Every finding on record at Good Shepherd Home

Based on observation, medical record review, review of infection control documents, staff interview, and review of facility policy, the facility failed to ensure resident infections were adequately tracked for potential trends, failed to ensure residents with wounds were in enhanced barrier precautions, and failed to ensure resident equipment used to inhale medications were kept and stored in a sanitary manner. This had the potential to affect all 80 residents residing in the facility. The facility census was 80.Findings include: 1. Review on 05/18/26 at 9:00 A.M. of the facility's infection control surveillance plan for April 2026, revealed there was no surveillance of the bacteria found in the infections identified. It was noted there were 13 urinary tract infections (UTIs), one respiratory infection, and one skin infection. Interview on 05/18/26 at 9:20 A.M. with the Director of Nursing (DON), who also served as the Infection Preventionist (IP), confirmed there was no tracking of the bacteria found in the infections identified for April 2026, and furthermore, the DON could not answer how the facility kept track of trends other than mapping. 2. Review of the medical record for Resident #2 revealed an admission on [DATE]. Diagnoses included unspecified dementia, major depressive disorder, and normal pressure hydrocephalus. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment. Further review of revealed Resident #2 was dependent on staff for activities of daily living (ADLs). Review of the physician's orders for Resident #2 revealed an order on 04/23/26 to cleanse the resident's buttocks with soap and water and apply triad to bilateral buttocks twice a day and as needed. Further review of the physician's orders revealed an order on 02/18/26 to skin prep the resident's erythema and cover with bordered dressing and offload per facility protocol to the right hip area. Review of Resident #2's active physician orders revealed no orders for enhanced barrier precautions (EBP). Review of the wound care notes revealed Resident #2 had been seen by wound care since 03/14/23 and was last seen on 05/07/26 for a stage three wound (full-thickness skin damage) to the coccyx. Observation on 05/11/26 at 9:00 A.M. revealed Resident #2's bedroom did not have an EBP sign on the door and also did not have personal protective equipment (PPE) available inside or outside of the room. Interview on 05/11/26 at 2:52 P.M. with Licensed Practical Nurse (LPN) Unit Manager #173 confirmed Resident #2 did not have an order, PPE readily available, or signage indicating the resident required EBP for her coccyx wound. 3. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure, vascular dementia, paranoid schizophrenia, diabetes mellitus type two and chronic respiratory failure. Review of a physician order dated 03/10/26 revealed Resident #1 was ordered levalbuterol inhalation nebulization solution 1.25 milligrams per three (3) milliliters for one dose inhaled orally by nebulizer three times a day for wheezing/shortness of breath. Observation on 05/11/26 at 12:05 P.M. revealed Resident #1 was sitting in the recliner and the nebulizer machine was sitting on a nightstand with the medication chamber attached to the mask and tubing. The medication chamber had residue from a previous medication treatment. Interview on 05/11/26 at 12:09 A.M. with Licensed Practical Nurse (LPN) #244 revealed Resident #1's medication chamber was not cleaned, and the mask, tubing, and chamber were not covered. Review of facility policy for nebulizer therapy, dated 02/2025, revealed nursing staff should disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag.

Based on observation, staff interview, and policy review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner. This affected all 77 residents who received food from the kitchen. The facility identified three (#4, #60, and #61) residents received nothing by mouth. The facility census was 80.Findings included:1. Observation of the facility kitchen on 05/11/26 at 7:45 A.M. revealed Dietary Aide (DA) #195 was in the kitchen pouring drinks and assisting with breakfast preparation. DA #195 was noted to have a long beard and hair. His hair was covered with a hairnet, but his beard was not covered.Interview with [NAME] #190 on 05/11/26 at 7:50 A.M. verified DA #195 failed to wear a beard protector while preparing food for residents.Review of the facility policy titled, Personal Hygiene, dated 05/01/19, revealed beards or any body hair that may be exposed (i.e., arms) must be covered.2. Observation on 05/13/26 at 10:52 A.M. revealed a plastic scoop was imbedded in the flour bin.Interview with [NAME] #221 on 05/13/26 at 10:53 A.M. confirmed the flour scoop was to be stored outside of the bin and not inside of the flour.Review of the undated facility policy titled, Scoop and Ladle Storage Policy, revealed scoops may be stored outside the product in a clean holder or inside the product with the handle extending out of the food. Scoops may not be buried completely in food products.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were were properly stored, labeled, and dated. This had the potential to affect all 80 residents residing in the facility. The facility census was 80.Review of the medical record for Resident #73 revealed an admission on [DATE]. Diagnoses included allergic rhinitis, hypertensive heart disease with heart failure, and anxiety disorder. Review of the physician's order dated 05/06/26 revealed an order for ipratropium bromide nasal solution 0.03 percent (%) for two sprays in both nostrils every 24 hours as needed for rhinitis related to allergic rhinitis.Review of the medical record for Resident #71 revealed an admission on [DATE]. Diagnoses included hyperlipidemia, major depressive disorder, and anxiety. Review of the physician's orders dated 11/08/23 revealed an order for fluticasone propionate nasal suspension 50 micrograms per actuation (mcg/act) for one spray in each nostril one time a day for nasal congestion. Review of the medical record for Resident #11 revealed an admission on [DATE]. Diagnoses included acute kidney failure, schizophrenia, and depression. Review of the physician's orders dated 10/04/24 revealed an order for Flonase allergy relief nasal suspension 50 mcg/act for one spray in both nostrils one time a day for allergies. Review of the medical record for Resident #37 revealed an admission on [DATE]. Diagnoses included acute-angle-closure glaucoma, hypertensive heart disease, and aphasia. Review of the physician's order dated 10/31/25 revealed an order for latanoprost ophthalmic solution 0.005% to instill one drop in both eyes at bedtime related to acute-angle-closure glaucoma. Observation on 05/12/26 at 9:17 A.M. of the 100 hall medication cart revealed Resident #73's ipratropium bromide nasal solution was opened and not dated, Resident #71's fluticasone nasal spray was opened and not dated, Resident #11's fluticasone nasal spray was opened and not dated, and Resident #37's latanoprost ophthalmic solution was unopened with a label reading to, Keep refrigerated until opened.Observation on 05/12/26 at 9:23 A.M. of the 100-hallway medication storage room revealed a bottle of tuberculin purified protein derivative (an intradermal aid in the detection of infection with Mycobacterium tuberculosis) with an open date on 02/21/26.Interview on 05/12/26 at 9:23 A.M. with Registered Nurse (RN) #44 confirmed Resident #73's ipratropium bromide nasal solution was opened and not dated, Resident #71's fluticasone nasal spray was opened and not dated, Resident #11's fluticasone nasal spray was opened and not dated, and Resident #37's latanoprost ophthalmic solution was as not opened with a label reading, Keep refrigerated until opened. Further interview with RN #44 confirmed the tuberculin purified protein derivative had an open date of 02/21/26 and the solution should be thrown away after 30 days, and that all nasal sprays and eye drops that were opened were to be dated. Review of the facility policy for medication storage, dated 02/2024, revealed all medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room.

Based on observation, staff interview, review of the activities calendar, and review of the facility policy, the facility failed to implement the activities calendar as scheduled and provide activities to meet resident needs. This affected 37 (#41, #28, #31, #17, #69, #64, #77, #3, #70, #49, #80, #51, #56, #39, #15, #82, #5, #32, #48, #36, #50, #62, #52, #38, #30, #24, #29, #22, #21, #9, #58, #20, #83, #76, #65, #79, and #2) of 37 residents who resided in the memory care unit. The facility census was 80.Findings include:Review of the activities calendar for the memory care unit revealed every day at 9:30 A.M. there was an activity called, Morning Greetings. Repetitive activities were noted on the same day each week. Further review of the activities calendar revealed there were no activities offered past 2:30 P.M. with the exception on 04/07/26 for music time at 3:15 P.M.Observation on 05/11/26 at 9:30 A.M. of the memory care unit revealed there was no activity completed. Observation on 05/11/26 at 10:15 A.M. revealed Activities Director (AD) #142 painting some of the female resident's nails; however, no male residents were observed receiving nail care.Interview on 05/11/26 at 10:15 A.M. with AD #142 confirmed there were no activities completed at 9:30 A.M. AD #142 further stated she was doing the activity called Manicure Hour, which consisted of painting nails, and sometimes filing resident's nails. AD #142 stated not all residents are asked if they want their nails done, and stated the male residents can have their nails filed.Observation on 05/12/26 at 9:30 A.M. of the memory care unit revealed there was no activity completed as scheduled and 16 residents were sitting in the common area with a movie on. Observation on 05/12/26 at 10:25 A.M. revealed an activity called, Devotion with the Chaplin was in progress with residents noted sitting in recliner chairs, and a Chaplin put on religious music and singing.Further observation on 05/12/26 at 2:05 P.M. of the memory care unit revealed two residents and Case Manager (CM) #146 sitting at a table with a puzzle in front of them. One resident was sleeping and the other resident was not actively participating in the activity. The posted activity was called, Puzzle Time, and there were 22 residents sitting in the common area with the television on.Interview on 05/12/26 at 2:05 P.M. CM #146 revealed she did not work for the facility and was at the facility to do one-on-one behavioral health with the residents.Interview on 05/12/26 at 2:08 P.M. with Licensed Practical Nurse (LPN) Unit Manager #173 revealed CM #146 did not work at the facility. LPN Unit Manager #173 further confirmed that residents on the memory care unit were not offered the scheduled activities that week because the regular activity aid was doing certified nurse aide (CNA) training.Observation on 05/13/26 at 10:11 A.M. of the memory care unit revealed residents sitting at two tables. There were six residents placing stickers on an umbrella and one resident was sleeping. AD #142 went back and forth assisting residents with completing the activity.Observation on 05/14/26 at 9:30 A.M. of the memory care unit revealed there was no activity completed as scheduled and 17 residents were sitting in the common area with a movie on.Review of the facility policy for activities, dated 04/2025, revealed activities would be designed with the intent to enhance the resident's sense of well-being, belonging, and usefulness, create opportunities for each resident to have a meaningful life, promote or enhance physical activity, promote or enhance cognition, promote or enhance emotional health, reflect resident's interests and age, reflect cultural and religious interests of the resident's, and reflect choices of the resident's. Activities were to include, indoor and outdoor activities, and activities away from the facility.This deficiency represents non-compliance investigated under Complaint Number 2666521.

Based on observation, medical record review, staff interview, pest control staff interview, and facility policy review, the facility failed to ensure the facility was free from bed bugs and affected areas were properly treated. This affected one (#89) of one residents reviewed for pests. The facility census was 80.Findings include:Record review for Resident #89 revealed the resident was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, history of malignant neoplasm of the rectum, vascular dementia, and congestive heart failure.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, required supervision with toileting and dressing, and moderate assistance with bathing.Observation on 05/11/26 at 9:45 A.M. revealed Resident #89 was not residing in room [ROOM NUMBER]. A blanket was laid in front of the door with a laundry cart in front of the door.Interview on 05/11/26 at 9:47 A.M. with Licensed Practical Nurse (LPN) #244 revealed Resident #89 was moved to room [ROOM NUMBER].Observation on 05/12/26 at 1:22 P.M. of room [ROOM NUMBER] with Plant Operations (PO) Staff #241 revealed bed lines were on the bed; clothing was in the closet and drawers; a specialty wheelchair, cloth recliner, two tables, food and cups were on a table by the chair, and two fans.Interview 05/12/26 at 11:10 A.M. with Plant Operations (PO) Staff #241 revealed bed bugs were found on Resident #89 on 05/10/26. PO Staff #241 contacted Housekeeper #116, who came into the facility and placed two fans in room [ROOM NUMBER], and placed a blanket in front of the door and a laundry cart so no one would enter.Interview on 05/12/26 at 12:04 P.M. with Housekeeper #116 recalled receiving a call on 05/10/26 and came into the facility to set up fans and in room [ROOM NUMBER]. Housekeeper #116 stated no training was given and a call was made on 05/11/26 to a pest control company with bed bug treatment scheduled for 05/15/26.Interview on 05/12/26 at 1:22 P.M. with PO Staff #241 verified all of Resident #1's clothing and personal items were in the room (#118), lines were on the bed, and a cloth recliner, wheelchair, and two tables were also in the room. PO Staff #241 stated he would contact the pest control company to try to schedule a sooner visit.Observation of room [ROOM NUMBER] on 05/13/26 at 8:23 A.M. with the Director of Nursing (DON) revealed five adolescent bed bugs and multiple eggs were present on the cloth recliner. Interview on 05/13/26 at 10:15 A.M. with Pest Control Company Staff (PCCS) #1 confirmed an active bed bug infestation in room [ROOM NUMBER]. PCCS #1 confirmed bed bugs were located in screw wholes of the tables and dresser and found throughout the room with new and old feces found along with eggs. PCCS #1 stated he was in the facility on 05/10/26 for a routine spray and spoke with Housekeeper #116 to get diapers, clothes, and all personal items out of Resident #1's room before heat treating. He stated the drawers and closets needed to be open as well. PCCS #1 stated that due to everything still being left in the room, he could only spray around the perimeter of the room and another appointment would be needed once the facility cleaned out the room.Review of the undated policy titled, Bedbugs/Pest Control/Infestation Policy, revealed a pest management professional should inspect the suspect room, adjacent rooms, resident(s) new room, all furniture and equipment, and lounge and public area the family may have been using. The facility should frequently vacuum the premises, wipe down mattresses, launder bedding and clothing in hot water, and clean and sanitiz the dwelling.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure gastric contents were replaced when verifying placement of a feeding tube. This affected one (#44) of one residents reviewed for feeding tubes. The census was 80.Findings include: Review of the medical record for Resident #44 revealed an admission on [DATE]. Diagnoses included gastro-esophageal reflux disease without esophagitis, multiple sclerosis, and cerebral ischemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had cognitive impairment and was assessed with a percutaneous endoscopic gastrostomy (PEG) tube (a soft, flexible feed tube inserted through the abdomen directing into the stomach to deliver nutrition, fluids, and medication).Review of the care plan dated 10/29/24 revealed Resident #44 required tube feeding related to inadequate nutritional intake due to poor appetite, swallowing problems, dysphagia, weight loss, and anemia. Interventions included Resident #44 required total assistance with tube feeding and water flushes. Review of the physician's orders for Resident #44 revealed an order on 10/25/23 to flush with 30 cubic centimeters (cc) before and after medications were given per PEG tube. Observation on 05/12/26 at 11:38 A.M. revealed Registered Nurse (RN) #44 checking placement of Resident #44's PEG tube. RN #44 connected the PEG tub to a syringe and pulled back approximately 30 milliliters (ml) of gastric content. RN #44 then disconnected the syringe from the PEG tube and disposed of the gastric content into the toilet.Interview on 05/12/26 at 11:40 A.M. with RN #44 confirmed Resident #44's gastric content was disposed in the toilet, and RN #44 was aware it should have been placed back into Resident #44's stomach.Review of the policy for feeding tubes, dated 07/25, revealed prior to flushing the feeding tube, the nurse verifies proper placement by noting the length of the tubing or performing a measure of the pH of gastric secretions.

Based on medical record review and staff interview, the facility failed to ensure orders and interventions were in place to address a resident's need for leg braces. This affected one (#59) of one residents reviewed for brace devices. The census was 80.Findings included:Review of Resident #59's medical record revealed an admission date of 06/28/25. Diagnoses included displaced comminuted fracture of the shaft of the right femur, intellectual disabilities, epilepsy, and anxiety.Review of Resident #59's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and participated in physical and occupational therapy.Review of Resident #59's current comprehensive care plan revealed the plan did not address the resident's need or care related to knee braces. Review of Resident #59's nurses note dated 03/25/26 revealed the resident was present at his care conference. The resident's family was questioning the need for the new bilateral knee braces. The nurse spoke to physical therapy, and they confirmed it was mandatory to wear the braces and Resident #59 would require adjustments throughout the day for proper placement.Review of Resident #59's nurses note dated 03/26/26 revealed the nurse discussed with the resident regarding the podiatrist orders for physical therapy, and she would call his family regarding insurance refusal to cover therapy to treat his right foot. The nurse gave education and instruction regarding applying his new bilateral knee brace and having them adjusted if slipping. The resident voiced understanding the braces were mandatory for him to wear.Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 05/14/26 at 9:10 A.M. revealed Resident #59 had leg braces he applied every morning. The staff members stated the resident's family requested he put the braces on by himself, which he wore for knee strength. Review of Resident #59's current physician orders revealed it was silent regarding an order regarding bilateral knee braces.Interview with the DON on 05/14/26 at 3:51 P.M. revealed Resident #59 really did not wear leg braces and they were elastic sleeves. The DON stated the resident applied them when he wished to wear them and took them off on his own. The DON stated the devices did not require a physician's order nor was a care plan needed or developed for them.Interview with Therapy Director (TD) #247 on 05/18/26 at 10:17 A.M. revealed he was unaware if there was a physician's order for Resident #59's knee braces. TD #247 stated the resident was independent of applying and removing the braces, but they needed adjusting periodically. TD #247 revealed he ordered the resident new braces two months ago due to the fasteners being worn out.

Based on observation, medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure adequate care was provided for residents dependent on staff for finger nail care. This affected two (#22 and 26) of two residents reviewed for activities of daily living. The census was 80.Findings include: 1. Review of the medical record for Resident #22 revealed an admission on [DATE]. Diagnoses included cerebrovascular disease, epilepsy, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severe cognitive impairment. Further review of the MDS assessment revealed Resident #22 required substantial assistance with personal hygiene. Review of the care plan dated 12/05/24 revealed Resident #22 had an activities of daily living (ADLs) self-care performance deficit related to vascular dementia. Interventions included Resident #22 required substantial assist with personal hygiene. Observation on 05/11/26 at 10:18 A.M. revealed Resident #22 sitting in her recliner chair in the common area. Resident #22 had just completed the an activity involving manicures with Activities Director (AD) #142. Further observation of Resident #22's finger nails revealed a large amount of build-up under all of her nails. Interview on 05/11/26 at 10:21 A.M. with Certified Nurse Aide (CNA) #144 confirmed there was a large amount of build up under all of Resident #22's finger nails. CNA #144 stated hospice staff were who completed ADL care for Resident #22 during her showers. CNA further confirmed anyone can complete nail care to residents who needed it. Interview on 05/11/26 at 10:27 A.M. with AD #142 revealed sometimes activities will complete nail care, but the resident activity involving manicures was just filing the residents' nails and applying nail polish. AD #142 confirmed she did not clean under Resident #22's finger nails. 2. Review of Resident #26's medical record revealed an admission date of 04/28/26. Diagnoses included acute kidney failure, hemiplegia, and Parkinson's disease. Review of Resident #26's admission MDS assessment dated [DATE] revealed the resident had an intact cognition and was dependent on staff for personal hygiene. Review of Resident #26's most recent care plan dated 05/11/26 revealed he was dependent on staff for personal hygiene and required substantial assist with oral care. Review of Resident #26's shower records revealed he received a shower on 04/29/26, 04/30/26, 05/01/26, 05/02/26, 05/04/26, 05/05/26, 05/06/26, 05/06/26, 05/07/26, 05/08/26, 05/09/26, 05/10/26, 05/11/26, 05/12/26, and 05/14/26. Interview with Resident #26 on 05/11/26 at 9:49 A.M. revealed he had not had his finger nails trimmed since admission and would like them trimmed. Observation of Resident #26's fingernails on 05/11/26 at 9:49 A.M. revealed the nails were grown out and extending approximately one-half an inch over his fingertips. Observation and interview with Resident #26 on 05/14/26 at 10:34 A.M. revealed the resident was sitting in his recliner dressed for the day and his hair was damp. His finger nails continued to be long and uncut. The resident confirmed his nails were long and he wished to have them cut. Interview with CNA #107 on 05/14/26 at 10:37 A.M. revealed Resident #26 had a shower that morning. Further interview with CNA #107 on 05/14/26 at 10:42 A.M. revealed the nurse aid verified Resident #26's finger nails were in need of cutting, but only nurses could provide that task since the resident was diabetic. Review of the facility policy titled, Activities of Daily Living (ADLs), dated 04/2024, revealed care and services will be provided for the following activities of daily living including bathing, dressing, grooming, and oral care. A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident rooms were in good repair. This affected one (#5) of one residents reviewed for environment. The facility census was 80.Findings include:Review of the medical record for Resident #5 revealed a care conference was held on 03/11/26. It was noted the wall behind the resident's chair was getting bad due to the chair hitting it, and maintenance would fix it and order a tool to place behind the chair.Observation on 05/11/26 at 10:56 A.M. of Resident #5's bedroom revealed a large area behind the recliner chair that had chipped drywall and large scratches without paint.Interview on 05/12/26 at 2:39 P.M. with Plant Operations (PO) Staff #241 revealed he was unaware there was an issue with Resident #5's bedroom and confirmed the areas were in bad repair. PO Staff #241 further stated there was not a device to place behind the chair to protect the wall.Review of the facility policy for resident environmental quality, dated 02/2025, revealed the facility will maintain a sanitary and comfortable environment for residents, staff and the public.

Based observation, medical record review, staff interview, and policy review, the facility failed to ensure proper notifications were made when a resident changed rooms. This affected one (#89) of one residents reviewed for room changes. The facility census was 80.Findings include:Record review for Resident #89 revealed the resident was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, history of malignant neoplasm of the rectum, vascular dementia, and congestive heart failure.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 had moderately impaired cognition, was assessed to require supervision with toileting and dressing, and required moderate assistance with bathing.Review of the care plan dated 02/05/26 revealed Resident #89 had an activities of daily living (ADLs) self-care performance deficit related to vascular dementia, chronic pain, shortness of breath, fibromyalgia, spondylosis, intervertebral disc degeneration, and fatigue.Review of nursing notes revealed Resident #89 moved from room [ROOM NUMBER] to room [ROOM NUMBER]. There was no documentation in the medical record of the facility notifying the resident's Power of Attorney (POA) or physician of the room change.Observation on 05/11/26 at 9:45 A.M. revealed Resident #89 was not residing in room [ROOM NUMBER]. A blanket was laid in front of the door with a laundry cart in front of the door.Interview on 05/11/26 at 9:47 A.M. with Licensed Practical Nurse (LPN) #244 revealed Resident #89 was moved to room [ROOM NUMBER].Interview on 05/11/26 at 10:13 A.M. with the Director of Nursing (DON) revealed Resident #89 was moved to deep clean the room and will be moving back later today or tomorrow.Interview 05/12/26 at 11:10 A.M. with Plant Operations (PO) Staff #241 revealed Resident #89 was moved to room [ROOM NUMBER] on 05/10/26 due to bed bugs.Interview on 05/12/26 at 12:10 P.M. with Operations Director (OD) #229 verified that there was no evidence that the facility notified Resident #89's POA or physician of the resident's room change.Interview on 05/14/26 at 3:12 P.M. with the DON verified the medical record contained no documentation that the resident's POA or physician of Resident #89 room change.Review of the facility policy for notification of change, dated 10/24, revealed the facility will notify the physician and resident representative when there is a change of room or roommate assignment.

Based on observation, staff interview, and policy review, the facility failed to store foods properly in the refrigerator and failed to discard expired food items. This had the potential to affect all 83 residents who the facility identified received food from the kitchen. The facility census was 83. Findings include: 1. Observation of the main kitchen refrigerator on [DATE] at 8:10 A.M. revealed there was a container of thickened pudding dated [DATE] and a container of thickened juice dated [DATE] which were outdated and failed to be discarded. Observation of the walk in refrigerator on [DATE] at 8:23 A.M. revealed a box of sliced mushrooms were on a wire shelf and were open to air. The cardboard lid failed to be secured to the box. Interview with Culinary Director #251 on [DATE] at 8:25 A.M. verified the thickened pudding and thickened juice were outdated and not discarded and the mushrooms were not stored properly. 2. Observation of the pureed food preparation on [DATE] at 10:45 A.M. revealed Chef #282 was preparing pureed beef stroganoff. After placing the stroganoff in the food processor, he mixed hot water with beef base to use as the thinning agent. Observation of the beef base jar revealed it had a best if used by date of [DATE]. Interview with Chef #282 and Culinary Director #251 on [DATE] at 10:47 A.M. verified the chef was utilizing the beef base past the expiration date. The beef stroganoff mixture was then discarded and a new mixture was prepared. Review of the facility policy titled Date Markings dated ,d+[DATE] revealed the facility should discard all food past their used by date. Date marking is required for foods that are considered held under refrigeration for more than a cumulative total of 24 hours before service. If the food is maintained at a temperature of 41 degrees Fahrenheit or less, mark the foods use by date for seven calendar days.

Based on record review, observation, staff interview, and policy review, the facility failed to prepare pureed foods per the recipe and follow the dietician recommendations for serving sizes. This had the potential to affect six residents (#2, #37, #38, #46, #47, and #68) who received pureed meals and had to the potential to affect 77 residents who received regular or mechanical soft meals from the kitchen. The facility census was 83. Findings include: 1. Review of the Dining Manager's recipe for pureed vegetables revealed the recipe called for one quart of vegetables with one-fourth cup of melted margarine. Observation on 10/08/24 at 10:48 A.M. revealed Chef #282 was preparing the vegetable for the pureed diets. The chef placed the vegetables in the food processor then began pouring in a butter tasting substance used for grilling, sauteing, and pan frying. Chef #282 failed to measure the vegetables nor the butter substance. He poured at least one cup of butter substance in the food processor. Interview with Culinary Director #251 on 10/08/24 at 10:44 A.M. verified Chef #282 did not follow the Dietary Manager's recipe for pureed vegetables. 2. Review of the facility menu spreadsheet for the week of 10/07/24 revealed the residents should be served three four ounce meatballs per serving. Observation on 10/09/24 between 11:03 A.M. and 11:15 A.M. revealed Dietary Assistants #273 and #384 were plating spaghetti and meatballs. Dietary Assistants #273 and #384 were serving between three and six meatballs on the plates. Interview with Dietary Assistant #384 on 10/09/24 at 11:13 A.M. revealed he was unaware of the serving sizes and not necessarily following the facility's menu spreadsheet. Interview with Culinary Director #251 on 10/09/24 at 11:24 A.M. verified Dietary Assistants #273 and #384 were not serving the portion size of meatballs as stated in the facility's menu spreadsheet. Review of the facility's undated policy titled Good [NAME] Home Puree Food Preparation revealed each resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor, and appearance.

Based on observations, medical record review, staff interview, facility policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) in COVID-19 positive resident's rooms. This had the potential to affect all nine (#48, #49, #65, #67, #73, #76, #82, #88, and #189) residents in the 200 hall who were not COVID-19 positive. In addition, the facility failed to ensure four (#1, #11, #54, and #79) residents with a wound or indwelling medical device had enhanced barrier precautions in place. The facility identified an additional nine (#17, #30, #45, #48, #52, #53, #55, #68, and #189) residents who required enhanced barrier precautions. Additionally, the facility failed to ensure hand hygiene prior to administering medications to Resident #14. The facility census was 83. Findings include: 1. Review of the medical record revealed Resident #188 was admitted on [DATE]. Diagnoses included COVID-19 (10/03/24). Review of the social service progress note, dated 10/04/24, revealed Resident #188 had been diagnosed with COVID-19 and remained in isolation. Review of Resident #188's physician order, dated 10/08/24, revealed an order for a single room contact droplet isolation for ten days with all services brought to the resident in room. Observation on 10/07/24 at 11:34 A.M. revealed Registered Nurse (RN) #213 was in Resident #188's room assisting the resident . RN #213 was wearing a N-95 mask over a surgical mask and gloves. RN #213 was not wearing a gown or eye protection. Interview on 10/07/24 at 11:40 A.M. with RN #213 verified she was not wearing eye protection and a gown. RN #213 verified she was assisting Resident #188 with care as he needed assistance. RN #213 stated there was no gown in the PPE cart. 2. Review of the medical record revealed Resident #30 was initially admitted on [DATE]. Diagnoses included COVID-19 (09/29/24). Review of the Minimum Data Set (MDS) assessment, dated 08/09/24, revealed Resident #30 was cognitively intact. Review of Resident #30's physician orders, dated 09/29/24 to 10/09/24 revealed an order for single room contact/droplet isolation for ten days with all services brought into the resident room. Observation on 10/07/24 at 11:52 A.M. revealed Registered Nurse (RN) #235 entered Resident #30's room. RN #235 donned a N-95 mask placed over the surgical mask and no eye protection in place prior to entering the resident's room. Interview on 10/07/24 at 12:07 P.M. with RN #235 verified Resident #30 was COVID-19 positive. RN #235 verified the N-95 mask was placed over the surgical mask and no eye protection was worn. RN #235 stated the resident was not coughing or spewing saliva; therefore the eye protection was not necessary. Observation on 10/08/24 at 2:30 P.M. revealed State tested Nursing Assistant (STNA) #338 entered Resident #30's room after donning gloves, a N95 mask over a surgical mask, and a gown. No eye protection was worn in the resident's room. Interview on 10/08/24 at 2:36 P.M. with STNA #338 verified a N-95 mask was donned over the surgical mask and no eye protection was worn. STNA #338 stated there was no eye protection available in the PPE cart outside Resident #30's room. Review of CDC's guidance titled Infection Control Guidance: SARS-CoV-2, found at https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, dated 06/24/24 revealed healthcare professionals who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a N-95 mask or higher, gloves, gowns, and eye protection. Review of CDC's guidance titled How to Use your N95 Mask Respirator, found at https://www.cdc.gov/niosh/topics/publicppe/use.html#:~:text=Place%20the%20N95%20respirator%20under,Do%20not%20crisscross%20the%20straps, dated 05/16/23, revealed N95 respirators must form a seal to the face to work properly. This is especially important for people at increased risk for severe disease. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnosis included pressure induced deep tissue damage of right heel, and non-pressure chronic ulcer of right ankle with fat layer exposed. Review of Resident #11's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had an open lesion on his foot and required dressings to the feet. Review of the medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included protein malnutrition, adult failure to thrive, and dysphagia. Review of the most recent care plan revealed Resident #54 required tube feeding due to dysphasia, adult failure to thrive, malnutrition, and weight loss. Review of the medical record revealed Resident #1 was admitted on [DATE]. Review of the MDS assessment, dated 09/20/24, revealed Resident #1 had a feeding tube. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included retention of urine and neuromuscular dysfunction of bladder. Review of the MDS assessment, dated 09/16/24, revealed Resident #79 had an indwelling catheter. Observations on 10/08/24 at 4:10 P.M. revealed Residents #1, #11, #54, and #79 did not have enhanced barrier precautions in place. Interview on 10/08/24 at 4:15 P.M. with State tested Nursing Assistance (STNA) #341 verified when providing care to residents with a catheter or tube feed, gloves were worn but no additional PPE such as a gown have been donned. Interview on 10/08/24 at 4:22 P.M. with STNA #362 verified when providing care to residents with a catheter or tube feed, gloves were worn but no additional PPE such as a gown have been donned. Interview on 10/08/24 at 4:32 P.M. with the Director of Nursing (DON) verified no residents in the facility had enhanced barrier precautions in place. Review of the policy titled Enhanced Barrier Precautions, dated 2024, revealed an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with MDRO (multidrug-resistant organisms). Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), reviewed 07/12/22 and located at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html revealed enhanced barrier precautions apply to all residents with any of the following infections or colonization with MDRO (when contact precautions do not apply): wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. 47057 4. Review of the medical record for Resident #14 revealed she was admitted on [DATE] with diagnoses of anxiety, cerebral vascular accident (CVA) (stroke), anemia, anxiety, thyrotoxicosis, gastroesophageal reflux disease (GERD), osteoarthritis, hypertension (HTN), chronic kidney disease (CKD), visual loss, and metabolic encephalopathy. Review of the current physician orders from 10/24 for Resident #14 revealed she was prescribed a acetaminophen 500 milligrams (mg), potassium chloride 10 milliequivalence (meq), metoprolol 12.5 mg (HTN), areds2 preservision (visual loss), amlodipine 10 mg, pantoprazole 40 mg (GERD), glucosamine chondroitin (osteoarthritis), folic acid 400 micrograms (mcg), Buspar 2.5 mg (anxiety), Plavix 75 mg (CVA), and iron supplement 325 mg (anemia). Observation on 10/09/24 at 8:07 A.M. during medication pass observation of Medication Aide (MA) #290 revealed she did not use hand hygiene prior to pulling the medications for administration for Resident #14. MA #190 removed metoprolol 25 mg from the pill bottle and broke the pill in half (for a dose of 12.5 mg as prescribed) and handled the medication without gloves and placed the other half of the pill back into the medication bottle. Further observation at 10/09/24 at 8:16 A.M. of MA #290 revealed to count the number of pills in the medication cup, MA #290 poured the entire cup of pills onto the top of medication cart without a barrier and picked up each pill to count without gloved hands and placed them back into the medication cup for administration. Interview on 10/09/24 at 8:18 A.M. with MA #290 verified she did not complete hand hygiene prior to preparing the medications for administration for Resident #14. MA #290 verified she broke the metoprolol in half without using gloves and poured pills directly onto the medication cart without a barrier and continued to touch the medication for Resident #14 with ungloved hands and then administered the medications to Resident #14. Review of the facility policy titled, Medication Administration Guidelines, dated 02/2019 revealed medications are to be administered per physician order to promote positive resident outcomes. Wash hands prior to handling medications, after administering medication, and after direct resident contact.

Based on observation, resident interview, staff interview, and record review, the facility failed to ensure wound prevention boots were in place as physician ordered and failed to obtain a resident's weekly weight as physician ordered. This affected one (Resident (#11) of one resident reviewed for wounds and 21 residents reviewed for physician orders. The facility census was 83. Findings include: 1. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included cerebral vascular accident, diabetes mellitus, pressure induced deep tissue damage of right heel, and non-pressure chronic ulcer of right ankle with fat layer exposed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11's cognition was intact. Resident #11 had an open lesion on his foot and required dressings to the feet. Review of the care plan revealed Resident #11 had altered skin integrity related to a right ankle vascular wound, right anterior third toe traumatic wound, and a left posterior ankle wound. Interventions included pressure relieving devices as ordered. Review of Resident #11's physician order dated 10/24/23 revealed an order for a heel lift boot to the right lower extremity every day and night shift. Observations of Resident #11 on 10/07/24 at 9:26 A.M. and 11:33 A.M., and 10/08/24 at 1:02 P.M. revealed Resident #11 was not wearing right heel lift boot. Interview with Resident #11 on 10/08/24 at 1:02 P.M. stated the facility staff did not apply the heel lift boot daily and he was unsure where the boot was located. Interview with the Wound Care Nurse Practitioner #600 on 10/10/24 at 11:58 A.M. stated the right lateral ankle wound was chronic and the main goal was to avoid infection. The wound had not worsened. Interview with Unit Manager (UM) #302 on 10/10/24 at 12:02 P.M. verified Resident #11 was not wearing his right heel boot lift as physician ordered. UM #302 stated she could not locate Resident #11's boot. Observation on 10/10/24 at 3:40 P.M. revealed Resident #11 was in his wheelchair and the heel lift boot was in place. 2. Review of Resident #54's medical record revealed an admitted [DATE]. Diagnosis included disease of the pericardium, vitamin deficiency, protein malnutrition, cystic fibrosis, and adult failure to thrive. Review of Resident #54's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderate cognitive function. Review of Resident #54's care plan revealed he required tube feeding related to dysphagia, adult failure to thrive, malnutrition, and weight loss. Goals included the resident will maintain adequate nutritional and hydration status as evidenced by a weight stable and no signs of malnutrition. The resident received nothing by mouth and was provided nutrition via a feeding tube. Review of Resident #54's medical record dated 05/24/24 revealed a physician's order for weekly weights every night shift every Friday. Review of Resident #54's weight record from 04/12/24 through 10/01/24 revealed the resident's weight were not obtained on the following dates: on 04/12/24, 04/26/24, 05/03/24, 05/17/24, 05/24/24, 05/31/24, 06/21/24, 06/28/24, 07/19/24, 07/26/24, 08/02/24, 08/16/24, and 09/06/24. Interview with the Director of Nursing (DON) on 10/10/24 at 8:18 A.M. verified Resident #54's weekly weight were not obtained as physician ordered. The DON verified Resident #54's weight was not obtained on 04/12/24, 04/26/24, 05/03/24, 05/17/24, 05/24/24, 05/31/24, 06/21/24, 06/28/24, 07/19/24, 07/26/24, 08/02/24, 08/16/24, and 09/06/24. Interview with the Clinical Operations Director #500 on 10/10/24 at 2:35 P.M. revealed the facility had no policy regarding following physician orders.

Based on record review, resident and staff interview, and review of the facility policy, the facility failed to provide showers timely to residents who were dependent on staff for showers/bathing. This affected one (Resident #8) of three residents reviewed for activities of daily living (ADL). The facility census was 83. Findings include: Review of Resident #8's medical record revealed an admitted [DATE]. Diagnosis included severe sepsis without shock, chronic obstructive pulmonary disease, and congestive heart failure. Review of Resident #8's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a moderate cognitive impairment. Resident #8 required substantial assistance from staff for showers, baths, and personal hygiene. Review of Resident #8's care plan revealed she had an ADL self-care self-care performance deficit related to activity intolerance, impaired gait and balance, limited mobility, musculoskeletal impairment, and neuropathy, Interventions included the resident required substantial assistance from staff with bathing and showering. Review of Resident #8's shower schedule revealed showers were scheduled every Tuesday and Friday. Review of Resident #8's shower documentation dated August 2024 through 10/07/24 revealed Resident #8 did not receive four scheduled showers between 09/03/24 through 09/13/24. Review of Resident #8's nurses notes revealed no documentation of why the showers were missing. Interview with Resident #8 on 10/07/24 at 10:25 A.M. revealed she wished to receive showers timely but the staff failed to assist her regularly. Interview with Licensed Practical Nurse (LPN) #433 on 10/08/24 at 1:01 P.M. verified Resident #8 failed to have showers completed timely between 09/03/24 through 09/13/24 and the medical record was silent as to why. Review of the facility policy titled Good [NAME] Home Resident Showers dated 01/19/23 revealed it is the practice of the facility to assist residents with bathing to promote proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure resident centered comprehensive care plans were in place. This affected two residents (#5 and #77) of 21 residents reviewed for resident centered comprehensive care plans. The facility census was 83. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included dementia, anxiety, and lewy body dementia. Review of the admission physician orders dated 07/22/24 for Resident #5 revealed she was admitted with an order for Geodon (antipsychotic) 20 milligrams (mg). Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed she was cognitively impaired and was prescribed routine antipsychotic medications. Review of the current physician orders for 10/2024 for Resident #5 revealed the Geodon was discontinued, and Seroquel (antipsychotic) 25 mg was prescribed. Review of the comprehensive care plan initiated 07/2024 for Resident #5 revealed there was no comprehensive care plan in place for psychoactive medications. Interview on 10/10/24 at 11:04 A.M. with the Director of Nursing (DON) verified there was not a comprehensive care plan in place for psychoactive medications for Resident #5. 2. Review of the medical record for Resident #77 revealed she was admitted to the facility on [DATE]. Diagnoses included dementia and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively impaired and incontinent of bowel and bladder. Review of the comprehensive care plan initiated 04/2024 for Resident #77 revealed there was no comprehensive care plan in place for incontinence care. Interview on 10/09/24 at 10:52 A.M. with State tested Nursing Assistant (STNA) #220 stated Resident #77 was incontinent of bowel and bladder. Interview on 10/09/24 at 1:37 P.M. with Registered Nurse (RN) #235 verified there was no comprehensive care plan in place for incontinence care for Resident #77. RN #235 stated Resident #77 had been incontinent of bowel and bladder since admission and should have had a care plan for incontinence care since the initiation of her comprehensive care plan. Review of the facility policy titled Good [NAME] Home Comprehensive Care Plans, dated 09/2024 revealed the facility will develop and implement a comprehensive person-centered care plan for each resident. The comprehensive care plan will be developed with seven day after the completion of the comprehensive MDS assessment.

Based on medical record review, staff interviews, and review of facility policy, the facility failed to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in actual harm when a resident experience repeated falls, with one resulting in a fracture requiring surgery. This affected one resident (#46) out of four residents reviewed for falls. The census was 89. Finding include: Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, [CONDITION(S)], dementia, anxiety, [CONDITION(S)] and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. The resident required extensive assistance of two people for bed mobility, toilet use and transfers. The assessment revealed Resident #46 had no history of falls prior to admission. Review of the Care Area Assessment (CAA) worksheet revealed falls and functional status would be addressed in the care plan to avoid complications and minimize risks. Review of a fall risk assessment dated [DATE], revealed Resident #46 was at high risk for falls. Review of the baseline care plan dated 01/19/22, revealed the care plan did not address Resident #46's risk for falls and did not include interventions to potentially prevent falls. Review of the comprehensive care plan dated 01/31/22, revealed the care plan did not address Resident #46's risk for falls and did not include interventions to potentially prevent falls. Further review of the of the admission MDS assessment dated [DATE] revealed Resident #46 triggered the CAA Summary for falls. Review of the CAA Fall Summary, completed on 02/04/22, revealed falls would be addressed in the care plan to avoid complications and to minimize risk due to injury associated with falls related to weakness, mobility, transfer, and balance impairment along with vision impairment, frequent incontinence, decreased safety awareness and severe cognitive impairment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. The resident required extensive assistance of two people for bed mobility, toilet use and transfers. Review of the updated comprehensive care plan dated 03/17/22 revealed the care plan continued to lack evidence of any documentation for Resident #46's risk for falls and did not include interventions to potentially prevent falls. Review of a document titled, Summary Fall Event, dated 03/23/22 at 3:50 P.M., revealed Resident #46 was found sitting on the bathroom floor with her pants at her ankles. The resident reported she was taking herself to the bathroom. Mild injury noted, skin tear to left buttock which required first aide. Resident #46 was re-educated to use of the call light and the importance of staff assistance. Review of a document titled, Incident Audit Report, dated 04/14/22 at 3:45 P.M., revealed Resident #46 was heard yelling for help and was found sitting on buttocks on the bathroom floor with her wheelchair beside her. Resident #46 complained of right hip pain. Staff noted right leg to be shorter. Documentation revealed the resident was trying to go to the bathroom. Resident #46 was assessed and due to pain and crying, emergency services were called. Resident #46 was sent to the hospital for evaluation and treatment. Resident #46 was found to have a right femoral neck fracture requiring a right hip replacement. Review of Good Shepherd Home communication dated 04/14/22 sent to the facility nurses and nursing assistants revealed Resident #46 was not to be left in her wheelchair unattended in her room or left in the bathroom on the toilet unattended. Review of Resident #46's hospital medical record revealed the resident sustained a closed, displaced right femoral neck fracture that required a right hip hemiarthroplasty (hip replacement) on 04/16/22. Review of the updated comprehensive care plan dated 04/27/22, again revealed the care plan lacked documentation for Resident #46's risk for falls and did not include interventions to potentially prevent falls. Further review of the comprehensive care plan revealed a fall care plan with interventions was not developed until 05/02/22. The resident returned to the facility from her surgery on 04/19/22. Interview on 05/12/22 at 2:35 P.M. with the Director of Nursing (DON) verified Resident #46 was identified upon admission as a high fall risk resident and was at risk for injury related to falls. The DON further validated the comprehensive care plan for Resident #46 was absent of fall interventions until interventions were initiated on 05/02/22. The DON verified Resident #46 had a fall resulting in a fracture, which required surgery. Review of the facility policy titled, Fall Policy, indicated when a resident is identified at risk for falls the facility is to implement a fall prevention program to reduce the risk of falls and serious injury related to falls and to incorporate the fall risk prevention in the resident's care plan.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored properly, staff prepared food in a sanitary manner, and failed to ensure the dishmachine reached appropriate temperatures. This had the potential to affect 88 residents in the facility. The facility identified one resident (#32) did not receive oral nutrition. The facility census was 89. Findings include: 1. Observations on [DATE] beginning at 8:33 A.M. revealed an open bag of chicken, an open box of hashbrowns, and individual flatbread lying loose on the shelf in the walk-in freezer, and one large can of mandarin oranges and one large can of raspberry filling dented near the seal stored with the in-use canned food items. Interview on [DATE] at 8:46 A.M. with the Culinary Director #507 confirmed the chicken, hashbrowns and flatbread were stored inappropriately, and the dented cans should be removed from use. Observation and interview on [DATE] at 8:52 A.M. with the Culinary Director #507 revealed two opened, undated bags of hardboiled eggs with cloudy fluid inside, leaked when they were picked up, and were inappropriately stored in an additional walk-in refrigerator. Observation and interview on [DATE] at 8:58 A.M. with the Culinary Manager #507 confirmed deli ham dated [DATE] was in the refrigerator of the kitchen on the locked unit. The Culinary Manager #507 confirmed the ham was beyond the date of use. Observation and interview on [DATE] at 9:03 A.M. with the Culinary Manager #507 confirmed personal food and expired chocolate milk were in the stand-up refrigerator on the 200-hall. The Culinary Manager #507 further confirmed the coleslaw located in the low reach-in refrigerator on the 200-hall was expired. Review of the facility policy titled, Date Marking for Food Safety, dated [DATE], revealed food items should be marked to indicate the date by which the food shall be consumed or discarded, and refrigerated food items should be held for a maximum of seven days. 2. Observation on [DATE] at approximately 8:56 A.M. revealed Dietary Assistant #388 wearing disposable gloves and used a handle to open a compartment, removed a clean plate, closed the compartment, put a toasted sandwich on the plate, opened another compartment, removed bacon slices with her gloved hands, and placed the bacon on the plate. Interview on [DATE] at approximately 8:57 A.M. with the Dietary Assistant #388 confirmed she did not change gloves between touching handles and touching consumable food. Further interview revealed the sandwich and bacon was for Resident #88. Interview on [DATE] at approximately 8:57 A.M. with the Culinary Director #507 confirmed the Dietary Assistant #388 did not practice appropriate hand sanitation while plating the sandwich. Observation on [DATE] at 8:48 A.M. revealed the sandwich and bacon was delivered to Resident #88. 3. Observation on [DATE] at 1:35 P.M. of the dishmachine revealed the wash temperature ranged from 100 degrees fahrenheit to 105 degrees fahrenheit. Further observation of the dishmachine revealed posted guidelines for washing temperatures to be at least 120 degrees fahrenheit. Interview on [DATE] at 1:55 P.M. revealed Dietary Assistant #365 was running the dishmachine, but did not know who was required to complete the dishmachine temperature log. Interview on [DATE] at 1:53 P.M. with the Chef Manager #475 confirmed the washing temperature of the dishmachine ranged between 100 to 105 degrees fahrenheit. Interview and observation of the dishmachine on [DATE] at 12:35 P.M. with the Culinary Director #507 revealed the wash temperature was 93 degrees fahrenheit. Further interview revealed the dishmachine was a chemical sanitizer and a high temperature machine. Continued interview revealed most of the kitchen staff was new and had not been trained on monitoring and completing the logs for the dishmachine. Review of the facility policy titled, Good Shepherd Home Dishwasher Temperature, dated 2021, revealed the wash temperature should be 120 degrees fahrenheit for a chemical sanitizing machine, and should be ,d+[DATE] degrees fahrenheit for a high temperature machine. Review of the Infection Control logs from [DATE] to current revealed no foodborne illness had occurred at the facility.

Based on observation, staff interview, review of manufacturer's instructions, and review of facility policy, the facility failed to ensure staff properly cleaned and disinfected the blood glucometer per manufacturer's recommendations. This had the potential to affect eight residents (#8, #23, #28, #31, #39, #41, #74 and #75) receiving blood sugar checks in the Meadows Unit. Facility census was 89. Findings include: Observation on 05/10/22 at 7:36 A.M. revealed Licensed Practical Nurse (LPN) #376 administering medications on the Meadows Unit and cleaned the blood glucometer with two alcohol wipes. Interview with LPN #376 at the time of the observation on 05/10/22 at 7:36 A.M. verified blood glucometer's are cleaned with alcohol. Interview with LPN #376 on 05/10/22 at 2:30 P.M. verified LPN #376 used alcohol to clean the blood glucometer before and after the morning blood sugar check for Resident #74, with LPN #376 further stating she should have used a disinfectant wipe. Review of facility policy titled, Glucometer Disinfection, with a review date of 02/21 verified blood glucometer should be cleaned and disinfected after each use and according to manufacturer instructions. Review of the undated manufacturer's instructions for blood glucometer used revealed any disinfectant product with the Environmental Protection Agency (EPA) number -12 was to be used on the device for cleaning and disinfection. This deficiency substantiated Complaint Number OH 162.

Based on observation, resident interviews, and staff interviews, the facility failed to ensure resident rooms and wheelchairs were kept in a clean and sanitary manner. This affected eight residents (#2, #32, #39, #50, #52, #56, #60, and #87) out of eight residents reviewed for environmental concerns. The facility census was 89. Findings include: 1. Observation on 05/10/22 at 8:20 A.M. revealed Resident #39's room smelled of urine. Resident #39 was not in the room at the time. Interview on 05/10/22 at 8:20 A.M. with Medication Aide #513 confirmed Resident #39's room smelled of urine. Observation of Resident #50's room on 05/10/22 from 11:15 A.M. to 11:21 A.M. revealed an unmade bed, dirty linen on the sink and dirty clothing in a pile on the floor in the left hand corner of the room. There was dark, sticky debris on the floor in four of four corners of the room and on the metal threshold between the room and the hallway and the dark, sticky debris rubbed off when scuffed with the Surveyor's shoe. There was also a sticky substance on the floor in front of sink which caused the Surveyor's shoes to stick to the floor. Observation of Resident #87's room on 05/10/22 at 11:27 A.M. revealed dark discoloration to four of four corners in the room along with a dark sticky substance built up on the metal threshold between the hallway and room. The dark sticky substance on the metal threshold scuffed off with the Surveyor's shoe. Observation of Resident #52's room on 05/10/22 at 11:34 A.M. revealed a tile floor with a change in color from light to dark from the bathroom to the room and had multiple scuff marks. The line of change was uneven and sticky when walked on. There was a maroon colored reclining chair in the corner of room with white substance on the cushion of chair. There was an opened wound dressing package, four inches by four- and three-quarter inches sitting on the right side of the sink with a notation on the package which indicated the dressing was sterile. Interview with Licensed Practical Nurse #439 (LPN) on 05/10/22 at 11:40 A.M. stated the Resident #52 had been transferred to the hospital two days ago. Interview with Housekeeper #413 at 05/10/22 at 11:52 A.M. verified Resident #52's room had not been cleaned since the resident discharged two days ago. Housekeeper #413 further added rooms were to be cleaned daily. Housekeeper #413 stated she was unable to complete her work each shift. Housekeeper #413 stated she was required to clean staff areas, the break room and then nurses stations prior to resident rooms, further, Housekeeper #413 admitted she does not get to all resident rooms every day. Observation of Housekeeper #413 cleaning cart on 05/10/22 at 11:52 revealed a full unlabeled spray bottle with purple liquid. Interview with Housekeeper #413 at the time of the observation verified the spray bottle containing the purple liquid was unlabeled. Housekeeper #413 was unable to provide the name of liquid in the spray bottle. Observation on 05/10/22 at 11:53 A.M. of Resident #32 and Resident #56's room revealed scuff marks on the tile floor and a dirty, used glove on the floor next to an empty trash can. Observation on 05/10/22 at 12:21 P.M. of Resident #60's room revealed a tile floor with dark colored build up in four of four corners of room and on the floor around the wood vanity. The transition from the carpeted hallway with a metal transition strip contained dark debris which rubbed off with the Surveyor's shoe. There was also additional dark sticky areas on the tile floor next to the bed with scuff marks on the floor throughout the room. Interview on 05/12/22 at 11:23 A.M. Resident #60 stated the housekeeping staff do not sweep or mop her bedroom floor often enough and stated her room was not as clean as she would like it. Interview on 05/12/22 at 3:15 P.M. Housekeeping Supervisor #400 verified the discoloration, debris and scuff marks on the floors of Resident (#32, #50 #52, #56, #60 and #87) rooms. Housekeeping Supervisor #400 further added he received complaints about the condition of the floors in the Vineyard Unit from both residents and resident's family members. 2. Review of Resident #2's medical record revealed an admitted [DATE]. Diagnoses included restlessness and agitation, dementia, major depressive disorder, and cerebral infarction. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #2 was severely cognitively impaired. Resident #2 was totally dependent on staff for transfer, and locomotion. Resident #2 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Review of Resident #2's care plan revised 04/28/22 revealed supports and interventions for self-care deficit, and impaired physical mobility. Resident #2 was noted to slide down nearly out of his customized specialty wheelchair. A wheelchair provider recommended the use of a seatbelt. Observation on 05/09/22 11:47 P.M. found Resident #2 seated in his customized wheelchair in the dining room for lunch. Resident #2 was found to have dried bacon and dirt and debris built up on the brakes and connecting bars of his wheelchair. Observation and attempted interview on 05/09/22 at 11:56 A.M. found Resident #2 was not able to be interviewed. Resident #2 had been provided his lunch meal and was observed feeding himself bite size pieces using his hands. Resident #2 was observed having some difficulty getting the food from his plate to his mouth and was observed dropping pieces of chicken onto his lap. Interview on 05/09/22 at 12:01 P.M. with State tested Nursing Assistant (STNA) #380 verified Resident #2's wheelchair had dried bacon as well as built up dirt and debris on his wheelchair. STNA #380 stated resident wheelchairs were to be cleaned at the end of the day. STNA #380 verified Resident #2's wheelchair did not appear to have been cleaned. Interview on 05/09/22 at 12:08 P.M. with Dietary Staff #498 verified the dried bacon on Resident #2's wheelchair was from breakfast. Dietary Staff #498 was not able to determine what the other built up debris was and verified the wheelchair was dirty. This deficiency substantiates Master Complaint Number OH 531.

Based on record review, staff interview and review of a facility policy, the facility failed to implement interventions when a resident was assessed at a high risk for development of pressure ulcers. This resulted in actual harm when Resident #2 developed a deep tissue injury pressure ulcer on the coccyx. This affected one (Resident #2) of three residents reviewed for pressure ulcers. The facility identified one resident with a pressure ulcer currently residing in the facility. The facility census was 108. Findings include: Review of the medical record of Resident #2 revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's significant change minimum data set ((MDS) dated [DATE] revealed the resident had moderate cognition deficits. The document further indicated she was at risk for developing pressure ulcers and had none upon admission. Review of the Braden Scale for Predicting Pressure Ulcer Risk Score dated 04/08/17 revealed Resident #2 was at a high risk for developing a pressure ulcer and on 04/17/17 was assessed as being a very high risk for developing a pressure ulcer. No new interventions were put into place with either of the assessments. Review of the most recent plan of care revealed the resident had an intervention of a pressure relieving mattress. The care plan was not updated after her readmission on 04/08/17. Review of the progress notes for Resident #2 from 04/08/17 to 05/03/17 and all documentation revealed no indication of any skin impairment until the discovery of the open area on the coccyx. Review of the form titled Pressure Ulcer Investigation with a date of discovery documented as 05/03/17 revealed the wound was located on the coccyx with measurements of 1.0 centimeters (cm) in length, 1.5 cm in width and 0.1 cm in depth. No stage or drainage was indicated. The initial treatment was a foam dressing. Interventions included to turn and reposition every two hours, moisture barrier after incontinence episode, float heels and encourage fluids. Resident #2's mobility status was in bed most of the day, and was always incontinent of both bowel and bladder. Review of the document titled Wound/Skin Documentation Record dated 05/03/17 indicated the above described wound to be a Stage II pressure ulcer. The entry dated 05/17/17 indicated the wound to be unstageable. Forms from the Wound Management Service by the Certified Nurse Practitioner (CNP) dated 05/03/17 indicated the wound to be deep tissue injury; purple, maroon and black in color. Positioning and pressure reduction interventions included redistribution gel or foam, float or offload the heels and a pressure redistribution mattress to the bed. Turn and reposition the resident was also indicated. On 05/10/17, the wound measured 2.5 cm length, 3.0 cm width and a depth of 0.1 cm with the status of deteriorating. On 05/17/17, the sacral wound with necrotic tissue with debridement required. The debridement was completed on that day and the measurements were length of 4.0 cm, width of 3.0 cm and a depth of 0.2 cm and the periwound area to be pink or normal for ethnic group. The necrotic amount was 50-75 % and the exudate (drainage) was serous (thin, watery and clear.) On 05/18/17, an observation of Resident #2's wound was unable to be observed as the dressing change had been completed by the staff on 05/17/17 and was not due to be completed again until 05/19/17. Interview on 05/18/17 with the Director of Nursing (DON) verified the lack of documentation of any skin impairment prior to the pressure area on 05/03/17 for Resident #2. She further verified there were no new interventions put into place after the Braden Scale for Predicting Pressure Ulcer Risk Score assessments that had been completed on 04/08/17 and 04/17/17. Review of the facility policy titled Skin Care Protocol revised 11/08 revealed any skin problems discovered will be addressed by the nurse. This deficiency substantiates Complaint Number OH 189.