Every finding on record at Havens at Pensacola, The

Based on observations, interviews, record review, and review of the facility policies and procedures, the facility failed to follow infection prevention and control standards including hand hygiene, proper use and ready availability of Personal Protective Equipment (PPE) and storage of oxygen tubing, to prevent the spread of infections by staff involved in direct resident care in 3 of 4 residents observed. (Resident #13, #85, #131)The findings include:1. An observation was conducted outside of Resident #13's room on 5/31/26 at approximately 2:00 PM. It was noted that two signs were posted on the room door, one for contact precautions and one for enhanced barrier precautions (EBP). A personal protective equipment (PPE) cart was located outside the room door; however, closer observation revealed it was out of isolation gowns. (Photographic evidence obtained)An interview was conducted with Staff D, Certified Nursing Aide (CNA) on 5/31/26 at approximately 2:00 PM. After independently inspecting the PPE cart, Staff D confirmed that there was no isolation gowns stocked in the cart. She stated that, when gowns are unavailable and resident care is needed, she would obtain an isolation gown from another PPE cart. After walking to the room another resident who was on EBP precautions and checking that PPE cart, Staff D observed that this cart was also out of isolation gowns. Staff D then proceeded to go to the clean storage room to restock the PPE carts. However, upon entering the clean storage room, Staff D noted this was out of isolation gowns as well. She further explained that she would need to go to the facility's main supply room to restock the gowns.An observation was conducted on 5/31/26 at approximately 3:00 PM of the PPE cart located outside Resident #13's room. It was observed that the PPE cart had been restocked with isolation gowns. Upon entering Resident #13's room, Staff D was observed completing incontinence care to the resident. During this observation, it was noted that Staff D was not wearing the required isolation gown while providing incontinence care to Resident #13 even though Resident #13 was ordered to be on contact precautions and EBP.An interview was conducted with Staff D on 5/31/26 at approximately 3:00 PM following this observation. Staff D confirmed that she was providing incontinence care to Resident #13 without wearing the appropriate PPE/isolation gown as required. She stated that she is aware of the PPE requirements under EBP during resident contact care. She stated that she understood the infection control concerns associated with the failure to do so and added that she had received infection control and PPE education during onboarding when she started at the facility in March 2026.An interview was conducted with Staff B, Registered Nurse (RN) Supervisor on 5/31/26 at approximately 3:05 PM. Staff B confirmed that Resident #13 required appropriate PPE, including isolation gowns, during resident contact care, and that it was the facility's expectation for staff compliance with all infection control practices.An interview was conducted with Resident #13 on 5/31/26 at approximately 3:15 PM. Resident #13 recalled that Staff D had just finished providing her with incontinence care and confirmed that Staff D did not wear a gown during the task. She added that the staff did not always wear gowns while assisting her with care.Review of Resident #13's medical record revealed that she had a stage 4 sacral wound culture positive for MRSA (Methicillin-resistant Staphylococcus aureus-a highly contagious bacterial infection that is resistant to many common antibiotics). Resident #13 was identified as being at risk for complications of infection, and EBP was identified as an intervention to mitigate this risk. Further review of the wound care order dated 5/13/26 and 5/27/26 revealed Cleanse sacral wound with Washe and pat dry. Apply Hydrofera Blue to wound bed. Change outer wound dressing to sacrum with bordered foam daily. Cleanse peri wound at 5 o'clock with normal saline and apply Triad paste daily.A wound care observation was conducted for Resident #13 on 6/1/26 at approximately 2:24 PM. Staff C, Registered Nurse (RN) and Staff H, Certified Nursing Assistant (CNA) were present for this observation. After washing hands with soap and water, Staff C donned the appropriate PPE, including an isolation and gloves. Staff C prepared a single cup with wound Washe (a sterile 0.9% sodium chloride [or saline] solution) and Triad paste (zinc oxide-based wound dressing that creates a protective, moisture-retentive barrier). Staff C then gathered the following supplies: sterile 4x4 gauze and a foam dressing. Staff H failed to perform hand hygiene prior to donning PPE and providing resident care. Both staff assisted in providing bowel incontinence care. Staff C then removed the old/contaminated wound dressing from the MRSA positive wound located on Resident #13's sacral area. Staff C then placed the old dressing into the old incontinence brief and placed both items inside of a regular clear garbage bag. Staff C then changed her gloves without performing hand hygiene. Staff C cleansed the sacral wound per physician order with wound Washe. She applied Triad paste to the sterile 4x4 gauze, placed it inside the wound, and covered it with a bordered foam dressing. The ordered Hydrofera Blue dressing (a highly absorbent, antibacterial foam dressing designed to promote moist wound healing) was not applied as prescribed. Upon completion of the treatment, both staff removed their PPE and performed hand hygiene. Staff C then picked up the clear plastic garbage bag containing the contaminated dressing with her bare hands and transported it to the soiled utility room, where it was discarded into the main garbage rather than a biohazard waste bag, failing to ensure proper disposal of contaminated materials and prevention of potential cross-contamination related to MRSA.An interview was conducted with Staff H on 6/1/26 at approximately 2:56 PM following the observation. Staff H acknowledged not performing hand hygiene prior to donning PPE and assisting with Resident #13's care. She stated that she forgot to do so and recognized it was her mistake.An interview was conducted with Staff C on 6/1/26 at approximately 2:59 PM following the observation. Staff C acknowledged that, after providing incontinence care and removing the dressing, she changed her gloves but failed to perform hand hygiene. After reviewing the culture result in the medical record, Staff C confirmed the sacral wound was positive for MRSA. She acknowledged that the contaminated dressing was discarded in a regular garbage bag instead of a biohazard waste bag. After reviewing the active wound care order, she acknowledged that she forgot to apply the Hydrofera Blue dressing as ordered and instead applied a 4x4 sterile gauze. She explained that she became distracted by the incontinence care that was required and forgot to apply the ordered dressing. She stated that she received infection prevention education at least annually and understood the concerns related to cross contamination during the task.An interview was conducted with the facility's Director of Nursing (DON) on 6/2/26 at approximately 1:47PM. The DON explained that her expectations for staff prior to performing wound care was to perform hand hygiene before and after the procedure, review the wound care orders, and gather all the appropriate supplies according to the physician's order.2. An observation was conducted for Resident #131 on 6/1/26 at approximately 1:59 PM. Resident #131 was observed with a dialysis Central Venous Catheter (CVC-a plastic tube inserted into a large vein in the neck, chest, or groin to provide immediate blood access for hemodialysis). Resident #131 was identified as being on EBP as evidenced by signage posted on the room door and PPE supplies available on the PPE cart. During incontinence care provided by Staff K, Licensed Practical Nurse (LPN), and Staff L, LPN, it was observed that neither staff member donned an isolation gown as required under the EBP precautions for resident contact care.An interview was conducted with Staff K on 6/1/26 at approximately 2:05 PM. Staff K acknowledged that Resident #131 was on EBP precautions and that she was not wearing the appropriate PPE, specifically an isolation gown, while performing the incontinence care. She further explained that it was the facility's expectation for staff to utilize appropriate PPE when indicated by appropriate isolation signs. Staff K also stated that she understood dialysis residents with CVC access were at increased risk for infection.An interview was conducted with Staff L on 6/1/26 at approximately 2:05 PM. Staff L acknowledged not wearing the required isolation gown during incontinence care for Resident #131, who was on EBP.3. An observation was conducted of Resident #85 on 5/31/26 at approximately 4:51 PM. Resident #85 was observed self-propelling from the dining room to her room with an indwelling catheter bag observed hanging below her wheelchair. Closer observation revealed Resident #85 had a dialysis CVC. Observation of Resident #85's room door revealed there was no EBP signage posted on the door and no PPE cart available outside of the room. (Photographic evidence obtained)An observation was conducted of Resident #85 on 6/1/26 at approximately 8:08 AM. Resident #85 was observed sitting in her wheelchair with a portable oxygen tank attached. The oxygen tubing was observed wrapped around the wheelchair's handle and uncovered (Photographic evidence obtained). The resident's nebulizer treatment mask was observed sitting uncovered on the bedside table. Additional oxygen tubing was observed wrapped around a teddy bear on Resident #85's bed and uncovered (Photographic evidence obtained). During this observation, it was noted that no EBP signage was posted on the room door and no PPE cart or supplies available for staff use outside the room.An observation was conducted of Resident #85 on 6/2/26 approximately 8:00AM. Resident #85's oxygen tubing for the portable oxygen tank attached to the wheelchair remained wrapped around the wheelchair's handle, uncovered. Additionally, there continued to be no EBP sign posted on the room door and no PPE cart available outside the room. (Photographic evidence obtained)An interview was conducted with Resident #85 on 5/31/26 at approximately 3:00 PM. Resident #85 explained that she was on dialysis and had recently undergone a procedure to receive the new CVC access in her right chest, as well as an indwelling catheter related to a chronic kidney condition. She further explained that she has been hospitalized many times recently due to kidney complications and recurrent infections.A follow up interview was conducted with Resident #85 on 6/1/26 at approximately 8:08 AM. Resident #85 explained that, during catheter care, staff wore gloves but that the use of isolation gowns was inconsistent.An interview was conducted with the facility's DON on 6/2/26 at approximately 11:25AM. The DON explained that Resident #85 was admitted during a holiday weekend and the omitted EBP signage and PPE cart was an oversight by the facility. She explained that the Infection Preventionist monitored and initiated EBP throughout the facility. She further stated that any nursing staff could initiate and implement isolation precautions for a resident. She confirmed that Resident #81 was a newly admitted dialysis patient with CVC access and an indwelling catheter, which placed her at an increased risk for infection and that EBP should have been initiated upon admission. The DON independently observed the uncovered oxygen tubing wrapped around the wheelchair's handle and stated that it should have been secured and in a bag while not in use. She further stated that it was the facility's expectation, regarding infection control prevention, for nebulizer masks and oxygen tubing to be stored in a dated bag while not in use.An interview was conducted with the facility's Infection Preventionist on 6/2/26 at approximately 2:20PM. He stated that he placed the EBP sign on Resident #85's door and the PPE cart that day. He acknowledged that Resident #85 was at high risk for infections. He explained that if he was not on site, the nursing staff should initiate the isolation precautions and that they had been educated to do so. He confirmed in the case of Resident #85, it was an oversight. Regarding the uncovered nebulizer mask and oxygen tubing, he stated those items should always be placed in a bag when not in use. He acknowledged that those failed practices placed the residents at risk of infection. Review of Resident #85's medical record revealed the resident was re-admitted to the facility with a history of recent sepsis, as a new dialysis patient with CVC access site and an indwelling urinary catheter. Resident #85 was identified as being at risk for complications of infection, with EBP identified as an intervention. Further review of physician orders revealed an electronic order for EBP was entered on 5/27/26.Review of the facility's policy titled Administrating Medications through a small Volume Nebulizer (last revised 1/26) revealed that, when the nebulizer treatment is completed, the equipment will be rinsed and disinfected. Once dry, it will be stored in a plastic bag labeled with the resident's name and date.Review of the facility's policy titled Enhanced Barrier Precautions (last revised 1/26) revealed, EBPs our infection prevention and control interventions intended to reduce the transmission of multidrug resistant Organism (MDRO) during high contact resident care activities. residents with wounds or indwelling medical devices including central lines and urinary catheters. The policy further revealed that EBPs required the use of gowns and gloves in addition to standard precautions during high contact resident care activities. Gloves and gowns are to be donned prior to resident care and changed before caring for another resident. Examples of high contact care activities included changing briefs, device care, and wound care involving any skin opening requiring a dressing. The policy further revealed that staff were trained on EBP prior to caring for residents, and signs were posted on the door or wall outside the residents' rooms to communicate the type of precaution and personal protective equipment required. PPE equipment and alcohol-based hand rub are readily accessible to staff.Review of the facility's policy titled Dressing, soiled/contaminated (last revised 1/26) revealed, Soiled dressings that are heavily soiled with exudate or drainage or from a resident with an infectious condition must be placed in specially designed by your hazard containers for disposal. Gloves must be worn when changing your dressing and/or when handling items contaminated with blood, body fluid or potentially infective materials.Review of the facility's policy titled Dressings, dry/clean (last revised 1/26) revealed guidelines for dressing applications. The wound care procedure preparation and steps included reviewing the residents care plan, current orders, and treatment record; assembling the required equipment and supplies, including clean dressings, PPE, gowns, gloves, mask, etc., as needed. The procedure steps included:5-Wash and dry hands thoroughly.6-Put on clean gloves Loosen tape and remove soiled dressing.7-Pull glove over dressing and discard into plastic or biohazard bag8-Wash and dry hands thoroughly.9-Open dry, clean dressing(s)10-Label tape or dressing with date, time and initials. Place on clean field.12-Wash and dry hands thoroughly.13-Put on clean gloves.15-Clean the wound with ordered cleanser.16-Use dry gauze to pat the wound dry.17-Apply the ordered dressing and secure with tape or bordered dressing per order.18-Discard disposable items into the designated container.

Based on observations, interviews, and record and policy review, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication error rate of 8% (2 errors out of 25 opportunities). The findings included: A medication administration observation was conducted with Staff I, Licensed Practical Nurse (LPN) on 6/1/26 at approximately 8:15 AM. Using the electronic medical record, Staff I prepared Resident #81's medications. Staff I was observed retrieving one Olmesartan/amlodipine/hydrochlorothiazide 40/10/25 milligram (mg) tablet (a combination medication used to treat high blood pressure) and one Meclizine 25mg tablet (a medication used to treat dizziness) and placing them into a medication cup. Staff I entered Resident #81's room and placed the medication cup onto the resident's table and stated to Resident #81 here's your medication. The surveyor intervened before Resident #81 ingested the medications and encouraged Staff I to review Resident #81's physician orders. Review of Resident #81's physician orders revealed the order for Olmesartan/amlodipine/hydrochlorothiazide 40/10/25mg included instructions for the staff to give one tablet by mouth daily. Hold if systolic blood pressure is less than 100 for high blood pressure. Further review of the physician orders revealed the order for Meclizine was written for 12.5mg, not 25mg as Staff I was prepared to administer. (Photographic evidence obtained.) An interview was conducted with Staff I on 6/1/26 at approximately 8:30 AM following the observation. Staff I confirmed she was prepared to administer the medications as she had set up. Staff I stated she was unaware of Resident #81's blood pressure status prior to the medication administration observation. Staff I independently reviewed Resident #81's clinical record and stated the last blood pressure had been obtained on 6/1/26 at 6:00 AM. She reviewed the Meclizine label and confirmed it read 25mg. Staff I stated she was unaware the Meclizine she had prepared to administer was the wrong dosage. Staff I confirmed that Resident #81's blood pressure should have been obtained prior to administering the Olmesartan/amlodipine/hydrochlorothiazide. An interview was conducted with Staff J, Unit Manager on 6/1/26 at approximately 9:15 AM, Staff J stated it was her expectation that medications were to be administered according to the physician orders. Staff J stated that required vital signs were to be obtained and nurses were to check the medication for correct dosage prior to administration of any medication.A review of Resident #81's Comprehensive Care Plan included a care plan focus area for at risk for fluctuation in blood pressure with an intervention which instructed staff to administer medications as directed. (Photographic evidence obtained.)A review of facility's policy titled Administering Medications (dated 1/2026) revealed: Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label (3) times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. (Photographic evidence obtained.)

Based on review of the electronic medical record (EMR) and staff interviews, the facility failed to maintain complete and accurate documentation of the consent and administration for immunizations for 4 out of 5 residents sampled. (Resident #32, #46, #100, #261) The findings include: On 3/5/25 at approximately 11:00 AM, a review of vaccination consents and administration forms in the EMR was conducted with the Infection Control Nurse (ICN). The record revealed the consent form for Resident #58 did not have a completion date of the administration, nor did it have the vaccine lot number and expiration date. Resident #46 did not have a vaccine lot number or expiration date recorded. For Residents #100 and #261, the consent form did not have date the consent was offered and declined by the residents recorded. On 3/5/25 at approximately 12:05 PM, an interview was conducted with the ICN concerning why the dates, vaccine lot numbers and expiration dates where not recorded on the consent forms. The ICN indicated she was not certain why the information was not recorded on the consent form and agreed that it should have been documented. 03/06/25 at approximately 1:52 PM, an interview was conducted with Director of Nursing (DON). She stated that obtaining vaccine consent or refusal was a part of the facilities admission process, the forms would be uploaded to the EMR showing this was done on admission. On 03/05/25 review of the facilities vaccine policy titled Influenza Vaccine last revised March 2022 was conducted. Which revealed under section 5 For each resident who receives the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's medical record.

Based on observations and interviews, the facility failed to post the required staffing data in a prominent place readily accessible to residents and visitors. The findings include: On 12/11/23 at 11:00 AM, an initial tour of the 100 Hall was conducted. There was no visible daily staffing observed throughout the unit. There was a daily staffing sheet inside the nourishment room that had the name of nurses and Certified Nurse Assistants (CNAs) working in each of the 4 units and the facility total census. The sheet did not contain the census per unit nor the rooms assigned to staff. On 12/11/23 at 11:10 AM, an interview was conducted with Staff D, a Licensed Practical Nurse (LPN), that was working in the 100 Hall. She indicated that the facility used to have large boards at the nurse station that were visible to residents and family members but they were taken down months ago. Staff D stated she was unsure of the reason for the boards being taken down and verified that the only daily staffing information was the sheet inside the nourishment room that was available for staff only. On 12/12/23 at 12:30 PM, an interview was conducted with Staff E, another LPN. She stated the facility did not keep the daily staffing listed visible for residents and families because family members were harassing staff. She further stated that visitors would be calling staff by their names and trying to find them while staff were busy. On 12/12/23 at 5:04 PM, an interview was conducted with the Director of Nursing (DON). She was asked the reason the facility did not have visible daily staff assignments. She stated the facility was following company's protocols. She further stated she thought there was a daily staffing sheet on the bulletin board located at the entrance of each unit. On 12/13/23 at 9:32 AM, an interview was conducted with the Assistant Director of Nursing (ADON). She stated the facility posted the daily staffing on the bulletin board located at the entrance of each unit. Surveyor verified with Assistant Director of Nursing ADON that the form (8x12 inches sheet) neither included the unit's census nor the room assignments. Staff G, ADON replied that this was how it was done at the facility. On 12/13/23 at 10:00 AM, an interview was conducted with Staff E, LPN. She confirmed Administration placed the daily staffing sheet on the bulletin board after the surveyors brought it to their attention. She further stated that the facility should still place the big boards back, so staffing can be visible to residents and families, because some residents were not able to read the flyer on the bulletin board. 47306 On 12/11/23 at approximately 11:40 AM, an initial tour was conducted of the 300 Hall. The 300 Hall and unit area were observed for a daily staffing posting site. The daily staffing posting was found behind the nurses' station and within the nourishment area posted on a bulletin board. The staffing sheet was hanging from a bulletin board within a transparent page protector sleeve. The location of the staffing sheet was not visible to residents or visitors. The daily staffing sheet listed the names of nurses and Certified Nursing Assistants (CNAs) working in all 4 units and the total facility census. The staffing sheet did not list the census in each unit or the room numbers assigned to listed staff. On 12/11/23 at approximately 11:53 AM, an interview was conducted with Staff S, a Unit Assistant, regarding posting of staff each day. Staff S indicated the staffing is posted on the bulletin board at the beginning of each week. Staff S was asked if the staffing is posted any other place on the unit for residents and visitors to view. Staff S indicated she does not know of any other place the staffing would be posted. On 12/11/23 at approximately 1:44 PM, an observation was made of the 400 Hall to locate the posted staffing for the current day. The 400 Hall Unit did not have any visible staff postings. The staffing post was located on a bulletin board behind the nurses' station adjacent to the nourishment area. The staffing sheet was located within a transparent sleeve page protector. The sheet listed the names of Nurses and CNAs working in all 4 units and the total facility census. The staffing sheet did not list the census in each unit or the room numbers assigned to listed staff. On 12/12/23 at approximately 3:32 PM, an interview was conducted with the Director of Nursing (DON) regarding how facility posts staffing in each unit for residents and visitors to view. The DON indicated the staffing list is located at the nurses' station and visitors can always ask who is providing care to residents. The DON indicated she was not aware the staffing had to be posted for residents and visitors to view.

Based upon record review, resident interview and staff interview, the facility failed to ensure that a resident's preferred advanced directives were documented for 1 of 2 residents reviewed for advanced directives. (Resident #22) The findings include: On [DATE], a record review was conducted for Resident #22. The resident's electronic record contained an order for a Full Code dated [DATE]. However, the resident had a Living Will dated [DATE] which indicated the resident did not want Cardiopulmonary Resuscitation (CPR). On [DATE] at approximately 1:22 PM, an interview was conducted with Resident #22. The resident was asked if they she wanted CPR should she need it. The resident stated she did not want CPR and the facility was made aware that they are to let her go peacefully as per her living will. On [DATE] at approximately 1:33 PM. an interview was conducted with Staff J, a social services case manager. When asked to review the resident's orders and the resident's living will, the staff member verbally agreed the resident had an order to be a full code and the residents's living will documented the residents wish to not have CPR. On [DATE] at approximately 10:57 AM, an interview was conducted with staff K, a long term care social worker. When asked how she ensures the residents advanced directives are up to date, the staff member stated she goes over the advanced directive quarterly, annually, and when there are significant changes. The advanced directives are reviewed with the resident and family members during the care plan meetings. The staff member reviewed the residents orders and living will and verbally agreed there was a conflict in the information.

Based on observation, record review, policy review and interviews, the facility failed to develop a comprehensive care plan for 2 of 4 residents sampled. (Residents #22 and #21) The findings include: Resident #22 On 12/12/23 a record review was conducted for Resident #22. The resident had Advanced Directives which included a code status of full code (a full code indicates the resident is to receive cardiopulmonary resuscitation in the event of cardiac and or respiratory arrest). A review of the plan of care was conducted as part of the record review. The plan of care did not address the residents Advanced Directives or code status. On 12/14/23 at approximately 1:38 PM, an interview with Staff L, a minimum data set (MDS) coordinator for long term care, was performed. Staff L stated she ensures resident's care plans are comprehensive and up to date by communicating with the interdisciplinary team for significant changes and in morning meetings. Staff L stated the facility never included advanced directives in the care plans to her knowledge. On 12/14/23 at approximately 1:42 PM, an interview with staff M, an MDS coordinator, revealed that the facility does not have advanced directives in the care plan library in the electronic record program. The MDS staff was not aware of this until it was brought to their attention on 12/13/23. A review of the policy Advanced Directives 2001 states, .the director of nursing services or designee will notify the attending physician of advanced directives so that appropriate orders can be documented in the residents medical record and plan of care . 43857 Resident # 21 On 12/11/23 at 1:22 PM, Resident # 21 was observed with cloudy urine in their urinary catheter. On 12/13/23 at 9:07 AM, an observation of Resident #21 revealed there was not a visible urinary catheter. On 12/13/23 at 1:24 PM, Resident #21 had a urinary catheter securely in place below the bladder which had yellow clear urine. On 12/11/23, a review of Resident # 21's electronic medical record (EMR) revealed no active orders for a urinary catheter. The current comprehensive plan of care revealed no goals and interventions for a urinary catheter. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no urinary catheter care and services were documented during December 2023. An order summary review revealed Resident # 21 had a physician order to insert a foley (urinary) catheter one time only for wound healing for one day dated 10/2/23. There were no other orders for urinary catheters after this date. The most recent Minimum Data Set (MDS) dated [DATE] indicated Resident # 21 had an indwelling catheter. On 12/13/23 at 10:10 AM, an interview was conducted with the Assistant Director of Nursing (ADON). She stated Resident # 21 pulled out her urinary catheter the previous night. On 12/14/23 at 11:38 AM, an interview was conducted with the Director of Nursing (DON). The DON reviewed Resident # 21's EMR and confirmed there was not an active order for a urinary catheter. She further stated it could be a verbal order written on Resident # 21's chart. The DON reviewed Resident # 21's paper chart and there was no orders for urinary catheters present. On 12/14/23, a follow-up review of Resident# 21's EMR revealed a new order that read replace foley (urinary) catheter dated 12/13/23 at 11:46 AM. A verbal written order was later provided by the DON that read replace foley catheter for urinary retention dated 12/13/23 at 10:37 AM. On 12/15/23 at 11:22 AM, an interview was conducted with Staff L, a Minimum Data Set (MDS) coordinator. Staff L stated she had corrected the care plan today by adding urinary catheter goal and interventions. She further stated Resident #21 was previously care planed for urinary catheter with a revision date of 9/18/23 but had been discontinued because Resident # 21 did not have an active order for a urinary catheter. A review of the facility policy titled Care Plans, Comprehensive Person-Centered was conducted, revised December 2016 was reviewed. This policy stated, The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and The comprehensive, person-centered care plans are revised as information about the residents and the resident's conditions change.

Based on observation, interview, and review of records the facility failed to maintain a method of communication for residents to call a staff member from the bedside and bathrooms in 1 of 4 resident care units at the facility. The findings include: On 12/11/23 at approximately 1:18 PM during the initial tour of the facility, an interview was conducted with Resident #67. Resident #67 was asked to describe care and services at the facility. She immediately reported that she has no way to call for assistance when she needed help. The resident explained that the call button at her bedside had not been working for some time. She reported that she previously had a bell; but the push bell has been missing for some time. She has been looking for the bell has not been able to locate it. The surveyor attempted to activate the call bell that was attached to Resident #67's bed, but it did not work. The surveyor proceeded to test call bells in each of the other rooms and bathrooms in the memory care area. None of the call buttons worked. On 12/11/23 at approximately 1:23 PM, Staff Member A, a Certified Nursing Assistant (CNA) was notified that the call buttons were not working in the resident rooms. She explained that the call systems in the building were in the process of being repaired. She mentioned that repairs were being done unit by unit but that they had not gotten to the memory care unit yet. Staff Member A asked Resident #67 if a replacement push bell was in her drawer. Resident #67 explained that she has been looking all over her room and had not located the push bell anywhere in the room. On 12/11/23 at approximately 1:33 PM Staff B, a Licensed Practical Nurse (LPN) came into the room with a handful of push bells. She provided a bell for Resident #67 to use. Nurse B placed push bells at the bedside in each room in memory care. She explained that she does not know why the residents do not have push bells to replace call bells while the call system is not working. On 12/14/23 at approximately 11:47 AM an interview was conducted with the Building Facility Manager regarding the call system not functioning on the memory care unit. He explained that repairs on the call system had been ongoing in the upstairs units. When the repairmen disconnected the system upstairs, both the upstairs and downstairs call systems were controlled by the same control box. The Building Facility Manager explained that he does not think the repair men working on the system realized that they also disconnected the call system downstairs. He explained that the call system has been worked on for the past few weeks. He was asked whose responsibility it was to ensure the residents have a means to call for help. He explained that the CNA's, Nurses, and Maintenance staff work together to pass out bells when the system is down. A copy of the invoice for repairs was requested for review. The Building facility Manager provided an email stating that the project had been initiated on 11/2/23 and should be completed by 1/5/24. On 12/14/23 at approximately 2:00 PM an interview was conducted with the Director of Nursing (DON) regarding the call system. She explained that they have been working on the call system for quite some time. She explained that a census was taken and rooms were checked to ensure safety after it was brought to their attention that the call system was not working. The DON was asked to explain what was being done to ensure that the residents are able to call for help while repairs are in progress. She said that they are frequently monitoring the residents to ensure resident safety. The DON did not provide specific information regarding who is responsible for checking the residents. She did not provide information about how frequently the residents were being checked. The surveyor requested information regarding the date that monitoring was initiated, frequency of monitoring to ensure residents have access to call bell, and any documentation of the monitoring, and any staff training regarding checking the call system for functioning. The DON explained that she would get the Facility Administrator (FA) to provide this information. On 12/14/23 at approximately 2:30 PM an interview was conducted with the DON and the FA. The FA was asked to explain what was being done to ensure that residents at the facility have continuous access to call for help. The FA explained that the call system is being fixed and the process takes time. She explained that frequent checks and frequent rounding is being completed to ensure access to call for help. The surveyor asked who is responsible for checking on the call system. The FA explained that CNA's, nurses, therapy staff, hospitality staff, and housekeeping staff participate in randomly checking to ensure that the call system is working. The surveyor asked if there are specific times staff are checking to ensure the system is intact. The FA was asked to further explain the process for monitoring to ensure the call system is always functional while repairs are being completed. The FA was asked to provide documentation that the frequent checks were occurring, documentation of staff training regarding a specific process for checking the call system during repairs. On 12/14/23 a review of the Daily Clinical Meeting Agendas provided by the DON was conducted. The Daily Clinical Meeting Agenda from 9/21/23 was signed by 8 staff members The minutes stated that the new call system was approved and was discussed. The Daily Clinical Meeting Agenda from 10/10/23 signed by 8 staff members stated that there was discussion regarding call light updates. The Daily Clinical Meeting Agenda from 11/22/23 signed by 7 staff members stated that there was discussion regarding call bell system updates. The Clinical Meeting agendas did not provide specific information regarding the process frequent checks during call system repairs. During the survey, the facility did not provide specific information regarding any processes for checking the integrity of the call system. Documentation of call system monitoring was not provided. The training provided by the facility did not provide staff with specific information regarding maintenance of a functional call system while the system was being repaired.

Based on observation, record review, and interview the facility failed to honor resident's rights to be treated with respect and dignity, and to be free from any physical or chemical restraints imposed for discipline or convenience, for 1 of 1 resident reviewed for restraints (#45). Findings include: On June 7, 2021, between approximately 10:30 AM and 11:15 AM, resident #45 was observed sitting in a wheelchair with a lap belt (a seat belt type device that if a resident cannot remove independently is considered a restraint) secured around her waist, in the common area of the Memory Care Unit on Serenity Hall. On June 7, 2021, at approximately 2:46 PM, a follow up observation was made of resident #45, who remained sitting in her wheelchair with the lap belt secured. On June 8, 2021, at approximately 9:00 AM, resident #45 was observed, sitting in her wheelchair with the lap belt secured. No distress was noted with resident's behavior. No observation was made of attempts by resident #45, to stand up or remove the device. On June 8, 2021, between 1:45 PM and 2:00 PM, resident #45 was observed sitting in her wheelchair with the lap device in place and secured. On June 8, 2021, at approximately 2:05 PM, an interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) staff C. She said, If (resident #45) has a lap belt, then she is probably capable of taking it off and maybe stand up. The unit manager can tell you about it. There has to be an order by the Physician or Nurse Practitioner. I would have to look at her chart to be more accurate. We don't have many residents with restraints that I know off. On June 8, 2021, between approximately 2:20 PM and 3:00 PM, Resident #45 was observed sitting in a wheelchair with the lap device secured. During this observation an interview was conducted with 3 staff on duty, staff A, Licensed Practical Nurse (LPN), staff B, Certified Nurse Assistant (CNA), and staff F, CNA. Staff B, asked resident #45 to open her lap belt. Staff B, instructed the resident to open her belt, gave no other instructions. After 8 minutes resident #45 was unable to open her belt. All 3 staff members were asked if they had observed resident #45 removing the lap belt since being admitted to unit. Staff B immediately said, No. I have never seen her open it. Staff F said, No, I have not seen (resident #45) do that. Doesn't try to get out of her chair. Staff A said, I have seen (resident #45) get out of it before. On June 8, 2021, at approximately 3:05 PM, an interview was conducted with staff E, Rehabilitation Director. She said, Most of the time when a new patient comes in, if they have issues, we do a screen. We do quarterly screening, and we do the screen to see if there is anything we need to address. Complete an assessment as a walk by, for a decline, fall, quarterly screen, one of those things. We document how they transfer if walking with assistance with a walker or unable to perform. As far as I can see (resident #45) was not triggered for us to assess. We have not had any orders for resident #45. On June 8, 2021, at approximately 4:00 PM, an interview was conducted with staff D, Registered Nurse/Unit Manager (RN/UM). She said, We put (resident #45) in another wheelchair, they can't lock her in that, as it's a restraint. We took (resident #45) out of it. I have not seen (resident #45) with the belt on, only locked at the back of the chair. Somebody thought they could use it. On June 8, 2021, at approximately 4:20 PM, an interview was conducted with staff G, LPN. She said, I can't recall seeing the lap device on (resident #45), maybe saw it on once. (Resident #45) does not try to get out of the chair. Staff H, CNA, said, I did not know (resident #45) had it (Lap Belt), don't recall seeing it. On June 9, 2021, at approximately 7:10 AM, an interview was conducted with the Director of Nursing (DON) regarding the Lap Belt. He said, We started restraint education yesterday. It should never have happened. We rarely use these devices. I don't know how we missed it. If we had seen the lap belt we would have assessed (resident #45) immediately. Our expectations are, any admitted resident that has equipment brought in, the resident will be assessed by Therapy. We would have seen the device and had the resident assessed immediately. I have been in this unit 30-40 times and never noticed the device. We don't use them, and I was not looking for it. Don't know how we missed it. We did it and I own it. On June 9, 2021, a record review was conducted for resident #45, which failed to reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Fall Risk assessment dated [DATE] at 1630 (2:30 PM) on Admission revealed under Ambulation chair bound- does not require restraints. A review of resident's admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, (severely impaired cognition). The Care Plan did not address or identify restraint use. On June 10, 2021, at approximately 8:58 AM, an interview was conducted with staff J, LPN/ MDS coordinator, and staff K, LPN/MDS nurse. Staff K said, I completed the admission assessment on (resident #45), she was in a recliner when I did the assessment. If I had seen the wheelchair and device (the Lap Belt), I would have identified the belt and had it assessed. We do not have restraints here. Staff J said, We typically start the assessment by looking at information in the chart, talk with staff and resident if able. We can talk with family if needed. There is an extensive process if there is a device to be used for a restraint. It's a huge deal, everyone is aware of it, it is care planned, tasks in place to release it. Typically, there is documentation for nurses and whether the resident is able to release it. Expectations for new residents is to identify the wheelchair and belt and take care of it.

Based on observation, interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for 1 of 1 residents sampled for restraints (Resident # 45). The findings include: Multiple observations were made of resident #45 during which the resident was noted to be sitting in her wheelchair with a lap belt (a seat belt type device that if a resident cannot remove independently is considered a restraint) secured. The observations were conducted on June 7, 2021 between 10:30 AM and 11:15 AM, at 2:46 PM and June 8, 2021 at 9:00 AM, between 1:45 PM and 2:00 PM and again between 2:20 PM and 3:00 PM. At no point during these observations was the resident observed to attempt to remove the belt, to stand or to experience is distress. A record review was conducted for resident #45, which failed to reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Fall Risk assessment dated [DATE] at 1630 (2:30 PM) on Admission revealed under Ambulation chair bound- does not require restraints. On June 10, 2021 at approximately 8:58 AM, an interview was conducted with staff J, LPN/ MDS coordinator, and staff K, LPN/MDS nurse. Staff K said, I completed the admission assessment on (resident #45), she was in a recliner when I did the assessment. If I had seen the wheelchair and device (the Lap Belt), I would have identified the belt and had it assessed. We do not have restraints here. Staff J said, We typically start the assessment by looking at information in the chart, talk with staff and resident if able. We can talk with family if needed. There is an extensive process if there is a device to be used for a restraint. It's a huge deal, everyone is aware of it, it is care planned, tasks in place to release it. Typically, there is documentation for nurses and whether the resident is able to release it. Expectations for new residents is to identify the wheelchair and belt and take care of it.

Based on interview and record review, the facility failed to honor a resident's rights related to dining for residents in the Reverence Dining Room. (Resident #61) The findings include: An interview was conducted on 9/17/19 with resident #49 who resides on Reverence Court and has a Brief Interview for Mental Status (BIMS) score of 15, which indicates no cognitive impairment. Resident #49 expressed concern for another resident residing on Reverence Court, resident #61. Resident #49 stated that she feels staff neglect resident #61. When asked to explain what makes her feel that way, she stated that because of resident #61's physical condition, she requires staff to feed her, but staff don't assist her until they've finished passing meal trays to all of the other residents on the court. Resident #49 stated that resident #61 requested staff assistance to join resident #49 and others at the dining table for breakfast during the survey, however staff denied the request. She stated that staff informed the residents that it would be a violation of state regulations to seat resident #61 at the table without serving her or assisting her to eat. According to resident #49, staff told resident #61 that they would bring her to the table in a little while when they were able to sit down and feed her. An interview was conducted with resident #61 on 9/17/19 who shared resident #49's concerns. Resident #61 also has a BIMS score of 15 indicating no cognitive impairment. Resident #61 stated that she would like to be able to sit with the other residents at meal time to chat and socialize. When asked if she's ever been denied that right, she stated Oh, so I guess you heard about what happened. She stated that she needs staff's help to eat, but that they get to her when they get to her. When asked if it bothered her, she nodded her head yes. Review of resident #61's medical record revealed a physician's orders [REDACTED]. Review of the resident's care plan for nutrition instructs staff to assist with meals as needed. Review of the care plan for preferences reveals the goal is for resident #61 to continue to make choices regarding her daily routine and have preferences honored as much as possible through next review. An interview was conducted on 9/19/19 with staff B, a CNA observed feeding resident #61 during several observations. When asked if resident #61 is able to eat independently, she stated it depends on what it is, she can eat a banana and some snacks independently, but with meals she seems to be more dependent. She stated resident #61 has bad tremors and is afraid of using a fork to feed herself, but she can eat yogurt and soup through a straw. When asked if she is normally the one to assist resident #61 with meals, she stated not always, staff rotate. When asked if she is normally assisted with eating at the same time the other residents are eating, she stated it depends on what it is, if she wants to she will sit at the table and begin eating what she can independently before we sit down with her. When asked if she has ever been denied the opportunity to sit and eat with other residents due to her requiring assistance, she stated no and that she explained to resident #61 the other morning that if she waited a few minutes she would move her over to the dining room (from the recliner in the neighboring living area) and assist her, but knew she couldn't seat her at the table and put her food in front of her without assisting her. An interview was conducted on 9/20/19 with staff A, the Reverence Court Nursing Supervisor. When asked if she would expect her dependent diners to be fed at the same time as her independent diners, she stated that it's very seldom that she has a resident that requires assistance with meals, but she would assure the resident that they are not alone and not neglected and would educate staff and expect them to let the resident know that they will be there soon to assist them. She stated that she and other staff don't want residents seated at the table without their food watching others eat. When asked what the typical routine is for meals, she stated to first serve those in the dining room, then pass trays to the rooms, and then serve residents in need of assistance. She stated that if they were staffed where they could assist the resident at the same time trays were being passed, then they would do that. When asked if she thought it was fair for resident #61 to be denied a place at the table, she replied no, she wouldn't expect her staff to leave resident #61 sitting off by herself while everyone else was at the table eating, she wouldn't want that for herself either.

Based on observations and interviews, the facility failed to ensure the resident's call light was within reach for 1 of 11 residents sampled. (Resident #4) The findings include: On 09/16/2019 at 12:05 PM, Resident #4 was observed in bed, both top side rails were in the up position. The resident's call light was looped around the resident's walker, which was beside her bed. The resident stated she was not able to get out of bed on her own, and stated that she knew how to use her call light, but was not able to reach it. The resident stated this had happened before (staff placing the call light out of reach.) On 09/16/2019 at approximately 12:10 PM, Staff Member E, the resident's nurse, was asked if Resident #4 was capable of using her call light. He stated that Resident #4 was capable of using her call light and was not able to get out of bed on her own. Staff Member [NAME] confirmed the call light was not in reach and immediately un-looped the call light and gave it to the resident. On 09/17/2019 at approximately 03:35 PM, Resident #4 was observed in bed, both top side rails were in the up position. The resident's call light was not in reach. The call light was on the resident's walker, located out of the reach of the resident. On 09/17/2019 at approximately 03:40 PM, Staff Member D, the resident's nurse was asked if the resident was capable of using her call light, she stated she was. The nurse stated the call light should be within reach. Staff Member D, immediately went to check the location of the call light - retrieved it from the walker and gave it to the resident.

Based on observation, interview and record review, the facility failed to ensure implementation of a prescribed restorative nursing program to prevent a decline in range of motion (ROM) for 1 of 1 resident sampled (Resident #5). The Findings Include: On 8/27/18 at approximately 10:30am, resident #5 was observed laying in bed with bilateral hands in a closed fist position without any splinting devices and/or positioning devices observed. On 8/28/18 at 9:45am the resident was observed to have a rolled washcloth in the left hand in a closed fist position. Interview with the Physical Therapy Director on 8/28/18 at 2:00pm revealed nursing had referred the resident for Occupational Therapy screening in (MONTH) (YEAR). Resident #5 was picked up and then discharged with a passive range of motion restorative nursing program after unsuccessful splinting attempts. Review of resident's plan of care for decreased mobility documented nursing rehabilitation to be an intervention. The plan of care documented bilateral lower extremity active range of motion and upper and lower passive range of motion as directed. Review of restorative documentation in the resident's electronic medical record (EMR) revealed ROM had not been consistently performed for resident #5 by restorative nursing. August (YEAR): completed 5 days during the month - 8/11, 8/13, 8/22, 8/23, and 8/24. July (YEAR): completed 4 days during the month - 7/16, 7/17, 7/23, and 7/27. Interview with Employee B on 8/29/18 at approximately 1:00pm revealed she was the nurse responsible for the oversight of the Restorative Nursing Program. Employee B provided the Therapy/Restorative Program for Resident #5 that documented Passive Range of Motion to the left shoulder, left elbow and left hand with placement of a rolled washcloth in the resident's hand and a pillow under the resident's arm to be performed 3-5 times per week with an implementation date of 6/25/18. The Restorative Nurse confirmed was no documentation to support the restorative nursing care had been provided in accordance with the recommended program.

Based on observation, staff interview, record review and review of facility policies and procedures, the facility failed to provide respiratory care in accordance with professional standards of practice for 2 of 4 residents (#35 & #41) sampled by failing to assess the respiratory status before and after nebulizer treatments, and by not monitoring the resident during nebulizer treatments (Resident #35), and by failing to have orders for the administration of oxygen (Resident #41). The findings are: Resident #35 On 08/27/18 at approximately 01:24 PM, resident #35 was observed receiving a nebulizer treatment with no staff member present in the room. The nebulizer mask was noted hanging off of the resident's chin with mist infusing into the air. At 1:28 PM, employee D (unit nurse) entered resident #35's room and turned the treatment of [REDACTED]. On 08/28/18 at approximately 01:31 PM, employee F (registered nurse) was observed providing a nebulizer treatment to resident #35. Employee F entered the resident's room and was observed pouring the treatment liquid into the nebulizer mask, but was not observed to perform any type of respiratory evaluation or obtain vital signs of the resident prior to starting the treatment. She turned the nebulizer machine on and ensured the mask was fitted on the residents face and left the room. She stated she would return in about 15 to 20 minutes to turn the machine off. At approximately 2:03 PM, employee F entered resident #35's room and turned off the nebulizer machine and exited the resident's room without performing any type of resident assessment. A review of the facility's written policy and procedures for administering medications through a nebulizer was conducted. The procedure for providing a nebulizer treatment listed multiple steps. According to step 6 the nurse should Obtain baseline pulse, respiratory rate and lung sounds. The procedure also stated in step 17 to Remain with the resident for the treatment and in step 18 approximately 5 minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. Finally step 26 stated to obtain post-treatment pulse, respiratory rate, and lung sounds. The policy also indicated that staff should document the pulse, respiratory rate and lung sounds before and after the treatment and pulse during the treatment. On 08/29/18 at approximately 12:03 PM, an interview was conducted with employee F. She stated she was unaware of all the steps in the policy and procedure for nebulizer treatments and knew she did not complete all of the steps listed. She explained they did not have a place where they documented any before and after vital signs and lung sounds when giving a nebulizer treatment, but they did vital signs every shift for resident #35. She also stated she did not know she needed to stay with the resident throughout the treatment. Resident #41 Resident #41 was observed on 8/27/18 at 12:29 pm and again on 8/28/18 at 8:20am to have oxygen being administered per nasal cannula at 2 liters per minute. Review of the medical record for Resident #41 failed to reveal a physician's orders [REDACTED]. An interview was conducted with licensed practical nurse (LPN), Employee G, at 3:51 pm on 8/28/18. She was asked why Resident #41 was on oxygen and stated the resident's oxygen saturations would fall when she was not on it. Employee G was then asked if an order was needed for oxygen administration and she stated, Yes we are supposed to have an order. After review of the resident's medical record, Employee G was unable to locate a physician's orders [REDACTED].

Based on observations, staff interview and facility policy review, the facility staff failed to ensure multi-dose insulin vials were appropriately labeled with the open date and the expiration date and failed to ensure expired medications were discarded and not available for resident use on 2 of 4 medication carts (Hall 100 and Hall 400 carts). The findings are: On 08/30/18 at approximately 10:30 AM, an inspection was conducted of the medication cart for rooms 100-108 located on the Heritage Court unit. The inspection was conducted with sampled staff I, a licensed practical nurse (LPN). Inspection of the medication cart revealed one bottle of [MEDICATION NAME] 100units/ml in a pharmacy labeled medication bottle for resident #12, with the open date of 7/31/18 and expiration date of 8/28/18. Staff I confirmed that this vial of insulin was expired and she removed it from the cart. During interview with staff I, at the time of the observation, she stated per facility policy they were to label each insulin vial, once opened, with the open date and the expiration date (28 days after open date). An inspection was conducted on 08/30/18, beginning at approximately 11:10AM, of the medication cart for rooms 400-408 on the Trinity Court unit. This inspection was conducted with sampled employee H, the medication nurse. Inspection of the cart revealed a vial of [MEDICATION NAME]100units/ml, for resident #55, with an opened date of 7/28/18. The insulin vial was not labeled with an expiration date, but sampled staff H stated it had expired on 8/28/18 and should have been removed from the medication cart. Continued inspection revealed another opened/accessed 10 ml vial of [MEDICATION NAME]100 units/ml for resident #55, which had not been labeled with an open date or expiration date. Review of the facility's policy for Medication Administration Injectable Vials and [MEDICATION NAME] and the policy for insulin multi-dose vials revealed injectables; including insulin, were to be labeled with an open date and an expiration date that should not exceed 28 days once the vial had been opened.

Based on observation, staff interview and policy review, the facility failed to clean the oxygen concentrator filter for 1 of 4 oxygen concentrators (resident #41). The findings are: Resident #41 was observed to have oxygen being administered per nasal cannula at 2 liters per minute on 8/27/18 about 1:00pm, and the filter on the back of the oxygen concentrator was observed to be dusty. On 8/28/18 about 3:45 pm, the filter was again observed to be dusty, but the date on the resident's oxygen tubing was 8/27/18. (Photo evidence obtained) An interview was conducted with licensed practical nurse (LPN), Employee G, on 8/28/18 at 3:51 pm. She stated oxygen tubing was changed weekly on 11pm-7am shift. Employee G conducted on observation of the oxygen tubing and concentrator for resident #41, and confirmed the date on the tubing was 8/27/18 and also confirmed, after inspection, that the filter on the oxygen concentrator was dusty. Review of the facility policy on Respiratory Therapy revealed staff would change the oxygen tubing and wash concentrator filters every seven days or as needed. An interview was conducted with the director of nursing (DON) on 8/29/18 about 8:20am. He said all oxygen tubing was changed on 8/27/18 and that he had checked them to make sure they had been changed, but had failed to check the filters. He then said, Yes room [ROOM NUMBER] A's was dirty. I was the one who cleaned it.

Based on observations, staff interview and review of facility kitchen policy and procedures it is determined that staff did not follow proper procedure regarding sanitizing thermometer when checking temperatures of each food type on the steam table on two of three nursing units. The findings are: Observation revealed that on 6/9/14 at 7:40 AM on Trinity unit Dietary Aide A completed food temperatures from the steam table for the surveyors and cleaned the thermometer with a clean disposable glove and repeated the use of the disposable glove when between each food type observed. Observation revealed that on 6/9/14 7:55 AM on the Reverence unit Dietary aide B completed food temperatures from the steam table and cleaned the thermometer with a clean disposable dish cloth and continued the use of cleaning the thermometer with the disposable dish cloth between each food type observed. Policy and Procedure review of the facility policy presented on 6/11/14 by the Risk Manager for "Buffet Cart/Meal Service Checklist" indicated "Food thermometers will be calibrated prior to the breakfast meal each morning and properly sanitized at all times using alcohol wipes at all time." The policy origination/revision date was not noted on the policy. Interview with the Risk Manager on 6/11/14 at 11:20 AM indicated that the "Buffet Cart/Meal Service Checklist" was their policy. Interview with Staff A on 6/12/14 at 8:35 AM indicated she did clean the thermometer on 6/9/14 at breakfast with a clean disposable glove because she did not have any alcohol wipes on the cart.

Based on observation of breakfast trays, resident interview and staff interview, and review provided by food service supervisor the facility failed to provide food that is palatable and or at the proper temperature for 5 of 14 residents interviewed ( #2, #3, #6, #8 and #11) during complaint investigation. The findings are: During complaint investigation of cold food served on the rehabilitation unit it was determined that 5 of 14 residents interviewed found the food to be served cold and in some cases unpalatable. Resident #2 stated her tray of puree food was served cold. She stated, " I cannot eat that as she pointed to her tray." The tray was observed to have 3 scoops of substance on a plate. Two scoops were brown and one was yellowish looking. The scoops of food were shriveled around the edges. Resident #3 stated his breakfast has cold eggs this morning. Resident #8 says her scrabbled eggs are cold today. The eggs are observed to be limp with liquid around the edges. Resident #11 says her breakfast today had sausage "nuked"so hard it could not be eaten. She also says the fried eggs were too hard to eat. She says she has reported the food to dietary services. Resident #6 says her food was not cold today but it has been cold in the past. She has oatmeal today which was served at the correct temperature. An interview was conducted with the supervisor of the kitchen. He said he had recently addressed cold food with a resident that originated from the Resident Council. He denies having any other complaints. A review of Resident Council minutes revealed a complaint made by resident #14 in council meeting about cold food in July 31,2012 meeting. The food service supervisor met with resident regarding the concern. He told her the food could be warmed in the microwave. Resident #14 said she did not like food warmed in microwave. The Response according to follow-up provided by the food service supervisor is to monitor meals to ensure resident is receiving hot meals.

Based on observation and staff interview the facility failed to ensure food was served under sanitary conditions on one of three observed meal services. The findings include: At approximately 11:50 AM on 01/19/2011 an observation of the food service tray line was made. Kitchen staff was observed to place plates with incomplete meals on top of the seams where the steam pans meet, which allowed for the partially filled plates to hang over the prepared food in the steam pans. At one point during the preparation of the meal plates, one of the partially filled plates was accidentally knocked off of the seams of the steam pans, and fell into the steam pan holding the prepared rice for the meal. A kitchen staff member was observed to pick the plate up and remove it from the steam pan filled with rice, and place the plate behind the line on another counter. The kitchen staff was then observed to continue to serve rice from the steam pan to the plates to be served to the residents. Prior to balancing the plates on the steam table, the plates had been observed to have been sitting on a preparation counter. At approximately 2:00 PM on 01/19/2011 a food service policy review was conducted with the Dietary Department Manager. During review of the policies, the Summary of Basic Standards for Safe-Guarding the preparation and storage of foods was found to have a paragraph instructing kitchen staff to "discard any questionable food". The Dietary Department Manager and the Kitchen Manager were questioned about the practice of kitchen staff placing plates with food on them on the edges of two adjacent steam pans (balancing the plates with the bottom of the plates overhanging steam pans containing freshly cooked, and uncovered foods), and they both denied any knowledge of the practice by kitchen staff. Both the Dietary Department Manager and the Kitchen Manager denied knowledge of being informed of the incident the previous day when a plate was knocked off the edge of the steam pan and into the steam pan containing freshly cooked rice. Both agreed the rice should have been considered to be contaminated food.