Every finding on record at Mabry Health Care

Based on facility policy review, observations, and interviews, the facility failed to maintain kitchen equipment in good repair to store food under sanitary conditions and at proper temperatures to prevent foodborne illnesses, which had the potential to affect 71 of 73 residents. The findings include: Review of the facility's undated policy titled, Sanitation and Food Safety: Food Storage, revealed .Food storage areas are maintained within optimal temperature ranges .Freezers -10-0 F [Fahrenheit] .Food stock and prepared food products are stored at safe temperature ranges at all times . Review of the facility's undated policy titled, Sanitation and Food Safety: Equipment Failure and Repair, revealed .Dining services equipment shall be maintained in a good state of repair . During the initial tour of the dietary department on 5/4/2026 at 10:06 AM, the walk-in freezer was observed to have an external and internal temperature reading of 9 degrees Fahrenheit. Further observation revealed accumulation of ice throughout the unit, including on the floor, shelving, interior door surfaces, fan housing, and exterior of food packaging for two bags of queso cheese. Continued observation revealed ice buildup on the freezer floor prevented the freezer door from closing completely, which left a visible gap along the seal. The freezer door was observed to be in disrepair, with a broken gasket seal, visible condensation, and warping of the door structure, which prevented proper closure. Review of a Project Proposal dated 3/25/2026, revealed [NAME] Company had provided an estimate for the repair of the freezer door totaling $6,926.00 with a lead time (time to prepare materials for installation) of 6 to 7 weeks. Review of a maintenance statement dated 5/4/2026, revealed the Maintenance Director received verbal confirmation from the [NAME] President of Operations to move forward on repairs to the freezer door on 5/4/2026, after the state of door was brought to the facility's attention by this surveyor. During an interview on 5/4/2026 at 10:09 AM, the Dietary Manager (DM) confirmed the freezer temperature was out of range, the freezer door did not close properly, ice was accumulated on the floor, shelving and food packaging, and the freezer door was in disrepair. The DM stated the freezer door had been in disrepair for approximately two months, and the ice accumulation interfered with proper closure. During an interview on 5/5/2026 at 10:29 AM, the DM stated manual removal of accumulated ice was required to improve door function on a temporary basis. During an interview on 5/6/2026 at 10:35 AM, the Maintenance Director stated the freezer door had been in disrepair since approximately February 2026 but had gotten worse recently. The Maintenance Director further stated a work order for repair of the freezer door had been placed in March 2026, and bids were collected for the repair. The Maintenance Director stated the bid was approved on 5/4/2026.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain infection control practices when staff failed to implement and use Enhanced Barrier Precautions (EBP) for 1 resident (Resident #20) of 5 residents reviewed for EBP. The findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 8/2025, revealed .The facility should use Enhanced Barrier Precautions (EBP) .during high-contact resident care activities .EBP are indicated for residents with .wounds and/or indwelling medical devices .wounds generally include chronic wounds .examples of chronic wounds include .pressure ulcers, diabetic foot ulcers, unhealed surgical wounds .indwelling medical device examples include .urinary catheters .examples of high-contact resident care activities requiring gown and glove use include .dressing .bathing .changing briefs .Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Rheumatoid Arthritis, and Chronic Kidney Disease. Further review revealed Resident #20 was readmitted to the facility on [DATE] after a hospitalization.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.Review of the current Physician's Orders for Resident #20 dated 5/6/2026, revealed an order was present for an indwelling foley catheter. Further review revealed there was no Physician's Order for EBP.During an observation on 5/6/2026 at 9:49 AM, revealed a sign posted outside Resident #20's door which indicated EBP as follows: .Wear gloves and a gown for the following High-Contact Resident Care Activities .Dressing .Transferring .Changing briefs . and the sign was labeled for the resident in B bed (which was not Resident #20). Certified Nursing Assistant (CNA) A and CNA B were observed performing a transfer with a mechanical lift for Resident #20 in the resident's room, and a foley catheter drainage bag was visible. CNA A and CNA B wore gloves but did not don gowns.During an interview on 5/6/2026 at 9:51 AM, CNA A stated EBP is used for residents with a catheter, open wounds, tube feeding, and other things .EBP means we wear gloves and gown when giving care .[Resident #20] should be on EBP because he [Resident #20] has a catheter . CNA A confirmed she [CNA A] and CNA B wore gloves but did not don a gown when transferring Resident #20 to bed.During an interview on 5/6/2026 at 9:54 AM, CNA B stated .EBP means we wear gloves and a gown when it's called for .we are supposed to wear gowns if the resident has a tube, wound, catheter .we use EBP whenever we give them care where we're touching them .[Resident #20] has a catheter and should be on EBP . CNA B confirmed she [CNA B] and CNA A wore gloves but did not don a gown when transferring Resident #20 to bed.During an interview on 5/6/2026 at 10:30 AM, the Director of Nursing/Infection Preventionist (DON/IP) confirmed Resident #20 did not have an order for EBP and confirmed the resident should be under EBP due to having an indwelling urinary device (urinary catheter). The DON confirmed the CNAs were trained on EBP and the reasons EBP was needed and should have used EBP for Resident #20 as they were aware he (Resident #20) had an indwelling foley catheter.

Based on facility policy reviews, medical record reviews, observations, and interview, the facility failed to implement the comprehensive care plan's fall interventions for 2 residents (Residents #1 and #66) of 4 residents reviewed for accidents. The findings include: Review of the facility's policy titled, Guidelines For Incidents/Accidents/Falls, dated 6/2023, revealed .The resident has a care plan put into place with interventions . Based on the results of the incident/accident/fall, the residents care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place . Each fall needs a new care plan intervention .Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated 3/2021, revealed . The comprehensive care plan will further expand on the resident's risks, goals and interventions using the person-centered plan of care approach for each resident . in an effort to achieve the highest level of functioning and the greatest degree of comfort, safety .for the resident .Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes Mellitus, and Hypertension. Review of the Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #1 revealed .at risk for falls . with an intervention dated 2/17/2026, .gripper strips [non-skid strips] to both sides of the bed .Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Schizophrenia, Dementia, and Hypertension.Review of a quarterly MDS assessment dated [DATE], revealed Resident #66 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #66 revealed .at risk for falls . with an intervention dated 2/5/2026, .anti-roll back to wheelchair . and an intervention dated 2/8/2026, .non-skid strips to floor next to bed .During observations on 5/4/2026 at 11:00 AM and 5/5/2026 at 2:55 PM, revealed Resident #1 did not have non-skid strips on either side of the bed as stated on the care plan.During observations on 5/4/2026 at 11:05 AM and 5/5/2026 at 2:45 PM, revealed Resident #66 did not have non-skid strips next to the bed as stated on the care plan.During an observation on 5/6/2026 at 5:00 PM, revealed Resident #66 was in a wheelchair that did not have an anti-roll back device as stated on the care plan.During an observation and interview on 5/6/2026 at 5:25 PM, the Administrator confirmed there were no non-skid strips next to the beds for Resident #1 or Resident #66, the wheelchair Resident #66 was sitting in did not have an anti-roll back device, and confirmed these items were listed on both resident's comprehensive care plan.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 1 of 1 garbage dumpster. The findings include: Review of the facility's undated policy titled, .Drain Plugs in Waste Receptacles, revealed .all receptacles and waste handling units for refuse .must have drain plugs securely in place at all times, unless being actively cleaned or maintained in order to prevent leaks, environmental contamination, and health hazards . During an observation of the outside dumpster area on 2/4/2025 at 2:30 PM, with Dietary [NAME] B, revealed 1 dumpster for waste disposal. Further observation revealed the dumpster had no drain plug intact resulting in the dumpsters contents being left open to the elements and the potential exposure to pests. During an interview on 2/4/2025 at 2:37 PM, Dietary [NAME] B confirmed the drain plug for the dumpster was not intact and the dumpsters contents were not contained properly.

Based on facility policy review, observation, and interviews, the facility failed to ensure an expiration date was visible on an over the counter house stock medication bottle for 1 of 2 medication carts reviewed for medication storage. The findings include: Review of the facility's policy titled, Floor Stock Medications, dated 3/2023, revealed .floor stock medications are labeled .with expiration date .clearly exposed . During an observation on 2/4/2025 at 7:50 AM, on the C Hall medication cart, revealed one bottle of Ferrous Sulfate (iron supplement) had no expiration date visible on the bottle. Further observation revealed the bottle was opened on 1/14/2025 and was available for immediate resident use. During an interview on 2/4/2025 at 7:52 AM, Licensed Practical Nurse (LPN) A confirmed the house stock bottle of Ferrous Sulfate had no expiration date present on the bottle and the expiration date could not be verified. During an interview on 2/4/2025 at 8:43 AM, the Director of Nursing confirmed medications stored in the medication carts should have expiration dates present and listed on the bottle to ensure medications are used within their expiration date.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure tube feeding formula was appropriately labeled for 1 resident (Resident #41) of 1 resident reviewed for tube feeding management. The findings include: Review of the facility's undated policy titled, GUIDELINES FOR ENTERAL FEEDING [a tube surgically inserted in the stomach to provide nutrition, hydration, and medication] [gasrtric tube] : ADULT, revealed .hanging and maintaining and managing and administering Tube/Feedings and Enteral Nutrition .OPEN .ENTERNAL FEEDING SYSTEM .or use of formula from cans or bottles which is poured into a feeding tube bag .Enteral Feeding Formula .instructions .to be followed . Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Traumatic Brain Injury, Seizures, Stroke, and Dysphagia (difficulty swallowing). Review of a 5-day admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 was rarely understood. Further review revealed the resident received artificial nutrition through a gastric tube (a tube surgically inserted in the stomach to provide nutrition). Review of a Physicians Order for Resident #41 dated 1/25/2025, revealed .[name brand formula] .65 ML/HR [milliliters per hour] . During an observation on 2/3/2025 at 10:30 AM, revealed Resident #41 had enteral feeding infusing. Further observation revealed the feeding bag was not labeled to include the name of the formula infusing. During an observation and interview on 2/3/2025 at 10:35 AM, with Licensed Practical Nurse (LPN) D revealed Resident #41 had enteral feeding infusing. Further observation revealed the feeding bag was not labeled to include the name of the formula infusing. LPN D stated the enteral feeding bag should be labeled with the type of formula to be infused. During an observation on 2/4/2025 at 9:14 AM, revealed Resident #41 revealed Resident #41 had enteral feeding infusing. Further observation revealed the feeding bag was not labeled to include the type formula infusing. During an observation and interview on 2/4/2025 at 9:15 AM, with the Director of Nursing (DON) revealed Resident #41 had enteral feeding infusing and the feeding bag was not labeled with the type of the formula infusing. The DON confirmed the facility failed to label Resident #41's feeding bag to with the formula infusing.

Based on interview, record review, and facility policy review, the facility failed to report elevated fingerstick blood glucose (sugar) test results to the physician in accordance with professional standards and facility policy for 2 (Resident #11 and Resident #12) of 3 residents reviewed who were receiving insulin for diabetes mellitus. Findings included: A review of an undated facility policy titled, Blood Glucose Monitoring, indicated, Blood sugars found to be below 70 or above 400 will be reported immediately to the physician and the resident's representative. Any orders received from the physician will be implemented. 1. A review of Resident #11's Resident Face Sheet revealed the facility admitted the resident on 01/04/2022 and most recently readmitted the resident on 07/10/2023 with diagnoses that included Type 2 Diabetes mellitus and Dementia. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2023, revealed Resident #11 scored 7 on the Brief Interview for Mental Status (BIMS), which indicated the resident was severely cognitively impaired. The MDS indicated Resident #11 had signs and symptoms of delirium including an altered level of consciousness that fluctuated (comes and goes and changes in severity). According to the MDS, the resident received insulin daily during the seven-day review period. A review of Resident #11's Care Plan problem statement, with a start date of 07/12/2023, indicated the resident was at risk for potential signs and symptoms of hypoglycemia or hyperglycemia related to Diabetes mellitus. Approaches: direct staff to assess the resident's blood sugar by accucheck [Accu-Chek fingerstick blood glucose meter] and to notify the physician if the results were abnormal. A review of current physician's orders for Resident #11 indicated the resident had a physician's order, dated 01/04/2022, for Glipizide 10 milligrams (mg), once daily, and a physician's order, dated 07/23/2023, for Levemir (insulin detemir; a long-acting insulin), 15 units subcutaneously, at bedtime. The resident also had a physician's order, dated 06/12/2022, for insulin Lispro (a fast-acting insulin) based on a sliding scale. The sliding scale indicated that for a blood sugar of 151 to 200 mg/dL (milligrams per deciliter), staff were to administer 4 units of insulin; 201 to 250 mg/dL, 6 units of insulin; 251 to 300 mg/dL, 8 units of insulin; 301 to 350 mg/dL, 10 units of insulin; 351 to 400 mg/dL, 12 units of insulin; and if the blood sugar was greater than 400 md/dL, 20 units of insulin were to be administered. The physician's order indicated that Accu-Check blood sugar testing was to be completed before meals and at bedtime (6:30 AM, 10:30 AM, 4:30 PM, and 8:00 PM). A review of Resident #11's Medications Administration History records from March 2023 through August 2023 revealed the resident's blood sugar was greater than 400 mg/dL when obtained before meals and/or at bedtimes on the following dates: - March 2023: 03/02/2023, 03/03/2023, 03/07/2023, 03/10/2023, 03/15/2023, 03/16/2023, 03/21/2023, 03/22/2023, and 03/30/2023. The resident's blood sugar exceeded 500 mg/dL on 03/18/2023. - April 2023: 04/01/2023, 04/03/2023, 04/04/2023, 04/05/2023, 04/10/2023, 04/13/2023, 04/15/2023, 04/16/2023, 04/20/2023, 04/22/2023, 04/25/2023, 04/25/2023, 04/29/2023, and 04/30/2023. The resident's blood sugar exceeded 500 mg/dL on 04/06/2023, 04/17/2023, 04/19/2023 and 04/25/2023. - May 2023: 05/02/2023, 05/05/2023, 05/08/2023, 05/11/2023, 05/14/2023, 05/15/2023, 05/16/2023, 05/18/2023, 05/23/2023, 05/24/2023, 05/25/2023, 05/26/2023, 05/27/2023, 05/28/2023 and 05/31/2023. On the following days the resident's blood sugar exceeded 500 mg/dL: 05/01/2023, 05/06/2023, 05/07/2023, 05/12/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 05/22/2023. - June 2023: 06/01/2023, 06/02/2023, 06/06/2023, 06/07/2023, 06/08/2023, 06/10/2023, 06/12/2023, 06/14/2023, 06/17/2023, 06/18/2023, and 06/19/2023. On 6/17/2023 the resident's blood sugar before the evening meal (4:30 PM) was 500 mg/dL and at bedtime (8:00 PM) the blood sugar was High. - July 2023: 07/03/2023, 07/05/2023, and 07/15/2023. The resident's blood sugar exceeded 500 mg/dL on 07/01/2023. - August 2023: 08/06/2023, 08/11/2023, 08/12/2023, 08/26/2023, 08/29/2023, 08/30/2023, and 08/31/2023. A review of progress notes and medication administration records from March 2023 through August 2023, indicated the resident's physician was not notified of blood sugar levels greater than 400 mg/dL. A telephone interview was held with Licensed Practical Nurse (LPN) #5, who no longer worked at the facility, on 09/01/2023 at 9:37 AM. LPN #5 indicated that when he was employed at the facility, he provided care that included blood sugar testing and insulin administration for Resident #11. LPN #5 stated blood sugar test results were reported to a resident's physician according to the parameters set by the physician and added that in the absence of parameters, he would report a blood sugar greater than 400 mg/dL unless that was a normal blood sugar for the resident. LPN #5 stated communication with a physician regarding high blood sugars was documented in the progress notes or on the back of the medication administration record. LPN #5 stated Resident #11's physician had not set any parameters for notification related to high blood sugar. LPN #5 stated he had not reported Resident #11's blood sugar test results that exceeded 400 mg/dL because the resident's physician had not set parameters, and since there were no parameters, he was not required to report the blood sugars. LPN #8 was interviewed on 09/01/2023 at 10:37 AM. LPN #8 stated that when she completed blood sugars testing, if the blood sugar was greater than 400 mg/dL she called the physician. The LPN stated if the resident had no parameters set, she would use her nursing judgement and still call the physician. A telephone interview was held with the Medical Doctor (MD) on 09/01/2023 at 11:07 AM. The MD stated he expected to be notified of any blood sugar that was greater than 400 mg/dL, whether there was an order or not. The MD stated he was unsure if he had been called regarding Resident #11's blood sugar test results, since he did not have the resident's chart available. The MD stated he had just assumed care of Resident #11 and his focus was on trying to maintain the resident's mentation that was affected by the resident's ammonia level and added he had not really had time to assess the resident's blood sugar. The MD stated Resident #11 had not been hospitalized due to hyperglycemia. The Director of Nursing (DON) was interviewed on 09/01/2023 at 12:34 PM and stated she expected documentation of staff conversations with the physicians to be in the progress notes. The DON reviewed the blood sugar values for Resident #11 and stated she expected the nurses to report any blood sugars greater than 400 mg/dL. The DON stated she was unaware the resident's elevated blood sugars were not being reported to the physician. 2. A review of the Resident Face Sheet indicated the facility admitted Resident #12 on 10/06/2021 with diagnoses that included Type 2 diabetes mellitus with hyperglycemia. A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, indicated Resident #12 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The MDS indicated Resident #12 was independent with locomotion on and off the unit and eating, required supervision for bed mobility, transfers, dressing, and toilet use, and required limited assistance from staff for personal hygiene. The MDS indicated Resident #12 received insulin daily during the seven-day review period. A review of Resident #12's Care Plan problem statement, with a start date of 07/12/2023, indicated the resident was at risk of complications related to diabetes. Approaches directed staff to observe for signs of hyperglycemia or hypoglycemia and to notify the physician of abnormal blood sugar results. A review of current physician's orders indicated Resident #12 had a physician's order, dated 02/04/2022, for glyburide 1.25 milligrams (mgs), daily, and a physician's order, dated 08/23/2023, for Lantus insulin glargine (a long-acting insulin) 15 units, subcutaneously, twice a day. The physician's order indicated that Accu-Chek blood sugar testing was to be completed before meals and at bedtime (6:30 AM, 10:30 AM, 4:30 PM, and 8:00 PM). A review of Resident #11's Medications Administration History records from March 2023 through August 2023 revealed the resident's blood sugar was greater than 400 mg/dL when obtained before meals and/or at bedtimes on the following dates: - March 2023: 03/19/2023. - April 2023: 04/01/2023. On 04/10/2023 the resident's blood sugar exceeded 500 mg/dL. - May 2023: 05/31/2023. On 05/04/2023 the resident's blood sugar exceeded 500 mg/dL before the evening meal at 4:30 PM and before bedtime at 8:00 PM. - June 2023: 06/21/2023 and 06/28/2023. - July 2023: 07/03/2023, 07/05/2023, 07/09/2023, 07/11/2023, 07/13/2023, 07/14/2023, 07/17/2023, 07/22/2023, 07/27/2023 and 07/28/2023. On 07/09/2023 the resident's blood sugar exceeded 500 mg/dL. - August 2023: 08/01/2023, 08/02/2023, 08/03/202, 08/04/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/15/2023, 08/16/2023, 08/18/2023, 08/20/2023, 08/21/2023, 08/26/2023, and 08/30/2023. A review of progress notes and medication administration records from March 2023 through August 2023, indicated the resident's physician was not notified of blood sugar levels greater than 400 mg/dL. A telephone interview was held on 09/01/2023 at 9:37 AM with Licensed Practical Nurse (LPN) #5, who no longer worked at the facility. LPN #5 indicated that when he was employed at the facility, he provided care that included blood sugar testing and insulin administration for Resident #12. LPN #5 stated blood sugar test results were reported to a resident's physician according to the parameters set by the physician and added that in the absence of parameters, he would report a blood sugar greater than 400 mg/dL unless that was a normal blood sugar for the resident. LPN #5 stated communication with a physician regarding high blood sugars was documented in the progress notes or on the back of the medication administration record. LPN #5 stated it was not unusual for Resident #12's blood sugar to be high, and the Medical Doctor (MD) knew this and had not wanted to be notified. LPN #5 stated he had not reported the elevated blood sugars since Resident #12's orders did not include parameters for reporting. LPN #5 said without the parameters there was no indication that elevated blood sugars needed to be reported. LPN #8 was interviewed on 09/01/2023 at 10:37 AM. LPN #8 stated that when she completed blood sugars testing, if the blood sugar was greater than 400 mg/dL she called the physician. The LPN stated if the resident had no parameters set, she would use her nursing judgement and still call the physician. A telephone interview was held with the MD on 09/01/2023 at 11:07 AM. The MD stated he expected to be notified of any blood sugar that was greater than 400 mg/dL whether there was an order or not. The MD stated he was unsure if he had been called regarding Resident #12's blood sugar test results, since he did not have Resident #12's chart available. The MD added that Resident #12's blood sugar had been difficult to control, and he had adjusted the resident's insulin. The MD stated Resident #12 had not been hospitalized due to high blood sugar levels. The DON was interviewed on 09/01/2023 at 12:34 PM and stated she expected the nurses to report any blood sugar result greater than 400 mg/dL and document the notification in the progress notes. The DON stated she was unaware the resident's elevated blood sugars were not being reported to the physician.

Based on review of facility policy, medical record review, and interview, the facility failed to provide a stop date for an antidepressant for 1 resident (#30) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Medication Utilization and Prescribing-Clinical Protocol, dated December 2018, showed .[MEDICAL CONDITION] medications that are ordered PRN (as needed) will have a 14 day stop date and reevaluated by PCP (primary care physician) or MD (medical doctor) . Resident # 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a faxed physician's order dated 3/2/2020 showed [MEDICATION NAME] (an antidepressant used to treat anxiety) 50 milligrams (mg) every 6 hours as needed (PRN) for anxiety. Medical record review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 3/18/2020 at 8:30 AM, confirmed the [MEDICATION NAME] order did not have a stop date. The DON stated PRN [MEDICAL CONDITION] medications were to have a 14 day stop date.

Based on review of facility policy, medical record review, review of facility investigation witness statements, and interviews the facility failed to prevent abuse for 1 resident (#1) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Resident Abuse, revised 11/14/2018 revealed .The right to be free from verbal, sexual, physical and mental abuse . Medical record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set assessment dated (MDS) 11/15/2019 showed Resident #1 had severe cognitive impairment, had no physical, verbal, or behavioral symptoms directed toward others, and required assistance of one or more persons with activities of daily living (ADL's). Medical record review showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS assessment dated [DATE] showed Resident #2 had severe cognitive impairment, was rarely/never understood and had continuous disorganized thinking. Resident #2 required supervision with walking in his room and in the corridor and required assistance of one or more persons with all other ADL's. Review of Resident #2's current Comprehensive Care Plan revealed .resident may have fluctuation in mood and behavior problems r/t (related to) becomes agitated . Medical record review showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS assessment dated [DATE] revealed Resident #3 had moderate cognitive impairment. Review of the facility investigation revealed a witness statement by Physical Therapy Assistant #1 dated 11/4/2019, .I heard the sound of someone hitting the floor nearby. Walked up on (Resident #1) laying on the floor on his L (left) side, kicking at (Resident #2) who was standing over him . A witness statement by the Director of Nursing (DON) revealed Resident #3 stated Resident #2 was in the hall and went up to Resident #1 and hit him. Review of an Incident Note by the DON on 11/4/19 revealed .When asked resident (Resident#1) what happened he stated, I got into a fight with that man (Resident #2) and I fell trying to hit him (Resident #2). Another resident (Resident #3) states that resident (Resident #1) .hit this resident (Resident #2) and then this resident (Resident #2) attempted to retaliate and fell .resident has half dollar size abrasion to left elbow area .Resident (Resident #2) assisted back to wheelchair and removed from the immediate area of the other resident (Resident #1) for safety: MD of other resident (Resident #1) notified for further orders . Review of a Behavior Note by Licensed Practical Nurse (LPN) #1 dated 11/4/2019 revealed .notified by CNA (Certified Nurse Aide #1) that resident (Resident #2) started yelling at another resident (Resident #1) becoming physically aggressive .witnessed by another resident (Resident #3) which reported this resident (Resident #2) had hit and pushed a man (Resident #1) in his w/c (wheel chair) . Interview with CNA #1 on 1/15/2020 at 10:25 AM, revealed on 11/4/2019 she heard someone yell for help by the nurse's station. She observed Resident #1 on the floor. Resident #1 seemed upset and told her to make sure that man (Resident #2) stayed away from him. Interview with the DON on 1/15/2020 at 10:33 AM, revealed Resident # 2 had been more agitated on 11/4/2019. Resident #1 had been observed lying on the floor on 11/4/2019 with Resident #2 standing near Resident #1. In summary, Resident #2 was on 1:1 behavior monitoring prior to incident on 11/4/19 related to agitation. The incident was observed by Resident #3 as per interview by the Assistant Director of Nursing. Resident #1 was found on the floor after the incident by facility staff and was moved from the immediate area for safety concerns.

Based on facility policy review and interview, the facility failed to implement an Antibiotic Stewardship program for 48 residents of 48 residents residing in the facility. The findings include: Review of facility policy Antibiotic Stewardship Policy and Procedures, undated, revealed .Objective .To collect, document, and analyze antibiotic usage and outcome data .This data will be used to guide decisions for improvement of individual resident antibiotic use . Interview with the facility's Infection Preventionist (IP) on 3/5/19 at 10:02 AM, in the IP's office, confirmed the facility had not implemented an antibiotic stewardship program. Interview with the Director of Nursing on 3/5/19 at 10:36 AM, in the Administrator's office, confirmed the facility failed to implement an antibiotic stewardship program.

Based on review of facility policy, observation, and interview, the facility failed to follow infection control practices for urinary catheter care for 1 resident (#4) of 7 residents reviewed with an indwelling urinary catheter of 48 residents residing in the facility. The findings include: Review of facility policy Insertion of Urinary Catheter, undated, revealed .3. Foley (urinary catheter) drainage bag and/or tubing is not allowed to touch the floor at any time . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident 4's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). Further review revealed the resident had an indwelling urinary catheter. Observation of Resident #4 on 3/3/19 at 2:03 PM, in the resident's room, revealed the resident was sitting in her wheelchair and the urinary catheter tubing was touching the floor. Observation of Resident #4 on 3/4/19 at 5:17 PM, in the resident's room, revealed the resident was sitting in her wheelchair and the urinary catheter tubing was touching the floor. Interview with Licensed Practical Nurse #2 on 3/4/19 at 5:18 PM, in the resident's room, confirmed .It's (Resident #4's urinary catheter tubing) on the floor . Interview with Director of Nursing on 3/05/19 at 10:14 AM, in the conference room, confirmed the facility failed to ensure Resident #4's urinary catheter tubing was not touching the floor and the facility failed to follow facility policy.

Based on review of the facility's Payroll-Based Journal Worksheet the facility failed to provide the services of a Registered Nurse (RN) for the minimum requirement of 8 hours per day on 40 days (between the period of 4/1/18 and 1/14/19) of 289 days reviewed. The findings included: Review of a Payroll-Based Journal Worksheet dated 4/1/18 through 1/14/19 revealed no RN services were provided on 4/14-15/18, 4/28-29/18, 5/26-27/18, 6/9/18, 6/23-24/18, 7/7-8/18, 7/15/18, 7/21-22/18, 8/4-5/18, 8/18-19/18, 9/2/18, 9/16/18, 9/29/18, 10/13-14/18, 10/15-20/18, 10/27-28/18, 11/11/18, 11/24/18, 12/8-9/18, 12/22-23/18, 1/6/19, and 1/12/19. Continued review revealed RN coverage was only provided for 5.5 hours on 4/22/18. Interview with the Director of Nursing on 1/29/19 at 2:55 PM, in the conference room, confirmed the facility failed to meet the minimum requirement of 8 hours of RN coverage per day on 40 days between the period of 4/1/18 and 1/14/19.

Based on review of facility policy, review of personnel files, and interviews, the facility failed to revise their abuse policy to meet federally required standards for screening potential employees, failed to complete Criminal Background Checks prior to employees providing direct patient care, and failed to obtain and document reference checks, in 8 of 8 personnel files reviewed. The findings included: Review of the facility policy Resident Abuse dated 4/18, revealed .Screening of new hires will include: A) A check of the licensing registry for reports of previous abuse. B) A reference check of previous employment will be completed . Review of the facility personnel files revealed the following: 1). Licensed Practical Nurse (LPN) #3 was hired on 8/9/18, Criminal Background Check was completed on 8/15/18. 2). Certified Nursing Assistant (CNA) #1 was hired on 10/15/18, Criminal Background Check was completed on 10/17/18. 3). CNA #6 was hired on 8/31/18, Criminal Background Check was completed on 10/1/18. 4). CNA #7 was hired on 8/31/18, Criminal Background Check was completed on 9/5/18. 5). CNA #8 was hired on 10/23/18, Criminal Background Check was completed on 11/2/18. 6). CNA #9 was hired on 10/8/18, Criminal Background Check was completed on 10/16/18. 7). CNA #10 was hired on 10/4/18, Criminal Background Check was completed on 10/15/18. 8). CNA #11 was hired on 10/4/18, Criminal Background Check was completed on 10/12/18. Continued review of personnel files, revealed no documentation references checks were obtained by the facility. Interview with the Assistant Director of Nursing on 11/6/18 at 2:40 PM, in the conference room, confirmed we initiate the Criminal Background Checks within 7 days of employment, the background checks are not completed prior to the employee providing direct patient care. Continued interview confirmed the facility had not revised their abuse policy to meet Federal Regulations for the screening process of potential employees. Interview with the Administrative Assistant/Chief Financial Officer, on 11/6/18 at 3:00 PM, in the conference room, confirmed the facility had no written documentation reference checks had been completed. Further interview confirmed Criminal Background Checks were not completed before employees were permitted to provide direct patient care. Interview with the Administrator on 11/7/18 at 11:30 AM, in the conference room, confirmed he was unaware Federal Regulations had been revised in regards to the screening process of potential employees. Continued interview confirmed the facility had not revised their abuse policy to meet federally required standards for screening potential employees, resulting in Criminal Background Check not being completed by the facility prior to employees providing direct patient care, and the facility had no documentation references checks had been obtained.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement falls interventions for 1 resident (#103) identified as high risk for falls of 5 residents reviewed for falls of 24 residents sampled. The findings included: Review of the facility's, FALLING STAR PROGRAM Policy, not dated, revealed, Purpose: To help identify and alert staff of those residents that are at risk for falls. Procedure: 1. Upon admit .Fall Risk Assessment will be completed .2. Review of the assessment will determine if resident is placed on the Falling Star Program. 3 .implement the Falling Star Program by placing a star on the name sign of resident's room. The star will alert staff to monitor frequently for safety and intervene if needed . Medical record review of the office/outpatient visit report dated 2/21/18 revealed, .left the hospital yesterday and is not eating or drinking, complains of hurting all over .not at her mental baseline and is very uncooperative .Current Problems: Dehydration, Panic Attack, At risk for falling .gait unsteady and having to be led in the office .I'm going to put her back in the hospital and start IV antibiotics ad do swing bed to get her physical strength built back up . Medical record review revealed Resident #103 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #103 scored a 10 on the facility's Falls Risk assessment dated [DATE] where a score of 10 or above represents High Risk (for falls). Medical record review of the Nurses Notes dated 3/7/18, 9:00 AM, revealed, called to room per maintenance upon entering room observed resident (#103) sitting on buttock facing the foot of the bed .(sign for with) hands on foot board W/C (wheelchair) sitting beside resident when ask what she was doing she state she thought she could walk and she was going to walk and get her shawl and have husband take her home . Observation of the resident's name sign, outside the door of her room, on 3/12/18 at 11:15 AM, revealed there wasn't a star beside her name indicating the Falling Star Program had been implemented. Observation and interview with Resident #103 on 3/12/18 at 11:29 AM, in the resident's room, revealed she was seated in a wheelchair (w/c), holding her denture cup. Interview revealed she had fallen .a few days after .got here . and she volunteered the house shoes on her feet were slick on the bottom and her husband was going to bring other shoes. Interview with Registered Nurse (RN) #1, also the Minimum Data Set (MDS) Coordinator, on 3/12/18 at 12:05 PM, in the ABC nursing station, confirmed the Admission Care Plan had not identified Resident #103 as high risk for falls and had not initiated interventions on the care plan before or after the fall on 3/7/18. Continued interview confirmed, .We are all responsible to update the care plan . Medical record review of the Nurses Notes dated 3/13/18, at 12:20 AM, revealed, Called to room d/t (due to) res (resident) yelling out. Upon entering room observed res lying stretched out straight on R (right) side waving her L (left) arm in air on floor between her bed et (and) window .when asked her what happened she states she rolled out of bed while dreaming . Interview with Resident #103 on 3/13/18, at 3:15 PM, in the resident's room, revealed the resident spoke of rolling out of her bed during the night, I must have been dreaming .I haven't done anything like that since I was a kid . Interview with LPN #1 on 3/13/18 at 3:25 PM, at the ABC nursing station, confirmed the resident had fallen on the night of 3/13/18 at 12:20 AM .nightshift had reported the fall, and she had .put a call into her (the resident's) husband. Interview and observation with the Assistant Director of Nurses (ADON) on 3/13/18 at 3:35 PM, in the ABC nursing station, confirmed Resident #103 did not have the Falling Star Program implemented by placing a star on the name sign of the resident's room. Interview continued with concurrent review of the Patient Care Record provided to the CNA's, and confirmed information related to the resident's footwear, the evaluation of the resident as high risk for falls, and information related to the 2 recent falls was not provided. Interview with the DON and ADON on 3/14/18 at 2:10 PM, in the conference room, confirmed the required signage to alert the staff of residents who are high risk for falls had not been placed on the name sign outside the room for Resident #103. Interview confirmed the facility failed to develop and implement interventions to prevent falls for Resident #103.

Based on facility policy review, medical record review, observation and interview, the facility failed to revise a comprehensive care plan for 1 Resident (#23) of 24 residents reviewed for care plans. The findings included: Review of the facility policy of the MDS (Minimum Data Set) Assessment and Care Plan Policy, undated, revealed .ensure each resident assessment and care plan is performed and reviewed to adhere to CMS (Centers for Medicare and Medicaid Services) guidelines .Updates/changes to be made to care plan as needs of resident identified . Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician Transfer Orders dated 12/29/17, revealed Resident #23 was ordered oxygen at 2 liters/minute PRN (as needed). Medical record review of the Comprehensive Care Plan revised on 1/10/18, 1/17/18 and 1/31/18, revealed the care plan was not revised to include Resident #23's supplemental oxygen therapy. Medical record review of the Monthly Summary and Pain assessment dated [DATE] and 2/14/18 revealed, .Special Care Issues .Oxygen . Medical record review of Medication Administration Record [REDACTED]@ (at) 2L (2 Liters) PNC (per nasal cannula) PRN (as needed) . Continued review of the MAR indicated [REDACTED]. Observations on 03/13/18 at 8:05 AM and 9:11 AM, in the resident's room, revealed Resident #23's oxygen was set at 4.5 liters per minute by nasal cannula. Interview with RN #1 on 3/14/18 at 2:04 PM, in the MDS office, confirmed .oxygen should be on the care plan . Continued interview revealed the facility failed to revise the comprehensive care plan.

Based on medical record review, observation, and interview, the facility failed to provide an Admission Care Plan (baseline care plan) that included risk for falls for 1 resident (#103) of 5 residents reviewed for falls of 24 residents sampled. The findings included: Medical record review revealed Resident #103 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the History and Physical dated 2/21/18 revealed, .left the hospital yesterday and is not eating or drinking, complains of hurting all over .not at her mental baseline and is very uncooperative .Current Problems: Dehydration, Panic Attack, At risk for falling .gait unsteady and having to be led in the office . Medical record review revealed Resident #103 scored a 10 on the facility's Falls Risk assessment dated [DATE], and revealed, .score of 10 or above represents High Risk (for fall). Medical record review of the resident's Admission Care Plan, completed on 3/6/18, revealed the care plan did not include a problem of Fall Risk. Observation and interview with Resident #103 on 3/12/18 at 11:29 AM, in the resident's room, revealed she was seated in a wheelchair (w/c), holding her denture cup. Interview revealed she had fallen .a few days after .got here . and she volunteered the house shoes on her feet were slick on the bottom and her husband was going to bring other shoes. Continued interview revealed the resident was unaware of a pair of shoes with nonskid soles at her bedside. Interview with Licensed Practical Nurse (LPN) #1 on 3/12/18 at 11:50 AM, at the ABC nursing station, confirmed the resident had fallen in her room on 3/7/18. Interview with Registered Nurse (RN) #1, also the Minimum Data Set (MDS) Coordinator, on 3/12/18 at 12:05 PM, in the ABC nursing station, confirmed the Admission Care Plan had not identified Resident #103 as high risk for falls and the nursing staff had not initiated interventions on the care plan before or after the fall on 3/7/18.

Based on facility policy review, medical record review, observation and interview, the facility failed to provide the necessary care and services to ensure oxygen therapy was administered as ordered for 1 Resident (#23) of 5 residents reviewed for oxygen therapy of 24 residents sampled. The findings included: Review of the facility's policy Nursing Round Communication Policy, undated, revealed .At the end of each shift .Each nurse will be responsible for communicating .care of the residents and/or specific needs . Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Transfer Orders dated 12/29/17 revealed, .02 (oxygen) @ (at) 2Lmin (2 liters per minute) PRN (as needed) . Medical record review of the Physician order [REDACTED].#23 had an order for [REDACTED]. Medical record review of Medication Administration Record [REDACTED]@ (at) 2L (2 Liters) PNC (per nasal cannula) PRN (as needed) . Observations on 03/13/18 at 8:05 AM and 9:11 AM, in the resident's room, revealed Resident #23's oxygen was set at 4.5 liters per minute by nasal cannula. Observation and Interview with the Director of Nursing (DON) on 3/13/18 at 10:48 AM, in Resident #23's room, confirmed the resident was on 4.5 liters per minute. Continued interview confirmed .it should be less than that . Interview with the DON on 3/13/18 at 10:50 AM, at the ABC nursing station, confirmed the oxygen was ordered for 2 liters per minute. Continued interview revealed the facility failed to ensure oxygen therapy was administered as ordered.

Based on policy review, observation, and interview, the facility failed to maintain food preparation equipment in a clean and sanitary manner for 4 of 9 steam table pans, 1 of 1 can opener, 2 of 2 deep fryer baskets, and 1 of 2 ice machines; failed to date stored food that had been opened; and failed to wear a hair restraint while serving food on the tray line. The findings included: Review of facility policy Sanitation and Safety Procedure, undated revealed, .The dietary manager ultimately is responsible for the supervision of all sanitation and housekeeping procedures to maintain an environment that is safe for the storage, preparation, and service of food. Federal and state guidelines are followed .All dishes, pots and pans .are properly cleaned and sanitized and are handled by methods that are compatible with the long term care regulations . Review of facility policy Administration and Personnel Procedure, undated revealed, .Hair cover, covering all hair, must be worn at all times by employees .The dietary department must be kept clean and sanitary at all times . Observation on 1/30/17 at 9:17 AM, in the dietary department walk-in refrigerator with the Dietary Manager (DM) present revealed one ten pound bag of sliced pepperoni, approximately 25% used, was not dated. Further observation revealed one five pound bag of cooked Italian sausage, approximately 50% used, was not dated. Interview with the DM on 1/30/17 at 9:18 AM, in the dietary department walk-in refrigerator confirmed the facility failed to date the open bags of pepperoni and Italian sausage. Observation on 1/30/17 at 1:35 PM, in the dietary department with the DM present, revealed the ice machine with dried debris on the exterior of the sliding cover and on the interior sliding tracks. Further observation revealed dried debris on two of five, 2 ½ quart steam table pans and on two of four, 4 ½ quart steam table pans on the clean storage rack and ready for use. Continued observation revealed the can opener attached to the table with dried tan sticky debris on the blade and on the slot. Further observation revealed dried debris on 2 of 2 deep fryer baskets sitting on top of the deep fryer ready for use. Interview with the DM on 1/30/17 at 1:50 PM, in the dietary department office, confirmed the facility failed to maintain the food preparation equipment in a clean and sanitary manner. Observation on 1/31/17 at 6:40 AM, in the dietary department, revealed the DM was serving food from the steam table and was not wearing a hair restraint. Continued observation revealed the DM continued filling breakfast trays until completion of all trays at 7:10 AM. Interview with the DM on 1/31/17 at 7:12 AM, in the dietary department, confirmed she had failed to wear a hair restraint while serving breakfast trays and stated I forgot. Observation on 1/31/17 at 9:06 AM, with Licensed Practical Nurse (LPN) #6 in the front nourishment room that served A,B,C halls, revealed 4 different types of cereal in 4 separate plastic containers that were not dated. Observation on 1/31/17 at 9:10 AM, in the dietary department with the DM present, revealed 4 different types of cereal in 4 separate plastic containers that were not dated. Interview with the DM on 1/31/17 at 9:12 AM, in the dietary department, confirmed the facility failed to date the cereal containers in the front nourishment room and in the dietary department.

Based on facility policy review, observation, and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly interior for 33 of 63 resident rooms, 4 of 8 shower rooms,1 of 2 dining rooms, and 2 of 5 hallways. The findings included: Review of facility policy, Housekeeping Daily Cleansing and routine care of rooms and social areas, undated revealed, .PURPOSE: To achieve a clean environment to help prevent the spread of microorganisms .OPERATIONAL DIRECTIVES: Routine cleaning of environmental surfaces and non-critical patient care items should be performed according to a predetermined schedule .Surfaces that are frequently touched by the hands of health care providers and residents, such as nurse call systems, surfaces of medical equipment and knobs for adjustment or opening require frequent cleaning . Review of facility policy, Maintenance Department Policy and Procedures, undated revealed, .Direct and coordinate the operations and activities of the facility maintenance, including but not limited to: .buildings and grounds maintenance .environmental compliance .Maintenance manager will assure that all request for repairs are reviewed and completed repair in a timely manner. Staff will complete a request for repair sheet that is located at each nurses station .Maintenance staff will review and repair request .This includes resident rooms, social areas, any restroom, spas .Repairing of facility structures .Flooring repairs . Observations by the survey team from 1/30/17 to 2/1/17 included the following: 1. Baseboards discolored yellow/brown in 18 resident rooms. 2. Floor tile loosened in 4 resident rooms. 3. Yellow/tan debris around faucet and handle bases in 13 resident restrooms. 4. Scuff marks on lower walls in 28 resident rooms. 5. Torn sheetrock in 7 resident rooms. 6. Shower Room, A Hall - Heater beside the shower was rusty with a hole near the base of the heater nearest the shower; toilet seat with black marks; paint peeling on the ceiling. 7. Shower Room, B Hall - Black marks on the toilet, paint peeling on the ceiling, paint peeling on the door and door frame was rusted. 8. Shower Room, C Hall - loose toilet seat, black marks on the toilet; missing tile near the tub. 9. Shower Room, D Hall - rusted cabinet and shelves containing supplies for residents. 10. Hallway C near the A/B/C nurses station - torn and peeling wallpaper. 11. Hallway C near the D Nurses Station extending from the front of the D Nurses Station to room D6 - floor tiles were chipped and curling at the corners and edges. 12. Dining Room D - torn sheetrock with tears and unpainted patched hole near the entrance door from D hall, baseboards with yellow/brown discoloration with debris. Interview on 2/1/17 at 11:30 AM, with the Maintenance Supervisor and the Housekeeping Supervisor in the hall near the A/B/C nurses station confirmed all of the noted environmental observations. The Maintenance Supervisor and the Housekeeping Supervisor confirmed the facility had failed to maintain a sanitary and orderly interior.

Based on policy review, observation, and interview, the facility failed to maintain the dumpster in a sanitary condition, easily cleanable, covered and water tight. The findings included: Review of facility policy, Sanitation and Safety Procedure, undated revealed, .Garbage and waste are disposed of promptly and properly . Observation on 1/30/17 at 1:55 PM, at the outside dumpster behind the dietary department with the Dietary Manager (DM) present, revealed a white to tan colored liquid leaking from the dumpster and pooled on the pavement around the dumpster. Continued observation revealed five large cardboard boxes had been flattened and were lying on the pavement around the dumpster. Further observation of the dumpster revealed the dumpster was rusted with scattered holes on the exterior perimeter. Continued observation revealed the dumpster had a two part lid, the lid was missing on one side of the dumpster and the other side was broken. Interview with the DM on 1/30/17 at 1:57 PM at the outside dumpster confirmed the facility had failed to maintain the dumpster in a sanitary condition, covered, and water tight.