Every finding on record at Life Care Center of Cleveland

Based on facility policy reviews, facility documentation reviews, observations, and interviews, the facility failed to maintain a clean and sanitary kitchen which had the potential to affect 87 of 87 residents.The findings include:Review of the facility policy titled, Food Safety and Sanitation, dated 4/30/2025, revealed .Cleaning Schedule .The Director of Food and Nutrition Services shall .ensure that the Food and Nutrition Services department is maintained in a clean and sanitary manner in accordance with regulatory requirements .Equipment and Utensil Cleaning and Sanitization - A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease .Review of the facility's policy titled, Sanitation and Food Safety, revised 9/8/2022, revealed .food is placed in a .sanitary .container .is labeled .with date .Associate food will not be stored with resident food .Opened packages of food are resealed tightly to prevent contamination of the food item .During an observation of the kitchen with the Food Services Director (FSD) on 12/15/2025 from 9:45 AM to10:30 AM, revealed the following items:(1) at 9:48 AM, the floor under and around the stove and cook top griddle was visibly soiled with unknown thick debris, dried food debris, and accumulated grime. (2) at 9:51 AM, the walk-in refrigerator contained an opened container of Barbecue Sauce, 1 gallon, with less than 1/4 contents left. There was old residue on the container, the container was not labeled with the opened date, the manufacturer expiration date was 10/2025, and was available for resident use.(3) at 9:55 AM, the walk-in refrigerator contained an opened container of Caesar Dressing, 1 gallon, with less than 1/4 contents left. There was old dressing residue with gray/black spots on the outside of the container, the container was not labeled with the opened date, the manufacturer expiration date was 8/1/2024, and was available for resident use.Review of the facility document titled, Daily Cleaning Logs, revealed the kitchen including the floor and kitchen equipment were to be cleaned daily and recorded on the log. The last documentation recorded on the log was 12/12/2025, there was no documentation recorded for cleaning on 12/13/2025 or 12/14/2025. Review of the facility document titled, Dish Machine Temperature Log, dated 12/1/2025 to 12/15/2025, revealed data for testing the dishwasher sanitizer was not recorded on 12/14/2025 for all 3 meals. Review of the facility document titled, Food Temperature Log, dated 12/1/2025 to 12/14/2025, revealed there were 9 out of 42 meals served where the food temperatures were not recorded on the log as follows: lunch 12/1/2025, dinner 12/4/2025, lunch 12/6/2025, all 3 meals 12/7/2025, lunch 12/12/2025, 12/13/2025, and 12/14/2025. During an interview on 12/15/2025 at 11:15 AM, the FSD confirmed the expired Barbeque sauce and Caesar dressing was available for resident use, the floor around the stove/griddle was visibly soiled and had not been cleaned and confirmed the kitchen and food storage were not maintained in a clean and sanitary condition. The FSD confirmed all food temperatures and dishwasher sanitizer results had not been documented or recorded in 12/2025 and the logs had incomplete documentation.

Based on facility policy review, observations, interviews, and medical record review, the facility failed to properly store medications and biologicals in 3 medication carts (Cart South-Even, South-Odd, and Skilled) of 3 medication carts observed, and 1 medication room (South) of 2 medication rooms reviewed, and in 1 resident room (Resident #2) of 18 residents reviewed.The findings include:Review of the facility policy titled, Storage and Expiration Dating of Medications and Biologicals, dated [DATE], revealed once any medication or biological package is opened . follow manufacturer/supplier guidelines with respect to expiration dates for opened medications .facility staff should record the date opened on the .medication container .if a multi-dose vial on an injectable medication has been opened or accessed .the vial should be dated and discarded within 28 days unless the manufacturer specifies a different .date .facility should ensure medications and biologicals are stored at their appropriate temperatures .facility should destroy or return all discontinued, outdated/expired .in accordance with .guidelines .facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .facility should request that pharmacy perform routine nursing unit inspection .to assist facility in complying with .proper storage .Review of the facility policy titled, Self-Administration of Medications, dated [DATE], revealed .the facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) .the facility will determine through an interdisciplinary assessment if the resident is able to either safely administer medications .or the resident is able to safely store the medication in a secure area in their room and safely administer the medication as prescribed . If the resident desires to self-administer medication, the IDT will contact the resident's primary physician .of the resident request .the IDT in consultation with the primary physician .will conduct an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility .the assessment will contain .the resident's cognitive status including .ability to correctly name their medications and know what conditions they are taken for .capability to follow directions and tell time to know when medications need to be taken .comprehension of instructions .the resident's ability to ensure that medication is stored safely and securely .During an observation on [DATE] at 8:30 AM, the following was observed on South Even Medication Cart: (1) ipratropium/albuterol 0.5 milligram (mg)/3 mg per 3 mL (milliliter) vials - foil package containing vials was open, was not labeled with the date opened, and the medication box stated, .once removed from foil pouch, the individual vials should be used within 2 weeks . (2) a vial of lantus (long-acting insulin) and a vial of lispro (short-acting insulin) - both vials were sent from pharmacy on [DATE], both vials were unopened and had labels that stated .refrigerate until opened . (3) ofloxacin 0.3% drops - instill 1 drop into left eye 4 times daily for 7 days for eye infection. Eye drops were sent by the pharmacy and opened on [DATE], medication was discontinued [DATE] and remained in the medication cart. During an interview on [DATE] at 8:40 AM, Licensed Practical Nurse (LPN) G confirmed the ipratropium/albuterol was not labeled with a date when the foil package was opened and was available for resident use, unopened insulin vials were not stored in the refrigerator as stated on the label, and the ofloxacin eye drops had been discontinued several weeks prior and had not been removed from the cart.During an observation on [DATE] at 8:45 AM, the following was observed in the South Medication Room: (1) semaglutide 1 mg dose (4 mg/3mL) multi-dose pen - sent from pharmacy [DATE], not labeled with an open date. semaglutide 2 mg dose (8mg/3mL) multi-dose pen - sent from pharmacy [DATE], not labeled with an open date. (2) Adapt 7917 Box of Skin Protective Wipes, 4 remaining, expiration date [DATE]; Heparin Lock Flush Solution 5 mL syringe, expiration date [DATE]; Female Leur Lock Cap, expiration date [DATE] and were available for resident use.During an interview on [DATE] at 9:10 AM, the LPN/Unit Manager (UM) confirmed the Heparin Lock Flush, the Skin Protective Wipes, and the Female Leur Lock found in the South med room were past the expiration dates and were available for resident use. The LPN/UM confirmed insulin should be stored in the fridge, the 2 semaglutide pens in the medication room's fridge and the ipratropium/albuterol 0.5 mg /3 mg per (in) 3 mL vials in the med cart had not been dated when opened and should have been dated as they have a shortened expiration date once opened.Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Spinal Stenosis, Lower Femur Fracture, Lung Disease, and Bi-polar Disorder.Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation and interview on [DATE] at 4:20 PM, accompanied by the Regional [NAME] President (RVP), the room for Resident #2 revealed medications at bedside, unsecured, as follows: (1) Albuterol Sulfate 90 mcg (micrograms) inhaler, expiration date of 6/2023 (2) clindamycin phosphate gel 1% (prescription antibiotic gel for skin conditions) (3) triamcinolone acetonide 0.1% cream (prescription corticosteroid used to reduce inflammation to skin) (4) mupirocin ointment 2% (prescription antibiotic to treat skin conditions) (5) clear graduate container with a lid, containing several Tums in the bottom of the container, and a small medicine cup with an unidentified cream in the top area of the container (6) fluticasone propionate (prescription corticosteroid used to reduce inflammation in the body) (7) 32 fl oz (fluid ounces) container of isopropyl alcohol, 70% (8) spray bottle 8 fl oz hydrogen peroxide topical solution. Further observation revealed the RVP removed the medications from Resident #2's room and gave them to LPN F, who confirmed the medications were in the resident's room and should not have been.During an interview on [DATE] at 4:31 PM, the Assistant Director of Nursing (ADON) stated a resident should only have medications in their room if they were assessed for medication self-administration, have a Physician's Order for self-administration, and the resident should use a lock-box to secure their medications. The ADON confirmed Resident #2's medical record did not contain an assessment for self-administration of medications, nor a Physician's Order for self-administration of medications, and confirmed Resident #2 had medications at the bedside and should not have had medications at the bedside or left unsecured.During an observation and interview on [DATE] at 8:27 AM, the South-Odd Medication Cart was against the wall on south hall, there was an 8.3-ounce container of Polyethylene Glycol 3850 (mild laxative used for constipation) on top of the medication cart, and no licensed nurse was visible on the hall. RN E was observed exiting a resident room and walked to the medication cart. RN E confirmed the medication of Polyethylene Glycol was left on the medication cart unattended and not secured. RN E further conformed the medication was improperly stored and should have been locked in the cart.During an observation and interview on [DATE] at 8:37 AM, the Skilled Medication Cart was against the wall on the skilled hall, the medication cart was unlocked, and there was no licensed nurse visible on the hall. LPN H was observed exiting a resident room and walked to the medication cart. LPN H confirmed the medication cart was left unlocked and unattended, the medication cart should always be locked when unattended, and confirmed the medications were improperly stored.During an interview on [DATE] at 9:45 AM, the Assistant Director of Nursing (ADON) confirmed insulin had not been stored in the refrigerator until opened as recommended, the discontinued medications had not been removed from the medication carts promptly, the observed injectables and nebulizer medications were not dated when opened and should have been labeled due to the shortened expiration once opened, and all were available for resident use. The ADON confirmed medication carts should be locked when unattended, and medications should not be left on the cart or unsecured and confirmed the items were not stored and secured appropriately.

Based on facility policy review, medical record reviews, observation, and interviews, the facility failed to ensure the residents' health information remained private and confidential for 2 residents (Residents #73 and #113) on 1 medication cart (skilled cart) of 5 medication carts observed, which had the potential to allow individuals unauthorized access to the residents' private health information.The findings include:Review of the facility policy titled, Safeguarding Electronic Health Information, dated 3/10/2025, revealed .[the facility] protects the confidentiality of all residents regardless of the storage method .access to electronic resident information is controlled by a system that involves passwords as well as restrictions based on job function .computer screen placement should be reviewed .to ensure unauthorized viewing is not easily possible .all users should be trained to log off .when away from their workstations .laptop computers .containing PHI [Protected Health Information] should not be left unattended .Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Stroke with Hemiplegia, Right Tibia Fracture, and Cognitive Impairment.Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #73 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment.Review of the medical record revealed Resident #113 was admitted to the facility on [DATE] with diagnoses including Diabetes, Metabolic Encephalopathy, Fatty Liver, and High Blood Pressure.Review of a BIMS Interview/Observation assessment dated [DATE], revealed Resident #113 scored a 14 which indicated the resident was cognitively intact.During an observation on 12/17/2025 at 8:27 AM, the skilled medication cart was in the hallway against the wall, the laptop screen was facing the hallway and was open to Resident #113's electronic Medication Administration Record (eMAR), with medications visible to passersby. Further review revealed the narcotic sign out book was lying open on top of the medication cart, with Resident #73's controlled substance reconciliation log visible, and within view of any passerby.During an interview on 12/17/2025 at 8:28 AM, LPN H returned to the medication cart and confirmed health information was visible to a passerby for Resident #113 on the open laptop screen, and for Resident #73 on the open narcotic book. LPN H confirmed the laptop screen should have been locked or closed and the narcotic book should have been closed, so resident information was not visible to others.During an interview on 12/17/2025 at 9:15 AM, the Assistant Director of Nursing (ADON) stated the residents' sensitive health information should not be open to view and confirmed the nurse should ensure the residents' personal and confidential medical information was secured by covering any papers and closing or locking the laptop screen prior to leaving the medication cart and Resident #113's, and #73's medical information was not maintained confiedntial.

Based on facility policy review, medical record reviews, observations, and interviews, the facility failed to provide a clean and sanitary environment by ensuring cleanliness of personal fans for 2 residents (Residents #41 and #6) of 4 residents reviewed for cleanliness of personal fans.The findings include:Review of the facility policy titled, Daily Room Cleaning, dated 2/24/2022, revealed .The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections .clean low-touch surfaces on a scheduled basis (ie [for example] weekly) .Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Colon Cancer, Heart Disease, Chronic Pain, and Major Depressive Disorder.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.During an observation and interview on 12/15/2025 at 9:45 AM, revealed Resident #41 lying in bed, with a small stand-up fan on the bedside table, approximately 3 feet from the resident's head and turned to blow toward the resident's face. Resident #41 stated it was his personal fan, and his preference for the fan to be blowing on his face. The fan blades had some gray dust accumulated, and thick debris resembling clumped gray fibers had accumulated on the protective grille. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Heart Valve Disease, Heart Failure, and Chronic Respiratory Failure with Hypoxia.Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 10 on the BIMS assessment which indicated the resident had mild cognitive impairment.During an observation on 12/16/2025 at 2:29 PM, revealed Resident #6 had a small fan on the bedside table, turned to blow toward the resident's face. The fan blades had some gray dust accumulated, and thick debris resembling clumped gray fibers had accumulated on the protective grille.During observations and interview on 12/16/2025 at 3:38 PM, the Environmental Services Director (ESD) stated rooms and equipment in rooms should be dusted/cleaned daily. The ESD confirmed the fans in both Resident #41 and Resident #6's rooms were not clean and confirmed they both had gray dust accumulated on the fan blades, and thick debris resembling clumped gray fibers had accumulated on the protective grille and was not maintained in a clean and sanitary condition.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, facility policy review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Residents #3) of 3 residents reviewed for MDS assessments. The findings include:Review of the MDS 3.0 RAI Manual, dated 10/2025, revealed .Health-related Quality of Life .residents covered by Level II [2] PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .Review of the facility policy titled, Certification of Accuracy of the MDS reviewed 8/29/2025, revealed .Accuracy of Assessment .the appropriate, health professional correctly document the resident's medical status .the assessment must accurately reflect the resident's status .Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Anxiety.Review of a PASRR dated 8/16/2024, revealed Resident #3 had a PASRR Level II Outcome related to serious mental illnesses of Dementia, Depression, and Anxiety. Review of a significant change in status MDS assessment dated [DATE], revealed Resident #3 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had active diagnoses of Dementia, Depression, and Anxiety. Continued review revealed the resident was not coded for a Level II PASRR condition. Review of the Psychiatric Periodic Evaluation note dated 12/15/2025, revealed .history of dementia, depression, and generalized anxiety disorder, seen today in follow-up for ongoing management .During an observation on 12/15/2025 at 11:35 AM, revealed Resident #3 was sitting in wheelchair in her room. Resident stated she was happy here. Further observation revealed the resident required assistance with toileting, and transfers and no behaviors were noted. During a medical record review and interview on 12/16/2025 at 3:06 PM, Registered Nurse (RN) MDS Coordinator reviewed the significant change in status MDS assessment, dated 11/20/2025 and the Level II PASRR dated 8/16/2024 for Resident #3. The RN MDS Coordinator confirmed the significant change in status MDS assessment for Resident #3 was inaccurate and did not include the Level II PASRR.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow physician's orders and the facility policy, for 1 (Resident #24) of 6 residents reviewed for medication administration. The findings include:Review of the facility policy titled, Administration of Medications, dated 11/15/2024, revealed .Facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Resource: Oral Dosage Forms that Should Not Be Crushed and/or facility policy .Exceptions to Should Not Crush medications may occur when physician/prescriber orders are documented in the medical record including a statement explaining why crushing the medication will not adversely affect the resident .Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Diabetes, and Dementia.Review of a Physician's Order for Resident #24 dated 7/31/2025, revealed .May crush meds [medications] unless contraindicated. The order was discontinued on 12/2/2025 due to a hospitalization and was resumed on 12/9/2025.Review of a Physician's Order for Resident #24 dated 7/31/2025, revealed Isosorbide Mononitrate Extended Release (ER) 24 Hour 30 milligram (mg), give 1 tablet by mouth one time a day for hypertension. The medication was discontinued on 12/2/2025 due to a hospitalization and was resumed on 12/9/2025.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #24 had severe cognitive impairment.Review of the comprehensive Care Plan dated 10/30/2025, revealed Resident #24 .has a swallowing problem .Complaints of difficulty or pain with swallowing .During an observation and interview on 12/16/2025 at 8:22 AM, Licensed Practical Nurse (LPN) F removed Resident #24's medications from the original packaging, placed the medications including Isosorbide Mononitrate ER Tablet (medication used to treat chest pain and Hypertension caused by Coronary Artery Disease) 30 mg, into a plastic sleeve used for crushing medications. LPN F stated Resident #24 swallowed medications better crushed in applesauce. LPN F poured the crushed medications into a plastic cup with the applesauce, entered Resident #24's room, rechecked the resident's blood pressure, which read 145/82, and administered the medications to the resident. During an interview on 12/16/2025 at 8:31 AM, LPN F stated, .it [the order for Isosorbide Mononitrate Extended Release] does not say it cannot be [crushed] . LPN F retrieved the medication card label for the Isosorbide Mononitrate ER from the drawer and stated, .the card says not to crush it [the medication] . LPN F stated she normally crushed the medication every morning. During an interview on 12/16/2025 at 4:31 PM, the Assistant Director of Nursing (ADON) confirmed the facility failed to follow a physician's order for medication for Resident #24 by crushing an extended-release medication that should not be crushed and administered.Review of the Order Recapitulation (Recap) Report for 12/2025 revealed Resident #24's order for Isosorbide Mononitrate ER Tablet 24 Hour 30 MG .Give 1 tablet by mouth one time a day for Hypertension . was discontinued on 12/16/2025 at 10:26 AM by the Nurse Practitioner (NP) due to not being crushed .can't crush . Further review revealed .May crush meds unless contraindicated .Review of a Physician's Assistant [PA] Progress Note for Resident #24 dated 12/16/2025, revealed .[Resident #24] is being seen today because nursing .also reports his medications need to be crushed and .is taking isosorbide mononitrate that should not be crushed . Continued review revealed .Physical Exam .No apparent distress .Cardiovascular .RRR [Regular Rate and Rhythm] .I [PA] did call cardiology nurse practitioner in consult. He recommended to discontinue isosorbide as it should not be crushed .Cardiology nurse practitioner states he will see patient [Resident #24] on Monday and follow-up .During an interview on 12/17/2025 at 11:35 AM, LPN D stated Resident #24 was evaluated by the NP on 12/16/2025 and the order for the Isosorbide Mononitrate ER was discontinued due to the contraindication for the medication to be crushed. LPN D further stated Resident #24's blood pressure reading taken on 12/17/2025 was 138/83 and had no adverse outcomes from the medication error.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene during meal service for 4 residents (Residents #74, #24, #92, and #19) of 10 residents observed during meal tray distribution on 1 of 4 hallways.The findings include:Review of the facility policy titled, Hand Hygiene for Residents ., dated 7/8/2025, revealed .the facility should educate .residents .about hand hygiene and encourage frequent hand hygiene .the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections .the facility should assist either physically or through reminders to residents to perform hand hygiene .before meals .Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Diabetes, Dementia, and Blindness One Eye. Review of a significant change in status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #74 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #74 was dependent upon staff assistance with personal hygiene (which includes washing face and hands). Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Diabetes, Dementia, and Delusional Disorder.Review of a quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #24 required substantial/maximal assistance with personal hygiene.During an observation on 12/16/2025 at 7:51 AM, revealed Certified Nursing Assistant (CNA) A brought Resident #74's meal tray into the room and sat it on the bedside table. Resident #74 sat up on the edge of the bed and began eating without being assisted with hand hygiene. Continued observation at 7:53 AM, revealed CNA A brought Resident #24's meal tray into the room, and sat it on the bedside table. Resident #24 sat on the side of the bed and began eating without being assisted with hand hygiene. During an interview on 12/16/2025 at 7:54 AM, CNA A confirmed Residents #74 and #24 were not offered or assisted with hand hygiene prior to meal service. CNA A stated staff carried small hand sanitizer bottles to perform hand hygiene for the residents but confirmed the bottle he had was unopened and had not been used.Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses including Cervical Spinal Cord Fracture, Heart Failure, and High Blood Pressure.Review of an annual MDS assessment dated [DATE], revealed Resident #92 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #92 required substantial/maximal assistance with personal hygiene.During an observation and interview on 12/16/2025 at 7:56 AM, revealed CNA B brought Resident #92s meal tray into the room and sat it on the bedside table. Resident #92 was sitting up in bed and began eating. CNA B did not assist the resident with hand hygiene prior to the meal service and confirmed hand hygiene had not been performed for Resident #92 prior to the meal.Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Brain Hemorrhage, Dysphagia (difficulty swallowing), and Respiratory Failure with Hypoxia.Review of a quarterly MDS assessment dated [DATE], revealed Resident #19 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #19 required substantial/maximal assistance with personal hygiene.During an observation and interview on 12/16/2025 at 8:00 AM, the Director of Admissions (DA) brought Resident #19's meal tray into the room, sat it on the bedside table in front of the resident's wheelchair and the resident began eating. Resident #19 was not assisted with hand hygiene prior to the meal service. The DA confirmed hand hygiene was not performed for Resident #19 prior to serving the meal. The DA stated staff usually had small 2-ounce bottles of hand sanitizer they carried with them and confirmed she did not have her bottle of hand sanitizer with her.During an interview on 12/16/2025 at 2:00 PM, the Executive Director stated the staff were to offer hand hygiene assistance to all residents before meal service and stated the facility had provided small hand sanitizer bottles to employees for resident's hand hygiene. The Executive Director confirmed infection prevention and control practices were not maintained during the breakfast meal on 12/16/2025.

Based on facility policy review, medical record review, and interview, the facility failed to follow a physician's order for the administration of Oxygen for 1 resident (Resident #1) of 4 residents reviewed for Oxygen administration. The findings include: Review of the facility's policy titled, Oxygen Administration/Safety Storage/ Maintenance dated 10/7/2022 showed .Oxygen will be administered in accordance with physician orders and current standards of practice . Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus. Review of the 5 day admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. The resident required assistance of one to two facility staff members for activities of daily living (ADL's).The resident received oxygen therapy on all 7 days of the look back period. Review of the Medication Administration Record (MAR) dated 3/1/2023-3/31/2023 showed a physicians order dated 6/28/2021 for .Oxygen at 5 liters/min [liters per minute] continuously per nasal cannula . The Oxygen was not administered as ordered on 3/16/2023. Licensed Practical Nurse (LPN) #1 documented on 3/16/2023 Resident #1 received 5 liters of continuous flow Oxygen. Medical record review of a nurses progress note dated 3/17/2023 12:21 AM, showed .Health Status Note .Note Text: Approx. 10:30 pm [3/16/2023] resident c/o [complained of] SOB [Shortness of Breath]. O2 sat [Saturation] 86% [percent] on 4L [Liters] O2 [Oxygen]. Head of bed elevated and resident encouraged to take deep breaths. Sats[oxygen saturation] came up to 90 [Normal range 90-100%] then almost immediately back down to 86. With repeated reminders to deep breath, sats would come up then back down. Resident c/o feeling fuzzy headed. Nurse suggested resident go to ER [emergency room ] for evaluation, resident agreed. 911 was called for transport . Review of Resident #1's current care plan last revised 4/7/2023, showed .The resident has altered respiratory status/difficulty breathing .Oxygen dependent . During a telephone interview on 6/6/2023 at 9:46 AM, LPN #1 stated on 3/16/2023 she was informed by Certified Nursing Assistant (CNA) that Resident #1 had an episode of respiratory distress, LPN #1 entered room to assess the resident and noted the oxygen concentrator set at 2 liters per minute. LPN #1 confirmed the liters per minute was wrong and was set to 4 liters per minute. Resident #1's oxygen saturation level was 86% and at points returned to 90%. LPN #1 confirmed she checked Resident #1's oxygen flow during medication pass, resident was on a portable oxygen cylinder at that time, and it was set to 4 liters per minute. During an observation/interview on 6/6/2023 at 5:00 PM, the Director of Nursing (DON) confirmed the facility failed to follow physicians orders for Resident #1's prescribed oxygen flow rate, the physicians orders were oxygen at 5 liters per minute and nursing documentation on 3/17/2023 at 12:21 AM reflected oxygen set at 4 liters per minute.

Based on facility policy review, medical record review, observations, and interviews the facility failed to implement a care plan intervention for 1 resident (Resident #50) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Fall Management, dated 8/2/2021 showed .promote patient safety and reduce patient falls by care planning .The facility will assess the resident with every fall event for .fall risks .identify appropriate interventions to minimize the risk of injury related to falls .resident receives assistance devices to prevent accidents . Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Incident Follow-Up and Recommendation Form dated 2/12/2022 showed .Fall in room, pt [patient] stated he was having flashbacks to war . Recommendations included .Mats placed at bedside . Review of a Progress Note dated 2/12/2022 showed .resident was in the floor .checked from head to toe .no injuries were noted .Call button within reach. Safety meausres [measures] in place . Review of a Progress Note dated 2/14/2022 showed .Reviewed in risk management meeting by IDT (Interdisciplinary Team) for fall. No apparent injuries. Resident unable to explain what happened. Intervention for fall mats to bedside . Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] showed Resident #50 had moderate cognitive impairment. He required supervision of 2 staff persons with bed mobility and toileting. The resident required extensive assistance of 2 staff persons with transfers and dressing. Fall history showed Resident #50 had falls prior to admission; he had a fall since admission with injury. Review of the Comprehensive Care Plan dated 2/22/2022 showed .at risk for falls .h/o [history of] multiple falls at home, weakness, new environment . Interventions included .Orient resident to room .Anticipate .meet The resident's needs .Call light within reach .Complete fall risk assessment .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs .Mats to bedside (2/14/2022) . During multiple observations on 3/28/2022-3/29/2022 of Resident #50's room showed no fall mat to bedside. During an interview on 3/29/2022 at 1:05 PM, the Director of Nursing confirmed the fall mats were not in place in the resident's room. During interviews on 3/29/2022 at 1:45 PM, Licensed Practical Nurse (LPN) #2 stated she does not recall a fall mat at Resident #50's bedside.

Based on facility policy review, Lippincott Procedures review, medical record review, observation, and interview the facility failed to administer enteral feedings (liquid nutrition provided through a tube inserted into the stomach) as ordered for 1 resident (#90) of 3 residents reviewed for enteral feedings. The findings include: Review of the facility's policy titled, Feeding Tubes (Gastrostomy, Jejunostomy, Transgastric Jejunal), reviewed 7/14/2021, showed .The facility will utilize .Lippincott procedures . Review of Lippincott Procedure titled, Enteral tube feeding, intermittent, gastrostomy and jejunostomy, revised 11/19/2021, showed .Verify the practitioner's order .enteral feeding device; prescribed enteral formula; administration method, volume, and rate . Resident #90 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Care Plan dated 3/18/2022, showed .The resident requires tube feeding .RD [Registered Dietician] to evaluate .Make recommendations for changes to tube feeding as needed .See MD [Medical Doctor] orders for current feeding orders . Review of weights for Resident #90 showed on 3/20/2022 a weight of 168 pounds (lbs) prior to the Dietician recommendation. Continued review showed on 3/30/2022 Resident #90's weight of 168.4 lbs (slight gain). Review of Resident #90's current active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 1.5 [nutritional supplement] .at 120 ml/hour [milliliters per hour] .x [times] .10 .hours .(ON AT 10PM AND OFF AT 8AM) . During an observation on 3/30/2022 at 7:24 AM, Resident #90 was awake and laying in bed with the head elevated. The Resident had [MEDICATION(S)] 1.5 at 70 ml/hr enteral feeding infusing. During an interview on 3/30/2022 at 8:35 AM, the RD stated she had assessed Resident #90's nutritional status on 3/23/2022. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She also stated the resident was in her ideal body weight and had a normal body mass index for her age. The RD confirmed, after the resident's nutritional assessment, she had recommended for the enteral feeding be changed to [MEDICATION(S)] 1.5 at 120 ml/hr to meet the caloric needs of the resident. During an observation and interview on 3/30/2022 at 8:43 AM, in Resident #90's room, Registered Nurse (RN) #1 and the Director of Nursing (DON) confirmed the resident had received [MEDICATION(S)] 1.5 enteral feeding at 70 ml/hr from 10 PM on 3/29/2022 until 8 AM on 3/30/2022. During an interview on 3/30/2022 at 8:45 AM, the DON confirmed Resident #90 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/30/2022 at 11:27 AM, the Medical Director stated the failure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director also stated the resident's weights were currently stable.

Based on facility policy review, observation, and interview the facility failed to ensure infection control practices were followed to prevent the potential spread of infection when 1 of 2 Licensed Practical Nurses (LPN #1) failed to perform hand hygiene during medication administration. The findings include: Review of the facility policy titled, Transmission-based Precautions and Isolation Procedures revised 4/20/2020 showed, .Hand hygiene .Before and after doffing of personal protective equipment ( .gloves, gown .) Resident #89 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's order dated 3/14/2022, showed .CONTACT/DROPLET ISOLATION . During a medication administration observation on 3/29/2022 at 8:05 AM, LPN #1 sanitized hands, donned (put on) a gown and gloves prior to entering Resident #89's room. Further observation showed LPN #1 administered the resident's medication, removed gown and gloves, and exited the room without sanitizing hands. During an interview on 3/29/2022 at 8:09 AM, LPN #1 confirmed she exited Resident #89's room, which was an isolation room, and failed to sanitize hands.

Based on facility policy, record review, and interview, the facility failed to provide employee screenings at the beginning of the shift for 472 of 1,125 shifts between 5/11/2020 and 5/25/2020, which had the potential to result in the transmission of Coronavirus (COVID-19). The findings include: Review of the facility policy titled, Coronavirus (COVID 19) ([DIAGNOSES REDACTED]-CoV-2), revised on 5/22/2020, showed, .All associates will be . screened at the beginning of their shift .will include questions about COVID-19 symptoms, and if they work in another location where COVID-19 has been identified. The associate must also have their temperature actively taken to rule out fever . Review of Coronavirus Screening logs and employee time punches from 5/11/2020 through 5/25/2020, showed 472 staff screenings out of 1,125 staff screenings opportunities were not completed by the facility. During an interview on 5/26/2020 at 4:22 PM, the Executive Director stated employees are screened on arrival to their unit, prior to the start of their shift, with a temperature check and questionnaire regarding respiratory symptoms and COVID-19 exposure. The Executive Director further stated the facility had trusted that employees were screening themselves prior to the start of their shift at the facility. During an interview on 5/27/2020 at 9:48 AM, the Regional Director of Clinical Services stated her expectation would be for a designated person to screen every person who enters the facility with a temperature check and questionnaire. The Regional Director of Clinical Services further stated the facility had been trusting employees to do their own screenings, which was not her expectation. During an interview on 5/27/2020 at 5:16 PM, the Director of Nursing (DON) confirmed that not all employees had been screened prior to the start of their shift between 5/11/2020 and 5/25/2020.

Based on review of facility policy, facility weekly cleaning schedule, observation, and interview, the facility failed to date and label food items, failed to discard expired foods, failed to maintain clean and sanitary kitchen equipment, failed to separate personal and resident dining items, and failed to secure hair in a hair covering in the 1 of 1 kitchen possibly affecting 117 of 119 residents. The findings include: Review of the Infection Prevention and Control Program (IPCP), not dated, revealed .an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment .a system for preventing, identifying .controlling infections and communicable diseases .appropriate storage .of supplies and equipment . Review of the facility policy Use by Date Guide, revised [DATE] revealed .all opened containers of food .should be placed in an enclosed container, labeled, and dated .expiration date - the last day the product should be used for best quality .cheese, processed, opened .30 days .store in enclosed container after opening .ham, sliced .7 days .hotdogs/Franks, opened .7 days .vegetables, frozen .6 months . Review of the facility policy Food Safety, dated [DATE], revealed .food is stored and maintained in a clean, safe and sanitary manner .pre-packaged food .labeled with the name of the contents and date (when the item is transferred to the new container) 'Use by Date' is noted on the label .leftovers are dated properly and discarded after 72 hours .opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' . Review of the facility policy Dress Code, dated [DATE] revealed .The Food and Nutrition Services associates wear a hair covering, which covers all unpinned hair at all times . Review of the facility's weekly cleaning schedule dated [DATE], [DATE], [DATE], [DATE], and [DATE] revealed Ovens (Inside & (and) Out) to be cleaned by the PM (evening) Cook on Sundays. Continued review revealed no documentation the Ovens (inside & out) were cleaned the week of [DATE] and [DATE]. Observation and interview with the Certified Dietary Manager (CDM) on [DATE] at 10:00 AM, of the desert cooler, in the kitchen revealed 10 racks of unlabeled, undated Boston Cream pie 96 slices. Interview with the CDM confirmed the facility failed to date and label the pie slices. Observation and interview with the CDM on [DATE] at 10:05 AM, of the walk-in cooler, in the kitchen, revealed the following: 3 unlabeled, undated, opened packages of orange cheese slices, all re-wrapped in plastic wrap; 1 partially sliced corned beef, labeled use in 7 days dated ,[DATE]; 1 repackaged hot dog dated ,[DATE]; and 1 plastic bag of unlabeled, undated shredded carrots. Interview with the CDM confirmed the facility failed to date and label the cheese slices and shredded carrots. Continued interview confirmed the facility failed to label and discard the expired corned beef and hot dog. Observation and interview with the CDM on [DATE] at 10:10 AM, of the walk-in freezer, in the kitchen, revealed the following unlabeled, undated food items in plastic bags: 3 beef patties and 4 boneless chicken breasts. Interview with the CDM confirmed the facility failed to date and label the repackaged frozen meats. Observation and interview with the CDM on [DATE] at 10:15 AM, of the cooks freezer, in the kitchen, revealed 20 unsecured, open to air breaded chicken patties;1 bag of unsecured, open to air onion rings; 2 bags of unsecured, open to air tater tots; and 1 bag of opened, undated, and unlabeled french fries. Interview with the CDM confirmed the facility failed to properly secure the chicken patties, onion rings, and tater tots, and failed to date and label the french fries. Observation and interview with the CDM on [DATE] at 10:20 AM, of the combination stove/oven, revealed dried debris with grease streaks on the front of the 2 oven doors; and dried debris and grime on the 7 stove/oven knobs and on the shelf of the flat holding area of the oven. Interview with the CDM confirmed the facility failed to maintain a clean and sanitary stove/oven. Observation and interview with the CDM on [DATE] at 10:20 AM, in the paper storage room, of the kitchen, revealed on a metal bakers rack, along with coffee carafes and coffee pots, 1 blue hoodie (touching 1 coffee carafe) and 1 unzipped woman's purse with visible contents. Interview with the CDM confirmed the facility failed to separate personal and resident items. Observation and interview with the Dietary Aide (DA) #1 on [DATE] at 12:15 PM, in the kitchen revealed DA #1 walked across the length of the kitchen without a hair covering. Interview with DA #1 confirmed she failed to secure her hair with hair covering in the kitchen. Interview with the CDM on [DATE] at 12:11 PM, in the conference room, confirmed the facility failed to ensure hair covering use in the kitchen.

Based on facility policy review, observation, and interview the facility failed to ensure expired medical supplies were not available for resident use in 2 of 3 medication storage rooms observed. The findings include: Review of the facility policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised on [DATE], revealed . Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis . Observation with Licensed Practical Nurse (LPN) Unit Manager #1 on [DATE] at 1:45 PM, in the South Wing medication storage room, revealed the following expired items: 1 enema kit with use by date of ,[DATE] 8 blue top laboratory (lab) tubes (tube used for blood collection) with expiration date of [DATE] 1 hand sanitizer 4 ounce (oz.) bottle with expiration date of ,[DATE] 1 yellow top lab tube with expiration date of [DATE] 1 hand sanitizer 4 oz. bottle with expiration date of ,[DATE] 2 red top lab tubes with expiration date of [DATE] 23 vacutainer blood collection sets with expiration date of [DATE]. Interview with LPN Unit Manager #1 on [DATE] at 1:45 PM, in the South Wing medication storage room, confirmed the expired medical supplies were available for resident use. Interview with the Director of Nursing (DON) on [DATE] at 2:28 PM, in the DON's office, confirmed expired supplies were avaiable for resident use. Observation with the LPN Unit Manager #2 on [DATE] at 4:00 PM, in the Skilled Wing medication storage room, revealed the following expired items: 3 enema kits with use by date of ,[DATE] 1 urine leg bag with expiration date of ,[DATE] 3 enema kits with use by date of ,[DATE] 1 catheter securement device ½ inch with expiration date of [DATE] 1 enema kit with use by date of [DATE] 3 catheter securement devices ½ inch with expiration date of [DATE]. Interview with LPN Unit Manager #2 on [DATE] at 4:00 PM, in the Skilled Wing medication storage room, confirmed the expired medical supplies were available for resident use and the facility failed to follow their policy.

Based on facility policy, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 (#96, #111) residents of 24 residents reviewed for MDS assessments. The findings include: Review of the facility policy Certification of the Accuracy of the MDS, reviewed 4/22/19, revealed .the MDS accurately reflects the patient's status . Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Continued review revealed a limb restraint was utilized for Resident #96. Observation and interview with Resident #96 on 8/13/19 at 7:45 AM, in the resident's room, revealed she did not have restraints applied durind her stay at the facility. Medical record review and staff interviews revealed no documentation of restraint use for Resident #96. Interview with MDS/Licensed Practical Nurse #1 on 8/13/19 at 2:05 PM, in the MDS office, confirmed Resident #96 restraint documentation was inaccurate. Interview with the Director of Nursing (DON) on 8/14/19 at 11:00 AM, in the DON's office, confirmed the quarterly MDS dated [DATE] for Resident #96 was not accurate in the use of restraints. Medical record review revealed Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a discharge summary MDS dated [DATE] revealed Resident #111 was discharged to an acute hospital. Medical record review revealed Resident #111 was discharged home with his parents on 6/4/19. Continued review revealed no documentation of a hospitalization or transfer during the resident's admission to the facility. Interview with the DON on 8/14/19 at 11:00 AM, in the DON's office, confirmed Resident #111 was not transferred to a hospital and the discharge MDS did not reflect an accurate assessment of the resident's discharge from the facility.

Based on medical record review and interview, the facility failed to address a wound on the Baseline Care Plan for 1 resident (#259) of 17 residents reviewed for baseline care plans of 24 sampled residents. The findings include: Medical record review revealed Resident #259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the baseline care plan dated 8/9/19 revealed .Resident is at risk for break in skin integrity .maintain intact (undamaged) skin with no skin breaks through next review . Medical record review of a Skin/Wound Progress Note dated 8/11/19 revealed .noted to have a small .open area to posterior left thigh .Patient .states that it was previously a bump she could not stop picking at, turned into open wound . Medical record review of a physician's orders [REDACTED].cleanse area left posterior (back) thigh with wound cleanser .place drsg (dressing) change daily and prn (as needed) . Interview with the Licensed Practical Nurse (LPN) Unit Manager #2 on 8/13/19 at 4:22 PM, in the LPN Unit Manager's Office, confirmed the wound (non-pressure) to the back of Resident #259's left thigh was present on admission on 8/9/19. Interview with Minimum Data Set (MDS)/LPN #1 on 8/14/19 at 10:20 AM, in the MDS office, confirmed the facility failed to address the wound to the back of Resident #259's left thigh on the Baseline Care Plan.

Based on facility policy review, medical record review, observation, and interview the facility failed to develop a comprehensive care plan to address a pressure ulcer for 1 resident (#101) of 5 residents reviewed for pressure ulcers of 24 sampled residents. The findings include: Review of the facility policy Resident Assessment Instrument & Care Plan last revised 11/28/16 revealed .develop an individualized person-centered care plan that provides a path toward the resident achieving or maintaining their highest practicable level of well-being . Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Further review revealed the resident had a risk for pressure injury. Medical record review of the care plan dated 5/28/19 revealed .At risk for break in skin integrity . Continued review revealed no documentation to address a pressure ulcer for Resident #101. Medical record review of a Skin/Wound Progress Note dated 7/8/19 revealed .Unstageable wound to left heel .Cleansed with wound cleanser and placed foam dressing . Medical record review of a physician's order dated 7/8/19 revealed .Left Heel- Unstageable Wound . Medical record review of a Wound Observation tool dated 8/9/19 revealed .Location: Left heel .Type: pressure .Wound started as unstageable to left heel . Observation of Resident #101 on 8/14/19 at 7:36 AM, in the resident's room, revealed the resident lying on the bed with the heels floated on a cushion. Observation of Resident #101's wound with the Wound Care Nurse on 8/14/19 at 8:47 AM, in the resident's room, revealed a small round open area to the left heel with a small amount of yellow slough and the wound was clean and dry. Interview with the MDS/Licensed Practical Nurse #1 on 8/14/19 at 10:16 AM, in the MDs office, revealed she was aware of the pressure ulcer to Resident #101's left heel. Further interview confirmed the facility failed to develop a care plan to address the resident's pressure ulcer.

Based on medical record review, observation, and interview, the facility failed to address a recommendation from the Registered Dietitian (RD) timely for 1 resident (#78) of 3 residents reviewed for nutrition of 24 sampled residents. The findings include: Medical record review revealed Resident #78 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 7/31/19 revealed .The resident requires tube feeding .RD to .Make recommendations for changes to tube feeding as needed . Medical record review of the 14 day Minimum Data Set (MDS) assessment dated [DATE] revealed modified independence for decision making. Further review revealed the resident received nutrition by a feeding tube (tube placed into the stomach to provide nutrition). Medical record review of the Order Summary Report dated 8/14/19 revealed .Enteral Feed (tube feeding) .every shift .50 ml (milliliters) .via (by) pump .Start Date .8/6/19 . Medical record review of a Nutrition/Dietary Note dated 8/7/19 revealed .Current TF (tube feeding) .@ (at) 50ml/hr (hour) .Current TF does not accurately meet resident's needs .R/C (recommend) .(tube feeding) @ 60ml/hr x (times) 22hrs . Observation of Resident #78 on 8/13/19 at 2:24 PM, in the hallway, revealed the resident sitting up in a wheel chair with the tube feeding infusing at 50 ml/hr via pump. Observation of Resident #78 on 8/14/19 at 7:40 AM, in the resident's room, revealed the resident lying on the bed with the tube feeding infusing at 50 ml/hr via pump. Interview with the RD on 8/14/19 at 9:15 AM, in the RD office, confirmed she had written a progress note on 8/7/19 to recommend increasing the tube feeding to 60 ml/hr .to better meet her needs . Continued interview revealed she communicated her recommendations to the unit manager who was then responsible for obtaining the order from the Physician. Interview with the Licensed Practical Nurse (LPN) Unit Manager #2 on 8/14/19 at 9:25 AM, in the LPN Unit Manager's office, revealed she had not checked her box used for communication of recommendations from the RD to the nurse. Continued interview confirmed the recommendation had been made 7 days ago (8/7/19) and had not been addressed with the Physician for a new order to be obtained. Interview with the Director of Nursing (DON) on 8/14/19 at 2:46 PM, in the DON's office, confirmed the RD recommendations were to be addressed no later than 72 hours . after the recommendation was made. Continued interview confirmed the facility failed to address the RD recommendation to increase the tube feeding for Resident #78's nutritional needs timely.

Based on facility policy review, observation, and interview, the facility failed to discard expired yogurt by the use by date, failed to obtain and record temperatures in 2 of 2 nourishment freezers, and failed to properly store ice creams in 1 of 2 nourishment freezers, potentially affecting 110 of 114 residents. The findings include: Review of the facility policy, Food Safety, last revised [DATE], revealed, .Temperatures recorded at least twice daily on the Refrigerator/Freezer Temperature Log using an inside thermometer . Further review revealed, .Ambient temperatures in freezers remain at 0 degrees F (Fahrenheit) or lower and all food is frozen solid . Observation and interview with the Director of Food Service (DFS) on [DATE] at 9:15 AM, in the kitchen, revealed one 32 ounce container of half used vanilla yogurt. Further observation revealed a use by date of [DATE], and an open date of [DATE]. Interview with the DFS at the same time confirmed, it needs to be thrown away . Observation and interview with the DFS of the nourishment freezer on [DATE] at 9:05 AM, in the skilled wing nourishment room, confirmed no thermometer in the freezer. Observation and interview of the nourishment freezer with the DFS on [DATE] at 9:25 AM, in the south wing nourishment room, revealed no thermometer in the freezer. Further observation revealed 27 4 ounce ice creams that were soft to the touch. Further observation revealed 2 ice creams were 10 degrees F. Interview with the DFS confirmed the ice creams were not at the appropriate temperature. Interview with the Administrator on [DATE] at 10:45 AM, in the dining room, confirmed the facility failed to monitor the temperatures of the nourishment freezers on the skilled and south wings of the facility.

Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 1 resident (#159) of 45 sampled residents. The findings include: Resident #159 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Resident #159's care plan, initiated 6/14/18 revealed, .Resident has [DIAGNOSES REDACTED]. Continued review revealed, .Approaches .Meds .as ordered by MD (medical doctor) . Medical record review of Physician's Orders for (MONTH) (YEAR) revealed, . [MEDICATION NAME] (anti-convulsant) 300 mg (milligrams) capsule PO (by mouth) daily . at 8:00 AM. Medical record review of a nurse Progress Note dated 8/27/18 revealed, .late entry for 8/23/18. At approximately 1:30 PM, resident turned on call light requesting pain medication for left hip. This nurse was getting ready to sign out pain medication [MEDICATION NAME] (narcotic pain medication) .this nurse mistakenly signed out [MEDICATION NAME] instead of [MEDICATION NAME] . Interview with Licensed Practical Nurse (LPN) #1 on 10/23/18, at 3:25 PM, at the nurses' station, confirmed the LPN had mistakenly gave an additional dose of the medication [MEDICATION NAME]. Interview with the Director of Nursing (DON) on 10/24/18, at 8:35 AM, in the DON's office, confirmed LPN #1 had not followed the physician's order for medication administration and confirmed Resident #159 had received an additional dose of [MEDICATION NAME].

Based on medical record review, review of facility investigation, and interview, the facility failed to ensure a safety device was connected and functioning, to alert staff of unassisted transfers for one resident (#1) of six residents reviewed. The facility's failure to ensure the bed alarm was connected and functioning for resident #1 resulted in a fall and a frontal sinus fracture (fracture within the bones located above the eyes within the frontal bone of the skull), a C2 fracture (fracture involving the second vertebra, or second cervical vertebra, of the spinal column), a right radius fracture (wrist fracture, or fracture of one of the two large bones in the forearm) and a laceration on the right arm (Actual Harm). The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Fall Risk Evaluation form revealed a resident who scores ten or higher is at risk (of falls); the resident was evaluated on August 29, 2011, November 2, 2011, January 9, 2012, and scored nineteen on each evaluation. Medical record review of a Physician's Telephone Order dated August 29, 2011, at 2030 (8:30 p.m.) revealed, "...Bed chair pad alarm for safety..." Medical record review of the Physician's Recapitulation Orders dated January 2012, revealed the order for the bed and chair pad alarm for safety continued. Medical record review of a care plan dated August 29, 2011, revealed, "...Problem: Potential for injury r/t (related to) falls secondary to impaired mobility, impaired safety awareness...Approached:...MD (Medical Doctor) order 8/29/11 (August 29, 2011) bed/chair (bed and chair) alarm for safety..." Medical record review of nurse's notes dated October 19, 20, 21, 23, 24, and 26, 2011, revealed the resident was receiving skilled nursing services for Dementia, was confused and oriented to person only. Medical record review of a nurse's note dated November 14, 2011, revealed the resident had a decline in tolerance and independence with ambulation. Medical record review of a nurse's note dated January 19, 2012, at 1:30 p.m., revealed, "...heard someone screaming...yelling 'We need help down here!'...entered pt's (patient's) room...was observed lying face down in doorway of room...dark red blood noted around...face...911 (9-1-1) called at 1:32 p.m. Pt. left in position until EMS (emergency medical services) arrives (arrived)...1:40 p.m., (EMS) here to transport pt to ER (emergency room )...0 (no) chair alarm sounding at time of incident..." Review of a facility investigation dated January 19, 2011, revealed "...resident was observed lying facedown (face-down) in the (resident's) room doorway...blood around face...EMS notified...(resident) remained in the position (resident) had been discovered until EMS placed in immobilization for transport to ER...(resident)...wasn't sure what occurred, but had lost a baby in the past & (and) (resident) saw this baby & was attempting to run to it. Management staff began...safety device audit...an emergency PI (performance improvement) meeting was conducted...to include checks of alarm orders, functioning, & placement. Suspension of CNA (certified nursing assistant) occurred...Associate (suspended CNA) was terminated..." Review of written statements dated January 19, 2012, revealed: Licensed Practical Nurse (LPN) #1 heard screaming and responded to observe the resident lying face-down, with blood around the (resident's) head. "...(Resident) was looking for (resident's) baby..." CNA #1 was across the hall with another resident when a scream was heard. CNA #1 responded to resident #1's room. "(The) bed (pad) alarm was on with (alarm) box intact (connected). Chair pad (alarm) was in place to chair, but was not hooked up (connected) to (alarm) box...(resident) more confused today talking about (resident's) baby..." Unit Manager #1 heard someone screaming, the resident was in the floor. LPN #2 observed the resident face-down in the doorway with blood around the resident's head. Medical record review of a hospital Physician's Trauma History and Physical Form dated January 19, 2012, revealed the resident had a "fall from wheelchair on to face." Diagnostics completed at the hospital on January 19, 2012, with positive findings included an x-ray of the right upper extremity, with a fracture of the right radius (wrist). CT Scans (Computed Tomography, a radiologic imaging that uses computer processing to generate an image of tissue density in slices through the patient's body) were completed on the head and spine; the head confirmed a nondisplaced frontal sinus fracture, (with no acute intracranial hemorrhage), and of the spine confirmed a C2 fracture. Plastic Surgery was consulted on January 20, 2012, for the frontal sinus fracture. Mild facial tenderness was evidenced, and the consult revealed the resident could be treated on a nonoperative basis. Neurology was consulted on January 20, 2012, for the cervical fracture, which was being treated and supported with a cervical collar. The consult revealed the resident was demented and confused, and was unable to fully cooperate with neurological testing. The physical examination revealed the resident was "in no apparent distress." Continued review revealed the cervical fracture would "ideally be treated with a stabilization procedure; however, in light of the patient's...Dementia, Coagulopathy, age, etc., (et cetera, "and so on"), this may not be well tolerated. Will discuss further with the patient's family when available..." Medical record review of Trauma Services Progress Notes dated January 20, 21, and 22, 2012, revealed the resident remained confused and demented, but stable. Continued review of the progress notes dated January 23, 2012, revealed the following: 6:15 a.m., "...Family wants hospice eval (evaluation);" (No time), "...Multiple concurrent med (medical) issues...c-collar (cervical collar) 24/7 (24-hours per day, seven days per week)." 10:10 a.m., "...Family notes h/o (history of) compression fx (fracture)..." Medical record review of a hospital physician's orders [REDACTED]. Medical record review of a Hospice Patient Information Sheet revealed the resident was admitted to hospice services with Senile Dementia, on January 24, 2012. Medical record review of a Hospice Physician's Progress Note dated January 25, 2012, revealed the resident had a Dementia FAST score of 7C (a seven-stage functional scale designed to evaluate patients at the more moderate to severe stages of Dementia, with stage seven being severe Dementia). Medical record review of a progress note completed by the Hospice Medical Director on January 30, 2012, revealed the resident passed away on January 27, 2012, at 4:00 a.m., from Senile Dementia. Review of a Termination Form dated January 24, 2012, revealed on January 19, 2012, CNA #1 failed to place a safety alarm on resident after transferring to the wheelchair. "Due to no alarm being placed in chair, resident arose from chair & sustained a fall....no alarm sounded to alarm staff...Due to severity of incident & resident outcome, Associate (CNA) is being terminated...I did fail to place an alarm on a patient. This is my fault..." The surveyor made multiple, unsuccessful telephone attempts to reach CNA #1 for an interview, on October 23, 2012, at 11:30 a.m., and 6:15 p.m.; and on October 24, 2012, at 1:09 p.m. Each attempt resulted in no answer, and a recording which confirmed the voicemail service had not been set-up. Interview with LPN #1 on October 23, 2012, at 5:00 p.m., in the Admission's Office, revealed the resident was confused, looking for (resident's) baby, and fell from the wheelchair. Continued interview confirmed the chair pad alarm was in the seat of the wheelchair, but LPN #1 was "unsure where the alarm box was that connects to the chair pad alarm; but it wasn't connected and the alarm was not sounding." Interview with Unit Manager #1 on October 23, 2012, at 5:20 p.m., in the Admission's Office, confirmed on January 19, 2012, the resident attempted to get out of the wheelchair, unattended, and fell face-forward onto the floor. The resident had physician orders [REDACTED]. At the time of the resident's unattended fall from the wheelchair, the chair alarm pad was in the seat of the wheelchair, but was not connected to the alarm box, and was not sounding as a result. Unit Manager #1 confirmed when CNA #1 transferred the resident from the bed to the wheelchair on January 19, 2012, CNA #1 failed to connect the chair alarm pad to the alarm box. Continued interview with Unit Manager #1 confirmed the facility failed to ensure the chair alarm pad and alarm box were connected. Interview with the Administrator on October 23, 2012, at 6:53 p.m., in the Admission's Office, confirmed the facility failed to ensure the chair alarm pad was connected and functioning, to alert staff of the unassisted transfer. Continued interview confirmed the fall resulted in multiple fractures and a laceration with sutures. C/O