Every finding on record at Heritage Home

Based on staff interview, medical record review, incident report review, and facility investigation review, the facility failed to ensure resident's were free from significant medication errors for 1 of 7 sampled residents (#1) reviewed. This failure resulted in harm to resident #1 who was hospitalized following an insulin overdose. The findings were: 1. Review of the admission Minimum Data Set assessment dated [DATE] showed resident #1 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which include heart failure, atrial fibrillation, renal insufficiency and diabetes mellitus. Further review showed the resident was insulin dependent for diabetes mellitus. The following concerns were identified: a. Review of the facility incident report dated 7/18/25 showed a potential medication error for resident #1 involving sliding scale insulin administration. b. Review of physician orders dated 7/10/2025 for sliding scale insulin showed the resident was to receive 8 units of insulin for blood sugars ranging from 351-400 mg/dl (milligrams per deciliter). c. Review of the resident's medication administration record dated 7/18/25 showed the residents blood sugar was 377 mg/dl prior to insulin administration.d. Review of the Mediation Error Report dated 7/18/25 showed registered nurse (RN) #1 administered 80 units of insulin instead of 8 units on 7/18/25. Further review showed the resident was transferred to an acute care hospital setting following the insulin administration utilizing the wrong type of syringe. e. Review of nursing report titled; Supplemental Statement of Events dated 7/19/25 showed RN #1 documented 8 units of insulin was administered to the resident at approximately 4:30 PM on 7/18/25. Further review showed the resident was not acting like him/herself and exhibited diaphoresis, cool skin, rapid breathing, and changes in level of consciousness. f. Review of the hospital physician note dated 7/19/25 showed the resident was admitted to the Intensive Care Unit for management for hypoglycemia and hypotension following accidental insulin overdose. g. Interview with RN #1 on 8/19/25 at 10:08 AM confirmed the resident was administered 80 units of insulin instead of 8 units on 7/18/25 at approximately 4:30 PM. She revealed during administration of the insulin, she utilized a tuberculin syringe instead of an insulin syringe because she couldn't find any insulin syringes.h. Interview with the director of nursing on 8/19/25 at 9 AM confirmed the wrong insulin dose was administered due to the nurse utilizing the wrong syringe for administration.

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure proper infection control practices for 1 of 2 sample residents (#10) with foley catheter placement and during 2 meal observations. The census was 35. The findings were: Regarding residents with foley catheters: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a brief interview for mental status score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included neurogenic bladder, diabetes mellitus, and dementia. Further review showed the resident required substantial/maximal assistance with toileting, showers, upper body dress, lower body dress, putting on footwear, and personal hygiene and had an indwelling urinary catheter. Review of the resident's care plan dated 3/13/25 showed Problem: NURSING: Resident requires a suprapubic catheter related to neurogenic bladder with history of UTI and the interventions included Cath to be emptied every 4 hours with resident checked for incontinent bowel during each encounter to prevent increased risk for infection. Cath care every shift & PRN [as needed] .Do not allow tubing or any part of the drainage system to touch the floor .The following concern was identified: a. Observation on 6/9/25 at 7 PM showed the resident was sitting in the recliner with his/her leg rest up. Under the leg rest, the urinary catheter bag was lying directly on the floor. No barrier was seen between the bag and floor and dark yellow urine was noted in the bag and in the catheter tubing. 2. Interview with CNA #1 on 6/10/25 at 3:38 PM revealed the urinary drainage bag was to be in a basin, and never on the floor. 3. Interview with the infection preventionist on 6/11/25 at 11:25 AM revealed it was the facility expectation for the urinary drainage bags to never be on the floor and to be covered. 4. Review of the procedure Care of an indwelling Catheter hand delivered on 6/11/25 at 11:30 AM by the infection preventionist showed .9.g. Ensure drainage bag is secure in an opaque bag or wash basin. Bags may not rest on the floor or remain uncovered. Regarding meal service: 1. Observation on 6/10/25 at 7:59 AM staff member #1 was assisting with passing resident meal trays. While passing the trays, the staff member was observed touching residents' arms and wheelchairs. Without performing hand hygiene, the staff member approached a resident and assisted the resident by using her ungloved left hand to hold the resident's toast and applying butter with a knife in her right hand. 2. Observation on 6/11/25 at 11:53 AM showed dietary staff member #1, who was wearing gloves, rubbed his face with his left hand. Without removing the gloves, the staff member held the bun of a sandwich using his left hand, and cut the sandwich in half. 3. Interview with the infection preventionist on 6/12/25 at 10:43 AM revealed if staff were touching residents' food items, hand hygiene should be performed before contact with the food items and gloves were to be worn. Further interview revealed after staff touched contaminated surfaces, contaminated gloves should be doffed, hand hygiene should be performed, and new gloves should be donned. 4. Review of the facility policy titled Hand Hygiene last reviewed on 1/23/25 showed .A. Indications for hand hygiene included: 1. Before touching a patient or resident .4. After touching a patient or resident .11. After contact with inanimate surfaces and objects in the immediate vicinity of the patient or resident . 14. After blowing or wiping the nose, coughing, or sneezing, even if a tissue is used .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure adequate monitoring of psychotropic medications for 2 of 6 sample residents (#2, #90) reviewed for unnecessary medications. In addition, the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days unless there was a documented rationale for 1 of 6 sample residents (#89) reviewed for unnecessary medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had diagnoses which included non-Alzheimer's dementia, anxiety disorder, and depression. Review of the physician orders showed the resident had an order for duloxetine (antidepressant) 60 mg daily. The following concern was identified: a. Review of the medical record showed there were no identified target symptoms for the antidepressant. 2. Review of the medical record for resident #90 showed the resident admitted on [DATE] and had diagnoses which included disorientation, history of falling, and depression. Review of the resident's physician orders showed the resident had orders for mirtazipine (antidepressant) 7.5 mg and citalopram (antidepressant) 10 mg. The following concerns were identified: a. Review of the medical record showed no evidence the facility had identified or was monitoring target symptoms for the either antidepressant medication. 3. Review of the medical record showed resident #89 admitted to the facility on [DATE] with diagnoses which included dementia with psychotic disturbance, depression, and personal history or suicidal behavior. Review of the resident's physician orders showed an order for trazadone 50 mg PRN which was ordered on 6/9/25 and there was no stop date indicated. The following concerns were identified: a. Review of the medical record showed no evidence the physician provided a rationale for the PRN trazadone to not have a stop date. 4. Interview with the facility administrator on 6/12/25 at 9:02 AM confirmed some medications only have diagnosis and the facility did not identify target symptoms. Further she confirmed the physician did not provide a rationale for not indicating stop dates for the prn psychotropic medications. 5. Review of the facility policy titled Psychotropic Utilization last reviewed 2/14/25 showed . (4) PRN orders for psychotropic are limited to 14 days. Except as provided in §483.45 (e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order .Medication Management: The regulations associated with medication management include consideration of: adequate monitoring for efficacy and adverse consequences .Monitoring for Efficacy and Adverse Consequences .Monitoring and accurate documentation of the resident's response to any medication(s) is essential to evaluate the ongoing benefits as well as risks of various medications. Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches, such as prior to administering PRN medications .

Based on medical record review, staff interview, and review of the CMS RAI manual review, the facility failed to ensure MDS assessments were transmitted within 7 days of completion for 1 of 15 sample residents (#3) reviewed. The findings were: 1. Review of a progress note for resident #3 dated [DATE] and timed 10:03 AM showed the resident expired at the facility. Review of the MDS data for the resident showed the discharge assessment had been completed; however, it had not been submitted. 2. Interview with the MDS coordinator on [DATE] at 3:36 PM confirmed the resident was discharged from the facility in February 2025, the assessment had been completed, and the assessment had not been transmitted. Further interview revealed she transmitted the assessment at that time. Further interview confirmed it should have been submitted prior. 3. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated [DATE] showed .Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A1600 +14 days for Entry records and A2000 + 14 days for Death in Facility records) .

Based on observation, medical record review, resident and staff interviews, review of the facility's investigation, state survey agency incident database review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 1 (#2) sample residents reviewed for abuse allegations. The findings were: 1. Review of the medical record for resident #2 showed an admitted [DATE] and diagnoses which included hemiplegia/hemiparesis affecting the right/dominant side of the body. Further review showed the resident received comfort care to manage symptoms and the resident's prognosis was poor for recovery. Observation on 4/17/24 at 10 AM showed the resident was resting comfortably in bed with family at the bedside. Observation at that time showed the resident appeared thin and frail but was able to open his/her eyes and answer yes/no questions. Interview with the resident at that time, revealed the resident was comfortable, felt safe, and had no complaints related to care. The following concerns were identified. a. Review of the state survey agency incident database showed the facility reported an incident on 3/25/24 which involved resident #2 and CNA #3. The incident alleged CNA #3 was providing incontinence care to resident #2 and said you are the most disgusting [woman/man] ever, why would you do this. This is disgusting. What kind of person does this? Further review showed the CNA admitted her comments were unprofessional and she deserved whatever punishment you see fit. b. Interview with the administrator on 4/17/24 at 10:25 AM confirmed an allegation of verbal abuse towards resident #2 on 3/20/24 and was reported to administration on 3/25/24. She verified an internal investigation was started immediately after notification and the facility substantiated the allegation of verbal abuse towards resident #2 by CNA #3. Further interview revealed the facility notified the proper authorities and terminated the CNA. c. Interview with CNA #1 on 4/17/24 at 11:55 AM revealed the aide witnessed verbal abuse towards resident #2 by CNA #3 on the evening of 3/20/24. The incident disturbed the CNA and it was reported to the nurse on duty that evening; however, it was not reported to administration until 3/25/24. CNA #1 stated she was new to the facility and at the time was not familiar with the procedure for reporting abuse allegations to administration. d. Review of the statement provided by CNA #3 dated 3/26/24 showed an acknowledgement of unprofessional behavior towards resident #2 on 3/20/24 after an episode of incontinence. e. Review of the statement provided by CNA #2 dated 3/26/24 showed on the night of 3/20/24 resident #2 had an incontinence accident in the bed and CNA #3 was heard calling the resident a disgusting [woman/man] while assisting the resident with care. 2. Review of the resident's rights, no date, showed It is the goal of our facility to promote and protect the rights of each resident .26. The right to be free from physical, psychological, or sexual abuse or punishment . 3. Review of the facility policy Abuse, neglect, mistreatment of residents'' dated 12/2023, showed verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability .g. Reasonable Person Concept: A person with an ordinary degree of reason, foresight or intelligence, whose expectation in relation to a particular circumstance is used as an objective standard by which to measure or determine something. In other words, a resident who has mental incapacity/dementia who is victim of abuse may not show a reaction, however, a reasonable person could experience harm related to the abuse, which would be applied in these situations.

Based on review of the facility's incident log, staff interviews, state survey agency incident database review, and policy and procedure review, the facility failed to report all alleged violations of abuse immediately after the occurrence for 1 of 1 sample residents (#2). The findings were: 1. Review of the facility incident log showed an allegation of verbal abuse of a resident during the month of March, 2024. 2. Review of the state survey agency incident database showed an allegation of verbal abuse was reported on 3/25/24; however, the incident occurred on 3/20/24 at 10:20 PM, 5 days before it was reported. 3. Interview with the administrator on 4/17/24 at 10:25 AM confirmed an allegation of verbal abuse towards resident #2 occurred on 3/20/24 and was reported to administration on 3/25/24. 3. Interview with CNA #1 on 4/17/24 at 11:55 AM revealed the aide witnessed verbal abuse towards resident #2 by CNA #3 on the evening of 3/20/24. The incident disturbed the CNA and it was reported to the nurse on duty that evening but not reported to administration until 3/25/24. CNA #1 stated she was new to the facility and at the time was not familiar with the procedure for reporting abuse allegations to administration. 5. Review of the facility policy Abuse, neglect, mistreatment of residents . dated 12/2023 showed, any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect .shall immediately report to the Director of Nursing or the Nursing Home Administrator .

Based on medical record review and resident and staff interview, the facility failed to develop a comprehensive care plan for 4 of 15 sample residents (#4, #9, #12, #20). The findings were: 1. Review of the 12/15/23 admission MDS assessment showed resident #4 received opioid medication and had indicators of pain on 3-4 days during the look-back period. Further review of the assessment showed pain triggered and review of the care area assessment (CAA) for pain showed the resident had a recent fracture, a weekly Butrans patch, oxycodone, and Tylenol was used to control pain. Review of current orders and the February 2024 MAR showed the resident was ordered the following medications for pain: acetaminophen 325 mg, 2 tablets, every 6 hours PRN; Butrans patch weekly, 7.5 mcg/hour, on Friday; morphine concentrate 100 mg/5ml, 0.4 mL (8 mg), four times a day; and morphine concentrate 100 mg/5 mL, 0.4 ml (8 mg) every 8 hours PRN. The following concerns were identified: a. Review of the care plan provided by the facility on 2/22/24 at 4:53 PM showed pain was not addressed. b. During an interview on 2/23/24 at 9:15 AM the DON confirmed the care plan did not address pain. She stated care plans were developed for triggered items on the MDS and she was not sure why the care plan didn't address pain. 2. Review of the 11/13/23 admission MDS assessment showed resident #20 had a diagnosis of hip fracture, received opioid medication, and had pain frequently at a 7 on a scale of 0 to 10. Further review of the assessment showed pain triggered and review of the CAA for pain showed the resident had a recent hip surgery and reported his/her worst pain was a 7 out of 10. Review of physician orders and the February 2024 MAR showed the resident was ordered the following medications for pain: acetaminophen 325 mg, 2 tabs, every 6 hours PRN; Fentanyl patch 72 hour, 25 mcg/hr, every 72 hours; and hydrocodone-acetaminophen 5-325 mg, 1 tab, every 4 hours PRN. The following concerns were identified: a. Review of the care plan provided by the facility on 2/22/24 at 4:40 PM showed pain was not addressed. b. During an interview on 2/23/24 at 9:15 AM the DON confirmed the care plan did not address pain. She stated care plans were developed for triggered items on the MDS and she was not sure why the care plan didn't address pain. 37603 3. Review of the 7/5/24 annual MDS assessment showed resident #12 had diagnoses which included arthritis, non-Alzheimer's dementia, dementia in other diseases classified elsewhere, severe, with psychotic disturbance, polyarthritis, pain, edema, repeated falls, and urinary tract infection. The resident was at risk for pressure ulcers and had 1 unstageable pressure ulcer. The facility's treatment for the pressure ulcers included a pressure reducing surface for the chair and bed, nutrition, and ointments. Review of the 12/18/23 quarterly MDS assessment showed the resident had a stage 2 pressure ulcer. The following concerns were identified: a. Review of the 7/5/23 annual MDS care area assessment showed pressure ulcers were triggered and care planned. b. Review of the care plan showed Risk for impaired skin integrity [related to] R/T urinary incontinence requiring extensive assistance with toileting with the goal target date of 1/1/24. The care plan did not address the actual stage 2 pressure ulcer. c. During an interview on 2/23/24 at 9:15 AM the DON confirmed the care plan did not address pressure ulcers. She stated care plans were developed for triggered items on the MDS and she was not sure why the care plan didn't address the pressure ulcer. 4. Review of the 1/8/24 annual MDS assessment showed resident #9 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The resident had behaviors of rejection of care. The mobility device used in the last 7 days was a wheelchair. The resident had diagnoses which included medically complex conditions, non-Alzheimer's dementia, anxiety, depression, bipolar, chronic obstructive pulmonary disease, Respiratory failure, Encephalopathy, Morbid (severe) obesity due to excess calories, Unspecified dementia, unspecified severity, with anxiety, and anoxic brain damage. The following concerns were identified: a. Interview with the resident on 2/21/24 at 2 PM revealed I had to work to lose 30 pounds to get an electric wheel-chair. We got a new doctor and new DON and they took it from me. It limits me from where I can go, and when I can go. They did not have a reason why. Interview with the resident on 2/23/24 at 8:57 AM revealed the facility never went over alternatives for his/her wants to go to town. b. Review of the care plan last revised on 1/9/24 showed there were no interventions related to access to the community following the removal of the electric wheelchair. c. Interview with the DON on 2/22/24 at 4:08 PM revealed the resident would need to use transportation services to access the community and the service would cost money. Further interview revealed the resident did not have money for the transportation service.

Based on medical record review, staff interview, and review of facility protocol, the facility failed to implement interventions to treat constipation for 3 of 3 sample residents (#4, #10, #20) reviewed for bowel management due to opioid medication use. The findings were: 1. Review of the 12/15/23 admission MDS assessment showed resident #4 had a femur fracture and received opioid medication. Review of current orders and the February 2024 MAR showed the resident was ordered the following opioid medications: Butrans patch weekly, 7.5 mcg/hour, on Friday; morphine concentrate 100 mg/5ml, 0.4 mL (8 mg), four times a day; and morphine concentrate 100 mg/5 mL, 0.4 ml (8 mg) every 8 hours PRN. The following concerns were identified: a. Review of the bowel movement (BM) record for the past 28 days showed the resident had no BM for 4 days on two occasions (2/9/24-2/12/24 and 2/17/24-2/20/24). b. Review of the February 2024 MAR and progress notes showed no evidence the resident received any interventions for constipation during those timeframes. 2. Review of the 1/31/24 admission MDS assessment showed resident #10 had almost constant pain. Review of physician orders showed the resident was ordered the following opioid medications: morphine 15 mg twice per day and oxycodone 5 mg every 6 hours PRN. In addition, the resident was ordered polyethylene glycol 3350 powder (used to treat constipation), 17 gram/dose, every 24 hours PRN. The following concerns were identified: a. Review of the BM record for the last 28 days showed the resident had no BM for 4 days on two occasions (2/3/24-2/6/24 and 2/17/24-2/20/24). b. Review of the February 2024 MAR and progress notes showed no evidence the resident received any interventions for constipation during those timeframes. 3. Review of the 11/13/23 admission MDS assessment showed resident #20 had a diagnosis of hip fracture, had frequent pain, and received opioid medication. Review of physician orders and the February 2024 MAR showed the resident was ordered the following opioid medications: Fentanyl patch 25 mcg every 72 hours and hydrocodone-acetaminophen 5-325 mg every 4 hours PRN. In addition, the resident was ordered Miralax powder, 17 gram/dose, every 48 hours for constipation. Review of a physician's note dated 1/4/24 showed the resident had drug induced constipation. The following concerns were identified: a. Review of the BM record for the last 28 days showed the resident did not have a BM from 1/29/24-2/2/24 (5 days), 2/4/24-2/8/24 (5 days), and 2/10/24-2/12/24 (3 days). b. Review of the February 2024 and progress notes showed no evidence the bowel protocol was followed during those timeframes. 4. During an interview on 2/23/24 at 9:15 AM the DON stated the facility bowel protocol would apply to residents #4, #10, and #20. She stated staff should follow the protocol or contact the provider. She confirmed there was no evidence to show the protocol was followed for residents #4, #10, and #20. 5. Review of the facility's bowel protocol Constipation Treatment, undated, showed .Day 1: Drink at least 2 liters of water/fluids daily if not contraindicated. Day 2: Psyllium husks 1 tbsp (3.5 g) three times daily, or 6 prunes twice daily. Day 3: Senna 17-25.6 mg daily or Bisacodyl 10-30 mg daily. Day 4: Polyethylene glycol 17-34 g daily. Day 5: Bisacodyl 10 mg suppository daily. Document bowel sounds. Day 6: Warm water enema daily. Document bowel sounds, notify PCP if no BM.

Based on medical record review and staff interview, the facility failed to ensure orders for psychotropic medications were limited to 14 days or the physician documented rationale for an extended order, for 1 of 5 sample residents (#34) reviewed for unnecessary medications. The findings were: 1. Review of the 11/22/23 admission MDS assessment showed resident #34 received antianxiety medication and had diagnoses which included dementia and anxiety disorder. The following concerns were identified: a. Review of the current physician orders showed a PRN order for alprazolam (antianxiety) 0.25 mg three times daily which started on 11/20/23 and did not have a stop date. b. On 11/29/23 the pharmacist sent a consultation report to the physician regarding the PRN Alprazolam that did not have a stop date. The pharmacist noted that PRN orders for non-antipsychotic psychotropics were limited to 14 days unless the prescriber documented the rationale for an extended time period. The physician responded on 1/4/24 I will schedule Rx [prescription] . c. Review of the physician orders showed an order dated 1/10/24 for alprazolam 0.25 mg every morning; however, the PRN order remained an active order. Review of the February 2024 MAR showed the PRN order remained active, and the resident received a dose on 2/4/24. d. Interview with the DON on 2/23/24 at 9:15 AM confirmed there was no rationale for the PRN medication being longer than 14 days. She stated she sent a message to the physician the day before regarding the PRN order.

Based on medical record review, staff interview, and review of facility documentation, the facility failed to ensure the drug regimen was free from unnecessary medications for 1 of 5 sample residents (#6) reviewed for unnecessary medications. Resident #6 received a medication for excessive duration due to the facility's failure to follow the physician's order. The findings were: 1. Review of the 12/27/22 admission Minimum Data Set (MDS) assessment showed resident #6 received opioid medications, was incontinent of bowel, and did not have constipation. Review of physician orders for February 2023 showed the resident was ordered Butrans (opioid) patch, 7.5 micrograms/hour, every week and oxycodone (opioid) 5 milligrams (mg) 1/2 tab four times a day PRN (as needed). Further review showed on 12/20/22 the resident was ordered loperamide (antidiarrheal) 2 mg twice a day, with instruction to hold for no bowel movement more than one day, and then resume after the first loose stool. Review of a 12/30/22 quarterly nursing assessment showed the resident had diarrhea. Review of a typed summary by the DON dated 2/2/23 showed the resident had a history of chronic diarrhea and .giving [him/her] medication to induce a bowel movement only increased [his/her] discomfort and caused more diarrhea. Therefore, [resident] was removed from the bowel protocol .Currently, [resident] is prescribed Loperamide 2 mg PO BID with instructions to hold if no bm>1 day then resume after first loose stool. The following concerns were identified: a. Review of the bowel movement record showed the resident did not have a bowel movement on 1/16/23 through 1/20/23. Per the physician's order, the loperamide should have been held starting on 1/18/23 (more than one day without a BM). However, review of the medication administration record (MAR) showed the medication was not held until 1/19/23. b. Review of the bowel movement record showed the resident did not have a bowel movement on 1/23/23 through 1/27/23. Per the physician's order, the loperamide should have been held starting on 1/25/23 (more than one day without a BM). However, review of the MAR showed the medication was not held during that time. c. During an interview on 2/2/23 at 10:08 AM the DON confirmed staff did not follow the physician's order to hold the loperamide when the resident did not have a bowel movement for more than one day.

Based on observation, staff interview, and policy review, the facility failed to ensure medications available for use were not expired in 1 of 1 medication storage rooms. The findings were: 1. On 2/1/23 at 8:38 AM observation in the medication storage room showed in a cupboard marked OTC there were several prescription medications. The expired medications in the storage area included 1 tube of triamcinolone acetonide 0.1% ointment, lot number 1BT0433 with expiration date 12/22 and 1 bottle of ketoconazole 2% shampoo, lot number 151646 with expiration date of 09/2022. 2. Interview with RN #1 on 2/1/23 at 8:45 AM revealed the outdated medications should have been stored where they could not be used. 3. Interview with the DON on 2/1/23 at 4:55 PM revealed it was the expectation that all outdated medication be removed from service. 4. Review of the policy titled Disposal/Destruction of Expired or Discontinued Medications with the revision date of 10/10/22 showed: a. Once an order to discontinue a medication is received, the nurse will remove the medication from the medication cart. b. The nurse will place all discontinued medications in the medication room for disposal/destruction.

Based on observation, staff interview, and review of Food Code standards, the facility failed to ensure food equipment and surfaces were maintained in a sanitary condition in 2 of 3 meal service areas (TV room and sun room) and for 2 of 3 ice machines (kitchen and beauty shop). The census was 31. The findings were: 1. Observation on 11/15/21 at 4:04 PM showed the ice machine located in the kitchen was not clean. The interior white plastic piece that was located above the full ice bin was soiled with a black and pinkish build-up. 2. Observation on 11/17/21 at 11:49 AM showed the ice machine on the resident unit was located in the beauty shop. There was no separation between the area where hair was done and the area where the ice machine was located. In addition, the original cover/lid to the ice machine was missing and there was a homemade cover to the ice machine which was made from a thick pliable plastic and duct tape. The interior of the ice making mechanism had a visible dark build-up on the plastic. Observation in the beauty shop on 11/18/21 at 9:36 AM showed a blue garbage can labeled East Bath was located in front of the ice machine and was in contact with the ice machine lid. The garbage can contained bagged linen. 3. Observation on 11/17/21 at 5:47 PM showed 2 tables in the sun room dining area that had not been cleaned. There was visible dried liquid/food on the tables. Additionally, the over bed tables used for dining in the TV room had visible dried food/liquids remaining from previous dining. Observation at 5:47 PM showed a resident was delivered her evening meal to one of the over bed tables in the TV room. CNA #1 did not acknowledge or attempt to clean the dirty over bed table the meal was served on. At 5:52 PM CNA # 2 served the residents seated in the sun room meals on the unclean tables. 4. Interview with the DON on 11/18/21 at 9:47 AM confirmed there should be a process to ensure the tables were cleaned prior to meal service. 5. Interview with the maintenance director on 11/17/21 at 10:38 AM revealed an outside service company came in to clean and sanitize the ice machines at least once per year and as needed. He confirmed the service was completed in April 2021. He stated there had been a work order from the dietary manager on 10/22/21 to have the kitchen machine cleaned and sanitized and they were due to come this week. He confirmed the service company had been delayed and he was uncertain when they would arrive. 6. Interview with the certified dietary manager on 11/18/21 at 10:44 AM verified the kitchen ice machine needed to be cleaned and she had put in the work order, and it was delayed. She stated she had no control over the ice machine located in the beauty shop. 7. According to Food Code 2017, U.S. Public Health Service: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 8. According to Food Code 2017, U.S. Public Health Service: 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, medical record review, policy and procedure review and staff interview, the facility failed to ensure physical restraints were evaluated to determine they were the least restrictive method and to ensure they were used to treat medical symptoms for 2 of 2 sample residents (#2, #6). The findings were: 1. Review of the 8/16/21 quarterly MDS assessment showed resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance for transfer and walking with one person physical assistance. The assessment further showed the resident used a physical restraint daily coded as other and used a bed and chair alarm daily. Review of the care plan with a revision date of 8/20/21 showed the use of the physical pelvic restraint was used for agitation and freedom of movement .staff to reposition every 2 hours. There was also an approach with a start date of 3/2/21 for a pressure alarm to be used when in bed and in the recliner. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Observation on 11/16/21 at 4:01 PM showed the resident was in the wheelchair at the dining table with a soft cloth restraint that came between the resident's legs and tied to the wheelchair back. The restraint prevented the resident from rising from the chair or falling forward. Additional observations showed the resident used the restraint daily and was released from the restraint to ambulate with staff and to be transferred to the recliner in the TV area. b. Observation on 11/17/21 at 2:13 PM showed the resident was in the recliner in the TV room and a chair alarm was attached to the resident which would alarm if the resident moved too far. c. Review of the pre-restraining assessment dated [DATE] and the corresponding IDT note dated 5/7/21 showed the need for a pelvic restraint and The resident's doctor and family along with staff agree that at this time the above measures are necessary for safety. However, further record review showed there were no more current notes or re-evaluation regarding the continued use of the pelvic restraint. In addition, there was no evaluation or assessment found regarding the use of the alarms. d. Interview with the DON on 11/17/21 at 6:03 PM confirmed the facility did not have a process to assess the position alarms as potential restraints. She also confirmed the alarms were used to alert staff if the resident was at risk for falling, and the process was to re-evaluate the pelvic restraint at least quarterly which had not been done. 2. Review of the 9/2/21 Admission MDS assessment showed resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment did not show any use of physical restraints or alarms being used. Review of the care plan related to risk of falls showed it was implemented on 9/7/21. The approaches included 11/13/21 updates to include: Pressure alarm in bed and personal alarm in recliner [and] wheelchair for safety with frequent reposition. The following concerns were identified: a. Observation on 11/17/21 at 12:33 PM showed the resident was eating his/her meal in the TV room while seated in a specialized wheelchair. The resident had an alarm attached to his/her clothing and the chair. Interview with RN #2 at that time confirmed the alarm was active and was attached to the resident's shirt. The RN stated the resident did not attempt to get up from this wheelchair; however, s/he was known to do so when seated in the recliner. The resident had been transitioned to the wheelchair because of a foot injury and they were better able to position the resident. b. Review of the medical record failed to show any assessment related to the use of the chair or bed alarm. c. Interview with the DON on 11/17/21 at 6:03 PM confirmed the facility did not have a process to assess the position alarms as potential restraints. She further stated the alarms were used to alert staff if the resident was at risk for falling. 3. Review of the Restraint Policy last reviewed October 2019, showed if a restraint needed to be placed, 1. The physician must be notified and an order must be obtained; 2. The family must be notified and consent must be obtained; 3. The DON must be notified; 4. A pre-restraining assessment must be completed as soon as possible; 5. Documentation in the nurses notes must be completed q [every] shift for 72 hours; 6. The restraint must be re-evaluated within 24 hours for appropriateness; 7. IDT [Interdisciplinary team] will re-evaluate for appropriateness within a week and then quarterly.

Based on observation, resident and staff interview, review of consent and release, and medical record review, the facility failed to ensure bed rails assessments were completed for 2 of 2 sample residents (#9, #82). The findings were: 1. Review of the Admission Assessment and Interim Care Plan dated 11/11/21 showed resident #82 was oriented to his/her room, had some ADL limitations, used a walker, was at a high risk for falls, and was mentally alert and oriented. Under the category for room orientation the assessment showed a check mark next to the item Bed Side Rails Acknowledgement Signed. The following concerns were identified: a. Interview with the resident on 11/17/21 at 11:23 AM revealed s/he was pleased with the care and environment. The resident stated s/he used the side rail bars to move around in bed and had no concerns or issues with them. Observation at that time showed the resident was in bed with the bars in an upright position on both sides of the bed which was not against a wall. b. Observations with the maintenance director on 11/18/21 at 10:16 AM showed, when measured, the openings of the side rails included a 4 inch by 4 and 5/8 inch opening, and a 12 and 1/2 inch by 4 inch opening on each bed rail. Interview with the maintenance director at the time revealed he was not aware of any safety assessment performed related to the bed rails. c. Medical record review failed to show an assessment was completed to determine entrapment risk for the resident, and the signed Bed Side Rails Acknowledgement was not found. 2. Review of the 9/9/21 quarterly MDS assessment showed resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance with 1 to 2 person physical assistance for ADLs including bed mobility and transfers. The resident was not shown to use any physical restraints. The following concerns were identified: a. Observation on 11/18/21 at 11:27 AM showed the resident had a mobility bar attached to the side of the bed which was away from the wall. It was approximately a 1/4 of the mattress length located near the head of the bed. Measurements taken at that time by the maintenance director showed openings that measured 8 inches by 3 and 5/8 inches, and 4 7/8 inches by 2 and 3/8 inches. b. Review of the medical record showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was nothing to show the bed rails had been evaluated for entrapment risk. 3. Review of the Side Rail Informed Consent and Release showed the risks and benefits of side rail usage were described and there was a place for signatures and dates to acknowledge these items. The risks showed .entrapment in the following ways: 1. Through the bars of an individual side rail; 2. Through the space between split side rails; 3. Between the side rail and the mattress; 4. Between the headboard or footboard, side rails and the mattress. 4. Interview with the DON on 11/17/21 at 10:34 AM verified there was not any assessment done related to entrapment with the use of side rails. She stated they were not considered a restraint so they were not assessed. She was unaware of a policy and procedure related to bed rail assessments.

Based on observation, staff interview, review of resident council minutes, and resident council interview, the facility failed to ensure meals were palatable for 1 of 1 meals tested (the evening meal on 11/17/21). The census was 31. The findings were: Review of the 8/30/21 and 9/27/21 resident council meeting minutes showed there was dissatisfaction with the evening meals. Review of the 10/25/21 meeting minutes did not include complaints about the meals. However, the resident counsel interview on 11/16/21 at 2:30 PM revealed 5 of the 5 residents in attendance had concerns that had not been resolved with the evening meals. The residents expressed the meals were not satisfying for quality, temperature or variety. The residents thought it may be due to lack of experience of the cooks and shortages in the dietary department. Review of the menu for the evening meal on 11/17/21 showed quiche of the day, peas, tossed salad, and chocolate mousse. There was an always available menu for those who preferred an alternative. These items included: cottage cheese and fruit, chicken strips, egg salad sandwich, peanut butter and jelly sandwich, hamburger on bun, macaroni and cheese, and a variety of soups. The following concerns were identified: a. Observation during the food preparation and service on 11/17/21 at 4:23 PM showed cook #1 was in the process of cooking. Interview with her at that time revealed she started in October and was still learning. She confirmed some residents picked items from the alternate menu and there were times items were not available. That evening's meal included a resident that had ordered chicken strips for the meal and was receiving a substitute of baked chicken breast. b. Observation of a test tray on 11/17/21 at 6:20 PM showed the quiche had an acceptable taste, was slightly warm and the temperature was 118.8 degrees Fahrenheit (F). The peas were unremarkable for taste and were not warm and the temperature was 93 degrees F. There were pickled beets that were served chilled and they were acceptable at 55 degrees F. There was no chocolate mousse, instead a prepackaged chocolate pudding was served. c. Interview with the certified dietary manager (CDM) on 11/18/21 at 10:44 AM verified the food was being delivered to the residents on trays with plate covers due to the current quarantine measures in place. There were no covers for the carts with the trays and no heated plates. The CDM stated she was not surprised the food did not maintain temperature and agreed another process was needed to keep the food hot and more palatable. She further confirmed she was aware of resident complaints regarding the evening meal and they continued to work on a solution. There had been some staff who were out and she was providing coverage which reduced her time to manage the concerns. She was aware communication to residents regarding substitutions was important for meal satisfaction. However, she was uncertain if the resident who received the baked chicken had been informed of the substitution prior to the meal.

Based on observation, staff interview and review of manufacturer instructions for use, the facility failed to ensure point of care equipment was cleaned as required for 2 of 2 random observations. The findings were: 1. Observation on 11/16/21 at 11:29 AM showed RN #1 obtained a blood glucose using a glucometer. The RN used a Sani-Cloth AF3 wipe and cleansed the glucometer for less than a minute, then placed the glucometer back in its case. Continued observation on 11/16/21 at 11:45 AM showed RN#1 obtain another blood glucose using the same glucometer. The RN used a Sani-Cloth AF3 and wiped the glocumeter for less than a minute and placed the glucometer back in the case. The following concerns were identified: a. Interview on 11/16/21 at 4:35 PM with RN #1 confirmed she did not follow the manufacturer instructions for disinfection time. She stated she did not think about how long the glucometer should stay wet for proper disinfection. b. Interview on 11/17/21 at 9 AM with the DON revealed she had misunderstood the manufacturer instructions for proper disinfection and confirmed the staff was not trained to follow manufacturer instructions for proper disinfection. c. Review of the Sani-Cloth AF3 manufacturer instruction for use showed, .Cleaning Procedure: .Open and unfold first germicidal cloth to remove heavy soil Contact Time: use second germicidal cloth to thouroughlyl wet surface. Allow to remain wet three [3] minutes, let air dry.

Based on observation, medical record review, resident and staff interview, and policy and procedure review the facility failed to ensure safety assessments were completed as required for 1 of 1 residents (#4) reviewed for smoking. The findings were: 1. Review of the 8/20/21 quarterly MDS assessment showed resident #4 was admitted on [DATE] with diagnoses which included hypertension, [CONDITION(S)], transient ischemic disease, anxiety and pain. Further review showed a Brief Interview for Mental Status (BIMS) score of 12 which was indicative of moderate cognitive impairment. Continued review showed a health condition for tobacco use. Observation on 11/16/21 at 10 AM of the resident's room showed a pack of cigarettes and a lighter on the bedside table. Interview with the resident at that time revealed s/he went outside twice a day to smoke. S/he further stated, they let me keep my cigarettes and lighter in my room because it was too difficult to find a nurse to get them where they were locked up. The following concerns were identified: a. Medical record review showed a safe smoking assessment form was completed on 9/20/20. The assessment failed to address the resident having smoking materials in the room. b. Interview with the DON on 11/17/21 at 9:16 AM revealed she completed the smoking assessment on 9/20/20. She further revealed the process was to re-evaluate the resident for safe smoking quarterly, and confirmed that had not been done. c. Review of the Resident Smoking Policy, last revised on 4/21 showed, .3. The smoking assessment will be reviewed quarterly and if there is a significant change in the resident's condition or in the resident's compliance with the smoking policy.

Based on medical record review and staff interview the facility failed to ensure the physician responded to pharmacy reports of medication irregularities for 1 of 4 sample residents (#9). The findings were: Review of the 9/9/21 quarterly MDS assessment showed resident #9 had diagnoses that included dementia, anxiety and depression. The resident received antipsychotic and antidepressant medications daily. Review of the 10/26/21 pharmacy recommendation report showed the resident was receiving [MEDICATION(S)] (an antidepressant medication) 60 milligram (mg) daily and [MEDICATION(S)] (an antidepressant medication) 25 mg daily at bedtime. The recommendation showed Please review and consider an attempt at a gradual dose reduction (GDR) while concurrently monitoring for reemergence of depressive and/or withdrawal symptoms. Further, the report showed this was a repeated recommendation from 9/15/21. The following concerns were identified: a. Review of the pharmacy report and the medical record showed there was no physician response to the recommendation. b. Interview with the DON on 11/18/21 at 9:47 AM revealed the physician was on vacation and had not acknowledged the pharmacy irregularity report. She confirmed it had been since 9/15/21 and there was no physician response.

Based on medical record review, staff and resident interview, and review of facility policies and procedures the facility failed to ensure residents were free from unwanted sexual contact for 2 of 2 abuse investigations reviewed (involving residents #6 and #7). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 14 of 15 indicating the resident was cognitively intact. The following concerns were identified: a. Review of the progress note dated 3/18/21 at 2:23 PM showed another resident walked up behind him/her, called him/her sweetie and kissed the residents neck. The other resident (#5) then reached inside resident #7's shirt and grabbed his/her breast. Resident #7 said, You get your hand out of there. This progress note was entered by the DON. b. Interview with activity aide #1 on 4/7/21 at 10:20 AM revealed she was doing a craft activity with resident #7 on 3/18/21 in the sun room, when resident #5 leaned over from the back of the chair, whispered in resident #7's ear, kissed his/her neck and slid his/her hand down the front of resident #7's shirt. It was not heard what was whispered, however resident #7 said, Get your hand out of there and seemed very upset. Activity aide #1 immediately told the nurses of the incident. c. Interview with the DON on 4/7/21 at 9:40 AM revealed the incident with resident #7 had occurred as described, the leadership staff investigated the incident, and resident #7 had been offered access to therapeutic counseling services, but declined. d. Interview with the resident on 4/6/21 at 11:30 AM revealed s/he Never had any problems with the other residents here. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #6 had a BIMS score 15 of 15 indicating the resident was cognitively intact. The following concerns were identified: a. Review of the progress notes for resident #6 showed on 4/3/21 s/he was sitting alone in the sun room when resident #5 came up behind him/her, wrapped his/her arms around his/her upper body and grabbed his/her breasts. Resident #6 said, No, No, No!. Resident #5 left the sun room. The facility staff was immediately informed of the occurrence. b. Interview with resident #6 on 4/6/21 at 11:45 AM revealed s/he feels residents are treated well, with respect, and s/he feels safe in the facility. The resident stated, I know that another person got attacked. I was sitting in the sun room and [s/he] came up behind me, put [his/her] arms around me and grabbed my breasts. I told [him/her] No! No! and [s/he] left the room. I told the aide and she told the nurse. I don't think anyone saw it happen. The resident further revealed s/he had not been bothered since. c. Interview with the DON on 4/7/21 at 9:40 AM revealed she had done the preliminary investigation on the incident and confirmed the incident between resident #5 and resident #6 did occur as reported on 4/6/21. The clinical leadership staff had not had time to meet and complete the investigation. 3. Review of the facility policy number 105 (revised on 1.2021) showed (a)ii sexual abuse is non-consensual sexual contact of any type with a resident. The policy also showed It is [the facility's] policy that each resident well be free from abuse. Residents will be protected from abuse, neglect, and harm while they are residing at the facility.

Based on medical record review, staff interview and resident interview, the facility failed to ensure the MDS assessment was accurate for 1 of 12 sample residents (#19) reviewed. The findings were: Review of the quarterly MDS assessment dated [DATE] showed resident #19 had a stage 2 pressure injury. Interview with the resident on 2/25/20 at 9:57 AM revealed the resident denied any sores or open injuries. Interview with RN #1 and RN #2 on 2/26/20 at 11:21 AM revealed resident #19 had never had a pressure injury at any time. Interview with the DON on 2/26/20 at 11:23 AM revealed the resident had never had a pressure injury and the expectation was the entry in the MDS assessment would reflect that.