Every finding on record at Jolley Acres Healthcare Center

Based on review of facility policy, observation, record review and interview, the facility failed to ensure a medication administration pass rate of less than 5% (percent), for 2 of 25 medications observed during medication pass administration. The medication error rate was 8% based on 2 medications not being administered at the correct time to Resident (R)21.Findings include:Review of the facility policy titled Medication Management Program revised on 01/15/25 revealed, Authorized staff must understand: .The 8 Rights for administering medication: . 4) the Right Time .On 09/03/25 at approximately 8:28 AM during medication pass observation, Licensed Practical Nurse (LPN)1 administered one tablet each of Lorazepam 0.5 mg (milligram), Tramadol 50 mg, Multivitamin, Docusate 100 mg, Meloxicam 7.5 mg and Bupropion 100 mg to R21 and stated she would have to pull Gabapentin 100 mg from the PYXIS (automated dispensing machine) since none was in the cart. Gabapentin 100 mg was administered to R21 approximately 10 minutes later.On 09/03/25 at approximately 8:50 AM during medication reconciliation, a review of the September 2025 physician orders and MAR (medication administration record) for R21 revealed the following orders: bupropion tablet 100 mg Administer three times a day at 6:00 AM, 2:00 AM, 10:00 AM and gabapentin 100 mg; administer 100 mg three times a day at 6:00 AM, 2:00 PM, 10:00 PM.During an interview on 09/03/25 at approximately 9:10 AM, LPN1 stated she administered bupropion 100 mg with the other meds around 8:30 AM, and after removing gabapentin 100 mg from the PYXIS machine, she had administered gabapentin 100 mg shortly thereafter. LPN1 was unable to verify the electronic medical record showing the times these two medications were scheduled and did confirm again that she had given the bupropion 100 mg and gabapentin 100 mg.On 09/03/25 at approximately 9:14 AM, the Director of Nursing (DON) was asked to provide a hard copy of R21's MAR and physician orders for 09/03/25.On 09/03/25 at approximately 10:12 AM, the DON provided copies of the MAR and physician order and stated that both bupropion 100 mg and gabapentin 100 mg should not have been administered by LPN1 during medication pass around 8:30 AM, since both medications had been administered according to schedule on 09/03/25 at 6:00 AM by the night shift nurse.

Based on review of the facility policies, observations and interviews, the facility failed to follow proper infection control guidelines related to handling soiled clothes, and linens for transport in 3 of 3 soiled linen rooms. The facility further failed to ensure the proper handling of clean wet and dry linens, and the folding of clean linen in 1 of 1 main laundry room. Findings include: Review of the facility policy titled, Indications for Glove Use, states, The facility recognizes and implements Standard Precautions. The use of enhanced and transmission-based precautions is implemented as clinically indicated and recommended by health authorities. Procedures: Gloves are worn when: 3. Touching or having the potential to touch urine, stool or vomitus while providing care, treatment or services. 4. Handling items or environmental surfaces that are likely soiled with blood or body fluids, except sweat. 6. When staff has non-intact skin on the hands or wrist. Review of the facility policy titled, Hand Hygiene/Handwashing, revealed Hand Hygiene/Hand Washing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff. Procedures: A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as mucous membranes, non-intact skin, body fluids, blood or wounds. Review of the facility policy titled, Laundry, states, Laundry services will comply with appropriate guidelines to assure that measures are implemented to provide pro effective laundry service. The procedures for personnel are, 5. Personnel in the laundry services are properly garbed at all times. When handling soiled linens, gowns, and gloves, at a minimum will be donned. These are removed as soon as possible after completing of duties involving soiled linens. Handwashing, Hands are washed after handling soiled linens even if gloves have been worn. At all times laundry service personnel are in compliance with the Facility Handwashing Policy. All Linens, 1, Linens are to be handled in a safe manner to prevent contamination of the linen, the personnel and the environment. Clean linen is never held up against personnel's body. An observation on 09/19/2024 at 08:20 AM, revealed the laundry worker (LW) picking up soiled laundry from 3 shower rooms throughout the facility. The laundry worker went into the areas and took the lid off of bins and reached in with her bare hands and removed soiled clothes and soiled linens and placed them into a bin that she had brought into the soiled area. Some of the soiled clothes and linens were in bags and some were not. The LW continued the same practice in all three soiled areas. She brought the bin back to the laundry room and washed her hands and put on gloves and a gown and removed the lid from the bin of soiled linens and clothes and started to sort them into individual bins. The LW then removed the gown and gloves and opened the clothes dryer to remove dry linens to be folded. When she opened the dryer door, a washcloth fell to the floor and she picked it up and put it into a basket with other clean clothes to be folded. The LW then went to the washer and opened it, the clothes were ready for the dryer. Another washcloth fell to the floor, and as she was holding most of the clean wet clothes up against her uniform, she stepped on it, then picked it up and placed it with the clean wet clothes, she was putting in the dryer. The LW then turned on the dryer. She then put on a gown and gloves and pushed the bin of soiled clothes to the washer and placed them in the washer and turned it on. She then removed the gown and the gloves, washed her hands and started folding the clean basket of clothes. The sheets and bedspreads were observed touching the floor and the clothes she was wearing, while she was attempting to fold them. During an interview on 09/19/2024 at 08:45 AM with the LW, this surveyor informed the laundry worker of the following concerns. 1. Using bare hands to pull soiled clothes and linens from a bin in the 3 shower rooms. She had also failed to wash her hands after placing them in the bin. The LW confirmed that she had picked up the soiled clothes and linens without wearing gloves and a gown and did not wash her hands until she returned to the laundry room. 2. The laundry worker confirmed that she had picked up the clean washcloth from the floor and placed it with the clean linens to be folded and used for residents. 3. She also confirmed that the wet washcloth she had stepped on, she had picked it up and then placed in the clothes dryer with clean wet linens. She stated, I thought the dryer would get hot enough to kill any germs on it. 4. Lastly, the LW confirmed that the sheets and bedspreads had touched her uniform and had touched the floor during the folding process.

Based on observation, interview, review of the facility policy and manufacturer labeling, the facility failed to ensure that medications were safely stored in 1 of 3 medication carts. Findings include: Review of the facility policy titled, General Guidelines for Medication Storage dated 6/21/2017 states Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. On 9/18/24 at approximately 4:01 PM, inspection of the facility's treatment cart revealed one opened 100 ml (milliliter) bottle of Sterile 0.9% (percent) Normal Saline, USP (United States Pharmacopoeia) by Medline which was had been dated by the facility as opened on 9/18/24 and was approximately 90% full. During an interview on 9/18/24 at approximately 4:05 PM, Licensed Practical Nurse (LPN)2 read the manufacturer's label which states Contents sterile unless container is opened or damaged and the facility dating of the opened container and acknowledged that the contents were no longer sterile, since it had been opened and returned to the treatment cart.

Based on observations, record review, interviews, and policy review, the facility failed to protect and value residents' private space by failing to knock on doors and/or request permission and/or pause prior to entering resident (R) rooms for 3 (R46, R205, and R51) of 4 residents sampled for dignity. Findings include: A review of the facility policy Resident Rights, revised 11/01/17, revealed The facility staff will provide the patient/resident with his/her right to privacy and security. The procedures of the policy included 2. Staff: A. Knocks on doors for permission to enter. (a) During an observation of medication administration on the 200 Hall on 08/24/22 at 8:55 AM, Licensed Practical Nurse (LPN)1 walked into R46's room to administer medication without knocking and waiting to enter. Review of R46's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/22, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderately impaired cognition. Per the MDS, the resident also had unclear speech. Review of R46's care plan revealed an intervention with an approach start date of 08/09/22. The intervention directed staff to provide privacy during care to maintain dignity. Another intervention with an approach start date of 08/09/22 directed staff to avoid overstimulating the resident. However, there were no interventions directing staff not to knock on the resident's door prior to entering (to avoid startling and/or agitating the resident, for example). (b) During an observation of medication administration on the 200 Hall on 08/24/22 at 9:03 AM, LPN1 walked into R205's room to detach R205's G-tube for transport without knocking and waiting to enter. Review of R205's MDS with an ARD of 07/04/22, revealed the resident had a BIMS score of 8, indicating moderately impaired cognition. Per the MDS, the resident also had unclear speech. Review of R205's care plan revealed an intervention with an approach start date of 07/07/22. The intervention directed staff to talk with the resident during care and allow the resident time to respond. However, there were no interventions directing staff not to knock on the resident's door prior to entering (to avoid startling and/or agitating the resident, for example). (c) During an observation of medication administration on the 200 Hall on 08/24/22 at 9:06 AM, LPN1 walked into R51's room to perform a blood sugar finger stick without knocking and waiting to enter and, again, at 9:09 AM without knocking and waiting to enter to administer medications. Review of R51's admission MDS with an ARD of 07/13/22, revealed the resident had BIMS score of 13, which indicated the resident was cognitively intact. During an interview with R51 on 08/24/22 at 9:22 AM, the resident stated staff sometimes knocked prior to entering his/her room and sometimes did not, noting he/she expected staff to knock on the door before coming into the room. During an interview on 08/24/22 at 9:11 AM, LPN1 stated she knew she was supposed to knock on residents' doors and wait to be told to come in before entering their rooms. LPN1 also stated she did not know why she did not do it and thought she knocked on one door. An interview with Certified Nursing Assistant (CNA)1 was conducted on 08/24/22 at 2:32 PM. The CNA stated he worked at the facility for three years and knew to knock on residents' doors and wait to be invited to enter. An interview with CNA2 was conducted on 08/24/22 at 2:49 PM. CNA2 stated she had worked at the facility for six years. CNA2 stated the facility was the residents' home and she always knocked and waited to hear a resident tell her to enter. Per CNA2, if a resident was nonverbal, then she waited a few seconds after knocking prior to entering the room. During an interview with the Assistant Director of Nursing (ADON) on 08/25/22 at 12:27 PM, the ADON stated staff were expected to knock on open or closed doors and wait until someone granted permission to enter or, if a resident could not speak or was hard of hearing, staff should knock, wait, and then enter. The ADON noted if a resident did not want someone to knock on his/her door, then it would be care planned. During an interview with the Administrator on 08/25/22 at 11:54 AM, the Administrator stated she expected staff to knock and wait for permission to enter all resident rooms. She stated the facility was the residents' home and privacy was expected. Per the Administrator, staff should knock and wait.

Based on record review, interviews, and facility policy, the facility failed to adequately supervise Resident (R)1 to prevent resident-resident altercations, 1 of 3 reviewed for abuse. Failure to provide adequate supervision has the potential for harm/accidents for all residents. Finding include: Review of the facility policy and procedure titled Abuse, Neglect, Exploitation, or Mistreatment last revised 2019, revealed ongoing assessment, care planning, and monitoring of those patients/ residents with special needs that may lead to neglect, for example: History of aggressive behavior; history of entering other patient/resident rooms; patients/residents requiring excessive nursing care or staff attention; residents with history of resident to resident altercations. Record review revealed R1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a progress note dated 10/16/21 at 11:15 AM revealed resident approached another resident in the dayroom and hit her on the left side of her face. Charge Registered Nurse called 911 at 12:15 PM. Police officers and EMS in route to facility. Officers arrived to facility at 12:25 PM. Officers explained that they could not take resident to jail due to his mental illness. The officers secured the scene and cleared report to EMS and sent paperwork including the Bed Hold Policy to hospital with resident. This nurse called resident representative but was unable to reach them. Voicemail left to return call, resident left facility via ambulance with EMS at 1:15 pm in good condition, alert, disoriented with bouts of confusion which is his baseline. Record review of a progress noted dated 10/21/21 revealed this nurse was informed by speech therapist that resident had hit another resident on the shoulder. EMS was called at 2:08 PM to transfer resident to TRMC for evaluation. Resident representative was called and notified at 2:12 pm. This nurse called TRMC to give report at 2:13 PM but was on hold for 45 minutes with no answer. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R2 admitted to the facility on [DATE]. R2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Record review of a progress noted dated 10/17/21 revealed, At 11:15 AM, resident was approached by another resident and was hit on the left side of her face. This nurse checked resident for injuries, no injuries, concerns, or pain noted. Resident requested to go to emergency room , 911 called at 11:30 A.M., EMS in route. Resident Representative and Medical Director notified of incident . Continue to monitor resident when she returns to the facility. Record review of a progress note dated 10/17/21 revealed resident arrived back to facility via stretcher with Emergency Medical Staff (EMS) at 5:15 P.M. No new orders per hospital given medication as needed for pain. Resident is alert and oriented times three with bouts of confusion. No injuries or bruises noted. Staff will continue to monitor. An interview on 10/26/21 at 12:05 PM with R2 revealed she was able to recall incident and became tearful when speaking about what happened. R2 stated that He just came up and hit me out of nowhere, I don't feel safe here anymore. Record review of the MDS assessment dated [DATE] revealed R3 admitted to the facility on [DATE]. R3 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Record review of a progress note dated 10/22/21 revealed Resident is okay today, she enjoyed activities today, 0 signs of distress or bruising from incident on 10/21. She is in a great mood today. All meds taken as ordered, she continues breathing treatment. An interview on 10/27/21 at 11:50 AM with R3 revealed I was coming down the hallway in my wheelchair and R1 was running down the hallway and hit me on the top of my head and kept running. I don't know why they let that man come back in here after the first incident with R2 but when he hit me that was enough. From my understanding they tried to send him out after the first time but somehow between the hospital and the police they let him come back and that's when he hit me. I don't trust them (the facility) to do the right thing anymore because look what happened and twice. An interview with Social Services, the Director of Nursing, the Administrator, and Floor Technician on 10/27/21 revealed that R1 had hit R2 on 10/16/21 and were both immediately sent to the emergency room for evaluation. R1 was placed on one to one supervision with mostly male staff because R1 could better relate and be re-directed by male staff. Since admission, R1 has refused care and medication along with yelling at staff. On the day of the second incident with R1 hitting R3 on the top of her shoulder (10/21/21), R1 was being supervised by the Floor Technician #1 however, when a truck arrived at the facility, the Administrator switched positions to provide one to one supervision for R1. During when the Administrator was supervising R1, R1 ran out of his room and past the Administrator and went jogging down the hall and hit R3 on the top of her head. After the incident on 10/21/21 with R1, the facility immediately started the discharge process to find R1 a better suited facility that can accommodate R1's behaviors.

Based on record review, interviews, and facility policy, the facility failed to adequately supervise Resident (R)1 to prevent resident-resident altercations. Failure to provide adequate supervision has the potential for harm/accidents for all residents. Finding include: Review of the facility policy and procedure titled Abuse, Neglect, Exploitation, or Mistreatment last revised 2019, revealed ongoing assessment, care planning, and monitoring of those patients/ residents with special needs that may lead to neglect, for example: History of aggressive behavior; history of entering other patient/resident rooms; patients/residents requiring excessive nursing care or staff attention; residents with history of resident to resident altercations. Record review revealed R1 admitted to the facility on [DATE] with diagnoses including but not limited to [CONDITION(S)] and Unspecified dementia with behavioral disturbances. Record review of a progress note dated 10/16/21 at 11:15 AM revealed resident approached another resident in the dayroom and hit her on the left side of her face. Charge Registered Nurse called 911 at 12:15 PM. Police officers and EMS in route to facility. Officers arrived to facility at 12:25 PM. Officers explained that they could not take resident to jail due to his mental illness. The officers secured the scene and cleared report to EMS and sent paperwork including the Bed Hold Policy to hospital with resident. This nurse called resident representative but was unable to reach them. Voicemail left to return call, resident left facility via ambulance with EMS at 1:15 pm in good condition, alert, disoriented with bouts of confusion which is his baseline. Record review of a progress noted dated 10/21/21 revealed this nurse was informed by speech therapist that resident had hit another resident on the shoulder. EMS was called at 2:08 PM to transfer resident to TRMC for evaluation. Resident representative was called and notified at 2:12 pm. This nurse called TRMC to give report at 2:13 PM but was on hold for 45 minutes with no answer. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R2 admitted to the facility on [DATE]. R2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Record review of a progress noted dated 10/17/21 revealed, At 11:15 AM, resident was approached by another resident and was hit on the left side of her face. This nurse checked resident for injuries, no injuries, concerns, or pain noted. Resident requested to go to emergency room , 911 called at 11:30 A.M., EMS in route. Resident Representative and Medical Director notified of incident . Continue to monitor resident when she returns to the facility. Record review of a progress note dated 10/17/21 revealed resident arrived back to facility via stretcher with Emergency Medical Staff (EMS) at 5:15 P.M. No new orders per hospital given medication as needed for pain. Resident is alert and oriented times three with bouts of confusion. No injuries or bruises noted. Staff will continue to monitor. An interview on 10/26/21 at 12:05 PM with R2 revealed she was able to recall incident and became tearful when speaking about what happened. R2 stated that He just came up and hit me out of nowhere, I don't feel safe here anymore. Record review of the MDS assessment dated [DATE] revealed R3 admitted to the facility on [DATE]. R3 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Record review of a progress note dated 10/22/21 revealed Resident is okay today, she enjoyed activities today, 0 signs of distress or bruising from incident on 10/21. She is in a great mood today. All meds taken as ordered, she continues breathing treatment. An interview on 10/27/21 at 11:50 AM with R3 revealed I was coming down the hallway in my wheelchair and R1 was running down the hallway and hit me on the top of my head and kept running. I don't know why they let that man come back in here after the first incident with R2 but when he hit me that was enough. From my understanding they tried to send him out after the first time but somehow between the hospital and the police they let him come back and that's when he hit me. I don't trust them (the facility) to do the right thing anymore because look what happened and twice. An interview with Social Services, the Director of Nursing, the Administrator, and Floor Technician on 10/27/21 revealed that R1 had hit R2 on 10/16/21 and were both immediately sent to the emergency room for evaluation. R1 was placed on one to one supervision with mostly male staff because R1 could better relate and be re-directed by male staff. Since admission, R1 has refused care and medication along with yelling at staff. On the day of the second incident with R1 hitting R3 on the top of her shoulder (10/21/21), R1 was being supervised by the Floor Technician #1 however, when a truck arrived at the facility, the Administrator switched positions to provide one to one supervision for R1. During when the Administrator was supervising R1, R1 ran out of his room and past the Administrator and went jogging down the hall and hit R3 on the top of her head. After the incident on 10/21/21 with R1, the facility immediately started the discharge process to find R1 a better suited facility that can accommodate R1's behaviors.

Based on observation, record review, and interviews the facility failed to ensure that changes made to the menu were done by a qualified professional. In addition, the facility failed to inform the residents in advance and provide them with the opportunity to participate in this activity. The Certified Dietary Manager (CDM) removed and added food items from and to the menu without consulting the Physician, Dietitian, and Residents. During the initial walk through of the kitchen on 6/08/21 at 10:29 AM the CDM stated that [s/he] had made changes to the menu because [s/he] knows that the Residents won't eat certain foods, such as Brussels Sprout, Oatmeal, and Mushrooms. In an Interview with R #33 on 6/8/2021 at approximately 11:15 AM [s/he] stated that [s/he] prefers Bacon and Sausage with Breakfast and that [s/he] was getting it until a couple of weeks ago. R #33 said that [s/he] has requested these items back multiple times to no avail. On 6/8/21 at approximately 2:30 PM the CMD stated that R #33 cannot have bacon and sausages because [s/he] is on a Renal Diet. When asked if [s/he] has a food preference list/card for R #33 the CMD was unable to locate it and [s/he] could not record R #33 ' s food preference. Review of the menu provided by the CDM found breakfast does not have grits or oatmeal and has either boiled, scrambled or cheddar scrambled eggs daily. For the lunch menu mushroom was scratched off and yellow rice handwrote below. Seasoned Brussel sprout was also scratched off and cauliflower handwrote below. Resident choice meal, scampi, rice, cauliflower/broccoli blend, and garlic toast were handwritten on the menu. The Dietary Manager (DM) was not able to provide evidence to indicate that this meal was chosen by the residents. Review of the facility's position description. Job Title: Dietary Manager. Summary Description: The dietary the manager is responsible for planning, organizing, developing, and directing the overall operation of the Dietary Services Department in accordance with the current applicable federal, state, and local standards, guidelines, and regulation, established facility policies and procedures and as may be directed by the administrator, to ensure that the quality of food services and nutritional care is provided at all times. Review of the facility's policy titled Nutrition Policies and Procedures Subject: Menus under Procedures: The Facility Dietitian approves and signs all menus, diet modifications, and menu changes. In a phone interview with the Registered Dietitian on 6/10/2021 at approximately 11:35 AM [s/he] stated that [s/he] has not made changes to the facility ' s menu since 2020. The Dietitian concurred that the CDM does not have the credential to make changes to the menu without consulting a dietitian, physician, and resident.

Based on observation, record review the facility failed to provide to make proper and timely accommodations for Resident #6 for one of one residents reviewed for environment. Resident (R) #6 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R #6 has the Brief Interview Mental Status (BIMS) of 15. An Observation and Interview on 6/8/2021 at 10:33 AM revealed that R #6's restroom had been out of order for almost a year. R #6 stated that they had to use the restroom across the hall or use one of the other public restrooms in the facility because the one in their room is locked. Upon observation of the restroom door was an OUT OF ORDER sign and was locked. An Interview with the Maintenance Director on 6/10/2021 at approximately 10:00 AM revealed that R #6's restroom was not out of order, but was locked because R #6 had gotten stuck last year because they used their electric wheelchair which does not fit. R #6 stated that they have enough sense to not do that anymore and would love to be able to use their own restroom instead of having to go across the hall but believed the restroom was not working.

Based on Record Review, including the [CONDITION(S)] Services Agreement, and staff interview the facility failed to assess and monitor the Resident's health condition before and after [CONDITION(S)] treatments for one of one sampled resident reviewed for [CONDITION(S)] services. Findings: The facility admitted Resident (R) #33 on 1/27/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [CONDITION(S)] communication record, for May and June, on 6/10/2021 at 11:02 AM revealed no record of assessment and/or monitoring of the Resident's health condition before and after [CONDITION(S)] for the following dates: 5/19/2021, 5/21/2021, 5/24/2021, and 6/9/2021. Review of the [CONDITION(S)] services agreement on 6/10/2021 at approximately 11:30 AM states under A. Obligations of nursing facility and/or Owner. 1. [CONDITION(S)] Residents information. The nursing facility shall ensure that all appropriate medical and administrative information accompanies all [CONDITION(S)] Residents at the time of referral to [CONDITION(S)] [CONDITION(S)] Unit. This information, shall include, but not limited to, where appropriate, the following: D. Appropriate medical records, including the history of the [CONDITION(S)] Resident's illness, laboratory and x-ray findings; In an interview with the Director of Nursing (DON) s/he acknowledged that required documentation to indicate the R #33 has been properly assessed and monitored pre and post [CONDITION(S)] was not in the Residents' clinical record or the facility records.

Based on observation and staff interview, the facility failed to ensure the kitchen dishware was dried and stored according to standard practice to prevent bacterial growth and cross-contamination. The findings included: During the initial kitchen observation on 12/16/19 at 10:19 AM, the following was noticed: Six wet nesting pots on a solid concrete surface, the cleaned/dried dishware storage area, and two stainless steel wet bowls on top of them. The certified dietary manager (CDM) was present during the kitchen observation and confirmed the wet nesting pots and bowls.

Based on record review and staff interview, the facility failed to notify the resident and the resident's representative in writing. In a language and manner, they understand the discharge/transfer to the hospital emergency room (ER) for 2 of 3 sample residents reviewed for hospitalization . The findings included: The facility admitted Resident #1 on 01/11/19 with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 12/17/19 at approximately 2:00 PM revealed that on 10/15/19, Resident #1's nurse found the pe[DEVICE] on the floor. The physician was notified, and the resident was sent to the hospital for pe[DEVICE] replacement. According to the residents' hospital discharge summary, the resident was admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE] with the peg tube in place. Resident #1 was sent to the hospital for pe[DEVICE] replacement again on 12/2/19. S/he returned to the facility on [DATE]. In an interview with the administrator, director of nursing and social worker on 12/19/19 at approximately 11: 15 AM, they stated that they were unable to locate any documentation to support that the resident and the resident's representative were notified in writing, the reasons for Resident #1 hospitalization . The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/18/19 at approximately 11:53 AM revealed Nursing progress noted dated 12/11/19 stating Resident #14 was transferred to the hospital on [DATE] after experiencing a [MEDICAL CONDITION]. No written Notice of transfer could be located in the electronic health record. In an interview on 12/18/19 at approximately 12:31 PM the Business Manager stated the facility did not issue a written Notice of Transfer to Resident and/or Resident Representative for Resident #14 due to his/her private pay status.

Based on record review and interview the facility failed to provide written Notice of Bed Hold to the Residents #1 and #14 and/or their Resident Representatives, 2 of 3 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/18/19 at approximately 11:53 AM revealed a Nursing progress noted dated 12/11/19 stating Resident #14 was transferred to the hospital on [DATE] after experiencing a [MEDICAL CONDITION]. In an interview on 12/18/19 at approximately 12:31 PM the Business Manager stated the facility did not issue a written Notice of Bed Hold to Resident #14 and/or the Resident Representative for Resident #14 due to his/her private pay status. The facility admitted Resident #1 on 01/11/19 with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 12/17/19 at approximately 2:00 PM revealed that on 10/15/19, Resident #1's nurse found the pe[DEVICE] on the floor. The facility notified the physician and sent the resident to the hospital for pe[DEVICE] replacement. According to the residents' hospital discharge summary, the hospital admitted the resident was with IV fluid and planned for replacement of peg-tub, after numerous attempt to reinsert the tube failed. The resident returned to the facility on [DATE] with the peg tube in place. Resident #1 was sent to the hospital for pe[DEVICE] replacement again on 12/2/19. S/he returned to the facility on [DATE]. In an interview with the administrator, director of nursing and social worker on 12/19/19 at approximately 11:15 AM, they stated that they were unable to locate any documentation to support that the resident or the resident's representative was provided with the bed-hold policy.

Based on observation, interview and facility policy, the facility laundry staff failed to observe standard practice related to hand washing and glove use while sorting soiled linen. The findings included: In a laundry observation on 12/17/19 at approximately 10:55 AM the laundry aide washed his/her hands, donned personal protective equipment including plastic gloves and disposable apron, sorted the soiled linen into the washing machine. Then, while still wearing the contaminated gloves, the aide started the washing machine, changed the plastic liner for the container and handled other items in the room before removing the gloves and washing his/her hands. In an interview on 12/17/19 at approximately 3:30 PM the Head of Housekeeping and the Administrator confirmed the laundry aide should have removed the soiled gloves after sorting the laundry. Review of facility policy entitled Maintenance/ Housekeeping Policies and Procedures: Laundry, states, Handwashing: 2. Hands are washed after handling soiled linens even if gloves have been worn. At all times laundry service personnel are in compliance with Facility Handwashing Policy in the Facility Surveillance, Prevention and Control of Infections Manual #4.

Based on observation, interview, and record review, the facility failed to ensure resident rights. Resident #52 was exposed during bathing/bed change (1 of 1 reviewed for dignity). Residents on the 300 hall were referred to as feeders, and residents received dessert service off paper plates (1 of 2 meals observed). The findings included: Observation on 09/06/18 at 12:30 PM revealed the residents in the main dining room were eating dessert (sweet potato pie) on small paper plates. Interview with the Dietary Manager on 09/06/18 at 01:40 PM revealed pie was not served often but s/he likes to serve something special occasionally. S/he stated that the facility did not have any regular dessert plates. During observation of the noon meal on 9-4-18 on the 300 Hall, Certified Nursing Assistants (CNAs) #2 and #3 referred to residents as feeders multiple times. Trays were left on the cart for distribution at a later time because these residents required assistance with eating. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. During the Initial Pool process on 9-4-18, the surveyor knocked on the resident's door and CNA #1 answered, Come in. Resident #52 was observed on a work-height bed with only the fitted sheet on the mattress. The resident had no covers and had on only a disposable brief. The window blinds were open. The CNA quickly grabbed a towel to cover the resident's mid-section and stated s/he had been bathing him/her. During an interview on 9/07/18 at 1:51 PM, the Director of Nurses (DON) stated, They should keep body parts covered except for what is being bathed. When informed that CNAs referred to residents as feeders, the DON stated,We no longer use that term. The facility policy titled Bathing - Tepid Sponge Bath (7/1/2016) states: .Keep bath blankets over body parts not being sponged .

Based on interview and observation the facility failed to notify residents of the State Agency (SA) survey results and post the required information in an accessible location for facility residents and community persons to review. Nine of nine residents attending group interview were not aware of the SA annual survey, the report that comes to the facility and the location of the results of that report for them to review. The findings included: On 9/6/2018 a group interview with 9 facility residents was held. These 9 residents were members that regularly attended the monthly resident council meetings. When asked about their knowledge of the SA survey that is conducted annually, they were not aware. When asked about their knowledge of the survey results to be posted in the facility for them to review, they were not aware of the posting or the location in the building of the posting. A review of the resident council minutes did not reveal that these findings were ever discussed with resident council members during the meetings.

Based on observation, interview, and record review, the facility failed to complete restraint assessments for alarm use for Residents #20, 51, 52, 4, 256, 42, 35 (7 of 7 reviewed with alarms). The findings included: Resident #20 was observed on 09/04/18 at 11:00 AM, 09/06/18 at 05:55 PM, and 09/07/18 at 09:15 AM with a bed alarm. Record review of the (MONTH) (YEAR) physician's orders [REDACTED]. Record review of the 7/5/18 Care Plan revealed: Requires total assistance with transfers, locomotion, toilet use, and bathing. Extensive assistance with bed mobility, dressing, and personal hygiene. Supervision with eating. APPROACH: Clip alarm for bed/chair, check every shift for placement and functioning. Record review of the 7/2/18 Quarterly Minimum Data Set (MDS) revealed Section P was coded for bed alarm and chair alarm as used daily. Record review of the 4/3/18 Annual MDS and the 1/8/18 Quarterly MDS revealed Section P was coded for bed alarm as used daily and chair alarm as used less than daily. Resident #51 admitted with [DIAGNOSES REDACTED].#4 admitted with Depression were both observed on 9/5/18 up in the chair with a tab alarm and in bed with a bed alarm attached. Review of the resident's MDS revealed they were coded to use the alarms daily. There was no evidence an assessment had been done for use of the alarms and if they were the least restrictive. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Observations during the survey and review of Physician's 0rders on 9-5-18 at 2:13 PM and Medications Administration History on 9/07/18 at 10:10 AM revealed that a clip alarm to bed and wheelchair was applied as ordered. Review of the 8-2-18 Quarterly Minimum Data Set (MDS) Assessment on 9-5-18 at 2:43 PM revealed that the alarm use was coded under Section P but no restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey and review of 7-25-18 Physician's 0rders on 9/06/18 at 11:50 PM and Medications Administration History on 09/07/18 12:02 AM revealed that a clip alarm was applied to bed and wheelchair as ordered. No restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Observations during the survey and review of Physician's 0rders on 9/06/18 at 12:02 PM and Medications Administration History on 9/06/18 at 8:43 PM revealed that a clip alarm to bed and chair was applied as ordered. Review of the 8-24-18 30 Day Minimum Data Set Assessment on 9/06/18 at 2:17 PM revealed that the alarm use was coded under Section P but no restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. The facility admitted Resident #256 with [DIAGNOSES REDACTED]. Observations during the survey and review of Physician's 0rders on 9/06/18 at 6:10 PM 9/06/18 and Medications Administration History on 9/06/18 at 10:57 PM revealed that a clip alarm to bed and wheelchair was applied as ordered. No restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. During an interview on 9/06/18 at 3:31 PM, the MDS Coordinator and Registered Nurse #1 reviewed the record and found no assessment for use of alarms as possible restraints. They contacted the Assistant Director of Nursing who stated no assessments had been completed prior to use to determine if the use of the alarms was because of an underlying medical symptom, resulted in possible restraint, or was being used for convenience of the staff. There was no evidence of alternative interventions attempted prior to use of alarms. During an interview on 9-7-18 at 3 PM, the Administrator stated the facility had no written policies regarding alarm use.

Based on record review and interview, there was no evidence of provision of Range of Motion (ROM) to prevent further decline for Resident #20 (1 of 3 reviewed for ROM). The findings included: Record review of the (MONTH) (YEAR) physician's orders [REDACTED]. The physician's orders [REDACTED]. Record review of the Medication Administration Record [REDACTED]. As a result, there was no evidence that ROM was provided to Resident #20. RN #1 provided a 4/1/18 Nursing Weekly Summary Progress Note regarding the ROM, but no other documentation was located. The current Care Plan dated 7/5/18 listed ROM as an approach for the following goal: Will have no decline in activities of daily living through next review date.

Based on record review and interview, the facility failed to identify and complete a comprehensive assessment for 1 of 1 sampled resident with a significant decline in status. The facility did not complete a Significant Change in Status Assessment (SCSA) when required for Resident #35. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review of the 8-2-18 Quarterly and 2-9-18 Admission/5-Day Minimum Data Set (MDS) Assessments on 9-5-18 at 2:43 PM revealed that the resident had sustained a significant decline and no Significant Change in Status Assessment (SCSA) had been completed. The resident's cognitive status had declined from cognitively intact to moderately impaired. S/he was noted as feeling depressed. His/her locomotion on the unit declined from minimal to extensive assistance required while locomotion off the unit required total assistance. The ability to feed him/herself declined from supervision to extensive assistance required. Functional range of motion (ROM) was impaired in one upper extremity while the resident had no impairment on admission. Bowel incontinence declined. S/he exhibited moderate pain requiring PRN (as needed) pain medication when previously the resident required none. Weight loss was noted and the resident developed a pressure ulcer. During an interview on 9/06/18 at 3:11 PM, the MDS Coordinator reviewed the assessments and verified the changes. S/he stated the resident had been treated in (MONTH) and (MONTH) for urinary tract infections. On 9/07/18 at 12:08 PM, the MDS Coordinator stated s/he had spoken to her/his consultant and that a SCSA should have been done. We missed him.

Based on observation, interview, and review of the facility policy titled Gastrostomy Tube Flush/Irrigation (Revised 6/16/17), the facility failed to ensure that professional standards of practice were followed for care of 1 of 1 sampled resident reviewed for tube feeding. The nurse failed to wash hands appropriately prior to the tube feeding and failed to check for residual prior to initiating a water flush for Resident #42. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. During observation of tube feeding on 9/06/18 at 1:00 PM, Licensed Practical Nurse (LPN) #1 initially washed her/his hands. She proceeded to measure 100 milliliters of water into each of 2 cups. S/he elevated the bed to work height, closed the privacy curtain, changed gloves without washing her/his hands, and continued with the feeding procedure. After adjusting the resident's clothing and draping her/him, the nurse connected the 60 milliliter (ml) syringe barrel to the open gastrostomy tube and began pouring water into the syringe without checking for placement. The surveyor stopped the procedure and questioned LPN #1 who confirmed s/he had not checked for residual. After the feeding and flushes were completed, the nurse rinsed and dried the 60 ml syringe, then stored it in a plastic bag with the plunger in the barrel and moisture in the tip. During an interview immediately following the procedure, LPN #1 verified all of the above information. The facility policy titled Gastrostomy Tube Flush/Irrigation (Revised 6/16/17) states: Verify correct tube placement at least every eight (8) hours: A. Prior to beginning a feeding/flushing . by: 1) Checking for gastric residual . The policy/procedure did not address post-use care of the 60 ml. syringe.

Based on observation, interview, and review of facility policies, the facility failed to distribute and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 56 of 56 residents with ordered diets as evidenced by failing to do the following: Temp foods without cross contamination. The findings included: On 5/1/17 at 4:36 PM, during an observation of the dinner line temping with the Dietary Manager (DM) revealed, the DM used the same temperature probe between food items, mash potatoes, pork sausage, carrots, and green beans, sanitizing the probe with the same alcohol pad between food items. Following the observation of the dinner line temping, the DM verified the same sanitizing pad was used between food items and indicated a new pad should have been used between food items to avoid cross food contamination. Review of the facility policy Safe Food Temperatures, states under, Guidelines For Checking Food Temperatures (1.) Make certain the thermometer is clean and has been sanitized with an appropriate sanitizer (100 ppm (parts per million) bleach solution or 25 ppm iodine solution). The use of individual, foil wrapper alcohol pads also is acceptable for sanitizing probes; however, allow time for the alcohol to evaporate before inserting the probe into the food. Another method is to utilize the coffee urn making sure water temperature is 180F. Note: The thermometer must be cleaned and sanitized between each product that is tested .