Every finding on record at Lenbrook

Based on observations, staff and resident interviews, record review, and review of the facility policies titled, Infection Prevention and Control Program, Wound Care, and Handwashing/Hand Hygiene, the facility failed to maintain appropriate infection control practices for two of 29 sampled residents (R) (R8 and R28). Specifically, the facility failed to ensure the Infection Prevention and Control Program policy was reviewed and updated annually, conduct required infection surveillance audits, maintain proper infection control practices by not disinfecting reusable items after wound care, follow standard infection control procedures during medication administration, and perform hand hygiene between glove changes. These failures had the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors. Findings include: Review of the facility's policy titled Infection Prevention and Control Program revised December 2023 revealed in section Elements of the IPCP (Infection Prevention and Control Program) .item 2. Under Policies and Procedures . c. The infection prevention and control committee, medical director, director of nursing services, and other key clinical and administrative staff review the infection control policies at least annually. Item 3. under Surveillance and reporting . b. Surveillance tools are used for identifying the occurrence of infections.monitoring adherence to infection prevention and control practices. Review of the facility's policy titled Wound Care revised October 2010 revealed under section Steps in the Procedure . step 21. Wipe reusable supplies with alcohol as indicated (i.e. outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to resident's drawer in treatment cart. Review of the facility's policy titled Handwashing/Hand Hygiene revision date October 2023 revealed under section Administrative Practices to Promote Hand Hygiene, number 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 1. Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/26/2026 for R8 revealed in section I (Active Diagnoses) diagnoses of but not limited to hip fracture, paraplegia, malnutrition, and depression. Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating R8 was cognitively intact. Observation and interview on 02/25/2026 at 10:05 AM revealed Charge Nurse-Licensed Practical Nurse (LPN) GG performing wound care on R8. During the procedure, the nurse used a reusable black marker to date the bandage, which had been used and remained in the resident care environment. Upon completion of the wound care, the nurse exited the resident's room and then placed the marker directly into her uniform pocket without disinfecting it. LPN GG acknowledged that failing to disinfect the marker could have resulted in cross-contamination. Review of the facility's infection surveillance audits revealed the only audits on file were related to hand hygiene; however, these audits lacked documentation of dates and the frequency with which they were conducted. No surveillance audits were completed for other key areas of infection prevention, including but not limited to wound care practices, isolation precautions, medication administration, environmental cleaning, or reusable equipment disinfection. Interview on 02/25/2026 at 11:25 AM with the Infection Preventionist (IP) revealed that auditing and surveillance processes had been under development since January 2026. The IP stated that audits were conducted visually on a weekly basis; however, the only documented audit information available pertained to hand hygiene. No audits had been completed for other critical areas of infection prevention, including wound care, medication administration, environmental cleaning, or reusable equipment disinfection. Interview on 02/26/2026 at 11:37 AM with the Director of Nursing (DON) confirmed that the black marker used during the wound care procedure should have been sanitized with a sanitary wipe prior to being placed back into the nurse's pocket to prevent cross-contamination. She emphasized that proper sanitation of reusable items would have minimized the risk of cross-contamination. 2. Review of the quarterly MDS assessment with an ARD of 12/30/2025 for R28 revealed in section I (Active Diagnoses) diagnoses of but not limited to heart failure, hypertension, seizure disorder or epilepsy, and asthma. Section C (Cognitive Patterns) revealed a BIMS score of 11, indicating R28 has moderate cognitive decline. During medication observation on 02/24/2026 at 8:08 AM with LPN MM, a pill dropped on top of the uncleaned medication cart, the pill was picked up and crushed and given to R28. R28 was given an inhaler, gloves were removed and replaced with clean gloves to perform eye scrub, however, hands were not washed between glove changes. Interview on 02/24/2026 at 8:40 AM with LPN MM revealed that she was aware of the handwashing policy when gloves were changed. She stated she thought she had cleansed the top of her cart, but she did not usually put down a barrier.

Based on observations, record review, staff interviews, and review of the facility policy titled, Restorative Nursing Services, the facility failed to provide evidence that restorative nursing services for splinting and range of motion (ROM) were consistently provided for one of 29 sampled residents (R) (R61).Findings include:Review of the facility policy title, Restorative Nursing Services dated July 2017 revealed under Policy Interpretation and Implementation: Restorative nursing consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services (e.g., Physical, occupational, or speech therapies).Review of R61's electronic medical record (EMR) revealed that the resident was admitted with diagnoses including but not limited to contracture, left hand, flaccid hemiplegia affecting left nondominant side, cerebral infarction due to embolism of right middle cerebral artery (stroke).Review of Restorative Notes dated 02/25/2026 revealed: Splint/Brace assistance program was initiated on 08/14/2025.Review of Restorative Notes dated 12/02/2025 revealed: R61 has been discontinued from restorative and turned over to the floor to continue wash cloth in hand and pillows between her knees.Review of the care plan for R61 revealed: Focus: RESTORATIVE NURSING PROGRAM: For contracture management: Resident Wash cloth rolled splint to left hand and pillow between knees, Goal: Maintain ROM and prevent further contractures x 90 days. Apply pillow between the knees, Place hand rolled washcloth in resident's hand, R61 has limited physical mobility r/t (related to) history of CVA (stroke) with contractures, Dementia with mental and physical deficits and dependent on staff for mobility, The resident will remain free of complications related to immobility such as thrombus formation, skin-breakdown, fall related injury through the next review date.Observation on 02/24/2026 at 9:30 AM revealed R61 in a Geri chair (specialized medical recliner designed to provide comfort, support, and mobility for elderly or physically challenged individuals) in the day room on floor four, left hand contracted and no washcloth or splint observed.Observation on 02/24/2026 at 4:30 PM of R61 in bed, left hand contracted and no washcloth or splint observed.Observation on 02/25/2026 at 8:45 AM of R61 in a Geri chair in the day room, left hand contracted and no washcloth or splint observed.Observation on 02/25/2026 at 3:45 PM of R61 in bed, left hand contracted, no splint or washcloth observed.Observation on 02/26/2026 at 10:14 AM of R61up in a Geri chair in the day room, with a rolled washcloth in her left hand.Interview on 02/26/2026 at 10:18 AM with Certified Nursing Assistant (CNA) EE revealed that night shift staff got the resident up and dressed and was responsible for putting on her hand roll. She stated that once restorative nursing was discontinued, the responsibility went to the floor staff.Interview on 02/26/2026 at 10:25 AM with Licensed Practical Nurse (LPN) FF revealed that the CNA's on the floor have an ADL (activities of daily living) task book and they were responsible for splints and rolls once the resident was discharged from the restorative nursing program.Interview on 02/25/2026 at 10:29 AM with Restorative LPN BB revealed that therapy would assess a resident then she would add the recommendations to the care plan for the time period that restorative CNAs would provide the splint or roll for the resident.Interview on 02/25/2026 at 2:32 PM with the Director of Nursing (DON) revealed that they maintained a restorative book. Therapy would screen the resident and provide instructions to the restorative nurse. Each resident had their own program. Restorative Aides put the splints on in the morning (hand or palm rolls or splints). She stated that once restorative nursing was completed, it was then turned over to the staff on the floor, and the Charge Nurse was responsible for checking to make sure it was completed.

Based on observations, staff interviews, record review, and review of the facility's policy titled Departmental Respiratory Therapy - Prevention of Infection, the facility failed to prevent the spread of infections by not replacing or cleaning a nasal cannula for one of five residents (R) (R9) requiring oxygen therapy. This failure had the potential to increase the risk for infection and medical complications. Findings include: Review of the facility's undated policy titled Departmental Respiratory Therapy - Prevention of Infection, under the section titled Purpose revealed, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Under the section titled Infection Control Considerations Related to Oxygen Administration revealed, 8. Keep oxygen cannulae and tubing used PRN in a plastic bag when not in use. Review of the Electronic Medical Record (EMR) for R9's medical record revealed diagnoses that included but were not limited to dementia, chronic rhinitis, shortness of breath, chronic obstructive pulmonary disease (COPD), and hypoxemia. Review of R9's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment; Section O (Special Treatments and Programs), received oxygen therapy while a resident. Observation on 1/17/2025 at 10:45 am revealed R9 in bed not wearing her nasal cannula. The nasal cannula was observed unbagged and lying on the floor. Certified Nursing Assistant (CNA) JJ retrieved the nasal cannula from the floor and placed it back in R9's nose without cleaning or replacing it. Observation on 1/17/2025 at 11:25 am revealed CNA HH entered the room, observed the situation, and reminded CNA JJ that any equipment that falls on the floor must be discarded and replaced. CNA JJ acknowledged the mistake and notified Licensed Practical Nurse (LPN) II. LPN II then replaced the nasal cannula with a new one and reminded CNA JJ of the importance of following infection control protocols. Interview on 1/17/2025 at 11:30 am with CNA JJ stated, I know the protocol is to discard equipment that falls on the floor, but I didn't replace it right away. Interview on 1/17/2025 at 11:35 am with LPN II stated, Respiratory equipment must be replaced immediately if contaminated to prevent infections. The nasal cannula was replaced as soon as I was informed of the issue. Interview on 1/17/2025 at 12:00 pm with the Director of Nursing (DON) stated, All respiratory equipment must be discarded if it comes into contact with non-sterile surfaces, as contamination can lead to respiratory infections. This is the expectation for all staff.

Based on staff interviews, record review, and review of the facility's policy titled Psychotropic Medication Use, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two of five residents (R) (R7 and R21) reviewed for unnecessary medications. Findings include: A review of the facility policy titled Psychotropic Medication Use, dated July 2022, under the section titled, Policy Interpretation and Implementation revealed, 12. (a.) PRN (as-needed) orders for psychotropic medications are limited to 14 days. 1. A review of R7's clinical records revealed, diagnoses that included but not limited to personal history of mental and behavioral disorders and agitation. A review of R7's physician orders dated 12/17/2024 revealed, an order for lorazepam (an antianxiety medication) 0.5 milligram (mg) via (by way of) transdermal (absorbed through skin) every six hours, as needed (PRN) for agitation. The order had no stop date. A review of the Medication Administration Record (MAR) revealed, R7 was administered lorazepam 0.5 mg via transdermal on 12/23/2024 at 10:00 am, 12/23/2024 at 4:00 pm, 12/28/2024 at 8:00 am, 12/28/2024 at 5:00 pm, 12/29/2024 at 8:00 am, 12/31/2024 at 5:00 pm, 1/5/2025 at 9:00 pm, 1/6/2025 at 3:00 am, 1/7/2025 at 8:00 am, and 1/9/2025 at 9:00 am. 2. A review of R21's clinical records revealed, a diagnosis that included but not limited to anxiety. A review of R21's physician orders dated 11/9/2024 revealed, an order for lorazepam 0.5 mg by mouth (PO)/sublingual (SL) every four hours PRN for anxiety. The order had no stop date. A review of the Medication Administration Record (MAR) revealed the staff administered R21 0.5 mg of lorazepam by mouth (PO)/sublingual (SL) on 11/9/2024 at 9:05 pm, 11/13/2024 at 9:15 pm, 11/14/2024 at 11:00 pm, 11/15/2024 at 12:00 am, 11/126/2024 at 7:58 pm, and 12/22/2024 at 10:00 pm. During an interview on 1/17/2025 at 12:50 pm with the Licensed Practical Nurse (LPN) AA revealed that she audited all charts to ensure that a 14-day stop date was applied to all psychotropic medications ordered for the residents. LPN AA confirmed no 14-day stop date for R21's lorazepam, which she stated was an oversight. During an interview on 1/18/2025 at 4:03 pm with the Director of Nursing (DON) revealed, that she expected all psychotropic medications to have a 14-day stop date unless otherwise indicated by the MD. The DON acknowledged that there was no 14-day stop on R21's and R7's lorazepam, and she stated it was an oversight.

Based on record review and staff interview the facility failed to ensure a Registered Nurse (RN) was designated as the Director of Nurses (DON) from 3/8/19 through 8/12/19. This resulted in no actual harm but had the potential for more than minimal harm for the 55 residents in the facility. Findings include: An interview with the facility Administrator on 8/14/19 at 10:30 a.m. revealed she had appointed the Assistant Director of Nurses (ADON) to be Director of Nurses (DON) on 3/15/19. Review of a letter dated 3/15/19, addressed to the State Survey Office (SSO) revealed the facility had named the ADON to serve in the role as DON, and had all the requirements to hold the position. A review of the SSO electronic record of Administrators and DONs revealed there had been no change in DON recorded for the facility since (YEAR). An interview was conducted with the Medical Director on 8/14/19 at 12:25 p.m. The Medical Director revealed he did not know who the DON was after the last DON resigned in March. He was not notified of who the DON was. He had not experienced any problems that the ADON and Rehabilitation Manager could not address. An interview was conducted on 8/15/19 at 9:05 a.m. with the Compliance Officer. The Compliance Officer revealed she was not aware of who had been appointed to the DON position last (MONTH) after the former DON resigned. She had not been notified that anyone was taking over the DON position after the former DON resigned. During and interview on 8/14/19 at 4:20 p.m. RN EE revealed the Administrator had said she was going to be the DON until a new DON was hired. The Administrator had said since the facility had 60 beds or less that she could be the Administrator and DON at the same time. Interviews were conducted with LPN AA on 8/14/19 at 12:48 p.m., CNA BB on 8/14/19 at 1:20 p.m., CNA CC on 8/14/19 at 1:47 p.m. and LPN DD on 8/14/19 at 2:22 p.m. They revealed no notice had been sent out to announce who the DON was after the former DON had resigned. They had continued to follow the chain of command and there had not been any problems from 3/8/19 through 8/12/19. On 8/27/19 at 2:50 p.m. the ADON, who had been promoted to Vice President of Healthcare Services on 8/15/19, revealed she had never been appointed to be the DON last (MONTH) after the former DON resigned. She revealed an agency nurse who is no longer with the facility had taken over some of the DON duties such as training and troubleshooting, but the ADON had not performed any of the DON duties and had continued to work as the ADON in the clinic and assistant to the Administrator. The ADON/ Vice President of Healthcare Services reviewed the letter the Administrator had given to the surveyor on 8/14/19, designating the ADON as DON on 3/15/19 and said she had never seen this letter before and that it was not correct, she was not the DON. An interview was conducted on 8/27/19 at 3:00 p.m. with the Human Resources (HR) Director. The HR Director revealed after the former DON resigned, he had heard the Administrator say she was the DON until a new DON could be hired. The HR Director reviewed the letter the former Administrator had given the surveyor on 8/14/19 that was dated 3/15/19 and addressed to the SSO revealing the facility had named the ADON to be the DON. The HR Director revealed he sends out the changes in Administrator and DON notices to the SSO. The HR Director revealed he had not sent this letter and had never seen it before.

Based on record review, staff interviews, and review of facility policy titled Abuse, Neglect, and Exploitation, revision date 10/1/18, the facility failed to ensure an allegation of abuse was reported to the State Survey Office (SSO) for one resident (R) R#5. The sample of six residents were reviewed for abuse. The facility census was 55 residents. Findings include: Review of facility policy titled Abuse, Neglect, and Exploitation, revision date 10/1/18, revealed the facility is to report allegations of abuse or suspected abuse immediately. The facility should ensure that all alleged violations involving abuse neglect exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents{sic} that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other official {sic}(including the State Survey Agency and adult protected services where state law provides for jurisdiction in long term care facilities) in accordance with State law. When suspicion of abuse, neglect, exploitation, or misappropriation of resident property occur, and investigation is immediately warranted. Once the resident is cared for initial reporting has occurred, and {sic} investigation should be conducted. The Administrator should follow up with government agencies, during business hours to confirm the report was received . Review of Facility Reported Incidents from 5/1/19 through 8/8/19 revealed there were no allegations of abuse reported to the SSO. Review of the clinical record revealed R#5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed R#5 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment at the time of her discharge. Review of the care plan for R#5 revealed she was care planned on 12/1/18 for confusion, delusions and being physically aggressive. A review of Social Service Care Plan notes for R#5 revealed a Care Plan Conference was conducted on 2/28/19. R#5 did not attend. R#5's family did not attend. The Care Plan Conference notes revealed R#5 had behaviors at times but did not specify what behaviors. Social Service Progress Notes revealed on 6/20/19 R#5 threw her coffee on a Certified Nursing Assistant (CNA). There were no further explanations of the incident. On 8/14/19 at 9:00 a.m. during an interview with the Administrator she revealed that allegations of abuse were very rare in this facility, and she could not think of any allegations that had not been reported. The Administrator revealed she would look through grievances and incidents and copy them for the surveyor if they could be considered abuse allegations. The Administrator revealed the Compliance Officer receives any allegations of abuse and investigates and reports the allegation to the SSO and keeps the Administrator informed. Interviews were conducted on 8/14/19 at 12:48 p.m. with Licensed Practical Nurse (LPN) AA, on 8/14/19 at 1:20 p.m. with Certified Nursing Assistant (CNA) BB, on 8/14/19 at 1:47 p.m. with CNA CC and on 8/14/19 at 2:22 p.m. with LPN DD. They revealed they did not know of any residents that had alleged abuse in the last six months. An interview was conducted on 8/14/19 at 2:10 p.m. with the Assistant Director of Nursing (ADON) and she revealed she was certain that the Compliance Officer reported all allegations of abuse to the SSO. The ADON revealed that allegations of abuse were very rare in this facility and she could not recall any recent allegation of abuse. An interview on 8/14/19 at 4:20 p.m. with Registered Nurse (RN) EE revealed that sometime in (MONTH) a resident made an allegation of abuse while in the Bistro on the first floor. The resident had told a Security Officer that her Outside Personal Provider (OPP) had hit her in the head. RN EE was unable to recall the residents name or the date. RN EE had not heard any more about the allegation of abuse. During an interview conducted on 8/14/19 at 5:30 p.m. the Administrator revealed she had searched and been unable to find any concerns that could be considered allegations of abuse. On 8/15/19 at 9:05 a.m. the Compliance Officer called the surveyor and was interviewed. The Compliance Officer revealed she was familiar with reporting requirements and reported allegations of abuse to the SSO. The Compliance Officer revealed she was able to remember an issue that took place between a resident and her OPP in the Bistro last (MONTH) that she had not reported because it was just an argument on the part of a resident with dementia and the OPP had not responded to the resident arguing. She revealed there was no allegation of abuse to report and there was no investigation. On 8/21/19 at 9:06 a.m. the Compliance Officer called back and asked for clarification related to who could report abuse and what was considered timely reporting to the SSO. An interview was conducted on 8/27/19 at 8:35 a.m. with the Human Resources (HR) Director. The HR Director revealed the former Administrator/Vice President of Healthcare Services had been suspended on 8/15/19 and the current Administrator was the former Manager of Rehabilitation and Education. The former ADON was now the Vice President of Healthcare Services. The HR Director also revealed the Compliance Officer had been suspended on 8/15/19 and resigned on 8/25/19 without notice. Information related to the allegation of abuse that occurred in (MONTH) by a resident in the Bistro was submitted by the facility on request and reviewed as follows: Review of an Incident/Accident Report dated 6/21/19 at 1:15 p.m. revealed LPN DD had received a call from a security officer stating that R#5 had accused her care giver of hitting her on the back of her head. A full body assessment was completed. LPN DD also documented on 6/21/19 that R#5 and her caregiver had signed out to leave the unit for lunch. An hour later the care giver had returned to the unit and said R#5 had fired her and explained the resident had accused her of hitting R#5 in the back of the head. The care giver said she was going to call the son of R#5 and left. A few minutes later a security officer called and said R#5 was at the front desk and gave details of the allegation. The ADON and the Social Service Director (SSD) for Independent Living and Rehabilitation residents came to the floor to speak with the resident. Another care giver was in the main lobby on 6/21/19 at approximately 12:30 p.m. with R#5 and her OPP and was interviewed by the SSD for Independent Living and Rehabilitation and did not see the OPP hit R#5. The care giver did reveal to the SSD that she had witnessed R#5 shout profanity at the OPP. The ADON documented on 6/21/19 that at approximately 1:45 p.m. Security stated that R#5 had accused her care giver of hitting her on the head. When the ADON interviewed R#5 she said she did not have any problem with her caregiver except personality differences. The ADON documented that she had notified the Manager of Rehabilitation and Education, the SSD for the Nursing Home, and the Administrator on 6/21/19. According to the documentation the Administrator had instructed the ADON to place the packet under the Compliance Officers office door and the Administrator would finish the investigation the next day. The SSD for the Independent and Rehabilitation residents documented on 6/21/19 that at 1:45 p.m. the accused OPP was seen leaving the floor. The SSD revealed LPN DD had told her R#5 had a history of [REDACTED]. R#5 told the SSD that she was happy now that she fired her caregiver and that she just didn't like her, that the OPP had not physically done anything to her. A document dated 6/21/19 and signed by the SSD for the Nursing Home revealed she had interviewed R#5 and the resident told her nothing bad happened that day and she had not been hit by her OPP. A Social Progress Note dated 6/24/19 and signed by the SSD for the Nursing Home revealed R#5 was interviewed and said she was happy with the OPP she had alleged hit her in the head three days prior, and that the OPP was her ray of sunshine. Fax confirmations of the cover sheets for this facility reported incident to the State Office were reviewed as follows: 8/23/19 at 12:19 p.m.- five pages with result OK 8/22/19 at 8:47 a.m. three pages- no response 8/22/19 at 8:37 a.m. four pages- no response On 8/27/19 at 12:02 p.m., the SSD for the Nursing Home was interviewed. She revealed the R#5 had told her she did not remember making the statement that she had been hit by her OPP. The resident had issues in the past related to rejecting care giver suggestions and encouragement. On 8/27/19 at 12:30 p.m. the current Administrator revealed he thought this allegation of abuse was not reported to the SSO because the resident denied her allegation when she was interviewed by the Social Worker. The Administrator acknowledged he was aware that reporting to the SSO was to come first according to the policy and according to the regulation and that no allegation of abuse was to be screened to determine if the allegation was credible until after it was reported to the State. During an interview on 8/27/19 at 2:36 p.m. in the conference room with the Chief Executive Officer (CEO) he revealed he expected the Compliance Officer to report any allegations of abuse to the SSO in a timely manner and to be familiar and compliant with regulatory reporting requirements.

Based on observation, review of policy and procedure and staff interviews, the facility failed to maintain appropriate concentration levels of the Ecolab Quaternary sanitizing solution in the three (3) compartment sink; failed to label and date opened food items before storing in the walk-in freezer and dry storage; failed to ensure food items were discarded past the use by date for one (1) of six (6) resident nourishment refrigerators. This deficient practice had the potential to effect fifty one (51) residents consuming an oral diet. Findings include: Review of policy titled Food and Supply Storage Procedures (Issued 05/1995, revised 01/2012) revealed that the use-by date is the last date food can be consumed, foods past the use-by date should be discarded, and open/unused packages are to be covered, labeled, and dated. Observation and interview with Head Chef and Dietary Manager on 10/11/2016 at 11:20 a.m. revealed that the sanitizer in the three (3) compartment sink was not registering on the indicator strip. The Head Chef confirmed that the indicator strip did not change colors to indicate the presence of quaternary sanitizing solution in the three (3) compartment sink. He retested the water with a new test strip, the test strip did not change color to indicate the presence of quaternary sanitizing solution in the three (3) compartment sink. He emptied the sink and added fresh water and sanitizer and retested with a fresh indicator strip, the strip did not change colors. The Head Chef instructed the dishwasher to empty the sink and obtain water and sanitizer from the mop closet sink and transfer it into the sanitizer sink in the three (3) compartment sink. The Head Chef tested the water obtained from the sink in the mop closet and the strip turned green, corresponding with 200 ppm (parts per million) concentration. Observation and interview with Dietary Manager on 10/11/2016 at 11:24 a.m. in the walk-in freezer revealed an open, unsecured, unlabeled, undated brown paper bag, and an open, unlabeled, undated, chocolate cake. The Dietary Manager confirmed that the open bag was French fries and per his expectations both the French fries and cake should have been secured, dated, and labeled. Observation and interview with Head Chef and Dietary Manager on 10/11/2016 at 11:30 a.m. in dry storage room revealed an undated, open bag of pasta (secured with plastic wrap) and an unlabeled 1-gallon Ziploc bag with a white grain- like substance. The Head Chef identified the grain-like substance as quinoa. The Dietary Manager confirmed that he expected staff to date, label, and secure open dry goods prior to placing them in the storage area. Observation on 10/13/2016 at 10:11 a.m. of the fourth (4th) floor nourishment refrigerator revealed 2 milk cartons with expiration dates of 10/11/2016. Observation and interview with Dietary Manager on 10/13/2016 at 10:30 a.m. of the fourth (4th) floor nourishment refrigerator the Dietary Manager confirmed the 2 cartons of milk were expired and immediately discarded the cartons.

Based on observation, review of policy and procedure and staff interview, the facility failed to maintain the required amount of emergency water on site for a maximum bed capacity of sixty (60) residents. The current facility census was fifty-three (53) residents. Findings include: A review of the policy titled Emergency Preparedness (dated 05/95, revised 09/14) revealed a minimum allotment of one (1) gallon of water per day per person, including patients and staff. Review of the Disaster Contingency Plan Statement of Understanding for Emergency Services dated 10/01/2016 revealed a contingency plan that Sysco would provide the facility bottled water, as available, during an actual disaster situation. An observation and interview on 10/11/2016 at 11:45 a.m. with the Dietary Manager, revealed a total of thirty (30) gallons of water stored for emergency use. The Dietary Manager confirmed that thirty (30) gallons of water did not meet the facility emergency water requirement and explained that he would order 200 gallons of water and have it delivered the following day (10/12/2016). Observation with the Dietary Manager on 10/13/2016 at 1:45 p.m. revealed 200 gallons of water designated for emergency use.

Based on observations and staff interview, the facility failed to ensure there was a thermometer in the freezer, and foods were labeled, dated and stored correctly in the walk in freezer. The facility census was fifty one (51) residents. Findings include During the initial tour of the kitchen on 3/30/15 at 8:30am with the Sous Chef "AA" , the following were observed: The walk in freezer did not contain a thermometer. There was a large white plastic bucket full to within approximately twelve (12) inches above the lip of the container with uncovered, undated chicken parts, sitting in the middle of the freezer floor. There was a bag of frozen chicken, not dated, and four (4) pieces of chicken had fallen out of the open bag to the floor of the freezer. There was one (1) frozen biscuit on the floor of the freezer. There was a large pan of frozen soup open to air, because the cover had come loose. One (1) large pan of uncooked Philly Cheese Steaks with an expiration date of 2/19/15. Frozen meats were stored haphazardly over breads, vegetables, ice cream, and soups through out the freezer. Interview with the Sous Chef "AA" on 3/30/15 at 8:30am revealed that the chicken in the white plastic bucket was going to be used for chicken stock, and should have been dated and covered. "AA" further indicated that all food should be dated and labeled, and that all meats should be store separately, or on the bottom shelves of the freezer.

Based on observation, record review and staff interview the facility failed to follow a physician's order for heel protectors for one (1) resident ("X") from a sample of sixteen (16 ) residents. Findings include: Observation on 6/29/2014 at 11:30 AM revealed resident "X'' was sitting up in her wheelchair in her room with TED hose and blue house shoes on. Resident was not wearing heel protectors. Observation on 6/29/2014 at 12:35 PM revealed the was in the fourth floor dining room, resident was wearing TED hose and blue heel protectors. Observation on 6/30/2014 at 11:15 AM revealed the resident was in the wheelchair with TED hose and blue house shoes on but no heel protectors. Observation on 6/30/2014 at 1:45 PM revealed the resident was in fourth floor dining room eating lunch while sitting in the wheelchair. The resident did not have heel protectors on or any shoes. Review of Physician's Order dated 6/1/2014 - 6/30/2014 revealed a physician's order for heel protectors when in bed or wheel chair. Review of Treatment Record for resident ('X') revealed documentation that heel protectors were applied on 6/29/2014 but no evidence that heel protectors were applied 6/30/2014. Further review of the June treatment record indicated that resident was receiving treatment for [REDACTED]. Interview with resident "X" on 6/30/2014 at 11:15 AM revealed she does not always wear heel protectors, sometimes she wears socks. Interview on 7/1/2014 at 8:33 AM with Licensed Practical Nurse (LPN) "AA" revealed the resident is supposed to have heel protectors on while in bed or wheel chair.