Every finding on record at Franklin Woods Center

Based on observations and interviews it was determined that the facility staff failed to consistently maintain infection control practices related to clean linen on the unit. This deficient practice was evidenced in 2 linen closets on the lower level. The findings include: On 05/08/25 at 11:17 AM while on the lower level with the Director of Nursing (DON), the surveyor observed the door to the linen closet open. The DON apologized for the door being open and closed the door. At 11:21 AM while on [NAME] with the DON the linen closet door was open, and the DON closed the door and verbalized that the staff are aware that the door should be closed. On 05/08/25 at 12:47 PM during an interview with Infection Preventionist (IP) #4 the surveyor asked what the expectation of the staff in relation to infection control practices of the linen in the closets on the units. The expectation is for them to keep the door closed. An in-service was completed with the staff to ensure the doors are kept closed. Maintenance would check the doors to ensure they latch completely.

Based on observations and interviews with facility staff, it was determined that the facility: 1) failed to ensure refrigerator temperatures were monitored and food items were labeled, and 2) failed to store and prepare food in accordance with professional standards. This was evident for 2 of 2 kitchen observations, and for 2 of 2 nourishment refrigerators observed during the annual survey. The findings include:1) During a tour of the 1st floor's nourishment room on 05/12/25 at 07:34 AM the surveyor identified:- no visible log of daily temperatures for the refrigerator- no internal thermometer identified in the freezer - the last documented temperature was documented on 5/9/25- one 20 oz cup with a straw, containing a brown colored liquid in the freezer- one container of Butter Pecan ice cream , opened, no resident label- two Thick & Easy bottles, opened with out an open date/resident label in the refrigerator- one 40 ounce bottle of applesauce, opened, without an 'open date/resident label in the refrigerator- one 32 ounce liquid coffee creamer, opened, no labelDuring a tour of the 2nd floor's nourishment room on 05/12/25 at 07:48 AM the surveyor identified:- no visible log of temperatures for refrigerator and the freezer- no internal thermometer identified in the freezerOn 5/12/25 at 9 AM, the surveyors conducted a tour of the nourishment room on the first floor with Registered Nurse, Staff #8, and confirmed the unlabelled items in the freezer and refrigerator.On 05/12/25 at 9:30 AM the surveyors discussed with the Infection Preventionist, Staff #4, the concerns identified in the nourishment room on both floors.2) On 5/7/25 at 7:43 AM, the surveyor conducted an initial tour of the kitchen. Upon entering the kitchen no hairnets were available at the entrance to apply. On further observation Dietitian Staff # 17 and Dietary Aide #14, both did not have hairnets on. The surveyor asked Staff #17 if she was supposed to be wearing a hairnet and she replied it must have fallen off.On 5/7/25 at 7:46 AM, the surveyor observed the walk in refrigerator with [NAME] #13. The surveyor observed several trays of frozen meat thawing on a rack. None of the meats were labeled or dated as to when the meat was pulled from the freezer. What appeared to be ground beef was open to air and not covered. Staff #13 stated that the meat was pulled from the freezer yesterday to prep later today and confirmed that the meat should be covered and labeled.Next the surveyor observed a cut onion and tomato wrapped however had no date or label. Staff #13 stated she would dispose of the items and that they should not have been stored like that. Additionally, no date was noted on an open jar of apple sauce, an opened bag of diced potatoes and a crate of eggs. Staff #13 stated she would dispose of the apple sauce and potatoes and that she had pulled the crate of eggs from the box next to it and she would return it to the box that had the label and date.A pan of sliced peppers and onions, and a pan of crumbled substance were noted without labels or dates. Staff #13 stated she would dispose of those items, as well. Multiple trays of individual wrapped containers were noted on a rack in the walk in refrigerator. Two trays had no label as to what the containers were or a date to indicate when the containers were made. Staff #13 stated that the trays were made this morning and that there should have been a label and date.On 5/7/25 at 7:57 AM, the surveyor observed the walk in freezer. A container of ice cream was noted with minimum ice cream remaining. No date as to when the ice cream was opened. Hot dogs were noted wrapped in cellophane without a label or date. Staff #13 stated she would dispose of the ice cream and address the hotdog's.Next the surveyor observed the dry storage. Two bags of long pasta were both opened. No date was noted as to when the bags were opened or to indicate which bag should be used first. Loose elbow pasta was noted in the box. Next to this box was additional pasta that was open to air and not secured with a cellophane wrapping.The surveyor observed a storage rack that had two bags of items that were not to be labeled or dated. One was next to the coconut flour and the other Staff #13 stated was bread crumbs. She stated she would dispose of the items.Also noted on the shelf items that were opened and not dated were; butternut mix, cake mix, cream of wheat, and grits.On 5/12/25 at 11:07 AM, the surveyor conducted an additional observation of the kitchen. The Certified Dietary Manager Staff #12 was present.On 5/12/25 at 12:03 PM, the surveyor observed a cell phone and headphone next to the utensil baskets at the start of the food assembly line. The surveyor asked Staff #13 if the items should be kept in the kitchen. Staff #13 responded, no, and that she would have them removed.On 5/12/25 at 12:08 AM, the surveyor observed a dietary aide, grab the fork, spoon and knife from the eating surface of the silverware and place them onto the tray. The surveyor asked the CDM if the silverware should be handled in this way. The CDM confirmed that the silverware should be grabbed from the non-eating side and that the silverware was placed incorrectly in the basket. The CDM was then able to switch out the silverware basket which allowed the staff to grab the silverware without touching the eating surface.

Based on record review, observation and interview, it was determined the facility staff failed to provide a resident with assistive devices as ordered. This was evident of 1 (Resident #65) of 10 residents reviewed for food concerns during the survey process. The findings include: On 5/7/25 at 8:50 AM the surveyor observed detailed instructions on eating posted in Resident #65's room. On 5/7/25 at 12:06 PM, the surveyor conducted an interview with Resident #65's family member. The family member stated that he/she had not seen the specialized spoon that his/her parent was supposed to have recently. Next the surveyor reviewed Resident #65's care plan. A care plan related to dysphagia (difficulty swallowing) was initiated in April of 2024. One of the interventions listed was, provide rehabilitation eating devices: adaptive spoon and scoop bowl during meals. On 5/12/25 at 8:09 AM, the surveyor observed Geriatric Nursing Assistant (GNA) #10 assist Resident #65 with his/her meal. No specialized spoon or bowl were observed on the tray. On 5/12/25 at 11:11 AM, the surveyor conducted an interview with the Certified Dietary Manager (CDM). During the interview the CDS could not recall that any resident has adaptive equipment ordered. He stated that if they had it ordered it would be on the meal ticket. The surveyor requested to see Resident #65's lunch meal ticket. The meal ticket for Resident #65 listed adaptive equipment; Scooper bowl and right angled spoon. The surveyor reviewed the concern that neither of these devices were observed on Resident #65's breakfast tray.

Based on interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 2 (Resident #38 & #65) out of 33 residents reviewed during the survey. The findings include: 1a) On 5/7/25 at 9:43 AM, the surveyor conducted an interview with Resident #38. During the interview Resident #38 stated that he/she washed him/herself up at the bedside and was never offered to be set up for a shower. On 5/8/25 at 12:46 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated that shower days are established on admission. She further stated that the Geriatric Nursing Assistants GNA's utilize shower book to document the showers. The surveyor requested the documented showers for Resident #38. On 5/13/25 at 6:44 AM, the surveyor conducted a follow-up interview with the DON. During the interview the DON stated that she had spoken to the GNA's and that Resident #38 refused showers and was set up at the bedside per his/her request. However, there was no documentation completed on the days Resident #38 refused to utilize the shower. 1b) On 5/7/25 at 10:52 AM, the surveyor reviewed the Social Service Assessment that was completed for Resident #65 on 3/31/25. The assessment documented that Resident #65 had Advanced Directives and that a copy was in the Resident's medical record. The surveyor reviewed the electronic and paper medical record and was not able to find the Advanced Directive. On 5/13/25 at 8:56 AM, the surveyor conducted an interview with Social Service Director Staff #3. During the interview Staff #3 stated that after review the medical record she was able to confirm that Resident #65 does not have an Advanced Directives and that documented yes to Advanced Directive was done in error.

Based on record review, and interviews, it was determined the facility failed to notify the Ombudsman of resident's transfers and failed to provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was found evident for 1 (Resident #67) of 5 residents reviewed for hospitalization during the survey. The findings include: On 5/7/25 at 2:06 PM, the surveyor reviewed Resident #67's medical record. The review revealed that in early January of 2025 Resident #67 was transferred to the hospital and the Resident's daughter was notified of the transfer. On 5/8/25 at 11:50 AM, the surveyor requested the bed policy notice that was given to Resident #67's Responsible Party (RP) along with the notice to the Ombudsman for Resident #67's January 2025 transfer to the hospital. On 5/8/25 at 12:42 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON confirmed that the bed hold information was not given to Resident #67's RP. On 5/12/25 at 9:33 AM, the surveyor conducted an interview with the Social Service Director, Staff #3. During the interview the surveyor reviewed the email that the surveyor was provided to show the names of the residents that were transferred out in January of 2025 and sent to the Ombudsman. Resident #67's name was not on the list even though he/she had been hospitalized in January of 2025. Staff #3 stated she was not sure why his/her name was not on the list but had sent the list that the report generated.

Based on record review and interview it was determined that the facility failed to appropriately prescribe a psychotropic medication for a resident without a diagnosed need for one. This was found evident in 1 (Resident #38) out of 5 residents reviewed for unnecessary medications. The findings include: Psychotropic medications are used to treat mental health disorders and are considered any drug that affects behavior, mood, thoughts, or perception. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are: antidepressants, anti-anxiety, stimulants, antipsychotics and mood stabilizers. On 5/08/25 at 10:47 AM, the surveyor reviewed Resident #38's medical record. The review revealed that Resident #38 was admitted in early February 2025. On further review it was noted that a Psychiatry progress note was written on 2/12/25 by Psychiatric Nurse Practitioner, NP #18, that stated a gradual dose reduction was recommended for Seroquel (also known as Quetiapine, an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) from 100 mg daily due to the absence of acute psychosis. On further review the surveyor noted that Resident # 38's Seroquel dose was changed on 2/13/25 to the new recommended reduced dose. Next the surveyor reviewed the Psychiatry progress note that was written on 3/5/25 by Psychiatric Nurse Practitioner NP #18. Seroquel was listed on the medications reviewed with the dose of 25 mg twice a day with the indication; for agitation -unknown medical condition. On 5/8/25 at 10:55 AM, the surveyor reviewed the Medication Regimen Review (MRR) for Resident #38. The review revealed the Pharmacist wrote a recommendation on 4/21/25. The surveyor requested the recommendation report. The report stated this resident is receiving the antipsychotic agent Quetiapine (Seroquel) but lacks an allowable diagnosis to support its use. The Pharmacist then listed acceptable uses. Further on in the report the Physician responded and wrote, delirium related to current medical illness. Delirium without manic psychotic symptoms was not listed as an acceptable diagnosis or condition. The surveyor reviewed that the Psychiatry progress note was written on 4/23/25 by the Psychiatric Nurse Practitioner NP #18. In the note NP #18 wrote, 'staff report Resident #38 is doing well and has not exhibited any psychosis, depression, agitation, anxiety or behavioral problems. The note stated that the medications were reviewed and recommended no changes at this time. Quetiapine (Seroquel) was listed at 100mg twice daily for delirium current mental illness. Nowhere in the note did it explain the increase in the psychotropic or give a diagnosis, symptoms or condition that would indicate the use for Quetiapine. On 5/12/25 at 1:28 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concerns that not only did Resident #38 not have an appropriate diagnosis for the use of Quetiapine (in which the Pharmacist reviewed and informed the provider) but Resident #38 also had the dose increased without any reason or rationale given in his/her medical record for what was considered unnecessary medication.

Based on observations and interviews it was determined that the facility failed to provide Resident #69 with a reasonable accommodation of need. This was found evident during one random observation on the survey. The findings include: On 5/12/25 at 8:08 AM, the surveyor observed Resident #69 tell the Geriatric Nursing Assistant (GNA) #10 that he/she was wet and needed assistance being changed. The surveyor observed GNA #10 tell Resident #10 that she would change him/her after she assisted him/her with eating breakfast. Next the surveyor observed GNA #10 go and assist Resident #69's roommate with his/her breakfast tray. On 5/10/25 at 8:10 AM, the surveyor asked GNA #10 if she had anyone to assist her with her work. She stated she had colleagues but concluded that they were assisting feeding their assigned residents. On 5/12/25 at 8:16 AM the surveyor observed GNA #11 walk into Resident #69's room and talk to GNA #10 and then leave the room. On 5/12/25 at 8:18 AM, the surveyor interviewed GNA #11 in the hallway. During the interview the GNA confirmed that she was not asked to help Staff #10 with her assignment. The surveyor asked GNA #11 what the protocol was if multiple residents assigned to you had immediate needs at the same time. Staff #11 stated she would ask for help from another staff member. On 5/12/25 at 8:26 AM, the surveyor observed GNA #10 obtain a cup of juice from the hallway and return to Resident #69 to assist in feeding him/her. On 5/12/25 at 8:45 AM, the surveyor observed the GNA grab linens from the closet and confirm that she was going to now wash Resident #69 up. On 5/12/25 at 8:52 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that Resident #69 had to wait 37 minutes to be changed. The DON stated that it is her expectation that staff reach out for help if a situation like this occurs.

Based on observation, interview and medical record review, it was determined that the facility staff failed to ensure the development of comprehensive person-centered care plans as evidenced by failure to develop an integrated care plan to address a resident's needs related to hearing loss. This was found to be evident for 1 (Resident #24) out of 4 residents in the care plans reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 05/07/25 at 10:12 AM During a floor round, an issue was brought up that Resident #24 had an unresolved problem of difficult hearing, and the facility staff were made aware. Further observation, this resident was not wearing the hearing aids at that time. Record Review, on 05/08/25 at 11:22 AM, found that Resident #24's hearing aids were checked on 3/17/2025 by an Audiologist and both hearing aids were functioning and fit well in good working order. The Audiologist's recommendation was the following: nurse to insert and remove hearing aid, change hearing aid batteries, clean and keep them in good working condition and store extra 8 hearing aid batteries. During an Interview, on 05/12/25 at 09:46 AM, the assigned nurse Staff # 20 stated that she was troubleshooting Resident #24's hearing loss issue, but she did not know about the Audiologist's recommendations nor the care plan. On 05/12/25 at 11:49 AM, Resident #24 reported again that, I could not hear and added it could be the ear wax built up, but no one cares. Interview, on 05/12/25 at 11:51 AM, the Director of Nursing reviewed the above findings, and she was unable to provide a person-centered care plan to address this resident's hearing loss needs. She agreed that the facility staff failed to have a thought-out resident centered care plan.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure that a dependent resident's personal hygiene needs were provided according to resident preference. This was evident for 1 (Resident # 76) of 3 residents reviewed during the annual survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. On 05/07/25 at 8:40 AM, the surveyors held an interview with Resident #76 who indicated they had not received a shower in the past two weeks. During that time, the resident mentioned receiving a bed bath, which they did not request. On 05/08/25 at 09:34 AM, a follow-up interview with the resident revealed that s/he did not receive a shower. On 05/08/25 at 09:37 AM, an interview with the Geriatric Nursing Assistant (GNA), Staff #19, confirmed that the resident would be assisted with their toilet needs and would take a shower as per Resident #76's request. On 05/08/25 at 01:15 PM, the Director of Nursing (DON) provided surveyors with a copy of the Resident #76's shower preference agreement, which the resident signed on 04/08/25 and several shower documentation logs which the GNAs completed for the month of April 2025. The additional worksheets indicated that the resident received one shower on 04/24/25, and refused a shower on 04/28/25. On 05/09/25 at 10:58 AM, a review of the Minimum Data Set (MDS) completed during the admission assessment, showed that the resident required partial assistance with showering/bathing. The task records indicated that a shower was given on 04/24/25, at 9:49 PM. On 05/12/25 at 1:10 PM, the DON was interviewed regarding Resident #76's activities of daily living (ADL) and acknowledged that showers were not provided for a resident that was identified as in need of partial assistance with showers.

Based on observation, record review, and interviews, it was determined that the facility failed to provide treatment to prevent further decreased range of motion for residents. This was found evident of 2 (Resident #74 & #65) out of 5 residents reviewed for mobility. The findings include: 1a) On 5/7/25 at 9:10 AM, the surveyor interviewed Resident #74. During the interview Resident #74 stated that he/she could not move his/her left arm. The surveyor noted Resident #74's arm next to him/her. There was no splint or supportive device noted. On 5/12/25 at 8:25 AM, and at 11:01 AM, Resident #74 was observed and noted not to be utilizing anything to support his/her left arm. Next the surveyor reviewed Resident #74' s Occupational Therapy (OT) notes. On the discharge summary note written from OT it stated, Resident #74 has tolerated wearing left upper extremity orthotic for 6 hours and functional maintenance program in place for nursing staff to carryover. On 5/13/25 at 11:13 AM, the surveyor conducted an interview with the OT #16. During the interview OT #16 stated that Resident #74 worked with therapy and had a splint for his/her left upper extremity. She further stated that on discharge from OT an order was written for the resident to continue a functional maintenance plan for orthotic management. She provided the order and the plan that stated, left resting hand splint to be applied after morning care, 6 hours as tolerated. The surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that the splint ordered for Resident #74 was not observed being applied per order. There was also no documentation in the medical record to support that the device was applied or offered as ordered. 1b) On 5/7/25 at 8:50 AM, the surveyor conducted an interview with Resident #65. During the interview Resident #65 stated that he/she has a splint but it had not been applied in some time. The surveyor noted a sign on the wall that stated splints to be applied after Activity of Daily Living (ADL)s. On 5/7/25 at 11:58 AM, the surveyor observed that Resident #65 did not have the splint on. On 5/12/25 at 8:14 AM, the surveyor observed no splint was on and again at 10:59 AM, no splint was on and the resident was noted to be dressed and up in the chair, indicating the morning ADLs had been performed. On 5/8/25 at 7:44 AM, the surveyor reviewed Resident #65's orders. An order was written on 10/14/24 that stated, Resident #65 to wear left upper extremity splint for 6-8 hours as tolerated and adjust splint as needed. Also to perform skin checks. On 5/13/25 at 6:44 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that the splint ordered for Resident #65 was not observed as being applied per order. There was also no documentation in the medical record to support that the device was applied or offered as ordered.

Based on observation, review of the medical record and interview with facility staff it was determined the facility failed to provide necessary respiratory care services for residents by failing to date label oxygen administration equipment as prescribed. This was evident for 2 ( #17 and #37 ) of 5 residents reviewed for Respiratory Care.The findings include:A nasal cannula is a device that delivers oxygen directly to a person' nostrils via a flexible plastic device. On 5/7/2025 at 12:22 PM the surveyor observed during initial screening noted that the tubing for the oxygen nasal canula at Resident #37's bedside were not labeled as to when they were put into use or when it should be replaced. A physician's order was written on 1/19/2025 to change tubing and labeling the respiratory elements with the time and date. The order also required the tubing to be changed every seven days.In a follow-up observation on 5/9/2025 at 1:14 PM. It was again noted that the nasal canula tubing was not labeled with the date it was put into use. The surveyor requested the policy regarding the administration of oxygen from the Director of Nursing (DON) and identified with her that on the policy it was required to date the tubing and humidifier bottle with the date it was put into use.On 05/07/25 at 09:00 AM, surveyors conducted a tour of the 1st floor. The surveyors observed Resident #17 receiving supplemental oxygen, via a nasal cannula, at a rate of 3 Liters per minute (L/m). Review of Resident #17's electronic medical record on 05/07/25 at 9:10 AM, revealed s/he was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and pulmonary hypertension. On 05/08/25 at 09:22 AM, a second observation showed the oxygen flow rate meter remained at 3 L/m at the time of inspection.On 05/08/25 at 12:50 PM, a review of Resident #17's physician orders revealed that oxygen was ordered at 2 L/m via Nasal Cannula continuously for every shift for Hypoxia. The order also specified that the oxygen tubing should be changed weekly, with all components labeled with the date and initials. On 05/09/25 at 09:01 AM, a review of Resident #17's Treatment Administration Record (TAR) indicated that nursing staff initialed entries for 5/8/25 at 18:55, that Resident #17's oxygen saturation level measured 97.0% via Nasal Cannula and on 5/8/25 at 10:36, that Resident #17's oxygen saturation measured 94.0% via Nasal Cannula. On 05/09/25 12:53 PM, a third observation showed that the resident was still receiving supplemental oxygen at a rate of 3 L/min. On 5/12/25 at 9:20 AM, the surveyors observed Registered Nurse, Staff #8, replace an empty sterile water bottle (used to add humidification of the supplemental oxygen) and adjust the oxygen flow rate to 2 L/min, as per the provider's order. An interview with Staff #8 confirmed the resident's prescribed oxygen rate. At 1:10 PM, a meeting was held with the Director of Nursing (DON) to discuss the concerns identified regarding Resident #17's supplemental oxygen settings.

Based on observations of the facility's kitchen food services, and staff interview, it was determined that 1.) The facility failed to maintain food service equipment in a manner that ensured sanitary food service operations, and 2.) The facility staff failed to serve beverages in a manner that ensured sanitary food distribution during meal service to rooms. This was identified while observing the facility's dish washing machine in operation and meal distribution service to residents' rooms. The findings include. 1.) On 8/11/21 at 10:45 AM, during an observation of the facility dishwasher with the food service director, it was revealed that the temperature of the wash water was not reaching the minimum requirement of 160 degrees Fahrenheit (F). The food service director acknowledged that the wash temperature gauge was only reading 140 degrees F and indicated that the facility's maintenance man was notified. On 8/13/21 at 12:16 PM, review of the Machine Warewashing Sanitizing Log and the Manual Warewashing Sanitizing Log failed to show that the staff were monitoring the wash and rinse levels of the dish washer. Review of both logs revealed that the staff had failed to record the wash and rinse temperatures for noon and evening on 8/11/21, failed to record morning, noon, and evening water temperatures and manual warewashing sanitation levels on 8/12/21, and failed to record the morning dishwasher temperatures and manual warewashing sanitation levels on 8/13/21. The cook (staff #50) in-charge of the kitchen at the time was made aware that the dishwasher and manual ware wash logs were incomplete as the documentation was blank after breakfast on 8/11/21. On 8/13/21 at 1:10 PM, the dietitian was asked if she knew the status of the dishwashing machine. She indicated that she heard that the maintenance man had ordered a thermostat and she was going to follow up with maintenance. At 2:25 PM on 8/13/21, the dietary staff were observed washing the lunch time dishes and dishware with the observed wash level temperature of 146 degrees F. An interview was conducted with the cook in charge (staff #50) at 2:28 PM. She indicated that she did not know that there was a problem with the dishwasher. She indicated that maintenance had told her to break the machine down and put Lime-away into the machine to see if that brought the water temperature up. She revealed that she was going to do this after the lunch time dishes were cleaned. At 2:32 PM on 8/13/21, a maintenance man (staff #53) informed the surveyor that a part was ordered for the dishwasher and he placed an emergency call to [NAME] (the dishwasher manufacture service vendor). He indicated that the repair company was expected to arrive within a few hours. At 3:00 PM on 8/13/21, the Regional Corporate nurse (staff #13) was informed that the dietary staff failed to monitor and document the sanitation level of the dishwasher and the manual chemical sanitation level of the three compartment sinks. She was shown copies of the dishwasher log and manual warewashing sanitizing log showing the lack of documentation for the last 6 meal times. She confirmed that the [NAME] service company was expected to come to the facility by 5:30 PM. On 8/16/21 at 2:30 PM, observations of the dishwasher area revealed stacks of unwashed dishes and dishware. The maintenance director (staff #28) was working on the hot water booster component of the dishwashing machine. He indicated that the wash temperature was fixed by an outside vendor [NAME] on Saturday and the component he was working on, was to be fixed within the hour. Review of the dish washer and manual sanitizing logs shown that there was not any documentation related to monitoring of sanitizing since the morning of 8/11/21. The facility had failed to monitor the hot water temperatures and the chemical sanitation level for over 5 days. The regional corporate nurse was shown the incomplete logs on 8/16/21 at 2:45 PM. Observations of the dishwasher in operation on 8/17/21 at 11:55 AM revealed a wash cycle temperature of 140 degrees F and the rinse gauge was observed to be 190 degrees F. Review of the sanitizing logs for the morning of 8/17/21 revealed that the wash cycle was recorded as 165 degrees F and the rinse was documented as 172 degrees F. On 8/18/21 at 9:30 AM, observations of the dishwasher gauges revealed a wash cycle temperature of 160 degrees F. and the rinse cycle was 192 degrees F. 2.) Periodic observations of meal and beverage distribution on the 1st floor revealed that the facility staff failed to serve beverages in a manner that ensured sanitary beverage distribution during meal service to rooms. Observations of breakfast tray and beverage room delivery service on 8/10/21 at 8:05 AM, revealed dietary had parked a beverage cart in a central location near the nursing station on the first floor. The beverage cart had numerous pitchers of juices, thermoses of coffee, and cartons of milk. A geriatric nursing assistant (GNA) (staff #22) had poured 7 plastic cups of milk, 7 plastic mugs of coffee, and 5 plastic glasses of juice. The GNA left the open air cart of uncovered beverages for several minutes to return with covered disposable plastic cups of ice water. She then proceeded to take the cart down the [NAME] I hallway. As she would take beverages into resident rooms, the cart remained unattended without lids on the individually poured beverages. On 8/17/21 at 7:50 AM, 6 plastic mugs of coffee, and 6 plastic cups of juice were noted on an open cart without lids and left unattended. An interview was conducted with the dietitian (Staff #25) at 10:45 AM on 8/17/21. When asked if the facility had a policy related to sanitary beverage and food distribution, she indicated that she did not know of any specific policy. During a test tray observation of food and beverage delivery at 12:35 PM on the Southwind I hallway, an unattended cart of 7 poured beverages were observed without lids. At 12:50 PM, the nurse practice educator was observed to place lids on the 7 beverages. The surveyor informed her that the cups were unattended for at least 20 minutes. Upon follow-up with the nurse practice educator at 1:10 PM, she indicated that the 7 uncovered beverages were discarded.

Based on review of employee files and staff interviews, it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) were evaluated annually. This was found to be evident for 5 out of 5 GNA employees (GNA #31, #32, #33, #34, #35) reviewed for annual evaluations. This deficient practice has the potential to affect all the residents in the facility. The findings include: During review of the employee files on 08/16/2021 at 10:02 AM, the surveyor was unable to locate annual evaluations for GNA #31, 32, 33, 34, and #35. During an interview conducted on 08/16/2021 at 11:45 AM, the DON stated that he/she was unable to confirm that annual evaluations had been conducted for GNAs #31, #32, #33, #34, and #35. During an interview conducted on 08/16/2021 at 12:02 PM, the Workforce Coordinator #38 stated that the facility policy required that he/she send a list to management for each department. The list provided staff names and due dates for annual performance evaluations. The Workforce Coordinator stated that the list had been sent out for several years, however, the annual performance evaluations were not completed. During the continued interview, the Workforce Coordinator confirmed that the annual performance evaluations had not been completed since year 2014. The DON was present during the interview with the Workforce Coordinator.

Based on interview of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the resident's in the facility have the potential to be affected by not having a qualified nutritional profession with the appropriate competencies and skill sets to carry out food and nutrition services. The findings include: On an initial tour of the facilities kitchen on 8/10/21 at 9:05 AM, it was revealed that the full time Food Service Director (staff # 4) was not clinically qualified as per Federal and state regulations. The food service director indicated that his predecessor had abruptly left and he was placed in-charge. Upon interview, he indicated that he was not a Certified Dietary Manager (CDM). He indicated that he has completed some of the educational course work towards becoming a CDM. Upon request for written documentation of the foodservice director's credentials on 8/11/21, no documentation was provided.

Based on resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature. Food complaints and concerns were made by 4 (#1, #55, # 86, #355) of 22 resident selected in the final sample and a failed test tray was identified on the unit that was served 2nd to last out of 6 units/hallways. The findings include. Random food complaints from residents included: on 8/10/21 at 11:00 AM, Resident #86 stated that the food is cold. During an interview with Resident #55 on 8/11/21 at 8:57 AM, the resident reported that the eggs were bad and always cold every day. On 8/11/21 at 12:04 PM, resident #355 indicated that the food is usually cold. On 8/12/21 at 8:41, AM resident #1indicated that the food is sometimes cold. On 8/17/21 at 11:50 AM, lunch time meal service observations were initiated in the kitchen. The tray line service was getting started. The main entrée for lunch was listed on the menu as Sloppy [NAME] with potatoes. The food temperatures of the food on the tray line was already taken and review of the documented temperatures revealed that the Sloppy [NAME] was documented as 179 degrees F. Interview of the food service director revealed that the food temperatures were recorded between 11:30 AM and 11:40AM. At 12:15 PM, the surveyor's [NAME] made thermometer was calibrated in an ice bath. A test tray was requested for the Southwind I unit. As soon as the food cart was loaded with trays, including the test tray, the cart was transport to the elevator and delivered to the 1st floor unit at 12:29 PM. Initially, there was only one GNA delivering the meal trays one at time to the residents. The last tray was delivered to a resident at 12:52 PM. The test tray was tested at 12:53 PM. The sloppy [NAME] on a bun measured to be at 112 degrees F. The Potatoes measured to be 110 degrees F. Upon taste test, the sloppy [NAME] was lukewarm. The whipped pineapple desert was measured to be 53 degrees F. Resident #355 was re-interviewed at 1:06 PM on 8/17/21. Resident #355 stated The Sloppy [NAME] was barely warm, it was good though. The potato was awful. Hot food should be served hot and cold food should be served cold.

Based on review of medical records and interview with residents, their representatives and facility staff, it was determined that the facility failed to ensure that transportation arrangements were made for a resident who required wheelchair-enabled transport for a known medical appointment. This was evident for 1 (Resident #147) of 43 residents reviewed during the survey. The findings include: The surveyor reviewed Resident #147's medical record on 8/17/21 at 10:18 AM. The review revealed that Resident #147 was admitted to the facility on [DATE] following hospitalization for a complex fracture of the left ankle. Review of discharge paperwork from the hospital indicated that the resident had an orthopedic appointment scheduled for 6/1/21 at 9:42 AM. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 9:40 AM, [physician's name, address, and telephone number]. The surveyor interviewed Resident #147 and his/her family representative by telephone on 8/17/21 at 12:52 PM. During the interview, the resident and his/her representative stated that the resident had an appointment scheduled for 6/1/21, that the facility failed to obtain transportation for the resident, and that the appointment ended up being rescheduled to 6/2/21 because of the delay. They alleged that, this in turn, delayed the resident's surgery, scheduled 6/2/21, until later. The resident and his/her representative stated that they had not been contacted regarding difficulties arranging transportation until late at night on 5/31/21, the day before the appointment. The surveyor interviewed Unit Secretary (US) #41 on 8/18/21 at 9:08 AM. During the interview, US #41 stated that she was primarily responsible for arranging appointments and transportation to appointments for residents on her unit. She confirmed that Resident #147 had been a resident on her unit. She reviewed her appointment book with the surveyor that included all of the appointments she had made arrangements for, and there was no appointment listed for Resident #147 on 6/1/21. US #41 stated that she began vacation on 5/28/21 and would have been away for Memorial Day weekend, returning on 6/1/21. She stated that when she is away, appointments are made by other nursing staff or the Unit Manager (UM, Staff #5). When shown the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . US #41 stated that the facility usually arranged transportation with Transportation Company (TC) #1, but sometimes would arrange transportation with TC #2. The surveyor contacted TC #1 on 8/18/21 at 9:42 AM and spoke with Transportation Agent #39. The agent stated that there was no record of any scheduled transportation for Resident #147 on 6/1/21. The agent did indicate that transportation was scheduled for the next day, 6/2/21, which had been scheduled by the facility on 6/1/21. Agent #39 indicated that there was a note in the file that stated TC #2 had been scheduled for 6/1/21 but was 3 hours late for pickup and the resident's appointment had to be rescheduled for 6/2/21. Agent #39 stated that the 6/2/21 scheduled transportation had been requested by UM #5. The surveyor contacted TC #2 on 8/18/21 at 9:57 AM and spoke with the owner of TC #2 (Staff #40). The owner stated that the facility had called TC #2 regarding Resident #147's appointment on the day of the appointment, 6/1/21, at 9:49 AM. The owner stated that no promises of transportation had been made that morning, but that the facility had been desperate. The owner said that all vehicles had been busy that morning but one of the vehicles managed to get to the facility at 2:30 PM. The surveyor interviewed UM #5 on 8/18/21 at 10:02 AM. During the interview, UM #5 indicated that the transportation companies were very busy over Memorial Day weekend. She stated that she had reached out to multiple companies for the transportation of Resident #147. We tried everyone, she said. When asked if there was any documentation of the multiple attempts to arrange transportation, UM #5 indicated there wasn't. The surveyor reviewed Resident #147's medical record again on 8/18/21 at 10:30 AM. The review failed to reveal any evidence of attempts to arrange transportation prior to 6/1/21, nor evidence that the resident or family were notified of difficulties in transportation. The review did reveal a note on 6/1/21 at 6:39 PM that had been written by UM #5. The note stated, Resident had an orthopedic appointment scheduled for today but was unable to go due to transportation delays. Appointment was rescheduled for 6/2/21 @ 9:30 AM with facility to transport resident to the appointment and back. Resident and spouse were notified of the above arrangements.

Based on review of resident medical records and interview with residents, their representatives, and facility staff, it was determined that the facility failed to notify a recently discharged resident or their representative of a positive COVID-19 test. This was evident for 1 (#146) of 43 residents reviewed during the survey. The findings include: In the course of investigating a complaint, the surveyor interviewed Resident #146's responsible party (RP) on 8/18/21 at 12:12 PM. During the interview, the resident's RP stated that the resident was hospitalized on [DATE]. The RP stated that, upon arriving to the hospital, the resident was tested for COVID-19 and the result of the test was positive for COVID-19. The RP stated that s/he had never been told by the facility that Resident #146 had contracted COVID-19. The surveyor reviewed Resident #146's paper medical record on 8/18/21 at 1:20 PM. The review revealed that the resident was admitted to the facility in January, 2021, was hospitalized mid February, and returned to the facility at the beginning of March. The surveyor found a lab sheet for a PCR (polymerase chain reaction) COVID-19 test that was performed on Resident #146 on 3/17/21at 9:11 AM, was received by the laboratory on 3/18/21 at 6:57 AM, and was reported to the facility on [DATE] at 9:56 AM. Further review of Resident #146's medical record revealed that the resident was discharged to the hospital on 3/18/21. The medical record did not reveal any evidence that Resident #146's positive test result was communicated to the resident, their family, or the resident's physician. The surveyor interviewed Regional Registered Nurse (RN) #13 on 8/18/21 at 2:37 PM. During the interview, RN #13 indicated that the facility did not notify Resident #146's family of the positive COVID-19 test result because the family already knew of the positive result from the test performed at the hospital. RN #13 stated that the facility knew that because Resident #13's RP had called the facility after discharge and told them so. RN #13 did not indicate whom Resident #13's RP had spoken to. Final review of the medical record on 8/18/21 at 2:45 PM did not reveal documentation of this communication or decision making.

Based on observations and interviews, it was determined that the facility failed to ensure residents received their meal in a timely manner. This was found to be evident for 1 (resident #21) out of 7 residents observed for dining. The findings include: During a tour conducted on 08/10/21 at 12:22 PM, surveyors observed the lunch cart arrive to the 2nd floor nursing unit. At 12:48 pm, the surveyor observed Resident# 21 lying in his/her bed, and their roommate (resident #40) was sitting in a wheel chair. Resident# 40 stated that he/she had already eaen lunch and that their lunch tray had been removed from the room. Resident #21 stated that he/she had not yet received a lunch tray. During an interview on 08/10/2021 at 12:49 PM, the Unit Manager (UM) #10 stated that Resident #21's tray was not delivered to their room, because he/she normally ate lunch in the dining room. The UM went on to say that the kitchen was contacted 4 times to request that resident #21's lunch tray be delivered to their room. At 12:52 PM, The surveyor observed that resident #21's tray was delivered. Afterward, Resident #21 stated that the food arrived warm and was tasty.

Based on resident record review and facility report of an incident, the facility failed to protect resident # 246 from verbal abuse. This was evident for 1 out of 2 reports of abuse. Findings include: A record review was conducted for resident # 246 on 8/16/21 at 11:28 AM. Resident # 246 reported in June 2019 that Geriatric Nursing Assistant (GNA) #20 leaned on her wheelchair and looked into her face and stated, 'you need an attitude adjustment. According to GNA# 20, resident # 246 was complaining about her roommate. GNA #20 did admit during an interview with the Director of Nursing held with her/him on 6/13/21 that he /she did make this comment. GNA #20 was placed on suspension until the facilty's investigation was completed and her/his employment was terminated on 6/19/21.

Based on observation, interview, and record review, the facility staff failed to provide a clean shower room for the female residents on the first floor. This was evident for the female residents who wanted a shower on the rehabilitation unit. The findings include: On 08/10/21 at 7:50 am, this surveyor checked the women's shower room located on the Long term Care Unit for cleanliness. The surveyor observed dried brown matter on the floor, about 6 inches away from the drain. The second shower stall had a used mask on the shelf, gauze with a piece of tape was on the floor were observed in the left corner of the second stall. The fourth shower stall, near the bathroom, had a pail of standing water underneath a shower chair. The bathroom had a glove turned inside out and another glove on the floor. This surveyor observed a Daily Shower Room Cleaning log taped to the exit door. The cleaning log was removed and Assistant Director of Nursing (ADON) #5 provided this surveyor with a copy. According to the log, the shower room was last cleaned 08/08/21, during the 7:00 am - 3:00 pm shift. There was no documentation on the log that the shower room was cleaned on 07/17/21, 07/18/21, 07/21/21-07/23/21, 07/26/21-07/29/21, 07/31/21 -08/06/21, 08/09/21 and 08/10/21. On 08/16/21 at 9:30 am, a review of the Work Flow of Daily Assignments Schedule (which is a cleaning schedule of timed duties for the housekeeping staff) revealed that, at 7:10 am, the housekeeping staff are to check the shower room for cleanliness. At 2:30 pm, environmental rounds are done to check/clean the shower room. On 08/16/21 at 9:04 am, the Environmental Services Director(ESD) # 46, was interviewed andreported that the shower room is cleaned two times a day, inthe morning when staff first come in, and later during the day. At the end of their work day, rounds are done. Surveyor received a copy of the Daily Shower Room Cleaning log and the Work Flow of Daily Assignments. The Daily Shower Room Cleaning log had documentation that was not present when ADON # 5 provided a copy to the surveyor. The Daily Shower Room Cleaning log that the ESD #46 provided had 08/09/21 - 08/15/21 documented as being cleaned. When ESD #46 was shown a copy of the Daily Shower Room Cleaning log, he stated They forget to sign, it was done. The surveyor asked ESD #46 if the form iwas not signed, how would you know if the shower room had been cleaned. ESD #46 stated again, they forget to sign off, it was done.