Every finding on record at Loris Rehab And Nursing Center, LLC

Based on interview, record review, and facility policy review, the facility failed to ensure each resident received their mail on the day that it was delivered by the postal service for 4 (Residents (R)8, R20, R21, and R54) of 6 residents who attended the Resident Council meeting.Findings included:A facility policy titled, Resident Right to Privacy in Communication, dated 04/2023, revealed, It is the policy of this facility to support and facilitate a resident's rights to privacy in communications with individuals and entities within and external to the facility. Policy Explanation and Compliance Guidelines: 1. The facility will honor the resident's right to privacy in communications including the right to: a. Send and promptly receive mail that is unopened. The policy specified, 2. Business Office Coordinator or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly. Mail will be given to the resident unopened.During the Resident Council meeting on 02/05/2026 at 10:08 AM, R8, R20, R21 and R54 stated if mail was delivered on the weekends it was not delivered to them until the following Monday, although activity staff was usually present in the building for part of the day on Saturdays.A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2025, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.A quarterly MDS, with an ARD of 11/23/2025, revealed R20 had a BIMS score of 15, which indicated the resident had intact cognition.A quarterly MDS, with an ARD of 01/03/2026, revealed R21 had a BIMS score of 15, which indicated the resident had intact cognition.A quarterly MDS, with an ARD of 01/12/2026, revealed R54 had a BIMS score of 15, which indicated the resident had intact cognition.During an interview on 02/06/2026 at 8:00 AM, Activity Assistant (AA)1 stated she worked Mondays through Fridays and every other Saturday. AA1 stated when mail or packages came in, the person at the front desk would put it in the activities mailbox. AA1 stated that if mail came late on Fridays and she was getting ready to leave, the mail was distributed to the residents the following Saturday morning. AA1 stated mail was delivered by the postal service on Saturdays, but she did not have access to it. According to AA1, the main mailbox was outside the building, which was locked, and she did not have access to it on the weekends.During an interview on 02/06/2026 at 8:14 AM, the Activity Director (AD) stated she worked Mondays through Fridays and alternating Saturdays. The AD stated the Business Office Manager (BOM), who worked Mondays through Fridays, got the mail out of the main mailbox and placed it in activities mailbox. The AD stated they did not have mail on Saturdays because the BOM was not there to open up the main mailbox to retrieve the mail and any mail delivered by the postal service would be obtained by the BOM on the following Monday.During an interview on 02/06/2026 at 8:28 AM, the BOM stated she typically worked Mondays through Fridays. She stated every morning she went to the mailbox to check for mail, which was located outside the building and kept locked. She stated she took the mail out of the mailbox and sorted it. The BOM stated on days that she did not work, no one checked the mailbox. She stated that the mail service usually delivered the mail around 4:00 PM, and if mail came in on Fridays after she had left for the day or on Saturdays, it would just stay in the mailbox until the following Monday morning.During an interview on 02/06/2026 at 8:38 AM, the Social Services Director (SSD) stated she only assisted with mail by making sure it got to activities, and that she typically didoes not work on Saturdays.During an interview on 02/06/2026 at 8:47 AM, the Director of Nursing (DON) stated the facility process for resident mail delivery was that the BOM and SSD had access to the mailbox which was located outside and was locked, and they checked for mail daily. The DON stated the BOM or AD would sort through the mail and then distribute it to the appropriate resident. The DON stated that if there was mail delivered over the weekends the door greeter or weekend supervisor were to distribute the mail. The DON stated her expectation was that residents got their mail the day that it was delivered.During an interview on 02/06/2026 at 8:58 AM, Registered Nurse (RN)2 stated she was the weekend supervisor and worked 7:00 AM to 7:00 PM, Fridays, Saturdays, and Sundays. RN2 stated she had not dealt with packages or mail. RN2 stated the business office got residents' mail from the mailbox.During an interview on 02/06/2026 at 9:07 AM, the Chief Clinical Officer (CCC), who covered in the absence of the Administrator stated her expectation for resident mail was timely delivery of unopened mail. The CCC stated residents should be able to get their mail the six days that it was delivered.

Based on interview, record review, and facility policy review, the facility failed to implement their grievance procedure as evidenced by the failure of the staff to record the nature and specifics of a grievance filed by 1 (Resident (R)29) of 18 sampled residents. Findings included: A facility policy titled Concern/Grievance Procedure dated 11/23, revealed b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. An Admission Record revealed the facility admitted R29 on 07/13/23. According to the Admission Record, the resident had a medical history that included diagnoses of acute upper respiratory infection and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/17/24, revealed R29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 12/02/24 10:29 AM, R29 stated the Environmental Services Director (ESD) spoke ill to them and accused them of stealing a resident's clothes. During an interview on 12/04/24 at 9:11AM, the Wound Care Nurse (WCN) stated she received a complaint/grievance from R29 on 12/02/24 that the ESD yelled at them and stated they stole a resident's clothes. The WCN stated she spoke with the ESD about the resident's concerns, the ESD apologized and stated she did not feel she raised her voice at the resident, but she had not documented R29's grievance on a grievance form yet. During an interview on 12/04/24 at 9:24 AM, the Director of Nursing (DON) stated a resident's grievance/concern should be documented on the grievance form. The DON stated she was not aware of R29's grievance.

Based on review of facility policy, observation, and interview, the facility failed to ensure: 1) Accurate labeling and dating of foods, 2) Removal of expired foods from refrigeration and storage. This failure had the potential to affect all residents Findings include: Review of the 2020 facility policy and procedure titled, Food Storage (Dry, Refrigerated, and Frozen) states: Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: A.) All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. B.) Discard Food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. C.) Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and/or freezers. 4. Dry storage guidelines to be followed: F.) Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure. During the initial kitchen tour on [DATE] at 11:00 AM, an observation revealed in Cooler 1 contained, an open tube of ground beef with no label or date. One carton container Molly's Kitchen, no open or expiration date. A plastic Ziploc bag with approximately 22 boiled eggs with the use by date of [DATE]. Approximately five shrivel red peppers that were soft to touch. A clear container of chopped mushrooms with a use by date of [DATE]. A clear container of cream corn with the use by date of [DATE]. A metal bowl of salad not labeled, no expiration date. Two tomato soup cups, no label. Small container with red chopped onions, no label or expiration date. During the initial kitchen tour on [DATE], an observation revealed in Freezer ONE contained one container of barbeque pork. The container was cracked and had visible freezer burn. During the initial kitchen tour on [DATE], an observation revealed in the dry storage area contained Devils food cake mix, opened, with no expiration date. A ten-pound bag of chocolate chips opened, no expiration date. A carton of orange gelatin mix, opened with no open or expiration date. A four-tier rack with damaged can goods in the entry of the dry room storage area, no label. On [DATE] at 09:40 AM, an interview with the Certified Dietary Manager (CDM)/ Food Service Director revealed she encourages staff to do spot checks twice a week to make sure there is no expired foods in the freezer or coolers. The CDM stated that the kitchen supervisor doesn't work on weekends, but she is supposed to throw out all foods that are going to expire on the weekend. She further stated all staff is responsible to check temperatures daily. Additionally, the CDM stated that when the company sends dented or damaged cans, the kitchen staff is responsible for taking pictures and sending the pictures via email to the company in order to receive their food credit. She then stated that once they receive credit for the damaged cans, then they can discard them in the dumpster.

Based on review of facility policies, record review, observations, and interviews, the facility failed to assist residents with Activities of Daily Living (ADL) care for 1 of 1 Resident (R)40, reviewed for ADLs. Findings include: Review of the undated facility policy titled Facial Hair, Removal read, Facial hair will be removed as needed per resident preference. Review of the undated facility policy titled, Nail Care read, Resident's will receive proper nail care .To clean the nail bed, to keep nails trimmed, and to prevent infections and injury . Review of the undated facility policy titled Oral care read, This facility will provide necessary service to maintain good oral hygiene . Review of R40's Face Sheet, provided by the facility, revealed R40 was admitted to the facility on [DATE] with diagnoses which included stroke, kidney failure, and heart failure. Review of R40's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/28/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R40 was cognitively intact. The MDS revealed R40 required limited physical assistance of one person for her personal hygiene needs. Review of R40's Care Plan, provided by the facility, last updated 10/01/22 read, Resident requires assistance with bed mobility, transfers, walking, toilet use, personal hygiene . One of the interventions included in the care plan was, Assist with bathing, dressing, and grooming needs every shift. Review of R40's Behavior and Mood report, provided by the facility, dated 12/2022 did not document refusal of care by R40. During an observation and interview on 12/11/22 at 10:58 AM, R40 was lying in bed. Her fingernails had a black build up under the nails and a black substance at the base, along the cuticle line. R40 had long chin hair. Her teeth had a buildup of white substance along the upper gumline. R40 stated she has been sick and unable to care for herself as much as she used too. R40 felt on her chin and said Oh my, I'm so sorry. I didn't realize they were that long. R40 stated her teeth have not been brushed in a while. She said no one had offered to help her and she was unable to brush them herself. During an observation and interview on 12/12/22 at 9:06 AM, R40 had long chin hairs. She had a black buildup under her fingernails and along the cuticle line. Her teeth continued to have a white build up along the gum line. R40 said she would be leaving for dialysis soon and did not think she would be able to get her teeth brushed or shaved before she left. During an interview on 12/12/22 at 2:29 PM, Certified Nurse Aide (CNA)1 stated R40 was at dialysis. She stated she did not brush R40's teeth or shave her before R40 left for dialysis. CNA1 stated CNAs did not do nail care. CNA1 stated, Activities usually does that. During an observation on 12/13/22 at 10:15 AM, R40 was lying in bed asleep. R40 had long chin hairs, a buildup of black substance under her fingernails and a white substance along her gum line. During an observation and interview on 12/13/22 at 11:24 AM, R40 was clean shaven. She continued to have a black substance under her nails and a white buildup along her gum line. R40 stated no one brushed her teeth yesterday and no one had offered to help her brush her teeth today. During an interview on 12/13/22 at 11:53 AM, the Activity Director stated she provided nail care as an activity weekly, but nursing was responsible for routine nail care. During an interview on 12/13/22 at 12:33 PM, the Director of Nursing (DON) stated her expectation was that females should not have chin hairs. The DON stated she expected residents' teeth to be brushed at least daily. She stated CNAs were responsible to ensure residents' fingernails were cleaned. The DON stated she expected nail care to be completed daily and as needed if hands were soiled.

Based on review of the facility policy, record review, interview, and observations, the facility failed to ensure each resident received oxygen therapy in accordance with professional standards of care for 1 Resident (R)40 of 2 residents reviewed for respiratory care. R40 received oxygen via an oxygen concentrator. The oxygen concentrator required a filter that was not present. The opening where the filter was supposed to be had an accumulation of dirt and lint covering the outer edges and inner surfaces. This failure could place residents receiving oxygen at risk for infection. Findings include: Review of the undated facility policy titled, Oxygen Therapy, read, If using an oxygen concentrator, check and clean filter on outside of concentrator weekly as indicated by washing the foam filter with soap and water to prevent dust from entering concentrator. Review of the undated user manual for the oxygen concentrator read, .NOTE: There is one cabinet filter located on the back of the cabinet .CAUTION DO NOT operate the concentrator without the filter installed . Review of the undated Face Sheet provided by the facility, revealed R40 was admitted on [DATE] with diagnoses which included respiratory failure. Review of R40's Care Plan, last revised on 10/01/22, provided by the facility, revealed R40 had a potential for respiratory distress and infection. The care plan indicated R40 was to receive oxygen therapy. The care plan did not address ensuring the oxygen concentrator filter was in place. Review of R40's Physician Orders dated 12/2022, provided by the facility, revealed R40 was to receive oxygen at three liters a minute as needed. The orders also indicated, since 08/26/22, the oxygen filter was to be cleaned once a week if it has a filter. Review of R40's Treatment Administration Record (TAR) dated 12/2022, provided by the facility, revealed the filter on R40's oxygen concentrator was to be changed weekly on Fridays. The TAR was signed as completed every Friday in December. During an observation on 12/11/22 at 10:58 AM, R40 was lying in bed. She was receiving oxygen at 3 liters per minute (LPM) via an oxygen concentrator. The area on the back of the concentrator meant to contain a filter was empty. The empty space had an accumulation of dust and lint around the edges and inner surface. During an observation on 12/12/22 at 09:06 AM, R40 was lying in bed. She was receiving oxygen at 3 LPM via an oxygen concentrator. The area on the back of the concentrator meant to contain a filter was empty. The empty space had an accumulation of dust and lint around the edges and inner surface. During an interview on 12/13/22 at 12:03 PM, Registered Nurse (RN)2 stated the night nurses were responsible to clean oxygen concentrator filters and ensuring they were in place. She stated when orders read if it has a filter it meant if the concentrator required a filter. She said nurses knew if the concentrator required a filter because there was a space on the back of the concentrator for the filter. During an observation on 12/13/22 at 12:10 PM, RN2 verified the filter on R40's oxygen concentrator was missing. During an interview on 12/02/22 at 1:52 PM, the Director of Nursing (DON) stated R40's oxygen concentrator required a filter. The DON stated the facility did not have a process for ensuring the oxygen concentrator filter was in place.

Based on review of facility policies, observations, and interviews, the facility failed to ensure expired medications were removed from 1 of 2 medication storage rooms. Furthermore, the facility failed to ensure all medications were securely stored in their original packing to prevent the medications from falling into the bottom of 1 of 4 medication carts. Failure to provide accurate labeling of medications nullifies the ability to facilitate consideration of precautions and safe administration of medication, to ensure they work as they should, as well as minimizing loss or diversion. Findings include: Review of the undated facility policy titled, Storage of Drugs, states, All drugs shall be stored appropriately. 1. Drugs shall be stored in an orderly manner in a locked area. 4. Drugs shall not be kept on hand after the expiration date on the label. Review of the facility's policy titled, Destruction of Controlled Substances, dated 08/2018 states: All discontinued, contaminated, or expired controlled substances shall be disposed of in accordance with state laws and regulations. 1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. An observation on 12/12/22 at 3:23 PM in medication storage room [ROOM NUMBER] revealed three boxes of Assure Dose Control Solution with an expiration date of 10/05/22. Additionally, a four-week pill box of medications, not labeled or in their original packaging was also discovered. The expired medication was verified by Licensed Practical Nurse (LPN)4. An observation on 12/12/22 at 3:44 PM of medication cart 1 revealed two loose pills, one discovered in drawer 2, a large white oval pill, identified by LPN2 as a Sucralfate 1MG tab. Two half size small white oval pills, not identifiable, were found in drawer 3 of the medication cart. The loose medications were confirmed by LPN2, and the Unit Manager, Registered Nurse (RN)1. An interview on 12/13/22 at 2:01 PM with the Unit Manager, RN1, disclosed that expired medications should go back to the pharmacy and loose medicine should be put in the drug buster. RN1 included that staff should be aware of the policy and they all attend yearly training on their medication policy. She also explained the staff should be cleaning the carts and rooms and checking for expired medications and loose or damaged items nightly. An interview on 12/13/22 at 2:03 PM with the Pharmacist revealed medications come in on totes and are put in the carts by the nurses, they are stored and locked in the carts and dispensed from there. The Pharmacist further expressed narcotics are double locked and refrigerated items are kept in the refrigerator, non-controlled substances are sent back to the pharmacy and controlled substances are destroyed with her and the Director of Nursing (DON), in the drug buster, a form is completed, and then the loose medications are put in the drug buster. Medication carts and rooms are checked weekly by the nursing staff, and she comes in and does a monthly check. The Pharmacist inserted staff should be checking carts daily, but she will plan to come by weekly and ensure they are complying, educate staff with an in-service and keep following up with weekly visits. An interview on 12/13/22 at 2:33 PM with the DON revealed she was unsure of why the pill box, containing medication was in medication storage room [ROOM NUMBER]. She explained it was a possibility that it was bought in by a resident's family and they had not come back to retrieve them. She stated they were locked in the cabinet in the room so that no one else would have access to them.

Based on record reviews, staff interviews, and review of the facility policy titled, Abuse Policy, the facility failed to ensure Resident (R) 1 was free from misappropriation. Specifically, Certified Nursing Assistant (CNA) 1 used the resident's Electronic Benefit Transfer (EBT) card for personal use. This failure placed R1 at risk for abuse, neglect, misappropriation of resident property, and exploitation. Findings include: The facility admitted R1 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 4/1/22 at 9:30 AM, of the facility reported and investigated allegation of misappropriation, revealed CNA 1 used the EBT card belonging to R1 to purchase snacks for her own personal use in the amount of $64.25. Further review revealed a copy of the police report, with a copy of the store receipt, which confirmed the purchase of snacks on 12/1/21 in the amount of $64.25. An interview on 4/1/22 at 12:02 PM with CNA 1 confirmed that she had used the EBT card belonging to R1 for snacks in the amount of $64.25. CNA 1 stated she had used the card belonging to R1, but at the time of the purchase, she also had a card that belonged to her Uncle, and used the wrong one. Several attempts were made to interview R1 with no success. Review of the facility policy titled, Abuse Policy, states under Policy, This facility strives for person-centered care, focusing on the residents and supporting the resident in making their own choices and having control over their daily lives. We have a zero tolerance for abuse including, neglect, exploitation and misappropriation of resident property by anyone including, but not limited to, staff, residents and others serving the resident. The purpose of the policy, Residents have the right to be free from abuse. The policy included the definition of Misappropriation of Resident Property as, Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observations, interviews, and record review, the facility failed to implement an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) and other infections in two (Unit #1 and Unit #2) of three resident units. Specifically, the facility failed to: 1. Ensure housekeeping staff changed gloves between room cleaning tasks and cleaned from dirty to clean area for two of three units; 2. Ensure housekeeping staff adhered to proper dwell time for the disinfectant used in the cleaning process for two of three units; 3. Ensure nursing staff performed/offered hand hygiene to residents during noon meal; 4. Ensure staff encouraged residents to protect/cover their face when staff went in their rooms; and 5. Ensure activity staff used personal protective equipment (PPE) appropriately. This deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents. Findings included: 1. The Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidance, updated 1/30/2020, retrieved on 01/13/2021, read in part, Healthcare personnel should use an alcohol-based hand rub or wash their hands with soap and water for the following clinical indications: Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or the patient's immediate environment. After contact with blood, body fluids, or contaminated surfaces and immediately after glove removal. On 01/13/2021 at approximately 9:52 AM, housekeepers (HSK #1, #2, and #3) were continuously observed as they wiped frequently touched surfaces and cleaned residents' rooms across the facility. Observations of resident room cleaning revealed HSK #1 started cleaning from room [ROOM NUMBER] on Unit #1. S/he donned new gloves without performing hand hygiene. The HSK was already wearing a surgical face mask before s/he went in the room. The resident was served a room tray and was eating at the time of the observation. The HSK retrieved a dust mop from the cleaning cart in the hallway. The HSK dust mopped the floor, starting in the bathroom, then the bedroom areas. S/he swept the dust and particles from the floor to the doorway, used a dustpan to pick up the debris, emptied the dustpan into the trash on his/her cart, and returned the dust mop to the cart. S/he then pulled a spray bottle labeled, Spartan Diffense Multipurpose, Broad Spectrum Cleaner Disinfectant with Bleach, and sprayed the content into the toilet, the surrounding walls, and flush handle. S/he immediately wiped down the surfaces and flushed the toilet after having washed the toilet bowl with a brush. S/he went back to his/her cart which sat on the hallway to get a feather brush which s/he used in cleaning the overhead fixtures in the room. S/he did this while the resident sat up in bed and was eating. The HSK then retrieved a wet mop from the cart and mopped the residents' bathroom floor. When s/he was done mopping the floor, s/he returned the mop to his/her cart, got a cleaning cloth, and wiped down the bedside tables, which had the residents' meal sitting on them. As s/he wiped down the table, s/he picked up and replaced the resident's meal plate, water pitcher, and a book. After cleaning and mopping the rest of the residents' room, the HSK returned to the cleaning cart in the hallway while still wearing the gown and gloves that were now potentially contaminated. S/he moved his/her cleaning cart, and his/her next stops were at room [ROOM NUMBER] and room [ROOM NUMBER]. While at the later rooms, the HSK repeated the same sequence described above except that the residents in the later rooms were not eating when HSK #1 cleaned their rooms. Further observations of HSK #2 and HSK #3's cleaning procedure revealed they failed to change gloves between cleaning tasks. In addition, the HSKs failed to advise residents to cover/protect their faces when they went in the residents' rooms. The HSKs had worn the same pair of gloves to clean the entire room, potentially cross contaminating the residents' rooms with their soiled gloves after handling the mop used on the bathroom floor. By dust-mopping the residents' rooms starting in the bathroom, they had potentially cross-contaminated the flooring in the residents' bedroom area with whatever might have been on the bathroom floor. In addition, by touching the resident's food packs, cups, books and book (See observation of HSK #1 above), s/he had potentially cross contaminated the resident's meals with whatever contaminant that was retained on his/her soiled gloves. On 01/13/2021 at 3:56 PM, the housekeeping supervisor (HKS) was interviewed. S/he said housekeeping staff were last trained on cleaning procedures approximately two months ago. S/he said housekeepers should clean from the clean areas to dirty areas and use different rags to clean the different living areas of residents and the entire room. S/he said, Not following the proper cleaning procedures; touching residents' personal effects with used gloves and not using the cleaning products correctly can increase the spread of infections. S/he said it was important for staff to follow the recommended use of PPE as with glove changes, because of the risk of exposure, infection and reinfection of the staff and residents across the facility. S/he said s/he would do more one-on-one training with the housekeepers going forward. 2. The CDC, Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, updated 04/01/2020, retrieved on 01/13/2021, read in part, Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. On 01/13/2021 at approximately 9:52 AM, housekeepers (HSK #1, #2, and #3) were continuously observed as they wiped frequently touched surfaces and cleaned residents' rooms across the facility. The room cleaning observation with HSK #1 revealed s/he pulled a spray bottle labeled, Spartan Diffense Multipurpose, Broad Spectrum Cleaner Disinfectant with Bleach, and sprayed the content into the toilet, the surrounding walls, and flush handle. S/he immediately wiped down the surfaces and flushed the toilet after having washed the toilet bowl with a brush. HSK #1 repeated the same sequence of spraying and immediately wiping down the chemical disinfectant mentioned above when she cleaned room [ROOM NUMBER], #136, and #137. Further observations of HSK #2 and HSK #3's cleaning procedure revealed they failed to adhere to the manufacturer's recommended dwell time for the chemical disinfectant used as described above. Specifically, HSK #2 and HSK #3 cleaned room [ROOM NUMBER] and #235 consecutively. Observations with HSK #2 and HSK #3 during the cleaning process revealed they sprayed and immediately wiped down the chemical disinfectant immediately. The same observation was made of them when they wiped down frequently touched surfaces (doorknobs, handrails, etc.) across the facility. On 01/13/2021 at 3:56 PM, the housekeeping supervisor (HSK) was interviewed. S/he said housekeeping staff were last trained on cleaning procedures approximately two months ago. The HSK emphasized that not following the manufacturer recommended dwell time could affect the disinfecting properties of the disinfectants. S/he acknowledged that the disinfectant, Spartan Diffense Multipurpose, Broad Spectrum Cleaner Disinfectant with Bleach, observed with the HSKs was the product the facility utilized in disinfecting across the facility. S/he verified the manufacturer's recommended kill time for the disinfectant was 1-2 minutes. S/he acknowledged that by spraying and immediately wiping off the disinfectant, the HSKs failed to let the disinfectant sit for as long as it was recommended hence, not ensuring the disinfectant performed its disinfecting function. A review of the Spartan Diffense Product Specification Sheet, dated 04/2020, indicated the following kill times, - Kills Escherichia coli, extended betalactamase resistant (ESBL), [MEDICAL CONDITION] Virus, [MEDICAL CONDITION] Virus, [MEDICAL CONDITION] Virus, Norovirus, Rotavirus, Influenza A (H1N1) Virus,[MEDICAL CONDITION] 1 in 30 seconds - Kills Staphylococcus aureus, Pseudomonas aeruginosa in 60 seconds - Kills [MEDICAL CONDITION] in 8 minutes A review of the Environmental Protection Agency List N website indicated the kill time for Spartan Diffense, EPA 5741-28, for [DIAGNOSES REDACTED] CoV-2 was 30 seconds. 3. On 01/13/2020 between 12:15 PM and 1:20 PM, observations were conducted during in room tray delivery of the noon meal on the Units #1 and #2. Unit #2 had residents who were under investigation for COVID-19, while Unit #1 were not under investigation for COVID-19. Licensed Practical Nurse (LPN #1), Certified Nurse Aide (CNA #1) and CNA #2 served meals to residents on Unit #1 while CNA #3, CNA #4 and CNA #5 served meals to residents on Unit #2. The nursing staff intermittently missed hand hygiene opportunity prior to delivering the meal trays in the residents' rooms. They did not offer and/or encourage hand hygiene when they delivered the noon meal to the residents. The entire population of residents on Units #1 and #2 did not have hand hygiene performed or offered when they ate their meal. The identified failures and breaches in infection control practices identified above failed to ensure residents ate their meal under sanitary condition and direct care staff did not cross-contaminate the residents by failing to advise the resident to protect their faces when staff went in their rooms. On 01/13/2021 at 4:13 PM, the Director of Nursing and Infection Control Preventionist (DON/ICP) was interviewed. S/he said staff were trained on frequent handwashing. S/he said potential breach of infection control could result from staffs' failure to follow proper infection control practices taught to them. S/he agreed the breach in infection control practice had risk of spreading infection quickly within the facility. 4. According to the Centers for Disease Control and Prevention (CDC) updated 06/25/2020, retrieved on 01/13/2021, included the following recommendations: Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. Observations conducted of nursing, activity and housekeeping staff revealed the staff failed to encourage the residents to cover or protect their faces by any means when the staff went in their rooms. Specifically, continuous observation of the Activities Director (AD) on 01/13/2021 from 9:15 AM through 12:00 PM revealed the AD went in the rooms of residents under investigation for COVID-19. The AD failed to advise the residents to protect or cover their faces. The AD's action failed to ensure s/he was not potentially cross-contaminating the population of residents s/he had encounters with when s/he did the one-on one activity with them. Observations conducted during in room tray delivery of noon meal on 01/13/2020 between 12:15 PM and 01:20 PM on Units #1 and #2 revealed nursing accessed residents' rooms without encouraging or advising the population of residents to cover or protect their faces when staff went in their rooms to serve meals. In addition, observation of housekeeping staff when they performed residents' room cleaning duties on 01/13/2021 at approximately 9:52 AM revealed the housekeeping staff went into the residents' rooms without advising the residents to use a facial covering. The housekeeping staff stood in proximity that was less than six feet from the residents when they cleaned their rooms. The HSK's action failed to ensure they were not potentially cross contaminating the population of residents they had encounters with when they cleaned their rooms. On 01/13/2021 at 4:13 PM, the Director of Nursing and Infection Control Preventionist (DON/ICP) was interviewed. S/he said residents and staff were trained on social distancing, frequent handwashing, cough etiquette, use of PPE, and adherence to County and State Health Department directives. S/he said potential breach of infection control could result from staffs' failure to follow proper infection control practices taught to them. S/he said the breach in infection control practice of not advising resident to cover their faces when staff went in their rooms had risk of spreading infection quickly within the facility. 5. According to the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 12/14/2020, retrieved on 01/21/2021, included the following recommendations: Health Care Provider who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. During a continuous observation of the Activities Director (AD) on 01/13/2021 from 9:15 AM through 12:00 PM, it was revealed that the AD went in the rooms of residents under investigation for COVID-19 without wearing full PPE. Specifically, the AD failed to ensure s/he wore eye protection when s/he performed one-on-one activities with the residents under investigation for COVID-19. The AD was sometimes observed as s/he stood at the entry door of some residents when s/he conducted trivia questions with them, however, at other times, s/he physically accessed the residents' rooms without wearing the required PPE as described above. In addition, the AD went from Unit #2 (the unit with residents under investigation for COVID-19) to Unit #1 (the unit with cleared residents). S/he failed to change out the respirator mask s/he had worn when s/he went in residents' rooms on isolation. The AD's practice had the potential of cross contaminating the population of the residents at the facility. On 01/13/2021 at 4:13 PM, the Director of Nursing and Infection Control Preventionist (DON/ICP) was interviewed. S/he said residents and staff were trained use of PPE and adherence to County and State Health Department directives. S/he said potential breach of infection control could result from staffs' failure to follow proper infection control practices taught to them. S/he said the breach in infection control practice of the lack of proper use of PPE when going in/and out of an isolation room and not replacing masks between going in and out of isolation rooms and caring for residents who were not on isolation, had risk of spreading infection quickly within the facility.

Based on record review, observation, interview, and review of the facility policy titled Gastrostomy/PEG Tube Medication Administration, the facility failed to maintain a medication rate of less than 5%. There were 6 errors out of 35 opportunities for error, resulting in a medication error rate of 17.14%. The findings included: ERROR #1-5: Observation of Licensed Practical Nurse(LPN)#1 on 11/15/18 at 11:40 AM revealed s/he crushed [MEDICATION NAME] NA 100 milligrams(mgs), [MEDICATION NAME] 5 mgs, ASA chew 81 mgs, [MEDICATION NAME] 20 mgs, and Vitamin C 500 mgs. After crushing the medications, the crushed medications were mixed with water and administered through a gastrostomy tube. After administering the medications to Resident #79, LPN #1 was asked to show the cup to the surveyor. Residual medication was observed in the bottom of the cup. At the time of the observation, LPN #1 confirmed there was residual in the bottom of the cup. LPN #1 added more water to the the cup several times to ensure all the medication was administered. ERROR #6: During reconciliation, Resident #79 had a current physician's order for [MEDICATION NAME] 220 mgs/5 mls administer 7 mls in which LPN #1 did not administer during the medication pass observed. Review of the facility policy titled Gastrostomy/PEG Tube Medication Administration did not address ensuring all crushed residual medication to be given.

Based on record review and interview, the facility failed to document behaviors prior to administration of psychoactive drug therapy for 1 of 5 sampled residents reviewed for unnecessary medications. The findings included: Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Nurses Notes on 9-21-16 at 4 pm for July, August and September 2016 revealed no behaviors were documented. Review of the 4-13-15 care plan on 9-21-16 at 11 am revealed interventions that the staff should: observe and record behaviors for which the drug is being used administer [MEDICATION NAME] as ordered, attempt alternative intervention prior to administration of PRN medications and document results of interventions tried. During an interview on 9-22-16 at 2 pm, the Director of Nursing (DON) reviewed the MARs for July to September 2016 as well as the Nursing Notes in the same period. S/he acknowledged the lack of documentation of behaviors as directed in the care plan.

Based on record review, interview, and review of a hospice form entitled, Visit Note Report, the facility failed to ensure coordination of care for hospice services for 1 of 1 residents reviewed for hospice care and services. There was a lack of documentation of services provided by hospice for Resident #18. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review on 5/28/2015 at approximately 1:41 PM revealed Resident #18 was a patient of Hospice since 2013. Further review of Resident #18's medical record revealed a Registered Nurse from hospice was to visit 2 times weekly. The last documented visit in the medical record was 5/7/2015. No other documentation was found in the resident's medical record to ensure the hospice nurse had visited and assessed Resident #18. During an interview on 5/28/2015 at approximately 3:22 PM, the Director of Nurses (DON)confirmed the nurse visit documentation for hospice care and services was not in the medical record or in the facility for Resident #18. The DON stated that (s)he would call the hospice nurse and have the documentation faxed to the facility. Nurse visits from 5/12/2015, 5/15/2015, 5/18/2015, 5/19/2015, and 5/27/2015 were faxed to the facility on [DATE] at 3:50 PM. Included with the nursing visits was a chaplain visit dated 5/22/2015 and a social service visit dated 5/19/2015. Neither were in the medical record for Resident #18. Review on 5/29/2015 at approximately 10:44 AM of the faxed nurses visits from hospice entitled, Visit Note Report, revealed assessments, interventions, and goals that had not been conveyed to the facility and the nurses caring for Resident #18 on a daily basis to ensure coordination of care.

Based on observation, interview, and review of the facility policy entitled Gastrostomy/ PEG Tube Medication Administration, facility staff failed to ensure appropriate treatment for 1 of 1 sampled residents reviewed for a Percutaneous Endoscopic Gastrostomy (PEG)-tube medication administration. The facility failed to follow established PE[DEVICE] medication administration procedures and follow physician's orders. The findings included: The facility admitted Resident #145 with [DIAGNOSES REDACTED]. On 5/28/15 at 8:25 AM, review of Resident #145's May 2015 Medication Administration Record [REDACTED]> 50 ML (milliliters), HOLD TF (TUBE FEED) AND NOTIFY MD (medical doctor). During medication pass observation on 5/28/15 at approximately 8:30 AM, Licensed Practical Nurse (LPN) #2 attempted to administer medication through Resident #145's PE[DEVICE] without checking Resident #145's residual stomach content. LPN #2 was stopped and asked by the surveyor if s/he was going to check if Resident #145 had residual stomach content. LPN #2 stated, I forgot. After the medication pass, LPN #2 wrapped the wet syringe containing white debris in a paper towel and placed it a plastic bag. LPN #2 was asked by the surveyor if s/he needed to clean the syringe. LPN #2 stated, No, it doesn't need it. LPN #2 then removed the syringe from the bag and verified the white substance inside the syringe and indicated the substance as stomach content. On 5/28/15 at approximately 10:00 AM, a review of the facility policy entitled Gastrostomy/ PEG Tube Medication Administration, revealed under Procedure: (11) Check placement by aspirating residual. DO NOT DISCARD residual, gently push contents back into the stomach. If residual is > 120 cc (cubic centimeters) notify MD, unless otherwise directed per MD order. Procedure (19) furthermore stated, Rinse syringe with water and separate to dry.

Based on record review, observation, and interview, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchens with the potential to effect 3 of 3 residents receiving nourishment at [MEDICAL TREATMENT]. The facility failed to package Resident #40's meat sandwich in a method to maintain a safe temperature. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. On 5/26/15 at 4:40 PM, review of Resident #40's medical record revealed a cognitive score of 14 in section CO500 of the clinical assessment Minimum Data Set (MDS) on 3/27/15. Also, Resident #40's care plan stated under Problem/Need, Resident is at risk for complications of [MEDICAL TREATMENT] (bleeding, graft site clotting, infection, fluid overload, dehydration). Has [MEDICAL CONDITION], and under bullet 6 of the approaches to the problem stated, Have ready for transportation on [MEDICAL TREATMENT] days. Resident will take bag lunch/snack to [MEDICAL TREATMENT]. On 5/27/15 at 10:35 AM, an observation on Unit 2 with Licensed Practical Nurse (LPN) #1 revealed Resident #40 and a blue bag being transported via stretcher to the [MEDICAL TREATMENT] clinic. Resident #40 indicated the blue bag contained his/her lunch, a bologna meat sandwich. Resident #40 was asked if the sandwich was kept cool with an ice pack, or if it was refrigerated at the [MEDICAL TREATMENT] clinic. Resident #40 stated No, it is warm. Following the observation, LPN #1 verified that the bologna meat sandwich was in a non-insulated blue bag without an ice pack or stored in a method to keep the sandwich meat from spoiling. During an interview on 5/27/15 at 4:10 PM, the Food Service Director was asked if Resident #40's meat sandwich should be sent out in an insulated bag with an ice pack. S/he stated, Yes, all meat and perishable foods need to be put in a cooler with an ice pack. S/he was then asked if s/he packed Resident #40's bologna sandwich for [MEDICAL TREATMENT] on 5/27/15. The Food Service Director stated, I sent the sandwich with CNA (Certified Nursing Aide) #1 and nursing is supposed to pack it. During an interview on 5/28/15 at 8:55 AM, CNA #1 was asked if Resident #40's meat sandwich was ever kept cool by putting it in an insulated bag or with an ice pack. CNA #1 stated, No, the sandwich comes from the kitchen cool and I take it to the microwave and heat it up from 2 seconds to a minute and send it out with Resident #40 in a blue bag.

Based on observation, interview, and review of the manufacture recommendations, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 2 medication storage rooms. Expired Aplisol, Tuberculin Purified Protein Derivative (PPD) was found in the Unit 1 medication storage room. The findings included: On 5/26/15 at 11:00 AM, an observation of the Unit 1 medication storage room refrigerator with Licensed Practical Nurse (LPN) #1 revealed one 1 milliliter (ml), 10 test, vial of Aplisol, Tuberculin Purified Protein Derivative (PPD) with Lot Number 5, which was labeled, opened 4/23/15 and exp. 5/21/15. Following the observation, LPN #1 verified the PPD was expired and indicated the PPD should have been removed. On 5/26/15 at 1:45 PM, a review of the Aplisol, Tuberculin Purified Protein Derivative (PPD) box insert manufacture recommendations stated under Storage: Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

On the days of the survey, based on observation, interview, and review of facility policies titled "Medication Storage" and "Consultant Pharmacist Monthly Medication Regimen Review", the facility failed to follow a procedure to ensure expired medications were not stored with other medications available for resident use and medications were properly labeled for 1 of 4 medication carts, 1 of 2 treatment carts and 2 of 2 medication rooms reviewed for medication storage. The findings included: On 1/9/14 at approximately 3:00 PM, observation of the 100 Unit Medication Room revealed one vial of Novolog insulin with an illegible open date. This was confirmed by LPN (Licensed Practical Nurse) #1 on 1/9/14 at 3:14 PM. On 1/10/14 at 11:15 AM, observation of the 200 Medication Room revealed one bottle of Glucosamine 500 mg(milligrams)/Chondroitin 400 mg (150 easy swallow capsules) that expired 12/13 with a Lot # 00 and one vial of Novolog with an open date of 11/6/13, expiration date of 10/2015 and a control #czf0357. These findings were verified by the Interim DON(Director of Nursing). Per recommended guidelines, Novolog should be discarded 28-30 days after the vial has been punctured. During an observation of 1 of 2 medication carts on Unit 2 on 1/10/2014 at approximately 2:15 PM 6 tablets of Ondansetron 4 milligrams (mg), Lot# CF / 012PT3, Manufactured by TEVA had expired on 11/8/2013 and were available for use. Approximately 1/2 of a can of NutriSource Fiber, NDC# -0975-50, manufactured by Nestle was available for use that had expired on 11/23/2013. An interview on 1/10/2014 at approximately 2:15 PM with License Practical Nurse (LPN) #2 verified the items had expired. During an observation of the Wound/Treatment cart on Unit 1 on 1/10/2014 at approximately 3:25 PM revealed a plastic bag with a pharmacy label for Eucerin Creme with an expiration date of 12/17/2013. Inside the plastic bag was a 4 ounce jar of Eucerin Creme that had never been opened and no expiration date could be found on the jar. A boxed tube of Triamcinolone Dental Paste was also in the plastic bag and the outside of the box had a pharmacy label noting an expiration date of 12/17/2013. However, the actual tube of Triamcinolone Dental Paste had a manufacture expiration date of January 2016. An interview on 1/10/2014 at approximately 3:30 PM with Registered Nurse (RN) #2, Unit 1 Nurse Manager verified the expiration dates on the pharmacy labels. An interview with the interim Director of Nursing (DON) confirmed the findings and he/she stated."the labels on the packages do show an expiration date of 12/17/2013, but the medications are not expired." The facility policy titled "Medication Storage" states the following: Medication storage conditions are monitored on a (monthly) basis by (the consultant pharmacist) and corrective action taken if problems are identified. Review of the facility policy titled "Consultant Pharmacist Monthly Medication Regimen Review" states the following: The consultant pharmacist or designee reviews medication storage areas and emergency medication kits; 1) Reviews all medications in the facility for expiration dates and assures removal of discontinued or expired medications from use. 2) Verifies proper storage of medications and biological in the facility and makes recommendations concerning handling, sorting and labeling of medications. During an interview on 1/10/14 at 5:02 PM with the Interim DON, he/she stated that the night shift nurses are also responsible to check medications for expiration dates. He/she continued by stating there was no log documenting when the nurses check the medications.

On the days of the survey, based on observations and interview, the facility failed to serve food under sanitary conditions in 1 of 3 areas observed for meal service. Observation of tray delivery on the 100 Unit Hall revealed staff touched residents' food with their bare hands while setting-up residents' lunch trays. The findings included: Observation of delivery of lunch trays to the 100 Unit Hall on 1/07/14 at approximately 12:10 PM revealed staff setting-up lunch trays for residents in their rooms. During two random observations, Certified Nurses Assistant (CNA) #1 was observed to open the package containing a dinner roll, reach into the package with his/her bare hands, take the roll out of the package, and place the roll on top of the package on the tray. In addition, observation of delivery of the lunch tray to Resident #130's room revealed Resident #130 sitting in his/her wheel chair. Resident #130 was observed wearing knit slipper socks and asked CNA #1 to re-position his/her feet prior to CNA #1 setting-up the tray. CNA #1 was observed to pick-up the resident's feet and, with both hands placed on the bottom the resident's feet, positioned Resident #130's feet on the wheelchair foot rests. CNA #1 then proceeded to set-up the resident's tray. CNA #1 opened the package containing a roll, took the roll out of the package with his/her bare hands, and placed the roll on top of the package on the tray. When asked for facility policies related to meal service, the Certified Dietary Manager (CDM) provided a policy entitled "Food and Nutrition Services" which related to dietary personnel in the kitchen. No policy was provided related to set-up of trays for resident rooms, and on 1/10/14 the CDM confirmed that the facility had no written policy on tray delivery and set-up.

On the days of the survey, based on observation and interviews, the facility failed to follow a procedure to ensure that expired laboratory testing supplies were not stored with other laboratory testing supplies available for resident testing in 1 of 2 medication room.(Unit 200 Medication Room) The findings included: On [DATE] at approximately 11:15 AM, observation of the 200 Unit Medication Room revealed (16) Gastroccult Test Slides available for use that expired ,[DATE]. This was confirmed by the Interim DON(Director of Nursing) on [DATE] at 11:48 AM.

On days of the survey,based on observation and interview, the facility failed to maintain equipment in a safe and effective operating condition. Two of three refrigerators had black/brown buildup on gaskets and multiple spills. The findings included: During an environmental tour of the facility on 08/29/2012 at 9:30 AM, the Unit 100 Nourishment Room refrigerator had a black/brown buildup on the gasket and multiple spills inside. Unit 200 Nourishment Room refrigerator had a black/brown buildup on the gasket and multiple spills inside. Above findings were confirmed by the Engineering/Maintenance Director during the environmental tour on 8/29/2012

On the days of the survey, based on observations, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff were observed standing to feed 2 of 9 sampled residents(Resident #1 and Resident #3) observed at meal time and 1 random observation of an unsampled resident. The findings included: The facility admitted Resident #1 in 2012 with the resident requiring total care with activities of daily living and Resident #3 in 2010 with the resident requiring total care with activities of daily living. On 8/27/12 at 5:30 PM, during observation of the PM meal, Registered Nurse #1 was observed standing to feed a resident. On 8/27/12 at 5:45 PM, a staff member was observed standing to feed a resident the PM meal. On 8/28/12 at 12:15 PM staff was observed standing to feed Resident #3 and at 12:25 PM, staff was observed standing to feed Resident #1.

On the days of survey, based on record review and interview, the facility failed to ensure a resident was receiving an antipsychotic drug for a specific condition as diagnosed and documented in the clinical record. Resident #5 did not have a [DIAGNOSES REDACTED]. (One of five residents reviewed for the use of antipsychotic drugs). The findings included: The 8/1/12 physician orders [REDACTED].@ BT (Bedtime). The Admission Minimum Data Set (MDS) Version 3.0 Section I dated 8/9/12 included Active [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) Summary for [MEDICAL CONDITION] Drug Use documented "noted to have no behavior problems." The resident's Brief Interview for Mental Status (BIMS) was coded as 13. Section D Mood and Section E Behavior were both coded as none. There was no Behavior Monitoring Form as noted in other residents reviewed for antipsychotics. In an interview with Unit 200 Nurse Manager on 8/29/12 at 9:20 AM, she stated that she could not specify any behaviors other than sometimes the resident confused her previous long term residence with the current one.