Every finding on record at Homestead Manor a Palace Community

Based on observations, interviews and record review the facility failed to prepare food under sanitary condition by ensuring the gas burner stove was cleaned and maintained on a regular basis. The gas burner contained brown-like food stains and food particles on top and black like buildup on the side panel of the stove and grill. This has the potential to affect 84 out of 85 residents who eat orally residing in the facility at the time of the survey. The findings included: Observation of the gas stove burners on 8/07/24 at 11:24 AM with the Dietary Supervisor revealed brown-like food stains and food particles on top and black like buildup on the side panel of the stove and griddle. Photographic evidence submitted. On 8/07/24 at 11:26 AM, interview with the Dietary Supervisor. She revealed the gas stove is cleaned everyday and that the facility is purchasing a new stove. On 8/07/24 at 1:38 PM, interview with the Registered Dietitian (RD). She revealed the stove is cleaned daily and weekly with a deep clean monthly. On 8/07/24 at 1:43 PM, interview with the Administrator. He revealed he could probably produce kitchen cleaning task sheet for weekly and monthly that the staff has done but not for daily cleaning. He revealed that the black like buildup was soot and was accumulated from cooking on it at breakfast and lunch. Record review of the Kitchen Cleaning Task Weekly dated 7/05/24, 7/12/24, 7/19/24, 7/26/24 and 8/02/24 and Kitchen Cleaning Task Monthly dated 1/01/24, 2/01/24, 3/01/24, 4/01/24, 5/01/24, 6/03/24, 7/01/24 and 8/01/24. No documentation of the Kitchen Cleaning Task Daily was provided. Kitchen Cleaning Task Weekly and Kitchen Cleaning Task Monthly documented wash behind your ovens and fryers to eliminate grease and clean underneath any appliances and other surfaces. Second observation of the gas stove burners on 8/08/24 at 7:31 AM during breakfast preparation with the Dietary Supervisor and the Administrator revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted. On 8/08/24 at 7:32 AM, interview with the Dietary Supervisor. She stated, At the end of the shift at 7:00 PM yesterday, I cleaned the stove. I spray with degreaser, scrubbed and wash it out. On 8/08/24 at 7:33 AM, interview with the Administrator. He stated, She cleans daily for particles and soot. She cleans weekly and scrubs every part of the stove. Once a month, we remove the burners and clean them with [ ] from Corporate and do a complete cleaning of the stove. Third observation of the gas stove burners on 8/08/24 at 11:11 AM during lunch preparation revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted.

Based on observation, interviews, and record review the facility failed to prepare food under sanitary conditions by ensuring the gas burner stove was cleaned and maintained on a regular basis. The gas burner contained brown-like food stains and food particles on top and black like buildup on the side panel of the stove and grill. This has the potential to affect 84 out of 85 residents who eat orally residing in the facility at the time of survey. The findings include: Oberservation of the gas stove burners on 8/7/2024 at 11:24 AM with the Dietary Supervisor revealed brown-like food stains and food particles on top and black like buildup on the side panel of the stove and griddle. Photographic evidence submitted. On 8/7/2024 at 11:26 AM, interview with the Dietary Supervisor, she revealed the gas stove is cleaned everyday and the facility is purchasing a new stove. On 8/7/2024 at 1:38 PM, interview with the Registered Dietician (RD), she revealed the stove is cleaned daily and weekly with a deep clean monthly. On 8/7/2024 at 1:43 PM, interview with the Administrator, he revealed he could probably produce a kitchen cleaning task sheet for weekly and monthly cleaning staff has done but not for daily cleaning. He revealed the black like buildup was soot and accumulated from cooking on it at breakfast and lunch. Record review of the Kitchen Cleaning Task Weekly dated 7//5/2024, 7/12/2024, 7/19/2024, 7/26/2024, and 8/2/2024 and Kitchen Cleaning Task Monthly dated 1/1/2024, 2/1/2024, 3/1/2024, 4/1/2024, 5/1/2024, 6/1/2024/ 7/1/2024, and 8/1/2024 had no documentation the Kitchen Cleaning Task Daily was provided. Kitchen Cleaning Task Weekly and Kitchen Cleaning Task Monthly documented wash behind your ovens and fryers to eliminate grease and clean underneath any applicances and other surfaces. Second observation of the gas stove burners on 8/8/2024 at 7:31 AM during breakfast preparation with the Dietary Supervisor and Administrator revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted. On 8/8/2024 at 7:32 AM interview with the Dietary Supervisor, she stated, At the end of the shift at 7:00 PM yesterday, I cleaned the stove. I spray with degreaser, scrubbed and wash it out. On 8/8/2024 at 7:33 AM interview with the Administrator, he stated, She cleans daily for particles and soot. She cleans weekly and scrubs every part of the stove. Once a month, we remove the burners and clean them with [ ] from Corporate and do a complete cleaning of the stove. Third observation of the gas stove burners on 8/8/2024 at 11:11 AM during lunch preparation revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted.

Based on observation, interview and record review the facility failed to promote resident's dignity and respect for one resident (Resident number 10) out of eleven residents during dining in the [NAME] wing. This practice has the potential to affect all seven residents out of eleven residents who eat orally and required assistance with feeding on the [NAME] wing at the time of the survey. The findings included: Record review of the Dining Room Policy and Procedures revision date 11/01/2016, review date 1/08/2024 documented: Policy-The facility residents will be provided with nourishing, palatable and attractive meals to meet resident's daily nutrition and special dietary needs; Procedure: 3) Positioning and assistance at mealtime must be appropriate for the resident's needs and 4) Treat residents with dignity and respect. Review of the Demographic Face Sheet for Resident number 10 documented the resident was admitted on [DATE] with a diagnosis of cerebral Atherosclerosis end stage, alzheimer's disease, Cerebrovascular disease, dementia, hypertension and encounter for palliative care. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident number 10 documented the resident's Mental Status (BIMS) Summary Score was 00, indicating severe cognitive impairment, required dependent assistance for ADLs (activities daily living) and eating and received hospice care. Observation of Resident #10 on 8/05/24 at 12:13 PM revealed the resident sitting up in bed and being fed a pureed lunch by the Hospice CNA standing over her. On 8/05/24 at 12:14 PM, interview with the Hospice CNA. She stated, I know I am not supposed to feed her standing up but there is not a chair for me to sit. She was observed continuing to stand over the resident and feeding the resident. On 8/07/24 at 8:43 AM, interview with the Director of Nursing (DON). She stated, I was told about the Hospice CNA standing over the resident and feeding the resident. They have been educated about dignity when feeding the resident. If there is no chair in the room, they should ask for a chair. They are to sit at the resident level and feed the resident. On 8/08/24 at 10:06 AM, interview with Staff B, Registered Nurse (RN). She stated, She is a hospice resident. She is total dependent for ADLs and for feeding. When feeding a resident that needs assistance, we reposition the resident, take a chair and sit beside the resident to feed them.

Based on record review and interview the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed in a timely manner for two residents (Resident #31 and Resident #46) out of 18 residents sampled as evidenced by Level I PASRR dated 2/13/15 for Resident#31 omitted diagnosis of Depression and Psychotic disorder with delusions due to known physiological condition and Level I PASRR dated 4/3/24 for Resident#46 omitted diagnosis of Major depressive disorder, and Psychotic disorder. There were 85 residents residing in the facility at the time of survey. The findings included: Resident #31 Record review of Level I PASRR for Resident #31 Screen and Determination Admitting diagnosis: Paralysis Agitation others: Altered Mental status: PASRR: Section I: Guide for Determining an indication of, or a Diagnosis of, a serious mental illness (MI), Mental Retardation (MR) or Related Condition: check those that apply: none checked. Section II: Part A: Mental Illness: No Part B- Mental Retardation: No. Signed by Social Worker from Hospice on 2/13/2015. Record review of demographic sheet for Resident #31 revealed an admitted [DATE] and readmitted [DATE] with diagnosis that included Depression and Psychotic disorder with delusions due to known physiological condition. Record review of an Annual Admission Minimum Data Set (MDS) with a reference date of 7/8/24 Section A (Identification) revealed the resident is not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section N (medications) revealed Resident #31 was taking antidepressant medication during the last seven (7) days. Section O (special treatments and therapy) revealed the total number of minutes Psychological Therapy (by any licensed mental health professional) administered to the resident in the last 7 days was Zero (0). Record review of Care Plan with Start Date 02/11/2022 and Reviewed/Revised date of 08/04/2024 revealed Resident #31 was at risk for alteration in thought process secondary to diagnosis that included depression, psychotic disorder with delusions. Interventions included: Psychiatry/neurology consult and follow up as needed and anticipate all possible needs and provide them to resident accordingly. Record review of physician orders dated 10/13/2023 revealed Seroquel 25 milligram(mg) tablet directions: one tablet by mouth twice a day for Delusions and Sertraline 25 mg tablet directions: take one tablet by mouth once a day for Depression. Record review of a physician progress note dated 10/19/17 revealed family requested Resident #31 be followed up by a Neurologist from psychiatric point of view. Record review of a Report of Consultation dated 7/7/23 revealed a consulting physician Neurologist Report with findings of a diagnosis that included: Depression. Record review of a Psychiatric Note dated 2/2015 with diagnosis that included: Anxiety. On 08/08/24 10:09 AM The Director of Nursing (DON) stated Resident #31's diagnosis of Depression and Psychotic disorder were secondary to Parkinson Disease, and therefore the PASRR did not need to be reviewed. There is no documentation specifying that this resident's diagnosis of Depression is secondary to Parkinson Disease. The Gradual Dose Reduction (GDR) from pharmacy indicated that the hallucinations were secondary to Parkinson. Review of Consultant Pharmacist Services Note to Attending Physician/Prescriber for Resident #31 dated 1/14/24 revealed a recommendation to review the following medications and consider for GDR: Zoloft 25mg QD (daily) and Seroquel 25 mg (milligrams) BID (twice daily). Physician response dated 2/27/24: cannot be reduced or discontinued (d/c) for treatment of Depression and Seroquel cannot be reduced of discontinue (d/c) for treatment of hallucinations secondary to Parkinson disease. Resident #46 Record review of demographic sheet for Resident #46 revealed an admitted [DATE] with diagnosis that included Major depressive disorder and Psychotic disorder. Record review of Preadmission Screening and Resident Review (PASRR) for Resident #46 dated 2/19/24 PASRR: Section I: PASRR Screen Decision Making: no diagnosis checked Section IV: PASRR Completion: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability Indicated. Level II PASRR evaluation not required. Electronically signed by Social Worker of local hospital on 4/3/24. Record review of a significant change MDS with reference date of 4/10/24 revealed Section A 1500: PASRR: The resident was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Further Record review of a quarterly MDS with reference date of 07/09/2024 Section I (Active diagnosis) revealed Depression. Section N revealed antidepressants and anticoagulants were taken in last 7 days and Section O the number of days psychological therapy (by any licensed mental health professional) was administered for at least 15 minutes a day in the last 7 days was 0. Record review of a Care Plan started on 3/20/24 and revised / reviewed on 7/29/24 revealed R#46 had the potential for changes in mood related to a diagnosis of Depression and history of Psychosis. Interventions included: Approach resident in a calm friendly manner, administer medications as ordered, and encourage interactions with others. Record review of physician orders revealed an order on 4/04/2024 for Trazodone 50 mg directions: take a half of tablet at bedtime for diagnosis of Depression. Record review of a Psychiatric Initial Evaluation/Consultation observation date 4/11/24 and recorded date of 4/27/24 revealed reason for initial psychiatric evaluation was for psychotropic use and a past medical history that included Depression. On 08/08/24 10:09 AM The DON and Director for Admissions revealed they both work together to ensure an accurate PASRR is completed for all residents. The process is to review the PASRR before admission by reviewing all the medications to determine if there is any psychiatric diagnosis and if the resident has a qualifying mental diagnosis, check the appropriate box and submit the PASRR to Atrezzo and they report if a Level II is required. The PASRR stays with the resident for the duration while residing in the facility unless there is a change in behavior or if the psychiatrist is involved or a mental illness history is discovered. Then a resident review of PASRR is performed after consent from the family is obtained. Then the clinicals are submitted to Atrezzo and they inform us if a Level II is required and if the needs for the resident can continued to be met in the facility. A review did not need to be submitted for [Resident #46] prior because her Depression and Psychosis are secondary to a medical diagnosis. Record review of the facility's policy titled Resident Assessment and PASAAR effective date: November 2016 Last revision date: January 7, 2017 last review date: January 7, 2017, April 11, 2017, January 11, 2024 revealed Policy: The facility must make a comprehensive assessment of each residents' needs, strengths, goals, life history and preferences, using the residents assessment instrument (RAI) specified by CMS. Procedure: 2. Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability d. A nursing facility must notify the state mental health authority or a state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental disorder or intellectual disability for resident review.

Based on observation, interview and record review, the facility failed to complete a significant change assessment (MDS) for 1 (Resident#28) out of 18 sampled residents whose assessments were reviewed. The facility had 87 residents at the time of the survey. The findings included: On 12/14/2021 at 10:30 am, Resident # 28 was observed in bed. The resident did not respond when spoken to, but her eyes were open. It was observed that the resident had two small siderails up on the bed. The resident's left arm appeared to be flaccid, had decreased movement and to have limited range of motion as it laid on the bed. The resident was in a low bed and there were two mats next to the bed, one on the right side and one on the left side. It was observed that the resident had a tube feeding pump with Two Cal HN (High [MEDICATION(S)]) tube feeding bottle and a water flush at the bedside. The tube feeding was not infusing during this observation. The resident was offsite selected for limited range of motion, and tube feeding with weight loss/dehydration. Observation of Resident #28 on 12/16/21 at 11:50 AM, revealed the resident was sitting up in a high back wheelchair, asleep, the television (TV) was on, and the resident was observed to move both arms. Record review revealed Resident #28 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of Resident #28's Annual Comprehensive Minimum Data Set (MDS) dated [DATE] and a comparison of the most recent MDS quarterly assessment dated [DATE], revealed there were declines in Section G, Functional Status, G0110 Activities of Daily Living (ADL) Assistance and Section K Swallowing/Nutritional Status. The following declines were documented: The 01/13/2021 Annual MDS documented for: Section G - Bed Mobility - 3-Extensive Assistance and 2-One person physical assistance, a 3/2. Transfers - 3-Extensive Assistance and 2-One person physical assistance, a 3/2. Locomotion on Unit - 2-Limited Assistance and 2-One person physical assistance, a 2/2. Personal Hygiene - 3-Extensive Assistance and 2-One person physical assistance, a 3/2. The most recent MDS quarterly assessment dated [DATE] documented: Section G - Bed Mobility - 3-Extensive Assistance and 3-Two+ persons physical assistance, a 3/3. Transfers - 7-Activity occurred only once or twice and 3-Two+ persons physical assistance, a 7/3. Locomotion on Unit - 7-Activity occurred only once or twice and 2-One person physical assist, a 7/2. Personal Hygiene - 4-Total Dependence and 2-One person physical assistance, a 4/2. The 01/13/2021 Annual MDS documented for: Section K - Swallowing/Nutritional Status. K100 - None. K200 - 66 IN (inches), 131 lbs.(pounds). K300 - Weight Loss - 0 - No or unknown. The most recent MDS quarterly assessment dated [DATE] documented: Section K - Swallowing/Nutritional Status. K100 - None. K200 66 IN, 110 lbs. K300 - Weight Loss - 2- Loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Yes, not on physician prescribed weight loss regimen. During an interview on 12/16/21 at 4:46 PM with the MDS Coordinator about the declines in Section G and Section K. The MDS Coordinator reported, they followed the guidelines in the MDS manual for the significant change. During an interview on 12/17/21 at 12:59 PM with the MDS Coordinator and Chief Nursing Officer about the declines documented in the MDS, it was revealed that they did not think a significant change assessment needed to be completed.

Based on observation, interview, and record the facility failed to: 1) ensure that food was served under sanitary conditions during dining as evidenced by staff not [MEDICATION NAME] proper hand hygiene and 2.)store food under sanitary conditions by ensuring resident's food items were labeled. This has the potential to affect eighty-three residents who eat orally out of eighty-seven residents residing in the facility. The Findings included: 1). Record review of the facility's policy and procedures titled, Hand Hygiene, dated 06/25/2013, revised 01/10/2019, revealed, Hand Hygiene: The following is a list of some situations that require hand hygiene: Before and after eating or handling food (hand washing with soap and water); Before and after assisting resident with meals. Dining observation on 10/22/2019 revealed that the meal cart arrived at 12:05 PM. Further observations from 12:19 PM to 12:26 PM revealed the certified nursing assistant (Staff A) encouraging a resident to eat. She was observed touching the resident, and then grabbing the resident's beverage and touching his straw to get him to drink. Staff A touched the resident again, and then touched the chair and pulled it closer to the resident; throughout the whole process she did not practice hand hygiene by washing her hands or utilizing the hand sanitizer dispenser that was located in the dining area. Interview with Staff A on 10/22/2019 at 12:35 PM revealed that when passing out meals the first thing to do was to wash her hands. The times that she would wash her hands was whenever she touched the resident, and she would use hand sanitizer if she did not touch the resident. However, whenever she touched the resident she had to wash her hands. Staff A was aware that she should have practiced proper hand hygiene when assisting the residents. Interview with the Director of Nursing (DON) and Administrator on 10/23/2019 at 10:31 AM revealed that they were going to re-inservice staff on proper hand hygiene. 2. ) Record review of Foods Brought from Home Policy and Procedure (Effective 07/2012; Revised 1/01/19) documented: Purpose-In order to better meet each individual's, cultural and personal preference needs, residents should be able to enjoy safe, palatable, favorite foods brought in by their families or loved ones. Procedure-Perishable foods must be stored in original sealed container or in re-sealable containers with tightly fitting lids in the refrigerator. All containers will be labeled with the resident's name and dated. Observation on 10/22/2019 at 11:59 AM of the Kitchen Refrigerator used for storage of resident's foods brought from home showed half of an avocado in cellophane wrap that had a date written on it but was not labeled with a resident's name. A container of blueberries had a date written on it but was not labeled with a resident's name. Interview on 10/22/2019 at 12:01 PM with the Registered Diet Technician / Kitchen Supervisor revealed that she stated: The resident's food is kept in the refrigerator in the kitchen with the date written on it but no resident's name. I know who it belongs to.

Based on observation, interview, and policy review the facility failed to assure that the garbage and refuse area was clean and cardboard boxes were properly disposed and contained on the facility grounds. The Findings included: Record review of the Recycling-Selected Items Policy and Procedure dated 8/13/2019 documented:It is the policy of the Facility to recycle cardboard boxes that contain dry good items. Procedure : Maintenance personnel to open these boxes and place them in the cardboard housing area by the trash compactor. Maintenance staff will call the cardboard company for pick up when needed. Observation on 10/21/2019 at 1:59 PM of the garbage and refuse area with the Registered Diet Technician / Kitchen Supervisor revealed that the area had a garbage compactor and cardboard boxes were scattered on the ground. The cardboard boxes were not contained in a garbage bin. Interview on 10/21/2019 at 2:00 PM with the Registered Diet Technician / Kitchen Supervisor revealed that she stated: We contract with a company to pick up the cardboard. Maintenance is responsible for this. Observation on 10/21/2019 at 2:16 PM of the Environmental Services Director and Maintenance Worker revealed that they were attempting to pick up cardboard boxes off the ground and place them on palettes. The cardboard boxes were not contained in a garbage bin. Interview on 10/21/2019 at 2:17 PM the Environmental Services Director stated: I know the cardboard boxes are not supposed to be on the ground. I have a guy who picks up the cardboard boxes every other Monday.

Based on observation, interview and record review, the facility failed to ensure dishes and utensils were cleaned under sanitary conditions as evidenced by failure to maintain a minimum wash temperature of 150 degrees Fahrenheit (F) while operating a stationary rack, dual temperature dish machine. This has the potential to affect seventy nine residents who eat orally out of eighty six residents residing in the facility. Findings included: Observation on 6/26/18 at 9:03 AM revealed two staff members operating a stationary rack, dual temperature dish machine. The temperature gauge for the wash cycle registered 144 degrees F and the rinse temperature registered 182 degree F. The posted manufacturer recommended temperatures were 150-160 degrees F for the wash cycle and 180 degrees F for the rinse cycle. The dish machine was in use at the time of this observation. Three racks of dishes were observed being washed and the following temperatures were observed on the gauges: wash 138 degrees Farhenheit, rinse 180 degrees Farhenheit; wash 144 degrees Farhenheit, rinse 180; wash 158, rinse 180. During interview with the Dietary Aide (staff C) on 6/26/18 at 9:30 AM, he said the wash temperature has to be between 150-160 degrees. He pointed to the manufacturer recommended temperature posted on the machine. The dish machine was in use at the time of this observation. He said the temperature was below 150 degrees, but the dishes continued to be processed through the machine. At 9:35 AM, the Dietetic Technician (staff D) instructed the staff to stop using the dish machine until she could call the vendor to service the machine. Review of the dish machine temperature log indicated the wash and rinse temperatures were recorded three times daily. The recorded temperature indicated the wash temperature was 160 degrees F and the rinse temperature was 180 degrees F including the temperature recorded 6/26/18. During interview with the Dietetic Technician (staff D) on 6/26/18 at 9:35 AM, she said the wash temperature according to the manufacture's recommendation should be between 150 -160 degrees and the rinse temperature should be between 180-190 degrees. She said she instructed the staff to stop using the machine until it can be serviced. Staff D said they have never used a thermometer strip to verify the machine temperature. She said this must be something new that I am not familiar with. I will have to ask the service company. Observation on 6/26/18 at 9:46 AM revealed the staff operating the dish machine. The temperature gauge for the wash cycle registered 164 degree F. The gauge indicated the wash temperature had reach the appropriate temperature, but there were no temperature strips available to verify the temperature. Observation on 6/28/18 at 9:20 AM revealed staff operating the dish machine. The temperature gauge for the wash cycle registered 142 degrees F. A second cycle was observed and the was temperature gauge registered 144 degrees Farhenheit. During interview with the Dietary Aide (staff C) on 6/28/18 at 9:20 AM, he said the temperature had been over 150 degrees, but now he has to wait for it to go back up over 150. The Dietetic Technician (staff C) instructed the staff to stop using the machine until the temperature was over 150 degrees for the wash cycle. She said she would call again for service. During interview with the Dietetic Technician (staff D) on 6/29/18 at 8:18 AM, she said she oversees the operation of the kitchen along with the Registered Dietitian Consultant and the Dietary Supervisor. The dish machine is monitored three times a day after each meal prior to using the machine. The wash temperature should be 150-160 degrees F according the the manufacturer instructions. The rinse temperature should be 180-190 degrees F. On Monday when the wash temperature was not reaching 150 degrees Farhenheit we called for service. The temperature goes up and down and usually the staff should stop using the machine until the temperature goes back up. When the service company came out on Monday he said he could not find a problem with the machine. We called him back out yesterday when the wash temperature dropped below 150 degrees Farhenheit. He did a more thorough service and I know he raised the water temperature. The gauge and thermostat were changed and the wash and rinse cycle temperatures were adjusted to reach the correct temperature. I have never seen thermometer strips being used to check the temperature of the machine, but they have been ordered so we can monitor the temperature if we have a problem. The staff is supposed to report any discrepancy in the temperature to so we can call for service right away. Review of the service invoice dated 6/26/18 revealed: Reason for request: machine. Actions: fixed. Comments: temperature. Status: complete. The service invoice dated 6/26/18 indicated the wash temperature was initially 140 degrees and then over 150 degrees. Review of the service invoice dated 6/28/18 revealed: Reason for request: machine. Actions: installed. Comments: Machine was adjusted on Tuesday (6/26/18) to reach the correct temperature. It was good at the time, but now the machine is not reaching temperature. I changed the gauge and the thermostat of the machine to achieve the correct reading. Machine rinse cycle temperature was adjusted to be 180-190 and wash cycle temperature was adjusted as well to reach 150-160. Status: complete. Review of the manufacturer specifications provided by the facility revealed: Water requirements - wash temperature minimum 150 degrees F and rinse temperature 180 degrees F. Review of the facility's policy and procedure titled, Dish Machine dated 2003 revealed: Check dish machine gauges throughout the cycle to assure proper temperatures. Stationary rack, single tank, duel temperature machine 150 degrees. Mechanical dish machine using hot water to sanitize: water sanitizing rinse as it enter the manifold may not be more than 194, all other machines 180.

Based on observation, interview and record review, the facility failed to ensure essential equipment was maintained under safe operating conditions as evidenced by failure to maintain a minimum wash temperature of 150 degrees Fahrenheit (F) while operating a stationary rack, dual temperature dish machine. This has the potential to affect seventy nine residents who eat orally out of eighty six residents residing in the facility. Findings included: Observation on 6/26/18 at 9:03 AM revealed two staff members operating a stationary rack, dual temperature dish machine. The temperature gauge for the wash cycle registered 144 degrees F and the rinse temperature registered 182 degree F. The posted manufacturer recommended temperatures were 150-160 degrees F for the wash cycle and 180 degrees F for the rinse cycle. The dish machine was in use at the time of this observation. Three racks of dishes were observed being washed and the following temperatures were observed on the gauges: wash 138 degrees Farhenheit, rinse 180 degrees Farhenheit; wash 144 degrees Farhenheit, rinse 180 degrees Farhenheit; wash 158 degrees Farhenheit, rinse 180 degrees Farhenheit. During interview with the Dietary Aide (staff C) on 6/26/18 at 9:30 AM, he said the wash temperature has to be between 150-160 degrees F. He pointed to the manufacturer recommended temperature posted on the machine. The dish machine was in use at the time of this observation. He said the temperature was below 150 degrees, but the dishes continued to be processed through the machine. At 9:35 AM, the Dietetic Technician (staff D) instructed the staff to stop using the dish machine until she could call the vendor to service the machine. Review of the dish machine temperature log indicated the wash and rinse temperatures were recorded three times daily. The recorded temperature indicated the wash temperature was 160 degrees F and the rinse temperature was 180 degrees F including the temperature recorded 6/26/18. During interview with the Dietetic Technician (staff D) on 6/26/18 at 9:35 AM, she said the wash temperature according to the manufacture's recommendation should be between 150 -160 degrees and the rinse temperature should be between 180-190 degrees. She said she instructed the staff to stop using the machine until it can be serviced. Staff D said they have never used a thermometer strip to verify the machine temperature. She said this must be something new that I am not familiar with. I will have to ask the service company. Observation on 6/26/18 at 9:46 AM revealed the staff operating the dish machine. The temperature gauge for the wash cycle registered 164 degree F. The gauge indicated the wash temperature had reach the appropriate temperature, but there were no temperature strips available to verify the temperature. Observation on 6/28/18 at 9:20 AM revealed staff operating the dish machine. The temperature gauge for the wash cycle registered 142 degrees F. A second cycle was observed and the was temperature gauge registered 144 degree Fé. During interview with the Dietary Aide (staff C) on 6/28/18 at 9:20 AM, he said the temperature had been over 150 degrees, but now he has to wait for it to go back up over 150. The Dietetic Technician (staff C) instructed the staff to stop using the machine until the temperature was over 150 degrees for the wash cycle. She said she would call again for service. During interview with the Dietetic Technician (staff D) on 6/29/18 at 8:18 AM, she said she oversee the operation of the kitchen along with the Registered Dietitian Consultant and the Dietary Supervisor. The dish machine is monitored three times a day after each meal prior to using the machine. The wash temperature should be 150-160 degrees F according the the manufacturer instructions. The rinse temperature should be 180-190 degrees F. On Monday when the wash temperature was not reaching 150 we called for service. The temperature goes up and down and usually the staff should stop using the machine until the temperature goes back up. When the service company came out on Monday he said he could not find a problem with the machine. We called him back out yesterday when the wash temperature dropped below 150 degrees Farhenheit. He did a more thorough service and I know he raised the water temperature. The gauge and thermostat were changed and the wash and rinse cycle temperatures were adjusted to reach the correct temperature. I have never seen thermometer strips being used to check the temperature of the machine, but they have been ordered so we can monitor the temperature if we have a problem. The staff is supposed to report any discrepancy in the temperature to so we can call for service right away. Review of the service invoice dated 6/26/18 revealed: Reason for request: machine. Actions: fixed. Comments: temperature. Status: complete. The service invoice dated 6/26/18 indicated the wash temperature was initially 140 degrees and then over 150 degrees. Review of the service invoice dated 6/28/18 revealed: Reason for request: machine. Actions: installed. Comments: Machine was adjusted on Tuesday (6/26/18) to reach the correct temperature. It was good at the time, but now the machine is not reaching temperature. I changed the gauge and the thermostat of the machine to achieve the correct reading. Machine rinse cycle temperature was adjusted to be 180-190 and wash cycle temperature was adjusted as well to reach 150-160. Status: complete. Review of the manufacturer specifications provided by the facility revealed: Water requirements - wash temperature minimum 150 degrees F and rinse temperature 180 degrees F. Review of the facility's policy and procedure titled, Dish Machine dated 2003 revealed: Check dish machine gauges throughout the cycle to assure proper temperatures. Stationary rack, single tank, duel temperature machine 150 degrees. Mechanical dish machine using hot water to sanitize: water sanitizing rinse as it enter the manifold may not be more than 194, all other machines 180.

Based on record and interview the facility failed to report to the appropriate authorities, allegations of abuse by two residents out of nineteen sampled residents (resident #31 and resident #69) for which allegations of abuse were reviewed. The filing of an immediate report was mandatory for all allegations of potential abuse. This facility practice has the potential to have a negative impact on the health, quality of life and safety of all eight-six residents in the facility at the time of this survey. The Findings Included: Record review of the facility's Suspected Abuse Policy dated (MONTH) 2012, revealed a policy statement to include: Residents have the right to be free from abuse, neglect, exploitation or misappropriation of property. The procedure included but was not limited to: The facility evaluates all allegations, observations, and suspected cases of exploitation, abuse and/or misappropriation of property that is alleged to have occurred within the facility. The facility reports allegations, observations, and suspected cases of neglect, exploitation, and abuse to appropriate authorities based on its evaluation of the suspected events and in accordance with the and regulations. 1. Record review of the Quarterly Minimum Data Set (MDS) for resident #31 dated 04/11/2018 revealed, the resident had a score of 13 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was able to verbalize his needs and was not cognitively impaired. Further review of the MDS revealed, the resident had adequate hearing, speech was clear, and he had the ability to understand others and express ideas and wants. During an interview on 6/26/2018 at 11:26 AM resident #31 reported, he suffered abuse in the facility. He reported that he was physically tied up to his bed and pinched multiple times in the arms. The resident explained that the abuse happened in his room, about three months ago. The perpetrators were a man and a woman that he could recognize were working together.The resident added that he reported the abuse to his brother and to the Social Worker, but the Social Worker did not believe him and told him it was a dream. The resident explained, she (the Social Worker) said I was dreaming, but I had all these bruises in my hands, both hands . she kept insisting that I was hallucinating, but I was not. On 6/28/18 at 11:49AM, the Director of Social Services (DSS), revealed, resident # 31 spoke to her around the time that the resident came out of crisis care. The resident told her, the nurse that watched him tied him up, and tried to rape him, it was in the middle of the night, the resident was sleeping but managed to (fend him off). The Social worker explained, she did not report the residents' abuse allegations because it was not abuse, it was a delusion. As far as the investigation, the DSS stated that she talked to the psychiatrist and the psychiatrist noted that the resident had paranoia. The DSS also stated, the residents' brother, told her that resident #31 was in Jail in ( .another country) and he might have reverted to that era. In addition, the SSD stated, the residents' brother stayed in the room, with the resident during the night the alleged abuse happened.The DSS documented, her investigation in the progress notes that remained in the residents' file. A review of the DSS documented investigation revealed, only one note that addressed some of the resident's above-mentioned allegations. The note dated, 5/23/2018- Resident has been noted with delusion, expressed being in a dungeon, as per family, resident spent some time in ( ) jail and is reverting to his history. The note added, the resident can get agitated . The notes did not address the residents' allegations of abuse. Record review of the Nurses Notes for resident #31 revealed, the resident was discontinued from crisis care on 5/8/2018. The nurses notes dated 5/5/2018, timed 1:00 AM: Resident observed in bed awake. Hospice nurse at bedside. Became very agitated, combative to staff. Repeatedly stating, I'm going home, I'm leaving. Tries to climb out of bed. Attempted to administer as needed (PRN) [MEDICATION NAME] but not successful. 1:1, change position tried but not effective. Place call to hospice. New order. Called pharmacy to verify script and doctors signature. Called Hospice. Pending verification from Hospice. All safety measures in place. There are notes that resident #31 was combative and verbally abusive also noted on 5/7/2018 at 1:00 AM and at 6:40 AM, notes at 6:40 AM included that the resident was kicking staff. None of the Nurses Notes addressed the resident's bruises or his allegations of abuse. During an interview on 06/28/18 at 4:00 PM with resident #31, the facility Administrator, and the Social Services Director, the resident described what he remembered about that night; he stated, I reported it to her (pointing to the Social Services Director) and she told me you are crazy! I believe it all happened here, I was under some stairs, my brother was there, he was with me at first, (facility) staff, I believe her name was { }or something like that, a ( ) girl, I told her to keep away from me . I felt as if someone raised my hands and they tied me up to some iron, it was like a box with a latch, and they used a blanket to tie me up. (The resident explained that the person that was tying him up was a Certified Nursing Assistant (CNA) he kept seeing in the facility after the incident. The CNA went into the room to take care of the roommate, he continued . I was alone for some time, tied up, I began to scream, they heard me, and said to me your time has come. Resident #31 explained, the statement Your time has come meant that they were going to sexually assault him. I told them, you guys are going to have to kill me, that's not going to happen, you are going to have to kill me first they left and I could hear the clicking sound of a gun. I remained in the box I managed to untie myself and got out of there. I told my brother, after he finally showed up, then they took me to my room, I believe in a car. I fought the guy that did that to me, he remained sitting in my room, he did not even talk to me, I told the Social Services Director, the man still had his bag in my room when I told her. The resident appeared upset and began to cry as he continued to explain, I feel very bad, that this happened to me, can't you imagine? On top of that no-one believes me! I felt so bad and scared that my brother had to sleep here with me . The social worker confirmed, the resident's brother had to stay and sleep in the room with the resident, because the resident was feeling so bad. The resident explained, he had bruises on his arms at the time, the bruises were gone, but he showed them to social worker at the time. About the CNA, the resident reported, he recognized her in the facility and he warned her to stay away, the social worker knows her. When asked about the CNA, the social services director stated, she removed staff from working with him any time he asked. The Social Worker confirmed, resident #31 had indicated that the hospice male nurse was the one that had made him felt threatened. She later reported, she never took a statement from the CNA or from any of the Male Nurses that cared for resident #31, during crisis care. 2. Record review of the face sheet revealed that resident # 69 was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] for resident # 69 for the annual assessment revealed a Brief Interview for Mental Status assessment (BIMS) score of 13 out 15, identifying the resident as cognitively intact. Record review of the care plan dated 2/28/2018 for resident # 69 revealed, resident had potential for changes in mood related to depression, anxiety and potential for drug related complications related to use of [MEDICAL CONDITION] medications. Record review of the social services history/psychological assessment dated [DATE] for resident # 69 revealed, she was readmitted to the facility. Resident #69 was alert and oriented to self, place and time and was able to express her needs. Record review of the Physician order [REDACTED].#69 revealed, the following medications but not limited to, [MEDICATION NAME] 0.25 milligrams (mg) 1/2 tablet by mouth twice daily for anxiety; Gapapentin 300 mg 1 capsule by mouth three times per day (TID); [MEDICATION NAME] 15 mg 1 tablet daily for chronic pain. [MEDICATION NAME] 30 mg 1 tablet by mouth at bedtime; [MEDICATION NAME] 50 mg 1 tablet by mouth twice per day. Record review of the resident grievance complaint investigation report form for resident #69 dated 06/25/2018 revealed on 06/22/2018 resident #69 alleged she was pushed to the bed when she was putting on her night gown. The resident alleged that someone she had never seen before might have come in through the window. Spoke with Certified Nursing Assistant (CNA) and she went in the room and the resident was laying in bed when she was done with rounds. The facility camera was reviewed and no one was seen entering the room besides the CNA. After looking at the cameras and speaking to the CNA, it appeared resident #69 was dreaming and was startled. The CNA Continued to do rounds, and encouraged the resident to call for assistance when needed. The note was signed on 06/27/2018 by resident #69. Record review of the nurse's notes from 06/22/2018 to 06/24/2018 for resident #69 revealed, there was no skin assessment related to the abuse allegation. Record review of the social services note dated 06/25/2018 for resident # 69 revealed, the Social Worker and administrator met with the resident. Resident #69 was observed with delusions in the evening and appeared confused. The family was made aware and mentioned the resident would make up stories at times and had attention seeking behavior. The Social worker would continue to support her. Record review of the social worker notes dated 06/26/2018 for resident # 69 revealed, the social worker met with resident #69 and talked about the alleged allegations. Resident #69 expressed, she might sometimes call people racist names, since her former husband used to do the same to her. The Social worker assessed her and would try to help her with the best care. Record review of the CNA assignments dated 06/22/2018 revealed that staff B, a CNA worked the 3 PM to 11 PM shift and had the assignment 20A to 24 B. Record review of the CNA assignment dated 06/24/2018 for the 3 PM to 11 PM shift revealed, staff B, worked a special assignment. Record review of the CNA assignment dated 06/25/2018 for the 3 PM to 11 PM shift revealed, staff B, worked and had rooms 20A to 24 B. Record review of the CNA assignment dated 06/26/2018 for the 3 PM to 11 PM shift revealed, staff staff B, was not working that day. Observation and interview on 06/26/2018 at 04:10 PM with resident #69 revealed, the resident reported, last night and two nights ago staff made her take a shower and she had [MEDICAL CONDITION]. The [MEDICAL CONDITION] made her feel cold and the shower was very cold. Resident #69 stated, she was a ( ) lady. Resident #69 said, it was the 3 PM to 11 PM shift. Resident #69 said, she told the staff she did not want to take a shower three times. Resident # 69 reported, the staff told her they were the boss and gave her a shower. Resident #69 mentioned, the first name of a staff member associated with the incident. Resident #69 noted, the name tag was turned over. Resident # 69 reported, all the staff treated her with respect except for that staff. Interview on 06/27/2018 at approximately 4:25 PM with resident #69 in her room revealed, the incident happened last Saturday. Resident #69 noted, she did not tell her daughter at that time since it was late at night. Resident #69 said she was in the bedroom and a staff made her leave. Resident # 69 mentioned, the first name of a staff member associated with the incident. Resident #69 mentioned, she thought the staff was a certified nursing assistant. Resident #69 stated, she did not remember the last name of the staff and didn't see her name tag. Resident #69 said, the staff member threw her into the shower. Resident #69 stated, When I think about it, more is coming back to me. She grabbed my right arm and threw me against the shower wall. Resident #69 showed a medium sized bruise (brownish-yellow) to her right outer arm near her elbow. Resident #69 said, the staff member made her shower in cold water. Resident #69 said she dried herself with a towel. Resident #69 had told the staff she didn't want a shower. The staff used profanity and told her she should have a shower. Resident #69 said she wanted to go into the bed. The staff used profanity and told resident #69 she could not go to bed until she was told to. Resident #69 stated, the staff threw her on the bed. Resident #69 noted that the staff hurt her so bad. The staff member told her while utilizing profanity,that she should shut up with that crying. Resident #69 said, she finally went into the bed. Resident #69 noted that she fell asleep. Resident #69 said the staff was a ( ) person who worked there. Resident #69 stated that she felt this was abuse, since the staff was taking advantage of her. Resident #69 said that she didn't tell the other staff what happened. Interview on 06/28/2018 at 9:46 AM with the Activities Director regarding resident #69 revealed, during the Monday morning meeting it was either on Monday (MONTH) 25, (YEAR) or Monday (MONTH) 18, (YEAR). The Activities Director said, she can't be sure about the date. The Activities Director noted, at the morning meeting, the Director of Nursing and the administrator were there. The dietary supervisor was there and resident #69 was not there. The Admission Director (the manager on duty, MOD) had brought it up. The Activities Director said, resident #69 told the manager on duty what had happened. The Activities Director explained, there was a manager on duty on the weekend. Resident #69 had told the admission director (manager on duty) that she was pushed by a certified nursing assistant. Resident #69 had mentioned a staff member by the first name. Interview on 06/28/2018 at 10:40 AM with the Director of Admissions revealed, she knew resident #69. The Director of Admissions noted, she was working as the manager on duty for the weekend. The Director of Admission stated that she was part of the management team and anything that happened was handled as appropriate and/or they would call the administrator. Resident # 69's daughter was visiting on Saturday, (MONTH) 23, (YEAR). The director of admissions mentioned, at approximately 3:30 PM, the receptionist mentioned that resident #69 had called the front office and had a complaint. Resident #69 was in the dining room and was attending activities. The Director of Admissions asked resident #69 if she was okay and took her to her room. Resident #69 reported, on Friday night while she was putting on her night gown someone pushed her from behind onto her bed and told her that they where going to kill her. Resident #69 said, she didn't know who it was, since it was too dark and she couldn't see. The director of admissions (manager on duty) asked resident #69 if she was hurt and she had replied she was not. She asked her, what time this happened. Resident #69 told the manager on duty that this occurred Friday between 10:30 PM to 11 PM. The manager on duty noted, she reviewed the cameras from (MONTH) 22, (YEAR) from 10 PM to 11 PM and the only thing she saw was her CNA going into the room briefly and back out. The CNA was staff B. The manager on duty told resident #69 that she had reviewed the camera footage and saw staff B going in and out of her room. The manager on duty stated, she asked resident #69 if she was the one who had pushed her and resident #69 said it was not her, she was great. Resident #69 asked if her windows were locked, because that person might come in through the window. The manager on duty told resident # 69, they were locked and that maybe she was dreaming, since it felt real. She contacted her daughter and asked the daughter to come in to see the administrator on Monday. The daughter of resident #69 said she could not come in and wanted the administrator to contact her via phone before 10 am. The manager on duty stated, she spoke to staff B, the CNA on Saturday, (MONTH) 23, (YEAR) between 4:30 PM to 5 PM. The manager on duty asked staff B, if she heard anything with resident # 69 and if anything had happened. Staff B said, the only thing that happened with resident #69 was that she had asked her if she wanted a shower. Resident # 69 had said, no, she didn't want a shower. Staff B, told her she would sleep better and her daughter was picking her up for an event. Resident # 69 had yelled back at her with profanity stating to get out of her room. The Director of Admissions (manager on duty) said, she was there to follow up on the incident that had happened on Friday to resident #69. Resident #69 said, she didn't remember saying anything and didn't know why she had said it. The Director of Admissions (manager on duty) noted that she told the administrator on Saturday and did not report this as abuse. The manager on duty stated, the social services director who was the abuse coordinator was aware since Saturday, (MONTH) 23, (YEAR) of the incident with resident #69. The Director of Admissions concluded, resident #69 had an abusive husband and sometimes had flash backs or nightmares. Phone interview on 06/28/2018 at 1:06 PM with staff B, a CNA regarding resident # 69 revealed, she was was alert and recognized her sometimes. Staff B said, resident #69 asked for her by name. Staff B stated, she was working Friday, (MONTH) 22, (YEAR). She worked the 3 PM to 11 PM shift. Staff B noted, she took resident #69 to the shower. Staff B stated, she started to give her a shower. Resident # 69 could stand and they utilized a shower chair. Staff B noted, she was not able to shower resident # 69 completely, since resident #69 was mad. Staff B said, she didn't know why resident # 69 was mad and placed a night gown on her. Staff B said, this was after dinner. Staff B stated, she was the CNA for resident #69 for 2 years and also used to float to other assignments. Staff B, CNA said that she was not aware of anyone trying to hurt resident #69. Staff B, CNA noted that she was not aware of anyone trying to push or trying to kill resident #69. Staff B, CNA said that she was not aware of resident #69 being scared on Friday. Staff B, CNA noted that resident #69 never talked about her daughter or previous husband. Staff B, CNA said that she left Friday at 11:23 PM at the end of her shift and didn't notice anything. Staff B, CNA stated that she did not work on Saturday, (MONTH) 23, (YEAR). Staff B, CNA noted that she did work on Sunday, (MONTH) 24, (YEAR) and Monday (MONTH) 25, (YEAR). Staff B, CNA stated that on Tuesday a supervisor told her not to come to work due to an investigation, but didn't tell her what it was about. Staff B, CNA said that she has not been back to work since Tuesday, (MONTH) 26, (YEAR). Interview on 06/28/2018 at 1:43 PM with the Director of Social Services, who was also the abuse coordinator revealed, resident #69 was forgetful. Resident #69 was alert to name, place, situation, but not time and not date. Resident #69 had her good days and talked about her daughter. Resident # 69 talked about her history and told her she was a battered wife. Resident #69 had expressed how she had an abusive husband. The Director of Social Services stated that on Monday, (MONTH) 25, (YEAR) resident #69 was mad. The director of social services said that she was aware resident # 69 had alleged that someone pushed her from behind into the bed while she was putting on her gown. Resident #69 didn't know who the person was. The director of admissions (manager on duty) called her on Saturday and told her that resident #69 had alleged abuse. Resident #69 had said she couldn't see the person's face, because it was very dark. The person had pushed her to the bed. The Director of Admissions (manager on duty) looked at the camera. It was at midnight and the only person that went into the room was staff B, CNA. The Director of Admissions (manager on duty) told her on Saturday at approximately 3 PM. Resident #69 was visiting with her daughter at the nursing home. The daughter of resident # 69 left. Resident #69 mentioned this to director of admissions (manager on duty) and she followed up on this. The director of social services / abuse coordinator stated that she was not aware of someone trying to kill resident #69. The director of admissions (manager on duty) documented the incident on the manager on duty report. The admission director (manager on duty) started the investigation on Saturday and this was finished yesterday. The director of social services / abuse coordinator noted that regarding resident #69 it was not abuse. The Director of Social Services stated, resident #69 had the bruise to her right arm on 06/17/2018 from the hospital. The daughter of resident # 69 confirmed that she had a bruise upon admission from the hospital on [DATE]. The Director of Social Services said that she spoke to staff B, CNA that evening. Staff B, told her she did her rounds like normal. The director of social services said, staff B, told her she did not shower resident #69 at midnight. The director of social services noted that they looked in the cameras and it appeared resident # 69 was startled and had a nightmare. The director of social services / abuse coordinator confirmed that she did not report this as an allegation of abuse. The abuse coordinator concluded regarding resident #69, She was having nightmares or having a bad night. Maybe she had delusions. Maybe she was reverting back to her history of abuse.

Based on record review, observation, and interview, the facility failed to implement the care plan for two (resident #76 and #72) of twenty two residents whose care plans were reviewed as evidenced by failure to monitor for signs and symptoms of the recurrence of chronic ophthalmic conditions with redness and drainage in accordance with the care plan. Findings included: 1. Record review revealed resident #76 was admitted to the facility on [DATE]. A comprehensive minimum data set (MDS) assessment dated [DATE] revealed multiple diagnosed including: [DIAGNOSES REDACTED]. The MDS revealed resident #76 has impaired long and short term memory with severely impaired decision making skills and he was totally dependent for care. Review of the care plan revealed resident #76 had a Sensory Perceptual deficit R/T(related to) severely impaired vision. [DIAGNOSES REDACTED]. Goal: Eye consult at least annually or as deemed necessary. Approaches included: Observe resident for any visual problems, excessive tearing, redness, swelling, drainage, c/o (complaints of) eye pain, and burning or itching. Eye consult and follow up as needed. Review of the nursing notes through 6/29/18 revealed no reference to redness or drainage from resident #76's eyes. Observation on 6/26/18 at 4:18 PM revealed resident #76 in his room in bed. His left eye was very red and weeping a yellowish secretion. Observation on 6/27/18 at 2:00 PM revealed resident #76 in bed. His left eye was was draining a thick yellowish, type excretion and his eyelashes were matted with this yellow secretion. Observation on 6/28/18 at 9:51 AM revealed resident #76 in his room in bed. His eyes were closed during the initial observation. There was a yellowish discharge on his face below the left eye. His eyelashes were moist and coated with the yellow colored secretion. When resident #76 opened his eyes, the left eye was slightly reddened and the interior corner or the eye had an accumulation of this yellow colored secretion present. During interview with the 7AM-3PM shift Registered Nurse (staff E) on 6/28/18 at 3:33 PM, he said resident #76 has no current treatment for [REDACTED]. When I take care of him I have not noticed any redness or drainage from his eyes, but I can follow up on that. His last eye care consult was 5/22/18. The consult indicated his eyes were clean and the cornea was clear. The plan was to assess for changes and follow up in one year. During interview with the Certified Nursing Assistant (staff F) on 6/28/18 at 3:43 PM, she said resident #76 gets eye drops by the nurse for an infection. There is a yellow drainage that comes from his eyes. I have to report to the nurse when I see the yellow drainage and I have to clean his eyes. I did not notice this drainage today, but I have seen it before when I take care of him. When the nurse puts the drops in his eyes, the yellow liquids just runs out of his eyes. The nurse knows about the draining eyes. During interview with the 3PM-11PM shift Registered Nurse (staff G) on 6/28/18 at 6:02 PM, he said resident # 76 has not recently had any condition that would cause his eyes to drain. I know he has been treated in the past for [MEDICAL CONDITION]. If I saw any kind of drainage I would call the doctor to report the concern. The doctor would prescribe a treatment and I would place the order. He should be monitored regularly for drainage due to a history of [MEDICAL CONDITION]. He is currently not getting any treatment, but it is a chronic condition that keeps coming back. It is not contagious, but we would still take precautions to wash our hands and wear gloves during care. He is totally dependent on staff for care. Observation on 6/28/18 at 6:10 PM with staff G present revealed drainage from both of Resident #76 's eyes. Staff F stated, he has a greenish white secretion from both eyes. I do not see any redness. These secretions are not normal and I will need to report this to the doctor. I do not recall that he had the secretions yesterday. I called the doctor yesterday to report another concern, but not the eye secretions. Staff F was observed on the telephone leaving a message for the doctor. Observation on 6/28/18 at 6:14 PM revealed a small amount of yellowish colored secretions from resident #76's right eye and a more substantial amount from the left eye to include matted eye lashes and drainage from the interior corner and under the lower lid onto his face. 2. Record review revealed resident #72 was admitted to the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE] revealed resident #72 had impaired vision, impaired cognitive status with a BIMS (brief interview for mental status) score of 3, and required extensive assistance with ADL's (activities of daily living). Review of the care plan revealed resident #72 had impaired vision. Goals included: Eye care consults at least annually or per resident preference. Approaches included: Observe resident for any visual problems, excessive tearing, redness, swelling, draining, c/o (complaints of) eye pain, burning or itching and notify MD (medical doctor), eye Consult as indicated. The care plan was last revised on 5/23/18 to include: Resident is followed by Optometrist secondary to Blepharitis. Review of the nursing notes from 3/3/18 through 6/29/18 revealed no documentation of any signs or symptoms of infection, redness or drainage from resident #72's eyes. Review of the treatment administration record (TAR) revealed no evidence of monitoring the condition of Resident # 72 eyes. Observation on 6/26/18 at 11:50 AM revealed resident # 72 in the main dining room during a group activity. Her eyelids were very red in color and both eyes were matted with a thick yellowish colored drainage. The upper and lower eyelids of both eyes were matted. Observation on 6/26/18 at 12:30 PM revealed resident #72 observed in the West dining room during lunch. Her eyes remained red and were draining a yellowish colored substance. Observation on 6/27/18 at 12:25 PM revealed resident #72 in the dining room. Her eyes continued with draining under her eyes onto her face, matted eyelashes and reddened eyes. During interview with the 7AM-3PM shift Licensed Practical Nurse (staff H) on 6/28/18 at 3:19 PM, she said she is not the permanent nurse for resident #72. When I went to check on her this morning I noticed she had some substance in her eye like you get when you sleep. I wiped her eye and I instructed the Certified Nursing Assistant ( C N A) to make sure to give good eye care when she takes her into the bathroom. She does not currently have orders for eye drops or treatment to her eyes. I did not observe any redness. The last time I was assigned to care for her was a few days ago and I did not notice any redness or drainage from her eyes. Today when I saw her in the morning during rounds, the matter on her eyes was not green in color and did not appear to show sign of infection. She has a history of Blepharitis. Observation of resident #72 was made on 6/28/18 at 3:30 PM with staff G present. Staff G said resident #72's left eye is very red. I did not notice this before. Staff G said there is a discolored drainage below her right eye and on her eye lashes. I did not see this earlier. I will have to report this to the doctor. During interview with a 3AM-11PM shift C N A (staff I) on 6/28/18 at 4:05 PM, she said resident # 72 is on my regular assignment. She has problems with her eyes. The nurse is always putting eye drops in her eyes. She has some little yellow stuff on her eyes. She does not have this all of the time. When I see the yellow color I tell the nurse and she will use the drops. If I see any redness or yellow color from her eyes I will report to the nurse. She needs assistance with her care. I will always clean her eyes and report to the nurse. During interview with the 3AM-11PM shift Registered Nurse (staff J) on 6/28/18 at , he said resident # 72 has Blepharitis which is an inflammation of the eyelids. As a nurse I monitor for abnormal swelling and/or abnormal drainage. The redness to her eyelids is not abnormal. It is related to her condition. She is not currently receiving any treatment. Drainage would not be a normal condition. If there is draining it would be cleaned and if it was discolored it would reported to the physician. Observation of resident #72 was made on 6/28/18 at 5:57 PM with staff J present. Staff J observed the yellowish colored drainage from resident #72's right eye and said the C N A or nurse would clean her eyes. This color drainage would not need to be reported to the doctor. She does not have this drainage all the time I would call the doctor is the drainage was green in color. During interview with with the 7-3 shift Licensed Practical Nurse (staff K) on 6/29/18 at 7:39 AM, she said resident # 72 has a history of Blepharitis and she has been treated in the past. She is followed by our Mobile Eye Care service. She is not currently receiving treatment. She was treated in January. The eye doctor comes monthly. The last time she was seen was 2/26/18. If she is having drainage it would be reported to the eye doctor when he comes. The redness in her eyelids is Chronic. The drainage comes and goes. The treatment is ordered when the drainage is present, but she has no current treatment ordered. The treatment in the past has been [MEDICATION NAME] eye drops which is generally ordered for 30 day and this is effective to resolve the drainage. This condition is not contagious. The C N A and I clean her eyes regularly.

Based on record review and interview, the facility failed to ensure the comprehensive care plan was reviewed and revised for one (resident #76) of twenty two residents whose care plans were reviewed as evidenced by failure to ensure approaches included the use of hand rolls for contractures to bilateral hands. Findings included: Record review revealed resident #76 was admitted to the facility on [DATE]. Review of a quarterly minimum data set ((MDS) dated [DATE] and an annual MDS dated [DATE] revealed resident #76 was totally dependent on staff for Activities of Daily Living (ADL) care. He had Range of Motion (ROM) limitations to bilateral upper and lower extremities. Special services include Restorative Nursing for passive ROM. Review of the care plan implemented 9/6/17 revealed resident #76 had self-care deficits and is mostly bed bound. He requires total assistance with ADL ' s and has right lower extremity contracture and contractures to upper and lower limbs. The goal is to continue to receive and maintain optimum care. Approaches included Restorative therapy as indicated, but did not include the use of bilateral hand rolls. The care plan was last reviewed on 6/2/18. Review of the physician's order [REDACTED]. Review of a restorative nursing progress notes dated 5/24/18, 3/1/18, and 11/27/17 revealed bilateral had rolls are used for positioning. Review of Restorative Nursing Program logs indicated ROM services were provided, but observations revealed inconsistent use of bilateral hand rolls as ordered. During interview with the Registered Nurse (staff E) on 6/28/18 at 3:33 PM, she said resident #76 uses bilateral hand rolls. He has contractures to both hands. The orders are for bilateral hand rolls to be on during the day time. The hand rolls are provided by Restorative. They aides put them on in the morning. When I make rounds, I check to make sure he is wearing both hand rolls. During interview with the Certified Nursing Assistant (staff F) on 6/28/18 at 3:43 PM, she said resident #76 does not move too much on his own. We have to reposition every two hours because he is not able to do this for himself. He needs total care for ADL's (activities of daily living). He has contractures to his hands and one leg. We use a pillow between his legs and he has small blue pillows for both hands. We have to use these pillows in both hands every day. If not his nails could cut his hands. He is supposed to wear these all day, except when we clean his hands. They are removed during care only. He does not move, so he is not able to remove them. He also gets range of motion (ROM) done by restorative. During interview with the Registered Nurse (staff G) on 6/28/18 at 6:02 PM, he said resident #76 has contractures to his bilateral upper and lower extremities. He is basically bed bound and totally dependent for care. He uses bilateral hand rolls for the contractures. They should be on during the day and removed at night. During interview with the Restorative Nurse (staff L) on 6/29/18 at 8:32 AM, she said resident # 76 receives passive ROM at least three times per week to bilateral upper and lower extremities which is done by the restorative aides. He is totally dependent for ADL's. He has bilateral flexion ands and elbows. His Restorative ROM services have been ongoing to prevent further contractures and to promote comfort. The devices he uses include bilateral hand rolls during the day. He tolerates the hand rolls. He is not able to take them off. At times, they may slip off, but he does not remove them.

Based on observation, interview and record review, the facility failed to ensure ongoing assessment and treatment was provided for two (resident #76 and #72) of two residents reviewed for eye infections. This was evidenced by failure to recognize and treat signs and symptoms of the recurrence of chronic ophthalmic conditions. This has the potential to affect eighty six (86) residents residing in the facility. Findings included: 1. Observation on 6/26/18 at 4:18 PM revealed resident #76 in his room in bed. His left eye was very red and weeping a yellowish secretion. Observation on 6/27/18 at 2:00 PM revealed resident #76 in bed. His left eye was was draining a thick yellowish, type excretion and his eyelashes were matted with this thick yellow secretion. Observation on 6/28/18 at 9:51 AM revealed resident #76 in his room in bed. His eyes were closed during the initial observation. There was a yellowish discharge on his face below the left eye. His eyelashes were moist and coated with the yellow colored secretion. When resident #76 opened his eyes, the left eye was slightly reddened and the interior corner or the eye had an accumulation of this yellow colored secretion present. Record review revealed resident #76 was admitted to the facility on [DATE]. A comprehensive minimum data set (MDS) assessment dated [DATE] revealed multiple diagnosed including: [DIAGNOSES REDACTED]. The MDS revealed resident #76 has impaired long and short term memory with severely impaired decision making skills and he was totally dependent for care. Review of the most recent eye care consult dated 5/22/18 revealed the presence of an ocular lens, lids were clean and no treatment was ordered. Review of eye care consult dated 12/12/17 which revealed Blepharitis resolved, assess for the return of eye infection. Review of physician's orders [REDACTED].#76 received treatment for [REDACTED]. Review of physician ordered for (MONTH) (YEAR) revealed resident #76 received treatment for [REDACTED]. The treatment included [MEDICATION NAME] (an antimicrobial solution used for treatment of [REDACTED]. During interview with the 7AM-3PM shift Registered Nurse (staff E) on 6/28/18 at 3:33 PM, he said resident #76 has no current treatment for [REDACTED]. When I take care of him I have not noticed any redness or drainage from his eyes, but I can follow up on that. His last eye care consult was 5/22/18. The consult indicated his eyes were clean and the cornea was clear. The plan was to assess for changes and follow up in one year. During interview with the Certified Nursing Assistant (staff F) on 6/28/18 at 3:43 PM, she said resident #76 gets eye drops by the nurse for an infection. There is a yellow drainage that comes from his eyes. I have to report to the nurse when I see the yellow drainage and I have to clean his eyes. I did not notice this drainage today, but I have seen it before when I take care of him. When the nurse puts the drops in his eyes, the yellow liquids just runs out of his eyes. The nurse knows about the draining eyes. During interview with the 3PM-11PM shift Registered Nurse (staff G) on 6/28/18 at 6:02 PM, he said resident # 76 has not recently had any condition that would cause his eyes to drain. I know he has been treated in the past for [MEDICAL CONDITION]. If I saw any kind of drainage I would call the doctor to report the concern. The doctor would prescribe a treatment and I would place the order. He should be monitored regularly for drainage due to a history of [MEDICAL CONDITION]. He is currently not getting any treatment, but it is a chronic condition that keeps coming back. It is not contagious, but we would still take precautions to wash our hands and wear gloves during care. He is totally dependent on staff for care. Observation on 6/28/18 at 6:10 PM with staff G present revealed drainage from both of Resident #76 's eyes. Staff F stated, he has a greenish white secretion from both eyes. I do not see any redness. These secretions are not normal and I will need to report this to the doctor. I do not recall that he had the secretions yesterday. I called the doctor yesterday to report another concern, but not the eye secretions. Staff F was observed on the telephone leaving a message for the doctor. Observation on 6/28/18 at 6:14 PM revealed a small amount of yellowish colored secretions from resident #76's right eye and a more substantial amount from the left eye to include matted eye lashes and drainage from the interior corner and under the lower lid onto his face. Review of the care plan revealed resident #76 had a Sensory Perceptual deficit R/T(related to) severely impaired vision. [DIAGNOSES REDACTED]. Goal: Eye consult at least annually or as deemed necessary. Approaches included: Observe resident for any visual problems, excessive tearing, redness, swelling, drainage, c/o (complaints of) eye pain, and burning or itching. Eye consult and follow up as needed. Review of the nursing notes through 6/29/18 revealed no reference to redness or drainage from resident #76's eyes. Review of the nursing note dated 6/28/18 revealed: 7 PM Physician called back. New orders were received, transcribed and faxed to pharmacy. Physician order [REDACTED]. 2. Observation on 6/26/18 at 11:50 AM revealed resident # 72 in the main dining room during a group activity. Her eyelids were very red in color and both eyes were matted with a yellowish pus colored drainage. The upper and lower eyelids of both eyes were matted. Observation on 6/26/18 at 12:30 PM revealed resident #72 observed in the West dining room during lunch. Her eyes remained red and were draining a yellowish colored substance. Observation on 6/27/18 at 12:25 PM revealed resident #72 in the dining room. Her eyes continued with draining under her eyes onto her face, matted eyelashes and reddened eyes. Record review revealed resident #72 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #72 had impaired vision, impaired cognitive status with a BIMS (brief interview for mental status) score of 3,meaning resident has cognitive impairment, and required extensive assistance with ADL's (activities of daily living). Review of the most recent eye care consult dated 2/26/18 revealed of Unspecified Blepharitis to right and left eyes. Assess in one year for the return of eye infection. Review of the physician's orders [REDACTED]. During interview with the 7AM-3PM shift Licensed Practical Nurse (staff H) on 6/28/18 at 3:19 PM, she said she is not the permanent nurse for resident #72. When I went to check on her this morning, I noticed she had some substance in her eye like you get when you sleep. I wiped her eye and I instructed the Certified Nursing Assistant (C N A) to make sure to give good eye care when she takes her into the bathroom. She does not currently have orders for eye drops or treatment to her eyes. I did not observe any redness. The last time I was assigned to care for her was a few days ago and I did not notice any redness or drainage from her eyes. Today when I saw her in the morning during rounds, the matter on her eyes was not green in color and did not appear to show sign of infection. She has a history of Blepharitis. Observation of resident #72 was made on 6/28/18 at 3:30 PM with staff G present. Staff G said resident #72's left eye is very red. I did not notice this before. Staff G said there is a discolored drainage below her right eye and on her eye lashes. I did not see this earlier. I will have to report this to the doctor. During interview with a 3PM-11PM shift C N A (staff I) on 6/28/18 at 4:05 PM, she said resident # 72 is on my regular assignment. She has problems with her eyes. The nurse is always putting eye drops in her eyes. She has some little yellow stuff on her eyes. She does not have this all of the time. When I see the yellow color I tell the nurse and she will use the drops. If I see any redness or yellow color from her eyes I will report to the nurse. She needs assistance with her care. I will always clean her eyes and report to the nurse. During interview with the 3PM-11PM shift Registered Nurse (staff J) on 6/28/18 at 5:49PM , he said resident # 72 has Blepharitis which is an inflammation of the eyelids. As a nurse I monitor for abnormal swelling and/or abnormal drainage. The redness to her eyelids is not abnormal. It is related to her condition. She is not currently receiving any treatment. Drainage would not be a normal condition. If there is draining it would be cleaned and if it was discolored it would reported to the physician. Observation of resident #72 was made on 6/28/18 at 5:57 PM with staff J present. Staff J observed the yellowish colored drainage from resident #72's right eye and said the C N A or nurse would clean her eyes. This color drainage would not need to be reported to the doctor. She does not have this drainage all the time I would call the doctor is the drainage was green in color. During interview with with the 7AM-3PM shift Licensed Practical Nurse (staff K) on 6/29/18 at 7:39 AM, she said resident # 72 has a history of Blepharitis and she has been treated in the past. She is followed by our Mobile Eye Care service. She is not currently receiving treatment. She was treated in January. The eye doctor comes monthly. The last time she was seen was 2/26/18. If she is having drainage it would be reported to the eye doctor when he comes. The redness in her eyelids is Chronic. The drainage comes and goes. The treatment is ordered when the drainage is present, but she has no current treatment ordered. The treatment in the past has been [MEDICATION NAME] eye drops which is generally ordered for 30 day and this is effective to resolve the drainage. This condition is not contagious. The C N A and I clean her eyes regularly. Review of the care plan revealed resident #72 had impaired vision. Goals included: Eye care consults at least annually or per resident preference. Approaches included: Observe resident for any visual problems, excessive tearing, redness, swelling, draining, c/o (complaints of) eye pain, burning or itching and notify MD (medical doctor), eye Consult as indicated. The care plan was last revised on 5/23/18 to include: Resident is followed by Optometrist secondary to Blepharitis. Review of the nursing notes from 3/3/18 through 6/29/18 revealed no documentation of any signs or symptoms of infection, redness or drainage from resident #72's eyes. Review of the treatment administration record (TAR) revealed no evidence of monitoring the condition of Resident # 72 eyes.

Based on observation, interview, and record review, the facility failed to ensure that the appropriate equipment to prevent the worsening of contractures was consistently provided for one (resident #76) two residents reviewed for range of motion (ROM) as evidenced by inconsistent use of hand rolls. There were 60 residents with contractures in the facility at the time of this survey. Findings included: Observation on 6/26/18 at 10:30 AM revealed resident #76 in bed. He had contractures to his left and right hands. Both hands were tightly closed and there were no splint devices or hand rolls in place. Observation on 6/26/18 at 12:30 PM revealed resident #76 in bed. There were no splint devices or hand rolls in place. Observation on 6/26/18 at 4:21 PM revealed resident #76 in bed. There were no splint devices or hand rolls in place. Observation on 6/27/18 at 10:30 AM revealed resident #76 in bed. He wore soft hands rolls on his left and right hands. Observation on 6/27/18 at 2:00 PM revealed resident #76 in bed. He wore soft hand rolls on his left and right hands. Observation on 6/28/18 at 9:51 AM revealed resident #76 in bed. He wore a soft hand roll on his left hand. There was no right hand roll in place. A hand roll was observed sitting on the top of the bedside table. Observation on 6/28/18 at 11:00 AM revealed resident #76 in bed. He wore a soft hand roll on his left hand. No right hand roll was worn. Observation on 6/28/18 at 12:36 PM revealed resident #76 in bed. He wore a soft hand roll on his left hand. No right hand roll was worn. A hand roll was observed sitting on the top of the bedside table. Record review revealed resident #76 was admitted to the facility on [DATE]. Review of a quarterly minimum data set ((MDS) dated [DATE] and an annual MDS dated [DATE] revealed resident #76 was totally dependent on staff for Activities of Daily Living (ADL) care. He had ROM limitations to bilateral upper and lower extremities. Special services include Restorative Nursing for passive ROM. Review of the care plan implemented 9/6/17 revealed resident #76 had self-care deficits and is mostly bed bound. He requires total assistance with ADL and has right lower extremity contracture and contractures to upper and lower limbs. The goal is to continue to receive and maintain optimum care. Approaches included Restorative therapy as indicated, but did not include the use of bilateral hand rolls. The care plan was last reviewed on 6/2/18. Review of the physician's order [REDACTED]. During interview with the Registered Nurse (staff E) on 6/28/18 at 3:33 PM, she said resident #76 uses bilateral hand rolls. He has contractures to both hands. The orders are for bilateral hand rolls to be on during the day time. The hand rolls are provided by Restorative. The aides put them on in the morning. When I make rounds, I check to make sure he is wearing both hand rolls. During interview with the Certified Nursing Assistant (staff F) on 6/28/18 at 3:43 PM, she said resident #76 does not move too much on his own. We have to reposition every two hours because he is not able to do this for himself. He needs total care for ADL's (activities of daily living). He has contractures to his hands and one leg. We use a pillow between his legs and he has a small blue pillows for both hands. We have to use these pillows in both hands every day. If not his nails could cut his hands. He is supposed to wear these all day, except when we clean his hands. They are removed during care only. He does not move, so he is not able to remove them. He also gets range of motion (ROM) done by restorative. During interview with the Registered Nurse (staff G) on 6/28/18 at 6:02 PM, he said resident #76 has contractures to his bilateral upper and lower extremities. He is basically bed bound and totally dependent for care. He uses bilateral hand rolls for the contractures. They should be on during the day and removed at night. During interview with the Restorative Nurse (staff L) on 6/29/18 at 8:32 AM, she said resident # 76 receives passive ROM at least three times per week to bilateral upper and lower extremities which is done by the restorative aides. He is totally dependent for ADL's. His Restorative ROM services have been ongoing to prevent further contractures and to promote comfort. The devices he uses include bilateral hand rolls during the day. He tolerates the hand rolls when applied. He is not able to take them off. At times, they may slip off, but he does not remove them. Review of a restorative nursing progress notes dated 5/24/18, 3/1/18, and 11/27/17 revealed bilateral had rolls are used for positioning. Review of Restorative Nursing Program logs indicated ROM services were provided, but observations revealed inconsistent use of bilateral hand rolls as ordered.

Based on record review and interview, the facility failed to implement the abuse policy and procedures related to allegations of abuse voiced by two residents out of nineteen sampled residents (resident #31 and resident # 69) for which allegations of abuse were reviewed during the survey. Resident #69 reported a nursing assistant physically assaulted her. Resident #31 reported that Hospice staff tied him up and attempted to assault him sexually. The facility failed to report, document, and thoroughly investigate these allegations. This facility practice has the potential to result in physical as well as psychosocial harm to the residents, and to have a negative impact on the health and safety of all eighty six residents in the facility. The facility had nineteen Hospice residents at the time of the survey. The Findings Included: Record review of the facility's Suspected Abuse Policy dated (MONTH) 2012, revealed a policy statement to include: Residents have the right to be free from abuse, neglect, exploitation or misappropriation of property. The procedure included but was not limited to: The facility evaluates all allegations, observations, and suspected cases of exploitation, abuse and/or misappropriation of property that is alleged to have occurred within the facility. The facility reports allegations, observations, and suspected cases of neglect, exploitation, and abuse to appropriate authorities based on its evaluation of the suspected events and in accordance with the and regulations. 1. Record review of the Quarterly Minimum Data Set (MDS) for resident #31 dated 04/11/2018 revealed, the resident had a score of 13 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was able to verbalize his needs and was not cognitively impaired. Further review of the MDS revealed, the resident had adequate hearing, speech was clear, and he had the ability to understand others and express ideas and wants. During an interview on 6/26/2018 at 11:26 AM resident #31 reported, he suffered abuse in the facility. He reported that he was physically tied up to his bed and pinched multiple times in the arms. The resident explained that the abuse happened in his room, about three months ago. The perpetrators were a man and a woman that he could recognize were working together.The resident added that he reported the abuse to his brother and to the Social Worker, but the Social Worker did not believe him and told him it was a dream. The resident explained, she (the Social Worker) said I was dreaming, but I had all these bruises in my hands, both hands . she kept insisting that I was hallucinating, but I was not. On 6/28/2018 at 10:39 AM Staff M, a Hospice Registered Nurse revealed, that she was familiar with resident #31. She reported, she assessed him once a week but saw him almost every day. Staff M reported, R#31 was able to communicate his needs and feelings, and he did not suffer from [MEDICAL CONDITION] or hallucinations. During the interview, the nurse reported that on the previous month, resident #31 required high level continuous care, because the resident was unresponsive for 12 hours. During that time, the resident was lost and kept asking where he was, he was later convinced and repeated that someone tied him up and tried to abuse him sexually. The Hospice Nurse explained, the abuse did not happen and that the resident had sitters with him the whole time. She attributed the residents' abuse allegations to hallucinations that resulted from his condition at the time, combined with traumatic experiences he remembered from his time in the army. On 6/28/18 at 11:49AM, the Director of Social Services (DSS), revealed, resident # 31 spoke to her around the time that the resident came out of crisis care. The resident told her, the nurse that watched him tied him up, and tried to rape him, it was in the middle of the night, the resident was sleeping but managed to (fend him off). The Social worker explained, she did not report the residents' abuse allegations because it was not abuse, it was a delusion. As far as the investigation, the DSS stated that she talked to the psychiatrist and the psychiatrist noted that the resident had paranoia.The DSS also stated, the residents' brother, told her that resident #31 was in Jail in ( .another country) and he might have reverted to that era. In addition, the SSD stated, the residents' brother stayed in the room, with the resident during the night the alleged abuse happened.The DSS documented, her investigation in the progress notes that remained in the residents' file. A review of the DSS documented investigation revealed, only one note that addressed some of the resident's above-mentioned allegations. The note dated, 5/23/2018- Resident has been noted with delusion, expressed being in a dungeon, as per family, resident spent some time in ( ) jail and is reverting to his history. The note added, the resident can get agitated . The notes did not address the residents' allegations of abuse. A review of the Hospice visit summary reports revealed, resident #31 was under continuous care on 5/5/2018. The residents symptoms at the time included agitation and respiratory distress. The continuous care shift care Nurse noted, Family members not present at this time. Ongoing documentation for resident #31 described symptoms of agitation timed 01:02 through 04:00. Entries timed 01:30, 02:00, and 02:30 noted, Pt still restless in bed. Non-pharmacological interventions included, low stimulus environment, side rails up x 1, brake on, and bed in lowest position. Pharmacological intervention, administered at 2:00 AM, [MEDICATION NAME] 1 mg, 1 time dose for agitation. Hospice addendum interdisciplinary notes timed 12:00 to 16:30 noted that resident #31 speaks inconsistencies and offends everyone. Record review of the Nurses Notes for resident #31 revealed, the resident was discontinued from crisis care on 5/8/2018. The nurses notes dated 5/5/2018, timed 1:00 AM: Resident observed in bed awake. Hospice nurse at bedside. Became very agitated, combative to staff. Repeatedly stating, I'm going home, I'm leaving. Tries to climb out of bed. Attempted to administer as needed (PRN) [MEDICATION NAME] but not successful. 1:1, change position tried but not effective. Place call to hospice. New order. Called pharmacy to verify script and doctors signature. Called Hospice. Pending verification from Hospice. All safety measures in place. There are notes that resident #31 was combative and verbally abusive also noted on 5/7/2018 at 1:00 AM and at 6:40 AM, notes at 6:40 AM included that the resident was kicking staff. None of the Nurses Notes addressed the resident's bruises or his allegations of abuse. Record review of the psychotherapy notes for resident # 31 revealed, progress notes dated 5/31/2018, 5/24/2018, 4/19/2018, 11/9/17, 10/19/17 and 6/1/2017, only one of the progress notes dated 5/24/2018 noted, resident #31 had a paranoid delusional disorder. The psychotherapy notes did not address the resident's allegations that he was abused. During an interview on 06/28/18 at 4:00 PM with resident #31, the facility Administrator, and the Social Services Director, the resident described what he remembered about that night; he stated, I reported it to her (pointing to the Social Services Director) and she told me you are crazy! I believe it all happened here, I was under some stairs, my brother was there, he was with me at first, (facility) staff, I believe her name was { }or something like that, a ( ) girl, I told her to keep away from me . I felt as if someone raised my hands and they tied me up to some iron, it was like a box with a latch, and they used a blanket to tie me up. (The resident explained that the person that was tying him up was a Certified Nursing Assistant (CNA) he kept seeing in the facility after the incident. The CNA went into the room to take care of the roommate, he continued . I was alone for some time, tied up, I began to scream, they heard me, and said to me your time has come. Resident #31 explained, the statement Your time has come meant that they were going to sexually assault him. I told them, you guys are going to have to kill me, that's not going to happen, you are going to have to kill me first they left and I could hear the clicking sound of a gun. I remained in the box I managed to untie myself and got out of there. I told my brother, after he finally showed up, then they took me to my room, I believe in a car. I fought the guy that did that to me, he remained sitting in my room, he did not even talk to me, I told the Social Services Director, the man still had his bag in my room when I told her. The resident appeared upset and began to cry as he continued to explain, I feel very bad, that this happened to me, can't you imagine? On top of that no-one believes me! I felt so bad and scared that my brother had to sleep here with me . The social worker confirmed, the resident's brother had to stay and sleep in the room with the resident, because the resident was feeling so bad. The resident explained, he had bruises on his arms at the time, the bruises were gone, but he showed them to social worker at the time. About the CNA, the resident reported, he recognized her in the facility and he warned her to stay away, the social worker knows her. When asked about the CNA, the social services director stated, she removed staff from working with him any time he asked. The Social Worker confirmed, resident #31 had indicated that the hospice male nurse was the one that had made him felt threatened. She later reported, she never took a statement from the CNA or from any of the Male Nurses that cared for resident #31, during crisis care. 2. Record review of the face sheet revealed that resident # 69 was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] for resident # 69 for the annual assessment revealed a Brief Interview for Mental Status assessment (BIMS) score of 13 out 15, identifying the resident as cognitively intact. Record review of the care plan dated 2/28/2018 for resident # 69 revealed, resident had potential for changes in mood related to depression, anxiety and potential for drug related complications related to use of [MEDICAL CONDITION] medications. Record review of the social services history/psychological assessment dated [DATE] for resident # 69 revealed, she was readmitted to the facility. Resident #69 was alert and oriented to self, place and time and was able to express her needs. Record review of the Physician order [REDACTED].#69 revealed, the following medications but not limited to, [MEDICATION NAME] 0.25 milligrams (mg) 1/2 tablet by mouth twice daily for anxiety; Gapapentin 300 mg 1 capsule by mouth three times per day (TID); [MEDICATION NAME] 15 mg 1 tablet daily for chronic pain. [MEDICATION NAME] 30 mg 1 tablet by mouth at bedtime; [MEDICATION NAME] 50 mg 1 tablet by mouth twice per day. Record review of the resident grievance complaint investigation report form for resident #69 dated 06/25/2018 revealed on 06/22/2018 resident #69 alleged she was pushed to the bed when she was putting on her night gown. The resident alleged that someone she had never seen before might have come in through the window. Spoke with Certified Nursing Assistant (CNA) and she went in the room and the resident was laying in bed when she was done with rounds. The facility camera was reviewed and no one was seen entering the room besides the CNA. After looking at the cameras and speaking to the CNA, it appeared resident #69 was dreaming and was startled. The CNA Continued to do rounds, and encouraged the resident to call for assistance when needed. The note was signed on 06/27/2018 by resident #69. Record review of the nurse's notes from 06/22/2018 to 06/24/2018 for resident #69 revealed, there was no skin assessment related to the abuse allegation. Record review of the social services note dated 06/25/2018 for resident # 69 revealed, the Social Worker and administrator met with the resident. Resident #69 was observed with delusions in the evening and appeared confused. The family was made aware and mentioned the resident would make up stories at times and had attention seeking behavior. The Social worker would continue to support her. Record review of the social worker notes dated 06/26/2018 for resident # 69 revealed, the social worker met with resident #69 and talked about the alleged allegations. Resident #69 expressed, she might sometimes call people racist names, since her former husband used to do the same to her. The Social worker assessed her and would try to help her with the best care. Record review of the CNA assignments dated 06/22/2018 revealed that staff B, a CNA worked the 3 PM to 11 PM shift and had the assignment 20A to 24 B. Record review of the CNA assignment dated 06/24/2018 for the 3 PM to 11 PM shift revealed, staff B, worked a special assignment. Record review of the CNA assignment dated 06/25/2018 for the 3 PM to 11 PM shift revealed, staff B, worked and had rooms 20A to 24 B. Record review of the CNA assignment dated 06/26/2018 for the 3 PM to 11 PM shift revealed, staff staff B, was not working that day. Observation and interview on 06/26/2018 at 04:10 PM with resident #69 revealed, the resident reported, last night and two nights ago staff made her take a shower and she had [MEDICAL CONDITION]. The [MEDICAL CONDITION] made her feel cold and the shower was very cold. Resident #69 stated, she was a ( ) lady. Resident #69 said, it was the 3 PM to 11 PM shift. Resident #69 said, she told the staff she did not want to take a shower three times. Resident # 69 reported, the staff told her they were the boss and gave her a shower. Resident #69 mentioned, the first name of a staff member associated with the incident. Resident #69 noted, the name tag was turned over. Resident # 69 reported, all the staff treated her with respect except for that staff. Interview on 06/27/2018 at approximately 4:25 PM with resident #69 in her room revealed, the incident happened last Saturday. Resident #69 noted, she did not tell her daughter at that time since it was late at night. Resident #69 said she was in the bedroom and a staff made her leave. Resident # 69 mentioned, the first name of a staff member associated with the incident. Resident #69 mentioned, she thought the staff was a certified nursing assistant. Resident #69 stated, she did not remember the last name of the staff and didn't see her name tag. Resident #69 said, the staff member threw her into the shower. Resident #69 stated, When I think about it, more is coming back to me. She grabbed my right arm and threw me against the shower wall. Resident #69 showed a medium sized bruise (brownish-yellow) to her right outer arm near her elbow. Resident #69 said, the staff member made her shower in cold water. Resident #69 said she dried herself with a towel. Resident #69 had told the staff she didn't want a shower. The staff used profanity and told her she should have a shower. Resident #69 said she wanted to go into the bed. The staff used profanity and told resident #69 she could not go to bed until she was told to. Resident #69 stated, the staff threw her on the bed. Resident #69 noted that the staff hurt her so bad. The staff member told her while utilizing profanity,that she should shut up with that crying. Resident #69 said, she finally went into the bed. Resident #69 noted that she fell asleep. Resident #69 said the staff was a ( ) person who worked there. Resident #69 stated that she felt this was abuse, since the staff was taking advantage of her. Resident #69 said that she didn't tell the other staff what happened. Interview on 06/28/2018 at 9:46 AM with the Activities Director regarding resident #69 revealed, during the Monday morning meeting it was either on Monday (MONTH) 25, (YEAR) or Monday (MONTH) 18, (YEAR). The Activities Director said, she can't be sure about the date. The Activities Director noted, at the morning meeting, the Director of Nursing and the administrator were there. The dietary supervisor was there and resident #69 was not there. The Admission Director (the manager on duty, MOD) had brought it up. The Activities Director said, resident #69 told the manager on duty what had happened. The Activities Director explained, there was a manager on duty on the weekend. Resident #69 had told the admission director (manager on duty) that she was pushed by a certified nursing assistant. Resident #69 had mentioned a staff member by the first name. Interview on 06/28/2018 at 10:40 AM with the Director of Admissions revealed, she knew resident #69. The Director of Admissions noted, she was working as the manager on duty for the weekend. The Director of Admission stated that she was part of the management team and anything that happened was handled as appropriate and/or they would call the administrator. Resident # 69's daughter was visiting on Saturday, (MONTH) 23, (YEAR). The director of admissions mentioned, at approximately 3:30 PM, the receptionist mentioned that resident #69 had called the front office and had a complaint. Resident #69 was in the dining room and was attending activities. The Director of Admissions asked resident #69 if she was okay and took her to her room. Resident #69 reported, on Friday night while she was putting on her night gown someone pushed her from behind onto her bed and told her that they where going to kill her. Resident #69 said, she didn't know who it was, since it was too dark and she couldn't see. The director of admissions (manager on duty) asked resident #69 if she was hurt and she had replied she was not. She asked her, what time this happened. Resident #69 told the manager on duty that this occurred Friday between 10:30 PM to 11 PM. The manager on duty noted, she reviewed the cameras from (MONTH) 22, (YEAR) from 10 PM to 11 PM and the only thing she saw was her CNA going into the room briefly and back out. The CNA was staff B. The manager on duty told resident #69 that she had reviewed the camera footage and saw staff B going in and out of her room. The manager on duty stated, she asked resident #69 if she was the one who had pushed her and resident #69 said it was not her, she was great. Resident #69 asked if her windows were locked, because that person might come in through the window. The manager on duty told resident # 69, they were locked and that maybe she was dreaming, since it felt real. She contacted her daughter and asked the daughter to come in to see the administrator on Monday. The daughter of resident #69 said she could not come in and wanted the administrator to contact her via phone before 10 am. The manager on duty stated, she spoke to staff B, the CNA on Saturday, (MONTH) 23, (YEAR) between 4:30 PM to 5 PM. The manager on duty asked staff B, if she heard anything with resident # 69 and if anything had happened. Staff B said, the only thing that happened with resident #69 was that she had asked her if she wanted a shower. Resident # 69 had said, no, she didn't want a shower. Staff B, told her she would sleep better and her daughter was picking her up for an event. Resident # 69 had yelled back at her with profanity stating to get out of her room. The Director of Admissions (manager on duty) said, she was there to follow up on the incident that had happened on Friday to resident #69. Resident #69 said, she didn't remember saying anything and didn't know why she had said it. The Director of Admissions (manager on duty) noted that she told the administrator on Saturday and did not report this as abuse. The manager on duty stated, the social services director who was the abuse coordinator was aware since Saturday, (MONTH) 23, (YEAR) of the incident with resident #69. The Director of Admissions concluded, resident #69 had an abusive husband and sometimes had flash backs or nightmares. Phone interview on 06/28/2018 at 1:06 PM with staff B, a CNA regarding resident # 69 revealed, she was was alert and recognized her sometimes. Staff B said, resident #69 asked for her by name. Staff B stated, she was working Friday, (MONTH) 22, (YEAR). She worked the 3 PM to 11 PM shift. Staff B noted, she took resident #69 to the shower. Staff B stated, she started to give her a shower. Resident # 69 could stand and they utilized a shower chair. Staff B noted, she was not able to shower resident # 69 completely, since resident #69 was mad. Staff B said, she didn't know why resident # 69 was mad and placed a night gown on her. Staff B said, this was after dinner. Staff B stated, she was the CNA for resident #69 for 2 years and also used to float to other assignments. Staff B, CNA said that she was not aware of anyone trying to hurt resident #69. Staff B, CNA noted that she was not aware of anyone trying to push or trying to kill resident #69. Staff B, CNA said that she was not aware of resident #69 being scared on Friday. Staff B, CNA noted that resident #69 never talked about her daughter or previous husband. Staff B, CNA said that she left Friday at 11:23 PM at the end of her shift and didn't notice anything. Staff B, CNA stated that she did not work on Saturday, (MONTH) 23, (YEAR). Staff B, CNA noted that she did work on Sunday, (MONTH) 24, (YEAR) and Monday (MONTH) 25, (YEAR). Staff B, CNA stated that on Tuesday a supervisor told her not to come to work due to an investigation, but didn't tell her what it was about. Staff B, CNA said that she has not been back to work since Tuesday, (MONTH) 26, (YEAR). Interview on 06/28/2018 at 1:43 PM with the Director of Social Services, who was also the abuse coordinator revealed, resident #69 was forgetful. Resident #69 was alert to name, place, situation, but not time and not date. Resident #69 had her good days and talked about her daughter. Resident # 69 talked about her history and told her she was a battered wife. Resident #69 had expressed how she had an abusive husband. The Director of Social Services stated that on Monday, (MONTH) 25, (YEAR) resident #69 was mad. The director of social services said that she was aware resident # 69 had alleged that someone pushed her from behind into the bed while she was putting on her gown. Resident #69 didn't know who the person was. The director of admissions (manager on duty) called her on Saturday and told her that resident #69 had alleged abuse. Resident #69 had said she couldn't see the person's face, because it was very dark. The person had pushed her to the bed. The Director of Admissions (manager on duty) looked at the camera. It was at midnight and the only person that went into the room was staff B, CNA. The Director of Admissions (manager on duty) told her on Saturday at approximately 3 PM. Resident #69 was visiting with her daughter at the nursing home. The daughter of resident # 69 left. Resident #69 mentioned this to director of admissions (manager on duty) and she followed up on this. The director of social services / abuse coordinator stated that she was not aware of someone trying to kill resident #69. The director of admissions (manager on duty) documented the incident on the manager on duty report. The admission director (manager on duty) started the investigation on Saturday and this was finished yesterday. The director of social services / abuse coordinator noted that regarding resident #69 it was not abuse. The Director of Social Services stated, resident #69 had the bruise to her right arm on 06/17/2018 from the hospital. The daughter of resident # 69 confirmed that she had a bruise upon admission from the hospital on [DATE]. The Director of Social Services said that she spoke to staff B, CNA that evening. Staff B, told her she did her rounds like normal. The director of social services said, staff B, told her she did not shower resident #69 at midnight. The director of social services noted that they looked in the cameras and it appeared resident # 69 was startled and had a nightmare. The director of social services / abuse coordinator confirmed that she did not report this as an allegation of abuse. The abuse coordinator concluded regarding resident #69, She was having nightmares or having a bad night. Maybe she had delusions. Maybe she was reverting back to her history of abuse. Interview on 06/28/2018 at 2:22 PM with the Administrator and the Director of Nursing (DON) regarding resident #69 revealed, she was re-admitted on [DATE]. The administrator stated, resident #69 was alert to her name and time, but not sure if she knew the date. The administrator believed he was made aware of the incident regarding resident #69 on Saturday (MONTH) 23, (YEAR). The admission coordinator (manager on duty) had told him that resident # 69 had said that someone came through the window and pushed resident #69 to the bed. The administrator noted that he told the admission coordinator (manager on duty) to follow up on this. The administrator said that from his experiences, resident #69 had episodes of delusions. The admission coordinator (manager on duty) spoke to resident #69 and she denied that anyone had pushed her. The admission coordinator (manager on duty) had talked to the daughter of resident #69 and wanted to have a meeting on Monday, (MONTH) 25, (YEAR) and it was not related to the abuse allegation. Resident #69 had called staff a racist comment on maybe Friday or Saturday night. The administrator noted that on Saturday he didn't call the abuse coordinator after he learned that someone might have entered through the window and pushed resident #69. The administrator stated, he didn't submit a report of an allegation of abuse to the state agency, since within the same hour resident #69 denied abuse. The administrator said an investigation was completed based on what they heard from resident #69 at the resident council meeting. The administrator concluded that the allegation of abuse was unfounded, because the windows for resident # 69 were shut. They checked the cameras and didn't see anyone coming into the facility. The administrator said that within the hour resident #69 had changed her statement and said that no one had pushed her and denied what had happened or that she was abused. The administrator explained, this was not documented in the chart and was completed on an investigation report. The administrator said that if there was an allegation of abuse they would report abuse within the hour to the State. However if someone changed their statement and was delusional, then they would not report this until they completed their investigation. The administrator said, resident #69 had recanted her allegation of abuse. The DON said, resident #69 saw the psychiatrist. The administrator said that the psychiatrist spoke to him yesterday about what resident #69 alleged in the resident council meeting. That she was abused. The administrator spoke to the psychiatrist afterwards and noted that resident #69 was going through a memory relapse and reliving the past. The psychiatrist told him that he didn't think it was abuse regarding what happened to resident #69. Record review of the progress note by staff A, the Psychiatrist dated 06/28/2018 revealed, resident # 69 was seen. The chart was reviewed and the case was discussed with staff. The resident was talking about abuse in the facility by someone no name, never seen her before. The resident was tearful and became very anxious and mixed the story with abuse she suffered at her husbands hands. He had a gun to her head, resident #69 had said. Her children saved her, crying to let her live. Once calm she was easy to redirect. She felt safe here. People were good here. Discussed medications with resident # 69. Resident # 69 score was 14 out of 30. She was started on [MEDICATION NAME] low dose, increase as tolerated. She will continue with [MEDICATION NAME] and [MEDICATION NAME] as ordered. Follow up with psychotherapy. Record review of the mini mental exam completed by Staff A, Psychiatrist dated 06/28/2018 for resident # 69 revealed, a score of 14 out of 30. Record review of the telephone order for resident #69 dated 06/28/2018 revealed, [MEDICATION NAME] 5 mg by mouth daily for dementia. Phone interview on 06/29/2018 at 9:49 AM with the Psychiatrist, Staff A regarding resident #69 revealed, she was very alert to name and place and very manipulative. She wanted to use benzodiazepine medications. the Psychiatrist reported, Resident #69 knew she was in Florida. The Psychiatrist, stated resident #69 had seen him every 4 weeks and didn't recognize him. Staff A noted, resident #69 had a history of [REDACTED].#69 had told him that her husband had pointed at gun to her head. Staff A said, he believed resident #69 was having [MEDICAL CONDITION], anxiety disorder and dementia. Staff A stated, he knew of a complaint of resident #69 of being thrown in bed and showered. Staff A said he thought it was related to her abusive personal history. Staff A was informed that resident # 69 had an allegation of abuse in the resident council meeting and during an interview in which she named a CNA by first name. The psychiatrist, staff A responded that might be different. The psychiatrist, said he didn't have that impression. Staff A was asked if resident #69 was safe at the facility right now given the abuse allegation and replied: She is safe right now in the nursing home based on what I saw yesterday. The psychiatrist, staff A responded that resident # 69 was begging him for her to stay in the facility and not to take her out. Resident #69 told him the administrator made her feel safe. The psychiatrist, said he never saw her as confused as yesterday. Staff A stated, he completed a Mini Mental State Examination (MMSE) and resident # 69 had a score of 14 out of 30. The psychiatrist, was asked what the official [DIAGNOSES REDACTED].#69 and replied, Generalized anxiety disorder with depression and now dementia.

Based on observation, interview and record review, the facility failed to ensure that: 1) eight out of twenty-eight resident rooms were not in good condition as evidenced by room 10 on the south unit observed with standing water lining the floor near the air condition (A/C) unit; 2) nine out of twenty-eight resident rooms observed for environmental concerns were not in good condition. There were a total of 45 resident rooms in the facility. The findings included: 1. Record review of the maintenance request form dated July 18, 2017 revealed, room 10's a/c was leaking water. Remarks - cleaned unit - condensator pan and cleaned drain hole. Left unit running, done. Observation on 07/18/2017 at 10:05 am revealed, the maintenance worker staff J was suctioning up large amounts of stagnant water in the far corner of room 10 on the South unit. Both residents were in bed in room 10 at the time. Interview on 07/18/2017 at 10:05 am with the maintenance worker staff J revealed, he stated it had rained last night and the housing of the air conditioning unit was leaking this morning. Interview on 07/18/2017 with maintenance worker J and maintenance worker K revealed, housekeeping had called and the AC housing was leaking. They reported, the rain came in and it was suctioned up. Maintenance worker staff J stated that he used a wet-dry vacuum cleaner to suck up the water on the floor of room 10. Observation on 7/20/2017 at approximately 12:10pm of the room 10 with the maintenance director and maintenance worker staff J revealed, there was no A/C leakage in room 10 today. Record review of the undated facility policy revealed, It is the policy of this facility that our heating and air-conditioning system be inspected at least semi-annually. 2. Room#3 (South Unit): Observation on 07/18/17 at 11:48AM of resident room #3 revealed, the bathroom door frame was in disrepair. The paint was bulging, chipped and with signs of corrosion at the base. (photographic evidence taken) 3. Room#9 (South Unit): Observation on 07/18/17 at 11:04AM of resident room #9 revealed, the room entrance door frame was in disrepair. The paint was bulging, chipped and with signs of corrosion. The bathroom door frame was also in disrepair. The paint was chipped and a portion of the wooden door frame was missing at the base exposing the dry wall. In addition, the wall to the right side of the window near the window sill was not in good condition. There was about two to three inches of missing dry wall. (photographic evidence taken) 4. Room 14: Observation on 07/17/2017 at 11:02 am of Room 14 revealed that the wall in front of bed B was not in good condition; the side of the wall was cracked. Further observation revealed that the air conditioning (AC) unit was in disrepair; the panel for temperature control was detached. Inside of the residents' shower room revealed that the panel on the left side of the entrance had chipped paint and was cracked at the base of the panel. 5. Room 15: Observation on 07/17/2017 at 11:14 am of Room 15 revealed that at the bottom right hand corner of the AC unit the wall was not in good condition. Further observation in front of bed B on the left side of the dresser revealed that the paint was chipped. 6. Room 28: Observation on 07/17/2017 at 3:14 pm of Room 28 revealed that the door frame of the entrance into the residents' bathroom was in disrepair. The left side door, at the base, had chipped paint with deep indentations. The floor in front of the entrance to the bathroom was not cleaned. Further observation revealed that by bed B, the wall on the left side of the AC unit was not in good condition; the paint was chipped. 7. Room 19: Observation on 07/18/2017 at 10:08 am of Room 19 revealed that the wall in front of Bed B, on the right side of the resident's television, was in disrepair; the paint was chipped and the side of the wall was cracked. 8. Room 17: Observation on 07/18/2017 at 10:18 am of Room 17 revealed that the wall behind bed A was not in good condition; the paint was chipped and peeling. The dresser drawer next to bed A was chipped at the top. Further observation revealed discoloration at the entrance into the residents' bathroom. 9. Room 20: Observation on 07/18/2017 at 10:41 am of Room 20 revealed that at the front of the entrance into the residents' bathroom, the floor was discolored. Also, at the base of the door frame on both sides, the paint was chipped and the wood was cracked. Interview with the Unit Manager on 07/20/2017 at 11:57am revealed that she was the Unit Manager for both the North and South units. She said, any staff that observed environmental problems in the residents' rooms would fill out a maintenance request and submit it to the Maintenance Director. They would also follow up with maintenance staff to make sure that the repairs were done. Maintenance staff checked the maintenance requests folders on each unit daily. Interview with the Director of Engineering on 07/20/2017 at 1:37 pm revealed that he was the director of laundry services, housekeeping, and maintenance. With regards to maintenance, he had to keep the building safe for all staff and family members, which was done through weekly and monthly inspections of the facility. For residents' rooms, his maintenance staff conducted rounds on a daily basis. They utilized a check list where they look for burnt out lights, squeaky beds, and leaking toilets. If nursing staff saw anything, they had to write maintenance requests for areas that he may have missed, and for problems that himself and maintenance staff needed to check. Record review of the Maintenance Request Forms for the months of May 2017 to July 2017 revealed no maintenance work orders for the environmental concerns observed in the aforementioned resident rooms. An observational tour conducted with the Maintenance Director on 07/20/2017 from 1:42 pm to 2:01 pm revealed that the Maintenance Director confirmed that repairs were needed for the observed environmental concerns. Record review of the facility's undated policy and procedures titled, Resident Rights, revealed, The facility must provide-A safe, clean, comfortable and homelike environment .Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior.

Based on observation, interview and record review, the facility failed to ensure privacy for a resident being toileted for one (resident # 19) out six residents observed during medication administration. This failure to provide privacy occurred during medication administration to resident #41. The findings included: Record review of the face sheet revealed that resident # 19 was last admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the bladder and bowel flow record for resident # 19 for July 2017 revealed that the bowel and bladder monitoring was completed. Record review of the face sheet revealed that resident # 41 was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED].# 41 revealed, Aspirin 325 mg every day via Percutaneous Endoscopic Gastrostomy Tube (PEG tube), [MEDICATION NAME] 220 milligrams (mg) / milliliter (ml), [MEDICATION NAME] 500 mg via PEG (twice daily) BID, Zinc Sulfate 220 mg via PEG daily, [MEDICATION NAME] 25 mg give 1/2 tablet (12.5 mg) via PEG daily, Multivitamin 15 ml via PEG daily and Vitamin C 5 ml via PEG BID. Record review of the Medication Administration Record [REDACTED]. Percutaneous Endoscopic Gastrostomy (PEG) Tube medication observation on 7/18/2017 at 8:46 am with Licensed Practical Nurse (LPN) Staff A for resident # 41 revealed that she washed her hands. Staff A, accessed the oral medications for resident # 41 and placed them in medication cups. Staff A, crushed the medications for PEG administration with a pill crusher. Staff A, then sanitized her hands. Staff A, entered the room for resident # 41 and placed the PEG medications on the bed side table in the far corner of the room near the window of resident # 41. Staff A, then proceeded to wash her hands in resident # 41's bathroom. The PEG medications were out of her sight at the time. Staff A, had left the PEG medications unattended. Staff A, then noticed she was missing water for the PEG tube administration and left the medications that were on the beside table for resident # 41 again to get water in resident # 41 bathroom. Resident # 19 was in the bathroom on the toilet seat at the time being assisted by certified nursing assistant (CNA) staff G. Staff A, proceeded to get water for the PEG tube administration. Interview on 7/18/2017 at 9:30 am with staff A, regarding the PEG tube medication administration revealed that she confirmed that resident # 19 was in the bathroom while she went to get water for the PEG tube administration. Staff A, stated that she did knock on the door, but confirmed that it would be best practice to wait until resident # 19 was done with the bathroom. Record review of the facility's undated policy revealed, Upon admission, each resident or responsible party will receive a copy of the Federal List of resident rights. Privacy and Confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal Privacy includes .personal care.

Based on interviews, observations and records reviewed, the facility failed to follow the grievance policy and procedure for one resident (R#41) out of seven residents interviewed during stage I of the survey that expressed concerns with a roommate. This facility practice has the potential to affect all residents in the facility at the time of this survey The Findings Included: Interview on 07/17/2017 at 12:53 PM with R#41 revealed, the resident had concerns related to his roommate. The resident reported that his roommate (R#19) liked going through his drawer and that they could not even communicate because his roommate can't even speak English. R#41 explained that he yelled at the roommate and asked him to leave his stuff alone but his roommate did not seem to understand. During the interview, R#41 explained that he reported the issue to staff, he stated that he complained about the roommate's behavior to his CNA (Certified Nurse Assistant), he added that staff already knew about the issue because they witnessed the behavior. R#41 reported that staff did not address the issue to his satisfaction because the roommate went through his drawers almost every day since admission. Interview on 7/18/2017 at 11:04 AM with R#41 revealed, his roommate went through his drawers earlier that morning. R#41 reported, his roommate just wanted to see what I got. The resident yelled at the roommate to get out of there and did not report the incident to his nurses because they know about his behavior. Interview on 07/20/2017 at 10:16 AM with Staff A., LPN revealed, she was familiar with R#41 and his roommate. Staff A confirmed she was aware that R#41 had concerns with his roommate's behavior but stated that she was not aware that the language barrier was a problem to the resident. The LPN reported that the roommate got easily confused but was easily re-directed as well and that staff addressed R#41's concerns by instructing him to call for assistance whenever the issue arises. Staff A made no mention of filing a grievance report and stated that she did not notify the Social Services Director because she did not think it was necessary. Staff A indicated she was not familiar with the grievance procedure. Interview on 07/20/2017 at 11:15 AM with the Social Services Director (SSD) revealed, she recently heard from the LPN about the above-mentioned concerns with the roommate. The SSD agreed that R#41's concerns with the roommate was a grievance that should have been communicated to her, reported and she had started to address the resident's concerns. Record review of the grievance log from January - June 2017 revealed, no grievances filed during that time. Further review of the log revealed two grievances filed for the month of July 2017. No record found to indicate that the facility followed the grievance procedure address R#41's concerns. Record review of the Facility's Policy and Procedure titled, Resident Grievance/Complaint Policy & Procedures revealed the policy documented, The facility after receiving a complaint/grievance will actively seek a resolution and keep the resident appropriately appraised of its progress toward resolution. The facility procedure included: 1. Grievances and/or complaints may be submitted orally or in writing. 2. Grievance/ Complaint forms are located on each nurse station, Social Services Dept. And with the Director of Resident Services. 3. The Administrator has delegated the responsibility of grievance and/or complaint, an investigation of the allegation will be conducted and finding would be reviewed to determine what corrective actions, if any needs to be taken. 5. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems The administrator, or his/her designees will make such report, within 5 working days of receiving the grievance or complaint. 6. The Social Services Department as well as the Director of Resident Services will assist any resident or person(s) who cannot prepare a written grievance without help.

Based on observations, interviews and records reviewed, the facility failed to maintain dignity and respect for one of one resident (R#19) identified for dignity concerns during stage two of the survey by slamming the resident's door shut and preventing him from entering his room. The Findings Included: Observation on 07/19/2017 at 10:37 AM revealed, R#19 was in his wheelchair propelling himself down the hallway towards his room. Staff C, a Certified Nurse Assistant (CNA) was inside the resident's room, staff D, CNA was in the room to the left of the resident's room, about to provide care to another resident. R#19 was sitting in front of his room communicating to both CNAs that he just wanted to lay down on his bed, while staff D tried to redirect the resident into the activity room. The resident remained in front of his room insisting that he just wanted to lay on his bed and speaking to staff C. Staff D moved on to care for another resident at which point Staff C slammed R#19's door shut and kept R#19 out in the hallway while she remained inside the room. Staff C offered no reason or explanation to the resident before preventing him from entering his room. The resident was stunned and remained sitting there for a few seconds before attempting to open the door, Staff C remained behind the door holding it halfway closed as the resident yelled, Isn't this my room?!, This is my room right! The resident later received assistance first from Staff O, the RN supervisor. During an interview on 7/19/2017 at approximately 10:45 AM, Staff C, a CNA, reported that it was not her intention to slam the door on the resident. Staff C explained, she was trying to protect the roommate's privacy, but stated that the privacy curtain was in place. Staff C agreed, she had offered no explanation to R#19 and that the resident had the right to enter his room. Interview on 07/19/2017 at 11:51 AM, with Staff O, RN Supervisor, revealed, she walked up to assist the #19 and observed that staff C was standing behind and holding the resident's door. The RN assumed that the door bounced off of the CNA. The RN stated that there was no reasonable explanation to try to keep the resident out of his room and agreed with the dignity concern. Record review of the facility's policy and procedure titled Dignity and Respect revealed, the policy it is the policy of Homestead Manor, A Palace Community that all residents be treated with kindness, dignity and respect. The Procedure included but not limited to, 1. The staff shall display respect for residents when speaking with, caring for or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on observation, interview and record review the facility failed to maintain safety precautions by 1) storing oxygen tanks and oxygen concentrators in an unlocked oxygen storage room (six full oxygen tanks and six empty oxygen tanks and three oxygen concentrators) and 2) utilizing an electrical cable plugged into an outlet in the laundry room with dust-like and/or lint-like particles during the time of the survey. The findings include: 1. Observation on 7/19/2017 at 2:35 pm with staff M, unit manager revealed that the oxygen room was not locked. The oxygen room contained six full oxygen tanks in a metal rack and six empty oxygen tanks in a metal rack, sixteen containers of sterile water and three oxygen concentrators. Observation on 07/29/2017 at approximately 3:40 pm with the Interim Director of Nursing, Nurse Practitioner staff I and Staff M, unit manager revealed that they saw that there were six full oxygen tanks in a metal rack and six empty oxygen tanks in a metal rack, sixteen containers of sterile water and three oxygen concentrators in an unlocked oxygen room. Interview on 07/29/2017 at approximately 3:40 pm with the Interim Director of Nursing, Nurse Practitioner staff I and Staff M, unit manager revealed that the Interim Director of Nursing noted that it was not a concern to have the oxygen storage room unlocked, however she was not familiar with the regulations. Interview on 7/20/2017 at 10:38 am with Interim Director of Nursing, Nurse Practitioner staff I revealed that in an Abundance of caution we changed the handle to contain a lock and moved the biological's into the medication room. The Interim Director of Nursing, Nurse Practitioner, staff I noted that the oxygen storage room that contained the oxygen tanks was now locked. 2) Observation on 7/20/2017 at 2:45 pm with the director of housekeeping and laundry / maintenance director revealed that in the laundry room an electrical cord was plugged into an outlet along the wall in the laundry room with severe dust-like particles along it. Interview on 07/20/2017 at 2:50 pm with the maintenance director revealed that he confirmed that there was a white dust-like build up along the electrical cord plugged into the socket. The maintenance director clarified that he thought this was Lint. Observation on 07/20/2017 at 2:55 pm with staff L, nursing supervisor revealed that she saw the whitish buildup along the electrical cord plugged into the wall outlet behind the washing machine in the laundry room. Interview on 07/20/2017 at 2:55 pm with staff L, nursing supervisor regarding the whitish buildup along the electrical cord plugged into the wall outlet revealed that she noted, It should not be there. Interview on 07/20/2017 at 3:15 pm with the maintenance director revealed that he had no log for the cleaning of the laundry room. Record review of the facility's policy titled Environmental Services - Laundry / Linen for housekeeping revealed, Linen room will be vacuumed and mopped daily with germicide. Sorting bins, folding tables and other work areas will be wiped down with germicidal solution daily. There was no mention of keeping a log for cleaning the laundry room.