Every finding on record at Glenaire

Based on record review and staff interviews, the facility failed to update the comprehensive care plan to include the use of bed rails. This deficient practice was identified for 4 of 4 residents reviewed for bed rails (Resident #1, Resident #6, Resident #41 and Resident #49). Findings included: a. Resident #1 was admitted to the facility on [DATE]. Resident #1's bed rail assessment dated [DATE] was signed by Nurse #1 and indicated the resident had a bed rail on the left side of his bed to serve as an enabler and promote independence. Resident #1's significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and the bed rail was not used as a restraint. The MDS further revealed Resident #1 had no impairment of upper extremities but did have impairment to both lower extremities. Resident #1 was coded as being independent with rolling left to right in bed and required supervision when moving from lying to sitting on the side of the bed. Review of Resident #1's care plan last reviewed 11/21/25 did not reveal a care plan or intervention addressing the use of bed rails. On 12/29/25 at 10:30 AM Resident #1 was observed sitting in his wheelchair next to his bed. A black metal half-circle bed rail was observed in the raised position on the left side of the bed. During an interview with Resident #1 at the same time, Resident #1 stated he used the bed rail to assist with rolling in bed and sitting up on the side of the bed. Resident #1 was unsure if the bed rail could be lowered and reported he had always had the bed rail. b. Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired, and the bed rail was not used as a restraint. The MDS further revealed Resident #6 had no impairment to both upper extremities but had impairment to both lower extremities. It also showed that Resident #6 required supervision for rolling left and right and required partial/moderate assistance to move from lying in bed to sitting on the side of the bed. Review of Resident #6's bed rail assessment dated [DATE] revealed he used a bed rail on the left side of his bed as an enabler and to promote independence. Resident #6's care plan last reviewed on 12/1/25 did not reveal a care plan or intervention addressing the use of bed rails. On 12/29/25 at 10:35 AM Resident #6 was observed sitting in his wheelchair next to his bed. A rectangular bed rail was observed in the raised position on the left side of the bed. During an interview conducted at that time, Resident #6 stated he used the bed rail to help him roll in bed and to assist with sitting up on the side of the bed. He was unsure whether the bed rail could be lowered and reported that he had always had the bed rail. c. Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and the bed rails were not used as a restraint. The MDS further revealed Resident #41 had no impairment of upper or lower extremities. Resident #41 was coded as being independent with rolling left to right in bed and required supervision when moving from lying to sitting on the side of the bed. Resident #41's care plan last reviewed 10/21/25 did not reveal a care plan or intervention addressing the use of bed rails. On 12/29/25 at 10:15 AM Resident #41 was observed lying in bed asleep with bilateral rectangular bed rails in the raised position. On 12/30/25 at 11:30 AM, Resident #41 was observed sitting in her chair next to her bed where bilateral bed rails were in the raised position. In an interview at the same time, she stated she used the bed rails to reposition in bed and to assist with moving from lying to sitting on the side of the bed. d. Resident #49 was admitted to the facility on [DATE]. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and the bed rails were not used as a restraint. The MDS further revealed Resident #49 had no impairment of upper or lower extremities. Resident #49 was coded as needing supervision with rolling left to right in bed and required partial/moderate assistance when moving from lying to sitting on the side of the bed. Review of Resident #49's care plan last reviewed 9/4/25 did not reveal a care plan or intervention addressing the use of bed rails. On 12/29/25 at 10:44 AM Resident #49 was observed sitting in her recliner next to her bed. Bilateral black metal half-circle bed rails were observed in the raised position on the bed. During an interview with Resident #49 at the same time, she indicated she used the bed rail to assist with rolling in bed and sitting up on the side of the bed. Resident #49 was unsure if the bed rail could be lowered and reported she had had the bed rails since admission. An interview with Nurse #1 was conducted on 12/30/25 at 8:47 AM. Nurse #1 stated the MDS Nurse was responsible for updating care plans. In an interview with the Director of Nursing (DON) on 12/30/25 at 10:31 AM, she stated the MDS Nurse would have been responsible for updating the comprehensive care plan with bed rail information. She was unaware the care plan did not include bed rail documentation. In an interview with the MDS Nurse on 12/31/25 at 11:17 AM, she stated she was responsible for updating care plans. She was unaware the grab bars the facility used were considered bed rails and needed to be care planned. An interview was conducted with the Administrator on 12/30/25 at 10:51 AM He revealed he was unaware the grab bars that the facility used were considered bed rails and needed to be care planned.

Based on observations, record reviews, staff and resident interviews the facility failed to complete a bed rail assessment for one resident (Resident #49), failed to document consent for the use of bed rails for two residents (Resident #49 and Resident #6), failed to assess entrapment risk or document attempts for alternatives to bed rails prior to installing or using bed rails for four residents (Resident #1, Resident #6, Resident #41 and Resident #49). This deficient practice occurred for 4 of 4 residents reviewed for side rails (Resident #1, Resident #6, Resident #41 and Resident #49).Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and below the knee leg amputation. Resident #1's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and bed rails were not used as a restraint. The MDS further revealed Resident #1 had no impairment of upper extremities but did have impairment on both lower extremities. Resident #1 was coded as being independent with rolling left to right in bed and required supervision when moving from lying to sitting on the side of the bed. Resident #1's care plan last reviewed 11/21/25 did not include a care plan addressing the use of bed rails. Additionally, Resident #1's bed rail assessment dated [DATE], signed by Nurse #1, did not include documentation of alternatives considered prior to implementing bed rails. The bed rail assessment did not include an assessment for risk of entrapment. On 12/29/25 at 10:30 AM Resident #1 was observed sitting in his wheelchair next to his bed. A black metal half-circle bed rail was observed in the raised position on the left side of the bed. During an interview with Resident #1 at the same time, Resident #1 stated he used the bed rail to assist with rolling in bed and sitting up on the side of the bed. Resident #1 was unsure if the bed rail could be lowered and reported he had always had the bed rail. An interview with Nurse #1 was conducted on 12/30/25 at 8:47 AM. Nurse #1 stated the therapy department completed the bed rail assessment and it was then signed by a Registered Nurse (RN) indicating consent had been obtained from the resident or their Responsible Party (RP). She further explained she would notify maintenance to install bed rails on the bed after receiving the assessment from therapy recommending use. Nurse #1 indicated therapy probably did the entrapment risk evaluation as the nursing department did not complete this task. In an interview with the Therapy Manager on 12/30/25 at 9:07 AM, she stated that she had never heard of completing a bed rail risk assessment. She further explained that therapy had attempted alternatives to bed rails before recommending use; however, she noted that this information would have been scattered throughout therapy notes and would have been difficult to locate without reviewing every note from each visit. The Therapy Manager reported that she sometimes completed risk versus benefit education and obtained consent for the use of bed rails, while other times nursing would complete this step. She confirmed that an RN needed to sign the bed rail assessment after consent was obtained. In an interview with the Director of Nursing (DON) on 12/30/25 at 10:31 AM, she stated the therapy department was responsible for completing the bed rail assessment which was then signed by an RN. She further stated therapy should have completed a bed rail entrapment risk evaluation. The DON believed therapy attempted alternatives to bed rails before recommending use but did not know where that information could be found. An interview was conducted with the Administrator on 12/30/25 at 10:51 AM. The Administrator stated residents work with therapy to determine if the resident could benefit from the use of bed rails and that an entrapment risk evaluation was completed at that time. He was unaware entrapment risk evaluations had not been completed for residents who had bed rails. The Administrator did not know alternatives to bed rails needed to be documented. He revealed he was unaware the grab bars that the facility used were considered bed rails. 2. Resident #6 was admitted to the facility on [DATE] with a diagnosis of heart failure. Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and bed rails were not used as a restraint. The MDS further revealed Resident #6 had no impairment to both upper extremities but had impairment to both lower extremities. It also showed that Resident #6 required supervision for rolling left and right and required partial/moderate assistance to move from lying in bed to sitting on the side of the bed. Resident #6's bed rail assessment dated [DATE] did not include documentation regarding the use of alternatives to bed rails prior to implementation, nor did it contain a Registered Nurse (RN) signature indicating that risk versus benefit education had been completed and consent received from the resident or his Responsible Party (RP). The bed rail assessment did not include an assessment for risk of entrapment. Resident #6's care plan last reviewed on 12/1/25 did not reveal documentation regarding the use of bed rails. On 12/29/25 at 10:35 AM Resident #6 was observed sitting in his wheelchair next to his bed. A rectangular bed rail was observed in the raised position on the left side of the bed. During an interview conducted at that time, Resident #6 stated he used the bed rail to help him roll in bed and to assist with sitting up on the side of the bed. He was unsure whether the bed rail could be lowered and reported that he had always had the bed rail. During an interview with Nurse #1 on 12/30/25 at 8:47 AM she stated the therapy department completed the bedrail assessment and that an RN should have signed it to indicate risk versus benefit education had been completed and consent obtained. Nurse #1 was unsure why Resident #6's bed rail assessment was not signed by herself or another RN. She further explained that she would notify maintenance to install bed rails after receiving an assessment from therapy recommending use. Nurse #1 indicated therapy probably did the entrapment risk evaluation, as the nursing department did not. In an interview with the Therapy Manager on 12/30/25 at 9:07 AM, she stated she had never heard of completing a bed rail risk assessment. She explained that therapy attempted alternatives to bed rails before recommending use; however, she noted that this information would have been scattered throughout therapy notes and would have been difficult to locate without reviewing every note from each visit. The Therapy Manager reported that she sometimes completed risk versus benefit education and obtained consent for the use of bed rails, while other times nursing would complete this step. She confirmed that an RN needed to sign the bed rail assessment after consent was obtained. In an interview with the Director of Nursing (DON) on 12/30/25 at 10:31 AM, she stated the therapy department was responsible for completing the bed rail assessment which was then signed by an RN to indicate risk versus benefit education was completed and consent obtained. She further stated therapy should have completed an entrapment risk evaluation. The DON believed therapy attempted alternatives to bed rails before recommending use but did not know where to find that information. An interview was conducted with the Administrator on 12/30/25 at 10:51 AM. The Administrator stated residents work with therapy to determine whether they could benefit from the use of bed rails and that an entrapment risk evaluation was completed at that time. He was unaware entrapment risk evaluations had not been completed for residents who had bed rails. The Administrator indicated he did not know alternatives to bed rails needed to be documented. He also reported he was unaware the grab bars that the facility used were considered bed rails. The Administrator believed that nursing obtained consent for the implementation of bed rails after they were recommended by therapy. 3. Resident #41 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure. Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and bed rails were not used as a restraint. The MDS further revealed Resident #41 had no impairment of upper or lower extremities. Resident #41 was coded as being independent with rolling left to right in bed and required supervision when moving from lying to sitting on the side of the bed. Resident #41's care plan last reviewed 10/21/25 did not reveal documentation addressing the use of bed rails. Resident #41's bed rail assessment dated [DATE] and signed by Nurse #1 did not reveal documentation regarding the use of alternatives to bed rails prior to implementation. The bed rail assessment did not include an assessment for risk of entrapment. On 12/29/25 at 10:15 AM Resident #41 was observed lying in bed asleep with bilateral rectangular bed rails in the raised position. On 12/30/25 at 11:30 AM, Resident #41 was observed sitting in her chair next to her bed where bilateral bed rails were in the raised position. An interview with Nurse #1 was conducted on 12/30/25 at 8:47 AM. Nurse #1 stated the therapy department had completed the bed rail assessment, which was then signed by a Registered Nurse (RN). She further explained she would notify maintenance to install bed rails after receiving the assessment from therapy recommending use. Nurse #1 indicated therapy probably did the entrapment risk evaluation as the nursing department did not. In an interview with the Therapy Manager on 12/30/25 at 9:07 AM, she stated she had never heard of completing a bed rail risk assessment. She further explained that therapy had attempted alternatives to bed rails before recommending use; however, she noted that this information would have been scattered throughout therapy notes and would have been difficult to locate without reviewing every note from each visit. The Therapy Manager reported that she sometimes completed risk versus benefit education and obtained consent for the use of bed rails, while other times nursing would complete this step. She confirmed that an RN needed to sign the bed rail assessment after consent was obtained. In an interview with the Director of Nursing (DON) on 12/30/25 at 10:31 AM, she stated the therapy department was responsible for completing the bed rail assessment which was then signed by an RN. She further stated therapy should have completed an entrapment risk evaluation. The DON believed therapy attempted alternatives to bed rails before recommending use but did not know where that information could be found. An interview was conducted with the Administrator on 12/30/25 at 10:51 AM. The Administrator stated residents work with therapy to determine if the resident could benefit from the use of bed rails and that an entrapment risk evaluation was completed at that time. He was unaware entrapment risk evaluations had not been completed for residents who had bed rails. The Administrator indicated he did not know alternatives to bed rails needed to be documented. He revealed he was unaware the grab bars that the facility used were considered bed rails. 4. Resident #49 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and bed rails were not used as a restraint. The MDS further revealed Resident #49 had no impairment of upper or lower extremities. Resident #49 was coded as needing supervision with rolling left to right in bed and required partial/moderate assistance when moving from lying to sitting on the side of the bed. Resident #49's care plan last reviewed 9/4/25 did not reveal a care plan addressing the use of bed rails. Resident #49's medical record did not reveal documentation that included a bed rail assessment, a consent for the use of bed rails or entrapment risk evaluation prior to the use of bed rails. On 12/29/25 at 10:44 AM Resident #49 was observed sitting in her recliner next to her bed. Bilateral black metal half-circle bed rails were observed in the raised position on the bed. During an interview with Resident #49 at the same time, she indicated she used the bed rail to assist with rolling in bed and sitting up on the side of the bed. Resident #49 was unsure if the bed rail could be lowered and reported she had had bed rails since admission. An interview with Nurse #1 was conducted on 12/30/25 at 8:47 AM. Nurse #1 stated the therapy department completed the bedrail assessment after which she or another Registered Nurse (RN) signed it. She further explained she would notify maintenance to install bed rails on the bed after receiving the therapy assessment recommending use. Nurse #1 indicated that therapy probably completed entrapment risk evaluation as the nursing department did not perform this task. She was unaware Resident #49 did not have a bed rail assessment that also included the signed consent for the use of bed rails and was unsure how it was missed. In an interview with the Therapy Manager on 12/30/25 at 9:07 AM, she stated she had never heard of completing a bed rail risk assessment. She further explained that therapy attempted alternatives to bed rails before recommending use; however, that information would have been scattered within therapy notes and was not readily available. The Therapy Manager believed Resident #49 had not been assessed for bed rails as she had moved to skilled nursing from the assisted living section and the bed rails may have already been on the bed. In an interview with the Director of Nursing (DON) on 12/30/25 at 10:31 AM, she stated the therapy department had been responsible for completing the bed rail assessment which was then signed by an RN indicating consent was obtained. She further stated therapy should have completed an entrapment risk evaluation. The DON believed therapy attempted alternatives to bed rails before recommending use but did not know where that information could be found. She also stated that Resident #49 had not been assessed for the use of bed rails as the resident had moved directly to skilled care from the assisted living section. The DON acknowledged that the facility needed to develop a process to address this situation in the future. In an interview with the Administrator on 12/30/25 at 10:51 AM, he stated residents work with therapy to determine whether they could benefit from the use of bed rails and that an entrapment risk evaluation was completed at that time. He was unaware entrapment risk evaluations had not been completed for residents that had bed rails. The Administrator did not know alternatives to bed rails needed to be documented. He revealed he was unaware the grab bars that the facility used were considered bed rails. The Administrator acknowledged the need to implement a process ensuring that residents transitioning from assisted living to skilled nursing, such as Resident #49, receive a bed rail assessment, an entrapment risk evaluation, and obtain consent prior to the use of bed rails.

Based on record review and staff interviews, the facility failed to report an allegation of misappropriation of resident property to law enforcement. This deficient practice affected 1 of 3 residents reviewed for misappropriation (Resident #78).Finding Included:Resident #78 was admitted to the facility on [DATE] with a diagnosis of fracture of unspecified part of the left femur.The facility's 24 hour initial allegation report dated 1/13/2025, completed by the Director of Nursing (DON), documented that Resident #78 told a therapist she was missing $100 from her wallet. Adult Protective Services (APS) was notified. The DON offered to report the missing money to law enforcement, but Resident #78 declined to make a police report.The facility's investigation report dated 1/13/2025, completed by the DON, documented that law enforcement was not contacted because Resident #78 declined to do so.During an interview on 12/31/2025 at 10:23 a.m., the Social Worker stated she did not report the misappropriation to law enforcement because Resident #78 did not want the incident reported. She confirmed she did report the allegation to APS.During an interview on 12/31/2025 at 10:26 a.m., the DON stated the facility did not contact law enforcement because Resident #78 declined to do so.During an interview on 12/31/2025 at 10:35 a.m., the Administrator stated the facility did not contact law enforcement because Resident #78 declined to make a police report.

Based on record review, and staff, resident and Nurse Practitioner interviews, the facility failed to provide pneumococcal and influenza vaccinations to a resident with a signed consent form to receive the vaccinations. This deficient practice was identified for 1 of 5 residents reviewed for vaccinations (Resident #4).Findings included: Resident #4 was admitted to the facility on [DATE]. Resident #4's comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated moderate cognitive impairment. The assessment also showed that the influenza and pneumococcal vaccines had not been offered. Resident #4's medical record revealed no documentation of vaccination administration or any signed consent forms indicating acceptance or refusal of the pneumococcal or influenza vaccinations. On 12/30/25 at 9:30 AM the Infection Preventionist (IP) presented a pneumococcal and influenza vaccination consent form signed by Resident #4 on 11/21/25 stating he consented to receiving the vaccinations. An interview with Resident #4 was conducted on 12/31/25 at 10:15 AM. He recalled signing the vaccination consent form upon admission and confirmed he wanted to receive pneumococcal and influenza vaccinations. In an interview with the IP on 12/31/25 at 8:58 AM, she stated she was not involved in obtaining consents, administering, or tracking resident vaccinations. She explained that the Nurse Practitioner (NP) maintained a list of residents who received vaccinations during the twice-yearly clinics and provided that list to the IP for recordkeeping. The IP was unsure how or when residents admitted between vaccination clinics were offered or administered vaccinations. In an interview with the Director of Nursing (DON) on 12/31/25 at 9:00 AM, she stated Resident #4 did not receive pneumococcal and influenza vaccinations due to a breakdown in communication. She acknowledged there was no established process for ensuring residents admitted between clinics received vaccinations if desired. The DON indicated the Admissions Coordinator obtained the consents upon admission but was unsure what occurred after that step. In an interview with the Admissions Coordinator on 12/31/25 at 9:07 AM, she reported obtaining signed vaccination consents from residents or their Responsible Party (RP) at admission and uploading them into the medical record. The NP then reviewed records for consents. However, the Admissions Coordinator admitted she did not notify the NP or nursing staff when a consent was signed and was unsure why Resident #4's consent was missing from his medical record. In an interview with the NP on 12/31/25 at 9:13 AM, she stated nursing staff typically obtained consents prior to the twice-yearly vaccination clinics and provided them to her so she could prepare a list of residents scheduled for vaccinations. For residents admitted between clinics, the Admissions Coordinator obtained consent and sometimes notified her by text, but not consistently. The NP acknowledged the facility lacked a system to ensure residents admitted between clinics received vaccinations when they consented. On 12/31/25 at 9:20 AM an interview was conducted with the Administrator. The Administrator stated that the Admissions Coordinator notified the IP or the DON when a vaccination consent form was signed upon admission and nursing coordinated with the NP to administer the vaccinations.

Based on observations and staff interviews, the facility failed to date leftover and thawing food items and cover food in 1 of 1 kitchen walk-in refrigerator and failed to discard expired resident food in a nourishment room refrigerator (Central Hall). This had the potential to affect food served to residents. Findings included: 1. A tour was conducted of the facility kitchen on [DATE] at 11:15 AM with the executive chef. An observation of the walk-in refrigerator revealed a container of pepperoni with no label with date opened and an open plastic wrap cover, a container of pimento cheese with no label or date, a large container of cut melon with no label or date, a container of hard-boiled eggs with no label or date, two boxes of thawing chicken on the bottom shelf open to air with no label with date. During an interview on [DATE] at 11:25 AM, the Executive Chef revealed all foods in the walk-in and reach in refrigerators should have a label with the date opened and should be covered. An observation of the kitchen walk-in refrigerator on [DATE] at 9:50 AM, revealed a large container of cut eggplant with no label of date opened and a large container of cut parsnips with no label or date. 2. A tour conducted on [DATE] at 11:40 AM of the Central hall nourishment room refrigerator revealed a lidded plastic container containing pie with a resident's name and dated ,d+[DATE], a plastic bag of sugar snap peas with a resident's name and dated ,d+[DATE], and a sealed yogurt with manufacturer's expiration date [DATE]. During an interview on [DATE] at 11:45 AM, Nurse Aid (NA) #1 indicated the food brought in from home should have been thrown away after ,d+[DATE] days. The yogurt should have been discarded by the manufacturer's expiration date. During an interview on [DATE] at 9:55 AM, the Certified Dietary Manager revealed food and nutrition employees were responsible for maintaining nourishment room refrigerators and discarding food by use-by date. Food brought in from home should be used within 3 days and then discarded. She indicated food and nutrition checks the refrigerators every day. During an interview on [DATE] at 10:10 AM, the Administrator revealed that food [NAME] in from home should be label with the resident's name and the date it was brought in. The food should be used within 3 days. Food and nutrition employees and nursing employees were responsible for maintaining the nourishment room refrigerators.

Based on observation, staff and resident interviews, and record review the facility failed to accurately code restraint use on a minimum data set (MDS) assessment for 3 of 3 residents reviewed for restraints. (Resident #21, Resident #63, and Resident #15) Findings included: 1. Resident #21 was admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Resident #21's side rail evaluation dated 8/30/19 revealed she was assessed that the side rails did not impede the resident's freedom of movement and did not preclude the resident's access to her body. Resident #21's minimum data set assessment dated [DATE] revealed she was assessed as cognitively intact. She was also assessed in section P0100 question A to have bed rails used daily as a restraint. During observation on 1/6/20 at 2:09 PM Resident #21's bed was observed to have one quarter side rail on the right side of the bed in place. During an interview on 1/6/20 at 2:18 PM Resident #21 stated the side rail did not prevent her from getting out of bed if she wanted to. She stated she could not get out of bed by herself. During an interview on 1/8/20 at 11:22 AM Nurse Aide #1 stated Resident #21 had a small side rail to aide with mobility. She further stated it did not hinder Resident #21's movement and she was able to sit on the side of the bed with assistance. During an interview on 1/8/20 at 3:40 PM MDS Nurse #1 stated rehab and nursing performed an audit to determine if a bed rail was a restraint. The nurse said the side rail for Resident #21 was identified as not a restraint. A while back she was instructed that no matter if the facility assessed a bed rail and found it not to be a restraint, she still had to code it as used daily in question P0100A if it was care planned and a care area assessment was completed. During an interview on 1/9/20 at 9:42 AM the Director of Nursing stated Resident #21's side rails did not restrain the resident. She also stated minimum data set assessments should be accurate. The Director of Nursing concluded she now understood the purpose of section P and felt it was a learning experience for her staff who were trying to accurately capture the resident's status. 2. Resident #63 was admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Resident #63's restraint audit dated 1/3/19 revealed the physician agreed the resident needed the grab bar and it did not restrict freedom of movement or normal access to one's body. Resident #63's minimum data set assessment dated [DATE] revealed she was assessed as cognitively intact. She was also assessed in section P0100 question A to have bed rails used daily as a restraint. During observation on 1/6/20 at 11:50 AM Resident #63's bed was observed to have one quarter side rail on the right side of the bed in place. During an interview on 1/6/20 at 11:51 PM Resident #63 stated the side rail helped her be more independent in bed and did not restrain her in any way. During an interview on 1/8/20 at 11:22 AM Nurse Aide #1 stated Resident #63 had a small side rail to aide with mobility. She further stated it did not hinder Resident #63's movement or restrict Resident #63 in any way. During an interview on 1/8/20 at 3:40 PM MDS Nurse #1 stated rehab and nursing performed an audit to determine if a bed rail was a restraint. The nurse said the side rail for Resident #63 was identified as not a restraint. A while back she was instructed that no matter if the facility assessed a bed rail and found it not to be a restraint, she still had to code it as used daily in question P0100A if it was care planned and a care area assessment was completed. During an interview on 1/9/20 at 9:42 AM the Director of Nursing stated Resident #63's side rails did not restrain the resident. She also stated minimum data set assessments should be accurate. The Director of Nursing concluded she now understood the purpose of section P and felt it was a learning experience for her staff who were trying to accurately capture the resident's status. 3. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set Assessment ((MDS) dated [DATE] for Resident #15 indicated she was severely impaired for daily decision making. It further indicated Resident #15 required the extensive assistance of two persons for bed mobility and transfers, had no impairment in range of motion for upper or lower extremities and had restraints used daily. A review of the most current care plan for Resident #15 dated 10/16/19 revealed a focus area of at risk for fall related injury with a goal of staff will attempt to minimize injury from falls through next review and interventions including concave mattress for bed boundary reminders. On 1/6/2020 at 1:35 PM an observation of Resident #15 revealed her to be in her wheelchair. An observation of Resident #15's bed at that time revealed a concave (higher on sides than in middle) mattress in place. An interview with Resident #15's family member on 1/6/20 at 1:35 PM, who was present in the resident's room, indicated Resident #15 had a special mattress to help prevent her from falling out of the bed but she did not feel this impaired Resident #15's daily mobility or restrained her in any way. On 1/9/2020 at 9:54 AM an interview with Nurse #2 indicated she was familiar with Resident #15 and responsible for her care that day. She stated the concave mattress in place to Resident #15's bed did not restrain her or impair her daily mobility in any way. She went on to say to her knowledge Resident #15 had not had any restraints in use during her stay. On 1/9/2020 at 9:57 AM an interview with Nurse Aide #2 indicated she was familiar with Resident #15 and responsible for her care that day. She went on to say to her knowledge Resident #15 had not had any restraints in use during her stay. Nurse Aide #2 further indicated the concave mattress was for fall injury prevention, but it did not completely prevent Resident #15 from falling out of bed. On 1/9/2020 at 10:00 AM an interview with the MDS Nurse indicated she documented the concave mattress in use for Resident #15 as a restraint on Resident #15's MDS dated [DATE]. She went on to say that she believed that if a resident had fallen out of bed before and now a device such as a concave mattress prevented them from falling out of bed she considered this to be a restraint as residents had the right to fall. She further indicated she had made it clear to the facility's interdisciplinary team that she was documenting the use of the concave mattress as a restraint on Resident #15's MDS dated [DATE] although they had not agreed with her. On 1/9/2020 at 10:17 AM an interview with the Director of Nursing (DON) indicated she was familiar with Resident #15 and her use of the concave mattress. She further indicated she had not assessed the use of a concave mattress for Resident #15 as a restraint because it did not impair Resident #15 from her normal daily mobility.

Based on record review and staff and physician interviews the facility failed to provide a stop date for an as needed [MEDICAL CONDITION] medication for 1 of 5 residents reviewed for unnecessary medications. (Resident #46) Findings included: Resident #46 was admitted to the facility on [DATE]. The resident's active [DIAGNOSES REDACTED]. Resident #46's minimum data set assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired. The resident had no moods or behaviors. She was documented to be receiving an antianxiety medication 7 days of the previous 7 days. Resident #46's care plan dated 12/2/19 revealed the resident was care planned for receiving antianxiety drugs on a regular basis. The interventions included to engage the resident in group and individual activities that reduce periods of anxiety and monitor for side effects of medications (drowsiness, loss of coordination, fatigue, mental slowness, confusion, constipation) and notify the physician if side effects were noted. Resident #46's physician order [REDACTED]. The start date was 12/14/19 and the stop date was blank. A Pharmacist Recommendation Summary to Medical Director form dated 12/16/19 revealed the pharmacist recommended Resident #46's order for [MEDICATION NAME] 0.5 milligrams every six hours as needed should be limited to a 14-day duration. If the physician believed it was appropriate for the order to extend beyond 14 days, the rationale should be documented in the medical record and a duration should be indicated. During an interview on 1/7/20 at 2:29 PM Nurse #1 stated the [MEDICATION NAME] 0.5 milligram tablet as needed was available for Resident #46 at that time and did not have a stop date. She also clarified the order for max 2 doses meant Resident #46 was to get no more than two doses within a 24-hour period and not that there were only two doses available. During an interview on 1/8/20 at 9:31 AM the Facility Pharmacist stated she made a recommendation to the physician last month on 12/16/19 to provide a stop date or a rationale for Resident #46 to have a medication longer than 14 days and include a stop date. She stated she asked it to be added to the electronic Medication Administration Record, [REDACTED] During an interview on 1/8/20 at 9:39 AM Nurse Mentor #1 stated the as needed [MEDICATION NAME] had a recommendation from pharmacy that the physician would need to do a note for her to continue to have the medication available past fourteen days. This recommendation was made 12/16/19. She further stated the physician gave the order to discontinue the medication 1/7/20. She stated she did not remember when she got the recommendation from pharmacy about the need for a stop date for the as needed [MEDICATION NAME] as the recommendations go first to the Director of Nursing and then to the unit. She stated the first time she spoke with the physician about the need for a stop date was 1/7/20. She further stated yesterday was the first day she noted that the medication needed to have a stop date. Nurse Mentor #1 stated she was not aware [MEDICAL CONDITION] medications such as [MEDICATION NAME] were required to have a stop date if they were ordered as needed. She concluded Resident #46's [MEDICATION NAME] as needed did not have a stop date until 1/7/20 when it was discontinued by the physician and Resident #46 did not receive the medication at any time from 12/14/19 through 1/7/20. During an interview on 1/8/20 at 10:02 AM the Director of Nursing stated she got the recommendations from pharmacy and she then sends the recommendations to the specific units who then give it to the physician. She further stated she was aware [MEDICAL CONDITION] medications were to have a stop date of 14 days or, if they were not an antipsychotic, have a note from the physician with a rationale as to why the prn medication was extended past 14 days and still have a stop date. She further stated Resident #46's medication should have had a stop date of 14 days from 12/14/19 or a rationale as to why it extended past 14 days and have a stop date. She stated when the nurse mentor contacted the physician on 1/7/20 the physician indicated she was not aware of the recommendation. She concluded the medication was stopped on 1/7/20 when the facility became aware of the issue. During an interview on 1/8/20 12:14 PM Physician #1 stated she was not primarily a long-term care physician and not as familiar with the long-term care regulations. The physician stated she was not as familiar with the psychoactive medications regulations and relied on the pharmacy to help her navigate the regulations. She concluded today, 1/8/20, was the first time she was made aware of the concern with Resident #46's medications and ordered for the medication to be stopped.

Based on observations and staff interviews, the facility failed to discard expired medications in 2 of 2 medication rooms. The findings included: Review of the facility's policy, Storage of Medications revised (MONTH) 2007, stated the nursing staff shall be responsible for maintaining medication storage and the facility shall not use discontinued, outdated, or deteriorated drugs. On 2/27/2019 at 2:15pm, medications in the Central House medication room were reviewed with Nurse #11 present. Two expired medications were found in the stock storage bin. [MEDICATION NAME] 10 mg (for allergies [REDACTED]. [MEDICATION NAME] 50/3 (for pain), in a blister pack, expired 1/11/19. Medications stored in the North House medication room were reviewed with Nurse #12 present. A 12 ounce bottle of [MEDICATION NAME] antacid, unopened, was observed with expiration date of 01/2019. An interview, conducted with Nurse #11 on 2/27/19 at 2:20pm, revealed the third shift nurses and the pharmacist checked the medication rooms at least weekly for expired medications. An interview, conducted with Nurse #12 on 2/27/19 at 2:30pm, revealed the third shift nurses checked the medication rooms for expired medications at least weekly. On 2/27/19 at 3:19pm an interview was conducted with the Director of Nursing (DON) who stated that the third shift nurses are responsible for auditing the medication rooms for expired medications at least weekly. The Nursing Mentors should have checked and confirmed the audits were done at least weekly. The DON further stated that her expectation is that there are no expired medications in the medication rooms.

Based on record review and staff interviews, the facility failed to complete a discharge summary for 1 of 1 residents (Resident #68) reviewed for a planned discharge. Findings included: Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Tracking MDS (Minimum Data Set) dated 1/31/2019 revealed the resident had been assessed as being cognitively impaired. The documentation on the MDS also indicated the resident required extensive assistance with her activities of daily living. The MDS was coded as resident being discharged to the community and the discharge was a planned discharge. A review of resident's active care plan dated 11/30/2018 revealed an active care plan was in place for the resident to be discharged to the community. Review of a physician order [REDACTED]. During a review of the medical record, there was no documentation to indicate a discharge summary had been completed prior to the discharge on 1/31/19. During an interview with the Administrator and Director of Nursing on 2/27/2019 at 4:00 pm, they both indicated a discharge summary should have been completed on the day of discharge.

Based on observations and staff interviews, the facility failed to provide a safe environment for 2 of 2 resident rooms with space heaters on the North House unit (Resident #10 and Resident #31). Findings included: 1a. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#10 was totally dependent on staff for bed mobility and transfers. On 2/25/19 at 10:48 am an observation of room [ROOM NUMBER], where Resident #10 resided, revealed a white space heater positioned on the floor, across the room from the bed, plugged into the wall but not operating. On 2/28/19 at 8:12am, an observation of room [ROOM NUMBER] was made with the Maintenance Director. The space heater was positioned on the floor across from the bed, unplugged and not operating. b. Resident #31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #31 was totally dependent on staff for bed mobility and transfers. On 02/26/19 at 8:30am an observation of room [ROOM NUMBER], where Resident #31 resided, revealed a gray space heater, positioned on top of a dresser, blowing warm air. At 9:00am, an observation of room [ROOM NUMBER] revealed a space heater positioned on the floor, across from the bed, plugged into the wall but not operating. On 02/27/19 at 8:17am, an observation of room [ROOM NUMBER] revealed a gray space heater positioned on the dresser but not operating. At 9:00am, an observation of room [ROOM NUMBER] revealed a space heater positioned on the floor across from the bed, unplugged. On 2/28/19 at 8:30am, an observation of room [ROOM NUMBER], made with the Maintenance Director, revealed a gray space heater positioned on top of the dresser, blowing out warm air. An interview with the Maintenance Director on 2/28/19 at 8:35am revealed the heating unit that served room [ROOM NUMBER] (North House) was functioning poorly and there was only one heating unit for 3 resident rooms. When the facility had problems with a heating unit, the facility provided a space heater until the unit was fixed. The facility tried to keep space heaters in resident rooms no more than 2 days. The resident may have a space heater in their room more than 2 days if the facility had problems getting the parts in to repair a heating unit. A resident should not have a space heater more than 10-14 days. He stated it has been difficult keeping room [ROOM NUMBER] warm therefore the space heater has been used in this room for several months. The heating unit that serves room [ROOM NUMBER] will be replaced in April. The interview further revealed the space heater in room [ROOM NUMBER] did not belong to the facility. The Maintenance Director stated he was not aware there was a space heater in room [ROOM NUMBER]. The Maintenance Director stated he was not aware space heaters should not be used in resident rooms. An interview, conducted with NA #13 on 2/28/19 at 8:51am, revealed the space heater in room [ROOM NUMBER] has been there for approximately 2 months. On 2/28/19 at 8:58am an interview was conducted with the Director of Nursing and the Administrator, both of whom stated there should not be space heaters in resident rooms. resident rooms. When the facility had problems with a heating unit, the facility provided a space heater until the unit was fixed. The facility tried to keep space heaters in resident rooms no more than 2 days. The resident may have a space heater in their room more than 2 days if the facility had problems getting the parts in to repair a heating unit. A resident should not have a space heater more than 10-14 days. He stated it has been difficult keeping room [ROOM NUMBER] warm therefore the space heater has been used in this room for several months. The heating unit that serves room [ROOM NUMBER] will be replaced in April. The interview further revealed the space heater in room [ROOM NUMBER] did not belong to the facility. The Maintenance Director stated he was not aware there was a space heater in room [ROOM NUMBER]. The Maintenance Director stated he was not aware space heaters should not be used in resident rooms. An interview, conducted with NA #13 on 2/28/19 at 8:51am, revealed the space heater in room [ROOM NUMBER] has been there for approximately 2 months. On 2/28/19 at 8:58am an interview was conducted with the Director of Nursing and the Administrator, both of whom stated there should not be space heaters in resident rooms.

Based on observations and staff interviews the facility failed to discard expired food items, failed to label and date opened food items stored in 1 of 2 walk in coolers, and a facility staff member failed to cover her hair while in a food preparation area. The findings included: On [DATE] at 4:30 PM an observation of the facility kitchen with the Dietary Manager revealed a staff member in the food preparation area with her hair unsecured and uncovered. On [DATE] at 4:33 PM an observation of the first walk-in cooler revealed a bag of fresh cauliflower florets wrapped in plastic with gray discoloration visible on the surface of the florets. The bag was labeled [DATE]. On [DATE] at 4:35 PM an observation of the first walk- in cooler revealed an opened partially used container of whipped cream spread and an opened partially used block of queso cheese. No date opened was visible on either item. On [DATE] at 5:14 PM an interview with the dietary manager revealed that it was her expectation that staff present in food preparation areas would have their hair covered. She further indicated that it was her expectation that leftover food would be clearly labeled and dated before being refrigerated and that leftover food would be used within three days or discarded.

Based on record reviews and staff interviews the facility's Quality Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the recertification survey of [DATE]. This was for the deficiency originally cited in (MONTH) (YEAR) and subsequently recited on the current recertification survey of [DATE] in the area of F812 Food Procurement Prepare/store/serve. The continued failure of the facility during two federal surveys of records show a pattern of the facility's inability to sustain an effective Quality Assurance (QA) Program. The findings included: This tag is cross-referenced to: F812 Food Procurement- Prepare/store/serve - Based on observations and staff interviews the facility failed to discard expired food items, failed to label and date open food items stored in 1 of 2 walk in coolers, and a facility staff member failed to cover their hair while in food preparation areas. During the previous recertification survey of [DATE], the facility failed to discard outdated milk from 1 of 2 walk in corridors. On [DATE], during an interview with the Administrator and DON was conducted. The administrator stated that the facility's QA Program met quarterly and consisted of the Administrator, Director of Nursing, Medical Director and all facility department heads. The administrator reviewed the previous plan of correction and stated that checking for outdated milk was to be done daily for 1 month, then upon each food truck delivery, (no less than 2 times a week) for 1 month, then 1 x week for 1 month for a period of 3 months. If outdated milk was found, it was discarded. The Administrator stated that his expectation is that there will be no expired food products.

Based on observations and interviews the facility failed to discard outdated milk from 1 of 2 walk in coolers. The findings included: On [DATE] at 10:28 AM during the initial observations of the kitchen with the dietary manager, the dining services coordinator and the dining services director, 3 cartons of 1% milk were observed in a box on the shelf along with 4 other boxes of milk. The milk was dated [DATE]. Additional observations revealed another box of milk which was dated [DATE] on the outside of the box and contained 8 more cartons of 1% milk dated [DATE]. During an interview on [DATE] at 12: 54 PM with the production manager he stated he did not work on [DATE] so he was not present to monitor the walk in cooler for expired milk. He said the milk should have been labeled expired milk or it should have been discarded. During an interview on [DATE] at 12:54 PM the dining services director said We should not have outdated milk.

Based on observations, staff and resident interviews, and record review the facility failed to identify a right wrist fracture as an injury of unknown source and complete a 24 hour and 5 day report for 1 of 2 residents reviewed for accidents (Resident #46). Findings included: Resident #46 was admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #46's most recent minimum data assessment dated [DATE] revealed the resident was assessed as severely cognitively impaired. Review of Resident #46's incident reports revealed on 2/6/18 Resident #46 attempted to stand from her wheelchair without assistance, lost her balance, and fell . It was documented on the incident report there were no injuries noted and the resident denied pain or discomfort. On 2/24/18 the resident scooted off her mattress to the floor and no injuries were noted. Resident #46 denied pain and discomfort. On 2/25/18 Resident #46 attempted to get into bed unassisted and slid to the floor. No injuries were noted and there were no further incident reports for Resident #46. Again the resident denied any pain or discomfort. Review of a Nursing Note dated 3/5/2018 at 4:30 PM revealed Nurse #1 documented Resident #46 had complained of mild discomfort to her right wrist area. The nurse documented the wrist had some slight swelling and Resident #46 told the nurse she hit her wrist on a rock. The nurse noted Resident #46 had not been outside. The nurse noted the resident had been [MEDICATION NAME] locking and unlocking her wheelchair with therapy. Pain medications was given which Resident #46 reported relieved the pain. Review of the physician's communication book revealed on 3/5/18 a request was made by nursing for the physician to evaluate Resident #46 for wrist pain and swelling. Review of a physician's progress note dated 3/5/18 revealed the resident was assessed by a physician's assistant for right wrist pain and swelling. Resident #46 was noted to have stated she was not having any pain at that time and did note she broke the right thumb many years ago and it occasionally felt uncomfortable. Resident #46 was documented to move her right, arm, and hand without any issues. The physician documented the pain and swelling was not present upon the exam that day and Resident #46 denied any pain or swelling. The physician wrote to continue to monitor the right wrist at that time. Review of a Nursing Note dated 3/12/18 at 3:11 PM revealed Nurse #1 documented Resident #46 had complaints of mild pain to her right wrist. Tylenol was given as prescribed and Resident #46 stated it gave her relief and she was not in pain. Review of a physician's progress note dated 3/15/18 revealed Resident #46 was seen again per nursing request by Physician #1 for wrist pain which was mild and did not seem to limit her activity. Physician #1 noted Resident #46 told him she fell and her hand was swollen. The physician documented that given the reproducible tenderness in the right wrist, an x-ray was ordered to evaluate for possible fracture. Review of a mobile x-ray result dated 3/16/18 revealed Resident #46 had an acute [MEDICAL CONDITION] wrist. Review of a Nursing Note dated 3/16/2018 at 10:46 PM revealed Nurse #2 documented for Resident #46 the x-ray result reveled the resident had an acute distal [MEDICAL CONDITION]. The nurse practitioner was notified, family was notified, and an appointment was made with an orthopedic physician. Resident #46 denied pain, refused pain medication offered by the nurse, and yelled I'm not hurting! During observation on 4/4/18 at 8:18 AM Resident #46 was observed to have a splint placed to her right wrist. During an interview on 4/4/18 at 8:19 AM Resident #46 stated she did not know what she had done to her wrist but she had to wear the splint. She then stated she believed she hit her hand on her dresser and sprained it. She further stated the doctor made her get an x-ray and wear the splint which was silly because nothing had been wrong with her hand. During an interview on 4/4/18 at 8:52 AM Nurse #1 stated Resident #46 was alert and oriented to herself but her cognition level varied. She further stated Resident #46 originally told her the right wrist was hurting because she hit it on a rock. The nurse then stated the resident told her yesterday she was sitting in her wheelchair and it just happened and she didn't know why. The nurse stated to her knowledge they were never able to figure out exactly when or how she developed the injury because Resident #46 denied any pain except the two times she requested one Tylenol for wrist achiness. She further stated when they did not know how or when an injuries occurred, and the resident was not a reliable historian, the nurse was to notify the family, notify the doctor, and do an incident report. She further stated the managers would then follow up on the injury to try and identify where it came from. During an interview on 4/4/18 at 11:00 AM the Central House Nursing Manager stated when injuries were reported to her she insured the family and doctor were notified immediately. She further stated if they did not know where the injury came from she would interview the staff about the injury to try and identify what caused the injury. The nurse stated an incident report would be done as soon as the injury was identified. She further stated they did not know where the fracture on Resident #46's wrist came from and they could not accurately connect it to any incident prior because the resident was a poor historian. She concluded that an incident report should have been done on Resident #46's fracture but it was an unusual situation due to the timing and the resident indicated nothing was wrong after initially reporting pain in her wrist. During an interview on 4/4/18 at 11:17 AM Nurse #3 stated when a resident had an injury and she didn't know the origin she let her manager know and contacted the family, the doctor, and completed an incident report. She further stated she did not know how Resident #46 got the fracture. She stated she did not believe she needed to do an incident report because Resident #46 had multiple falls in February. She continued to state that because these falls were likely the cause of the fracture she did not do an incident report. During an interview on 4/4/18 at 1:17 PM the Administrator stated if an injury is assessed as an injury of unknown source based on the investigation of the nurse mentors he would perform a 24 hour and 5 day report. He further stated he had not completed any reports on Resident #46. The Administrator stated since the physician noted the fracture was likely due to her falls in (MONTH) based on the physician's interview with the resident, her [DIAGNOSES REDACTED]. He further stated the resident was a poor historian, but due to the evidence, he felt the injury did not qualify as an injury of unknown source. During an interview on 4/4/18 at 2:10 PM Physician #1 stated without having been there to witness the break and the resident being a poor historian he could not say with one hundred percent certainty the fracture was from a previous fall. He continued to state a fall seemed to be the most likely explanation. He stated the injury was consistent with being caused by an impact from a fall. He further stated on his assessment of the resident on 3/15/18 Resident #46's right wrist presented with mild tenderness to pressure and he decided to order an x-ray to rule out a fracture, however the resident had no complaints and did not have any decline of function as a result of the fracture. He stated when the physician's assistant first saw the resident on 3/5/18 there were no signs or symptoms of a fracture upon exam and they were lucky to have identified the break as Resident #46 did not present with signs and symptoms of a fracture to facility staff.

Based on record review, observations and interviews with family and staff the facility failed to develop a care plan to address a resident's [MEDICAL CONDITION] for 1 (Resident #63) of 18 residents' care plans reviewed. The findings included: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #63 was severely cognitively impaired and required extensive assistance for activities of daily living (ADLs) except she was independent with eating. The care plan with an effective date of 3/5/18 revealed problems which included that she required total to extensive assistance for ADLs, had a surgical wound on her left hip, was on a 1000 milliliter fluid restriction, required intermittent catheterization, had behavioral problems of yelling out for help or I want to go to my room. and potential for weight changes but none of the problems or potential problems or interventions addressed the [MEDICAL CONDITION] in her lower extremities. During an interview on 4/2/18 at 11:56 AM her responsible party stated the resident had swelling of her ankles which was present prior to admission to the facility. A review of the doctor's orders revealed an order dated 3/20/18 which said to apply compression stockings to bilateral lower extremities every morning and remove evening. Observations of the resident on 4/4/18 at 10/29 AM revealed she was sitting in a reclining chair watching TV in the common area. She was reclined and was wearing compression stockings. On 4/4/18 at 11:05 AM Nurse #1 stated Resident #63 continued to wear compression stockings but her swelling was not as severe as it was last week. She said the resident usually sat in the recliner in the common area with her feet elevated until lunch then after lunch she would go back to her room and sit in her recliner with her feet elevated. On 4/5/18 at1:25 PM the nurse house mentor reviewed the care plan and was unable to locate a care plan that addressed Resident #63's [MEDICAL CONDITION]. She added the resident wore compression stockings due to [MEDICAL CONDITION] in her lower extremities and they monitored her weight due for [MEDICAL CONDITION] so, she should have a care plan that addressed the resident's [MEDICAL CONDITION]. During an interview with the administrator on 4/5/18 at 2:30 PM he stated Resident #63 should have a care plan that addressed her [MEDICAL CONDITION].

Based on observations and staff interviews the facility failed to remove dented cans of applesauce in 1 of 1 dry storage area and failed to wear hair restraints for 2 of 2 staff who had beards which were not covered. The findings included: 1) During the initial tour of the main kitchen on 6/7/16 at 9:50 AM an observation of the dry storage area revealed a dented can of applesauce in the same location as the other cans of applesauce which were ready for use. On 6/7/16 at 9:55 AM the Production Manager stated the dented can should not have been in with the others. He stated it should be removed and placed in the area specified for dented cans so that it would not be used. 2) During initial tour of the main kitchen on 6/7/16 at 9:50 AM 2 food service staff members were observed to have a beard. They were not wearing a beard restraint while they were working in the food production area. On 6/9/16 at 4:45 PM the Production Manager stated beard covers were available and he expected staff to wear them while working in the kitchen.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) to reflect results of the Level II Preadmission Screening and Resident Review (PASRR) determination for 1 of 1 residents identified as Level II PASRR (Resident #7). The findings included: Resident #7 was re-admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of Resident #7 ' s annual Minimum Data Set (MDS) assessment (Section A) dated 4/1/16 indicated the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability. A Significant Change MDS assessment dated [DATE] also indicated Resident #7 was not considered to be Level II PASRR. Determination of a Level II PASRR resident is made by an in-depth evaluation. The results of this evaluation are used for formulating a determination of need, determination of an appropriate care setting and a set of recommendations for services to help develop an individual's plan of care. A review of the facility ' s list of Level II PASRR residents revealed that Resident #7 was named on the list. A review of Resident #7 ' s records included an FL-2 (Medicaid Program Long Term Care Services) dated 9/24/04. Resident #7 ' s Level II PASRR number included the letter code B. An interview was conducted on 6/9/16 at 10:05 AM with the facility ' s Director of Nursing (DON). The DON reported that she herself was the Registered Nurse who assumed responsibility for verifying accuracy of the facility ' s Minimum Data Set (MDS) assessments. During the interview, the DON confirmed Resident #7 was determined to be a Level II PASRR. An interview was conducted on 6/9/16 at 10:10 AM with the facility ' s SW. Upon inquiry, the SW also confirmed Resident #7 was determined to be a Level II PASRR. When asked how this information was shared among team members, she reported it would have been verbally shared in team clinical meetings. A follow-up interview was conducted on 6/9/16 at 10:15 AM with the facility ' s DON. Upon inquiry, the DON indicated that her expectation was for the Level II PASRR determination to be coded accurately on a resident ' s MDS assessment. She indicated coding the resident as a Level II PASRR on the MDS assessments had been missed.

Based on observations, staff interviews and review of facility records, the facility failed to 1) ensure foods were sealed after opening, 2) label and date food items when opened and stored in the freezer and refrigerator, 3) maintain the paper storage area in a clean and sanitary condition, and 4) remove splatter from a mayonnaise jar. This was evident in 2 of 2 observations of the kitchen. Findings included: The facility has a procedure titled " Procedures for Label and Dating foods " dated 9/2010 that read in part: All foods that have been opened must be labeled and must include the name of the food and the date by which it should be eaten or thrown away. 1. Observation of the kitchen on 6/30/14 at 9:50 am with dining service coordinator (DSC) and production manager (PM) revealed the following: A. In the product cooler: ? A ? full 5(five) pound bag of shredded carrots previously opened was not sealed and not dated. ? A 128 (one hundred twenty eight) fluid ounce container of Creole mustard was half used. There was no date when opened. The use by date was 6/17/14. ? A container of cottage cheese was opened and not dated. ? An 11 (eleven) pound container of parmesan grated cheese had been previously opened, not sealed and dated 5/16/2014. ? A brown substance was wrapped in plastic wrap and not labeled. Interview with the PM at the time of the observation revealed the contents in the wrapper was a 1(one) pound portion of Bacon Bits. ? There was a 16 (sixteen) ounce container of previously prepared creme in a pastry bag. The product was not labeled or dated. Interview during the observation with the PM confirmed the contents of the pastry bag. ? ? B. In the meat cooler ? There was a previously opened (one) 1 gallon container of sweet and sour sauce that was not dated. Although the use by date was October 14, 2014 the bottle was half empty and noted with a black substance on the inside portion of the container and inside part of the lid. ? A " Stir fry " container was half empty and not dated. ? There was a 1 (one) gallon container of horseradish that was previously opened with ? (one quarter) gallon left. This container was not dated when opened. ? A container of mayonnaise had splattered clumps of mayonnaise on the outside of the container. ? ? C. In the freezer section ? There was a ? (one quarter) case of thin sliced steak that was not sealed. Nor was the container dated when opened. ? There was ? (one quarter) pound container of meat not in the original container. This container was not labeled or dated. The PM during the observation revealed the contents in container was sausage crumbs. ? There was a 2-1/2 (two and one half) pound bag of curly seasoned fries which ? (one half) noted left in a plastic container and not sealed. ? There was a container of a green substance that was not dated nor labeled. Interview with the PM during the observation indicated the green substance was identified as pesto. ? There were appropriately 108 (one hundred and eight) frozen biscuits unsealed. ? During the initial kitchen observation DSC removed the above observed items. ? ? D. In the outside dessert freezer ? There was a 5 (five) pound container of pre-cut frozen (coconut) cookie dough that was stored in a plastic bag that was not sealed. ? There was a 5 (five) pound container of pre -cut frozen cookie (macadamia nut) dough that was stored in a plastic bag and was not sealed. Frost was noted on the cookies. ? There were 2 (two) containers of pre-cut chocolate chip cookies. These 1 (one) pound and 1 ? (one and one quarter) pound containers were unsealed. ? There was an opened box of pre-cut sugar cookies that were not sealed. The sugar cookies appeared dry. ? There was a 2 (two) pound sheet of previously baked brownies with one row used. The item was not dated. ? There were 3(three) pre-cut chocolate chip cookie dough formed together lying directly on the freezer shelf and not covered. 2. Second observations on 7/2/14 at 8:15 am of the produce cooler, meat cooler, dessert freezer and freezer revealed the 2 (two)pound sheet of previously baked brownies remained unchanged. The other food items were labeled and dated 6/30/14 as being the date opened. An interview with the DSC at the time of the observation revealed no explanation of why all the food items identified on 6/30/14 were now dated 6/30/14. Interview on 7/1/14 at 2:02 pm with dietary aide (DA) #1 revealed opened food items should be labeled and dated when opened. Interview on 7/1/14 at 2:10 pm with DA #2 revealed opened food items should be labeled and dated when opened. 3. A. Observation of the paper goods storage area located on the outside landing of the kitchen on 6/30/14 at 9:50 am with DSC and PM revealed: ? Racks of paper supplies (plastic ware, plates, cups etc.) in plastic sleeves that were not close and exposed to the air. ? The floor was dirty with dried foot prints. ? There was an accumulation of cobwebs, dust and dirt under the shelves and in the corners of the room and walls. B. A second observation of the outside paper goods area on 7/2/14 at 8:20 am with the DSC revealed the accumulation of dirt, cobwebs and dust remained. The black foot prints remained on the floor. Further observation revealed 5 (five) green shelves disassembled, 1 (one) serving tray, 2 (two) holding containers, 3 (three) gray colored beverage containers, a broken glass light cover which had an accumulation of dirt and dust on the surfaces. There was a box of straws and box of coffee filters stored directly on the dirty floor. At the time of the observation an inquiry was made about what was behind the green shelves. Utility aide (UA) #1 removed the green shelves. Observations once the shelves removed revealed an accumulation of dust and dirt in the corners of the floor. There was also 24 (twenty four) cup lids noted to be directly on the floor with balls of dust on them. Interview on 7/2/14 at 8:25 am with UA #1 revealed it was the responsibility of the utility aides to clean the paper storage area twice a week and he could not remember the last time it was clean. Interview on 7/2/14 at 8:45 am with the director of dining services (DDS), DSC, and administrator was held. The DDS indicated he expected all opened food items to be dated and labeled when opened. The DDS and PM indicated there was an expectation for the paper storage area to be cleaned twice a week. The administrator indicated that all food items were expected to be dated and labeled when opened. Further interview with the administrator revealed the paper goods storage area should be dust free and clean. The PM indicated that the dietary department has a " GI cleaning " (referring to an army style cleaning) schedule that indicated twice a week cleaning of the outside back area which included the location of the paper goods storage area.

Based on observations, facility record review and staff interviews, the facility failed to create an environment in the dumpster area free of conditions that might contribute to the growth and infestation of pests and rodents for 1 of 3 dumpsters. The findings included: The facility has " Utilities Cleaning Duties Tuesday & Thursday AM &PM " revealed in part: " 4. Mop and scrub loading dock and outside area daily. Hose down and clean trash dumpster and dumpster area daily. " On 6/30/14 at 10:30 am observation with (PM) production manager revealed there was garbage miscellaneous refuse such as paper, cigarette butt behind and on the sides of the 2nd dumpster. According to the PM revealed dietary staff and housekeeping staff are responsible for cleaning the area around the dumpster. The PM also indicated the waste company that picks up the garbage will also clean around the dumpster. A second observation of the dumpster areas on 7/2/14 at 8:20 am with the dining service coordinator (DSC) was conducted. There was still the accumulation of trash, paper and a cigarette butt on the sides and behind the 2nd dumpster. Interview at the time of the observation with DSC revealed the dumpster was emptied on 7/1/14. Interview on 7/2/14 at 8:45 am with director of dining services, DSC, and the administrator was held. The director of dining services indicated that the dumpsters are also used by the maintenance department and there was joint responsible for cleaning with the maintenance department. The administrator indicated her expectation was the dumpster area should be cleaned as needed. The PM joined the interview. The PM indicated that the dietary department has a " GI cleaning " schedule that indicated twice a week cleaning of the outside back area where the dumpsters was located. Interview on 7/2/14 at 3:45 pm with the facility director for maintenance and housekeeping revealed the kitchen staff was responsible for cleaning around the dumpster on Tuesdays and housekeeping was responsible for cleaning on Thursdays. Further interview revealed the dumpster area had not been cleaned by his staff this week (referring to 6/30/14 week).

Based on observations, staff and resident interviews and medical record review the facility failed to update the care plan to reflect the resident being placed on palliative care. This was evident for 1 of 2 residents in the survey sample recieving palliative care. (Resident#23). Findings included: Review of the consultation form from palliative services dated 11/29/10 revealed Resident #23 was placed on palliative care services due to the increase in chronic pain, poor appetite and chronic nausea. She required more assistance with her daily care needs due to the increase in pain, decreased in weight due to poor appetite and chronic nausea. Review of care plans revision dated 8/3/11, 8/4/11, 11/1/11, and 1/31/12 revealed no careplan for pallative care During an interview with the MDS coordinator on 3/22/12 at 1:48 PM revealed the resident had a change in status on 10/13/11 when the physician placed her on palliative care. She had increased pain, nausea and poor appetite. The MDS coordinator reviewed the care plan and indicated there was no update to reflect pallative care. Interview with DON (Director of Nurses) on 3/22/12 at 2:20 PM stated the resident has been on palliative care since 11/29/10. The DON stated her expectation was that when the resident was placed with palliative care services, the care plan should have reflected this information. Continued interview with the DON revealed Resident#23 was receiving palliative care and should have the information written on the care plan. The DON indicated Resident#23 had a decline in ADL (activities of daily living) associated with the disease process, increased pain and chronic nausea. Her expectation was that the care plan should be a picture of the care needs of each resident.