Every finding on record at Greenville Nursing and Rehabilitation

Based on interview, record review and facility policy review, the facility failed to ensure its grievance policy was followed regarding resident/guardian notification of grievance status and outcomes for one (Resident (R) 1) of three residents reviewed for grievances. R1's guardian caused a grievance to be filed on R1's behalf. The facility failed to provide R1's guardian with a written grievance decision which contained all required information, including, but not limited to, the date the grievance was received and the outcome of the grievance. The findings include: Review of a facility policy titled, Grievances, revised 09/06/2024, revealed the facility would support each resident's/patient's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy stated the Administrator was designated as the Grievance official and would keep the resident/patient appropriately apprised of progress towards resolution of the grievances. Further, the resident/patient had the right to obtain a written decision regarding the grievance and the Grievance official would issue a written decision on the grievance to the resident/patient or representative at the conclusion of the investigation. Review of an Admission Record revealed R1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and personal history of traumatic brain injury. Further review of the Admission Record revealed that R1 had a guardian. Review of a grievance, dated 11/24/2024 and completed by the Business Office Manager (BOM), revealed R1's guardian was the complainant. The grievance stated R1 was in the wrong wheelchair and the guardian asked Registered Nurse (RN) 1 to ask the four Certified Nursing Assistants (CNAs) to assist R1 into the correct wheelchair. R1's guardian stated RN1 was rude and responded that I highly doubt there were four CNAs standing around. The guardian also alleged R1 was made to stay in the bed. Further review of the grievance revealed the Grievance Officer, who is the Executive Director (ED), followed up by interviewing RN1 via telephone on 11/24/2024. The grievance form showed a resolution date of 11/24/2024 but did not specify what the resolution was. It was documented on the grievance form that the guardian was notified; however, it did not indicate when this notification occurred. During an interview with R1's guardian on 01/08/2025 at 11:55 AM, she stated that on 11/23/2024, she made a complaint to the BOM which was supposed to be filed as a grievance. R1's guardian stated she was unsure if the grievance was filed because she never heard anything else about it. The guardian denied being notified of the grievance status or its resolution. During an interview with the BOM on 01/09/202 at 11:29 AM, she stated she filed the grievance on behalf of R1's guardian on 11/24/2024. The BOM stated she reported the incident to the ED (Grievance Officer) who handled the situation and grievance from that point on. During an interview with the ED on 01/09/2025 at 2:40 PM, she confirmed she was the grievance officer and was responsible for all grievances in the facility. The ED stated the BOM made her aware of the grievance on 11/24/2024. The ED stated she did not speak to the guardian during the grievance process. Although the grievance form documented the guardian was informed of the results, the ED confirmed she did not notify the guardian in any way once the grievance was resolved. The ED did not give a reason as why this was not done, and stated she should have spoken with R1s guardian about the status and outcome of the grievance, saying she did not follow the facility's grievance policy.

Based on interview, record review, and facility policy review, the facility failed to ensure 3 (Residents (R) 30, R38, and R46) of 22 sampled residents received their nighttime medications at a time preferred by the residents. The findings include: Review of the facility's policy titled, Medication Administration, copyright 2024, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. An undated document titled, Medication times provided by the facility revealed evening medication times were from 6:00 PM to 10:00 PM. 1. Review of R30's Admission Record revealed the facility readmitted R30 on 01/13/2023 with diagnoses that included respiratory failure, type II diabetes, other sleep disorders, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2024, indicated R30 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of R30's Medication Administration Audit Report, for the timeframe of 06/06/2024 to 06/07/2024, revealed medications ordered was to be administered on 06/06/2024 at 6:00 PM, 8:00 PM, and 9:00 PM, and were documented to have been administered on 06/07/2024 at 12:48 AM by Licensed Practical Nurse (LPN) #16. Review of R30's Medication Administration Audit Report, for the timeframe of 06/15/2024 to 06/16/2024, revealed the medications were ordered to be administered on 6/15/2024 at 6:00 PM, 8:00 PM, and 9:00 PM; however, the medications were documented to be administered on 06/16/2024 at 1:12 AM and 1:13 AM by LPN #16. During an interview on 06/17/2024 at 10:44 AM, R30 stated they could not get their nighttime medication until midnight. The resident stated midnight was too late. Further, the resident stated staff had to wake them to take their medication, and they were unable to go back to sleep afterward. 2. Review of R38's Admission Record revealed the facility readmitted R38 on 11/25/2023 with diagnoses that included polymyalgia rheumatica (muscle pain and stiffness), atrial fibrillation, and heart failure. Review of R38's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed R38 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of R38's Medication Administration Audit Report, for the timeframe of 06/06/2024 to 06/07/2024, revealed the resident's medications were ordered to be administered on 06/06/2024 at 6:00 PM; however, review of the record revealed the resident's medications were administered 06/07/2024 at 12:51 AM by LPN #16. Review of R38's Medication Administration Audit Report, for the timeframe of 06/16/2024 to 06/17/2024, revealed the the resident's medications were ordered to be administered on 06/16/2024 at 6:00 PM; however, review of the record revealed the resident's medications were administered 06/16/2024 at 11:18 PM by LPN #16. During an interview on 06/18/2024 at 5:15 PM, R38 stated LPN #16 always gave their night medication after 10:30 PM or 11:00 PM, sometimes as late as 2:00 AM. R38 stated they preferred to get their medication around 7:00 PM or 8:00 PM, so they could go to bed earlier. 3. Review of R46's Admission Record revealed the facility readmitted R46 on 06/10/2022 with diagnoses which included: generalized anxiety disorder, polyneuropathy (pain in multiple nerves), restless leg syndrome, and other sleep disorders. Review of R46's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/2024, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of R46's Medication Administration Audit Report, for the timeframe of 06/06/2024 to 06/07/2024, revealed the resident's medications were ordered to be administered on 06/06/2024 at 6:00 PM and 9:00 PM. However, review of the record revealed the resident's medications were administered 06/07/2024 at 12:49 AM by LPN #16. Review of R46's Medication Administration Audit Report, for the timeframe of 06/15/2024 to 06/16/2024, revealed the medications ordered to be administered on 06/15/2024 at 6:00 PM and 9:00 PM, however, review of the documentation revealed the resident's medications were administered on 06/16/2024 at 1:13 AM by LPN #16. During an interview on 06/17/2024 at 12:14 PM, R46 stated they had been receiving their nighttime medications at 12:00 AM, that was too late, and staff had to awaken them to give the medications. During a telephone interview on 06/19/2024 at 10:06 PM, LPN #16 stated she finished administering medications by 10:30 PM each night, but if things got hectic it could be as late as 11:30 PM. During an interview on 06/20/2024 at 4:33 PM, the Director of Nursing Services (DNS) stated if a resident had a preference for medications, that a grievance should be completed and the facility should attempt to accommodate the preference of the resident and give the medications at a better time. Further, the DNS stated it was her expectation the facility would accommodate the residents' time preferences.

Based on observation, interview, record review, and facility policy review the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 2 medication errors out of 35 opportunities, affecting 1 (Resident (R)14) of 3 residents reviewed during the medication administration task, resulting in a medication error rate of 5.71%. The findings include: Review of the facility's policy titled, Medication Administration, copyright 2024, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy further indicated, 11. Review MAR [medication administration record] to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc. [et cetera, other similar things]) with MAR to verify resident name, medication name, form, dose, route, and time. Review of R14's Admission Record revealed the facility admitted R14 on 04/07/2023 with diagnoses to include type two diabetes mellitus with diabetic nephropathy and chronic kidney disease. Review of R14's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of R14's Order Summary Report, listing active orders as of 06/18/2024, contained an order, dated 06/12/2024, for prednisolone acetate ophthalmic suspension 1%, one drop in left eye three times a day for eye surgery until 06/26/2024. The Order Summary Report also contained an order, dated 06/12/2024, for ofloxacin ophthalmic solution 0.3%, one drop in left eye three times a day for eye surgery until 06/26/2024. During an observation of medication pass on the 300 Hall on 06/18/2024 at 8:33 AM, Qualified Medication Aide (QMA) #1 administered one drop of prednisolone acetate ophthalmic suspension 1% into both of R14's eyes. The label affixed to the prednisolone box specified to instill one drop in both eyes four times a day. QMA #1 also administered one drop of ofloxacin ophthalmic solution 0.3% into both of R14's eyes. The label affixed to the ofloxacin box specified to instill one drop in both eyes four times a day. During an interview on 06/20/2024 at 8:34 AM, QMA #1 stated the process for administering medications was to verify the five rights by verifying the name of the resident, checking for the right medication and dosage, and matching the order in the computer with the label on the medication. QMA #1 stated if something did not match, she should verify the order, and if the label was wrong, she would tell the nurse, and the nurse would have her put a label on the medication that read, Directions Changed Refer to Chart. QMA #1 said she followed the medication label on the eye drops instead of the active order in the resident's chart. QMA #1 stated the physician's orders were to administer one drop in the resident's left eye three times a day until 06/26/2024 and confirmed she should have only put the drops in the resident's left eye. During an interview on 06/20/2024 at 8:52 AM, Registered Nurse (RN) #2 stated if a QMA noticed an order did not match the medication label, they should notify the nurse, the nurse would clarify the order, make any needed corrections, and involve the nurse practitioner. RN #2 stated they would then put a sticker on the medication that would direct staff to refer to the order in the resident's chart. During an interview on 06/20/2024 at 11:45 AM, the Director of Nursing Services (DNS) stated if a QMA noticed an issue with a medication, they should double check the computer and the medication, take it to the charge nurse, then the nurse would verify the order, call the physician, and place a sticker on the medication to make sure the order in the chart was followed. The DNS said QMA #1 should have looked at the orders before administering the medications and followed the orders. The DNS stated her expectation was for staff to follow the policy and procedure for medication administration. During an interview on 06/20/2024 at 12:39 PM, the Executive Director (ED) stated QMA #1 should have checked the orders prior to administering the medications. The ED stated her expectation was for the staff to follow the policy and procedure.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure routine dental services were provided for 1 (Resident #12) of 2 residents reviewed for dental care. The findings include: Review of the facility's policy titled, Dental Services, copyright 2024, indicated, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Definitions: 'Routine dental services' means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g. [exempli gratia, for example], taking impressions for dentures and fitting dentures. The policy also indicated, The dental needs of each resident are identified through the physical assessment and MDS [Minimum Data Set] assessment processes, and are addressed in each resident's plan of care. Review of R12's Admission Record revealed the facility admitted R12 on 01/11/2024 with diagnoses that included: dysphagia (difficulty or discomfort with swallowing), anxiety disorder, depression, and chronic ischemic heart disease. Review of a document titled, Nursing Admission/Readmission Evaluation, dated 01/11/2024 at 5:44 PM, indicated R12 had missing teeth or dentures. Review of a document signed by R12's responsible party (RP) on 01/12/2024 reveled the RP's signature was their request and consent to any services not checked as declined. The document reflected R12's RP consented to vision, podiatry, dental, and audiology services. Review of R12's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2024, revealed R12 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for eating and oral hygiene, had no swallowing problems, had a feeding tube, and received a mechanically altered diet while a resident of the facility. The MDS also indicated the resident had no natural teeth or tooth fragments and had obvious or likely cavity or broken natural teeth. Review of R12's quarterly MDS, with an ARD of 04/15/2024, revealed R12 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for eating and oral hygiene, had no swallowing problems, had a feeding tube, and received a mechanically altered diet while a resident of the facility. The MDS indicated the resident did not have mouth or facial pain and did not have discomfort or difficulty with chewing. Review of R12's care plan included a focus area, initiated on 01/11/2024 and revised on 01/18/2024, that indicated the resident had natural bottom teeth with missing teeth and rotten teeth. Interventions dated 01/11/2024 directed staff to coordinate arrangements for dental care and to observe for signs of oral/dental problems needing attention, such as missing, loose, broken, eroded, or decayed teeth. Review of the facility's contracted dental company's documentation revealed 26 residents had scheduled dental appointments on 02/01/2024. R12, however, was not on the list to be seen by the dentist. Review of the facility's contracted dental company's documentation revealed 28 residents had scheduled dental appointments on 05/07/2024. Further review revealed R12 was not on the list to be seen by the dentist. Review of R12's social services Progress Notes for the timeframe from 03/14/2024 to 05/31/2024 revealed no documentation related to R12's dental care or dental referrals. During a concurrent observation and interview on 06/17/2024 at 10:04 AM, R12 stated they would like to have some top dentures. The resident was observed with natural teeth on bottom with some teeth missing and the ones that remained were brown in appearance. The resident did not have teeth on the top. During an interview on 06/18/2024 at 1:48 PM, State Registered Nurse Aide (SRNA) #3 stated if anything new was going on with a resident's mouth, like pain, it would be reported to the nurse. SRNA #3 stated R12 had a lot of breakage in their teeth and had complained about their teeth at times. During an interview on 06/18/2024 at 2:16 PM, Licensed Practical Nurse (LPN) #5 stated if a resident had mouth problems and it was something she could not resolve, she would notify the physician to get an order or would tell the Social Services Director (SSD) and put it on the computer medical records program home page. LPN #5 stated issues she would report to the SSD were missing teeth, ill-fitting dentures, no dentures, and no teeth, whether it was a new or old issue. LPN #5 reviewed R12's record and stated she could not find where the resident had seen the dentist, but the resident did have a consent filed under the contracted dental service consents. During a follow-up interview on 06/18/2024 at 2:34 PM, LPN #5 observed R12's mouth in the resident's room. LPN #5 stated the resident did not have any teeth on the top and on the bottom, were teeth with decay and missing teeth. LPN #5 stated the resident should have been seen by the dentist, and she did not know why the resident had not been seen. During an interview on 06/18/2024 at 2:05 PM, Family Member (FM) #4 stated R12 wanted dentures. FM #4 said the resident had a few teeth on the bottom but none on the top. FM #4 stated the resident had not been seen by a dentist while living at the facility but had seen a dentist a year ago before they came to the facility and all the resident's top teeth had been pulled. FM #4 stated R12 was very self-conscious about their teeth and appearance. During an interview on 06/18/2024 at 2:38 PM, the SSD stated when a resident was admitted to the facility, the Admission Director had the resident sign the contracted dental service consents if the resident wanted the company's services. The SSD stated she then would email the contracted dental company representative the name of the resident and the resident would get added to the list to be seen by the dental company. The SSD stated the dentist made trips to the facility every three months or if there was a problem. The SSD reviewed R12's record and said the resident had a consent for the dental services but she did not see any dental notes for the resident. The SSD stated no one had reported any problems to her concerning R12's teeth. During an interview on 06/19/2024 at 9:26 AM, the Director of Nursing Services (DNS) stated upon a resident's admission, the nurse would do a full body assessment, check for missing teeth, mouth pain, and any other problems. The DNS stated that during the admission process the resident or family would sign the contracted dental company's consent form. She stated the SSD would then put the resident on the dental list in the medical record program. The DNS stated the dentist came in the facility every three months. She stated if a resident had a concern and had signed a consent, they should be seen for a routine visit within three months. The DNS stated she did not know if R12 had been seen by the dentist but should have been seen at least once since their admission to the facility. The DNS stated she expected the staff to follow the process for dental services. During an interview on 06/19/2024 at 9:58 AM, the Executive Director (ED) stated that when a resident was admitted to the facility, the nurse completed an assessment, including an oral assessment. The ED stated on admission there was a 360 care form the resident could sign for dental services. The ED stated if the resident had broken or missing teeth, the nurse would notify the SSD to see if the resident signed a consent for dental services. She stated every resident who had signed a consent for dental services was referred to the dental service company. The ED said if there was no pain and the resident did not complain, they would not be referred to the dentist on admission but should have a routine visit. The ED stated R12 should have had a routine dental visit and that she expected the staff to follow the process for all admissions related to dental services.

Based on interview, facility document review, and facility policy review, the facility failed to ensure the posted staffing document included the total number of staff working for each discipline. This had the potential to affect all 59 residents residing in the facility. The findings include: Review of the facility's policy titled, Nurse Staffing Posting Information, copyright 2023, revealed, It is the policy of this facility to make nurse staffing information [sic] readily available in a readable format to residents and visitors at any given time. The policy also indicated, 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. Review of the facility's daily staff postings for the time frame from 05/21/2024 through 06/19/2024 revealed the name of the facility, facility census, the date, the actual hours worked for registered nurses (RNs), licensed practical nurses (LPNs), and aides/medtechs [medication technicians]. Further review of the document revealed it did not reflect the total number of RNs, LPNs, and unlicensed nursing staff scheduled to work each day. During an interview on 06/20/2024 at 11:37 AM, the Scheduler stated she was trained regarding how to complete the daily staff postings by the previous Scheduler, and she had never been told to include the number of RNs, LPNs, and certified nurse aides (CNAs) or medication aides. During an interview on 06/20/2024 at 2:51 PM, the Director of Nursing Services (DNS) stated her expectation was that the Scheduler followed the policy for completing the daily staff postings. During an interview on 06/20/2024 at 3:21 PM, the Executive Director (ED) stated she was unaware that the daily staff postings needed to include the actual number and hours worked for RNs, LPNs, and CNAs or medication aides. The ED stated she expected staff to follow the policy when completing daily staff postings.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure resident-identifiable information was not released to the public, for three (3) of three (3) sampled residents (Residents #1, #2, and #3). Registered Nurse (RN) #1, an employee of the facility, revealed she disclosed personal information regarding Residents #1, #2, and #3 to an unauthorized person, outside of the facility. The findings include: Review of the facility policy Safeguarding Protected Health Information (HP & S-10), dated 06/01/15, revealed it is each Center's policy to ensure, to the extent possible, that Protected Health Information (PHI) is not intentionally or unintentionally used or disclosed in a manner that would violate the Health Insurance Portability and Accountability Act (HIPAA) or any other federal or state law governing confidentiality and privacy of health information. The following procedure is designed to prevent improper uses or disclosures of PHI and limit incidental uses and disclosures of PHI that is, or will be, contained in a resident's clinical record. At the same time, the Center recognizes that easy access to all or part of a resident's clinical record by health care practitioners involved in a resident's care (nurses, attending and consulting physicians, therapists, and others) is essential to ensure the efficient quality delivery of health care. Review of the facility policy Privacy/Dignity, undated, revealed all team members are responsible for ensuring privacy and dignity of residents. We cannot disclose protected health information without proper consent. Report any suspected breaches to the Administrator immediately. 1. Record review revealed the facility admitted Resident #1 on 06/05/15 with [DIAGNOSES REDACTED]. 2. Record review revealed the facility admitted Resident #2 on 06/29/19 with [DIAGNOSES REDACTED]. 3. Closed record review revealed the facility admitted Resident #3 on 10/30/15 and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The facility discharged Resident #3 to his/her home on 07/23/19. Interview with the Complainant, on 07/23/19 at 1:24 PM, revealed Saturday, 06/29/19, (Resident #1) was given (his/her) daily bath; however, (he/she) was not bathed again until the afternoon of Tuesday, 07/02/19. On Sunday, 06/30/19, (Resident #2) had (his/her) daily dressing changed. (His/her) next daily dressing was not changed until after 7:00 PM on 07/03/19. On Tuesday, 07/02/19, (Resident #3) was ordered antibiotics by the physician to begin on 07/02/19. As of 07/04/19, (Resident #3's) antibiotics had not been filled by the pharmacy. Additionally, there were instances of staffing discrepancies on 07/04/19 and 07/05/19 (dayshift). Further interview with the Complainant revealed I do not work at the facility and do not know these residents, but I got the specifics listed in the complaint from (RN #1), an employee of the facility. Interview with RN #1, on 07/24/19 at 12:07 PM, revealed she had been employed as needed (PRN) at the facility since September 2018 and became full-time in February 2019. She stated I think I spoke with the Director of Nursing (DON) a couple of times about different issues, but nothing specific. When questioned about the specifics of the allegation, she revealed I did talk to the (Complainant) about it, who doesn't work at the facility. It was done out of frustration, and I gave specifics as far as incidences, and I only gave last names of residents. Additionally, she revealed she had been inserviced regarding HIPAA violations. Review of six (6) employee records revealed RN #1 was hired on 10/11/18, with a background screen completed. Further review revealed she had completed HIPAA training through the facility's Relias Learning Program on 07/09/19. Interview with the Administrator, on 07/26/19 at 1:30 PM, revealed she was unaware of any violation regarding residents' information. She stated employees received training on HIPAA upon hire and annually. A post-test had to be taken in order to mark them as completed, and they have three (3) attempts to pass. My expectation for PHI is to protect the residents, and to keep (him/her) protected. Only disclose minimal information that is needed among each other at the Center, and do not disclose to anyone outside the Center, or to anyone unauthorized.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User Manual, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for eight (8) of nine (9) sampled residents (Residents #2, #3, #4, #5, #6, #7, #8, and #9). The facility failed to implement a Care Plan related to not following the Care Plan for Restorative Services, for Residents #2, #3, #4, #5, #6, #7, #8, and #9. The findings include: Review of the Resident Assessment Instrument (RAI) User Manual, dated (MONTH) (YEAR), Chapter 4, pages 4-8 to 4-11, revealed the care plan was an interdisciplinary communication tool and must include measurable objectives and time frames, and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 1. Record review revealed the facility readmitted Resident #2 on 09/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/03/19, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score as a three (3), which indicated he/she was not cognitively intact or interviewable. Review of the Comprehensive Care Plan for inability to move body parts without assistance related to muscle weakness, dated 10/04/18, revealed to maintain current strength, restorative nursing six (6) to seven (7) days a week times fifteen (15) minutes. Review of the Physician Orders, dated 10/18/18, revealed an order for [REDACTED]. 2. Record review revealed the facility admitted Resident #3 on 02/13/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 05/22/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was cognitively intact and interviewable. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 01/03/19, revealed to maintain/gain current level, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes for edge of bed sitting forward. Review of the Physician Orders, dated 01/02/19, revealed an order for [REDACTED]. Interview with Resident #3, on 07/11/19 at approximately 1:05 PM, revealed the facility does not have enough staff and that residents have to wait for long periods of time before the call lights were answered. Resident #3 stated sometimes he/she will complain to staff about the wait time and things get better for a little while; however, the improvement does not last. Resident #3 stated there were a lot of days the aides were not able to provide Restorative services to the residents. 3. Record review revealed the facility readmitted Resident #4 on 08/28/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/03/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was not cognitively intact or interviewable. Review of the Comprehensive Care Plan for impaired mobility related to decrease strength in lower extremities and related to hip replacement muscle weakness, dated 11/10/18, revealed to maintain current level of function, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes for ambulation fifteen (15) feet with a rolling walker. Review of the Physician Orders, dated 11/10/18, revealed an order for [REDACTED]. 4. Record review revealed the facility admitted Resident #5 on 11/18/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/28/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was cognitively intact and interviewable. Review of the Comprehensive Care Plan for limited active joint range of motion related to muscle weakness, dated 12/14/18, revealed to maintain level of function, restorative nursing six to seven (6-7) days a week times fifteen (15) minutes for Active range of motion to bilateral extremities. Review of the Physician Orders, dated 12/14/18, revealed an order for [REDACTED]. 5. Record review revealed the facility admitted Resident #6 on 05/25/01 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/10/19, revealed the facility assessed the resident's BIMS score as a ten (10), which indicated he/she was cognitively intact and interviewable. Review of the Comprehensive Care Plan for inability to propel own wheelchair related to lack of trunk/limb control, dated 03/23/18, revealed to propel own wheelchair five (5) feet, to give active range of motion to right upper extremity to build strength, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Review of the Physician Orders, dated 03/23/18, revealed an order for [REDACTED]. 6. Record review revealed the facility readmitted Resident #7 on 08/30/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 07/08/19, revealed the facility assessed the resident's BIMS score as a twelve (12), which indicated he/she was cognitively intact and interviewable. Review of the Physician Orders, dated 04/29/19, revealed an order for [REDACTED]. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 04/30/19, revealed to walk fifty (50) feet with the assistance of device/person, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Interview with Resident #7, on 07/11/19 at approximately 1:25 PM, revealed staff don't even bother to answer him/her when he/she needed something. Resident #7 stated he/she was told he/she had to wait when he/she needed to be changed, and that he/she has had to sit in soiled briefs for about thirty (30) minutes. Resident #7 stated staff forgot to wake him/her up and get him/her dressed on one (1) occasion. He/she stated they don't always do his/her Restorative services with him/her and he/she had missed it on several occasions. 7. Record review revealed the facility readmitted Resident #8 on 03/14/19 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/14/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was cognitively intact and interviewable. Review of the Physician Orders, dated 06/04/19, revealed an order for [REDACTED]. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 06/05/19, revealed to walk fifty (50) feet with the assistance of device/person, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Interview with Resident #8, on 07/11/19 at approximately 3:00 PM, revealed residents have complained they have waited for periods of up to an hour for assistance. Resident #8 stated several days ago a staff member came to his/her room to do a call light audit, and that it took the aides forty-five (45) minutes to respond to the light. Resident #8 stated many days the aides were not doing Restorative sessions with him/her or any other residents. 8. Record review revealed the facility readmitted Resident #9 on 04/08/17 with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 05/07/19, revealed the facility assessed the resident's BIMS score as a twelve (3), which indicated he/she was cognitively intact and interviewable. Review of the Physician Orders, dated 06/10/19, revealed an order for [REDACTED]. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 06/12/19, revealed to walk fifty (50) feet with the assistance of device/person, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Review of Restorative minutes for the period of 06/17/19 through 07/11/19 revealed there were periods during the twenty-eight (28) time-frame that all eight (8) residents did not receive Restorative services due to Restorative Aides (RA's) not being able or available to perform services with the residents. Further review revealed Residents #2, #4, #5, #6, #7, and #8 missed six (6) out of 28 days, Resident #3 missed seven (7) out of 28 days, and Resident #9 missed ten (10) out of 28 days. Interview with State Registered Nurse Aide (SRNA) #1 on 07/12/19 at approximately 10:15 AM revealed staff try to respond to resident's call lights within five (5) to ten (10) minutes. SRNA #1 stated she felt for the most part that call lights were answered timely; however, she stated there were times staff were unable to complete all tasks during their shift and the tasks were carried over to the next shift to complete. SRNA #1 stated she was aware that several days a week Restorative services were not being provided to residents since those aides were pulled to the floor to help with SRNA work. SRNA #1 stated the facility could definitely benefit from additional staff. Interview with SRNA #2/Restorative Aide (RA) #1, on 07/12/19 at approximately 10:30 AM, revealed there was an issue with having enough RA's; however, in (MONTH) the facility hired more staff. She stated there were currently two (2) RA's; however, prior to now, there were many days when Restorative services were not being completed due to insufficient staff. She stated the week of (MONTH) fourth (4th) thru the seventh (7th), both RA's were on vacation at the same time. She revealed the sessions should have been completed during that time by other staff, but was unsure if the sessions were completed. Interview with SRNA #3, on 07/12/19 at approximately 11:00 AM, revealed occasionally with staffing shortages, the RA's were pulled from Restorative duties to assist with aide duties. She stated the facility was short-staffed, but felt it was better now. Interview with the Director of Nursing (DON), on 07/12/19 at approximately 11:30 AM, revealed she ensures there is sufficient staff. The DON stated the facility was currently cross-training all SRNA's to do Restorative services to ensure Restorative services were always completed. She revealed her expectation was for all residents to receive all the services they were care planned to receive, and if a resident does not receive a service, it should be reported to her immediately. She stated the facility was having issues with insufficient staff, and even though they felt they were staffed sufficiently, she would still like to add more staff.

Based on interview and record review, it was determined the facility failed to ensure sufficient staff was available to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being for eight (8) of nine (9) sampled residents (Residents #2, #3, #4, #5, #6, #7, #8, and #9.) Interviews with staff and residents revealed residents were not receiving Restorative services daily due to insufficient staffing. The findings include: The facility was unable to provide a policy related to staffing during the investigation. However, interview with the Director of Nursing (DON), on 7/10/19 at approximately 10:52 AM, revealed she was aware the facility had some issues with staffing recently, and she has continued to work to correct the situation. 1. Record review revealed the facility readmitted Resident #2 on 09/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/03/19, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score as a three (3), which indicated he/she was not cognitively intact or interviewable. Review of the Comprehensive Care Plan for inability to move body parts without assistance related to muscle weakness, dated 10/04/18, revealed to maintain current strength, restorative nursing six (6) to seven (7) days a week times fifteen (15) minutes. Review of the Physician Orders, dated 10/18/18, revealed an order for [REDACTED]. 2. Record review revealed the facility admitted Resident #3 on 02/13/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 05/22/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was cognitively intact and interviewable. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 01/03/19, revealed to maintain/gain current level, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes for edge of bed sitting forward. Review of the Physician Orders, dated 01/02/19, revealed an order for [REDACTED]. Interview with Resident #3, on 07/11/19 at approximately 1:05 PM, revealed the facility does not have enough staff and that residents have to wait for long periods of time before the call lights were answered. Resident #3 stated sometimes he/she will complain to staff about the wait time and things get better for a little while; however, the improvement does not last. Resident #3 stated there were a lot of days the aides were not able to provide Restorative services to the residents. 3. Record review revealed the facility readmitted Resident #4 on 08/28/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/03/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was not cognitively intact or interviewable. Review of the Comprehensive Care Plan for impaired mobility related to decrease strength in lower extremities and related to hip replacement muscle weakness, dated 11/10/18, revealed to maintain current level of function, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes for ambulation fifteen (15) feet with a rolling walker. Review of the Physician Orders, dated 11/10/18, revealed an order for [REDACTED]. 4. Record review revealed the facility admitted Resident #5 on 11/18/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/28/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was cognitively intact and interviewable. Review of the Comprehensive Care Plan for limited active joint range of motion related to muscle weakness, dated 12/14/18, revealed to maintain level of function, restorative nursing six to seven (6-7) days a week times fifteen (15) minutes for Active range of motion to bilateral extremities. Review of the Physician Orders, dated 12/14/18, revealed an order for [REDACTED]. 5. Record review revealed the facility admitted Resident #6 on 05/25/01 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/10/19, revealed the facility assessed the resident's BIMS score as a ten (10), which indicated he/she was cognitively intact and interviewable. Review of the Comprehensive Care Plan for inability to propel own wheelchair related to lack of trunk/limb control, dated 03/23/18, revealed to propel own wheelchair five (5) feet, to give active range of motion to right upper extremity to build strength, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Review of the Physician Orders, dated 03/23/18, revealed an order for [REDACTED]. 6. Record review revealed the facility readmitted Resident #7 on 08/30/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 07/08/19, revealed the facility assessed the resident's BIMS score as a twelve (12), which indicated he/she was cognitively intact and interviewable. Review of the Physician Orders, dated 04/29/19, revealed an order for [REDACTED]. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 04/30/19, revealed to walk fifty (50) feet with the assistance of device/person, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Interview with Resident #7, on 07/11/19 at approximately 1:25 PM, revealed staff don't even bother to answer him/her when he/she needed something. Resident #7 stated he/she was told he/she had to wait when he/she needed to be changed, and that he/she has had to sit in soiled briefs for about thirty (30) minutes. Resident #7 stated staff forgot to wake him/her up and get him/her dressed on one (1) occasion. He/she stated they don't always do his/her Restorative services with him/her and he/she had missed it on several occasions. 7. Record review revealed the facility readmitted Resident #8 on 03/14/19 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/14/19, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated he/she was cognitively intact and interviewable. Review of the Physician Orders, dated 06/04/19, revealed an order for [REDACTED]. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 06/05/19, revealed to walk fifty (50) feet with the assistance of device/person, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Interview with Resident #8, on 07/11/19 at approximately 3:00 PM, revealed residents have complained they have waited for periods of up to an hour for assistance. Resident #8 stated several days ago a staff member came to his/her room to do a call light audit, and that it took the aides forty-five (45) minutes to respond to the light. Resident #8 stated many days the aides were not doing Restorative sessions with him/her or any other residents. 8. Record review revealed the facility readmitted Resident #9 on 04/08/17 with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 05/07/19, revealed the facility assessed the resident's BIMS score as a twelve (3), which indicated he/she was cognitively intact and interviewable. Review of the Physician Orders, dated 06/10/19, revealed an order for [REDACTED]. Review of the Comprehensive Care Plan for impaired mobility related to muscle weakness, dated 06/12/19, revealed to walk fifty (50) feet with the assistance of device/person, Restorative Nursing six (6) to seven (7) days a week times fifteen (15) minutes. Review of Restorative minutes for the period of 06/17/19 through 07/11/19 revealed there were periods during the twenty-eight (28) time-frame that all eight (8) residents did not receive Restorative services due to Restorative Aides (RA's) not being able or available to perform services with the residents. Further review revealed Residents #2, #4, #5, #6, #7, and #8 missed six (6) out of 28 days, Resident #3 missed seven (7) out of 28 days, and Resident #9 missed ten (10) out of 28 days. Interview with State Registered Nurse Aide (SRNA) #1 on 07/12/19 at approximately 10:15 AM revealed staff try to respond to resident's call lights within five (5) to ten (10) minutes. SRNA #1 stated she felt for the most part that call lights were answered timely; however, she stated there were times staff were unable to complete all tasks during their shift and the tasks were carried over to the next shift to complete. SRNA #1 stated she was aware that several days a week Restorative services were not being provided to residents since those aides were pulled to the floor to help with SRNA work. SRNA #1 stated the facility could definitely benefit from additional staff. Interview with SRNA #2/Restorative Aide (RA) #1, on 07/12/19 at approximately 10:30 AM, revealed there was an issue with having enough RA's; however, in (MONTH) the facility hired more staff. She stated there were currently two (2) RA's; however, prior to now, there were many days when Restorative services were not being completed due to insufficient staff. She stated the week of (MONTH) fourth (4th) thru the seventh (7th), both RA's were on vacation at the same time. She revealed the sessions should have been completed during that time by other staff, but was unsure if the sessions were completed. Interview with SRNA #3, on 07/12/19 at approximately 11:00 AM, revealed occasionally with staffing shortages, the RA's were pulled from Restorative duties to assist with aide duties. She stated the facility was short-staffed, but felt it was better now. Interview with the Director of Nursing (DON), on 07/12/19 at approximately 11:30 AM, revealed she ensures there is sufficient staff. The DON stated the facility was currently cross-training all SRNA's to do Restorative services to ensure Restorative services were always completed. She revealed her expectation was for all residents to receive all the services they were care planned to receive, and if a resident does not receive a service, it should be reported to her immediately. She stated the facility was having issues with insufficient staff, and even though they felt they were staffed sufficiently, she would still like to add more staff.

Based on interview and record review, it was determined the facility failed to have sufficient nursing staff to answer call lights and provide toileting services timely for four (4) of eight (8) sampled residents (Residents #2, #5, #6, and #7) and three (3) residents not in the selected sample (Unsampled Resident A, B, and C). Interviews with staff and residents revealed the staff was unable to answer call lights timely and provide toileting due to a shortage of staff. The findings include: Interview with Director of Nursing (DON) on 05/21/19 at 7:13 PM revealed she did not have a policy on staffing, but staffing depended on the census and what the budget allows. 1. Record review revealed the facility readmitted Resident #2 on 04/17/19 with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment, dated 04/24/19 revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15). Interview with Resident #2 on 05/19/19 at 6:47 PM and 7:09 PM revealed he/she used the call light at 6:47 PM and had been waiting an hour for staff. Resident #2 stated someone came ten (10) minutes ago and said they were going to get help and have not come back. At 7:09 PM, Resident #2 stated he/she was still waiting to go to the bathroom. Resident #2 further revealed another time he/she had waited (1) one and a half (1.50) hours on the commode for staff and he/she became sore and numb sitting there. Interview with Certified Nurse Aide (CNA) #4 on 05/19/19 at 7:03 PM revealed she was leaving and had went into Resident #2's room but had told the other CNA that the resident had to go to the bathroom because of being a two (2) assist. CNA #4 stated she had not been back to the room, as she had been helping on another hall, and could not find the other aide at the time, and she was leaving. 2. Record review revealed the facility readmitted Resident #7 on 08/28/18 with [DIAGNOSES REDACTED]. Review of an annual MDS assessment, dated 03/06/19 revealed the facility assessed Resident #7's cognition to be intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of May 2019 Physician order [REDACTED]. Interview with Resident #7, on 05/21/19 1:10 PM and 3:30 PM revealed he/she had to wait a long time for call light to be answered for toileting. Resident #7 stated he/she had waited the previous night from 8:15 PM till 9:05 PM for someone to answer the call light and had wet him/herself, and stated that no one says anything because they are retaliated against. Resident #7 revealed the CNA's cannot answer call lights because there is not enough staff; and you cannot put one (1) CNA on the hall, and expect staff to answer the call lights. 3. Record review revealed the facility readmitted Resident #6 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] Review of the Admission MDS assessment dated [DATE] revealed the facility assessed Resident #6's cognition as moderately impaired with a BIMS score of twelve (12) which indicated the resident was interviewable. Interview with Resident #6's Responsible Party on 05/21/19 at 5:00 PM revealed it took a while for staff to answer call lights and Resident #6 had told her that toileting took longer than expected and staff had failed to answer the call light a couple of times when he/she needed to be toileted. Interviews on 05/21/19 with Unsampled Resident A at 4:00 PM, Unsampled Resident B at 4:37 PM, and Unsampled Resident B at 4:35 PM revealed it takes a while for staff to answer the call lights. Unsampled Resident B stated he/she had diarrhea and was told to wait the other day and by the time staff got there it was too late. Additionally, Unsampled Resident C stated the other day he/she waited for forty-five (45) minutes and he/she had an accident on him/herself. Interview with Certified Nursing Assistant (CNA) #3 on 05/19/19 at 8:10 PM revealed staff do not get the last round of checking and changing (toileting) completed, and it is hard to get to call lights and residents have to wait. CNA #3 stated she was the only one in the dining room feeding residents and there were four (4) residents that needed to be fed at one (1) table, and three (3) at another table with the Certified Medication Technician having to help feed them after completion of medication pass. Interview with CNA #1, on 05/19/19 at 8:15 PM revealed there was not enough staff to help the second shift, and the first round of check and change was not even completed until 9:00 PM and by that time they are supposed to have completed two (2) rounds of check and change. CNA #1 stated supper on the halls was awful because if they were short handed there was no time for feeding on the halls until 7:00 PM, and they had not come in until 5:00 PM so that did not allow for enough help in the dining room. CNA #1 stated residents have accidents because they can not get to the call lights. Interview with CNA #5 on 05/21/19 at 12:30 PM revealed more staff was needed when switching out staff because of feeding residents and she did not know if they got fed or not. She stated answering call lights may take awhile depending on what is being done with another resident. Interview with Certified Medication Technician (CMT) #1 on 05/19/19 at 8:07 PM and 05/21/19 at 3:38 PM revealed she has been working the floor as a CNA and as a CMT. CMT #1 stated she has been the only one administering medications on most halls and has had to do all the halls. Additionally, CMT #1 stated the facility was sending the CMT's to the floor and that between 6:00 PM and 10:00 PM there were only two (2) CNA's on the floor and they are not able to provide all the care needed and some nurses help and some don't. CMT #1 stated the administrative staff try to run the facility from the office and try to excuse staffing issues by saying that this is the laziest bunch of CNA's they have ever seen, and staff was leaving because of the staffing shortage. Interview with Licensed Practical Nurse (LPN) #3 on 05/21/19 at 5:29 PM revealed there is a shortage of staff from 6:00 PM-10:00 PM and the staff was unable to answer the call lights or use a hoyer lift for a resident with just two (2) aides on the floor. LPN #3 stated now there is talk of taking away the CMT's and the nurse will have to pass the medications and will not be able to help on the floor. LPN #3 further revealed that nurses were leaving because of the staffing shortage, placing more responsibility on them, and blaming them for things they have no control over. LPN #3 further stated the facility is trying to be run like a hospital but nurses cannot pass medications for forty (40) residents and assess and document on them; because something is not going to get done. Further interview with DON on 05/21/19 at 7:13 PM revealed anyone can help answer a call light and help with direct resident care. Interview with Administrator on 05/21/19 at 7:48 PM revealed the facility uses the PPD (hours per patient) method to determine the amount of staff needed and to stick to the budget. She stated if she feels a need of additional CNA's she can do that. The Administrator revealed the time frame varies on how long it should take to answer a call light but she would like it to be in fifteen to twenty (15-20) minutes timeframe She stated the facility no longer had shower aides and they were going to keep one CMT with the other one going to the floor.

Based on observation and interview, it was determined the facility failed to post the facility staffing information on 05/19/19. The findings include: Interview on 05/21/19 at 7:13 PM with Director of Nursing (DON) revealed she did not have a policy on the posting of staffing information. Observations on 05/19/19 at 5:45 PM and 7:12 PM revealed the staff posting was dated 05/17/19. Interview with Licensed Practical Nurse (LPN) #1 on 05/19/19 at 7:15 PM revealed it was the responsibility of the administrative staff to post it. Interview with Administrator on 05/21/19 at 7:48 PM revealed staffing should be posted daily. She stated the staffing was not posted for 05/19/19.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of (8) eight sampled residents (Resident #3). Observation revealed a Licensed Practical Nurse (LPN) #1 picked the oxygen nasal cannula up off the floor and placed it back on Resident #3. The findings include: Review of facility policy titled, Infection Control, dated 11/01/17, revealed the centers infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections with the policy and practices applying to all team members. Further review revealed the objectives were to prevent, identify, detect, investigate, report and control infections in the center; and, maintain a safe, sanitary, and comfortable environment for team members, residents. volunteers, visitors, and the general public. Record review revealed the facility readmitted Resident #3 on 09/15/16 with [DIAGNOSES REDACTED]. Observation on 05/15/19 at 6:14 PM revealed Licensed Practical Nurse (LPN) #1 picked up Resident #3's nasal cannula off the floor and proceeded to place it on Resident #3. Interview with LPN #1 on 05/15/19 at approximately 6:20 PM revealed she should have gotten a new nasal cannula because the one on the floor was contaminated. Interview with the Director of Nursing (DON) on 05/21/19 at 7:13 PM revealed the nasal cannula should not have been put back on Resident #3 because it was dirty. Interview with Administrator on 05/21/19 at 7:48 PM revealed she expected the nasal cannula to have been changed out after staff picked it up off the floor and before placing it on Resident #3's face.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, and serve food in accordance with professional standards for food service safety. Observation of the refrigerator in the Activity Room, used for storage of residents' snacks revealed three (3) food items were not labeled and dated. In addition, a staff member failed to sanitize her hands while distributing and setting up trays for eleven (11) residents. The findings include: 1. Review of the facility policy titled, Use & Storage of Food from Outside Sources, dated [DATE], revealed foods or beverages brought in from the outside will be labeled with the resident's name, room number, and dated by staff with the current date the item(s) was brought to the Center for storage. Further review of the policy revealed staff will monitor Center refrigerators for food and beverage disposal. Observation on [DATE] at 3:35 PM, of the resident nutrition refrigerator in the Activity Room, revealed numerous opened food and drink items in the refrigerator. These items included an opened container of cranberry cocktail with no label or date when opened; an opened container of tomato juice with no label or date; and an opened jar of salsa not labeled or dated. Interview with the Dietary Manager on [DATE] at 4:00 PM, revealed the refrigerator in the Activity Room was used to store snacks for all residents. She stated the Activity Director was responsible for ensuring the refrigerator unit was kept clean, all items were dated and labeled, and expired food items were discarded. Interview with the Activity Director on [DATE] at 4:41 PM, revealed she was responsible for maintaining the refrigerator in the Activity Room. She stated all food and drink items should be labeled and dated when placed in the refrigerator. The Activity Director stated she checks it often, but had been busy and failed to do so recently. 2. Observation on [DATE] at 12:07 PM revealed the Activity Director was assisting with delivering trays on E hall without sanitizing hands between meal trays. She delivered the trays without sanitizing her hands in between delivering and setting up the meal trays for eleven (11) residents. Interview with the Activities Director on [DATE] at 3:36 PM revealed she should have used hand sanitizer between trays and washed hands if they were soiled. Interview with Director of Nursing (DON) on [DATE] 4:07 PM revealed she expected all staff to sanitize their hands between each tray passed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of one (1) sampled resident receiving oxygen was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences (Resident #254). Resident #254 was care planned and had Physician order [REDACTED]. The findings include: Review of the facility's policy titled, Clinical Nursing Skills & Techniques, not dated, revealed the procedure included to verify setting on flowmeter and oxygen source for proper setup and prescribed flow rate. Check cannula/mask every eight (8) hours and assess adequacy of oxygen flow every shift. Record review revealed the facility readmitted Resident #254 on 04/26/19 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 03/18/19, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) Score to be a fifteen (15), which indicated he/she was interviewable. Review of Comprehensive Care Plan dated 03/12/19 revealed the resident was at risk for complications due to poor endurance due to shortness of breath related to Congested Heart Failure ([MEDICAL CONDITION]) and Chronic [MEDICAL CONDITION]. Further review of the care plan revealed an intervention for staff to administer resident's oxygen therapy as ordered. Review of Resident #254's Physician Orders, dated 04/26/19, revealed staff was to administer the resident oxygen at two (2) LPM per nasal cannula continuous to maintain oxygen saturation greater than 90% and check every shift. Observation of Resident #254, on 04/30/19 at 10:18 AM and at 4:19 PM, revealed the resident was being administered oxygen at three and a half (3.5) LPM per nasal cannula instead of the ordered two (2) LPM. Interview with Registered Nurse (RN) #3 on 04/26/19 at 4:22 PM revealed Resident #254's oxygen settings should be on two (2) LPM and RN #3 did not know how it got to three and a half (3.5) Interview with the Director of Nursing (DON) on 05/02/19 at approximately 5:05 PM revealed nursing staff were expected to make rounds twice daily to check oxygen levels and PRN (as needed). The DON stated nursing staff should talk with the physician if adjustments in the oxygen level were needed and can make adjustments in an emergency, but must notify physician immediately. The DON further stated she expected the oxygen levels to be set per physicians orders unless there was an emergency.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise a resident's person-centered comprehensive care plan for one (1) of three (3) sampled residents, (Resident #1). Resident #1 had falls on 12/20/18, 12/30/18. 01/02/19, and 01/08/19, however the facility failed to revise the care plan with an intervention to try to prevent future falls. The findings include: The facility used Center of Medicare/Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated (MONTH) (YEAR), titled, Care Area Assessment and Care Planning, for Comprehensive Care Planning which revealed as required at 42 CFR 483.25, the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically. and the services provided or arranged must be consistent with each resident's written plan of care. Record review revealed the facility admitted Resident #1 on 05/24/16 with [DIAGNOSES REDACTED].#1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan (CCP) for At Risk For Falls related to Vision Degeneration, Weakness, and Difficulty Walking, dated 06/03/16, revealed interventions to assist resident as needed with one (1) staff member for all ambulation when increased weakness and fatigue and to remind resident to ask for assistance for all ambulation when feeling tired or weak. Review of a Facility Fall Investigations revealed Resident #1 had an unwitnessed fall, on 12/20/18 at 5:30 PM, which resulted in a one (1) centimeter (cm) superficial laceration to right side of head. The post fall intervention to prevent re-occurrence was to remove Resident #1's recliner. Review of a Facility Fall Investigation revealed Resident #1 had an unwitnessed fall on 12/30/18 at 5:40 PM which resulted in no injury. The post fall intervention to prevent re-occurrence was to toilet resident every two (2) hours Review of a Facility's Fall Investigation revealed Resident #1 had an unwitnessed fall in his/her room on 01/02/19 at 10:33 PM which resulted in a small hematoma to the back of his/her head. Review of the Interdisciplinary Team (IDT) post fall assessment, dated 01/03/19, revealed intervention to replace all shoes with laces to slip on shoes. Review a Facility Fall Investigation revealed Resident #1 had a fall on 01/08/19 at 8:05 PM which resulted in a two (2) centimeter (cm.) hematoma to back of head. Interview with the Director of Nursing (DON), on 03/01/19 at 1:30 PM, revealed on 01/21/19 the IDT reviewed Resident #1 falls, therapy evaluated the resident, and the IDT determined to use a seat and pull tab sensor alarms to alert staff when resident attempted to ambulate and/or transfer without staff assistance. However, review of the Comprehensive Care Plan dated 06/03/16, revealed the facility failed to add an intervention to remove resident's recliner, going to activities; to replace all shoes with laces with slip on shoes. In addition, sensor alarms were not added to care plan until 01/29/19 (twenty-one {21} days after the 01/08/19 fall. Interview with the DON, on 02/28/19 at 4:04 PM, revealed the facility put in place for the resident to be brought out of room in wheelchair, and sat in commons area across from nursing desk after the 02/18/19 fall; however, review of the comprehensive care plan revealed this intervention was not included in the care plan. The DON stated, I would expect for the staff to identify Resident #1's care needs, he/she is end stage Dementia, and changes will have to be made to accommodate the resident care needs related to repeated falls. I would expect the resident's comprehensive care plan to be reviewed and revised by the staff on unit and the IDT and to meet the resident's care needs.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents, received adequate supervision and assistive devices to prevent accidents ((Resident #1). Residents #1 sustained falls on 12/29/18, 12/24/18, 12/30/18. 01/02/19, 01/08/19 and 02/18/19; however the facility failed to identify the root cause of each fall and/or failed to put interventions in place to provide adequate supervision and assistive devices to prevent future falls. The findings include: Review of the facility's policy titled, Falls, dated (MONTH) (YEAR), revealed the policy's purpose is to establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. A fall is an unintentional change in position coming to rest on the, floor, or next lower surface either unassisted or assisted. Post fall a fall huddle is called to help in investigating circumstances around the fall and help determine immediate interventions. The post fall evaluation is completed to assist in developing and implementing interventions to prevent future falls. Record review revealed the facility admitted Resident #1 on 05/24/16 with [DIAGNOSES REDACTED].#1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7) which indicated the resident was not interveiwable. Further review of the MDS assessment revealed the facility assessed Resident #1 required minimal assistance of one (1) staff for bed mobility, transfer, ambulation in room and corridor. Review of Resident #1's Fall Risk Assessments, dated 08/16/18 revealed the facility assessed the resident as a High Fall Risk. Review of Resident #1's Comprehensive Care Plan for At Risk For Falls related to Vision Degeneration, Weakness, and Difficulty Walking, dated 06/03/16, revealed interventions to assist resident as needed with one (1) staff member for all ambulation when increased weakness and fatigue and to remind resident to ask for assist for all ambulation when feeling tired or weak even though the facility assessed the resident's cognition to be severely impaired. Review of a Facility Fall Investigation revealed Resident #1 had an unwitnessed fall, on 12/20/18 at 5:30 PM, which resulted in a one (1) centimeter (cm) superficial laceration to right side of head. The resident was sent to the emergency room (ER) for evaluation and returned to the facility after treatment. Review of Resident #1's Post Fall huddle worksheet, dated 12/20/18, revealed the facility determined the root cause of the fall was resident spilled drink in floor, when in his/her leather recliner at the bedside and leaned forward resulting in the resident sliding out of the recliner and onto floor. Post fall intervention to prevent re-occurrence was to remove Resident #1's recliner from his/her room. Interview with the Director of Nursing (DON), on 02/28/19 at 4:04 PM, the facility decided not to remove the recliner from the resident's room and Resident #1 was evaluated by Occupational Therapy (OT), on 12/21/18, and Occupation Services were not implemented. However, further review revealed there was no intervention put in place to address the resident's fall from the recliner per facility policy. Review of a Facility Fall Investigation revealed Resident #1 had an unwitnessed fall on 12/24/18 at 11:15 PM, which resulted in no injury. The resident was noted sitting on the floor in his/her bedroom between the legs of his/her walker and stated, I was going to sit in this chair (recliner) but I guess I missed and landed on the floor. Review of the facility's post fall investigation dated 12/27/18 revealed the root cause of the fall was poor vision and ambulating without assistance and/or supervision. Intervention was for physical and occupational therapy to evaluate and treat related to bilateral lower extremity weakness. However, review of Occupational Therapy Evaluation and Plan of Treatment revealed the resident was not evaluated by therapy services after the fall. Review of the Comprehensive Care plan revealed an intervention was added on 12/24/18, to add a bright colored blanket to recliner to help identify. However, there was still no intervention to address the resident getting up and ambulating without assistance or adequate supervision. Interview with the DON, on 03/01/19 at 1:30 PM, revealed the Interdisciplinary Team (IDT) met with Resident #1's daughter, on 12/27/18, regarding the resident's falls. Review of the Comprehensive Care Plan dated 12/27/18, revealed to encourage Resident #1 to utilize wheelchair. Review of a Facility Fall Investigation revealed Resident #1 had an unwitnessed fall on 12/30/18 at 5:40 PM which resulted in no injury. Review of the facility's fall investigation revealed the resident was sitting in his/her recliner, leaned forward to pick up a shoelace, slid out of the recliner and hit her head. However, review of the facility's post fall huddle worksheet revealed the facility failed to determine the root cause of the fall. The facility listed toilet every two (2) hours as intervention, however, this intervention did not address the resident leaning forward to pick something up and falling out of wheelchair. Review of a Facility's Fall Investigation revealed Resident #1 had an unwitnessed fall in his/her room on 01/02/19 at 10:33 PM which resulted in a small hematoma to the back of his/her head. The resident stated was going to see if mother would let her stay on the porch for the night. Review of the facility's post fall huddle dated 01/02/19 revealed the facility determined the root cause of the fall was a decline in condition, unsteady gait, and unawareness in safety. The facility intervention was therapy evaluation for non skid strips by resident's bed. Review of the care plan revealed on 01/03/19, Resident #1 was evaluated by therapy and non-skid strips were added to floor beside residents bed. In addition, review of the IDT post fall assessment, dated 01/03/19, revealed intervention to replace all shoes with laces to slip on shoes however, review of the Comprehensive Care Plan revealed the intervention was not added. In addition, there was still no intervention to address the resident getting up and ambulating without assistance or adequate supervision. Review a Facility Fall Investigation revealed Resident #1 had a fall on 01/08/19 at 8:05 PM which resulted in a two (2) centimeter (cm.) hematoma to back of head. Review of the facility's post fall huddle revealed the facility determined the root cause of the fall was unassisted transfer and ambulation; however, further review revealed there was no documented evidence an intervention was put in place to address the resident's unassisted transfers and ambulation. Resident #1 had to be sent to hospital for evaluation and was transferred to another hospital for higher level of care due to a fracture to the occipital region of the skull with an [MEDICAL CONDITION]. Resident #1 returned to the facility on [DATE]. Review of Resident #1's hospital medical record revealed, on 01/08/19 at 9:00 PM, the resident was transported to the Emergency Department (ED) by Emergency Medical Services (EMS). Resident #1 was evaluated by the ED Doctor at 9:11 PM and assessed by the Advanced Practice Registered Nurse (APRN) at 9:25 PM. A Computed Tomography (CT) scan of the head revealed a closed occipital bone fracture with left front minor parenchyma hemorrhage, small subdural hematoma. The critical findings were relayed to the Provider (Doctor) and Resident #1 was transported back to ED. The ED Doctor discussed CT Scan results with Resident #1 and family, informed of need to transfer to another hospital for higher level of care. Resident #1 left the local ED at 11:44 PM and was transported to other hospital (46 miles and 59 minutes travel time) by EMS. The resident was provided therapy and transitioned from using a walker to using a wheelchair. Further record review revealed the facility readmitted Resident #1 on 01/15/19 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 01/30/19, revealed the facility assessed Resident #1's cognition as severely impaired with a BIMS of five (5) which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident required limited assistance of one staff for bed mobility, transfer, walking in room and/or corridor. Review of Resident #1's Fall Risk Assessment, dated 01/15/19, revealed the facility assessed the resident as a High Fall Risk. Interview with Certified Nursing Assistant (CNA) #1, on 02/28/19 at 9:05 AM, revealed she was a CNA on unit when Resident #1 fell on [DATE]. She stated her and CNA #2 were in room [ROOM NUMBER] next to Resident #1's room (#212) during fall. She revealed the resident was impulsive with decreased safety awareness. She stated Resident #1's call light was within reach at time of the fall however, the resident never used call light to notify for staff he/she needed assistance. She revealed Resident #1's was independent with transfers however, when the resident returned to facility after hospitalization , the resident condition had declined. Interview with CNA #2, on 02/28/19 at 10:49 AM, revealed she saw Resident #1, on 01/08/19 at approximately 6:00 PM, prior to the resident's fall. CNA #2 revealed the resident required minimal assistance from staff with care needs. CNA #2 revealed although, Resident #1 was blind, he/she was able to maneuver around his/her room with minimal assistance. CNA #2 stated Resident #1 would not use call light to notify staff when assistance needed with care but would call out help instead. CNA #2 stated, that fall impacted the resident ability to care for self and he/she have declined since return from hospital. Interview with Registered Nurse (RN) #1, on 02/27/19 at 3:02 PM, revealed she was the nurse that assessed and cared for Resident #1 after the fall on 01/08/19. RN #1 stated the resident had an unwitnessed fall and she was summoned to Resident #1's room by CNA #2 and upon arrival to the room, Resident #1 was noted lying supine on the floor. RN #1 revealed the resident was unable to tell staff how the fall happened however, assessment revealed the resident needed further evaluation and treatment and was sent to the hospital. RN #1 stated Resident #1 was assessed as a high falls risk related to limited vision, decreased safety awareness, and would not use call light to notify staff of care needs. She further stated she made rounds every two (2) hours to identify resident care needs, and stated, Resident #1 has poor safety awareness and did not use call light contributed to history of repeated falls. Interview with Director of Therapy, on 02/28/19 at 1:54 PM, revealed the IDT had discussed the use of a seat belt and/or lap buddy; however, risks outweighed benefits for this resident. She stated the IDT also discussed increased level of supervision for the resident, and activity involvement for the resident. She revealed upon Resident #1's return to the facility on [DATE], the IDT reviewed the resident's history of repeated falls, therapy evaluated, and implemented sensor alarms as intervention to alert staff of resident's need for care. Interview with the Director of Nursing (DON), on 03/01/19 at 1:30 PM, revealed on 01/21/19 (six {6}days after returning from hospital) the IDT reviewed Resident #1's falls, therapy evaluated the resident, and the IDT determined to use a seat and pull tab alarm to alert staff when resident attempted to ambulate and/or transfer without staff assistance. Review of a Facility Fall Investigation revealed Resident #1 had an unwitnessed fall on 02/18/19 at 2:45 PM, which resulted in no injury. Review of the facility's post fall huddle revealed the facility determined the root cause of the fall was poor safety awareness. Further Review of the POS [REDACTED]. Observation on 02/28/19 at 4:35 PM, revealed Resident #1 sitting on the floor in front of recliner with seat sensor alarm sounding. Observation revealed two (2) staff assisting the resident off of floor and back into recliner. Observation of nurse assessing Resident #1 revealed no injury. Review a Facility Fall Investigation revealed Resident #1 had an unwitnessed fall on 02/28/19 at 4:33 PM which resulted in no injury. Review of the facility's post fall huddle revealed the root cause was the resident sitting in leather recliner and slipped out to floor. Review of the staff's intervention related to the fall was to remove Resident #1's recliner from room. Interview with the Resident #1's daughter, on 03/01/19 at 9:55 AM and the DON on 03/01/19 at 1:30 PM, revealed the facility removed the recliner from Resident #1's room, on 02/28/19, after fall on this day. Interview with the DON, on 02/28/19 at 4:04 PM, revealed the facility identified the Resident #1's recliner was problematic and contributed to at least four (4) falls. The DON stated Resident #1's family did not want the resident's recliner removed from the resident's room because the resident enjoyed sitting in it. She revealed the IDT discussed for therapy to evaluate the resident for an assistive device to the recliner to prevent slipping out however, intervention was not implemented and facility did not implement any other intervention. The DON stated the facility put in place for the resident to be brought out of room in wheelchair, and sat in commons area across from nursing desk after the 02/18/19 fall; however, review of the comprehensive care plan revealed this intervention was not included in the care plan. The DON further stated, I would expect the staff to identify Resident #1's care needs, he/she is end stage Dementia, and changes will have to be made to accommodate the resident care needs related to repeated falls.

Based on observation, interview, record review and review of the facility policy, it was determined, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, related to the failure to maintain accurate temperatures in the milk cooler and walk-in refrigerator. The milk cooler temperatures, tested throughout the survey process, registered 41 to 42 degrees Fahrenheit (F,) with the milk temperature being 36 to 45 degrees F. In addition, the walk-in-refrigerator registered at 43-44 degrees F. Review of the Census and Condition, dated 03/27/18, revealed fifty-eight (58) of (58), residents received their food from the kitchen and one of them had a gastric tube. The findings include: Review of the facility policy Refrigerator Storage, dated 01/01/17, revealed As a variety of food is stored under refrigeration, it is essential that refrigerator temperatures be low enough to safely keep the most perishable foods. Refrigerator temperatures that are consistently 38 degrees F or below will provide this safety margin, and thermostat settings recommendations is to keep refrigerator thermostats set between 34 degrees F and 38 degrees F. This will ensure a consistent food temperature of 41 degrees F or below. Review of the last three (3) months of Refrigerator and Milk Cooler temperatures charts for January, (MONTH) and (MONTH) (YEAR), revealed with no concerns. Observation of the noon meal on 03/27/18 at 11:58 AM, revealed a temperature of a milk carton, sitting in a deep pan of ice, at 45.3 degrees F. The milk had not been served to the residents, at that time and the Dietary Manager (DM) removed all milks from the dining room and told staff they could not be served. More milks were retrieved from the milk cooler and a recheck of the milk served was 36 degrees F and the milk cooler tested at 42 degrees F. Observations of the milk temperatures on 03/29/18 at 3:15 PM through 3:40 PM, revealed the milk cooler tested at 42 F and a carton of milk was tested at 43 degrees F, as well as milk obtained from the back of the cooler, which registered at 43 degrees F. Several observations of the walk-in-refrigerator thermometer, during this time, revealed temperatures at 45 degrees F. Interview with the DM on 03/29/18 at 3:20 PM, revealed she stated the cooler should be under 41 degrees, and I won't serve milk if its not 41, and stated the the walk-in-refrigerator was possibly in defrost mode. Observation on 03/29/18 at 03:51 PM revealed a recheck of the milk cooler was 41 degrees F and milk was testing at 43 degrees F. A re-check of the walk-in-refrigerator was 44 degrees F and a glass of tea from the refrigerator registered 44 degrees F. There were no milks stored in the walk-in-refrigerator. Interview with the DM on 03/29/18 at 4:00 PM, revealed the cooler may have been in need of repair and she was going to call the milk provider, who also furnishes the cooler, and the company who services the refrigerator, to see what could be done. Interview on 03/29/18 at 4:30 PM, with the Administrator and Maintenance Supervisor revealed they were not aware of any problems with the temperatures, prior to being notified today.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure resident health information was maintained in a private and confidential manner during shift report for one (1) of fifteen (15) sampled residents, (Resident #3). The findings include: Review of the facility's policy titled, Safeguarding Protected Health Information, dated 06/01/15, revealed it is the facility's policy to ensure, to the extent possible, that Protected Health Information (PHI) is not intentionally used or disclosed in a manner that would violate Health Insurance Portability and Accountability Act (HIPAA) or any other federal or state law governing confidentiality and privacy of health information. The policy revealed the following procedures shall be followed for any meeting or conversation where PHI is discussed: A. Specific types of meetings where PHI may be discussed include, but are not limited to: 1. Shift Change Report B. Meetings will be conducted in a room with a door that closes, if possible C. Voices will be kept to a moderate level to avoid unauthorized persons from overhearing Observation, on 03/01/17 at 8:55 AM, revealed Registered Nurse (RN) #1 standing at the facility's central nursing station giving shift report to an oncoming staff member. Further observation revealed two (2) visitors and a surveyor were standing at the nursing station within hearing distance while RN #1 provided PHI on Resident #3. Interview with RN #1, on 03/02/17 at 2:40 PM, revealed shift report is given at the central nursing station; however, there is a secure location at the nursing station back office that staff can use also for report. RN #1 stated she aware of visitors at the nursing station while giving report; however, she did not realize others could hear the information she was reporting. RN #1 revealed she expected herself to be aware of her surroundings while giving report to ensure the residents' privacy is not violated. Interview with Licensed Practical Nurse (LPN) #1, on 03/01/17 at 5:00 PM, revealed shift report is given to the CNA's at the nursing station. LPN #1 stated if there are visitors and/or other persons at the nursing station during shift report, she would expect the staff member reporting to stop report, address visitors and/or others, and ensure report is not given to violate a resident's privacy. Interview with the Director of Nursing (DON), 03/02/17 at 12:00 PM, revealed the facility's preference is for shift report to be given at the nursing station in order for staff to remain on the hall; however, she would expect the reporting staff member to be aware of the surroundings, to not call the residents by name, and/or reveal any identifying information that would violate a resident's privacy.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to prepare and serve food under sanitary conditions. Dietary staff failed to wash their hands and change gloves prior to returning to the tray line. Review of the facility Census and Condition, dated 02/16/16, revealed fifty-eight (58) of fifty-nine (59) residents received their meals from the facility kitchen. The findings include: Review of the facility's policy and procedure titled, Dietary Food Handling, dated 08/01/12, revealed, It is the policy of this facility to provide guidelines for the safe preparation, handling, and storage of perishable food and proper environmental cleaning. Review of the facility's policy titled, Glove Use in the Dietary Department, last revised 05/2012, revealed, Employees will: Wash their hands thoroughly before and after wearing or changing gloves. Change disposable gloves between tasks and not wear them continuously. Observation of a lunch meal tray line service, on 02/17/16 at 12:10 PM, revealed Dietary Cook #4 left the tray line service then proceeded to touch drawer and plate warmer handles, used the microwave, touched the milk cooler, then returned to tray line service and handled bread with the same gloves without changing gloves or washing her hands. Observation, on 02/18/16 at 12:30 PM, revealed Dietary Cook #1 left the tray line, went back to wash dishes and retrieved items from drawers without changing gloves or washing her hands. Interview with Dietary Cook #1, on 02/18/16 at 12:40 PM, and Dietary Cook #4, on 02/17/16 at 12:45 PM, revealed they were aware of the need to change gloves and wash hands anytime tray line is interrupted. Interview with the Dietary Manager, on 12/18/16 at 9:00 AM, revealed the cooks were aware of the need to change their gloves and wash their hands after leaving tray line and that was her expectation. Interview with the Administrator, on 02/18/16 at 3:49 PM, revealed her expectations were the kitchen staff would follow proper procedures to safe guard food handling related to changing gloves and washing hands.

Based on observation, interview and review of the facility's "Housekeeping In-Service" documentation, it was determined the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. Observation of the facility's community shower rooms revealed cracked, broken or missing tiles. Continued observation of all the shower rooms revealed a brownish to black substance on the floors and walls. Additionally, observation of the shower chairs revealed one (1) of the safety belts on one (1) chair to have a brownish to black substance on the belt. The findings include: Review of the facility's "Housekeeping In-Service" documentation revealed it the subject was titled, "7-Step Daily Washroom Cleaning" dated 05/11/00. Review of the "7-Step Daily Washroom Cleaning" documentation revealed staff were to spray sanitizer on the shower stall walls and fixtures, and wipe it down using a brush if needed. Per the documentation this killed germs, mildew and mold. Continued review revealed when cleaning the shower chairs and gurney staff were to spray with a germicide and wipe them down using a brush as needed to get into grout easier. Review of the facility's, "Cleaning Procedures" documentation dated 05/01/05, revealed a procedure titled, "Scrub Ceramic Tile" which noted staff were to use a wire or grout brush to scrub while applying the cleaning solution to the tiles. Further review of the "Cleaning Procedures" revealed a procedure titled "Bathroom Cleaning" which noted staff were to spot clean the walls. Review of the facility's "Quality Control Inspection Housekeeping" documents dated 12/10/14 and 12/15/14 revealed deep cleaning of the bathroom walls and floor on those dates was completed with no issues noted. Review of the facility's "Deep Clean" schedules for the shower rooms revealed 11/12/14 and 11/26/14 "all shower rooms" were to be deep cleaned. Review of the December "Deep Clean" schedule revealed all shower rooms were to be deep cleaned every Wednesday. Observation on 12/16/14 at 9:08 AM during the initial tour of the facility revealed the shower room on the 200 hall had tile missing on corner of the shower stall with a brownish black substance in the grout lines. Continued observation on 12/16/14 at 9:20 AM, in shower room 230 revealed a brownish black substance in the grout lines between the tiles, and a shower chair with a safety belt attached which had a brownish black discoloration on the belt. Further observation during the initial tour of the facility revealed the shower room on the 300 hall had missing grout and a cracked peeling toilet lid cover. Interview with Certified Nursing Assistant (CNA) #2 on 12/17/14 at 9:10 AM, and with CNA #3 at 12:15 PM, revealed the CNAs were unsure of what the brownish/black substance in the grout lines between the tiles was. Both CNAs stated they thought it could be mold. CNA #3 stated the brownish/black substance should not be there. CNA #2 revealed CNAs used to spray showers down after use; however, starting in October the housekeeping department cleaned the shower rooms. Per interview, CNA #3 stated there should not be cracked/missing tiles in the shower rooms, it was not homelike. CNA #3 stated the safety belt on the shower chair which had the brownish/black substance could be mold and/or feces. CNA #3 reported the shower rooms were not homelike and she would not want to personally take a shower in the shower rooms. Interview with Housekeeper #1 on 12/17/14 at 3:40 PM, revealed his job duties were to clean the shower room during routine cleaning and every Wednesday the floor tech's scrubbed the floors in the shower rooms. Housekeeper #1 revealed he had observed possible mold in the caulking and grout areas between the tiles. Per interview, the tile in the shower rooms should not be broken or missing. Interview with the Housekeeping Supervisor on 12/18/14 at 3:00 PM, revealed shower rooms were cleaned daily using the "7-Step cleaning process" which included disinfecting walls, using a machine to clean the floor tiles and a brush for the grout lines between tiles. The Housekeeping Supervisor revealed shower rooms with the brownish/black substance between the tiles and the broken or missing tiles were not a homelike environment. Per interview, the shower rooms needed to be remodeled. According to the Housekeeping Supervisor, the safety belts on shower chairs were wiped down with bleach wipes every day and every week the belts were to be replaced and the ones removed laundered. Further interview revealed her expectations were for her staff to do every day cleaning and properly follow the facility's "7-Step" procedures. She stated she did rounds all day long every day to ensure her staff were doing their jobs as assigned. Interview with the Maintenance Director on 12/16/14 at 10:00 AM and 12/18/14 at 5:35 AM revealed he and the Administrator had been talking about "re-doing" all the facility's shower rooms; however, this had not been presented to "Corporate" yet, and they were just getting estimates at that time. Per interview, he currently felt like all the shower rooms were homelike, although he would not want showers in his home to be in the condition the facility shower rooms were. Additional interview revealed he was unsure how long the tiles had been broken and depended on staff to make him aware of such issues. Interview with the Administrator on 12/18/14 at 12:47 PM, revealed the brownish/black substance should not be between the tiles in the shower rooms. Per interview, the tiles should not be broken, cracked or missing either as this was not aesthetically pleasing and one could tell they had used different colors of grout in there. The Administrator revealed the shower chair safety belt with the brownish/black discoloration should not be on the chair. She stated staff were to spray the belts with bleach after each use and her expectation was for the belts to be taken off and laundered weekly. According to the Administrator, housekeeping was responsible for removing and replacing the safety belts on the shower chairs; however, she was unsure what day this was done on. The Administrator stated she would not want the conditions of the facility's shower rooms in her home, and that was why she was going to request renovations of the rooms.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure the environment was as free from accident hazards as possible as evidenced by observation of the storage cabinets in two (2) of three (3) of the facility's shower rooms which were locked; however, had the key hung on the cabinet handle within reach of residents. Additionally, toilet bolts were observed to be exposed and uncovered for seventeen (17) of seventeen (17) resident bathrooms. The findings include: Review of the facility's policy titled, "Chemical Storage" dated 08/01/12, revealed the facility was to store chemicals in a safe manner and doors would have locks for security purposes. Interview on 12/18/14 at 4:20 PM, with the Administrator revealed this was the only chemical storage policy the facility had. Review of the facility's Census and Condition revealed of the thirty (30) residents with Dementia, eleven (11) of them could move independently about the facility. These residents included Residents #4 and #6, and Unsampled Residents A, B, C, D, E, F, G, H, I. Observation on 12/16/14 at 9:05 AM, 9:08 AM and 9:20 AM, during initial tour of the facility, revealed the 200 and 300 hall shower room cabinets were locked; however, the key was hanging on the cabinet handle within reach of residents. Continued observation revealed the 200 shower room cabinet contained one (1) container of Sani-Cloth Wipes with Bleach, one (1) bottle of Spit Shine Speed Clean and one (1) Bio-hazard Sharps disposable container halfway full. Observation of the 300 shower room cabinet revealed it contained one (1) container of Comet Bleach Cleanser, one (1) container of Dispatch Disinfectant towels with Bleach, one (1) container of Sani-Cloths with Bleach, one (1) container of Bar Keepers Friend polish and cleaner, twenty-one (21) razors, a Bio-hazard sharps disposable container half way full, and one (1) bottle of Shout Triple Action spray. Review of the Material Safety Data Sheet (MSDS) for the Sani-Cloth with Bleach wipers revealed: to keep out of reach of children; avoid contact with eyes and skin; and the product might cause irritation to the gastrointestinal tract if swallowed. Further review of the MSDS revealed to contact poison control if ingested. Review of the MSDS for the Spit Shine Kleen and Burnish product revealed: it might be harmful if swallowed, could cause gastric distress and a blockage; might cause skin and eye irritation; and to keep out of reach of children. Review of the MSDS for the Bar Keepers Friend product revealed it contained a hazardous ingredient, oxalic acid (a poisonous crystalline acid with a sour taste used for bleaching and cleansing) which could cause eye and skin irritation and was harmful if swallowed. Review of the MSDS for the Dispatch Disinfectant with Bleach towels product revealed it caused gastrointestinal irritation if swallowed and eye irritation if it came in contact with the eyes. Review of the MSDS for the Shout Stain Remover product revealed it was harmful if swallowed and caused eye and skin irritation. Further review revealed to get medical attention immediately. Review of the MSDS for the Comet Bleach Cleanser product revealed ingestion could cause gastrointestinal irritation and if ingested to seek medical attention. Further review revealed the product was considered a hazardous chemical. Interview with Certified Nursing Assistant (CNA) #3 on 12/17/14 at 12:15 PM, revealed residents could reach the key to the shower room cabinet and possibly open the cabinet and access the items stored in it. Per interview, the key should not be hanging on the cabinet handle, as it was supposed to be hung on the hook in the back of the cabinet which was up high. CNA #3 stated the items stored in the shower room cabinets would be hazardous to residents. Interview with the Director of Nursing (DON) on 12/18/14 at 4:45 PM, revealed it was her expectation for staff to hang the key to the shower room cabinets up high and out of reach of residents. The DON stated staff should not hang the keys on cabinet handles accessible to residents after completing showers. Interview with the Administrator on 12/18/14 at 12:47 PM, revealed her expectation was for staff to ensure the shower room cabinets with chemicals were locked and the key hung out of residents' reach so they couldn't access the chemicals. Further interview revealed the facility had never had any incidents of residents accessing the chemicals; however, now that a concern had been identified the facility had improved their practice/process to further protect the residents. 2. Observation on 12/16/14 beginning at 9:00 AM, revealed seventeen (17) of seventeen (17) resident bathrooms had uncovered and exposed toilet bolts. Interview with the Maintenance Director on 12/18/14 at 5:35 PM, revealed safety would be an issue with the toilet bolts uncovered and exposed, as it could cause a possible injury to residents with the bolt covers missing. Additional interview with the Administrator on 12/18/14 at 12:47 PM, revealed there was a potential for a resident to be injured with the toilet bolts uncovered and exposed depending on the situation. The Administrator stated that was why they made the bolt covers. Per interview, it was her expectation for the toilet bolts to have covers over them.