Every finding on record at Garrison Nursing Home & Rehabilitation Center

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.1. The facility failed to ensure the dietary manager effectively wore a hair net to cover all hair.2. The facility failed to ensure foods stored in the refrigerated were labeled and dated.3. The facility failed to ensure foods stored in the pantry were not out of date. These failures could place residents at risk of foodborne illness and food contamination.Findings Include:During an observation on 07/28/2025 at 8:40am, the dietary manager had hair from under her hair covering on the back of her head. During an observation on 07/28/2025 from 8:49am to 9:30am, the following undated, unlabeled, and expired items were identified by the dietary manager in the refrigerator, and pantry:REFRIGERATOR:*2-gallon bags of red onions, with no date or label. *1 gallon of parmesan cheese expired 06/06/2025.PANTRY:*1 gallon of vanilla flavor expired 2/16/2023.*1 gallon of pancake/waffle syrup without date, label or expiration date. *1 gallon of Teriyaki Glaze expired on 8/27/2024.*1 gallon of Clabber Girl Baking Powder expired 6/13/2025.During an observation on 7/28/2025 at 9:36am during testing of the low temperature dishwasher, the sanitation test strip tested below recommended range at 25 parts per milliliter (recommended range for the test strip is between 50-100 parts per milliliter). The test strips expired February2025.During an interview on 7/30/2025 at 9:17am with DA-B she said all food should be dated and labeled as soon as the food arrives in the kitchen or as soon as it was opened and prepared. She said if food was not dated and labeled the staff could potentially serve the wrong food or expired foods to the residents that could cause food poisoning and make residents ill. She said hair should be covered at all times and if not covered it could fall into food and cause cross contamination and its gross for residents to consume. She said the staff check dates daily when they prepare food. She said all kitchen staff should check for expired foods daily. She said if expired foods are served a resident could get food poising or worse. During an interview on 7/30/2025 at 9:25am with the [NAME] she said food should be dated and labeled when food arrives at the facility, when food was opened, when food was prepared, when storing leftover, and when food was taken out of its original packaging. She said all hair should be covered at all times when in the kitchen. She said hair from under the hair nets could get into to the food and drinks. She said hair if hair gets in the food it will cause cross contamination. She said staff normally check for expired foods at least two times per week. She said she have not noticed expired foods in the kitchen.During an interview on 7/30/2025 at 9:34am with the DM she said foods should be dated and labeled as soon as food is delivered. She said any time there are leftovers stored or when an item is open, the staff should reseal, redate and label the item. She said all kitchen staff was responsible for dating and labeling and for checking for expired. She said all staff should cover all the hair on their head and face anytime they are in the kitchen. She said if hair was not properly covered hair could get in the food and cause cross contamination. She said prior to cooking or using a product staff should check the date prior to using the item. She said dates should be checked when food is received to the kitchen and daily. She said using expired food may cause foodborne illnesses and cause someone to be sick. She said she did not realize the test strips were expired and that she had tested the machine for breakfast dished and it tested correctly. She said if the sanitation solution is not between 50-100 parts per milliliter the dishes will not be properly sanitized. She said proper sanitation, dating, labeling and checking for expired foods is a must to assist in keeping residents from becoming ill, spreading germs and getting foodborne illnesses. During an interview on 7/30/2025 at 9:47am with DA-C she said food should be dated and labeled when vendors deliver food to the facility and the staff is supposed to date and label items prepared or opened daily. She said hair should be tucked in at all times because if hair is no properly covered hair could get in the food and drinks and cause contamination. She said staff should not ever touch hair and then touch food without washing their hands. She said staff should check for expired foods every day. She said some staff check dates and some staff don't. She said without proper dates, labels, handwashing, covering all hair it increases the chance for residents to get sick. During an interview on 7/30/2025 at 9:53am with DA-D she said food should be immediately dated and labeled daily if food is open, when trucks come in and when putting up leftovers. She said the pantry was not checked often for expired foods. She said she have not seen anyone going and check the expiration dates on foods in the pantry. She said serving expired foods could cause resident to get sick. She said all hair should be covered at all times when in the kitchen. She said hair will get in the food and cross contaminate and could possibly cause choking. She said hair in food was disrespectful as well as dangerous to residents.During an interview on 7/30/2025 at 12:50 pm ADON said she's the infection control preventionist for the facility. She said kitchen staff should cover all hair anytime they are in the kitchen. She said hair that gets into food causes infection control issues, food safety issues and is plain disgusting. She said staff should date and label all food and drink items as soon as they are delivered to the facility, when an item is opened or removed from its original packaging and when storing leftovers. She said the DM was responsible for making sure expiration dates are checked daily. She said all kitchen staff should check for expiration dates on any item used to prepare of serve food to residents. During an interview on 7/30/2025 at 1:10pm DON said staff should have hair covered before walking into the kitchen. She said if hair was uncovered it heightens the potential for negative issue with sanitation, infection control, weight loss and food born illness for all residents in the facility. She said food should be date and labeled within thirty minutes to an hour of being received at the facility. She said any stored foods in the refrigerators, freezers and pantries should have a date and label. She said staff should be checking for expired foods every day. She said no expired foods should be used for consumption for residents as this may cause the resident to become ill.During an interview on 7/30/2025 at 1:22pm Administrator said food should be dated and labeled as soon as it's received at the facility. She said kitchen staff should be checking daily for expired foods and discarding them if they are expired. She said with no date and label it increases the chances to serve expired foods and serve the wrong food to a resident. She said hair should be covered anytime staff was in the kitchen. She said hair could get in the food and cause cross contamination. She said her Dietary Manager is primarily responsible for checking dates, labels, appropriate hair coverage and for expired foods. She said these failures could cause any resident eating the food to become ill, choke, or have a negative outcome.Record review of an operational Policy and Procedure Manual for Long-Term Care (revised July 2014) titled Food Receiving and Storage Policy Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).Record review of facility policy 2001 MED-PASS, Inc. (revised October 2008). Titled Sanitation Policy Statement The food service area shall be maintained in a clean and sanitary manner. 4. Dishwashing machine must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitizing) b. Final rinse with 50 parts per million(ppm) hypochlorite (chlorine) for at least 10 seconds. Record review of a Dietary Services Policy & Procedure Manual 2012 titled Food Preventing Foodborne Illness-Employee hygiene and Sanitary Practices. Policy Statement: Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation: 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food. Clean equipment, utensils and linens.Record review of the Food and Drug Code dated 2022 indicated.3-602 Labeling3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified inLAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, markingdevices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, anadequately descriptive identity statement; 3-201.11 Compliance with Food Law.(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.182-402.11 Effectiveness. (Hair Restraints)1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1)Wearing outer garments suitable to the operation (4) Removing allunsecured jewelry (6) Wearing, where appropriate, in an effective manner,hair nets, head bands, caps, beard covers, or other effective hair restraints. (8)Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 5 residents (Resident #65) and 1 of 1 facility reviewed for accident hazards, in that: 1.The facility failed to ensure Resident #65 did not have a cigarette lighter and an alcoholic drink in her room on 7/28/25. 2.The facility failed to implement a policy and procedure to properly inspect the mechanical lift slings for signs of damage before each use and not removing damaged slings from service. These deficient practices could result in burn related injuries, medication interactions, and a loss of quality of life due to injuries if the damaged lift sling broke during transfer for residents that use a mechanical lift for transfers. The findings included: 1.Record review of a facility face sheet dated 7/30/25 for Resident #65 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants).Record review of a quarterly MDS assessment dated [DATE] for Resident #65 indicated a BIMS score of 13, which indicated she was cognitively intact. She was independent with most ADLs.During an observation on 7/28/25 at 9:57 a.m. a cigarette lighter was observed on the overbed table of Resident #65 and an alcoholic drink labeled Buzz Ball was observed in her personal refrigerator. Drink was labeled as 15% alcohol by volume. During an observation on 7/28/25 at 2:00 p.m. Resident #65 was observed lying in bed. She said the lighter was hers, but could not say why she had it, she just said she'd always kept it on her table. She said she does not smoke. She said she does not drink alcohol, and the drink in the refrigerator was just a chocolate drink.During an interview on 7/28/25 at 2:15 p.m. Administrator said they had no residents that were allowed to have cigarette lighters or alcohol in the facility. She said they were a non-smoking facility. She said Resident #65 would often go out of the facility with family and probably brought them back in after a visit. The Administrator said Resident #65 had no order for alcohol consumption.During a joint interview on 7/30/25 at 12:50 p.m. DON and Administrator both said the cigarette lighter, and alcohol could be a safety issue and lead to falls, interactions with medications, or injury. Administrator said going forward, she would be educating residents regarding prohibited materials and would be more mindful during administrative rounds. Record review of a facility policy titled Smoking Policy (Resident/Family Copy), undated, from facility admission packet read: .Smoking tobacco, matches, lighters, or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession.Record review of a facility policy titled Alcoholic Beverages, dated October 2010, read: .alcoholic beverages must be treated as medication and stored in the medicine room.2.During an observation on 7/30/2025 at 8:45 AM 4 mechanical lift slings were hanging on drying hooks in the clean area of the laundry department. 4 of 4 slings the care labels were illegible, and one sling had fading of the blue, green and purple connection straps. The Housekeeping Supervisor said she was responsible for the laundry in the facility including washing and drying of the lift slings used for resident transfers with a mechanical lift. She said the lift slings were washed and hung to air dry after resident use. She said if a lift sling was worn or frayed, had tears she would take them to nursing staff for them to remove from service. She said she was not aware that the slings should be taken out of service of the connection loops were faded and the care labels were illegible. The Housekeeping Supervisor said the facility had obtained new mechanical lift slings, but the new mechanical lift slings had not been put into service. During an interview on 7/30/2025 at 12:25 PM the ADON said all nursing staff members were responsible for ensuring all mechanical lift slings were in good condition and safe for use. She said the Restorative Aide in the therapy department oversees the mechanical lift use and sling conditions. She said the risk to the resident was a fall with injury if the lift sling broke. During an interview on 7/30/2025 at 12:30 PM Administrator said the mechanical lift slings should be replaced if worn or faded in color. She said the risk to the resident was a fall with injury if the lift sling broke.Record review of Nursing Services Policy and Procedure Manual for Long-Term Care Lifting Machine, using a Mechanical dated 2001 MED-PASS, Inc. (Revised July 2017) Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device.It is not a substitute for manufacturer's training or instructions.8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.Sling Care:1. Disinfect slings between residents (unless disposable).2. Wash and sanitize according to manufacturer's instructions.3. Discard any worn, frayed or ripped slings.Record review of Full Body Slings- Medline, Manufacturer's instructions for use www.medline.com accessed 07/30/25 indicated .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices.Check condition before each use. If there is any fraying or visible wear and tear, do not use. Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry.Record review of the manufacturer instructions for Proactive full body slings accessed https://proactivemedical.com/products/lifts-slings/patient-slings/full-body-sling/ accessed 07/30/2025 indicated, .Proactive medical products . Guideline for Identifying Deteriorated Slings Accelerated Deterioration from Bleach, High Temperature Wash or Drying Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a patient or resident. This Guide is intended to help staff and caregivers better identify slings that have been exposed to above laundry conditions and subsequent loss of tensile strength. We encourage any sling identified with the following characteristics to be removed from service immediately as a preventive measure. Proactive Medical slings have been designed and tested for laundry wash conditions of 170F degrees and air dry or dry at low temperature. The slings should never be bleached. Commercial washer and dryers are not recommended. Care instructions on the sling label should always be followed. Completely Faded / Missing / Illegible Tag while the main body of the sling fabric is still intact and in relatively good condition. Colors are not faded or show very little fading .

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 3 of 10 residents (Resident's #4, #16, and #23) reviewed for MDS assessment accuracy. 1.The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #4 captured a significant weight gain of 12.2% in 6 months. 2.The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #16 captured a significant weight loss of 5.8% in 1 month. 3.The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #23 captured a significant weight loss of 13% in 6 months. This failure could place residents at risk of not receiving adequate care and services to meet their needs.Findings include: 1. Record review of a facility face sheet dated 7/30/25 for Resident #4 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens). Record review of monthly weights for Resident #4 indicated she experienced a significant weight gain of 12.2% in six months. Resident #4's weights were: 02/06/2025 193.2 lbs and 07/02/2025 216.8 lbs. Record review of a quarterly MDS assessment dated [DATE] for Resident # indicated Section K 0310 answer recorded was no, indicating that Resident #4 had no weight gain of 10% or more in 6 months. Record review of a comprehensive care plan updated on 7/23/25 for Resident #4 indicated she had an alteration in nutrition related to significant weight loss. 2. Record review of a facility face sheet dated 7/30/25 for Resident #16 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness). Record review of a Quarterly MDS assessment dated [DATE] for Resident #16 indicated a BIMS score of 14, indicating she was cognitively intact. She required set up or clean up assistance with eating. Section K (Swallowing/Nutritional Status) indicated Resident #16 had not had a weight loss of 5% or more in one month or weight loss of 10% or more in six months. Record review of weights in an electronic medical record for Resident #16 indicated that on 6/9/25, her weight was recorded as 107.4 lbs and on 7/2/25 her weight was recorded as 101.2 lbs, which was a 5.8% loss in 1 month. Record review of a comprehensive care plan updated on 7/2/25 for Resident #16 indicated she had an alteration in nutrition related to significant weight loss. 3. Record review of a facility face sheet dated 7/30/25 for Resident #23 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of cerebral infarction (stroke). Record review of a Quarterly MDS assessment dated [DATE] for Resident #23 indicated a BIMS score of 6, which indicated severely impaired cognition. She was independent with eating. Section K (Swallowing/Nutrition Status) indicated there had been no weight loss of 5% or more in one month or loss of 10% or more in six months. Record review of weights in an electronic medical record for Resident #23 indicated that on 6/3/25, her weight was recorded as 137 lbs and on 12/16/24 her weight was recorded as 158 lbs, which was a 13% loss in 6 months. Record review of a comprehensive care plan dated updated on 6/26/25 for Resident #23 indicated she had an alteration in nutrition related to significant weight loss. During an interview on 7/30/25 at 12:45 pm MDS nurse said she had been doing MDS assessments for over 17 years. She said she must have just overlooked those residents' weights when doing those assessments. She said if the MDS was not accurate, then needed care may not be included on the care plans. She said going forward, she would ensure she got a copy of the weight gains and losses to ensure accurate MDS assessments. During a joint interview on 7/30/25 at 12:50 pm DON said she had been at the facility since March 2025 and the MDS nurse was responsible for MDS assessment accuracy. Administrator and DON both said the care plans were generated from the MDS triggers and if the MDS assessment was not completed accurately, then some things may not get added to the care plan. DON said she would educate MDS nurse on accuracy of assessments and going forward, she expected MDS assessments to be completed accurately. Record review of a facility policy titled Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy, undated, read: .The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. and .Federal regulations at 42 CFR 483.20 (b) (1) (xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status.

49017 Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #11, #12, and #43) reviewed for infection control. The facility failed to ensure CNA C sanitized or washed her hands between glove changes, CNA D changed gloves while providing incontinent care to Resident #11 and Resident #43 on 6/24/2024. The facility failed to ensure the COTA (certified occupational therapy assistant) followed enhanced barrier precautions when she provided care to Resident #12 on 6/24/2024. These failures could place residents at risk for cross contamination and infection. Findings included: 1. Record review of a face sheet dated 6/25/2024 for Resident #43 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of dysphagia (a swallowing disorder that may be due to various neurological, structural, and cognitive deficits), chronic respiratory failure (when the airways that carry air to your lungs become narrow and damaged), cognitive communication deficit (are problems with communication that have an underlying cause in a cognitive deficit), and hemiplegia and hemiparesis following cerebral infarction (total or nearly complete paralysis on one side of the body). Record review of a Quarterly MDS assessment dated [DATE] for Resident #43 indicated she had moderate impairment in thinking with a BIMS score of 9. She was always incontinent of bladder and always incontinent of bowel. Record review of a care plan revised 3/22/2024 for Resident #43 indicated an ADL self-care performance deficit. She required the extensive assist of direct care staff member for ADL completion for toilet use. During an observation on 6/21/2024 at 10:10 AM, CNA C and CNA D were in the room of Resident #43 to provide incontinent care. Both washed their hands and put on gloves. Supplies were in a plastic bag on the over bed table. CNA C assisted with positioning and holding the resident. CNA C and CNA D opened the brief and pulled it down between Resident #43's thighs. CNA D removed a wipe from the plastic bag and wiped the resident's right inner thigh and folded it over and wiped the left inner thigh and placed the wipe in the trash. CNA D removed a wipe from the plastic bag and wiped up the middle of the vagina from front to back. CNA C rolled Resident #43 onto her left side. CNA D removed wipes from the plastic bag and wiped Resident #43's perineal area from front (vagina) to back (buttocks) and placed wipe in the trash. CNA D rolled the soiled brief under Resident 43's buttocks and rolled Resident 43 to her right side. CNA C removed soiled brief and placed it in the trash. CNA C removed her gloves and placed in the trash and put clean gloves on without sanitizing hands. CNA C placed clean brief under Resident 43 and rolled Resident 43 to her left side. CNA D positioned clean brief under Resident 43. Resident #43 was rolled onto her back and the brief was secured by CNA C and CNA D and the resident was repositioned in the bed. CNA C removed her gloves and exited the room. CNA D removed her gloves and washed her hands. CNA D did not change her gloves while providing incontinent care and repositioning Resident #43. During an interview on 6/21/2024 at 10:20 AM, CNA C said she had been employed at the facility for less than 1 year and worked on the 6 am-2 pm shift. She said with the incontinent care provided to Resident #43 earlier, she should have washed her hands between glove changes. She said that she did not have hand sanitizer with her while providing care to Resident 43. She said that the facility did provide hand sanitizer for the staff. She said that the facility does in services on hand hygiene and infection control. She said residents could be at risk of infections if staff did not wash or sanitize their hands between gloves changes. During an interview on 6/21/2024 at 10:25 AM, CNA D said that she had been employed with the facility for [AGE] years and worked the 6-2 shift. She said that she should have changed gloves and sanitized her hands while providing incontinent care to Resident #43. She said that the facility provided training on hand hygiene and infection control. She said that the residents were at risk for infection if hand hygiene is not practiced. 2. Record review of a face sheet dated 6/25/2024 for Resident #11 indicated she was admitted to the facility on [DATE] and was [AGE] years old with the diagnosis of hypertension (high blood pressure), polyosteoarthritis (a degenerative joint condition that causes pain, stiffness, and inflammation), and dementia (a loss of cognitive functioning that interferes with daily life). Record review of a comprehensive MDS dated [DATE] for Resident #11 indicated she had severe impairment in thinking with a BIMS score of 3. She was always incontinent of bladder and incontinent of bowel. Record review of a care plan revised 4/18/2024 indicated that she required extensive to total assistance with ADL care related to dementia and failure to thrive and that Resident #11 was incontinent of bladder and bowel. During an observation on 6/21/2024 at 2:15 PM, CNA D was in the room of Resident #11 to provide incontinent care. CNA D washed her hands and put on gloves. Supplies were in a plastic bag on the over bed table. CNA D opened the brief and pulled it down between Resident #11's thighs. CNA D removed a wipe from the plastic bag and wiped the resident's right inner thigh and folded it over and wiped the left inner thigh and placed the wipe in the trash. CNA D removed a wipe from the plastic bag and wiped down the middle of the vagina from front to back. CNA D rolled Resident #11 onto her left side. CNA D removed wipes from the plastic bag and wiped Resident #11's perineal area from front (vagina) to back (buttocks) The soiled brief was removed from Resident #11. CNA D removed a brief from the plastic bag and placed it underneath the resident's buttocks. Resident #11 was rolled onto her back and the brief was secured and the resident was transferred to wheelchair with assist of another CNA. CNA D removed her gloves and sanitized her hands before exiting the room. CNA D did not change gloves or sanitize her hands while providing incontinent care to Resident #11. 3. Record review of a facility face sheet dated 6/25/24 indicated Resident #12 was [AGE] years old and admitted on [DATE] with diagnosis of disruption of surgical wound. Record review of an admission MDS assessment dated [DATE] indicated a BIMS score of 00 indicating severely impaired cognition and t required maximum assistance with all ADL care. Record review of an acute care plan dated 5/31/24 indicated Resident #12 had a wound and required EBP. Record review of consolidated orders dated 6/25/24 indicated Resident #12 had no order for EBP (enhanced barrier precautions). During an observation on 6/24/24 at 9:47 am, Resident #12 was observed with signs posted on door for Enhanced Barrier Precautions and PPE outside the room. During an observation on 06/24/24 at 2:06 PM, the COTA (certified occupational therapy assistant) was observed transferring Resident # 12 without wearing PPE. The COTA applied gloves and then placed a gait belt around Resident #12's waist. She positioned her next to the bed, locked the wheelchair, and transferred Resident #12 to a sitting position on the side of the bed. COTA then placed her arm around Resident #12's back and legs and turned her into a lowered position in the bed. The COTA removed Resident #12's bra and placed a heel boot on her left foot. The COTA then positioned Resident #12's blanket, call light and remote to the bed. The COTA then adjusted the table next to the bed. She removed her gloves and washed her hands before leaving the room. During an interview on 06/24/24 at 2:16 pm, the COTA said she worked at the facility as needed and had been a COTA for [AGE] years. She said she was trained by facility staff on EBP and should have put on a gown and gloves before performing care and just got nervous and forgot. She said by not following the EBP, cross contamination could have occurred. During an interview on 06/24/24 at 2:50 pm, the ADON said if a resident required EBP, then signs were posted and PPE were placed outside the room. The ADON stated staff were educated on the precautions, and the infection prevention nurse was notified. She said the infection prevention nurse completed an acute care plan. She said if EBP was not followed, it could introduce residents to infections. During an interview on 06/24/24 at 2:58 pm, the infection prevention (IP) nurse said she has been the IP nurse since February 2024 and when EBP was determined for a resident, the resident and family were educated, signs were posted on the doors and PPE was placed outside the room. She said she then provided education to the staff and completed an acute care plan for the EBP reason. She said that staff that did not follow EBP could place residents at risk of infections. During an interview on 6/26/2024 at 9:50 AM, the DON said she had been employed at the facility for [AGE] years and has been the DON for almost 1 year. She said EBP was for any resident that had a history of MDRO's (multi drug resistant organisms), current chronic wounds, feeding tubes, and foley catheters. She said EBP would stay in place for residents that had MDRO's indefinitely. She said staff were supposed to wear a gown and gloves when they are providing care that would include contact with the resident, when linens were changed, bathing, incontinent care, and wound care. She said staff were aware of the residents that had EBP in place because they placed protocols on the resident's door. She said the infection preventionist monitored that staff were following EBP protocols. She said there was a risk of spreading MDRO's to other residents if staff did not follow EBP. She said hand hygiene should be performed before care, between care, before and after glove changes and after care was provided. She said glove changes occurred during incontinent care when gloves were visibly soiled and after disposing soiled briefs and prior to placing clean brief on resident. She said would be performing hand hygiene and infection control in services for all staff as well as one on one hand hygiene check offs with direct care staff. She said residents could be a risk of infections if staff did not wash or sanitize their hands. During an interview on 6/26/2024 at 10:15 AM, the Administrator said EBP was for residents that had MDRO's, chronic wounds, and implanted devices to prevent spreading of bacteria. She said staff should don (put on) and doff (take off) gown and gloves to prevent cross contamination for residents who were on EBP. She said staff should wash or sanitize their hands anytime gloves were changed, and staff should be changing gloves during incontinent care. She said there was a risk of contamination and infections if staff did not wash their hands after glove changes or change their gloves when appropriate. Record review of a CNA Proficiency Skills Check dated 4/25/2024 for CNA C indicated she was satisfactory in perineal care for a female along with infection control on hand washing. Record review of a CNA Proficiency Skills Check dated 12/21/2023 for CNA D indicated she was satisfactory in perineal care for a female along with infection control on hand washing. Record review of course certification dated 3/30/24 indicated the COTA was trained on EBP. Record review of a facility policy titled Handwashing/ Hand Hygiene revised August 2015 indicated, .Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . j. after contact with blood or bodily fluids .m. after removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. The policy also indicated, Perform hand hygiene before applying non-sterile gloves and after removing gloves. Record review of CMS QSO-24-08-NH titled Enhanced Barrier Precautions in Nursing Homes dated March 20, 2024 indicated, .EBP is indicated for residents with chronic wounds, surgical wounds

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #27) reviewed for quality of care. 1. The facility failed to ensure Resident #27's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: Record review of a facility face sheet dated 6/25/2024 indicated Resident # 27 was a [AGE] years old female and admitted on [DATE] with diagnosis of heart disease and urinary retention. Record review of a comprehensive care plan dated 3/22/24 indicated Resident #27 was at risk for complications related to Foley catheter and to provide catheter care every shift. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #27 had a BIMS score of 08 indicating moderately impaired cognition, and she required an indwelling catheter. During an observation and interview on 6/25/24 at 9:45 am, Resident # 27 was observed with an indwelling catheter with no securement device for the catheter. Resident # 27 said there was a pulling feeling in her private area at times. During an interview on 6/25/24 at 9:55 am, CNA B said that when care was provided to a resident with a catheter, she made sure the catheter was not pulled but did not check for a securement device. She said the nurses were responsible for placing the securement device. She said a catheter that was not secure could come out or cause pain. During an interview on 6/25/24 at 1:11 pm, LVN A said she had been at the facility for 4 years. She said that residents with an indwelling catheter should be checked every shift and a securement device should be in place to prevent discomfort and dislodgment. She said she had received competency training on indwelling catheters and care. During an interview on 6/26/24 at 10:43 am, the DON said the charge nurses were responsible for checking residents with catheters each shift and each resident with a catheter should have a securement device. She said she was responsible for all nursing oversight and training and nurses had been trained on catheter assessment and ensuring a securement device was in place. She said if a catheter was not secure it could cause abrasions and become dislodged. During an interview on 6/26/24 at 10:46 am, the Administrator said that nursing management was responsible for overseeing that each resident with a catheter had a securement device. She said that an unsecured catheter could cause, pain, infections, and affect the skin. She said she expected the policy to be followed and that all residents with a catheter, had a securement device. Record review of competency check dated 01/26/2024 for catheter care for LVN A indicated LVN A was trained on catheter care and securing catheter according to policy. Record review of facility policy titled Evidenced Based Best Practices: Indwelling Bladder Catheters dated 01/2024 indicated, .the catheter tubing should be secured to prevent accidental displacement .

Based on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for nurse staffing information for 5 of 5 days (6/21/24, 6/22/24, 6/23/24, 6/24/24 and 6/25/24). The facility failed to ensure the daily staffing information was accurate and posted daily for 6/21/24, 6/22/24, 6/23/24, 6/24/24 and 6/25/24. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings: During an observation on 6/25/2024 at 9:00 am, there was a daily staffing posting for the facility on the 200-hallway bulletin board (not in a central location, easily visible to all residents and visitors) dated 6/21/2024. The staffing form was blank for reporting the daily census. The form was not easily legible to all residents and visitors due to misprinting of the copied form. During an interview on 06/25/24 at 9:41 am, the Assistant Regional Nurse said the facility should post the nurse staffing information for each discipline daily with the facility census. She said she could see if the posting was not posted and visible for residents and visitors, they could think there were not enough staff present to provide care. She said the restorative aide was responsible for the daily staff posting. The Assistant Regional Nurse said she would correct the posting and place the posting on a wall at the entrance so all residents and visitors could view it. During an interview on 06/25/24 at 10:00 am, the DON said the restorative aide was responsible for posting the staffing information and she should have been ensuring that it was posted. She said they would also start a binder to store the information for 18 months per the regulation. She said by not having the information posted residents and visitors might not think there was sufficient staff present to provide care. During an interview on 06/25/24 at 10:20 am, the Administrator said the restorative aide was responsible for posting the nurse staffing information. She said she was not sure when the last time the nurse staffing information was posted but would correct the problem and place the sign per the regulations that day. She said there was no policy for nurse staffing information. Record Review of a staffing policy undated titled Staffing read: .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and an environment free from hazards for 2 of 10 residents (Resident #1 and Resident #3) reviewed in that: 1. The facility failed to ensure Resident #1 did not sustain bruises due to her side rails. 2. The facility failed to ensure Resident #1 sustained bruises due to an improper transfer by an outside hospice aide. Resident #1 was a two person transfer and was transferred by one person. 3. The facility failed to ensure Resident #3 did not sustain at least two falls with side rails on his bed. 4. the facility failed to ensure Resident # 3 a resident did not suffer injuries from side rails. An IJ was identified on 2/8/24. The IJ began on 11/2/23and removed on 12/21/23. While the IJ was removed on 12/21/23, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because (e.g.) all staff had not been trained on fall interventions for residents at a high risk for falls. These failures placed residents at risk for physical harm. Findings Included: Record review of Resident #1's Annual MDS assessment dated [DATE] indicated Resident #1'scogntition was moderately impaired. She required extensive assist with bed mobility of one person. She did not get out of bed often but required two people for assistance. Resident #1 required extensive assist with dressing, she was totally dependent on one staff for eating, dressing, and toilet use. The MDS indicated the resident had limited range of motion, she had lower and upper extremities impairment on the left and right sides. She used a wheelchair for mobility. The MDS also indicated she did not have any restraints. Record review of Resident #1's acute care plan dated 6/14/22 indicated to pad the bed rails. Record review of Resident #1's hospice care plan dated 6/6/23 indicated the patients ADLS and personal care needs will be met with hospice aide. Record review of Resident #1's initial assessment for use of physical restraints dated 6/19/23. The reason listed for use of physical restraint was to aide in turning and positioning. The alternatives attempted was listed as siderail. The decision to restrain was the family and resident requested the siderails. The form stated a physician order is required. The family and resident were educated regarding the risks and safety of siderails and wished to continue risks. Record review of a fax cover sheet dated 6/12/23 indicated was called to Resident #1's room for a bruise to the lower left forearm measuring 13 cm x 7 cm. There were no signs and symptoms of pain. The resident reported hitting it on the siderail. Record review of a physician communication form dated 6/14/23 indicated Resident #1 had a bruise on her forehead and left inner elbow. The Resident thinks she did it while repositioning. Record review of Resident #1's nursing notes indicated on 7/3/23 at 7:30 p.m., an aide reported a dark purple discoloration of 16 cm x 11 cm to Resident #1's right shoulder and extending down to the breast area with edema noted. There were no signs and symptoms of distress or complaint of pain at this time. The hospice, MD, DON, and Administrator were notified as well as the RP. At 8:00 p.m., received an order from the MD to have right shoulder x-rayed. At 11:00 p.m. the hospice nurse was in the facility. Signed by LVN A. Review of a nursing note dated 7/4/23 at 12:00 a.m. indicated the hospice physician wanted to hold Aggrenax (blood thinner) at this time. At 7:30 p.m. x ray results received. Record review of hospice notes dated 7/3/23 indicated a hospice Aide was at the facility around 9:30 a.m. and provided care to the resident. She gave her a bed bath, changed the sheet, and provided ADL services. Record review of a hospice RN note dated 7/3/33 at 11:17 p.m. indicated a head-to-toe assessment was completed. Resident #1 was lying in bed sleeping. She reported pain to a bruised area on the right side of chest and shoulder area with light palpation. The area had a bruise with edema noted to the right upper arm and chest. The patient had right sided paralysis with contractures to the right hand and hardened raises area near the right elbow. It was unknown if new finding or related to right sided contracture from stroke. The physician was informed and ordered x-rays. The facility reported new onset of bruising, swelling and pain to right shoulder and right chest. Routine medications used for pain relief in the last 24 hours Tylenol routine and PRN doses were administred. The resident reported the area had moderate, severe pain, was aching and sore, and painful on movement and all activities. Record review of Resident #1's discharge summary indicated she was discharged on [DATE] to a facility closer to family. During an interview on 2/6/24 at 11:57 a.m., LVN A said Resident #1 had bruise on her shoulder that was reported and one of the hospice CNAs had seen it. She said she was not sure about bruise on the head. LVN A said Resident #1 was a two-person transfer, and she would fight during care. She said hospice would come and give bed baths in the morning. During an interview on 2/6/24 at 12:45 p.m., the ADON said Resident #1 had a bruise and her investigation indicated she had a history of favoring her right side. She had a large hematoma, eventually it was drained. She stated the family did not want her going to the hospital; she was on hospice there were some broken ribs, but she did not receive treatment. It was several weeks later before she was sent to the hospital to have the hematoma drained. She said the blood pooled in one spot and formed a large knot. She was under hospice care when she was transferred and something put some pressure on it which caused bruising. The ADON said Resident # 1 was a resident of the facility for [AGE] years. She said that staff reported Hospice aide said she knew the bruise was there and Resident #1 required two people to transfer. The hospice aide transferred her by herself, and did not report the bruise. She knew the bruise was there that morning but did not report it to anyone in the facility or to the hospice agency. The ADON said the incident where the resident bumped her head, she could not have bumped it on the wall due to the way the bed was situated. She said it was a possibility she bumped her head on the siderail. Resident #3 Record review of Resident #3's Face sheet dated 9/19/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were Parkinson's disease, abnormalities of gate and mobility, history of falling, trimmers, dementia, and anxiety. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #3's cognitive score was not listed. He required partial to moderate assistance to bed roll left to right, sitting to lying, lying to sitting on the side of the bed, sit to stand, chair to bed transfer and toilet transfer. The MDS indicated the resident required partial to moderate assist with walking 10 feet once standing and the ability to walk 150 in the corridor once standing did not occur. Record review of Resident #3 Care Plan dated 7/26/23 indicated a focused area of limited supervision with ADLs. Some of the interventions were. One to two aides to transfer the resident as needed. Assist with dressing and grooming by one to two CNA's and encourage the resident to assist as much as possible. A focused area that indicated Resident #3 had a history of Falls, related to gait pattern, changes, when walking, and functioning status, and unsteady gate. The resident had diagnoses of Parkinson's and Lewy body dementia. The resident had confusion. Disorientation, lack of familiarity with surroundings, and impaired judgments/decision-making. The plan had a note at the bottom that said see acute care plans for actual files, dated 10/19/23. Record review of Resident # 3 Fall assessment dated [DATE] indicated prior to admission. The resident had multiple falls, and he was on Psychotropics, and he had problems by exhibiting loss of balance while standing. Record review of Resident #3 bed Rail and Assistive Bar evaluation dated 7/3/23 indicated Resident #3 had half Rails on the left side of the bed. Record review of Resident #3 Incident report dated 9/10/23 indicated at 7:50 a.m. The resident was confused and disoriented bed rails were ordered, and bed rails were present. Called to the room and noted the resident laying on his back in between the chair and the bed feet towards the TV, head towards the head of the bed as resident what happened and he stated, I do not feel good. Record review of Resident #3 Acute care plan dated 9/10/23. Indicated the resident was observed on the floor in room between the bed and the chair. The approach was insured. The resident had proper footwear. Record review of Resident #3 Acute care plan dated 9/23/23 indicated the resident was observed on the floor in the room in front of the AC unit. The approach was to ensure the room has the proper comfortable temperature. Record review of Resident #3 Acute care plan dated 10/2/23 indicated the resident was observed on the floor against the bed with the laceration to the right eyebrow. The approach was to conduct a medication review. Record review of Resident #3 Acute care plan dated 10/ 29/23 indicated the resident was observed on the floor. Some of the approaches were to place mats by the bed and to conduct 15-minute checks. Record review of Resident #3 Incident report dated 11/2/23 indicated at 9:15 PM. The resident was confused and disoriented he had side rails ordered and the side rails were present. The aide alerted the nurse the resident had fallen. When in the room the resident was laying on his left side left side beside his bed. The resident cried out in pain when attempting to move his left leg, the resident was assessed and sent to the hospital. Record review of resident #3 Provider investigation report dated 11/2/23 indicated around 9:15 PM. The resident was found on the floor Resident #3 was laying on his left side on the floor by his bed with fall mat in place. The resident voiced pain and was sent to the hospital for evaluation. Resident #3 Was diagnosed with an acute displaced angulated fracture of the neck of the hip. The resident was admitted to the hospital for consultation with an orthopedic surgeon. Record review of Resident #3 Acute care plan dated 11/2/23 indicated the resident was observed on the floor. The goals were 15-minute check times 72 hours and 30-minute check times, and a scoop mattress. Record review of Resident #3 Hospital Records dated 11/3/23 indicated the patient had complained of severe pain on the left hip. His x-ray and CT scan of the pelvis found that the patient has a left hip fracture. Record review of Resident # 3's incident reports indicated he had 10 falls between 9/5/23 and 11/2/23. During an interview on 2/5/24 at 3:55 p.m. the Administrator said Resident #3 was found on the floor, sent to the hospital, and had a fractured. She said he had participated in therapy for few weeks and then they put him back on Hospice. She said he had a history of falls, diagnosis of Parkinson's and dementia. The Administrator said he passed away before Christmas. During an interview on 2/6/24 at 2:17 p.m. CNA C said she worked with Resident #3 and had laid him down on 11/2/23 around 9:15 p.m. He is usually up during the night, so we tried to put him down at the end of the shift, hoping he was all tired out. She said they (CNA E) left the room and it was only a few minutes. She said they heard a big bang. She said she thought he climbed over the rail. CNA C said Resident # 3's rail was up because she put them up before leaving the room. The aide said Resident #3 came over or around the half rail. CNA C said she had to re write the statement and take out the side rail part. She said she did not see him fall, but the rail was up. He his head was on the fall mat and his arm was under the chair. During an interview on 2/6/24 at 2:45 p.m. CNA E said we (CNA C) had just put Resident #1 in the bed on 11/2/23. She said they did everything right, went back to the seating area, heard a noise and he was on the floor. CNA E said Resident # 3 was a two person assist and he had two side rails on the bed. He was declining in his health, and he was restless. She said they were waiting for him to wind down and be ready to go to bed. She said she did not know how he got out of the bed, they heard a big boom, he was on the floor. She said the rail was still up when they went into the room. During interview on 2/6/24 at 3:04 p.m. LVN F said she thought Resident #3 was trying to get up to use the restroom. She said when she had gone in the room, he was on the floor between the bed and the chair. She said he could not stand unassisted, he could stand with two people assisting him, and could not bear all his weight. She said she did not remember if he had a scoop mattress or side rails. He did break his hip with that fall and had been on hospice prior to the fall. During an interview on 2/6/24 at 3:27 p.m., the DON stated Resident #3 fell out of his bed and sent to ER and had a fractured hip. He was admitted on hospice at that time. During an interview on 2/7/24 at 11:28 a.m. the ADON said she Resident #3 did not have side rails. He was not supposed to have any and if he did, she was not aware of the rails. She said she was working to reduce the side rails in the building.

Based on interview and record review the facility failed to implement written policies that prohibit abuse for 1 of 4 residents reviewed ( Resident #2) in that: The facility failed to ensure CNA B reported, to the abuse coordinator, Resident #1's allegation of sexual assault after she was informed of it by Resident #1's roommate. An Immediate Jeopardy (J) situation was identified on 2/7/24 at 3:35 p.m. as PNC. The noncompliance began on 9/30/23 and ended on 10/12/23. The facility corrected the noncompliance before the survey began. This failure caused a delay in retrieving possible evidence and could have caused serious harm, if the abuse was allowed to continue. Findings included: Record review of resident #2 Face sheet dated 9/19/23 indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Some of her diagnoses were schizoaffective disorder, major depression, severe with psychotic symptoms, and dementia. Record review of Resident #2 quarterly MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment. She required set up help with eating and hygiene, partial assist with showers and dressing. The resident was independent with rolling from left to right, and she required supervision with laying down and standing up. Record review of Resident #2 care plan dated 4/10/23. Indicated a Focus area of the resident received psychotic medication related to psychosis. The resident was taking antipsychotics before admission, and she went to outpatient program at the behavioral hospital three times a week. The resident had a history of giving things away and would forget that she gave them away. Some of the interventions were administer medication as needed, referred to psychiatric and social services as needed, and determine the cause of expressions, and if possible. Resident #2 Had a focused area of required limited assistance with ADLs. The resident required one person assist with transfers, and grooming and ADLs. Record review of Resident #2 Provider Investigation report dated 9/30/23 indicated the former roommate indicated Resident #2 was sexually abused by the outpatient clinic van driver. A full body assessment of the resident was conducted and showed no injuries. The resident attended a face-to-face appointment with her physician on 10/3/23 and a pelvic exam was completed. On 10/1/23 criminal investigation, division, interview resident with family member present. The local police department was notified and present at the facility on 9/30/23 to speak with the resident and family. The perpetrator was not employed with the facility. There were no other residents in the building were receiving services from the outpatient clinic . The resident was receiving weekly counseling services. Record review of a nursing progress note dated 9/30/23 at 12:15 p.m. indicated the nurse was informed the resident had alleged sexual assault and skin assessments were performed. At approximately 12:10 p.m. The sheriff's department spoke to the family and did not interview any other staff at that time. At 12:30 PM the sheriff came to the nurses' station and spoke to the writer and gave a description of the suspect, the writer called the behavioral hospital to get information on the van driver. At 3:39 PM. the nurse spoke to the resident's old roommate to see if she had heard of a confession from Resident #2. The roommate stated that the resident told her she was tired of being sexually assaulted. The roommate said Resident #2 would go to the outpatient clinic and her hair would look nice and she would come back in her hair was a mess. The roommate said Resident #2 told her that about three weeks ago. Record review of a statement written by CNA B dated 10/6/23 indicated when she was talking to the former roommate when she told her that Resident #2 had been molested at the Behavior Center around this time she stopped going to the outpatient clinic. She also thought that it was reported and that was the reason she was no longer going. The aid said she made a mistake by not going to report it to the Administrator. Because she thought it had already been reported. Record Review of labs collected from a pelvic exam on 10/3/23 with resulting labs completed 10/13/23 indicated there were no sexually transmitted diseases noted. Record review of a Corrective Action Form indicated CNA B was suspended due to failure to report an allegation of abuse to the abuse coordinator. The employee had been in-serviced on proper reporting requirements and was suspended pending investigation. The form did not have a date. Record review of an in-service conducted on 10/6/23 indicated staff were in-serviced on abuse and neglect and reporting abuse to the abuse coordinator. Record review of the QAPI Meeting sign-in sheet dated 10/12/23 indicated the medical director attended the meeting. The topic of discussion listed as Trauma informed and culturally competent care related to sexual abuse. The policy was required with QA and discussed the resident that experienced trauma due to sexual assault. Record review of the Sheriff's Office Report indicated it was initiated on 9/30/23 at 11:59 a.m. and closed on 12/15/23. The record indicated the case was closed due to lack of sufficient evidence. During an interview on 2/5/24 at 3:55 p.m., the Administrator said they called the Sheriff's Office, and the deputies came out the same day. She said a female deputy had interviewed Resident #2 multiple times. The Administrator said she did not know the outcome of those interviews; Resident #2 had not revealed anything to her staff. She said the SW and the counseling services had not gotten her to reveal anything to them. She said the Sheriff's office had basically handled the investigation; it was a criminal investigation. She suspended CNA B for not reporting the incident sooner. She said the police had not told her anything because the investigation was still on going. They had just suspended all services with the Behavioral Outpatient clinic at that time. However, they did not have any residents attending prior to being made aware of the incident with Resident #2. During an interview on 2/6/24 at 1:38 p.m. CNA B said Resident #2 was not going to the Outpatient Behavioral Clinic and seemed depressed. One day the roommate Resident #4 told her while they were in the bathroom that Resident #2 was upset because she had been F by the van driver. CNA B said she thought it was something that had already been reported because Resident #2 was no longer going to the program, so she did not report what the roommate had said. She said about 2 weeks later the family member came to her and said and something was wrong with Resident #2. The aide said at that time she told the family member what Resident #4 had told her. She said the family member was not aware and Resident #2 had never said anything. CNA B said she was suspended that day for not report the allegation to the Administrator. She said if anything like that ever happened again would report immediately. She said if she thought it was abuse or sounded like abuse she would report. CNA B said she knew what sexual abuse was but had not reported it because she thought the Administrator was aware. During an interview on 2/6/24 at 2:17 p.m., CNA C said she was aware of what abuse and neglect were; they were in-serviced all the time. She was able to identify the different types of abuse and neglect. She said if she heard or seen abuse, and she would immediately report to nurse and abuse coordinator. During an interview on 2/6/23 at 2:33 p.m. CNA D said he was able to identify the different types of abuse, multiple types of abuse, physical abuse, mental, verbal abuse, not seen or heard any abuse, and would report immediately to charge nurse and abuse coordinator. During an interview on 2/6/24 at 2:45 p.m., CNA E said she was able to identify different types of abuse and neglect. She said she had not seen or heard any abuse and would immediately report to the Administrator if she did. During an interview on 2/6/24 at 3:19, CNA G said she was familiar with abuse and neglect. She said if she heard or seen any abuse or neglect would report immediately to the abuse coordinator/Administrator. During an interview on 2/6/24 at 3:27 p.m., the DON said it was her understanding that Resident #2 was out to an outpatient service and one incident occurred. She said she did not know anything about the Resident #2's incident until they had taken statements. She said she knew the family stopped sending her to the outpatient clinic. She said Resident #2 never reached out to the facility staff, but apparently talked to the Sheriff's deputy. She said she did not know when occurred had to occurred sometimes before 9/14/23. She said when they go to outpatient treatment and the therapist recommended outpatient. The DON said she was not sure of what the process was. She said as far as she knew the resident may have requested to go, or the social worker may have completed a referral. She said they provided an outside service to the residents in the facility. The DON said the facility was responsible for getting them the clinic they provide their own transportation. During an interview on 2/6/24 at 4:00 p.m., Resident #2 said she did not remember the time frame for when she was molested by the van driver. She said she did remember the incident and provided details. She said she had not confided in anyone at the facility because she was embarrassed. She said she was feeling better now and was putting the incident behind her. During an interview on 2/6/24 at 4:22 p.m. the SW said she had worked at the facility for 3 years and during that time Resident #2 had never opened to her. She said she would try to explore things with her, but she never told her what happened. The SW said she went back and talked to her weekly and she would not tell me anything. She said the process that took place was the Outpatient liaison would come to the facility and did activities with the residents. The SW said if the liaison thought any of the patients qualified, and some with prior behavior hospital inpatients. She said she did not remember how long Resident #2 was the only resident attending the program. She said she discussed with the family member Resident #2's her depression. The SW said they started to note a change with Resident 2. The family member requested on 8/29/23 to change the amount of days Resident #2 attended from 5 days a week to 3 days a week. The Resident #2 continued to be depressed and lost weight and it was the family's decision to stop the Outpatient program. The SW said the family thought that may be too much for her so on 9/14/23 Resident #2 stopped attending the program. During an interview on 2/7/24 at 3:10 a.m. the Administrator said she had counseled CNA B about not reporting the incident with Resident #2 on 9/30/23 and she was suspended that day. The Administrator said she had spoken to the aide several times during the next few days, and they had done the counseling. The initial counseling started on 9/30/23. She said they had in serviced on abuse and reporting. They had also taken the issue to QA and discussed trauma informed care. Record review of the facility Abuse policy last revised April 2021 indicated If Resident abuse was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury or withing 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident has the right to be free from abuse. Protect residents form abuse from staff from other agencies, visitors, or any individual.

Based on interview and record review, the facility failed to report an allegation of abuse 1 of 4 residents reviewed ( Resident #2) in that: CNA B did not report to the abuse coordinator Resident #1's allegation of sexual assault after she was informed of it by Resident #1's roommate. This failure caused a delay in retrieving possible evidence and could have caused serious harm, if the abuse was allowed to continue. Findings included: Record review of resident #2 Face sheet dated 9/19/23 indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Some of her diagnoses were schizoaffective disorder, major depression, severe with psychotic symptoms, and dementia. Record review of Resident #2 quarterly MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment. She required set up help with eating and hygiene, partial assist with showers and dressing. The resident was independent with rolling from left to right, and she required supervision with laying down and standing up. Record review of Resident #2 care plan dated 4/10/23. Indicated a Focus area of the resident received psychotic medication related to psychosis. The resident was taking antipsychotics before admission, and she went to outpatient program at the behavioral hospital three times a week. The resident had a history of giving things away and would forget that she gave them away. Some of the interventions were administer medication as needed, referred to psychiatric and social services as needed, and determine the cause of expressions, and if possible. Resident #2 Had a focused area of required limited assistance with ADLs. The resident required one person assist with transfers, and grooming and ADLs. Record review of Resident #2 Provider Investigation report dated 9/30/23 indicated the former roommate indicated Resident #2 was sexually abused by the outpatient clinic van driver. A full body assessment of the resident was conducted and showed no injuries. The resident attended a face-to-face appointment with her physician on 10/3/23 and a pelvic exam was completed. On 10/1/23 criminal investigation, division, interview resident with family member present. The local police department was notified and present at the facility on 9/30/23 to speak with the resident and family. The perpetrator was not employed with the facility. There were no other residents in the building were receiving services from the outpatient clinic . The resident was receiving weekly counseling services. Record review of a nursing progress note dated 9/30/23 at 12:15 p.m. indicated the nurse was informed the resident had alleged sexual assault and skin assessments were performed. At approximately 12:10 p.m. The sheriff's department spoke to the family and did not interview any other staff at that time. At 12:30 PM the sheriff came to the nurses' station and spoke to the writer and gave a description of the suspect, the writer called the behavioral hospital to get information on the van driver. At 3:39 PM. the nurse spoke to the resident's old roommate to see if she had heard of a confession from Resident #2. The roommate stated that the resident told her she was tired of being sexually assaulted. The roommate said Resident #2 would go to the outpatient clinic and her hair would look nice and she would come back in her hair was a mess. The roommate said Resident #2 told her that about three weeks ago. Record review of a statement written by CNA B Dated 10/6/23 indicated when she was talking to the former roommate when she told her that Resident #2 had been molested at the Behavior Center around this time, she stopped going to the outpatient clinic. She also thought that it was reported and that was the reason she was no longer going. The aid said she made a mistake by not going to report it to the Administrator. Because she thought it had already been reported. Record Review of labs collected 10/3/23 indicated they were all negative, and also labs collected 10/13/23 indicated they were all negative as well. Record review of a Corrective Action Form indicated CNA B was suspended due to failure to report an allegation of abuse to the abuse coordinator. The employee had been in serviced on proper reporting requirements an was suspended pending investigation. The form did not have a date. Record review of an Inservice conducted on 10/6/23 indicated staff were in serviced on abuse and neglect and reporting abuse to the abuse coordinator. Record review of QAPI Meeting sing in sheet dated 10/12/23 indicated the medical director attended the meeting they had topic of discussion listed as Trauma informed and culturally competent care related to sexual abuse. The policy was required with QA and discussed the resident that experienced trauma due to sexual assault. Record review of Sheriff's office Report indicated it was initiated on 9/30/23 at 11:59 a.m. and closed on 12/15/23. The record indicated the case was closed due to lack of sufficient evidence. During an interview on 2/6/24 at 12:45 p.m. the ADON said Resident #2 was going to Out Patient Clinic and had a report the van driver for that facility was inappropriate with her. She said she went to her physician, and they completed a pelvic exam and made sure it was all clear. She said the problem was the timing was off she could not say exactly when it happened, and by the time Resident #1 had already stopped going to the clinic, and the incident had happened some weeks before then. The ADON said Resident #2 started having issues with depression and would not eat about a month before the alleged abuse was discovered. During an interview on 2/6/24 at 1:38 p.m. CNA B said Resident #2 was not going to the Outpatient Behavioral Clinic and seemed depressed. One day the roommate Resident #4 told her while they were in the bathroom that Resident #2 was upset because she had been F by the van driver. CNA B said she thought it was something that had already been reported because Resident #2 was no longer going to the program, so she did not report what the roommate had said. She said about 2 weeks later the family member came to her and said and something was wrong with Resident #2. The aide said at that time she told the family member what Resident #4 had told her. She said the family member was not aware and Resident #2 had never said anything. CNA B said she was suspended that day for not report the allegation to the Administrator. She said if anything like that ever happened again would report immediately. She said if she thought it was abuse or sounded like abuse she would report. CNA B said she knew what sexual abuse was but had not reported it because she thought the Administrator was aware. During an interview on 2/6/24 at 2:17 p.m. CNA C said she was aware of what abuse and neglect were, they were in serviced all the time. She was able to identify the different types of abuse and neglect. She said if she heard or seen abuse, and she would immediately report to nurse and abuse coordinator. During an interview on 2/6/23 at 2:33 p.m. CNA D said he was able to identify the different types of abuse, multiple types of abuse, physical abuse, mental, verbal abuse, not seen or heard abuse and would report immediately to charge nurse and abuse coordinator. During an interview on 2/6/24 at 2:45 p.m. CNA E said she was able to identify different types of abuse and neglect. She said she had not seen or heard any abuse and would immediately report to the Administrator is she did. During an interview on 2/6/24 at 3:19 CNA G said she was familiar with abuse and neglect. She said if she heard or seen any abuse or neglect would report immediately to the abuse coordinator/Administrator. During an interview on 2/6/24 at 3:27 p.m. the DON said it was her understanding Resident #2 out to an outpatient service and one incident occurred. She said she did not know anything about the Resident #2's incident until they had taken statements. She said she knew the family stopped sending her to the outpatient clinic. She said Resident #2 never reached out to the facility staff, but apparently talked to the Sheriff's deputy. She said she did not know when occurred had to occurred sometimes before 9/14/23. She said when they go to outpatient treatment and the therapist recommended outpatient. The DON said she was not sure of what the process was. She said as far as she knew the resident may have requested to go, or the social worker may have completed a referral. She said they provided an outside service to the residents in the facility. The DON said the facility was responsible for getting them the clinic they provide their own transportation. During an interview on 2/5/24 at 3:55 p.m. the Administrator said they called the Sheriffs Office, and the deputies came out the same day. She said a female deputy had interviewed Resident #2 multiple times. The Administrator said she did not know the outcome of those interviews, Resident #2 had not revealed anything to her staff. She said the SW and the counseling services had not gotten her to reveal a thing to them. She said the Sheriff's office had basically handled the investigation; it was a criminal investigation. She suspended her CNA B for not reporting the incident sooner. She said the police had not told her anything because the investigation was still on going. They had just suspended all service with the Behavioral Outpatient clinic at this time, however they did not have any residents attending prior to being made aware of the incident with Resident #2. During an interview on 2/6/24 R 4:00 p.m. Resident #2 said she did not remember the time frame for when she was molested by the van driver. She said she did remember the incident and provided details. She said she had not confided in anyone at the facility because she was embarrassed. She said she was feeling better now and putting the incident behind her. During an interview on 2/6/24 at 4:22 p.m. the SW said she had worked at the facility for 3 years and during that time Resident #2 had never opened to her. She said she would try to explore things with her, but she never told her what happened. The SW said she went back and talked to her weekly and she would not tell me anything. She said the process that took place was the Outpatient liaison would came to the facility and did activities with the residents. The SW said if the liaison thought any of the patients qualified, and some with prior behavior hospital inpatients. She said the Outpatient clinic would do an assessment and sign them up for outpatient services. The SW said she really had no interactions with signing them up and did not know exactly what services they received. She said she had the initial list of residents who attended made for nurses so they would have them ready in the morning when the clinic staff picked them up. She said it was up to the facility who they picked up on some days. They had one resident that required incontinent care and at one time he could not go. They said they did not have sufficient staff. She said she did not really do a referral. The SW said they did not have a contract with the outpatient clinic. They did not have a logbook of who went on what days. She said she did not remember how long Resident #2 was the only resident attending the program. She said she discussed with the family member Resident #2's her depression. The SW said they started to note a change with Resident 2. The family member requested on 8/29/23 to change the amount of days Resident #2 attended from 5 days a week to 3 days a week. The Resident #2 continued to be depressed and lost weight and it was the family's decision to stop the Outpatient program. The SW said the family thought that may be too much for her so on 9/14/23 Resident #2 stopped attending the program. During an interview on 2/7/24 at 3:10 a.m. the Administrator said she had counseled CNA B about not reporting the incident with Resident #2 on 9/30/23 and she was suspended that day. The Administrator said she had spoken to the aide several times during the next few days and they had done the counseling. The initial counseling started on 9/30/23. She said they had in serviced on abuse and reporting. They had also taken the issue to QA and discussed trauma informed care. Record review of the facility Abuse policy last revised April 2021 indicated If Resident abuse was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury or withing 24 hours of an allegation that does not involve abuse or result in serous bodily injury. Resident has the right to be free from abuse. Protect residents form abuse from staff from other agencies, visitors, or any individual.

Based on interview and record review, the facility failed to ensure services furnished by an outside resource complied in writing that the facility assumed responsibility to meet professional standards while providing care to 1 of 1 resident reviewed ( Resident #2) in that: The facility failed to have a contract with the Outpatient Behavior Day clinic and did not have any method in place to track the residents' progress, decline, or wellbeing. This negative finding resulted in emotional, mental, and possible physical harm. Findings Included: Record review of resident #2 Face sheet dated 9/19/23 indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Some of her diagnoses were schizoaffective disorder, major depression, severe with psychotic symptoms, and dementia. Record review of Resident #2 care plan dated 4/10/23. Indicated a Focus area of the resident received psychotic medication related to psychosis. The resident was taking antipsychotics before admission, and she went to outpatient program at the behavioral hospital three times a week. The resident had a history of giving things away and would forget that she gave them away. Some of the interventions were administer medication as needed, refer to psychiatric and social services as needed, and determine the cause of expressions, and if possible. Resident #2 Had a focused area of required limited assistance with ADLs. The resident required one person assist with transfers and grooming and ADLs. Record review of Resident #2 Provider Investigation report dated 9/30/23 indicated the former roommate indicated Resident #2 was sexually abused by the outpatient clinic van driver. A full body assessment of the resident was conducted and showed no injuries. The resident attended a face-to-face appointment with her physician on 10/3/23 and a pelvic exam was completed. On 10/1/23 criminal investigation, division, interview resident with family member present. The local police department was notified and present at the facility on 9/30/23 to speak with the resident and family. The perpetrator was not employed with the facility. There were no other residents in the building were receiving services from the outpatient clinic . The resident was receiving weekly counseling services. Review of the facility contract book on 2/6/24 did not reveal a contract with the Outpatient Clinic. During an interview on 2/6/24 at 3:27 p.m. the DON said it was her understanding Resident #2 was attending an outpatient service and an incident occurred. She said she did not know anything about the Resident #2's incident until they had taken statements. She said she knew the family stopped sending her to the outpatient clinic. She said Resident #2 never reached out to the facility staff, but apparently talked to the Sheriff's deputy. She said she did not know when the incident occurred but knew it had to have occurred sometimes before 9/14/23. She said when Residents went to outpatient treatment and the therapist recommended outpatient services. The DON said she was not sure of what the process was. She said as far as she knew the resident may have requested to go, or the social worker may have completed a referral. She said they provided an outside service to the residents in the facility. The DON said the facility was not responsible for getting them the clinic they provide their own transportation. During an interview on 2/5/24 at 3:55 p.m. the Administrator said they did not have a contact with the Outpatient Behavioral Clinic. She said the clinic provided transportation to and from their services. She was not sure how many residents they had going at one time. However, Resident #2 was the only resident going to the Outpatient Clinic in September 2023. She thought the social worker handled the referral for the residents to go. She was not sure of what the procedures were. During an interview on 2/6/24 at 4:22 p.m. the SW said she had worked at the facility for 3 years and during that time Resident #2 had never opened to her. She said she would try to explore things with her, but she never told her what happened. The SW said she went back and talked to her weekly and she would not tell me anything. She said the process that took place was the Outpatient liaison would come to the facility and did activities with the residents. The SW said if the liaison thought any of the patients qualified, and some with prior behavior hospital inpatients. She said the Outpatient clinic would do an assessment and sign them up for outpatient services. The SW said she really had no interactions with signing them up and did not know exactly what services they received. She said she had the initial list of residents who attended made for nurses so they would have them ready in the morning when the clinic staff picked them up. She said it was up to the facility who they picked up on some days. They had one resident that required incontinent care and at one time he could not go. They said they did not have sufficient staff. She said she did not really do a referral. The SW said they did not have a contract with the outpatient clinic. They did not have a logbook of who went on what days. She said she did not remember how long Resident #2 was the only resident attending the program. She said she discussed with the family member Resident #2's her depression. The SW said they started to note a change with Resident 2. The family member requested on 8/29/23 to change the amount of days Resident #2 attended from 5 days a week to 3 days a week. The Resident #2 continued to be depressed and lost weight and it was the family's decision to stop the Outpatient program. The SW said the family thought that may be too much for her so on 9/14/23 Resident #2 stopped attending the program. The SW said she did not have any notes or assessments from the Outpatient Clinic and was not sure what the residents did while at the clinic. The SW said she did not have any assessments or progress notes associated with Resident #2 or any residents that had attended the Outpatient Services.

Based on observation, interview and record review the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 2 of 4 halls (Hall 100 and Hall 200) and the dining area. The facility failed to ensure one hundred hall, two hundred hall, and the dining area were free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings Included: Record review of facility roster, Census Report, dated 05/08/2023 revealed: Resident #33 resided in room [ROOM NUMBER] in Hall 200. Resident #37 resided in room [ROOM NUMBER] in Hall 200 Resident #127 resided in room [ROOM NUMBER] in Hall 100. Resident #128 resided in room [ROOM NUMBER] in Hall 100. Review of the most recent pest control visit on 05/09/23 titled Service Report, revealed American roaches . Other Notes: Regular service was done today in kitchen . no other pests treated. Review of facility Pest Service Agreement, dated 06/22/2018 revealed a current contract for semi-monthly service. During an observation on 05/08/23 at 9:00 a.m., two live flies were flying around and crawling on the table in the conference room (beside the dining area) provided to the survey team. An insect repellant light was mounted on the wall but not functioning. During an observation and interview on 05/08/23 at 9:45 a.m. in room [ROOM NUMBER], Resident #127 who resided on the 100 hall said flies were around all the time. She said she had to shoo them away to eat at times. Two live flies were flying around the resident's overbed table then let and crawled around on her roommate, rResident #128 while she was sleeping. During an observation and interview on 05/09/23 in the dining room at 11:15 a.m. 4-5 flies were crawling on a dining table, food, plates, glasses of water and utensils of 3 resident occupying the table. Resident #37 said the flies had been bad, and she shooed them away with her hands. During an observation and interview with LVN F on 05/09/23 at 3:00 p.m. three flies were flying around and crawling on Resident #33, while she was lying in her bed on the 200 hall. LVN F said that the facility had a boom of flies recently and that the staff were to log when they see pests in the pest control log located at the nurse's station. During a record review and interview on 5/09/23 at 3:15 p.m. the Maintenance Director said he worked at the facility for [AGE] years, he provided a pest log of staff observations of pests. The pest log contained no entry concerning flies from 1/25/23 to 5/09/23. The Maintenance Director said he did not have a copy of receipts from the pest control company for review of what service had been provided at the facility for the past year, but he would obtain them. The Maintenance Director said that flies are unsanitary, a bother to residents, and they can promote illness. During a record review on 5/09/23 at 4:00 p.m. of pest control receipts for prior 12 months, there were no specific treatments for control of flies. During an interview on 05/09/23 at 3:30 p.m. the Administrator said she had been employed at the facility since October 2022. She did not know what exactly had been tried to control the flies or if the pest light in the conference room worked. The Administrator said she would call pest control to come back specifically for fly recommendations and treatment. She said she would have the Maintenance Director look at the pest light in the conference room to determine if it functioned. She said pests can potentially spread infection, cross-contamination, and cause decreased quality of life. The Administrator said she would be providing an in-service concerning the use of the pest log by staff. Review of facility policy, Pest Control, dated May 2008, provided by the facility on 05/09/2023 revealed Policy Statement . Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation . 1. This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Review of facility policy, Homelike Environment, dated February 2021, provided by the facility on 05/09/2023 revealed Policy Interpretation and Implementation . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary and orderly environment .

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 18 residents (Resident # 7) reviewed for resident rights. The facility failed to ensure Resident # 7 was assisted with eating in a dignified manner. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings: Record review of facility face sheet dated 05/09/2023 indicated Resident #7 was admitted on [DATE] with diagnoses of cerebrovascular disease (stroke), contracture (lack of movement of joint), dysphagia (difficulty swallowing), and impaired communication. Quarterly MDS dated [DATE] indicated a BIMS of 99 indicating Resident # 7 was unable to be interviewed and was totally dependent on staff for eating. Comprehensive care plan indicated Resident # 7 required total care assistance for activities of daily living and for facility staff to feed the resident. During an observation on 05/08/23 at 11:25 am CNA A announced openly in the dining room two times that Resident # 7 was a feeder and needed her tray with other residents present during the noon meal. During an interview on 05/09/23 at 10:13 AM CNA B stated she had been an aide for 4 years and had worked at the facility for 3 months. She stated a resident was a feeder when they could not feed themselves. She stated she had not been trained to use any other term but hearing it out loud that term does not sound good and could affect a resident's dignity. She stated she would do better when discussing a resident that needs assistance. During an interview on 05/09/23 at 10:19 AM LVN C stated residents that need help with meals are feeders. She stated that term is used throughout the building but did recall a training that educated on the term feeder versus needs assistance. She stated using that term could affect a resident's self-worth and dignity. During an observation on 05/09/23 at 11:46 AM the tray cart in the main dining room was observed with tape labeled feeders written in a size that was readable by those present in the dining room. During an interview on 05/10/23 at 07:53 AM CNA A stated she had been a CNA for [AGE] years and employed at the facility for 7 months. She stated all residents have the right to privacy and dignity and she had been trained on ways to maintain resident rights and dignity. She stated that referring to a resident as a feeder could affect their dignity because it labels them. During an interview on 05/10/23 at 7:59 AM the MDS coordinator stated that she was responsible for care plans and MDS and the term feeder had been used at the facility for a long time. She stated she had not seen an issue with the term until now and how labeling a resident could make them feel bad. During an interview on 05/10/23 at 08:01 AM the ADON stated nursing staff are trained on hire and annually regarding resident rights and dignity. She stated the training includes privacy measures, appropriate language and terminology for the resident care level. She stated the risk of using the term feeder could cause the resident embarrassment. She stated they would begin retraining all staff on dignity measures and remove the tags from the meal tray carts. During an interview on 05/10/23 at 08:13 AM CNA D stated she had been a CNA for [AGE] years and she was responsible for training new CNA's under the direction of the DON and ADON. She stated the training does include resident rights and dignity and how the facility was the resident's home. She stated there had been training in the past on not labeling residents as feeders but it had been a while. She stated that labeling a resident as a feeder could make them feel helpless. During an interview on 05/10/23 at 08:42 AM the Admin stated it was everyone's responsibility to maintain resident dignity. She stated she was not aware that the term feeder was not allowed but now could see how it could be demeaning and cause embarrassment. She stated they would train all staff on maintaining resident dignity and the appropriate language to use regarding residents level of care and expected all staff to respect residents dignity. Record review of facility policy titled Resident Rights, dated December 2016 indicated, .1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. dignified existence.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility did not ensure the ice chest used for distributing ice were clean and sanitized before serving ice. This failure could place residents at risk for food borne illness. Findings included: During an observation on 05/08/23 at 9:10 a.m., there were two dirty ice chest carts used to distribute ice on hallways in facility, located in the dining room with black grime on the lids as well as the carts. During an observation on 05/08/2023 at 5:00 pm Resident # 37 was [AGE] years old and admitted on [DATE] and has a BIMS of 15.Diagnosis include lack of coordination, pain and hypertension. The resident resided on 200 hall and was observed scooping ice from the now clean ice chest located in the dining room using her dirty personal cup. After surveyor intervention the Maintenance Supervisor removed the ice chest, dumped the ice, and sanitized the ice chest. During an interview on 05/09/23 at 1:39 p.m., the Maintenance Supervisor, said he was responsible for deep cleaning the ice chest as needed, and he hasn't deep cleaned them in a while. He stated if they were not cleaned it could cause a resident to become ill. During an interview 05/09/23 at 1:46 p.m., CNA D, she said she wiped the ice cart down this morning, but it didn't come clean. She said she didn't notify anyone that the ice chest needed to be deep cleaned. She said the Maintenance Supervisor would have to power wash them. She said that the ice chest not being clean could cause a resident to become sick. During an interview on 05/10/23 at 10:33 a.m., the Admin. said that there were no department responsible for cleaning the ice chest. She said housekeeping would be responsible for routine cleaning of ice chest and the Maintenance Supervisor would be responsible for power washing as needed. She stated the risk of the ice chest being dirty could be cross contamination and infection. She stated she would train the staff on proper sanitation of the ice chest and oversee that a log was maintained for monitoring. The Admin. said that Resident # 37 does not remember when instructed not to get ice out of the ice chest, to let the staff get it for her. She said that it could cause cross contamination because Resident # 37 touches everything and doesn't remember to wash her hands. A Policy titled: Ice Machine and Ice Storage Chest from Operational Policy and Procedure Manual for Long Term Care @ 2001 MED-Pas, Inc. (Revised January 2012. Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation: 1. Ice making machines, ice storage chest/containers, and ice can all become contaminated by: a. Unsanitary manipulation by employees, residents, and visitors. 2. To help prevent contamination of ice machines or ice storage chest/containers or ice, staff shall follow these precautions. a. Limit access to ice machines or ice storage chest to employees only. 3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to manufacturer's instructions. The Infection Preventionist (or designee maintains a copy of these procedures.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 3 of 5 residents (Resident #45, Resident #66 and Resident #1) reviewed for respiratory care and services. -The facility failed to have physician's orders for oxygen use for Residents #45, #66, and #1. The nasal cannula tubing and humidifier bottle were not changed timely. for Resident #45 and Resident #66. This deficient practice could place residents who use oxygen at risk of developing infections and other respiratory complications. The findings were: 1. Observation on 03/14/22 at 10:30 a.m., Resident #45 was lying in bed and had oxygen via nasal cannula at 2 L/min via the concentrator. The oxygen tubing and the humidifier bottle were labeled with date 02/21/22. Record review of the face sheet dated 03/15/22 indicated Resident #45 was admitted on [DATE]. Resident #45 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] indicated resident #45 had severe cognitive impairment Record review of Resident #45's care plan dated 01/23/22 revealed she was on hospice care and to provide oxygen at 2 liter per nasal cannula as needed to keep oxygen saturation above 92%. Record review of Resident #45's Physician Order Summary for March 2022 indicated Resident #45 had orders to Titrate Oxygen to keep saturation above 92% as needed (original order date 01/23/22). The order had no method of delivery specified. Record review of Resident #45's Treatment Administration Record (TAR) for February and March 2022 indicated no treatment or plan to change humidifier bottle or tubing as specified by policy. 2. Observation on 03/14/122 at 10:40 a.m., Resident #66 was lying in bed and had oxygen via nasal cannula at 2 L/min via the concentrator. The oxygen tubing and the humidifier bottle were labeled with date 03/04/22. Record review of Resident #66's face sheet dated 03/15/22 indicated Resident #66 was admitted on [DATE]. Resident #66 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated resident #66 had severe cognitive impairment. Record review of Resident #66's Physician Order Summary for March 2022 indicated Resident #66 had no orders for oxygen. Record review of Resident #66's TAR for February and March 2022 indicated one entry dated 2/21/22, indicating that the N/C and Humidifier bottle was changed once during the month of February on 2/21/22. The March TAR had no entries for changing of the N/C and humidifier bottle. 3. Observation on 03/14/2022 at 9:40 a.m., Resident #1 was observed lying in her bed, she had oxygen on at 2 liters per nasal cannula via a small portable concentrator. There was no date on the oxygen tubing. Review of Resident #1's face sheet dated 03/15/2022, revealed she was an [AGE] year-old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's most recent MDS dated [DATE], revealed a BIMS of 11 which indicated her cognition was moderately impaired . The MDS indicated Resident #1 had shortness of breath or trouble with breathing with exertion, while sitting at rest, when lying flat and received oxygen within the last 14 days. Review of Resident 1#'s Care Plan initiated 04/20/2021 and revised on 11/18/2021, revealed the resident required the use of oxygen. Interventions included oxygen as ordered. Review of Resident #1's handwritten physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a handwritten admission order for Resident #1 dated 07/04/2021 revealed there were no orders for oxygen administration. Review of Resident #1's electronic Physician's Orders for February 2022 and March 2022 revealed there were no orders for oxygen administration. Review of Resident #1's treatment sheets for the months of December 2021, January 2022, February 2022 did not indicate the use of oxygen. O2 saturations were monitored daily for COVID precautions. Interview on 3/14/22 at 11:00 a.m., LVN A said Resident #66's oxygen tubing and humidifier were dated 03/04/22. She stated the tubing and humidifiers were to be changed every Sunday night and the tubing for Resident #66's nasal cannula and humidifier should have been changed after 7 days on 03/11/22. During an interview on 03/15/22 at 1:35 p.m., LVN A said she was the nurse for Resident #1, she said Resident #1 used oxygen daily. She said she was unable to find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A said it probably just fell through the cracks. During an interview on 03/15/22 at 1:45 p.m., the DON said there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the use of oxygen requires a physician order and without a physician order staff is administering a treatment without an order. During an interview on 03/15/22 at 1:46 p.m., RN C said she put physician orders in the computer. She said there was no order for Resident #1's oxygen. She said there should have been a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/15/22 at 2:00 p.m., Resident #1 said that she had used oxygen for a long time due to her breathing problems and had used it since her admission to the facility. She said she had her own personal machine that she used, and her oxygen was on 2 liters via nasal cannula. Interview on 03/16/22 at 2:49 p.m., LVN B stated I worked night shift for years. She said that the filters are cleaned and changed every Sunday night with the Respiratory Equipment changes and documented on the TAR. Interview on 03/17/22 at 11:37 a.m., the DON said, it is the policy of the facility to change out Respiratory supplies weekly and she is in the process of auditing all O2 orders and has corrected the missing O2 orders for Resident #1, Resident #66 and clarified and updated Resident #66's oxygen orders. She said that not changing N/C and Humidifiers could increase chance of Respiratory illness and infections if not changed out as required per policy. Interview on 03/17/22 at 11:11 a.m., the Administrator said he and the DON were already auditing all charts for orders and TARS for correct Oxygen Orders. He knows it is essential to have correct orders for O2 administration and the Tubing and Humidifier bottles have to be changed weekly according to policy and also to prevent infection. Record review of Policy for Oxygen Administration revised 12/2020, documented: The purpose of this procedure is to provide guidelines for safe oxygen administration. General Guidelines: Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. General Guidelines C. Nasal cannula is changed out at least every 7 days and more often than needed. The cannula will be dated when changed out. D. The Humidifier bottle is changed out at least every 7 days and more often if needed. The humidifier bottle is dated when changed out.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 4 residents reviewed for abuse. (Resident #1) The facility did not transfer Resident #1 according to the MDS and care plan. CNA A transferred the resident without assistance, and the resident had a fall which resulted in a [MEDICAL CONDITION] femur (leg bone just above the knee joint) with soft tissue prominence of the mid thigh, possibly representing a hematoma (bruising). This failure could place residents who were dependent on staff during transfers at risk of injury during transfers. Findings included: A face sheet dated 03/03/20 indicated Resident #1 was [AGE] years old and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's note dated 08/11/15 by MD F indicated Resident #1's left hip and groin area could not be flexed or extended, and the physician noted he could not straighten the resident's leg, and her knee felt tight. The physician noted palpation (feeling of the area to assist with diagnosing) over the left hip and groin, and stiffness in the resident's hip. The physician's note indicated x-rays of the left hip showed [MEDICAL CONDITION] changes, bone spurs and it appeared [MEDICAL CONDITION], but no fracture was noted. MD F noted Resident #1 had significant osteopenia and severe arthritis in the left hip and she was not a candidate for surgery. An x-ray report of the left hip dated 09/17/15 indicated Resident #1 had generalized osteopenia and [MEDICAL CONDITION] osteoarthritic change with no fracture. A physical medicine and rehabilitation consultation dated 10/12/15 by MD G indicated Resident #1 had severe [MEDICAL CONDITION] of the left hip and knee. An x-ray report of Resident #1's left foot dated 02/23/18 indicated the resident had mild [MEDICAL CONDITION] joint disease with no fracture or dislocation. An x-ray report of the left hip dated 08/15/19 indicated Resident #1 had marked [MEDICAL CONDITION] arthritis in the left hip joint with possible avascular necrosis (death of the bone) of the femoral head (highest part of the thigh bone). An MDS dated [DATE] indicated Resident #1 sometimes understood and sometimes made herself understood. The MDS noted the resident had significant impaired cognition, was dependent on two or more staff for transfers and she had no falls since her prior assessment. A care plan dated 01/16/20 indicated Resident #1 had chronic pain due to [MEDICAL CONDITIONS] joint disease in her hip. The plan noted she required transfer using a mechanical lift, but it caused too much pain to the resident, so she was to be transferred by 2 CNAs. The plan noted she was total care. An incident/accident report dated 02/24/20 at 8:15 a.m. indicated LVN C was called to the room by the CNA who said she eased Resident #1 to the floor during a transfer. The resident was assessed by the nurse and had no swelling, abrasions, skin tears, or complaints of pain. A skin communication sheet dated 02/24/20 completed by LVN C indicated Resident #1 had no redness, swelling, bruising, abrasions, or skin tears. A nurse's note dated 02/24/20 at 8:15 a.m. completed by LVN C indicated she was called to Resident #1's room. The note indicated CNA A said she eased the resident to the floor and the resident did not have pain, swelling, bruising, abrasions, or redness. The note indicated Resident #1 requested to be put back into bed so 2 staff assisted the resident back to bed. A nurse's note dated 02/24/20 at 8:30 a.m. completed by LVN C indicated when she went back to Resident #1's room she complained of pain to her left hip. The note indicated she reported this to the physician, medicated the resident, and received an order for [REDACTED]. An x-ray report of Resident #1's left hip and pelvis dated 02/24/20 at 1:16 p.m. indicated no acute osseous abnormality (irregularities in the resident's bone that needed to be addressed) but noted there were [MEDICAL CONDITION] changes. The x-ray did not include the femur. A nurse's note dated 02/24/20 at 2:14 p.m. completed by LVN C indicated Resident #1's left hip x-ray was negative for a fracture, and the resident had no complaint of pain. A nurse's note dated 02/25/20 at 12:30 a.m. completed by LVN D indicated Resident #1 did not have any swelling or bruising to her left hip and did not show any signs of pain or discomfort. An incident/accident statement dated 02/26/20 indicated CNA B said Resident #1 was not complaining of any pain and did not have joint swelling to her left leg when she checked on her at 10:30 p.m. on 2/25/20. She said at 1:30 a.m. on 2/26/20 she noticed Resident #1's left hip and leg were swollen, so she notified the charge nurse. An x-ray report dated 02/26/20 at 4:45 a.m. indicated Resident #1 had [MEDICAL CONDITION] changes to her left hip. The left femur x-ray showed a [MEDICAL CONDITION] femur with soft tissue prominence of the mid-thigh possibly representing a hematoma (bruising) . A nurse's note dated 02/26/20 at 1:30 a.m. completed by LVN D indicated Resident #1's left leg from her knee down was turned outward with her foot laying inward. The note indicated Resident #1 had swelling to her left hip and the resident denied pain, but mild discomfort was noted when the resident's left leg was moved. The note indicated the resident denied the need for pain medication. The note indicated LVN D notified the physician who ordered an x-ray of the left hip and femur. A nurse's note dated 02/26/20 at 6:10 a.m. completed by LVN D said Resident #1's x-rays showed a [MEDICAL CONDITION] femur. The note indicated the physician ordered the resident to be transferred to the hospital for further evaluation and treatment. An Emergency Department Summary dated 02/26/20 indicated Resident #1 had a moderately displaced acute post traumatic oblique fracture (a slanted, complete fracture from trauma) involving the distal diaphysis/metadiaphysis (the main section of the bone/ narrow section of the bone) of the left femur, [MEDICAL CONDITION], and multifocal moderate to severe primary [MEDICAL CONDITION]. A nurse's note dated 02/26/20 at 12:30 p.m. completed by LVN C indicated Resident #1 returned from the hospital with a brace to her left leg. She said the resident was assisted over to the bed by 2 staff. She said the resident had new orders to keep the brace on the left leg all the time except to bathe and to do skin assessments. During an observation and interview on 03/12/20 at 12:56 p.m. Resident #1 was lying in bed and did not appear to have pain or discomfort. She said something was wrong with her left hip, but she was not sure what it was. She said she always hurts in her left hip. A progress note dated 03/06/20 completed by MD E indicated Resident #1 had been non-ambulatory for several years and had severe [MEDICAL CONDITION]. He wrote to continue with non-surgical treatment with a knee immobilizer and to return in a month for another x-ray and an update. During a phone interview on 03/12/20 at 4:22 p.m. CNA A said she transferred Resident #1 by herself on 2/24/20. She said she had to ease the resident to the floor because she could not get her from the bed to her chair. She said she did not know at the time of the transfer Resident #1 required 2 staff during transfer. She said after the transfer she found out the information on how many staff it took to transfer a resident could be found in the front of a notebook at the CNA desk. She said she had only seen Resident #1 out of bed about two times, so she was not sure how the resident needed to be transferred. She said the resident did not have a right leg, so the resident was not able to help with the transfer. During a phone interview on 03/12/20 at 2:00 p.m. LVN C said she was the charge nurse the day Resident #1 was eased to the floor by CNA A (on 2/24/20). She said she was called to Resident #1's room by CNA A. She said when she arrived in the room there was nobody with the resident. LVN C did not know if anyone assisted CNA A in transferring Resident #1. LVN C said Resident #1 was sitting on the floor with her back against the side of her bed. She said she assessed the resident for redness, swelling, or bruising and found none. She said she and CNA A assisted Resident #1 back to bed. She said the resident denied pain when they assisted her back to bed. LVN C said later on 2/24/20 in her shift Resident #1 complained of pain to her hip, so she notified the doctor and gave the resident some pain medication. She said the doctor ordered an x-ray of the left hip. She said the hip x-ray on 02/24/20 was negative for any fractures. She said Resident #1 did not have any redness, swelling, or bruising throughout that shift or the next day. She denied knowledge of any other assists to the floor or falls for Resident #1. She denied knowledge of Resident #1 having fractures in the past. During an interview on 03/12/20 at 5:05 p.m. the DON said CNA A attempted to transfer Resident #1 without assistance on 2/24/20 and had to assist the resident to the floor because she was not able to transfer her from the bed to the chair by herself. She said aides have a notebook at their stations on each hall that have information on how the resident is to be transferred and how many staff are required for the transfer. She said Resident #1 had brittle bones for years. She said the doctor said Resident #1's bones could break in every day care such as turning the resident in bed.

Based on interview and record review, the facility failed to ensure written policies and procedures were implemented to prohibit and prevent abuse, neglect and exploitation for 1 of 21 employees reviewed for abuse and neglect. (CNA B) The facility did not ensure CNA B was disqualified from working in the facility when her criminal history record indicated a criminal conviction permanently barring employment in a nursing facility. CNA B had worked in the facility from 6/13/19 through 7/10/19. This failure could place residents at risk for possible abuse, neglect or exploitation. Findings included: An undated Abuse Policy indicated .it is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. PR[NAME]EDURE: EMPLOYEE SCREENING AND TRAINING .The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation. A Background Screening Investigations policy and procedure dated (MONTH) (YEAR) indicated, .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For purposes of this pol icy direct access employee means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the State for purposes of the National Background Check Program. The HHSC regulated facilities based on Chapter 250 of the Health & Safety Code indicated . Facilities and agencies regulated by HHSC Regulatory Services are required to obtain criminal history checks for unlicensed staff whom they seek to employ. Nursing facilities and assisted living facilities are required to check the criminal history of all job applicants, both licensed and unlicensed. A conviction of certain criminal offenses prevents a person from employment . effective 1/1/19 .(A) Conviction of any of the following offenses bars employment .13) abandoning or endangering a child - P.C. 22.041 . The undated personnel file for CNA B indicated she was hired on 6/13/19. A criminal history report dated 6/10/19 indicated CNA B was convicted on 3/22/2002 for child criminal negligence, abandonment and endangerment. During an interview on 7/10/19 at 3:31 p.m., the BOM said she ran the criminal history for CNA B but did not recall reviewing the criminal history results for CNA B with the administrator. During an interview on 07/10/19 at 3:30 p.m., the administrator said she usually reviewed all criminal history checks with the business office manager prior to hire. She said she failed to review the criminal history for CNA B because she had a family member who currently worked at the facility. The administrator said being convicted of child criminal negligence was listed by citation number on permanently barred offenses and she would have to investigate the matter further. The administrator said the criminal history should be reviewed carefully and an individual who was convicted of an offense that permanently barred employment should not be employed. During an interview on 7/10/19 at 4:28 p.m., CNA C said she was the scheduling coordinator for CNAs and the staff sign in sheets indicated CNA B had worked all 4 halls since her employment date of 6/13/19.

Based on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 of 21 employees reviewed for abuse and neglect. (CNA B) The facility did not ensure CNA B was disqualified from working in the facility when her criminal history record indicated a criminal conviction permanently barring employment in a nursing facility. CNA B had worked in the facility from 6/13/19 through 7/10/19. The failure placed the residents at risk for possible abuse, neglect or exploitation. Findings included: The undated personnel file for CNA B indicated she was hired on 6/13/19. A criminal history report dated 6/10/19 indicated CNA B was convicted on 3/22/2002 for child criminal negligence, abandonment and endangerment. During an interview on 7/10/19 at 3:31 p.m., the BOM said she ran the criminal history for CNA B but did not recall reviewing the criminal history results for CNA B with the administrator. During an interview on 07/10/19 at 3:30 p.m., the administrator said she usually reviewed all criminal history checks with the business office manager prior to hire. She said she failed to review the criminal history for CNA B because she had a family member who currently worked at the facility. The administrator said being convicted of child criminal negligence was listed by citation number on permanently barred offenses and she would have to investigate the matter further. The administrator said the criminal history should be reviewed carefully and an individual who was convicted of an offense that permanently barred employment should not be employed. During an interview on 7/10/19 at 4:28 p.m., CNA C said she was the scheduling coordinator for CNAs and the staff sign in sheets indicated CNA B had worked all 4 halls since her employment date of 6/13/19. An undated Abuse Policy indicated .it is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. PR[NAME]EDURE: EMPLOYEE SCREENING AND TRAINING .The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation. A Background Screening Investigations policy and procedure dated (MONTH) (YEAR) indicated, .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For purposes of this pol icy direct access employee means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the State for purposes of the National Background Check Program. The HHSC regulated facilities based on Chapter 250 of the Health & Safety Code indicated . Facilities and agencies regulated by HHSC Regulatory Services are required to obtain criminal history checks for unlicensed staff whom they seek to employ. Nursing facilities and assisted living facilities are required to check the criminal history of all job applicants, both licensed and unlicensed. A conviction of certain criminal offenses prevents a person from employment . effective 1/1/19 .(A) Conviction of any of the following offenses bars employment .13) abandoning or endangering a child - P.C. 22.041 .

Based on observation and interview, the facility failed to store and serve food in accordance with professional standards of practice for food service safety. The facility did not clean the dust from the air vents and surrounding ceiling in the kitchen. The facility did not clean condensation from 2 of 2 air vents located over the steam table in the kitchen. The facility did not thoroughly clean dried food from 2 of 3 large metal bowls stored with the clean pots and pans. These failures could place the residents at risk for foodborne illness. Findings included: During an observation and interview on 07/08/19 at 9:35 a.m., 3 large metal serving bowls were stacked face up under the food preparation counter. Two large pots were sitting off in the bowls. The pots were also being stored face up. The DM said the pots and bowls were stored the wrong way and should be face down. She moved the 3 large serving bowls and there was dried white substance on the outside of 1 of the bowls and dried white substance on the rim of a 2nd bowl. The DM said the bowls were dirty. During an observation on 07/08/19 at 10:51 a.m., there was 1 of 2 air vent over the serving line which contained ice to hold the drinks and salads. The air vent was covered with water droplets. The condensation from the air vent dripped into the bin on the serving line. The 2nd air vent located partially over the steam table also had condensation, and dark dirty substance on the vent. The condensation was dripping over the hall cart rack. During an observation and interview on 07/08/19 at 11:24 a.m., the regular salad was placed, uncovered, on the food service line under the dripping condensation of the air vent for the lunch meal service. Following surveyor intervention, a piece of foil was placed on the salad to cover it. The dietician said the maintenance man was responsible for the cleaning of the air vents. During an observation on 07/08/19 at 11:42 a.m., the foil was removed from the regular salad located on the food preparation line under the air vent dripping condensation. A water drop fell on to the ice in the bin the bowl of salad was sitting in. During an interview on 07/08/19 at 11:58 a.m., the maintenance supervisor said the 2 of the 6 air vents between the stove and steam table had condensation due to the air blowing and it being warm in the kitchen. He said he was not sure what the brown substance on and around the air vents was. During an observation on 07/08/19 at 11:58 a.m., 4 of 6 air vents between the stove and steam table had dust on them and on the ceiling around them. During an interview on 07/08/19 at 1:46 p.m., the maintenance supervisor said it was dust on the air vents from the kitchen. The Food and Drug Administration Food Code dated 2009, section 4-601.11 titled Equipment, Food Contact Surfaces, Non-food Contact Surfaces, and Utensils indicated: .(A) Equipment food-contact surfaces shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces shall be free of an accumulation of dust, dirt, food residue and other debris .

Based on observation, interview and record review, the facility failed to maintain clinical records, in accordance with accepted professional standards and practices, that were complete and accurate for 1 of 21 residents reviewed for clinical records. (Resident #129) The facility did not obtain orders to address surgical dressings to Resident #129's right hip and outer right knee areas and the removal of staples. This failure could place residents at risk of not receiving proper care and services to meet their needs. Findings included: Physician orders [REDACTED].#129, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. The admission care plan dated 07/03/19 indicated Resident #129 had a surgical wound on her right hip. The intervention indicated dressing changes per physician order. The care plan did not address the surgical wound to her outer right knee area. The medical records dated 07/03/19 through 07/10/19 for Resident #129 did not include a physician's orders [REDACTED]. The records did not include orders regarding the treatment and removal of the staples. The admission skin assessment form dated 07/03/19 noted Resident #129 had a surgical dressing to her right hip, 4 staples visible on the right upper thigh, and a surgical wound dressing at her right outer knee. An undated TAR indicated the surgical dressing to Resident #129's right hip was to be left in place. The staples or the surgical dressing to Resident #129's outer right knee was not addressed. During an observation on 07/08/19 at 1:48 p.m., the therapist was prepared to get Resident #129 up for therapy. The resident had a dressing to the right hip area and outer right thigh near her knee. There was no date or initial on the dressings. Some staples were visible on the right thigh below the surgical dressing. During an interview on 07/10/19 at 3:30 p.m., LVN F said she was the admitting nurse for Resident #129 on 07/03/19. She said she saw in Resident #129's records where it was noted the surgical dressing to the resident's right hip and outer right knee were to remain in place until her follow-up visit to the physician. LVN F said the physician would be removing the staples to the right hip at that time as well. The LVN said she was unable to find any physician orders [REDACTED]. During an interview on 07/10/19 at 3:11 p.m., LVN A/treatment nurse said LVN G/treatment nurse completed the admission skin assessment form for Resident #129 and the treatment record. She said LVN G was no longer employed at the facility. LVN A/treatment nurse said the treatment record and admission skin assessment form provided were the only records in the skin treatment logs she had. During an interview on 07/10/19 at 3:38 p.m., the ADON said there should have been a TAR addressing Resident #129's right outer knee surgical dressing. She indicated there should be orders/documentation indicating when the staples should be removed and regarding the surgical dressing to the right hip. The ADON said she was unable to find the required documentation. During an interview on 07/10/19 at 3:40 p.m., the DON said the nurses should have been obtained physician orders [REDACTED]. During an interview on 07/10/19 at 3:55 p.m., the office staff for the physician who provided the [MEDICAL CONDITION] repair surgery for [REDACTED]. The physician's staff said the documentation at the physician's office indicated Resident #129 was transferred to the nursing facility 07/03/19 and indicated the resident's sutures were to be removed in approximately 2 weeks following Resident #129's surgery. She said the document also noted the facility staff were expected to remove the staples. The office staff said it was documented Resident #129 was to follow-up with the surgeon's office 6 weeks from surgery with an x-ray. The surgeon's office staff faxed a copy of the discharge information on 07/10/19 following surveyor intervention. The office staff said a copy had not been sent to the facility.

Based on observation, interview, and record review, the facility failed to maintain mechanical and electrical equipment in safe operating condition for the kitchen. The facility did not ensure the air conditioner was working in the kitchen. The temperature in the kitchen ranged from 85 to 87 degrees Fahrenheit (F) on 07/08/19 and 07/09/19. This failure could place dietary staff at risk of discomfort. Findings included: During an observation and interview on 07/08/19 at 10:44 a.m., the temperature in the kitchen was hot. The 2 larger air vents located near the reach-in refrigerators at the back of the kitchen did not have air blowing from them. The DM said the air conditioner did not work well in the kitchen. She said they notified the maintenance supervisor for the past few months about the air vents not working and of the dietary staff complaining of the heat. The DM said sweat was currently running down her back. During an observation on 07/08/19 at 11:24 a.m., the air conditioner thermostat indicated a temperature in the kitchen of 87 degrees F. During an interview on 07/09/19 at 3:05 p.m., the maintenance supervisor said dietary made comments previously about the heat in the kitchen, with the last complaints being within the last couple of weeks. During an interview on 07/08/19 at 11:58 a.m., the maintenance supervisor said the water condensation on 2 of the 6 air vents between the stove and steam table had condensation due to the air blowing and it being warm in the kitchen. He said the air conditioner thermostat located on the wall near the kitchen door into the dining room was accurate. He said the temperature was 85 degrees F in the kitchen. During an interview on 07/09/19 at 2:09 p.m., the administrator said she was not aware of the hot temperature in the kitchen. She said the air conditioner repairman was contacted on 07/08/19, following surveyor intervention. During an interview on 07/09/19 at 2:10 p.m., the assistant administrator provided a work order from the air conditioner repairman that indicated 1 of the 2 air conditioner compressors was bad. He said it was suggested the facility needed to buy a new unit. During an interview on 07/09/19 at 2:54 p.m., Cook [NAME] said on Saturday (07/06/19) it had been so hot in the kitchen, my head was hurting and my stomach was feeling bad. The cook said the last time staff reported the kitchen being too hot occurred about 2 weeks ago. During an observation and interview on 07/09/19 at 3:08 p.m., the temperature in the kitchen was 85 degrees F. The dietary staff were sweating. The DM reported the facility had been made aware of the temperature being too hot in the kitchen. She said the kitchen was even hotter in the evening and that some of the evening shift had reported feeling sick due to the heat in the kitchen.