Every finding on record at Glenflora

Based on record review and staff, Nurse Practitioner, Medical Director, and Responsible Party interviews, the facility failed to provide ongoing assessments after a fall and failed to communicate effectively to provide medical diagnostics and treatment for 1 of 3 residents reviewed for assessment after a fall (Resident #1). Resident #1 was found on the floor mat beside her bed by Nurse #1 on 4/27/26 at approximately 4:30 AM. Nurse #1 stated Resident #1 did not have any apparent injury and she and Nursing Assistant (NA) #1 picked the resident up and placed her back in her bed. Nurse #1 did not report the fall to the oncoming nurse for the 7:00 AM to 7:00 PM shift, Nurse #2. Later, on 4/27/26, Nurse #2 observed an area on the front of Resident #1's left lower leg that was red, swollen and felt warm to touch. Nurse #2 contacted the Nurse Practitioner (NP) who ordered a study from their mobile x-ray company to rule out a blood clot in the leg. Nurse #2 reported the condition of Resident #1's leg to Nurse #3 when she came in for the 7:00 PM to 7:00 AM shift. Nurse #3 heard Resident #1 scream out on 4/28/26 at approximately 3:15 AM and Nursing Assistant (NA) #4 informed her Resident #1's leg was hurting. Nurse #3 observed Resident #1's left lower leg to have discoloration from above the ankle to below the knee and observed her foot was blue. When Nurse #3 lifted Resident #1's left leg, her left foot dangled and the bones in her lower leg appeared broken. Nurse #3 contacted the medical provider and received orders to send Resident #1 to the Emergency Department (ED). X-rays taken at the hospital on 4/28/26 revealed acute fractures of the left tibia and fibula (the 2 bones in the lower part of her leg, below the knee) with significant displacement (both bones in lower left leg were broken and the bones were moved out of alignment). Surgical repair was not an option and Resident #1 was admitted to the hospital for monitoring. The hospital Discharge summary dated [DATE] indicated Orthopedic surgery was consulted and Resident #1 underwent bedside splinting under sedation with plans to continue to keep her leg immobilized by continuing with the splint.Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified dementia, severe, with other behavioral disturbance, cognitive communication deficit, muscle weakness, lack of coordination, other abnormalities of gait and mobility, restless leg syndrome, severe protein-calorie malnutrition, and vitamin D deficiency.A review of Resident #1's annual Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 was 1) moderately cognitively impaired, 2) had other behavioral symptoms not directed towards others that occurred 1-3 days, 3) had no impairment in her bilateral upper and lower extremities, 4) did not use a mobility device, 5) was dependent on staff for chair-bed-chair transfers, 6) was independent for rolling left and right in bed, sit to lying position in bed, and lying to sitting on side of the bed, 7) was dependent on staff for showers, toileting hygiene, putting on/taking off footwear, personal hygiene and oral hygiene, 8) required supervision or touch assistance with eating, 9) was frequently incontinent of her bowels and bladder, and 10) had one fall without injury since prior assessment.Resident #1's care plan, last revised on 3/10/26, revealed focuses of 1) impaired cognitive function/dementia or impaired thought processes related to dementia; 2) self-care and mobility performance deficit and indicated a) she required total staff assistance for her activities of daily living which included incontinence care and transfers, and b) required substantial assistance of staff with bed mobility due to impaired mobility and impaired cognition, and c) non-ambulatory and staff were to check on the resident frequently when performing care rounds; 3) behavior problems and noted that she would a) remove her clothing and place herself on the floor, b) often yelled and screamed at staff and others; 4) at risk for falls related to confusion, gait and balance problems, and poor safety awareness secondary to dementia, history of cerebral infarction, and history of falls and interventions included to follow the facility's fall protocol; 5) chronic pain and restless leg syndrome related to bilateral lower extremity pain and interventions included a) anticipate need for pain relief, b) respond immediately to any complaint of pain, c) administer analgesia as per physician orders, and d) evaluate the effectiveness of pain interventions.Record review of Resident #1's progress notes revealed there was no documentation of the resident on 4/27/26 written by Nurse #1 in the medical record.A telephone interview was conducted with Nurse #1 on 5/26/26 at 1:36 PM. Nurse #1 confirmed she worked on 4/26/26 from 7:00 PM to 7:00 AM on 4/27/26 and had been assigned to care for Resident #1. Nurse #1 explained Resident #1 had a lot of behaviors which included yelling out often, kicking her bedside table, and kicking at staff who come near her. She stated Resident #1 would also throw objects at staff. At one point in the night, Nurse #1 heard Resident #1 screaming out and she went to her room to check on her. Nurse #1 did not recall the time of this assessment. Nurse #1 stated another time she observed the resident in bed was when she heard Resident #1's tube feeding pump beeping and she went to the room to check on it. She stated she did not know the exact time of that visit to her room but explained she had been doing her medication pass at that time and thought it might have been around 4:30 AM. Nurse #1 stated Resident #1 was not yelling out at this time and when she got to the resident's room, she observed the resident lying on her back on the floor mat to the right of the resident's bed. Nurse #1 stated she stood in the doorway and yelled for nursing assistant (NA) #1. Nurse #1 explained that while she waited on NA #1 to get to the room, she turned her focus back to Resident #1 and noticed the resident had managed to wedge herself under her overbed table (below the tabletop and above the legs of the table on the floor). Nurse 1 stated Resident #1 started screaming, help me, help me. She asked the resident if she was in pain and said the resident just stared at her. As she continued to wait for NA #1, she took the resident's vital signs using a small blood pressure cuff that she kept in her pocket and stated that the resident's vital signs had been normal. She then assessed the resident and said she had no apparent injuries at that time. Nurse #1 stated when NA #1 got to the room, they lowered the resident's bed as low to the floor as it would go, approximately 12 from the floor. She admitted that she knew Resident #1 required a total mechanical lift but said the lift was not on the floor at that time, so when NA #1 got to the room, she said she instructed NA #1 to put her hands under the resident's shoulders while she stood between the resident's legs and placed her hands on the resident's buttocks and used her forearms to support the back of the resident's thighs. They lifted Resident #1 and placed her back in her bed. After they checked to see if the resident required incontinence care and found that she did not, Nurse #1 stated she resumed her medication pass on the 300 hall. She stated she had been very tired that night because she had been pulling a lot of shifts lately and that she forgot to do the incident report. She said she was tied to the medication cart for the rest of her shift. Nurse #1 explained after she completed her 300 hall medication pass, she then completed her medication pass on her half of the 100 hall and then she and another nurse went over to the Assisted Living Unit and completed their assigned medication passes on that unit. Nurse #1 stated by the time she returned to the 300 hall, the dayshift staff had begun to come in. She then counted the 100 hall cart with the medication aide and then counted the 300 hall cart and did report with Nurse #2. Nurse #1 stated by then, the incident of Resident #1 being found on the floor had slipped her mind and therefore she did not report it to Nurse #2. Nurse #1 confirmed that she also did not complete an incident report about it nor make notifications to the medical provider and Resident #1's Responsible Party. Nurse #1 stated after she and NA #1 had left Resident #1's room, she had no further conversations with her. She denied having told NA #1 not to tell anyone about the resident's fall and said she had heard that NA #1 told administration that, but it was not true. Nurse #1 thought that NA #1 said that to save her job because she got fired and NA #1 still had her job. She said she had to meet with the Administrator, Director of Nursing and another lady who she did not know. She said they asked her if she knew what processes she had to follow when a resident fell, she told them she did, and said she told them what those processes were. She added that if you are not in the middle of a medication pass that was what you were supposed to do but said she was in the middle of a medication pass. Nurse #1 stated she did not believe that the resident was hurt, that the resident never indicated she was in pain and said that to the best of her recollection, Resident #1 never screamed out again the rest of the night. A telephone interview was conducted with NA #1 on 5/22/26 at 8:53 AM. NA #1 confirmed she worked on 4/26/26 from 11:00 PM to 7:00 AM on 4/27/26 and had been assigned to care for Resident #1. NA #1 explained she did not recall the time she heard Nurse #1 calling her to go to Resident #1's room and said she thought it had been somewhere between 2:00 AM and 4:00 AM. NA #1 explained that when she got to the resident's room, she saw Resident #1 lying on the floor, on top of the floor mat on the right side of her bed. She said that the resident was laying on the bottom structure of the bedside table with her knees curled up to her chest. NA #1 stated the resident did not look injured; she had been yelling a little bit but was not crying. NA #1 said that Nurse #1 instructed her to help her get the resident back in her bed and she did so by grabbing the resident under her arms while Nurse #1 supported her thighs and then the two of them placed Resident #1 back in her bed. NA #1 said the resident cried out when they picked her up and then did not hear her cry out any other time. NA #1 stated when they find a resident on the floor, they have to report it to the nurse and then it was the responsibility of the nurse to inform the Director of Nursing, the doctors and the residents' families. NA #1 said that Nurse #1 did not report the fall to anyone. NA #1 explained that Nurse #1 told her as they were walking out of the resident's room, don't tell a soul this happened, this stays between me and you. NA #1 said she was a little shocked the nurse said that to her but said they parted ways and said that she had no further conversations with Nurse #1 that shift. NA #1 said she returned to Resident #1's room around 4:00 AM when she started doing her rounds. She explained she provided incontinence care to the resident during which the resident did not cry out. NA #1 said she thought that the nurse was going to do what she was supposed to do, like filing an incident report, and said she found out the next day that the nurse did not do that. A telephone interview was conducted with Nurse #2 on 5/21/26 at 3:46 PM. Nurse #2 confirmed she had worked on 4/27/26 from 7:00 AM to 7:00 PM and had been assigned to care for Resident #1. Nurse #2 confirmed she had not received any information regarding Resident #1's fall earlier that morning during report from Nurse #1. She said that while she was getting report from Nurse #1, they could hear Resident #1 yelling and Nurse #1 told her that she started that, and Nurse #2 assumed the yelling was her usual yelling behavior. After report, Nurse #2 explained she went to Resident #1's room because the resident continued to yell. Nurse #2 explained Resident #1 had spasms in her legs from her restless leg syndrome often. She said she asked the resident if she was having spasms and hurting in her legs and said the resident said yes. She asked the resident if she would like some acetaminophen. Resident #1 did not respond to the question and Nurse #2 stated she administered the acetaminophen to the resident around 8:00 AM. Nurse #2 stated Resident #1 continued to yell off and on throughout the morning but that it was not continuous nor was it unusual for her to yell throughout the day. She said she went and checked on Resident #1 around lunch time and observed the resident grabbing at her left leg. Nurse #2 said she looked at the resident's leg and saw nothing on her leg to indicate any injury. Around 3:00 PM, she went back to Resident #1's room to administer her scheduled medications through her gastrostomy tube (g-tube) and when she turned on the lights in the room, she observed an area on the front of the resident's left lower leg below the knee but above the ankle that appeared red, swollen and felt warm to touch. Nurse #2 stated that the resident was not yelling during that time. She explained that she has known this resident since she had been admitted to the facility and was familiar with her behaviors, like yelling all the time. She also said that sometimes Resident #1 would respond appropriately to questions and could voice her needs at times, but at other times she would not do that. She said she asked Resident #1 if she had hit her leg on anything and the resident did not respond. After she left the resident's room, Nurse #1 said she called the Nurse Practitioner (NP) to tell her about the resident's leg and said the NP asked her if the resident had hurt her leg, and she said she told the NP there had been no injury. She questioned whether the resident might have a clot in a vein and voiced her concern to the NP. She stated the NP ordered a doppler (a common test used to look for blood clots in veins; it uses sound waves to look at veins and the blood flowing through them) from their mobile x-ray company. Nurse #1 stated that at some point, the resident's yelling tapered off and when her shift ended, she explained to the oncoming nurse, Nurse # 3, what had been going on with Resident #1 throughout the day. When she returned to work the following morning, Nurse #3 informed her that Resident #1 had been taken to the hospital where it was discovered she had fractures in her leg.Review of the Medication Administration Record indicated Resident #1 had an order for acetaminophen 325 milligrams (mg) 2 tabs via g-tube (gastrostomy tube) as needed for general discomfort. Nurse #2 administered a dose of acetaminophen on 4/27/26 at 7:54 AM. Record review revealed a communication progress note to physician written by Nurse #2 on 4/27/26 at 3:43 PM. It read, Situation: discolored LLE [left lower extremity]; Background: reoccurring complaints of cramps; Assessment: resident observed with lower left extremity discolored, slightly swollen and warm; Recommendations: one time order for left lower venous doppler.A late entry progress note dated 4/27/26 at 5:30 PM, written by Nurse #2, read, During morning report resident noted hollering out. Night nurse reported she has started 'that'. Note resident has times when she hollers out. After [7:30 AM] nurse went into residents' room to administer morning medications. While in room resident rolling around in bed. grabbed her left leg and hollered. Nurse asked resident if she was having leg cramps and resident stated 'yes'. Nurse asked resident if she wanted some Tylenol, resident stated 'yes'. Nurse asked MT [medication technician] to crush Tylenol d/t [due to] resident showing signs of pain. Noted resident hollered off and on during shift. Approximately after [3:30 PM] this nurse went into room to administer meds and flush. when entering room I cut on the light in room As I was walking towards residents' bed I observed left leg discoloration (redness). I asked resident what happen to her leg and if she was still having cramps. Resident shook her head no. I administered meds and flush. Assessed LLE. Noted it to be discolored (redness) warm to touch and slightly swollen. Nurse notified [name of nurse practitioner] at approximately [3:43 PM] of assessment of LLE and previous complaints of pain/cramps during the shift. [Name of nurse practitioner] gave stat order for LLE venous doppler.A telephone interview was conducted with the facility's Nurse Practitioner (NP) on 5/22/26 at 12:36 PM. The NP explained that Nurse #2 had called her 4/27/26 and informed her how Resident #1 had slight discomfort in an area in the front of her left lower leg and that the area was warm and tender to touch. She stated that at that time, she did not know the resident had fallen. Since she presented with signs and symptoms of a deep vein thrombosis (a clot in a vein), the NP stated she ordered a doppler using the facility's mobile x-ray company. The NP explained that she had been seeing the resident since December 2025 and that she had been bedbound for two years. She said she had been unaware of the condition of Resident #1's bones until she went to the hospital and had x-rays. The NP explained that Resident #1 had falls in the past that resulted from the resident's attempts to get up out of bed. She further explained that the resident's chances for fractures were increased as compared to regular people secondary to her having been bedbound for so long, having protein malnutrition, and her diagnosis of failure to thrive. She stated Resident #1 was on hospice. The NP indicated these conditions as well as the condition of her bones would have made the fractures worse. The NP also stated by Nurse #1 not reporting the fall to anyone caused a delay in the diagnosis and therefore the care Resident #1 required.A telephone interview was conducted with NA #2 on 5/28/26 at 9:15 AM. NA #2 confirmed she worked on 4/27/26 from 7:00 AM to 3:00 PM and had been assigned to care for Resident #1. NA #2 explained that the nurse aides do not give each other report at the beginning of the shift like the nurses do. She stated she first saw Resident #1 around 7:15 AM and that she had been asleep and there was nothing out of the ordinary. NA #2 stated she saw her again when she went in to provide morning care to the resident around 9:15 AM. She said she observed Resident #1's leg during the bed bath and thought everything looked normal. She said the resident turned from side to side in the bed and did not grimace or yell out. Around 11:00 AM, she brought her some ice cream, and she got it all over herself and NA #2 said she had to clean her up and again showed no signs of being in pain. NA #2 explained Resident #1 would often yell out and she would go check on her and ask her if she was in pain, or if she needed the nurse, and said the resident would say no. She said the last time she checked on her was right before the end of the shift, right before 3:00 PM, and Resident #1 was not acting like she was in any pain. NA #1 said when she came in the next morning on 4/28/26, she was shocked to find out the resident had been sent out to the hospital through the night and had a broken leg.Multiple attempts to conduct a telephone interview with NA #3, who worked on 4/27/26 from 3:00 PM to 11:00 PM and had been assigned to care for Resident #1, were unsuccessful.The facility provided NA #3's statement, as told to the Administrator during a telephone interview with NA #3 on 4/30/26. It read as follows: States resident was unusually quiet and sleeping a lot during the shift. States the resident is normally awake and asking for water. She states she did not see the discoloration of the left leg until around 9:45 PM. Around 10:30 [PM], another CNA [certified nursing assistant] notified her that resident had black substance in g-tube and nurse [name of Nurse #3] was aware and in the room working on the issue with g-tube. She states she is unaware of anything else.A telephone interview was conducted with NA #4 on 5/27/26 at 12:26 PM. NA #4 confirmed that she worked on 4/27/26 from 11:00 PM to 7:00 AM on 4/28/26 and had been assigned to care for Resident #1. She explained that she first saw Resident #1 when she had been making her first rounds of the night around 11:00 PM. NA #4 stated that when she provided incontinent care to the resident, she noticed Resident #1's left leg was a little red but said that the resident was still moving her leg and did not yell out during care. She explained she saw the resident again during her second rounds of the night, around 2:30 AM. She stated that when she changed the resident's adult brief was when she started complaining of pain in her left leg. She said Resident #1 laid on her back and held her leg towards her chest. NA #4 said she asked the resident if her leg was hurting and if anyone had looked at it. She said Resident #1 told her that someone had looked at it during the day. NA #4 said that was when she left to get Nurse #3. It was sometime after that NA #3 said she heard the resident scream out but said that was not unusual because she yelled all the time. NA #4 stated she told Nurse #3 about the resident's leg pain and said did not return to the resident's room because Nurse #3 and Nurse #4 were in there and that was when everything started happening and Resident #1 got sent out. A telephone interview was conducted with Nurse #3 on 5/27/26 at 12:02 PM. Nurse #3 confirmed that she worked on 4/27/26 from 7:00 PM to 7:00 AM on 4/28/26 and had been assigned to care for Resident #1. She stated that Nurse #2 had reported to her that Resident #1 had a swollen, red, and tender-to-touch left lower leg. She had also told her that a doppler had been ordered but had not been done yet. Nurse #3 said she first saw the resident when she went into her room between 7:45 PM and 8:00 PM. She said she had some concerns with residuals from the resident's g-tube and continued to check on her regarding that matter. She stated that around 3:15 AM on 4/28/26, she heard Resident #1 scream very loudly and NA #4 came to her and said that the resident was complaining that her leg was hurting. Nurse #3 explained that she pulled some acetaminophen to give her and went to the resident's room. When she assessed her, Nurse #3 stated the resident had a lot of discoloration in her left lower leg from right above her ankle and all the way to her knee. She observed her left foot to be blue in color like there was no circulation going to it, and when she put her hand under the lower part of the leg to lift it off the bed, Resident #1's foot just dangled and her leg looked obviously broken at that time. Nurse #3 stated she called for Nurse #4 to come to the room to help her splint the leg with gauze. She stated at that time, she called the hospice nurse who asked her if she needed to come to the facility and Nurse #3 stated no, that she was sending Resident #1 out to the hospital and the hospice nurse agreed. Nurse #3 stated she called Emergency Medical Services (EMS). When EMS came, the nurse said EMS personnel began an intravenous line (IV), administered ketamine (a fast-acting anesthetic used for sedation and pain relief), splinted the resident's leg and then took her to the hospital. Nurse #3 indicated at 6:01 AM, she received a call from a doctor in the Emergency Department (ED), who informed her that Resident #1 had a massive tibia fibula fracture. After that call, Nurse #3 said she called the Director of Nurse (DON) to inform her. She stated the DON told her to call the Administrator which she did. Nurse #3 stated that after the g-tube issue had resolved, Resident #1 had settled down and never yelled out like she was known to do, until she heard her scream. A review of Resident's Medication Administration Record (MAR) for 4/28/26 revealed Nurse #3 administered a dose of acetaminophen on 4/28/26 at 3:20 AM.Record review revealed a progress note written by Nurse #3 on 4/28/26 at 4:20 AM. It read, .At approximately [12:30 AM] . Resident denied pain. At approximately [3:15 AM] resident hollered out complained of left leg pain; PRN [as needed] Tylenol administered. Tylenol tolerated.Another progress note written by Nurse #3 on 4/28/26 at 5:30 AM read, Assume shift change report from [name of Nurse #2]; stated resident had new area to left lower leg; red in color, warm to touch. Order was received for venous doppler study to be done. Resident lying in bed; alert; continues to deny pain. At approximately [3:20 AM]; resident hollered out several times; [Name of NA #4] checked on resident; stated resident said hurting. Prepared PRN Tylenol for pain; upon entering residents' room; resident was holding left leg; noted the discoloration to the mentioned area was now extending upward toward her left knee and her left foot was bluish in color and cool to touch; resident move her leg when touched by this writer; I observed the flaccidity of the lower leg at this time; leg was immobilized with myself and [name of Nurse #4], PRN pain medication administered via G-tube. Hospice was notified of findings of leg at [3:36 AM]. Order to send resident to ER [emergency room] for further evaluation. At 0400; 911 was initiated. leg assessed by EMS personnel; leg was immobilized by EMS personnel IV started. resident received pain medication via IV site by EMS personnel. At [6:00 AM], [name of hospital] confirm tib/fib [tibia and fibula] fracture of residents left lower leg. [6:03 AM] DON was notified of call and confirmation from hospital. At [6:07 AM] Executive Director [Administrator] was notified.A telephone interview was conducted with Nurse #4 on 5/22/26 at 8:16 AM. Nurse #4 confirmed she worked on 4/27/26 from 7:00 PM to 7:00 AM on 4/28/26. Nurse #4 stated she was not assigned to care for Resident #1. Nurse #4 explained that around 9:00 PM, she had gone outside to take a break and NA #1 was telling her the story of how Resident #1 had thrown herself on her bedside table and said NA #1 did not say anything else. Nurse #4 said she went back inside to continue with her medication pass and said at that point, what NA #1 had said was just a story, that she had said nothing about a fall, and that she did not think twice about it after 11:00 PM when NA #1 left. Later, Nurse #4 said that Nurse #3 asked her to look at Resident #1's g-tube (gastrostomy tube) and what was coming out of it and that they had talked about calling hospice about it. Nurse #4 said that while she was in the resident's room, she observed a bruise on her left leg and that was when she put two-and-two together and thought about the story that NA #1 had told about the resident. Nurse #4 said that when Nurse #3 went into the room to look at Resident #1's leg, the bruising and swelling looked worse and that the resident's left foot was blue down to her toes. Nurse #4 said that at that point, her leg looked broken and commented that 4 hours earlier, it had not looked like that. Nurse #4 explained that when Nurse #3 held Resident #1's leg up to get a better look at it, her bone in the leg looked like it was rubbery in that area and it looked floppy. Nurse #4 said Resident #1 had not yelled out through the night like she was in pain, but when Nurse #3 held her leg like that, the resident cried out in pain. She said when she first saw the bruise, she asked Nurse #3 if there was anything in the chart about it and they looked and saw that the resident had been given Tylenol around 7:00 AM that morning. Nurse #4 stated at that point, she felt like the Director of Nursing (DON) should have been called but Nurse #3 did not call her, although she does think that Nurse #3 called the hospice nurse. Nurse #4 stated the facility terminated her employment because she failed to report abuse in a timely matter. She stated she did not know anything about any abuse. She stated that when they were sending Resident #1 out to the hospital, Nurse #3 called the DON to inform her what was going on. Nurse #4 added that they fired her and said she thought it was because they thought she knew more than she actually did.Review of the Emergency Department (ED) records, dated 4/28/26, revealed that Resident #1 presented to the ED with complaints of left lower leg pain. The Physician Assistant (PA) indicated some of the resident's history had been provided by a family member who had explained that Resident #1 had been bedbound for at least 2.5 years and that she rarely got up out of bed in a wheelchair. A Medical Doctor (MD) who also saw the resident in the ED stated that an x-ray of her left tibia and fibula revealed acute fractures of the bones with significant displacement. The x-ray also revealed that Resident #1 had osseous demineralization (bones appeared weakened overall from things such as aging and lack of weight-bearing activity like being bedbound and these factors can make the bones more susceptible to breaking). The PA noted that because Resident #1 had not been out of bed in more than 2.5 years, it was highly likely that her bone quality is very weak and could not be surgically repaired the usual way as her bones would not hold pins and screws. She also stated that a surgical repair would not restore ambulation because she had not walked for years and therefore surgical repair was not an option. Resident #1 had been admitted to the hospital for monitoring with plans to continue to keep her leg immobilized by continuing with the splint that Emergency Medical Services (EMS) had placed on it prior to transporting her to the hospital from the facility. The MD noted that Resident #1 was evaluated by an orthopedic team while in the ED and recommended conservative management with splinting of the fracture injury and placing a hard cast likely the following day. A review of Resident #1's hospital Discharge summary, dated [DATE], revealed the resident's primary discharge diagnosis was a comminuted fracture (type of bone break in which the bone shatters or splits into three or more pieces) of the left tibia and fibula. During her hospitalization, orthopedic surgery was consulted and the patient underwent bedside splinting under sedation. The discharge summary indicated that given her advanced age and multiple comorbidities (additional co-existing illnesses) she had not been a candidate for surgical repair. At the time of her discharge, she was stable with well-controlled pain and stable fracture immobilization. The note stated she would be discharged back to the facility with plans for continued conservative orthopedic management, completion of antibiotic therapy, and close outpatient follow-up. During an interview with the Director of Nursing (DON) on 5/27/26 at 11:21 AM, the DON stated their investigation began as soon as they found out about Resident #1's fractures. The DON explained that on 4/27/26 Nurse #2 had informed her about Resident #1's leg being warm and tender-to-touch and that a doppler had been ordered. It had been on 4/28/26 when Nurse #3 called her and said that something was going on with the resident's leg, that it was deformed looking. She said they began to interview staff and an interview of NA #1 by their Clinical Nurse Consultant revealed some information that led them to the discovery of Resident #1's fall. She stated they eventually spoke with Nurse #1 who denied knowledge of anything that could have happened to Resident #1, saying that she went into her room so many times and that the resident had told her to shut up. The DON said she and the Administrator informed her about the resident's fractures and placed her on suspension. She said it was then that Nurse #1 opened up and explained to them how she found the resident lying on the floor and how she and NA #1 had picked her up and placed her back in the bed. She continued and said that Nurse #1 denied instructing NA #1 not to say anything about Resident #1's fall but then later stated she had instructed her not to tell anyone about the resident's fall. When asked why she thought the nurse did not inform anyone of Resident #1's fall, the DON said she can only state what Nurse #1 told them - that the resident's fall was around 5:30 AM, around the start of her medication pass time and towards the end of her shift. She said the nurse told them that she had something to do when she

Based on observations and staff interviews, the facility failed to maintain hot pureed food at 135 degrees Fahrenheit (F) or higher for 1 of 1 tray line observation. This practice has the potential to affect residents on a pureed diet. The findings included: An observation of the lunch meal tray line in progress was conducted in the main kitchen on 02/09/26 at 11:30 AM, with three lunch trays plated, covered and ready to be placed into the tray carts. Temperature monitoring was requested and performed by the Dietary Manager (DM) on 02/09/26 at 11:30 AM. The following temperatures were obtained: pureed chicken alfredo 128 degrees F and pureed spinach 130 degrees F. The temperatures of these items were taken using the facility's electronic food thermometer. The pureed items were taken off the steam table by the DM and re-heated. An interview was conducted with the DM on 02/09/26 at 11:45 AM. He stated that he expected dietary staff to serve hot foods at 135 degrees F or higher, and if temperatures of hot foods was below 135-degrees F the food items should be discarded or re-heated to 165 F prior to serving. The DM said the kitchen staff should have checked temperatures of all foods on the steam table to ensure hot food items were above 135 degrees F prior to the start of tray line and before serving them on the lunch tray line. He stated the cook responsible for taking tray line temperatures had called out and no one who was filling in for the cook thought of checking food temperatures on the steam table. An interview was conducted on 02/12/26 at 10:00 AM with the Administrator. He stated it was his expectation for the facility's kitchen to follow all regulatory guidelines for food and kitchen sanitation safety, which included daily monitoring hot food temperatures on the steam table and document temperatures in the temperature log, and for temperatures to be above 135 F, prior to plating.

Based on record review, observation, staff and Physician interviews, the facility failed to provide a safe transfer when the Transportation Aide did not ensure a resident's lower extremities were raised during a transfer onto the wheelchair lift platform of the facility van for 1 of 1 resident reviewed for supervision to prevent accidents (Resident #1). During a facility van transport on 10/31/23, Resident #1 was assisted onto the wheelchair lift platform by the facility Transportation Aide when she fell forward from the wheelchair resulting in a laceration to the head, fractures of cervical (neck) 1 and 2 vertebrae, fractures of the right tibia and fibula (bones of the lower leg), and fracture of the femur (hip). Resident #1 was sent to the emergency room for evaluation and treatment and required transfer via life flight to a second hospital on 10/31/23 for acute trauma care. Resident #1 had surgical closure of the laceration of the scalp and repair of the open fractures of the tibia and fibula. She demonstrated decline in her overall condition with decreased cognition and ability to swallow necessitating feeding tube placement while hospitalized . She was transferred to an inpatient hospice on 11/9/23 where she passed away on 11/10/23 with cause of death listed as complications of multiple blunt force injuries. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part: history of stroke with ataxia (impaired balance and coordination), muscle weakness and osteoporosis. Review of Resident #1's care plan revealed a 6/23/23 focus of at risk for falls related to confusion, gait, and balance problems and unaware of safety needs. The goal indicated Resident #1 would be free of falls resulting in major injury. The mobility interventions indicated Resident #1 used a wheelchair for locomotion, required supportive care and assistance with mobility, and staff were to anticipate and meet resident's needs. Review of Resident #1's 9/18/23 quarterly Minimum Data Set (MDS) assessment indicated resident was cognitively intact and demonstrated no behaviors. Resident #1 required extensive assistance with transfers, had impaired balance and required a wheelchair for mobility. Review of the 10/30/23 physical therapy progress note indicated Resident #1 had significant impairments in the bilateral lower extremities and core strength, transfers, functional mobility, and was at risk for falls. An interview was conducted on the facility van on 11/28/23 at 1:40 PM with the Transportation Aide with the Administrator present. Observation of the facility van revealed a wheelchair accessible van with the wheelchair lift mechanism on the side. The wheelchair lift mechanism included a threshold plate which bridged the gap between the lift platform and the vehicle floor and the metal grating surface upon which the wheelchair was positioned for entering and exiting the van. The floor of the interior of the van had a rubberized flooring material. The Transportation Aide stated when offloading a resident from the van, with the lift platform level with the vehicle floor in the fully raised position he backed the wheelchair up and then turned the chair to the right pushing the chair forward onto the lift platform located on the side of the van. The outer end of the lift platform had a metal raised outboard roll stop barrier that must be in place prior to lowering the lift platform to the ground. The Transportation Aide stated he stood on the lift platform behind the wheelchair as he lowered the lift platform to the ground. The Transportation Aide stated on 10/31/23 he had Resident #1 in her wheelchair and had turned the chair to the right and was attempting to get her wheelchair onto the lift platform. The Transportation Aide stated he was rolling the chair forward onto the lift platform when Resident #1 put both her feet down and tilted forward and she hit the corner of the metal outboard stop barrier at the end of the lift and went down on her knees. The Transportation Aide stated he lowered the lift platform down to the ground level and went to the therapy room to call for assistance. The Transportation Aide revealed he was trained in the use of the wheelchair van lift when the facility obtained the van about 12 or [AGE] years ago. The Transportation Aide stated he was trained that according to the lift manufacturer instructions he could position the resident in the wheelchair facing outboard (toward the outside of the van) or inboard (toward the interior of the van) when he raised and lowered the lift platform for entering and exiting the vehicle. On 11/29/23 at 9:30 AM a reenactment of the incident on 10/31/23 involving Resident #1 was completed with the Transportation Aide on the facility van using a standard wheelchair without leg rests. The Administrator was present for the reenactment. The reenactment also included an interview with the Transportation Aide for clarification of the information presented. The reenactment began as the Transportation Aide raised the wheelchair lift platform (located on the side of the vehicle) to the high position flush with the floor of the vehicle. The Transportation Aide then demonstrated that on 10/31/23, Resident #1 was sitting in the wheelchair without leg rests present when he released the locking hooks and lap/shoulder strap, unlocked her wheelchair brakes, and backed her wheelchair up to the back of the van in preparation to turn the wheelchair to the right to proceed to the lift platform. The Transportation Aide stated Resident #1 had her legs straight out in front of her initially. The Transportation Aide demonstrated that he then turned her wheelchair to the right and began pushing the wheelchair forward toward the lift platform. At this time, the Transportation Aide noted Resident #1 no longer had her legs straight out in front of her. The Transportation Aide indicated he did not provide Resident #1 with verbal instructions to lift her feet or to hold her feet up as he was pushing her wheelchair and getting her onto the lift platform. The Transportation Aide indicated Resident #1 had been on the transport van multiple times before, and he thought she knew what he was doing and what was required of her. The Administrator interjected that there was no need to provide instructions to Resident #1 regarding keeping her feet elevated when being moved in the wheelchair as she initially lifted her feet and she had been transported on the van many times previously. The Transportation Aide further stated he did not always provide instructions to the residents regarding the procedure of getting onto the lift platform or keeping their feet up. The Transportation Aide stated that he provided instructions regarding the procedure of being moved in the wheelchair onto the lift platform to the residents on an as needed basis. The Transportation Aide indicated he was not rushed or in a hurry when he was getting Resident #1 off the van. He explained that he had another transport scheduled for later that day and there were no other residents on the van with Resident #1. The Transportation Aide demonstrated he was behind Resident #1's wheelchair pushing her onto the lift platform as she put her feet down causing the wheelchair to stop. The Transportation Aide indicated Resident #1 went forward out of the wheelchair hitting her head on the left corner of the raised edge at the end of the lift platform and landing on her knees. The Transportation Aide demonstrated Resident #1 laying on the lift platform with her head at the outside end and her feet towards the van. The Transportation Aide demonstrated he stepped onto the lift platform with Resident #1 lying on the platform, lowered the platform to the ground and quickly went to the entrance of the building to summon help. The Transportation Aide indicated he did not move the resident and that the nurses and nursing assistants quickly responded and began administering first aid. An interview was conducted on 11/28/23 at 2:40 PM with the MDS Nurse. The MDS Nurse stated she responded to the overhead page for nursing STAT (respond immediately, without delay) to therapy on 10/31/23. When she arrived, the facility van was outside the therapy room and the MDS Nurse stated she observed Resident #1 lying on her back on the lift platform with her head at the outside edge of the platform and her feet towards the inside of the van. The MDS Nurse stated Resident #1 was bleeding from the top of her head with a large amount of blood dripping onto the ground, had a large laceration and blood bruise to her right leg and was in a lot of pain. The MDS Nurse stated she was instructed by the Administrator to ask Resident #1 why she put her feet down. The MDS Nurse indicated Resident #1 responded she did not know how she fell . An interview on 11/28/23 at 2:09 PM with Nursing Assistant (NA) #2 revealed she was familiar with Resident #1's care as she was assigned to her regularly since she started working at the facility 3 months ago. NA #2 indicated Resident #1 was alert and oriented, required assistance with toileting and transfers and was able to put her feet up when instructed to do so when pushed in the wheelchair. NA #2 stated on 10/31/23 she responded to the overhead page for nursing stat to therapy. NA #2 stated she observed Resident #1 lying on her back on the lift platform with her head at the end of the platform and her feet towards the van. NA #2 stated Resident #1 was bleeding from her head and her knee and kept repeating her head was hurting. NA #2 stated she observed Resident #1 was in a lot of pain from her head and leg, so she tried to comfort her and keep her calm until Emergency Medical Services (EMS) arrived. An interview was conducted on 11/28/23 at 2:20 PM with the Unit Manager. The Unit Manager revealed she responded to the overhead page for nursing stat to therapy on 10/31/23 and observed Resident #1 lying on the lift platform with a large amount of bleeding from her head. The Unit Manager stated she went to obtain medical supplies, returned, and observed Resident #1 crying complaining of severe pain to her head and her right leg. The Unit Manager observed bleeding from Resident # 1's right leg. An interview was conducted with the Staff Development Coordinator (SDC) nurse on 11/29/23 at 12:50 PM. The SDC nurse indicated she responded to the overhead page for nursing stat to therapy on the morning of 10/31/23. The SDC nurse indicated when she arrived at the area outside therapy, she observed Resident #1 lying on the lift platform with a significant amount of bleeding from her head and a laceration to her right leg. The SDC nurse stated Resident #1 was in a lot of pain. The SDC nurse indicated she assisted with emergency care to Resident #1 until EMS arrived. An interview was conducted with the Director of Nursing (DON) on 11/28/23 at 4:53 PM. The DON stated she responded to the overhead page for nursing stat to therapy on 10/31/23. The DON stated the other nurses were already providing emergency care to Resident #1's lacerations to the head and leg when she arrived outside to the wheelchair van. The DON stated she instructed Nurse #2 to call 911, obtain paperwork and notify the physician and the family. An interview was conducted with Nurse #2 on 11/29/23 at 1:00 PM. Nurse #2 stated she was familiar with Resident #1, was assigned to her care frequently and was assigned to her on 10/31/23 7:00 AM to 7:00 PM shift. Nurse #2 stated Resident #1 required assistance with mobility, had weakness in her legs and at times required reminders to lift her feet up during locomotion. Nurse #2 indicated on 10/31/23 she heard the overhead page for nursing stat to therapy and responded. Nurse #2 stated when she arrived, she observed Resident #1 lying on her back on the lift platform. Nurse #2 stated she was informed by a staff member, although she could not recall which one, that the Transportation Aide was pushing Resident #1 off the van when her legs dropped, and she tipped over. Nurse #2 stated she quickly left the scene of the incident called 911, prepared transfer paperwork and made phone calls. Review of Resident #1's medical record revealed a transfer to the hospital form dated 10/31/23 at 4:00 PM was completed by the Director of Nursing (DON). The transfer form indicated Resident #1 was transferred to the hospital due to a fall resulting in a scalp laceration, right lower leg laceration and a laceration to the palm of the right hand. Review of a 10/31/23 nursing post fall progress note written by Nurse #2 at 4:28 PM indicated Resident #1 wearing shoes at the time of the fall. Review of the hospital #1 emergency department note on 10/31/23 revealed Resident #1 presented at 11:11 AM in a cervical collar with a v shaped laceration of the head and obvious deformity of the right shin with a laceration over the deformity after a fall from a wheelchair. X rays and Computerized Tomography (CT) scans were completed with the following results: CT of the cervical spine revealed a non-displaced fracture of cervical vertebra 1, type 2 Dens fracture (an unstable break of the second bone of the neck), CT scan of the head revealed a large superficial left sided soft tissue hematoma, x ray of the right tibia fibula revealed comminuted and displaced fractures of the tibia and fibula. The note indicated Resident #1 received intravenous fluids, intravenous antibiotic cefazolin 2 grams for open fractures, and narcotic fentanyl 50 micrograms intravenous for severe pain. The emergency department note indicated at 1:56 PM Resident #1 was transferred via life flight to hospital #2 for further management and the need for more advanced care. Review of the 11/9/23 discharge summary from hospital #2 revealed Resident presented on 10/31/23 at 2:51 PM as a trauma transfer from hospital #1. Resident #1 was unable to recall what happened. Resident #1 presented at hospital #2 with pain in her right lower leg, head, and neck and a blood pressure of 77/36. Resident #1 underwent surgical closure of the laceration of the scalp and repair of the open fractures of the tibia and fibula. The discharge summary indicated Resident #1 demonstrated decline in her overall condition with decreased cognition and ability to swallow necessitating feeding tube placement while hospitalized . Hospice was consulted and Resident #1's family opted for comfort care. Resident #1 was transferred to the hospice care center on 11/9/23 for end-of-life care. Resident #1's discharge diagnoses included cervical vertebra 1 and 2 fractures, right tibia and fibula fractures, left femur fracture, scalp laceration with acute blood loss anemia and atrial fibrillation with rapid ventricular response. Review of a death certificate dated 11/10/23 revealed Resident #1 was pronounced dead on 11/10/23 at the inpatient hospice center with the cause of death listed as complications of multiple blunt force injuries sustained on 10/31/23 at the nursing facility. Review of a typed statement written and signed by the facility Administrator dated 11/27/23 revealed he heard an announcement for nursing stat to therapy over the overhead paging system on 10/31/23 around 10 AM. The statement indicated he walked to the therapy gym where the Unit Manager asked him to obtain towels which he did. The statement indicated he then walked back to the therapy gym and saw multiple staff members outside under the breezeway. When he walked outside, the statement indicated the Administrator saw the MDS Nurse providing care to Resident #1's head. The statement indicated the Administrator asked the Van Driver [Transportation Aide] what happened and was told Resident #1 put her feet down as the Van Driver [Transportation Aide] was pushing her onto the lift and she fell forward onto the lift. The statement indicated the Administrator instructed the MDS Nurse to ask Resident #1 Why did you put your feet down? Resident #1 replied to the MDS Nurse I don't know. The statement concluded staff stayed with Resident #1 until emergency medical services (EMS) arrived shortly after. During an interview with the Administrator on 11/29/23 at 2:15 PM he indicated the Transportation Aide reported the following when he (Administrator) interviewed him (Transportation Aide) about the 10/31/23 incident: he (Transportation Aide) observed Resident #1 with her legs lifted prior to moving the wheelchair, the resident put her feet down onto the lift platform, and he stopped pushing the wheelchair when she put her feet down. The Administrator stressed that instructions regarding keeping her feet up when the wheelchair was moved were not necessary as Resident #1 initially lifted her legs and had been on the facility wheelchair van in the past. The Administrator requested this surveyor re-interview the Transportation Aide to verify the events that occurred on 10/31/23 with Resident #1. A follow up interview was conducted with the Transportation Aide with the Administrator present on 11/29/23 at 2:20 PM. The 10/31/23 incident with Resident #1 that occurred on the facility van was again reviewed. The Transportation Aide reported the same information from the previous interviews and reenactment. The Transportation Aide stressed that he stopped pushing Resident #1 onto the lift platform when the resident put her feet down. An interview on 11/28/23 at 1:10 PM with NA #1 revealed she was assigned to Resident #1 on 10/31/23 on the 7:00 AM to 3:00 PM shift. NA #1 indicated on the morning of 10/31/23 she assisted Resident #1with her personal care prior to her leaving on the facility van for her doctor's appointment. NA #1 stated Resident #1 was normally alert, oriented, and able to follow directions. NA #1 stated Resident #1 had weakness in her lower extremities and required assistance with transfers and mobility using the wheelchair. NA #1 stated she instructed Resident #1 to hold her legs up when pushing her into the bathroom for toileting and she was able to do this. NA #1 stated Resident #1 did not normally use leg rests on her wheelchair. An interview on 11/28/23 at 11:30 AM with Physical Therapy Assistant (PTA) revealed she worked with Resident #1 frequently and was familiar with her care. The PTA indicated Resident #1 was alert, cooperative with care and able to follow directions. The PTA stated Resident #1 had weakness in both her lower legs, was fearful of falling and was working with therapy staff on transfers and wheelchair mobility. The PTA stated the resident required moderate assistance with transfers. An interview was conducted with the Physician via phone on 11/29/23 at 10:17 AM. The Physician stated he was familiar with Resident #1. The Physician stated Resident #1 was cognitively intact, however at her age, periods of forgetfulness could occur. The Physician stated residents can change what they do and how they do things daily. The Physician stated Resident #1 was alert, had weakness in her lower extremities and required a wheelchair at baseline. The Physician further indicated Resident #1 had diagnosis of osteoporosis and osteopenia and at her age was at increased risk of fractures. The Physician indicated with a diagnosis of osteoporosis and osteopenia, multiple fractures could occur from a fall on to a hard surface and could lead to terminal decline. An interview was conducted with the Payroll Specialist on 11/29/23 at 1:20 PM. The Payroll Specialist stated she transported residents to doctors' appointments using the facility wheelchair van at times. The Medical Records/Payroll Specialist indicated she was trained to operate the wheelchair lift but could not recall when she received training. The Payroll Specialist indicated when she offloaded a resident from the van, she explained the procedure, instructed the resident to keep their feet up off the floor and backed the wheelchair onto the lift platform. The Payroll Specialist explained she then locked the brakes of the wheelchair and lowered the lift platform to the ground. The Payroll Specialist indicated some residents had leg rests on their wheelchairs if they had weakness or were not able to keep their feet up off the ground. The Payroll Specialist indicated she received in service training following the incident on 10/31/23 regarding the procedure for loading and offloading residents from the van. The in-service training indicated to explain the procedure to the resident, instruct the resident to lift their feet off the floor and then proceed with assisting them onto the lift platform. The Payroll Specialist did not recall if she had transported Resident #1 on the facility van. An interview was conducted on 11/29/23 at 3:05 PM with the Activity Director. The Activity Director stated she transported residents to doctors' appointments and outings using the facility wheelchair accessible van. The Activity Director stated she was trained to operate the wheelchair lift but could not recall when the training occurred. The Activity Director stated wheelchair leg rests were used if the resident had any trouble lifting their legs. The Activity Director indicated when offloading a resident from the wheelchair van, she first explained the procedure including reminding the resident to lift their feet to move the wheelchair onto the lift platform. The Activity Director stated she slowly moved the resident backward onto the lift platform while observing their feet and arms for safety. The Activity Director stated she attended a recent in-service training regarding safe loading and offloading of residents on the wheelchair van including ensuring leg rests were on the wheelchair and instructing the resident on the procedure. The Activity Director did not recall if she had transported Resident #1 to an appointment or on an outing. An interview was conducted on 11/28/23 at 4:20 PM with the facility Administrator. The Administrator stated competencies and annual retraining of the Transportation Aide and other staff that transported residents in the facility wheelchair van were not completed since he was in the position of Administrator at the facility for the past 4 years. The Administrator stated the incident that occurred on 10/31/23 was discussed and a root cause was not determined. The Administrator further indicated the incident was used as an opportunity to provide education and conduct audits. The Administrator was notified of the Immediate Jeopardy on 11/29/23 at 1:35 PM. The facility provided the following corrective action plan with a completion date of 11/2/23. 1) Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/31/2023, the resident was immediately assessed by Hall Nurse and Minimum Data Set Nurse. The facility called 911 and the resident was taken to the hospital for further evaluation. The Administrator notified the resident's responsible party regarding the incident on 10/31/2023. 2) Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents needing transportation services have the potential to be affected. It is the new practice that leg rests will be in place on all wheelchairs for vehicle transports. The Transportation Aide was observed by the Administrator on 10/31/23 for the last appointment of the day; the Transportation Aide ensured leg rests were applied to the wheelchair and the resident's legs were positioned on the leg rests while the wheelchair was moved. 3) Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 10/31/2023, the Director of Nursing immediately in-serviced the Transportation Aide on the process applying leg rests to wheelchairs prior to resident being transported to an appointment. All teammates who do transportation which includes the Transportation Aide, Activities Director, Payroll Specialist, Treatment Aide, and a 3rd shift Certified Nursing Assistant for residents were in serviced by the Administrator and Director of Nursing on 10/31/2023. The education on 10/31/2023 included the new procedure of ensuring leg rests are applied to resident's wheelchair prior to resident being transported to an appointment and ensuring resident's legs remain on leg rests while the wheelchair is being moved. The facility Driver will be responsible for ensuring leg rests are applied to the resident's wheelchair prior to completing any transportations. The Administrator was responsible for making sure teammates not in serviced on 10/31/23 were in serviced prior to completing any facility transportations. If the resident chooses not to have or refuses leg rests, the resident will be educated by the Director of Nursing on the benefit of using leg rests, and their preference will be care planned. The Facility Driver will notify the Director of Nursing if a resident refuses to have leg rests. If a resident refuses leg rests, the transportation will not occur. It is standard practice at our facility to notify the Director of Nursing any time a resident deviate from their care plan or facility policy. 4) Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The decision to conduct monitoring audits and decision to take to Quality Assurance Performance Improvement committee were made on 11/1/2023. On 11/6/2023, the Administrator or Staff Development Coordinator began auditing 5 transports each week (if less than 5 scheduled, all will be observed at time resident loads onto or off the bus) ensuring leg rests are applied to the wheelchair. The audit also includes ensuring the resident's legs remain on the leg rests during loading or offloading while the wheelchair is being moved; after four weeks the audit will continue for 10 transports per month for a quarter. Any identified issues will be immediately corrected. The Administrator will present the findings of the audit to the Quality Assurance Performance Improvement committee during the quarterly Quality Assurance Performance Improvement meetings for the next two quarterly meetings. Alleged date of compliance: 11/2/2023 The corrective action plan was validated onsite on 12/04/23. Record review verified education was completed with staff who provide transportation related to the new procedure to ensure leg rests were applied to residents' wheelchairs prior to loading/unloading from the facility vehicle. Education included ensuring the resident's legs remain on leg rests while the wheelchair was being moved. Interviews with the Transportation Aide, Activities Director and Payroll Specialist showed they had been in-serviced on the process of applying leg rests to wheelchairs prior to resident being loaded/unloaded from the facility vehicle and ensuring resident's legs remain on leg rests while the wheelchair was being moved. Staff indicated they would notify the DON if a resident refused leg rests. During an interview with the DON, she indicated if the resident chose not to have leg rests or refused leg rests, the resident would be educated on the benefit of using leg rests and it will be care planned. Transportation would not occur if leg rests were refused. A resident observation verified the resident's leg rests were on a wheelchair prior transport to an appointment. The Transportation Aide confirmed the resident's legs were resting on the leg rests before moving the resident in and out of the facility's vehicle. The facility's corrective action plan was validated to be completed as of 11/2/23.

Based on record review and staff interviews, the facility failed to post accurate nurse staffing information for 8 out of 19 nursing staff postings reviewed for staffing during the third quarter of 2022. Findings included: A review of the nursing staff posting (a report of nursing staff directly responsible for resident care from 04/23/22 through 06/30/22 was conducted. The nursing staff posting included the day shift 7:00 AM - 3:00 PM, the evening shift 3:00 PM - 11:00 PM, and the night shift 11:00 PM - 7:00 AM. Each shift listed the category of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs), the facility census (number of residents in the facility), and a column for the number and actual hours worked. A review of the actual working assignment sheets compared to the daily nursing staff posting sheets from 04/23/22 through 06/30/22 revealed 8 out of 19 staff posting sheets were noted to have discrepancies of actual nursing staff that were physically in the facility working at the beginning of each shift including the RNs, LPNs, and CNAs. An interview was conducted with the Scheduler on 08/23/23 at 3:00 PM. The Scheduler stated her role as a Scheduler was to fill out the nursing staff posting sheets daily and she completed that by reviewing the monthly assignment schedule for nurses and nurse aides and recorded the facility census. She stated she completed the nursing staff posting sheet the evening before the next day and it was up to herself and the nursing staff to ensure it was updated to reflect the number of staff that were actually in the building. The Scheduler reported she had been working in this role since July 2023 and she was not working as the Scheduler in 2022. An interview was conducted with the Administrator on 08/23/23 at 3:15 PM. The Administrator reviewed the 8 nursing staff posting sheets compared to the staffing assignment sheets, and he confirmed that the staff did not update the facility nursing staff posting to reflect how many staff were in the building on those 8 days and they should have. He stated he needed to provide additional training to all nursing staff to ensure they understood that the nursing staff posting daily census needed to be updated to reflect the number of staff in the building to provide care to our residents.

Based on observations and staff interviews the facility failed to dispose of expired medications from the medication storage cabinet and medication refrigeration storage in one of 2 medication storage rooms observed and failed to date an inhalation medication when opened on 2 of 3 medication carts reviewed. Findings Included: On 04/12/22 at 9:00 AM an unopened bottle of Aspirin 81 milligrams with an expiration date of 01/21/22 was found in the stock medication cabinet in the medication storage room. In the medication refrigeration in the medication storage room an opened bottle of Magic Mouthwash (a liquid substance used orally by swishing the drug inside the mouth for a certain amount of time then spitting it out) was noted with instruction to dispose of the unused portion after the expiration date of 03/26/22. An interview was conducted with the Director of Nursing (DON) on 04/12/22 at 9:00 AM. The DON reported the medication room was checked for expired medications on 04/11/22 by the Pharmacist. The DON stated the medication rooms were also checked twice weekly by the night nurses. The DON stated the expired medications should have been seen by either the Pharmacist or the night nurse and should have been removed from the stock rotation and the refrigerator. On 04/12/22 at 10:00 AM a package of Budesonide (an inhalant medication) 0.5/2 milliliters was noted to be opened but had no open date written on the package or the box. An interview with Nurse #4 on 04/12/22 at 10:00 AM stated she should have dated the box when she opened it. An interview with the DON on 04/14/22 at 4:10 PM revealed she expected her designated nursing staff to ensure the medication carts and the medication storage rooms were free of any expired medications and all medications that were opened had an open date written on them.

Based on record review and staff interviews, the facility failed to have all hospice information including progress notes and care plan available in the medical record to assure that the services provided were coordinated for 1of 2 residents (Resident #7) reviewed. The findings included: Resident #7 was readmitted to the facility from the hospital on 10/25/21. Resident #7 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7 ' s medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/26/21 Hospice services which included skilled nursing, chaplain, nursing assistant (NA) and social worker began. Review of Resident #7 ' s medical record revealed a hospice plan of care for period of 10/26/21 through 1/23/22. Review of the hospice plan of care indicated that Resident #7 was to receive skilled nursing visits weekly, nursing assistant visits five times per week, social worker visits monthly and chaplain services two times per month. Review of Resident #7 ' s medical record revealed the last hospice nursing progress note was dated 12/2/21. The Director of Nursing (DON) obtained a progress note dated 1/13/22 from the hospice provider which indicated hospice provided weekly skilled nursing visits. DON verified that there were no other notes in the facility that had not been placed in the medical record. DON was unable to obtain more recent notes or notes from any other disciplines from the hospice provider. Review of Resident #7 ' s Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed received Hospice services and a condition or chronic disease resulting in six month or less life expectancy. Review of Resident #7 ' s care plan dated 2/4/22 revealed that resident was receiving hospice services with a goal of through next ninety days. Interview on 4/13/22 at 11:45 AM with Nurse #2 revealed she was not aware that Resident #7 was on hospice services and was not aware where or how hospice staff document on the residents. Interview with DON on 4/13/22 at 2:17 PM revealed that her expectation was that hospice provide their documentation in a timely manner. DON further indicated that there is no specific time frame for when hospice sends their notes to the facility to be placed in the medical record. Hospice developed a Plan of Care within the first week of admission. DON was not aware of when the facility received a copy of the Hospice plan of care. DON stated that the facility care plan should include Hospice services and interventions. The DON indicated that she was designated as responsible for coordinating care for resident ' s receiving hospice services. Interview with MDS Nurse on 4/13/22 at 2:20 PM revealed that progress notes from Hospice were left at the facility, but she was unaware of when or how this occurred. MDS Nurse did not know why the last documentation from Hospice in Resident #7 ' s medical record was dated 12/2/21. MDS Nurse stated hospice care was listed in the facility care plan but not specific interventions or services. Interview on 4/14/22 at 2:30 PM with the administrator revealed that he expected that all hospice documentation including progress notes and care plan would be available in the medical record. The administrator indicated that he was not aware that the hospice provider was not providing timely documentation for residents receiving hospice services.

Based on observation, staff interview, and record review a direct care staff member failed to implement the facility's COVID-19 Plan and Protocols for wearing the personal protective equipment (PPE) required when providing care and services to 2 of 4 sampled residents who were quarantined (Resident #3 and #4). In addition, this direct care staff member also failed to rewash her ungloved hands after touching the shoes of 1 of 4 sampled residents (Resident #3) and before handling the resident's condiments. These failures occurred during the COVID-19 pandemic. Findings included: The facility's Coronavirus Disease 2019 (COVID-19) Plan and Protocols (last revised on 06/08/20) documented, If resident has no symptoms of COVID, resident will be placed on quarantine measures for 14 days. This includes the following: Staff will utilize appropriate PPE (personal protective equipment) including surgical masks and gloves at all times Record review revealed Resident #4 was admitted to the facility on [DATE] and placed on the quarantine hall. Her documented [DIAGNOSES REDACTED]. Record review revealed Resident #3 was admitted to the facility on [DATE] and placed on the quarantine hall. His documented [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 06/23/20 at 11:08 AM she stated residents who were admitted or readmitted to the facility who were not known to be COVID positive were placed together on a hall where quarantine precautions were in place during their 14-day stay there. During observation of the lunch meal on the quarantine hall, beginning at 12:30 PM on 06/23/20, PPE was stacked on tables outside the resident rooms. This PPE included masks, gloves, gowns and eye protection. During meal observation on 06/23/20 at 12:40 PM Nursing Assistant (NA) #1 washed her hands in Resident #3's restroom. NA #1 was wearing a surgical mask. On her way to get the resident's lunch tray off the cart the resident informed her that he was uncomfortable, and requested that his feet be repositioned. NA #1 touched the resident's shoes while completing the repositioning. She immediately retrieved the resident's meal tray, and set it up for him without rewashing her hands. She tore open the resident's salt/pepper packets. NA #1 did not wear gloves at any time while in the resident's room. During meal observation on 06/23/20 at 12:44 PM NA #1 washed her hands in Resident #4's restroom. NA #1 was wearing a surgical mask. She set up the resident's meal tray which included removing bread from Resident #4's bread bag and tore open the resident's sugar packet. NA #1 did not wear gloves at any time while in the resident's room. During an interview with the DON on 06/23/20 at 12:49 PM she stated NA #1 should have worn the PPE required in the facility's COVID policies to help reduce chances of cross-contamination just in case one of the residents on the quarantine hall were COVID positive or began exhibiting signs and symptoms of respiratory illness. She also reported NA #1 should not have handled Resident #3's food and condiments after handling his shoes without washing her hands or washing her hands and re-gloving first. During an interview with NA #1 on 06/23/20 at 12:54 PM she stated she was not assigned to care for residents on the quarantine hall, but was trying to help out on that hall by passing meal trays. She reported she did not realize she was supposed to wear any PPE beside her surgical mask when entering the rooms of residents who resided on the quarantine hall. She also commented she did not realize she had touched Resident #3's food and condiments after she handled his shoes while repositioning his feet.

Based on observation and staff interview the facility failed to air dry kitchenware before stacking it in storage and failed to discard abraded kitchenware being used for serving residents their food. Findings included: 1. During observation of the kitchen on 02/26/20 at 8:54 AM 1 of 15 tray pans stacked on top of one another in storage had moisture inside of it. During observation of the kitchen on 02/26/20 at 8:56 AM 4 of 8 salad bowls were stacked on top of one another in storage with moisture trapped between them. During an interview with the Dietary Manager (DM) on 02/27/20 at 10:32 AM she reported she thought the kitchenware items found stacked wet on the morning of 02/26/20 had actually been placed into storage on the evening of 02/25/20. She stated dietary staff had been previously in-serviced that kitchenware should be clean and dry before being stacked in storage. She commented trapped moisture was a breeding ground for bacteria which had the potential of making residents sick. During an interview with Dietary Employee #1 on 02/27/20 at 10:43 AM she stated dietary staff had been told not to stack kitchenware wet because germs and mold could form in the moisture which could cross-contaminate food. 2. During observation of the kitchen on 02/26/20 at 9:40 AM 18 of 32 (56%) plastic soup and cereal bowls had abraded interior surfaces. During an interview with the Dietary Manager (DM) on 02/27/20 at 10:32 AM she reported abraded kitchenware surfaces could harbor bacteria, and pieces of abraded plastic could slough off into food. She commented dietary staff had been told not to heat soups in the microwave which was what she thought was causing the deterioration of the interior bowl surfaces. She stated dietary staff were trained to dispose of compromised kitchenware after they showed it to her for validation and a count for re-order. During an interview with Dietary Employee #1 on 02/27/20 at 10:43 AM she stated dietary staff were trained to throw away kitchenware that was cracked, chipped, or had abrasions inside of it. She reported germs and bacteria were more difficult to remove from compromised kitchenware surfaces, and in the case of the plastic soup and cereal bowls, tiny pieces of plastic could choke residents as they were eating from the bowls. She commented bowls with abraded interior surfaces posed both a sanitation and a safety risk.

Based on observations, record review and staff interviews the facility failed to ensure it was free of medication error rates greater than 5% as evidenced by 12 medications that were administered late out of 25 observations resulting in a medication error rate of 48% for 2 of 2 residents (Resident #147 and Resident #6) observed during a medication pass. Findings included: During a medication pass observation with Nurse #3 in 02/24/20 at 11:55 AM, Nurse #3 was observed administering the following medications to Resident #147: one tablet of [MEDICATION NAME] [AGE] milligrams (mg), one tablet of [MED] 2.5 mg, one tablet of [MEDICATION NAME] 20 mg, one tablet of [MEDICATION NAME] 25 mg, one tablet of [MED] DS [AGE]0 mg, and one tablet of [MEDICATION NAME] 500 mg. 1a.A medication reconciliation was conducted on 02/24/20 at 1:05 PM. The reconciliation revealed the [MED] DS and the [MEDICATION NAME] medications were due to be administered at 8:00 AM. The [MEDICATION NAME], [MED], [MEDICATION NAME], and the [MEDICATION NAME] medications were due to be administered at 9:00 AM. The [MEDICATION NAME] was scheduled to be administered four times per day at 9:00 AM, 3:00 PM, 9:00 PM and 3:00 AM. The [MEDICATION NAME] was scheduled to be administered three times per day at 8:00 AM, 4:00 PM and 8:00 PM. An interview was conducted with Nurse #3 on 02/25/20 at 5:35 PM. Nurse #3 reported the way the system worked with their new computer system was that the nurses had a time block to complete their medication pass. Nurse #3 explained all the AM medications that were due from 7:00 AM through 9:00 AM needed to be administered by 10:30 AM according to the time block on the electronic medical administration record (eMAR). Nurse #3 stated she realized she administered the medications late when she gave them to Resident #147 at 12:00 PM. Nurse #3 stated she kept getting called away from her medication cart and it caused her to be late. During a medication pass observation with Nurse #3 on 02/24/20 at 5:55 PM, Nurse #3 was observed administering the following medications to Resident #147: one tablet of [MEDICATION NAME] [AGE] mg, one tablet of [MEDICATION NAME] 500 mg, and three tablets of [MED] (1,000 units per tablet). 1b.A medication reconciliation was conducted for Resident #147 on 02/24/20 at 6:15 PM. The reconciliation revealed the [MEDICATION NAME] and the [MED] were scheduled to be administered at 3:00 PM. The [MEDICATION NAME] was due to be administered at 4:00 PM. During a medication pass observation with Nurse #3 on 02/25/20 at 5:30 PM, Nurse #3 was observed administering the following medications to Resident #147: one tablet of [MEDICATION NAME] [AGE] mg, one tablet of [MEDICATION NAME] 500 mg, and three tablets of [MED] (1,000 units per tablet). 1c.A medication reconciliation was conducted for Resident #147 on 02/25/20 at 6:00 PM. The reconciliation revealed the [MEDICATION NAME] and the [MED] were scheduled to be administered at 3:00 PM. The [MEDICATION NAME] was due to be administered at 4:00 PM. An interview was conducted with Nurse #3 on 02/25/20 at 5:35 PM. Nurse #3 reported the way the system worked with their new computer system was that the nurses had a time block to complete their medication pass. Nurse #3 explained all the medications that were due between 3:00 PM and 6:00 PM had to be given by 6:00 PM according to the time block on the electronic medical administration record (eMAR). Nurse #3 stated she did not realize the [MEDICATION NAME] had prescribed times to be given four times daily. Nurse #3 also reported she did not realize the [MEDICATION NAME] had prescribed times to be given three times daily. Nurse #3 stated the facility did not follow the protocol with administering medications one hour before they were due or one hour after they were due. Nurse #3 stated with the new eMAR system they now used the time blocks. During a medication pass observation of Nurse #4 on 02/26/20 at 10:45 AM, Nurse #4 was observed administering the following medication to Resident #6: one tablet of L[MED] 500 mg, one tablet of [MED] 6.25 mg and one tablet of [MEDICATION NAME] 300 mg. An interview was conducted with Nurse #4 on 02/26/20 at 10:50 AM. Nurse #4 reported the protocol for administering the medications was nurses had one hour before the scheduled medication was due to give the medication or one hour after the scheduled medication was due to be given. Nurse #4 reported she had no knowledge of administering medications in a time block. 2a.A medication reconciliation was conducted for Resident #6 on 02/26/20 at 11:00 AM. The reconciliation revealed the medications were due at 10:00 AM. These medications were administered on time. An interview was conducted with Director of Nursing (DON) on 02/27/20 at 4:05 PM. The DON reported the protocol for medication pass administration times was the nursing staff had one hour before the medication was due and one hour after the medication was due to be administered. The DON reported the current system did not have a liberal medication time pass and it was her expectation of the nursing staff to administer the medications as ordered per the eMAR prescribed times and the facility protocol.

Based on staff interview and record review the facility failed to complete acute charting regarding chewing/swallowing for 1 of 1 sampled residents (Resident #8) who experienced a near-choking episode followed by an actual choking incident. Findings included: Resident #8 was admitted to the facility on [DATE]. Her documented [DIAGNOSES REDACTED]. Resident #8's 08/30/19 quarterly minimum data set (MDS) documented her cognition was severely impaired, she required limited assistance by a staff member with eating, and she had no swallowing issues. Vital signs taken at 9:40 AM on [DATE] documented Resident #8's blood pressure was 108/70, her temperature was 98.3, her pulse was [AGE], and her respirations were 20. A [DATE] 2:15 PM progress note documented, Resident whines out at intervals when medications are given and holds hand over mouth. All medications taken. No swallowing difficulty noted. In a 11/20/19 1:45 AM progress note Nurse #1 documented, Elder placed on acute monitoring r/t (due to) near choking incident on ([DATE]). Swallowing without difficulty this shift. Took meds crushed in applesauce without difficulty. (Review of progress notes and change of condition notes from [DATE] revealed there was no documentation about a near-choking episode that occurred on that date. Review of staffing schedules revealed Nurse #2 was assigned to care for Resident #8 from 7:00 AM until 7:00 PM on [DATE]). Review of lab and x-ray results revealed Resident #8 had frontal and lateral radiographs (x-rays) of the chest taken on 11/19/19 secondary to choking. Findings documented, Lungs are clear without mass, consolidation, or effusion. No pneumothorax. Vital signs taken at 2:47 PM on 11/21/19 documented Resident #8's blood pressure was 126/[AGE], her temperature was [AGE].5, her pulse was 78, and her respirations were 18. A [DATE] 4:28 PM progress note documented, This writer called to resident's room at 8:15 AM by nursing assistant feeding resident breakfast. Resident continuous coughing as if choking. Resident suctioned several times per DON (Director of Nursing), clear frothy mucous obtained. Vitals: [AGE].9 (temperature), [AGE] (pulse), 24 (respirations), 134/90 (blood pressure). (Oxygen saturation) at 89%, oxygen placed on at 2 liters per minute increasing sats to 91 - 92%, skin color slightly pale, less coughing noted. Doctor informed of choking episode by this writer. Therapy in room with resident at 8:50 AM, blood pressure 96/74, (oxygen saturation) at [AGE]%. This writer informed DON of 8:50 AM assessment. RP (responsible party) contacted and informed of 8:50 AM assessment, and wants resident sent out to hospital. 11/25/19 hospital study results documented, Video fluoroscopic [MEDICATION NAME] swallow showed no aspiration or penetration. Resident #8's 12/04/19 annual MDS documented her cognition was severely impaired, she required extensive assistance by a staff member with eating, she experienced coughing and choking during meals, and she complained of difficulty or pain with swallowing. During a telephone interview with Nurse #2 on 02/26/20 at 3:59 PM she stated she was not aware of Resident #8 having a choking episode prior to the one on [DATE]. However, she reported a family member of Resident #8 commented the same nursing assistant (NA) who fed the resident on [DATE] was the one feeding her before. She commented she gathered from the family's comment that there was a previous episode during which the resident experienced some type of difficulty eating. During an interview with Nurse #1 on 02/27/20 at 8:21 AM she reported she worked from 7:00 PM until 7:00 AM, and she received report from the departing nurse on the night of [DATE] that Resident #8 had some type of choking event at breakfast on [DATE], and the resident was to be placed on acute charting due to this event. However, she commented she could not remember which nurse gave her the [DATE] report. She stated when a resident was placed on acute charting a nurse was supposed to assess the resident every shift; in this case assessing how the resident was swallowing medications and chewing and swallowing her food. During an interview with the Director of Nursing (DON) on 02/27/20 at 8:30 AM she stated when residents were placed on acute charting vital signs were taken and nursing assessments were completed each shift. After reviewing Resident #8's electronic medical record, she stated acute charting was not completed for this resident after a reported near-choking episode on the morning of [DATE]. She commented nursing did not take vital signs and did not evaluate the resident's swallowing each shift, and the resident had another apparent episode of choking documented on [DATE].

Based on record review and staff interviews, the facility failed to discontinue or consider continued use with rationale and duration for PRN (as needed) [MEDICAL CONDITION] medications after 14 days for 2 of 5 residents (Resident #147 and Resident #40) reviewed for unnecessary medications. Findings included: 1. Resident #147 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 5 day assessment dated [DATE] revealed the resident was mildly cognitively impaired. Resident #147 demonstrated no mood or behaviors and had received 7 days of an antidepressant, 5 days of hypnotic (sedative), 6 days of an anticoagulant (blood thinner), and 4 days of opioid medications (narcotic pain medications). A review of the physician's order [REDACTED]. The Medication Administration Record [REDACTED]. There was no stop date indicated on the MAR. A pharmacy medication review on 0[DATE] revealed a recommendation for the [MEDICATION NAME] mg for Resident #147 needed a stop date. The physician notes revealed there was no documentation to address continuing [MEDICATION NAME] medication beyond 14 days. An interview was conducted with Nurse #3 on 02/27/20 at 2:55 PM. Nurse #3 stated whenever a physician ordered a [MEDICAL CONDITION] medication such [MEDICATION NAME] be given PRN, the physician should have a stop date of 14 days to reassess the resident as to whether or not to continue the medication. Nurse #3 stated the order for [MEDICATION NAME] not have a stop date and the nursing staff should have clarified the order with the physician. Nurse #3 confirmed the stop date should have been 02/25/20. An interview with the facility ' s Pharmacy Consultant via phone on 02/27/20 at 3:10 PM revealed that any PRN [MEDICAL CONDITION] medication should have a stop date of 14 days from the order unless the facility physician could provide rationale as to why the resident should continue the medication. The Pharmacist stated the order for [MEDICATION NAME] written on 02/11/20 and should have had a stop date of 02/25/20. An interview was conducted with Director of Nursing (DON) on 02/27/20 at 4:05 PM. The DON reported the admissions nurse completed all the second checks on all physician orders [REDACTED]. The DON stated the staff nurses were aware if there was a PRN order for a [MEDICAL CONDITION] medication, it had to have a 14 day stop date. The DON stated her expectation was for the nursing staff to clarify with the physician and add a stop date to the order. 2. Resident #40 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS 5 day assessment dated [DATE] revealed the resident was cognitively aware. Resident #40 demonstrated no behaviors and had received 7 days of an antidepressant, 5 days of hypnotic (sedative), 7 days of an anticoagulant, and 7 days of opioids. A review of the physician's order [REDACTED]. A record review of the January and February MARs revealed the resident was receiving the [MEDICATION NAME] frequently as evidenced by a documented time stamp of when the medication was given. The MARs did not indicate there was a stop date for the PRN [MEDICATION NAME] medication. A pharmacy recommendation submitted to the facility on [DATE] via fax revealed the [MEDICATION NAME] 0.25 mg by mouth at bedtime PRN for [MEDICAL CONDITION] should be discontinued; or if continued use was appropriate, to provide the rationale and duration. The facility physician agreed to continue the medication for [AGE] days for [MEDICAL CONDITION] due to restlessness with pain and signed the recommendation on 02/24/20. An interview was conducted with Nurse #3 on 02/27/20 at 2:55 PM. Nurse #3 stated whenever a physician ordered a [MEDICAL CONDITION] medication such as [MEDICATION NAME] to be given PRN, the physician should have a stop date of 14 days to reassess the resident as to whether or not to continue the medication. Nurse #3 stated the order for the [MEDICATION NAME] did not have a stop date and the nursing staff should have clarified the order with the physician. Nurse #3 confirmed the stop date for the [MEDICATION NAME] should have been 02/18/20. An interview with the facility ' s Pharmacy Consultant via phone on 02/27/20 at 3:10 PM revealed any PRN [MEDICAL CONDITION] medication should have a stop date of 14 days from the order unless the facility physician could provide rationale as to why the resident should continue the medication. The Pharmacy Consultant stated the physician should either discontinue the medication or continue PRN for [AGE] days. The Pharmacy Consultant stated the order was written on [DATE] and should have had a stop date of 02/18/20. An interview was conducted with DON on 02/27/20 at 4:05 PM. The DON reported the admissions nurse completed all the second checks on all physician orders [REDACTED]. The DON stated the staff nurses were aware if there was a PRN order for a [MEDICAL CONDITION] medication, it had to have a 14 day stop date. The DON stated her expectation was for the nursing staff to clarify with the physician and add a stop date to the order.

Based on observations, record review and staff interviews the facility failed to: 1) accurately document the actual time of medication administration during 3 out of 3 observations for one resident (Resident #147) observed during a medication pass, and 2) failed to document the details of a near-choking episode for 1 of 1 residents (Resident #8) who experienced a near-choking episode. Findings included: During a medication pass observation with Nurse #3 in 02/24/20 at 11:55 AM, Nurse #3 was observed administering the following medications to Resident #147: one tablet of [MEDICATION NAME] [AGE] milligrams (mg), one tablet of [MED] 2.5 mg, one tablet of [MEDICATION NAME] 20 mg, one tablet of [MEDICATION NAME] 25 mg, one tablet of [MED] DS [AGE]0 mg, and one tablet of [MEDICATION NAME] 500 mg. 1a.A medication reconciliation was conducted on 02/24/20 at 1:05 PM. The reconciliation revealed the [MED] DS and the [MEDICATION NAME] medications were due to be administered at 8:00 AM. The [MEDICATION NAME], [MED], [MEDICATION NAME], and the [MEDICATION NAME] medications were due to be administered at 9:00 AM. A review of the Medication Administration Record [REDACTED]. An interview was conducted with Nurse #3 on 02/25/20 at 5:35 PM. Nurse #3 reported the way the system worked with their new computer system was that the nurses had a time block to complete their medication pass. Nurse #3 explained all the AM medications that were due from 7:00 AM through 9:00 AM needed to be administered by 10:30 AM according to the time block on the electronic medical administration record (eMAR). Nurse #3 stated she realized she administered the medications late when she gave them to Resident #147 at 12:00 PM. Nurse #3 stated she kept getting called away from her medication cart and it caused her to be late. Nurse #3 stated she was not aware of any way to put the actual time in the eMAR that a medication was given. Nurse #3 stated if there was a way, she was not aware of it with this new system. During a medication pass observation with Nurse #3 on 02/24/20 at 5:55 PM, Nurse #3 was observed administering the following medications to Resident #147: one tablet of [MEDICATION NAME] [AGE] mg, one tablet of [MEDICATION NAME] 500 mg, and three tablets of [MED] (1,000 units per tablet). 1b.A medication reconciliation was conducted for Resident #147 on 02/24/20 at 6:15 PM. The reconciliation revealed the [MEDICATION NAME] and the [MED] were scheduled to be administered at 3:00 PM. The [MEDICATION NAME] was due to be administered at 4:00 PM. A review of the Medication Administration Record [REDACTED]. During a medication pass observation with Nurse #3 on 02/25/20 at 5:30 PM, Nurse #3 was observed administering the following medications to Resident #147: one tablet of [MEDICATION NAME] [AGE] mg, one tablet of [MEDICATION NAME] 500 mg, and three tablets of [MED] (1,000 units per tablet). 1c.A medication reconciliation was conducted for Resident #147 on 02/25/20 at 6:00 PM. The reconciliation revealed the [MEDICATION NAME] and the [MED] were scheduled to be administered at 3:00 PM. The [MEDICATION NAME] was due to be administered at 4:00 PM. A review of the Medication Administration Record [REDACTED]. An interview was conducted with Nurse #3 on 02/25/20 at 5:35 PM. Nurse #3 reported the way the system worked with their new computer system was that the nurses had a time block to complete their medication pass. Nurse #3 explained all the medications that were due between 3:00 PM and 6:00 PM had to be given by 6:00 PM according to the time block on the electronic medical administration record (eMAR). Nurse #3 stated with the new eMAR system they now used the time blocks. Nurse #3 stated she was not aware of any way to put the actual time in the eMAR that a medication was given. Nurse #3 stated if there was a way, she was not aware of it with this new system. An interview was conducted with the Director of Nursing (DON) on 02/27/20 at 4:05 PM. The DON reported the protocol for medication pass administration times was the nursing staff had one hour before the medication was due and one hour after the medication was due to be administered. The DON reported the current system did not have a liberal medication time pass and it was her expectation of the nursing staff to administer the medications as ordered per the eMAR prescribed times and the facility protocol and to sign the medication off at the time it was given. The DON stated she expected her nursing staff to have working knowledge of the computer system and the eMAR program in order to be efficient and have accurate documentation. 2. Resident #8 was admitted to the facility on [DATE]. Her documented [DIAGNOSES REDACTED]. In a 11/20/19 1:45 AM progress note Nurse #1 documented, Elder placed on acute monitoring r/t (due to) near choking incident on ([DATE]). Swallowing without difficulty this shift. Took meds crushed in applesauce without difficulty. Review of progress notes and change of condition notes from [DATE] revealed there was no documentation about a near-choking episode that occurred on that date. Review of staffing schedules revealed Nurse #2 was assigned to care for Resident #8 from 7:00 AM until 7:00 PM on [DATE]. Review of lab and x-ray results revealed Resident #8 had frontal and lateral radiographs (x-rays) of the chest taken on 11/19/19 secondary to choking. During a telephone interview with Nurse #2 on 02/26/20 at 3:59 PM she stated she was not aware of Resident #8 having a choking episode prior to the one on [DATE]. However, she reported a family member of Resident #8 commented the same nursing assistant (NA) who fed the resident on [DATE] was the one feeding her before. She commented she gathered from the family's comment that there was a previous episode during which the resident experienced some type of difficulty eating. During an interview with Nurse #1 on 02/27/20 at 8:21 AM she reported she worked from 7:00 PM until 7:00 AM, and she received report from the departing nurse on the night of [DATE] that Resident #8 had some type of choking event at breakfast on [DATE], and the resident was to be placed on acute charting due to this event. However, she commented she could not remember which nurse gave her the [DATE] report. She stated when an event as serious as one involving choking occurred she thought the nurse who assessed the resident should have at least written a progress note to provide details about what happened. During an interview with the Director of Nursing (DON) on 02/27/20 at 3:16 PM she stated a nurse should have written a progress note on [DATE] regarding what she meant by a near-choking event. She reported details of the event were important so that the facility could develop interventions to prevent a similar event from happening in the future.

Based on record reviews and staff interviews, the facility failed to complete a 14 day Minimum Data Set (MDS) assessments within the regulatory timeframe for 1 of 15 residents selected to be reviewed for Resident Assessments (Resident #241). Findings included: Resident #241 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS) assessments for Resident #241 revealed a 5 day MDS was completed on 01/17/19, and that it was coded as not being an OBRA (Omnibus Budget Reconciliation Act) assessment, and only was coded as a Prospective Payment System (PPS) 5 day assessment; therefore, a 14 day PPS assessment was required, which was never completed. An interview and electronic medical record review was conducted with the MDS Coordinator on 03/12/19 at 10:30 AM. The MDS Coordinator confirmed Resident #241's 14 day MDS assessment was never completed until 03/12/19, after the omission was brought to her attention the morning of 03/12/19. The MDS Coordinator explained, the previous MDS nurse resigned, and as the new MDS nurse, she got behind on completing MDS assessments. She added the 14 day MDS assessment for Resident #241 should have been completed by the Assessment Reference Date (ARD) of 01/25/19. The MDS Coordinator acknowledged the 14 day MDS assessment for Resident #141 was not completed within the regulatory time frame. An interview was conducted with the Administrator on 03/13/19 at 8:35 AM. The Administrator stated it was her expectation that MDS assessments were completed, were accurate, and completed within the required time frame. An interview was conducted with the Director of Nursing (DON) on 03/13/19 at 2:45 PM. The DON stated it was her expectation that MDS assessments were completed, were accurate, and completed within the required time frame.

Based on record review and staff interviews the facility failed to transmit the resident Minimum Data Set (MDS) quarterly assessment after completion for 1 of 15 residents whose MDS was reviewed (Resident #1). Findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set ((MDS) dated [DATE] and coded as a quarterly assessment indicated Resident #1 was cognitively intact. She required extensive one-person physical assistance with activities of daily living (ADLs). A review of the quarterly MDS dated [DATE] was conducted on 03/11/19. It revealed the MDS was not transmitted by the MDS nurse after it was completed. An interview was conducted on 03/11/19 at 4:41 PM with the Director of Nursing who was responsible for transmitting the MDS assessments at the time the resident's quarterly assessment was due and completed. She stated she was the MDS nurse at that time, and did complete Resident #1's quarterly assessment. She stated she was not aware that it did not get transmitted on 01/15/19 which was an error on her part. She stated she would correct the error, and that it was her expectation that all MDS assessments were transmitted after completion. An interview was conducted with the Interim Administrator on 03/14/19 at 1:00 PM. She stated it was her expectation that MDS assessments were transmitted timely.

Based on record review and staff interviews, the facility failed to follow the care plan for alerting the Registered Dietitian (RD) of any weight fluctuations or declines for 1 of 15 (Resident #37) reviewed for weight loss. Findings included: Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had severe cognitive impairments. The resident required total assistance with all of her Activities of Daily Living (ADL), including feeding. Record review of the care plan dated 12/03/18 revealed a problem of: Nutritional needs and risk for weight loss/decline related to poor appetite. Approaches for this problem included, Alert Dietitian of any weight fluctuations or declines. Review of Resident #37's weights revealed the following significant weight change from 11/26/18 to 03/12/19: 11/26/18 - 125.6 lbs., 02/12/19 - 116 lbs., 02/20/19 - 115 lbs., 03/05/19 - 111 lbs., and 03/12/19 - 109 lbs. Record review revealed there were no RD notes or assessments to address Resident #37's weight loss or nutritional status from 11/26/18 to 03/14/19. Record review of the DM's Dietitian Referral Form (DRF) from 10/03/18 through 03/06/19 revealed no Dietitian referral for Resident #37. During an interview on 03/14/19 at 9:15 AM, the Dietary Manager (DM) revealed she was responsible for placing resident names on the Dietitian Referral Form (DRF), and to notify the Dietitian of any significant weight changes or fluctuations. She said she was aware of Resident #37 poor appetite and weight loss, and was doing what she could with the resident's family to address the resident's declining weight. She stated she did not feel the need to notify the Dietitian about Resident #37's weight loss, that she was addressing the issue. During an interview on 03/14/19 at 9:30 AM, the Dietitian revealed the DM was responsible for putting down information on the dietitian referral form. She said Resident #37's name should have been added to that list, due to her significant weight loss. The Dietitian stated she was not made aware of resident's weight loss, and if she knew, would have put in place additional nutritional interventions. She said the resident got missed somehow, and her name was never added to the DRF. The Dietitian said she should have been notified by the DM of Resident #37's weight loss, per care plan instructions, and wasn't. She said it was her expectation that the care plan be followed. During an interview on 03/14/19 at 9:20 AM, with the Dietary Manager (DM), Registered Dietitian (RD), and Director of Nursing (DON) revealed the DM should have alerted the RD of Resident #37's decline in weight, and did not.

Based on observation, staff interview, and record review the facility failed to provide double portions and cranberry juice as ordered by the physician for 1 of 5 sampled residents (Resident #25) reviewed for nutrition. Findings included: Record review revealed Resident #25 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. During the decision making process associated with Resident #25's 07/26/18 annual minimum data set (MDS) a care plan was not developed for the resident's nutritional status because he was eating 81% of his meals, and his weight was stable. Resident #25's weight record documented he was 66 inches tall and weighed 136 pounds on 08/10/18, weighed 141 pounds on 11/19/18, and weighed 134 pounds on 02/15/19 (his most recent weight). A hospital Discharge Summary documented Resident #25 was hospitalized between 12/31/18 and 01/03/19 with a [DIAGNOSES REDACTED]. The resident's 01/16/19 quarterly MDS documented his cognition was intact, he required limited assistance by a staff member with eating, his weight was stable, he received a mechanically altered diet, and he currently had no unhealed pressure ulcers. A 02/19/19 hospital History and Physical documented Resident #25 appeared to be septic due to a UTI/[MEDICAL CONDITION] ([MEDICAL CONDITION] or bacterial infection of the kidney/kidneys). 02/22/19 post-hospital discharge electronic physician orders [REDACTED]. During an observation on 03/12/19 at 12:29 PM Resident #25 was eating lunch in the main dining room. The resident did not have double portions or honey thick cranberry juice on his meal tray. His select menu tray slip did not document that the resident was to receive either of these items. During an observation on 03/13/19 12:20 PM Resident #25 was eating lunch in the main dining room. The resident did not have double portions or honey thick cranberry juice on his meal tray. His select menu tray slip did not document that the resident was to receive either of these items. During an interview with the Dietary Manager (DM) on 03/13/19 at 12:32 PM she explained that residents participating in the select menu process got a special tray slip on their meal trays which documented their circled food choices for each meal. She stated that the standard tray slip for Resident #25 did document that he was to receive cranberry juice and large portions at all meals. However, she reported that a dietary aide forgot to manually transcribe double portions and cranberry juice onto the resident's select menu tray slips which were what the dietary staff went by when preparing meal trays at the tray line. During an interview with the facility's Registered Dietitian (RD) on 03/14/19 at 9:28 AM she stated double portions would be large servings of all foods on the plate to promote weight gain and/or promote wound healing. She reported cranberry juice would be given to help protect the urinary tract system from infection, especially when residents had a history of [REDACTED].

Based on record review and staff interview the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. Findings included: In an interview conducted with the Administrator on 03/20/18 at 9:13 AM he stated that he was not aware that he needed to complete a facility assessment because he was not part of a corporation. He stated that the facility was a stand-alone facility and he did not have the support that a corporation would offer. He reported that he was scheduled to attend a meeting with other administrators in (MONTH) (YEAR) and would consult his peers at that time regarding the completion of a facility assessment. During the interview the Administrator demonstrated that he had access to Regulation 483.70(e), Facility Assessment.

Based on staff interviews, resident interviews, and record review the facility failed to allow residents the choice to take a whirlpool bath or shower as often as desired or scheduled for 3 of 11 residents, (Residents #12, #17 and #21). Findings included: 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] documented intact cognition, no moods or behaviors and he was not resistant to care. He was dependent for toileting and bathing. In an interview conducted on 03/22/18 at 10:05 AM with Resident #12 he stated that he was not getting enough showers. He said he would prefer to have a shower every other day. He commented that he would at least like to have 2 showers every week if he could not have one every other day. Review of the facility Hygiene Roster revealed that Resident #12 received a total of (2) showers between 01/01/18 and 03/20/18. He did receive a bed bath on the other days. Review of the Whirlpool/Shower Roster revealed that Resident #12 was scheduled to receive a whirlpool bath or a shower on every Monday and Wednesday each week. In an interview with Nurse Aide #1 on 03/22/18 at 11:46 AM she stated that she worked as the facility Transporter, Restorative Aide, Certified Nurse Aide I and II, and Medication Technician. She said that she got pulled to an assignment on the floor when there was a call out and the shower aide had already been pulled to an assignment. She said that she was able to complete her assignment but was not able to complete all the showers that were scheduled. She stated that she tried to make up the showers on the weekends because there were only showers scheduled Monday through Friday. She said she was aware whenever a whirlpool or shower was given to a resident on her assignment by the shower aide because she assisted with preparing the resident for the shower and took the resident to the shower room for the shower aide. She commented that she was responsible for charting that the activity occurred. In an interview with Nurse Aide #2 on 03/22/18 at 12:10 PM she said that she worked as a Certified Nurse Aide I, usually on the 100 Hall. She stated that if there was no shower aide that she could usually give 2 of 3 showers scheduled and would tell the shower aide to make up the missed showers on the next day. She stated that other resident care prevented her from giving showers to residents as they were scheduled. She revealed that she was aware when a whirlpool or shower was given by the shower aide because she got the resident ready to go and took the resident to the shower room. She said she charted each shift whether a resident on her assignment received a bed bath, a whirlpool or a shower for that day. In an interview with Nurse Aide #3 on 03/22/18 at 12:50 PM she reported that she was the shower aide for the facility. She stated that she would get pulled first to an assignment if there was a call out. She stated that when she was pulled to an assignment no one else was assigned to give showers. She commented that it was not the responsibility of the Nurse Aides to give the scheduled showers unless a resident requested one. She reported that when she was pulled to the floor all the residents received a bed bath unless a resident requested to take a shower. She said that she was pulled to the floor to work an assignment approximately twice a week because other staff members called out. She stated that when she was working as the shower aide that she was not responsible for charting when a whirlpool bath or shower was given. She said the aide assigned to the resident was responsible for all charting. In an interview with the Director of Nursing on 03/22/18 at 9:10 AM she stated that residents were scheduled to receive a whirlpool bath or shower twice a week. She stated that she expected the nurse aides on each assignment to complete the whirlpool baths or showers if the shower aide was pulled to cover an assignment on the floor. 2. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment dated [DATE] documented that he had intact cognition, no behaviors, and did not resist care. He was dependent for bathing. In an interview conducted on 03/21/18 with Resident #17 he stated that he was only getting one shower a week, but would like and should be getting two showers weekly. He reported he was on the shower schedule to receive two showers weekly. He commented that he would ask staff why he could not get his showers when they were scheduled, but no staff members would provide an explanation. He stated showers made him feel cleaner and more alert. Review of the facility Hygiene Roster revealed that Resident #17 received a total of (1) whirlpool bath and (1) shower between the dates of 01/01/18 and 03/20/18. He did receive a bed bath on the other days. Review of the Whirlpool/Shower Roster revealed that Resident #17 was scheduled to receive a whirlpool bath or a shower every Wednesday. In an interview with Nurse Aide #1 on 03/22/18 at 11:46 AM she stated that she worked as the facility Transporter, Restorative Aide, Certified Nurse Aide I and II, and Medication Technician. She said that she got pulled to an assignment on the floor when there was a call out and the shower aide had already been pulled to an assignment. She said that she was able to complete her assignment but was not able to complete all the showers that were scheduled. She stated that she tried to make up the showers on the weekends because there were only showers scheduled Monday through Friday. She said she was aware whenever a whirlpool or shower was given to a resident on her assignment by the shower aide because she assisted with preparing the resident for the shower and took the resident to the shower room for the shower aide. She commented that she was responsible for charting that the activity occurred. In an interview with Nurse Aide #2 on 03/22/18 at 12:10 PM she said that she worked as a Certified Nurse Aide I, usually on the 100 Hall. She stated that if there was no shower aide that she could usually give 2 of 3 showers scheduled and would tell the shower aide to make up the missed showers on the next day. She stated that other resident care prevented her from giving showers to residents as they were scheduled. She revealed that she was aware when a whirlpool or shower was given by the shower aide because she got the resident ready to go and took the resident to the shower room. She said she charted each shift whether a resident on her assignment received a bed bath, a whirlpool or a shower for that day. In an interview with Nurse Aide #3 on 03/22/18 at 12:50 PM she reported that she was the shower aide for the facility. She stated that she would get pulled first to an assignment if there was a call out. She stated that when she was pulled to an assignment no one else was assigned to give showers. She commented that it was not the responsibility of the Nurse Aides to give the scheduled showers unless a resident requested one. She reported that when she was pulled to the floor all the residents received a bed bath unless a resident requested to take a shower. She said that she was pulled to the floor to work an assignment approximately twice a week because other staff members called out. She stated that when she was working as the shower aide that she was not responsible for charting when a whirlpool bath or shower was given. She said the aide assigned to the resident was responsible for all charting. In an interview with the Director of Nursing on 03/22/18 at 9:10 AM she stated that residents were scheduled to receive a whirlpool bath or shower twice a week. She stated that she expected the nurse aides on each assignment to complete the whirlpool baths or showers if the shower aide was pulled to cover an assignment on the floor. 3. Resident #21 was admitted to the facility on [DATE] with a re-admission date of [DATE]. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] documented that she had intact cognition, and no behaviors. She was not resistant to care. She was dependent for bathing. In an interview conducted on 03/21/18 at 2:20 PM with Resident #21 she revealed that for the last three months she was only getting one shower or whirlpool a week. She commented when she asked why she could not get showers she was told the shower aide was pulled to work on the floor, and the facility was short of staff. She reported she would really like to have showers every other day, but would be satisfied with two weekly. She stated two showers a week helped her feel cleaner and her hair looked better. Review of the facility Hygiene Roster revealed that Resident #21 received a total of (5) whirlpool baths and (3) showers between the dates of 01/01/18 and 03/20/18. She did receive a bed bath on the other days. Review of the Whirlpool/Shower Roster revealed that Resident #17 was scheduled to receive a whirlpool bath or a shower every Tuesday and Thursday. In an interview with Nurse Aide #1 on 03/22/18 at 11:46 AM she stated that she worked as the facility Transporter, Restorative Aide, Certified Nurse Aide I and II, and Medication Technician. She said that she got pulled to an assignment on the floor when there was a call out and the shower aide had already been pulled to an assignment. She said that she was able to complete her assignment but was not able to complete all the showers that were scheduled. She stated that she tried to make up the showers on the weekends because there were only showers scheduled Monday through Friday. She said she was aware whenever a whirlpool or shower was given to a resident on her assignment by the shower aide because she assisted with preparing the resident for the shower and took the resident to the shower room for the shower aide. She commented that she was responsible for charting that the activity occurred. In an interview with Nurse Aide #2 on 03/22/18 at 12:10 PM she said that she worked as a Certified Nurse Aide I, usually on the 100 Hall. She stated that if there was no shower aide that she could usually give 2 of 3 showers scheduled and would tell the shower aide to make up the missed showers on the next day. She stated that other resident care prevented her from giving showers to residents as they were scheduled. She revealed that she was aware when a whirlpool or shower was given by the shower aide because she got the resident ready to go and took the resident to the shower room. She said she charted each shift whether a resident on her assignment received a bed bath, a whirlpool or a shower for that day. In an interview with Nurse Aide #3 on 03/22/18 at 12:50 PM she reported that she was the shower aide for the facility. She stated that she would get pulled first to an assignment if there was a call out. She stated that when she was pulled to an assignment no one else was assigned to give showers. She commented that it was not the responsibility of the Nurse Aides to give the scheduled showers unless a resident requested one. She reported that when she was pulled to the floor all the residents received a bed bath unless a resident requested to take a shower. She said that she was pulled to the floor to work an assignment approximately twice a week because other staff members called out. She stated that when she was working as the shower aide that she was not responsible for charting when a whirlpool bath or shower was given. She said the aide assigned to the resident was responsible for all charting. In an interview with the Director of Nursing on 03/22/18 at 9:10 AM she stated that residents were scheduled to receive a whirlpool bath or shower twice a week. She stated that she expected the nurse aides on each assignment to complete the whirlpool baths or showers if the shower aide was pulled to cover an assignment on the floor.

Based on staff interviews, resident interviews and record review the facility failed to provide adequate staffing to accommodate the needs of the residents to have a whirlpool bath or shower as often as desired or scheduled for 3 of 11 residents, (Residents #12, #17 and #21). Findings Included: This citation is cross-referenced to: F561: Self Determination: Based on staff interviews, resident interviews, and record review the facility failed to allow residents the choice to take a whirlpool bath or shower as often as desired or scheduled for 3 of 11 residents, (Residents #12, #17 and #21). Review of the daily staffing schedules for 01/01/18 through 03/20/18 revealed that the facility had not scheduled or had reassigned the whirlpool/shower aide to different duties 35 times. In an interview with the Director of Nursing on 03/22/18 at 9:10 AM she stated that the normal staffing schedule for day shift included (2) Licensed Practical Nurses, (4) administrative Registered Nurses, and (9) nurse aides including the ward clerk. On second shift the facility normally scheduled (4) nurse aides. The nurses worked 12 hour shifts. On third shift (3-4) nurse aides were normally scheduled. She said the facility did not use agency staff. If there were a nurse aide call out, she said the shower aide was pulled to the floor first, then the ward clerk followed by the restorative aide. She stated she would also offer overtime to staff on duty or try to call staff in who were not scheduled.

Based on observation and staff interview the facility failed to air dry kitchenware prior to stacking it in storage, failed to clean the back panel of the ice machine which had pink and gray build-up on it, and failed to label and date opened food items in storage. Findings included: 1. During initial tour of the kitchen, beginning at 1:45 PM on 02/27/17, 10 of 18 tray pans stacked on top of one another on a storage shelf were wet inside. At this time the dietary manager (DM) stated she thought these tray pans were placed in storage earlier that morning. During a follow-up tour of the kitchen at 9:38 AM on 03/01/17 1 of 5 tray pans stacked on top of one another on a storage shelf was wet inside, at 11:13 AM on 03/01/17 8 of 25 small bowls stacked on top of one another on a shelf above the steam table were wet inside, and at 11:21 AM on 03/01/17 1 of 10 tray pans stacked on top of one another on a storage shelf was wet inside. At 9:10 AM on 03/02/17 the DM stated the dietary staff were all in-serviced previously that they should air dry kitchenware or let it drain dry in racks before stacking it in storage. She reported moisture trapped between stacked items could grow germs, mold, and bacteria which could make residents sick. At 9:30 AM on 03/02/17 a dietary employee stated kitchenware should be dry and free of dried food particles before it was stacked in storage. She reported harmful bacteria could grow in trapped moisture which might make residents sick. 2. During initial tour of the kitchen, beginning at 1:45 PM on 02/27/17, there was pink and grey build up on the back panel of the ice machine. Moisture from the back panel was dripping into the ice. During a follow-up tour of the kitchen at 11:25 AM on 03/01/17 there was pink and grey build up on the back panel of the ice machine. Moisture from the back panel was dripping into the ice. At 9:10 AM on 03/02/17 the dietary manager (DM) stated the maintenance department cleaned the ice machine regularly, but she was unsure about the frequency of the cleanings. She reported she thought the last time the ice machine was cleaned was after the flood when the water and electricity were restored to the facility. At 9:30 AM on 03/02/17 a dietary employee stated the dietary department was not responsible for keeping the ice machine clean. She reported the maintenance department was responsible for the ice machine. She commented the ice machine should be kept free of mold which could contaminate the ice and make residents sick. At 10:23 AM on 03/02/17 the maintenance manager (MM) stated he cleaned the ice machine every six months. He reported he removed all removable parts, cleaned, rinsed, sanitized, and re-rinsed the ice machine during the service he provided. According to the MM, the last time he cleaned the ice machine was after the flood when the water and electricity were restored to the facility. He commented there was so much going on at that time that he thought he accidentally overlooked cleaning the back panel of the ice machine. 3. During initial tour of the kitchen, beginning at 1:45 PM on 02/27/17, a box of buttermilk pancake mix and 32-ounce bag of powdered sugar on a shelving unit in the food preparation area were opened but without labels and dates. In the dry storage room a 9-ounce packet of taco seasoning , a pound bag of marshmallows, a bag of hushpuppy mix, a 5-pound bag of cocoa, a 16-ounce box of corn starch, a 32-ounce bag of light brown sugar, a 32-ounce bag of confectioner's sugar, a 12-ounce packet of turkey gravy mix, two bags of elbow macaroni, and a bag of spaghetti noodles were opened but without labels and dates. In the walk-in refrigerator a 16-ounce bottle of grated parmesan cheese, a gallon container of heavy duty mayonnaise, a 128-ounce bottle of pickle relish, two 138-ounce containers of picante sauce, two storage bags of orange sliced cheese, and a bag of diced celery were opened but without labels and dates. In the walk-in freezer a bag of sweet green peas, a bag of mozzarella cheese sticks, a bag of potato cakes, a bag of biscuits, two bags of chicken breast, and one bag of hot dogs were opened but without labels and dates. During a follow-up tour of the kitchen at 9:55 AM on 03/01/17 a bag of rotini pasta was opened but without a label and date. At 9:10 AM on 03/02/17 the dietary manager (DM) stated designated employees on both the AM and PM shifts were supposed to sweep, mop, and check storage areas for labeling daily. She reported all food items which were opened but not used up, all food items which were removed from their original packaging, and all leftovers were supposed to have labels and dates on them. At 9:30 AM on 03/02/17 a dietary employee stated for about a year the facility had a system in place to help with labeling and dating where designated employees on both the AM and PM shifts were responsible for monitoring the storage areas daily. She also reported the DM spot checked the storage areas periodically to make sure opened food items had labels and dates on them. According to the employee, labeling and dating was important to ensure freshness and to remove spoiled or poor quality foods from storage areas.