by the facility had not received the 12 hours of inservice training annually as required based on his/her hire date. An interview on 2/2/7/2019 at approximately 9:15 AM with the Assistant Administrator confirmed that CNA's employed by the facility had not received the required 12 hours of inservice training annually based on their hire date.

Based on interview, record review of the facility's policy titled Dietary Consideration for Resident, and review of the facility's dietary disaster plan, the facility failed to maintain the emergency food supply following its policy and disaster plan. The findings included: During an interview on 2/25/19 at 10:15 AM with the director of food and beverages, when asked to show/point out the facility's emergency food supply s/he stated the facility did not have a separate emergency food supply but the facility had enough food throughout the kitchen to provide the residents food for seven days in case of an emergency. The director also stated that the facility had a generator which would allow the facility to maintain normal functions in the kitchen and a disaster and emergency response contract with a food company. Review of the facility's policy titled Dietary Consideration for Resident on 2/27/19 at approximately 9:30 AM revealed it stated that a minimum of food and water to last for seven days shall be maintained at the facility in a specific location. Review of the facility's Emergency Preparedness Program section titled Dietary Disaster Plan on 2/27/19 at 10:20 AM revealed it stated that the emergency food supply should be kept separately from other products, dated and marked FOR EMERGENCY USE ONLY. During an interview with the Registered Dietitian on 2/27/19 at approximately 2:15 PM, s/he confirmed that the facility did not have a separate emergency food supply per its policy and disaster plan.

Based on record review, interview, and review of the the facility policy titled, Influenza Vaccine, the facility failed to ensure Resident #7 was afforded the opportunity to make his/her own decision to receive the Flu Vaccine for 1 of 5 residents reviewed for the Flu and Pneumonia Vaccine. The findings included: The facility admitted Resident #7 on 9/25/2017 with a [DIAGNOSES REDACTED]. Review on 2/27/2019 at approximately 9:58 AM of the medical record for Resident #7 revealed a form titled, Informed Consent For Influenza Vaccine, which stated, I hereby give the facility permission to administer an influenza vaccination, unless medically contraindicated. Resident #7's personal representative had given verbal consent for his/her family member to receive the flu vaccine. Resident #7 was not afforded the right to choose to receive the influenza vaccine. Review on 2/27/2019 at approximately 10:00 AM of the facility policy titled, Influenza Vaccine, revealed it stated under Policy Statement, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The Policy Interpretation and Implementation stated under number 1. Between (MONTH) 1st and (MONTH) 31st each year, the influenza vaccine shall be offered to residents and and employees and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. During an interview on 2/27/2019 at approximately 10:00 AM, the Licensed Practical Nurse Unit Manager of the 100-200 Unit stated, I called the resident's family member because he/she is their personal representative. Resident #7 had not been deemed unable to make his/her own health care decisions by 2 physicians.

Based on record review, interview, and review of the facility policy titled, Advance Directives, the facility failed to ensure Residents #22 and #24 were afforded the right to formulate an advance directive. Residents #22 and #24 were not not deemed unable to make his/her own health care decisions for 2 of 2 residents reviewed for Advance Directives. The findings included: The facility admitted Resident #22 on 7/19/2018 with [DIAGNOSES REDACTED]. Resident #22 has long and short term memory deficits. Review on 2/26/2019 at approximately 2:10 PM of the medical record for Resident #22 revealed no documentation to ensure 2 physician's has deemed him/her unable to make own healthcare decisions. Resident #22 was listed by the facility with a Do Not Resuscitate Status. The Do Not Resuscitate form was signed by a family member, therefore Resident #22 was not afforded the right to make his/her own decision for code status. The facility admitted Resident #24 on 10/18/2018 with [DIAGNOSES REDACTED]. Review on 2/28/2019 at 9:10 AM of the medical record for Resident #24 revealed no documentation to ensure Resident #24 was deemed unable to make his/her own health care decisions by 2 physicians. Resident #24 was listed by the facility with a Do Not Resuscitate Status. The Do Not Resuscitate form was signed by a family member, therefore Resident #24 was not afforded the right to make his/her own decision for code status. During an interview on 2/28/2019 at approximately 10:40 AM with the Assistant Administrator, he/she confirmed that Residents #22 and #24 had not been afforded the right to make their own decisions for code status. Review on 2/28/2019 at approximately 2:30 PM of the facility policy titled, Advance Directives, revealed it stated, Advance Directives will be respected in accordance with state law and the facility policy. The Policy Interpretation and Implementation stated, Prior to or upon admission of a resident to our facility, the social services director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care including the right to accept or refuse medical or surgical, and the right to formulate advance directives. Number 15 stated, The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument.

Based on record review, interview, and review of the facility policy titled, Bed-Holds and Returns, the facility failed to ensure Resident #28 and/or his/her personal representative received a copy of the bed hold policy with the bed hold amount upon discharge/transfer to the hospital for 1 of 1 residents reviewed for hospitalization . The findings included: The facility admitted Resident #28 on 5/19/2015 with [DIAGNOSES REDACTED]. Review on 2/28/2019 at approximately 12:45 PM of the medical record for Resident #28 revealed a hospital stay for a planned surgical procedure. Further review on 2/28/2019 at approximately 12:45 PM of the the medical record for Resident #28 revealed no documentation to ensure Resident #28 and/or his/her responsible party received a copy of the bed hold policy with the bed hold amount upon transfer/discharge to the hospital. During an interview on 2/28/2019 at approximately 1:50 PM with the Unit Manager on the 100-200 Hall confirmed Resident #28 and/or his/her personal representative had not received a copy of the bed hold policy with the bed hold amount upon transfer/discharge to the hospital. Review on 2/28/2019 at approximately 2:00 PM of the facility policy titled, Bed-Holds and Returns, revealed it stated under the Policy Statement, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The Policy Interpretation and Implementation under #3 stated, Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid Residents.)

Based on observation, record review, and interview, the facility failed to provide/offer nail care for a resident that require, extensive assistance with activities of daily living (ADLs) for 1 of 1 resident reviewed for activities of daily living (Resident #13). The findings included: The facility admitted resident #13 on 11/23/18 with [DIAGNOSES REDACTED]. During an observation on 2/25/19 at 12:02 PM, observation revealed Resident #13 had long, chipped, and yellowish nails. During an interview with Resident #13 on 2/25/19 at approximately 12:05 PM, s/he stated that facility staff had not provided or offered him/her nail care. During a second observation on 2/26/19 at 10:15 AM, observation revealed Resident #13 was sitting in the television area. The resident's fingernails remained long, chipped, and yellowish. Resident #13's care plan reviewed on 2/28/19 on 9:14 AM revealed that the resident had a recent decline in ADLs since hospitalization [MEDICAL CONDITION], urinary tract infection, and pneumonia. Review of Resident #13's ADL verification worksheet on 2/28/19 at 9:44 AM revealed that resident #13 required extensive assistant with personal hygiene. Review on 2/28/19 at 9:46 AM of Resident #13's quarterly Minimum Data Set (MDS) assessment completed on 2/22/19 revealed that Resident #13 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During an interview with the facility Administrator on 2/28/19 at approximately 10:00 AM revealed s/he acknowledged that Resident #13's fingernails were long and unkempt. The administrator also stated s/he would address the resident's fingernails immediately.

Based on record review, interview, and review of the facility policy titled, Pneumococcal Vaccine, the facility failed to ensure Resident #24 received the Pnemococcal Vaccine after the personal representative had received the education and signed consent for the vaccine for 1 of 5 residents reviewed for Flu and Pneumonia Vaccines. The findings included: The facility admitted Resident #24 on 10 /18/2018 with [DIAGNOSES REDACTED]. Review on 2/28/2019 at approximately 9:10 AM of the medical record for Resident #24 revealed a form titled, Vaccination Consent Form dated 10/18/2018 and signed by the responsible party for Resident #24 requesting to receive the Pneumococcal Vaccine. Further review on 2/28/2019 at approximately 9:10 AM of the medical record for Resident #24 revealed it contained no documentation to ensure Resident #24 received the requested Pneumococcal Vaccine. During an interview on 2/28/2019 at approximately 9:45 AM with the Licensed Practical Nurse Unit Manager for the 100-200 Unit confirmed that no documentation could be found to ensure Resident #24 had received the Pneumococcal Vaccine. S/he stated, I will have to ask his/her daughter to ensure this resident received the Pneumonia Vaccine as requested. Review on 2/28/2019 at approximately 9:50 AM of the facility policy titled, Pneumococcal Vaccine, revealed it stated, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The Policy Interpretation and Implementation stated under #4. Pneumococcal Vaccines will be administered to residents (unless medically contraindicated, already given or refused) per our facility's physician-approved pneumococcal vaccination protocol.

Based on observation, interview, and review of the manufacturer's recommendations for the clothes dryers, the facility failed to ensure a large build up of lint was removed from the wiring of 2 of 3 clothes dryers currently in use. The findings included: Observations made on 2/27/2019 at approximately 7:20 AM of the laundry room revealed three clothes dryers. Two of the three clothes dryers were used by the facility and had a large build up of lint on the wiring above the lint baskets. An interview on 2/27/2019 at approximately 7:25 AM the Housekeeping Supervisor and Laundry Worker #1 confirmed the findings. During an interview on 2/27/2018 at approximately 11:20 AM with the Physical Plant Operations Manager, he/she confirmed that an outside entity was responsible for removing the lint from the wiring while servicing the clothes dryers quarterly, the clothes dryers were serviced in (MONTH) 2019, and a large amount of lint was already noted on the wiring above the lint baskets in the two clothes dryers in use. Review on 2/27/2019 at approximately 11:30 AM of the facility copy of the manufacturer's recommendations for maintenance of the clothes dryers revealed it stated under, Daily, 4. Carefully wipe any accumulated lint off of the cabinet high limit thermostat and thermistor. Failure to do so will allow a buildup of lint in this area to act as a insulator causing the tumbler to overheat.

Based on observation, interview, and review of the facility policy, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 3 kitchens reviewed and has the potential to affect 39 of 39 residents with ordered diets as evidenced by failing to do the following: Restrain facial hair, remove outdated food from freezer, air dry pans, clean food preparation knives, fan, vents and hood. The findings included: On 3/19/18 at 2:30 PM, a random observation of the main kitchen with the Food Service Director revealed: 1.) (4) Men with mustaches that were uncovered while food was being prepared. 2.) (4) Knives on the clean magnetic rack above the food preparation area that were dirty with food debris. 3.) The hood over the grill and stove had a build-up of grease and dust that was running and dripping grease below. 4.) (20) 1/6 pans, (14) 1/3 pans, (10) ½ hotel pans, (6) 2 inch hotel pans, (6) 1/9 pans, were stacked wet on the shelf in the food preparation area. 5.) (3) Vents in the food preparation area had a large build-up of dust and (1) vent over the 3 sink and pan rack had dust with a black substance growing that was dripping water below. 6.) The fan in the dish washing and drying area had a large build-up of dust that was blowing onto dishware. 7.) (1) Bag of meat dated 12/17 was in the walk-in freezer showing freezer burn and frost. Following the above random observation the Food Service Director verified the knives were dirty, the hood had a build-up of grease, and the pans were stacked wet. On 3/20/18 at 2:00 PM, a random observation of the main kitchen with the Kitchen Supervisor revealed: 1.) (3) Men with mustaches that were uncovered while food was being prepared. 2.) The hood over the grill and stove had a build-up of grease and dust that was running and dripping grease below. 3.) (3) Vents in the food preparation area had a large build-up of dust and (1) vent over the 3 sink and pan rack had dust with a black substance growing that was dripping water below. 4.) The fan in the dish washing and drying area had a large build-up of dust that was blowing onto the dishware. Following the above random observations the Kitchen Supervisor verified the hood had a build-up of grease and dust, vents had dust and a black substance growing, and a fan with dust build-up was blowing onto dishware Review of the facility policy entitled, Sanitization, states under procedure (10) states, Food preparation equipment and utensils that are manually washed will be air dry whenever practical. Furthermore, procedure (16) states, Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.

Based on observation, record review, interview and review of the manufactures recommendations, the facility failed to maintain a medication rate of less than 5%. There were 3 errors out of 29 opportunities for error, resulting in a medication error rate of 10.34%. The findings included: Error#1 On 3/20/18 at approximately 11:30 AM, during observation of Resident #3's medication administration on the [MEDICATION NAME] unit, Licensed Practical Nurse (LPN) #1 prepared the residents [MEDICATION NAME] by placing the [MEDICATION NAME] at a horizontal position and doing an air shot of 2 units. Furthermore, during observation of Resident #3's medication administration, LPN #1 administered 3 units of insulin with the [MEDICATION NAME] into the residents abdomen by putting the [MEDICATION NAME] device against the residents skin and pressing the injection button, then LPN #1 removed the device within 2-3 seconds after the button was pressed. On 3/20/18 at approximately 11:40 AM, an interview with LPN #1, s/he verified that the [MEDICATION NAME] was in a horizontal position during the air shot, the LPN #1 was then asked, Do you know the time limit for keeping the [MEDICATION NAME] against the residents skin after the button is pressed? LPN #1, stated, I should have held it for 10 seconds. Review of the [MEDICATION NAME] Flex Pen manufacture recommendation revealed under Preparing your [MEDICATION NAME], (A.) Pull of the pen cap, wipe the rubber [MEDICATION NAME] with an alcohol swab (B.) Attaching the needle. (C.) Pull off the big outer needle cap. (D.) Pull off the inner needle cap and dispose of it. (E.) Turn the dose selector to select 2 units. (F.) Hold your [MEDICATION NAME] with the needle pointing up .(G.) Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. Also, the recommendations revealed under Giving the Injection, (J.) Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. Error #2 On 3/20/18 at approximately 8:02 PM, during an observation of Resident #25's medication administration on the(NAME)Shores unit, Registered Nurse (RN) #1 prepared Residents #25's medication by placing (1) capsule of [MEDICATION NAME] 300 mg. into the residents medication cup. Prior to administration RN #1 was asked to review the physicians order for [MEDICATION NAME] 300 mg. which stated, [MEDICATION NAME] 300 mg. (Capsule) (2) Capsule Oral 8:00 PM. Following the review of the [MEDICATION NAME] physicians orders, RN #1 verified s/he was going to administer (1) 300 mg. capsule of [MEDICATION NAME] instead of the physicians order for (2). Error #3 On 3/20/18 at approximately 8:05 PM, during an observation of Resident #25's medication administration on the(NAME)Shores unit, Registered Nurse #1 administered 2 inhalations of [MEDICATION NAME] 80-4.5mcg. via the actuation device. On 3/20/18 at approximately 8:06 PM, a review of the Resident #25's physicians orders with RN #1 revealed an order stating, [MEDICATION NAME] 120 inhalations 80-4.5 mcg/actuation (1 PUFF) HFA Aerosol with Adapter (Gram) Inhalation) 8:00 PM. Following the review RN #1 verified Resident #25 was to receive (1) inhalation of [MEDICATION NAME] not (2).

Based on observations, interview, and review of physician's orders, the facility failed to follow a procedure to ensure accurate labeling to meet the needs of the residents for 1 of 6 residents reviewed for medication labeling. Resident #25's medication was not labeled in accordance to the physician's orders on the(NAME)Shores unit medication cart. The findings included: On 3/20/18 at approximately 8:05 PM, during a review of Resident #25's physician's orders with Registered nurse (RN) #1 revealed an order stating, [MEDICATION NAME] 120 Inhalations 80-4.5 mcg/actuation (1 PUFF) HFA Aerosol with Adapter (GRAM) Inhalation, Two Times Daily, 8:00 am 8:00 pm. On 3/20/18 at approximately 8:06 PM, an observation of the(NAME)Shores unit medication cart with RN #1 revealed Resident #25's [MEDICATION NAME] 80/4.5 medication box that contained the residents' inhaler. The medication box had a Pharmacy stamp that stated, INHALE 2 PUFFS TWICE DAILY. On 3/20/18 at approximately 8:06 PM, during an interview with RN #1, s/he verified Resident #25's physicians order for (1) inhalation did not reflect the Pharmacy stamped [MEDICATION NAME] inhaler box which stated, INHALE 2 PUFFS.