Every finding on record at Magnolia Manor of Marion County

Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive care plan related to fall prevention and contracture management for two residents (R) (R9 and R16) from a sample of 29 residents. The deficient practice had the potential to prevent residents from reaching their highest practicable level of functioning and compromise resident safety. Findings include:1. Review of R9's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R9 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia with agitation, diabetes, and peripheral vascular disease.Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/25 and located under the RAI [Resident Assessment Instrument] tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated moderate cognitive impairment. Review of R9's Care Plan dated 07/19/2025 revealed, [R9] has history of falling, prior to admission R/T [related to] low b/p [blood pressure]. She continues to be at risk for falls, no safety awareness, impaired mobility, impaired cognition. The approaches included, Replace non-skid socks in room with slip grip socks [and] provide proper, well-maintained footwear. Review of R9's Event Reports provided on paper by the Administrator revealed the following falls, without any injuries, over the past six months:1. On 07/16/2025, R9 fell in her room and had regular socks on. The intervention was, Replace regular socks with non-slip socks.2. On 07/19/2025, R9 fell in her room and had bare feet. Her non-slip socks were in her hand. The intervention was provide assistance to the bathroom at 5:00 AM. 3. On 07/29/2025, R9 fell in her room and had bare feet. The intervention was to apply non-skid strips to the floor next to her bed.4. On 11/18/2025, R9 fell in her room. She did not have non-slip socks on and the grip strips on the floor had decreased grip. The intervention was to replace the non-skid tape on the floor.5. On 01/21/2026, R9 fell in her room when she attempted to walk independently and her feet got tangled. No new interventions had yet been implemented as the investigation was still open. During an observation and interview on 01/27/2026 at 11:38 AM in R9's room, R9 was seated in her wheelchair behind the curtain, not visible from the doorway. She had regular socks on without non-slip strips. She stated she had just taken a shower, and the staff had put the socks on her. R9 was not wearing shoes. R9 stated she needed non-slip socks, so she did not fall. During an observation and interview on 01/27/2026 at 2:19 PM in R9's room, R9 was again seated in her wheelchair behind the curtain. She had regular socks on without non-slip strips and was not wearing shoes. R9 confirmed she was not wearing non-slip socks.During an observation and interview on 01/28/2026 at 8:50 AM in R9's room, R9 was lying in bed behind the curtain. She was wearing regular socks without non-slip strips. R9 confirmed she was not wearing non-slip socks and stated she would like them to be changed to the socks with the non-slip strips to prevent her from falling. During an interview on 01/28/2026 at 3:36 PM, Certified Nurse Aide (CNA) 3 stated R9's fall prevention measures included proper footwear and/or non-slip socks. During a concurrent observation in R9's room, CNA3 confirmed R9 was not wearing socks with non-slip grips and she should be. CNA3 found a pair of non-slip socks in R9's dresser and changed her socks. CNA3 stated the non-slip socks should be on whenever the resident was in bed and the resident should have shoes on when up in her wheelchair. During an interview on 01/29/2026 at 11:10 AM, CNA2 stated R9 was impulsive and had a tendency to get up independently no matter how many times she was reminded to call for help. CNA2 stated R9 should be wearing shoes while up in her wheelchair and should have non-slip socks on all other times. During an interview on 01/29/2026 at 1:42 PM, Unit Manager (UM) 2 stated R9's fall prevention measures included the use of non-slip socks in addition to the non-skid strips on the floor. UM2 confirmed the floor strips did not have much grip to them.Review of the facility's policy titled, Fall Management dated September 2014 documented, Resident's at high risk will be placed on a fall management program and appropriate interventions put into place as indicated by assessment. 2. Review of R16's Face Sheet located in the electronic medical records (EMR) under the Resident tab indicated an admission date of 12/14/2022, with diagnoses of but not limited to chronic kidney disease and type 2 diabetes.Review of R16's annual Minimum Data Set (MDS) located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 12/05/2025 indicated a Brief Interview for Mental Status (BIMS) score of two which indicated severe cognitive impairment.Review of R16's annual Care Area Assessment (CAA) located in the EMR under the RAI tab with an assessment date of 11/19/2025, documented the resident was at risk for functional decline because of contractures.Review of R16's Care Plan located in the EMR under the RAI tab revealed no mention of R16's right hand contracture.During an interview and observation on 01/26/2026 at 3:10 PM, R16 had her index through her little finger, on her right hand, in a contracted position, with her four fingers bent and her fingernails touching her palm. She stated she could not open any finger and wished she could open them. During an interview on 01/28/2026 8:50 AM, R16 stated she could not use any of the finger on her right hand, they are just stuck like that, so I do what I can. During an interview on 01/28/2026 at 9:43 AM, with Certified Nurse Aide (CNA) 2 who stated she remembered when R16 had a splint for her right hand. She stated she had not seen one in the last two years. CNA2 stated they are not currently doing anything for R16's contracture. During an interview on 01/28/2026 at 9:49 AM, with the Restorative Aide (RA) confirmed she remembered R16 used to have a splint but did not any longer. The RA stated currently they are not doing anything with her right hand. During an interview 01/28/2026 at 9:53 AM, the Director of Rehab (DOR) stated they would only screen a resident if there was a referral from nursing. She stated that she remembered when R16 had a splint, but she would decline wearing it. The DOR confirmed R16 had not received therapy services since that time. During an interview on 01/28/2026 at 9:58 AM, the Director of Nursing (DON) and the Assistant Director of Nursing (DON) stated that the contracture was documented on the quarterly nursing assessment. The DON stated the contracture should also be on the care plan and include interventions that indicated the contracture should be reassessed quarterly for pain and cleanliness as well as determine if the splint should be reconsidered based on R16's compliance. During an interview on 01/28/2026 at 10:30 AM, with the MDS Coordinator (MDSC) who stated with a contracture she would determine if the resident had splints or had refused. She stated that the contracture and the interventions should be on the care plan and confirmed currently there was nothing. She stated it was important to monitor the contracture to ensure it was not getting worse. The MDSC confirmed there was currently nothing in place to assess the contracture.

Based on record review, interview, and document review, the facility failed to ensure medications were held according to parameters ordered by the physician for one of five residents (R) (R9) reviewed for unnecessary medications. The deficient practice increased the potential risk of adverse clinical outcomes.Findings include:Review of R9's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed admitted to the facility on [DATE] with diagnoses including but not limited to essential primary hypertension, dementia with agitation, diabetes, and peripheral vascular disease.Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2025 and located under the RAI [Resident Assessment Instrument] tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated moderate cognitive impairment. Review of R9's Orders tab of the EMR revealed a physician's order dated 07/11/2025, for carvedilol (medication to lower blood pressure), 12.5 milligrams (mg) twice daily. The order documented, Hold for pulse less than 70 or SBP [systolic blood pressure] less than 120. Review of R9's Medication Administration Record (MAR) dated 12/01/2025 through 01/26/2026 and located under the Reports tab of the EMR revealed 25 doses of carvedilol were not documented as held when indicated by the physician-ordered parameters.1. On 12/03/2025, the PM dose was given with a SBP of 109 and pulse of 59.2. On 12/04/2025, the PM dose was given with a pulse of 54.3. On 12/05/2025, the AM dose was given with a SBP of 98 and pulse of 55.4. On 12/07/2025, the AM dose was given with a SBP of 109 and pulse of 64.5. On 12/08/2025, the AM dose was given with a SBP of 110 and pulse of 56.6. On 12/08/2025, the PM dose given with a pulse of 64.7. On 12/09/2025, the AM dose was given with a pulse of 60.8. On 12/09/2025, the PM dose was given with a pulse of 66.9. On 12/12/2025, the PM dose was given with a pulse of 61.10. On 12/13/2025, the AM dose was given with a SBP of 111 and pulse of 60.11. On 12/14/2025, the AM dose was given with a SBP of 106 and pulse of 60.12. On 12/16/2025, the AM dose was given with a pulse of 65.13. On 12/17/2025, the PM dose was given with a pulse of 68.14. On 12/20/2025, the PM dose was given with a pulse of 57.15. On 12/25/2025, the PM dose was given with a SBP of 118 and pulse of 58.16. On 12/26/2025, the AM dose was given with a SBP of 116 and a pulse of 66.17. On 12/26/2025, the PM dose was given with a SBP of 116.18. On 12/27/2025, the PM dose was given with a pulse of 64.19. On 12/28/2025, the PM dose was given with a SBP of 118.20. On 01/02/2026, the AM dose was given with a pulse of 50.21. On 01/03/2026, the PM dose was given with a SBP of 118 and pulse of 69.22. On 01/05/2026, the PM dose was given with a pulse of 66.23. On 01/12/2026, the AM dose was given with a pulse of 48.24. On 01/13/2026, the PM dose was given with a pulse of 65.25. On 01/17/2026, the PM dose was given with a pulse of 66.During an interview on 01/29/2026 at 1:52 PM, Unit Manger (UM) 2 stated this was a problem with the way the nurse input documentation on the MAR. UM2 stated even though if a nurse documented a medication was held, if the All Prepped and Given button was pressed rather than the Complete button, the MAR would not show the medication was held. UM2 stated she had reported this issue to the Director of Nursing (DON) but had not done any formal training with the nursing staff.During an interview on 01/29/2026 at 3:40 PM, the Director of Nursing (DON) stated she noticed the problem with medications appearing as if they were not held according to the ordered parameters and had discovered it was an issue with the nursing staff clicking the wrong button at the completion of medication administration. The DON stated the issue was followed by the facility's quality improvement committee from February 2025 to July 2025. She stated education was done with the staff along with MAR audits during that time. The DON stated she did not continue regular MAR audits but continued random checks, so in December 2025 she observed the same problem re-occurring. The DON stated she provided staff training on 12/19/2025, however there were no additional quality improvement activities to ensure compliance.Review of the facility's 12/29/2025 in-service record provided on paper by the DON revealed, It has been brought to our attention that medications are being signed in error due to a glitch in [the EMR]. Please ensure you are signing out refused medications first (separately from your prepped' medications). If meds are 'prepped' and 'not given' and you select 'all prepped given,' [the EMR] will sign all meds as administered, including those selected as 'not given.' Please ensure we are taking our time and being observant to ensure accurate documentation.

Based on observation, record review, and interviews, the facility failed to ensure one resident (R) (R16) from a sample of 29 residents received appropriate services for a contracture. This deficient practice had the potential for worsening contracture of the right hand and prevent maximum practicable level of function.Findings include:Review of R16's Face Sheet located in the electronic medical records (EMR) under the Resident tab indicated an admission date of 12/14/2022, with diagnoses of but not limited to chronic kidney disease and type 2 diabetes.Review of R16's annual Minimum Data Set (MDS) located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 12/05/2025 indicated a Brief Interview for Mental Status (BIMS) score of two which indicated severe cognitive impairment.Review of R16's annual Care Area Assessment (CAA) located in the EMR under the RAI tab with an assessment date of 11/19/2025, documented the resident was at risk for functional decline because of contractures.Review of R16's Care Plan located in the EMR under the RAI tab revealed no mention of R16's right hand contracture.During an interview and observation on 01/26/2026 at 3:10 PM, R16 had her index through her little finger, on her right hand, in a contracted position, with her four fingers bent and her fingernails touching her palm. She stated she could not open any finger and wished she could open them. During an interview on 01/28/2026 8:50 AM, R16 stated she could not use any of the finger on her right hand, they are just stuck like that, so I do what I can. During an interview on 01/28/2026 at 9:43 AM, with Certified Nurse Aide (CNA) 2 who stated she remembered when R16 had a splint for her right hand. She stated she had not seen one in the last two years. CNA2 stated they are not currently doing anything for R16's contracture. During an interview on 01/28/2026 at 9:49 AM, with the Restorative Aide (RA) confirmed she remembered R16 used to have a splint but did not any longer. The RA stated currently they are not doing anything with her right hand. During an interview 01/28/2026 at 9:53 AM, the Director of Rehab (DOR) stated they would only screen a resident if there was a referral from nursing. She stated that she remembered when R16 had a splint, but she would decline wearing it. The DOR confirmed R16 had not received therapy services since that time. During an interview on 01/28/2026 at 9:58 AM, the Director of Nursing (DON) and the Assistant Director of Nursing (DON) stated that the contracture was documented on the quarterly nursing assessment. The DON stated the contracture should also be on the care plan and include interventions that indicated the contracture should be reassessed quarterly for pain and cleanliness as well as determine if the splint should be reconsidered based on R16's compliance. During an interview on 01/28/2026 at 10:30 AM, with the MDS Coordinator (MDSC) who stated with a contracture she would determine if the resident had splints or had refused. She stated that the contracture and the interventions should be on the care plan and confirmed currently there was nothing. She stated it was important to monitor the contracture to ensure it was not getting worse. The MDSC confirmed there was currently nothing in place to assess the contracture.

Based on observation, interview, record review, and policy review, the facility failed to ensure identified fall prevention interventions were implemented for one of three residents (R) (R9) reviewed for falls. The deficient practice increased the risk of falls for R9.Findings include:Review of R9's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R9 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia with agitation, diabetes, and peripheral vascular disease.Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/25 and located under the RAI [Resident Assessment Instrument] tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated moderate cognitive impairment.Review of R9's Care Plan dated 07/19/2025 revealed, [R9] has history of falling, prior to admission R/T [related to] low b/p [blood pressure]. She continues to be at risk for falls, no safety awareness, impaired mobility, impaired cognition. The approaches included, Replace non-skid socks in room with slip grip socks [and] provide proper, well-maintained footwear. Review of R9's Event Reports provided on paper by the Administrator revealed the following falls, without any injuries, over the past six months:1. On 07/16/2025, R9 fell in her room and had regular socks on. The intervention was, Replace regular socks with non-slip socks.2. On 07/19/2025, R9 fell in her room and had bare feet. Her non-slip socks were in her hand. The intervention was to provide assistance to the bathroom at 5:00 AM. 3. On 07/29/2025, R9 fell in her room and had bare feet. The intervention was to apply non-skid strips to the floor next to her bed.4. On 11/18/2025, R9 fell in her room. She did not have non-slip socks on and the grip strips on the floor had decreased grip. The intervention was to replace the non-skid tape on the floor.5. On 01/21/2026, R9 fell in her room when she attempted to walk independently and her feet got tangled. No new interventions had yet been implemented as the investigation was still open. During an observation and interview on 01/27/2026 at 11:38 AM in R9's room, R9 was seated in her wheelchair behind the curtain, not visible from the doorway. She had regular socks on without non-slip strips. She stated she had just taken a shower, and the staff had put the socks on her. R9 was not wearing shoes. R9 stated she needed non-slip socks, so she did not fall. During an observation and interview on 01/27/2026 at 2:19 PM in R9's room, R9 was again seated in her wheelchair behind the curtain. She had regular socks on without non-slip strips and was not wearing shoes. R9 confirmed she was not wearing non-slip socks.During an observation and interview on 01/28/2026 at 8:50 AM in R9's room, R9 was lying in bed behind the curtain. She was wearing regular socks without non-slip strips. R9 confirmed she was not wearing non-slip socks and stated she would like them to be changed to the socks with the non-slip strips to prevent her from falling. During an interview on 01/28/2026 at 3:36 PM, Certified Nurse Aide (CNA) 3 stated R9'sfall prevention measures included proper footwear and/or non-slip socks. During a concurrent observation in R9's room, CNA3 confirmed R9 was not wearing socks with non-slip grips and she should be. CNA3 found a pair of non-slip socks in R9's dresser and changed her socks. CNA3 stated the non-slip socks should be on whenever the resident was in bed and the resident should have shoes on when up in her wheelchair. During an interview on 01/29/2026 at 11:10 AM, CNA2 stated R9 was impulsive and had a tendency to get up independently no matter how many times she was reminded to call for help. CNA2 stated R9 should be wearing shoes while up in her wheelchair and should have non-slip socks on all other times. During an interview on 01/29/2026 at 1:42 PM, Unit Manager (UM) 2 stated R9's fall prevention measures included the use of non-slip socks in addition to the non-skid strips on the floor. UM2 confirmed the floor strips did not have much grip on them.Review of the facility's policy titled, Fall Management dated September 2014 documented, Resident's at high risk will be placed on a fall management program and appropriate interventions put into place as indicated by assessment.

Based on observations, staff interviews and review of the facility's policy titled, Pureed Food Preparation, the facility failed to ensure the nutritional value of meat during the pureed process. Specifically, the facility failed to follow the recipe by not measuring all ingredients while pureeing meat. The deficit practice had potential to place 16 of 16 residents who received a pureed diet at risk of decreased nutritional intake. Finding included: Review of the facility's undated policy titled, Pureed Food Preparation revealed, Facility will prepare pureed foods in a manner that sustains nutritional value and taste. The foods will be pureed to assure the desired consistency. Procedure: Pureed foods will be made from regular menu items to assure similar taste and nutritional quality. Recipes for regular menu items will be followed during production. Puree procedures are as follows: 7. Please follow manufacturer's directions when adding thickeners to foods to assure proper consistency. An interview and observation on 1/15/2025 at 10:15 am with [NAME] AA revealed that she prepares pureed food for 16 residents. [NAME] AA did not follow the correct instructions per recipe as evidenced by pouring chicken base from the container without measuring it. [NAME] AA confirmed that she was supposed to follow instructions according to the recipe when preparing pureed food. An interview on 1/15/2025 at 10:35 am with the Certified Food Manager (CFM) confirmed that staff should follow recipe instructions when preparing pureed food for residents. An interview on 1/16/2025 at 9:48 am with the Register Dietitian (RD) revealed the cook should follow a recipe when preparing pureed food and if the recipe is not followed it could affect the nutritional value of the food. An interview on 1/16/2025 at 1:58 pm with the Administrator revealed he excepts the facility cooks to follow policy and procedure and follow the recipe for preparing pureed food.

Based on observations, staff interviews, and review of the facility's policy titled, Residents Rights/ Facility Responsibilities, the facility failed to provide a safe/clean/comfortable/homelike environment for six rooms of (49) rooms (Rm) (Rm 112, Rm 114, Rm 120, Rm 109, Rm 138b, and Rm 139). Specifically, Rm 112, Rm 114 and Rm 120 all had leaking faucets, Rm 138b had a broken bed side dresser, Rm 109 had a blown light bulb in the room, and Rm 139 had dirty blinds, and the air conditioning unit was discolored with a brown tent. Findings include: 1. Review of the facility's policy titled Residents Rights/ Facility Responsibilities with a revised date of 12/18/2023 revealed, Intent -It is the intent of [named facility] to ensure each resident is treated with respect and dignity and care, in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. We believe that such a program should include resident, family, and all employees of the nursing home. Resident Rights: The resident has the right to: 6. A safe, clean, comfortable, home-like environment and to receive treatment safely. An observation during screening on 1/14/2025 at 9:30 am; rooms [ROOM NUMBER]. All three rooms had a leaking faucet in the bathroom on the hot water side. Water was pooling on the top of the sink. An observation on 1/14/2025 at 9:33 am, on 1/15/2025 at 9:51 am, and on 1/16/2025 at 11:15 am revealed in Rm 138b a broken bedside dresser. An observation on 1/14/2025 at 9:42 am, on 1/15/2025 at 10:05 am, and on 1/16/2025 at 11:20 am revealed in the Rm 139, dirty blinds and air condition unit. An observation and interview during walking rounds on 1/16/2025 at 11:45 am with the Maintenance Director (MD) confirmed the leaking faucet in Rm 114, Rm 112 and Rm 120. Confirmed a broken bedside dresser in Rm 138b, a blown out light bulb in Rm 109, and confirmed dirty blinds and rusty/discolored air condition unit in Rm 139. The MD revealed the facility used TEL's system, he was not aware of the identified concerns needing repair. An interview on 1/16/2025 at 1:58 pm with the Administrator revealed he has been working at the facility since December 2023, all staff have access to the TELS system (electronic system used to monitor maintenance tasks) and he excepts staff to report all needed repairs in the TELS system. The system will alert the Administrator, and the Maintenance Director of repairs needed in the facility.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Capillary Blood Sampling (Finger Stick Blood Sugar), Cleaning and Disinfection of Resident-Care Items and Equipment, and Infection Prevention and Control, the facility failed to ensure infection control practices were followed for four of 39 residents (R) (R44, R20, R14, and R33). Specifically, the facility failed to ensure the glucometer was cleaned per the user instruction manual for R44; failed to ensure shared resident equipment was sanitized between uses and failed to ensure staff followed Enhanced Barrier Precaution (EBP) guidelines during wound care for R33. Findings included: Review of facility's policy titled, Capillary Blood Sampling (Fingerstick Blood Sugar), reviewed and updated March 2014, revealed under Procedural Guidelines, Our facility follows the manufacturers recommended guidelines in using their machine for FSBS. Follow current standards of care regulations related to handling potentially infectious materials including but not limited to standard precautions, use of personal protective equipment, hand washing and hand hygiene for capillary blood sampling and care of resident care equipment. Review of facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, revealed under Policy Statement, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Under the section Policy Interpretation and Implementation, Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Review of facility's undated policy titled, Infection Prevention and Control, under Section 3 subtitled Enhanced Barrier Precautions revealed, (the policy) expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (multi-drug resistant organism) to staff hands and clothing. Review of the electronic medical record for R44 revealed a diagnosis of Type 2 Diabetes Mellitus. Review of physician orders included Lantus Solostar U (unit)-100 Insulin (insulin glargine) 100 units/ml (units per milliliter) -24 units once daily, sliding scale insulin Novolog Flex Pen, fingerstick blood sugar before meals and at bedtime. Observation on 1/16/2025 at 11:25 am of fingerstick blood sugar procedure for R44 with Licensed Practical Nurse (LPN) EE revealed the nurse sanitized her hands, gathered equipment and put the equipment in a plastic cup. Once the procedure was completed LPN EE took off one glove and held the glucometer in her ungloved hand. The nurse put the used glucometer on the medication cart without a barrier then cleaned the glucometer with an alcohol swab. LPN EE revealed she was told it was okay to use an alcohol swab to clean the glucometer. During an interview on 1/16/2025 at 11:40 am with the Administrator, the policy on Capillary Blood Sampling (Fingerstick Blood Sugar) was reviewed and verified that the policy referred staff to the manufacturer guidelines for cleaning the glucometer. Review of the Assure Prism Blood Glucose Monitoring System - User Instruction Manual revealed under Cleaning and Disinfecting: .We have validated Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1 and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the meter. Observation on 1/15/2025 at 8:45 am, Certified Nursing Assistant (CNA) BB was taking vital signs and was observed using the blood pressure cuff on one resident, she sanitized her hands and proceeded to take the blood pressure of another resident. She did not sanitize the equipment between residents The two residents for blood pressure monitoring were R20 and R14. Interview on 1/16/2025 at 11:52 am with the Infection Control Nurse (ICN) revealed the glucometer could be cleaned using an alcohol swab. Interview on 1/16/2025 at 1:00 pm with CNA BB revealed she was asked if she cleaned the blood pressure equipment between residents and she revealed she does not and she cannot have the Sani wipes on the machine. 50808 Review of the physician orders revealed R4 was on Enhanced Barrier Precautions (EBP) due to his wound. Wound care observation on 1/16/2025 at 10:00 am for R4 revealed LPN GG did not don the appropriate PPE (personal protective equipment) (gloves and gown) before performing wound care for R4. LPN GG only donned gloves before performing wound care. Interview on 1/16/ 2025 at 10:15 am with LPN GG confirmed that she knew R4 was previously on EBP but was told by the corporate nurse that when R4's wound was downgraded from a stage 2 that it was her understanding that R4 no longer had to be on EBP. Interview on 1/16/2025 at 11:00 am with the DON (Director of Nursing) confirmed her understanding from CDC (Centers for Disease Control and Prevention) that states any wound that requires a dressing must be on Enhanced Precautions. DON revealed that she would ensure all staff know that R4 is on EBPs and any care in which bodily fluid may be exposed, staff must wear appropriate PPE before performing task.

Based on observation, staff interviews, record review, and review of the facility's policy titled, Medication Administration-General, the facility failed to ensure a medication error rate of less than five percent (5%) during medication administration for one of three residents (R) (R14). There were 26 opportunities observed and two medication errors for a medication error rate of 7.69%. This deficient practice had the potential to cause adverse drug reactions for R14. Findings included: Review of the facility's undated policy titled, Medication Administration-General, under the Guidelines section it was revealed, Prior to medication administration: The nurse should always identify the patient and verify the patient is available for medication administration. The nurse should read the administration directions on the MAR (Medication Administration Record) and verify correct medication, dose, and directions for use. Review of the electronic medical record for R14 revealed pertinent diagnoses of but not limited to hypertensive chronic kidney disease, essential primary hypertension, and morbid obesity. Review of Physician orders for R14 included Furosemide 40 mg (milligram) once a day by mouth, hold for SBP (systolic blood pressure) (the first, or top number of the blood pressure reading) less than 110, and losartan 100 mg 1 tablet by mouth daily, special instructions: hold for SBP less than 110. Review of vital signs for R14 revealed: 1/15/2025 8:20 am Blood Pressure: 108/68 mmHg (millimeters of mercury) (a unit of measurement for pressure used to measure blood pressure). The blood pressure (B/P) was taken before the medication was given. The time indicated when the B/P was documented. Medication administration observation on 1/15/2025 at 8:13 am with LPN CC revealed Certified Nurse Aide (CNA BB) reported R14's blood pressure level as 108/68 to the nurse before the medication was administered. The nurse administered the following medications to R14 during the medication administration observation; acetaminophen 325 mg - 2 tablets, losartan 100 mg - 1 tablet, fluoxetine HCL (hydrochloride) 10 mg - 1 capsule, furosemide 40 mg - 1 tablet, and potassium chloride 10 meq (milliequivalent) - 1 tablet. During an interview on 1/15/2025 at 12:00 pm with LPN CC, revealed that the nurse confirmed that the B/P for R14 was 108/68 which indicated the residents medications, furosemide 40 mg and losartan 100 mg should not have been given according to the parameters set by the physicians order, however LPN CC denied that she gave the medication. During an interview on 1/15/2025 at 12:30 pm with Assistant Director of Nursing (ADON), she was informed of two medication errors that occurred during the medication administration observation which included the nurse administering losartan 100 mg - 1 tablet and furosemide 40 mg - 1 tablet after having knowledge of R14s' SBP below 110. The ADON reviewed the Medication Administration Record which confirmed that the furosemide and the losartan were not to be given if the SBP was below 110. LPN CC confirmed to the ADON that she did give R14 the medication to the resident after knowing the systolic blood pressure was below 110.

Based on observations, interviews, record review, and review of the facility's policy titled, Restorative Nursing, the facility failed to obtain a physician order for one of five residents (R) (R3) with known contractures. The deficient practice had the potential to increase the progression of contractures for R3. Findings included: Review of the facility's policy titled, Restorative Nursing, reviewed and updated March 2014, under the Procedural Guidelines section revealed, The facility's rehabilitative/restorative nursing care program is designed to assist each resident to maintain their highest level of functioning. Review of the electronic medical record revealed R3 had diagnoses of but not limited to, intellectual disabilities, feeding difficulties, cerebral palsy, and anxiety disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] Section C- cognitive patterns, revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment; Section GG-functional condition revealed upper and lower extremity impairment on both sides, uses wheelchair; is dependent on staff to assist with eating, oral hygiene, toileting hygiene, and shower/bathe. Review of Physician's orders dated 9/5/2024 included Restorative: eating and swallowing and passive range of motion. There was no specific order for the splints until 1/16/2025 (during the survey). Continued record review revealed an order dated 1/16/2025 for Restorative: Splints to be applied to bilateral hands daily for 3-4 hours as tolerated by the resident. Review of the care plan dated 9/5/2024 revealed R3 requires assistance with activities of daily living (ADL), and the level of staff assistance may vary. Risk for pain related to diagnoses of cerebral palsy; anxiety; lack of muscle control; spasms; and risk of contractures (has splints & braces). Review of the Restorative Documentation revealed that from 12/16/2024 to 1/16/2025, the splint was applied nine out of 32 days, on 12/23/2024, 12/27/2024, 12/30/2024, 12/31/2024, 1/2/2025, 1/6/2025, 1/7/2025, 1/10/2025, 1/11/2025, for 240 minutes. There was no documentation that R3 refused the splints or refused care. Observation and interview on 1/14/2025 at 11:15 am with R3 revealed he was sitting up in wheelchair, both hands were contracted, and he could open them slightly. Observation and interview on 1/15/2025 at 9:30 am with R3 sitting up in wheelchair in the hallway revealed he is alright, both hands were contracted, there were no hand splints noted during observation. Observation on 1/15/2025 at 12:46 pm of R3 sitting up in dining room, there were no hand splints noted during observation. Observation on 1/16/2025 at 9:12 am of R3 sitting up in chair, hand splints to both hands. Interview on 1/16/2025 at 9:20 am with Certified Medication Aide (CMA) DD revealed R3 required total assistance by staff for all his care needs and resident did have hand splints that the Restorative aide was responsible for applying. Further interview also revealed that R3 only wore the splints a couple of hours a day. Interview on 1/16/2025 at 11:35 am with Restorative CNA FF revealed R3 was ordered to wear splint daily for 240 minutes. Documentation was reviewed with CNA FF for the period from 12/11/2024 to 1/16/2025. During the interview CNA FF confirmed the splint was not worn during this time frame due to no times were documented on the form, and if it was not documented then R3 did not get the splint applied that day. Interview on 1/16/2025 at 1:50 pm with the Rehabilitation Director revealed the Restorative staff is responsible for ensuring that R3 splints are applied daily, and R3 will refuse to wear the hand splints at times.

Based on observation, staff interviews, and review of the facility policy titled, Food Receiving and Storage, the facility failed to label, and date opened food items in the dry storage area and failed to date opened bulk food items. The facility census was 62 and all residents consumed an oral diet. Findings include: Review of the facility policy titled Food Receiving and Storage revealed dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Observation on 7/21/2023 at 9:00 a.m. of the dry storage area revealed a large clear plastic rectangle bin that contained a large open bag of Egg Noodles with no label or date also in this bin was an open bag of 10-inchch tortilla shells had no open date. No unattached food labels were noted loose on the bottom of bin. In separate large clear plastic rectangle bin was an open bag of Devil Food Cake Mix with no date. No unattached food labels were noted loose on the bottom of the bin. During an interview on 7/21/2023 at 9:00 a.m. dietary aide AA confirmed that the bag of egg noodles, tortilla shells and Devil Food Cake Mix all were opened with no label or date. The dietary aide stated that the labels likely fell off. The dietary aide stated that staff are to label and date any food item opened. Observation on 7/21/2023 at 9:18 a.m. of the shelf under the food preparation table revealed eight, 18 quart round clear plastic containers. The containers were labeled potato flakes, food thickener, flour, grits, and rice. The containers did not have a date when the food items were taken out of original package and placed in the containers. During an interview on 7/21/2023 at 9:18 a.m. the Certified Dietary Manager (CDM) confirmed that none of the round clear plastic containers with the bulk food items had a date of when the food products were placed in the containers. The CDM stated that they use most of the items quickly and replenish frequently. The CDM stated that she did not know it was necessary to date the food container.

Based on observations, staff interviews, review of pharmacy guidelines, review of latanoprost ophthalmic solutions manufacturer packet insert, review of the Trelegy Ellipta oral inhalant manufacturer packet insert; and review of the facility policies title, Medication Storage in the Care Center, and Metered Dose Inhalers (MDI), the facility failed to ensure drugs and biologicals used in the facility were labeled and stored properly and in accordance with manufacturer's recommendations on two of three medication carts (A Wing cart and B Wing cart). Findings include: Review of the policy titled, Medication Storage in the Care Center dated October 2017 revealed the intent of medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The Procedural Guidelines section line numbered 13 revealed medications requiring refrigeration or temperature between 2 degrees Celsius (C) (36 degrees Fahrenheit (F)) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Review of the undated policy titled Metered Dose Inhalers (MDI) revealed the intent of to properly administer metered dose inhalers on timing of administration and appropriate use. The Procedural Guidelines section line numbered 1 revealed to reference to the manufacturer's instructions for usage of inhalers. Review of the document titled, Multi-dose Packages of Medications Storage Conditions and Expiration Dates dated October 2017 indicated Lantus vial and pen insulin and Novolog vial and pen insulin had a shelf life of 28 days after the first use (indicating once opened, the medication should be discarded after 28 days). Review of the manufacturer's packet insert for latanoprost ophthalmic solutions revealed storage instructions was to protect the solution from light and store unopened bottle(s) under refrigeration at 2 degrees to 8 degrees Celsius (C) (36 degrees to 46 degrees Fahrenheit (F)). Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks. Review of the manufacture's packet insert for Trelegy Ellipta oral inhalant instructions numbered 16 and on page 33 revealed: Discard Trelegy Ellipta 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. Observation on 7/22/2023 at 8:50 a.m. of B Wing medication cart with Registered Nurse (RN) BB revealed one Trelegy Ellipta 100 microgram (mcg)/62.5 mcg/25 mcg oral inhalation discus 30 dose unit (a medication used to treat chronic obstructive pulmonary obstruction) stored on the medication cart opened without an opened date and with a count of 20 doses remaining on the counter. Interview on 7/22/2023 at 8:51 a.m. with RN BB verified there was not an open date label on the Trelegy Ellipta 100 mcg/62.5 mcg/25 mcg oral inhalation. She revealed there should have been a label indicating the opened date on the Trelegy Ellipta 100 mcg/62.5 mcg/25 mcg oral inhalation and further revealed without an opened date label there was no way to determine the discard date. Observation on 7/22/2023 at 10:10 a.m. of A Wing medication cart with Licensed Practical Nurse (LPN) CC revealed: one container of Latanoprost 0.0005% ophthalmic solution 2.5 milliliter (ml) (a medication used to treat glaucoma and ocular hypertension) stored on the medication cart, unopened and with a red label stating to store under refrigeration until opened. one Novolog Flex Pen 100 units/ml 3ml prefilled insulin pen (a medication used to treat diabetes mellitus) with an open date of 6/22/2023. one Lantus 100 units/ml 3ml prefilled insulin pen (a medication used to treat diabetes mellitus) with an open date of 6/22/2023. LPN CC verified the container of Latanoprost ophthalmic solution was not stored under the proper temperature on the cart and the Novolog and Lantus insulin pens were beyond the discard date and remained on the medication cart. Interview on 7/22/2023 at 10:14 a.m. with LPN CC revealed the night shift nurse was responsible for stocking the medication cart and ensuring medications were stocked according to manufacturer recommendations. She further revealed all nurses that pass medications should check each medication prior to administering to ensure it was within discard date. She revealed insulin pens should be discarded according to manufacturer's recommendations and further revealed there was a potential for the insulin to be less effective if given past the discard date. Interview on 7/23/2023 at 12:00 p.m. with the [NAME] President of Operations revealed her expectations were for nursing staff to follow the guidelines on the document titled Multi-dose Packages of Medications Storage Conditions & Expiration Dates for storage of medications. She revealed the document was located at each nursing unit and the nurses had access to reference it. She further revealed a Pharmacy Consultant performed an on-site quarterly audit of the medication storage and administration and provided education as needed to the nurses. Interview on 7/23/2023 at 12:05 p.m. with the Administrator revealed her expectations were for nursing staff to follow the policies and procedures of the facility for medication storage. She further revealed her expectations were for nursing staff to contact the consulting pharmacy for questions or concerns. Interview on 7/23/2023 a 12:15 p.m. with the Director of Nursing (DON) revealed her expectations were for insulin to be dated when opened and discarded on the discard date according to manufacturer recommendations and pharmacy guidelines, for ophthalmic medications to be stored according to manufacturer's recommendations, and for oral inhalant medications to be labeled and discarded according to manufacturer recommendations. She revealed her expectations were for nurses to check the medication cart each shift to ensure there were no medications being administered beyond their discard date, ensure medications that should be labeled were labeled correctly, and that medications were stored according to manufacturer's recommendations. She revealed insulin, ophthalmic medications, and oral inhalants could become less effective if used past their discard date and could provide less effective control of symptoms being treated. She revealed insulin could be less effective at controlling diabetes if given past the discard date.

Based on interviews, record review, and review of the facility policy titled, Abuse Prevention Program, the facility failed to report an allegation of abuse for one resident (R #50) of 13 residents on the Memory Care Unit. Findings include: Review of the policy titled Abuse Prevention Program, last reviewed and updated October 2016, revealed the following: D. Reporting: 1) Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse including injuries of unknow source/origin and misappropriation of resident property the incident will be immediately reported. a. The Administrator or designee will immediately notify HFR Complaint Investigation Intake and Referral Unit and resident representative of the incident and the pending investigation. The Ombudsman will also be notified as appropriate. The Administrator or designee will direct the investigation. c. The initial report of the incident will be faxed or emailed immediately but no more than 2 hours of abuse or an incident that results in serious injury or within 24 hours where there is no abuse or serious injury to the HFR Complaint Investigation Intake and Referral Unit. Review of Complaint Form dated 6/22/2023 indicated Certified Medication Aide (CMA) ZZ took the report from R#50's family member. Per written statement by CMA ZZ R# 50's family member asked to speak with charge nurse but was informed she was away. Based on the typed document R#50 confirmed what her daughter reported about someone coming into her room the week before trying to take her fork and stabbing her with it. R#50 reportedly told a nurse but could not remember who she told. Further review of the documentation indicated that CMA ZZ notified the Registered Nurse (RN) over her of this situation and the RN told her to make a report the next morning. The document does not indicate what date this incident took place on, but the document was signed by CMA ZZ on 6/22/2023. The Complaint Form indicated the complaint was referred to the appropriate department on 6/23/2023. The skin assessment that was completed at the time of assessment of R#50 was dated 6/23/2023. During interview on 7/22/2023 at 3:37 p.m. with the Social Services Director (SSD) and Interim SSD it was reported that SSD was aware of an allegation of R#50 being stabbed with a fork by another resident, but it was not reported to her. SSD then called the Director of Nursing (DON) for clarification on the allegation. SSD then reported that the DON informed her that she assessed R#50 but there were not any marks and R#50 denied being stabbed at that time. SSD reported that an allegation of a resident being stabbed by another resident should be reported to the Administrator. Interim SSD reported that the Administrator in this facility is responsible for reporting allegations of abuse to the State. During an interview on 7/22/2023 at 4:14 p.m. with the Administrator and the [NAME] President of Operations (VPO). The Administrator acknowledged that she was made aware of the allegation of abuse related to R#50 being stabbed with a fork by another resident. The Administrator reported that R#50 was immediately assessed as a result and R#50 did not have any marks to indicate that she had been stabbed. The Administrator also reported that since the resident was now denying that it happened she did not follow up with submitting the report. Administrator and VPO both acknowledge that policy does not suggest you get a finding before making a report related to an allegation of abuse.

Based on staff interviews, record reviews, and review of the facility policy titled, Controlled Drug Accountability and Reconciliation the facility failed to maintain accurate records on controlled substances on one of three medication carts (A Wing cart). Findings include: Review of the policy titled, Controlled Drug Accountability and Reconciliation dated October 2017 revealed the intent was to establish a method for accountability and reconciliation of controlled medications. Controlled medications should be tracked form the time they are received in the center through administration, discontinuation, discharge, or destruction. The Procedural Guidelines section lines numbered 2: During the next shift change, both the on-coming and off-going nurses should check the delivery sheet and verify that each controlled medication delivered has been placed in the appropriate place on the medication cart and documented on the Controlled Medication Audit (CMA) form. 4: Audits should be performed weekly, ideally by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Nurse Manager, or supervision. Observation on 7/22/2023 at 10:18 a.m. with Licensed Practical Nurse (LPN) CC of the A Wing controlled medication book revealed the Narcotic Shift Count document was missing 25 signatures of 86 required signatures used to verify the controlled medication count was correct at each shift change. Interview at 10:20 a.m. with LPN CC verified the missing signatures and she revealed she was unsure why there were missing signatures. She revealed each nurse was responsible to sign the document when the controlled medications were counted at each shift change to verify the controlled medications count was accurate. She revealed shift count of controlled medications was important to ensure there was no unauthorized use of the controlled medications. Interview at on 7/22/2023 at 11:15 a.m. with the Director of Nursing (DON) revealed her expectation was for nurses to count the controlled medications at each shift change and sign on the Narcotic Shift Count document to verify the medication count was correct. She revealed there had been no reported missing controlled medications since she began working at the facility four months ago. She further revealed if the nurses did not sign the form to verify the count of the controlled medications, there was no way to know if the medications were counted and revealed counting controlled medications at each shift change helped to ensure there was no unauthorized use of the controlled medications. She revealed the facility used some agency nurses, and agency nurses normally work on a medication cart for two weeks alongside another nurse to ensure competencies were met, but occasionally the agency sent a nurse to cover a shift that was unfamiliar with the facility. She revealed the facility normally placed agency nurses on the A Wing. Observation on 7/22/2023 at 11:20 a.m. of controlled medication count by the DON and LPN CC on A Wing medication cart revealed the controlled medication counts were correct. Review of the documents titled Narcotic Shift Count revealed: May 2023 A Wing was missing 29 of 128 required signatures used to verify the controlled medication count was correct at each shift change. June 2023 A Wing was missing 19 of 120 required signatures used to verify the controlled medication count was correct at each shift change. July 2023 (through 7/22/2023) A Wing was missing 25 of 86 required signatures used to verify the controlled medication count was correct at each shift change. Interview on 7/23/2023 at 12:05 p.m. with the Administrator revealed her expectations were for nursing staff to follow the policies and procedures of the facility for controlled medication storage and reconciliation. Interview on 7/23/2023 a 12:15 p.m. with the DON revealed her expectations were for the controlled medications to be counted at each shift change by the off-going and on-coming nurses and for the nurse's signatures to be documented to verify the count as correct, indicating no controlled medications missing. She revealed nurses working the medication carts were responsible for ensuring controlled medications were counted, verifying the count to be correct and providing their signature on the shift count form. She further revealed if the nurses did not sign the form to verify the count of the controlled medications, there was no way to know if the medications were counted and revealed counting controlled medications at each shift change helped to ensure there was no unauthorized use of the controlled medications. She revealed she (as the DON) was ultimately responsible for ensuring the controlled medications were verified to be correct, the shift change forms to be completed and she should have been providing an audit of the shift change count forms.

Based on record review, staff interview, and review of the facility policy titled, Automatic Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two residents (R) (R#9, R#50) of six residents reviewed for unnecessary medications. Specifically, the facility failed to ensure a stop date was implemented for antianxiety medication ordered as needed (PRN) for R#9 and R#50. 1.Findings are: A review of the facility policy Automatic Stop Orders, updated 10/2017, revealed as needed (PRN) psychotropics had a 14-day stop date. Additionally, the prescribed may specify a duration longer than 14 days for PRN psychotropic medications, but the prescriber must include a clinical rationale in the permanent medical record. PRN antipsychotics could not be renewed for longer than 14 days without a direct evaluation of the patient by the prescriber. A review of the physician (MD) orders revealed R#9 was prescribed one Xanax 0.5 Milligram (mg) tablet by mouth every 6 hours as needed (PRN) on 5/30/2023. The order had no end date. A review of the Medication Administration Record (MAR) revealed staff administered R#9 Xanax 0.5 mg PRN on the following dates and times: 6/15/2023 at 9:14 a.m., 6/16/2023 at 10:14 a.m., 6/18/2023 at 7:12 a.m., 6/20/2023 at 8:07 a.m., 6/23/2023 at 10:18 a.m., 6/28/2023 at 11:02 a.m., 7/1/2023 at 9:38 a.m., 7/7/2023 at 8:32 a.m., 7/8/2023 at 8:46 a.m., 7/12/2023 at 10:50 a.m., 7/13/2023 at 9:02 a.m., 7/17/2023 at 12:00 p.m., 7/18/2023 at 12:01 p.m., and 7/21/2023 at 8:36 a.m. Interview on 7/22/2023 at 9:13 a.m. with the Director of Nursing (DON) revealed the DON acknowledged R#9 did not have a stop date for the as-needed (PRN) Xanax 0.5 mg order. The DON explained that the pharmacy consultant would typically inform the Medical Doctor (MD) or staff that a stop date was missing for required medications. The DON added she and the Unit Managers would audit the charts to ensure the consultant reviewed them. She acknowledged this order was overlooked and would be corrected immediately. 36200 2. Review of the electronic medical record (EMR) for R# 50 revealed diagnosis that included generalized anxiety disorder and Alzheimer's disease. Further review of the medical record revealed the following order: lorazepam 0.5 mg tablet: take 1 tablet(s) oral every 6 hrs PRN as needed (PRN) for anxiety /agitation. Start date of 6/23/2023. There was no end date indicated for this PRN order. Review of the EMR revealed that R#50 last took this medication on 7/20/2023. During an interview on 7/22/2023 at 2:27 p.m. with the Director of Nursing (DON) it was who confirmed that the lorazepam 0.5 mg PRN order for R#50 did not have a stop date. DON further reported that R#50 is on hospice and hospice writes orders, but the facility does not know what they are sometimes. It was reported that the Pharmacist reviews the orders monthly and if an issue is identified as a result of the pharmacy review it is reported to the Physician. It is the Unit Manager's responsibility to make sure that recommendations are followed up on. DON reviewed Pharmacy Note to Attending Physician dated 7/6/2023 of which lorazepam 0.5mg q6hr PRN should have been discontinued per the Physician's request on 7/10/2023. Review of the electronic medication administration record (eMar) showed that the medication was received on 7/20/2023 and DON confirmed that the order should have been discontinued.

Based on observations, staff interviews, and review of the facility policy titled, Work Orders the facility failed to ensure the environment was free from potential hazards by not ensuring that three sinks on one of three Wings (on the A Wing in the bathrooms for rooms: 132, 133, 134) were securely fastened to the wall and the facility failed to ensure that one electrical outlet on one of three wings (on the A Wing in room 130) was not pulled loose from the wall. Findings include: Review of a facility policy titled, Work Orders, dated December 2012 documented the intent of the facility, that maintenance work orders be completed in order to establish a priority of maintenance service. Procedural guidelines documented in order to establish a priority of maintenance service, work orders should be filled out and forwarded to the plant operations/Maintenance Manager, and emergency repairs should be given priority in making necessary repairs. Observation on 12/14/21 at 9:11 a.m. in room 132, revealed a loose sink in the bathroom. Additional observations on 12/15/21 at 9:32 a.m. and on 12/16/21 at 9:29 a.m. revealed the sink in the bathroom of room 132 remained loose. Observation on 12/14/21 at 9:14 a.m. in room 133, revealed a loose sink in the bathroom. Additional observations on 12/15/21 at 9:33 a.m. and 12/16/21 at 9:30 a.m. revealed the sink in the bathroom of room 133 remained loose. Observation on 12/14/21 at 9:17 a.m. in room 134, revealed a loose sink in the bathroom. Additional observations on 12/15/21 at 9:34 a.m. and on 12/16/21 at 9:31 a.m., revealed the sink in the bathroom of room 134remained loose. Observation on 12/15/21 at 8:54 a.m., at 11:20 a.m., and at 3:34 p.m., and on 12/16/21 at 8:11 a.m. revealed an electrical outlet pulled out of the wall by the head of the bed, on the side by the window, in room 130. Interview on 12/16/21 at 8:05 a.m. with LPN AA revealed if staff see any maintenance or repair concerns, they are supposed to report to the Maintenance Supervisor by filling out a work order. Interview on 12/16/21 at 9:48 a.m. with the Maintenance Supervisor revealed they have a corporate policy on repairs and anyone who sees needed maintenance or repairs are supposed to fill out a work order form that is readily accessible on each wing. He revealed he utilized TELS, an Equipment Life Cycle System, that tracks weekly and monthly tasks, keeps up with preventive type maintenance task, and environmental maintenance checks. He said he does rounds once a month by schedule, he does a weekly walk through for observation of life safety issues and general repairs, each morning does a walk through check, and picks up work orders. During a walkthrough of the A wing on 12/16/21 with the Maintenance Supervisor the following concerns were identified and confirmed: On 12/16/21 at 9:56 a.m. confirmed an electrical outlet pulled out of wall and wire molding was loose in room 130. On 12/16/21 at 10:00 a.m. confirmed the sink was loose in the bathroom for room 132. On 12/16/21 at 10:03 a.m. confirmed the sink was loose in the bathroom for room 133. On 12/16/21 at 10:05 a.m. confirmed the sink was loose in the bathroom for room 134. Interview during the walk through on 12/16/21 at 10:06 a.m., with the Maintenance Supervisor revealed no one had reported the electrical outlet or loose sinks. The Maintenance Supervisor confirmed electrical outlets should not be pulled out of the wall and that sinks should not be loose, and the expectation was that the outlet be reattached to the wall and sinks be re-caulked immediately. The Corporate Administrator walked by, at this time, and was made aware of these maintenance/repair concerns. The Corporate Administrator stated her expectation was that repairs be made timely for a safe environment. Follow-up interview on 12/16/21 at 3:00 p.m. with the Maintenance Supervisor revealed reporting maintenance and repair concerns is covered during generation orientation with all staff, and anyone that sees a maintenance repair issue should report it by completing a work order.

Based on observations and staff interview, the facility failed to post the daily nurse staffing information in a prominent place readily accessible to residents and visitors during the three-day survey. The facility census was 59 residents. Findings include: Observation of the nurse staffing information on 12/14/2021 at 2:24 p.m., 12/15/2021 at 1:45 p.m., and 12/16/2021 at 12:26 p.m., revealed it was posted in a display box on the hallway of the B-Wing. In an interview with the Director of Nursing (DON) on 12/16/2021 at 12:35 p.m., revealed the nurse staffing information is always posted on the B-Wing which she confirmed is not readily accessible to residents and visitors unless they reside on or are visiting on the B-Wing.

Based on observation, staff interview and review of facility policies, the facility failed to label and date opened bulk food items located in the stand-alone chest freezer, and failed to label and date frozen meals located in two of three resident nourishment/pantry freezers. This deficient practice had the potential to affect 52 residents receiving an oral diet. The census was 55 residents. Findings Include: Initial tour on 11/5/18 at 9:05 a.m. of the kitchen was conducted with the Dietary Manager (DM) after the breakfast meal had been served and cleanup of the kitchen was in process. Observation of the stand-alone chest freezer revealed a frozen pizza with ice crystals on it was observed in a multiuse/bulk large plastic bag without a label or a use by date to indicate when it was opened. Continued observation revealed a large opened multiuse/bulk bag of frozen pancakes and a large opened multiuse/bulk bag of frozen French toast were observed to be unlabeled, without a use by date that would indicate when they were opened for use. One opened half-gallon multiuse vanilla ice cream container was found with approximately two inches of ice cream remaining. The container was observed without a label, or a use by date indicating when it was opened. During a tour on 11/6/18 at 1:29 p.m. of the Memory Unit's pantry, the resident nourishment refrigerator contained a frozen dinner of beef and peppers in the freezer that was unlabeled and undated. The Licensed Practical Nurse (LPN) AA and the Certified Nurse Assistance (CNA) BB working in the unit, denied knowing who it belonged to. During a tour on 11/6/18 at 1:40 p.m. of the B-Wing pantry area, in the resident nourishment refrigerator, one frozen dinner of lasagna was found in the freezer that was unlabeled and undated. The Registered Nurse Supervisor, working at the B-Wing nurses station, confirmed it should not have been there and stated she was going to throw it out. Interview on 11/6/18 at 3:36 p.m. with the DM, she confirmed that they have three nourishment pantries that they stock for snacks and juices and some nutrition supplements. She stated the nursing staff is responsible for most of the other supplements and food items for residents, and are responsible for keeping the refrigerator temperature logs. During a brief interview with the DM on 11/7/18 at 1:40 p.m. in her office, she confirmed the cooks were responsible for labeling food items after opening. She stated she had three cooks, no assistants, that her expectation of them was for them to label and place a best use by date on a label after opening any food items that would be accessed another time. A food storage policy was requested and provided. On 11/7/18 at 2:00 p.m. the DM provided copies of three dietary in-services, entitled Cleaning, Use by Date, Labeling and Food Storage Guideline conducted on 2/27/17, 7/18/18 and 8/6/18 with dietary staff sign-in sheets attached. Review of the provided facility policy entitled, Food Storage undated, documents to freeze leftover food, package in small airtight units for quick freezing, label and date. Review of the provided facility form entitled, Guidelines for Storage' undated, documents Date your products with Use by Date. This guideline indicated specific food items and indicated recommended storage time frames for food items stored in the pantry rooms, refrigerators and freezers. Review of the provided facility policy entitled, Personal food dated 4/2018, documents for pantry refrigerators any food stored in the pantry refrigerators must be in plastic containers with tight fitting lid and labeled with the resident's name and date it was placed in the refrigerator. Any food items not labeled will be discarded.

Based on observation, interview, and review of the facility policy titled, Handwashing/Hand Hygiene the facility failed to ensure staff were assisting with meal service utilizing proper hand hygiene; specifically, by failing to perform hand hygiene between resident contact during meal service during two dining observations on the Memory Unit. The sample size was 23 residents. Findings Include: Observation on 11/5/18 from 12:42 p.m. - 1:15 p.m. was conducted in the Memory Unit (MU) during the lunch meal where 12 of 13 residents were served in the MU dining room, with one resident dinning in his room. Nine of 12 residents were offered and wearing clothing protectors. Three staff members were observed serving and assisting residents with tray set up for the lunch meal. Two residents were observed being assisted with eating. The dining room was home like, noise and lighting normal, room clean and clutter free. Two mechanically altered meals were served. No alternative meal was noted. During this MU lunch meal dinning observation, Licensed Practical Nurse (LPN) AA assisted ten residents eating in the dining room. LPN AA was observed buttering bread, cutting up chicken and assisting residents with repositioning for nine out of ten residents, without washing her hands or using hand sanitizing gel between contact of those residents. The LPN was observed assisting with cutting meat for one resident including buttering his bread, then immediately sat down to assist with feeding resident (R) R#11, the LPN did not use hand sanitizer gel or wash her hands between serving this resident. Also during this MU lunch meal dinning observation, CNA BB was observed serving water and fluids to 12 residents and assisting with tray set up and repositioning with R#7, then sat down to help feed R#15 without washing her hands or using gel hand sanitizer between resident contact. No dignity issues were observed. A second dining observation was conducted on 11/7/18 at 12:49 p.m. during the lunch dining in the Memory Unit. Eleven residents were observed eating in the dining room, of which 7 residents were provided with clothing protectors. Three staff members were assisting. Lunch trays were brought to the MU at 12:53 p.m., CNA CC was observed assisting opening trays for two residents then assisted five residents, R#51, R#21, R#40, R#7, and R#29 with repositioning, then cutting up their meat without hand hygiene performed between assisting those five residents. CNA DD was observed with physical repositioning and a tray assist for R#15, without using hand hygiene prior to assisting R#20 with cutting up his food. The CNA was next observed assisting R#28 with cutting up her food items without using hand hygiene between those residents. No dignity issues were noted. During an interview with the Assistant Director of Nurses (ADON) on 11/7/18 at 2:40 p.m. in the conference room, she confirmed she was responsible for in-services, that the last in-service on hand washing was 8/23/18. She stated the provided in-service and sign in sheet was for the night shift. When asked, she stated she did not have evidence of any in-services on hand washing and infection control for CNAs on the day shift. During an interview On 11/7/18 at 2:45 p.m. with the Director of Nurses (DON) in her office she confirmed that it was an expectation of the nursing staff to use hand washing or gel sanitizer with contact between residents. She stated they are to keep clean from dirty, and have no physical contact between passing trays without using sanitation. A copy of the facility policy titled, Hand Washing/Hand Hygiene was provided. A review of the facility policy titled, Handwashing/Hand Hygiene revised 8/2015. Documentation of the Policy Statement reflects the facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation indicates (No. 7) to use an alcohol-based hand rub containing at least 62% alcohol, or alternatively antimicrobial or non-antimicrobial soap and water for several situations (including No. 7, b & p) such as before and after direct contact with residents and before and after assisting a resident with meals.

Based on observation, staff interview and review of facility policy, the facility failed to discard outdated food in the dry good storage area and walk-in refrigerator, failed to label and date opened food in the dry good storage area and walk-in refrigerator, and failed to ensure two (2) fans in the walk-in refrigerator were free of dust. This deficient practice had the potential to effect sixty-two (62) residents receiving an oral diet. Findings Include: Observation on 2/6/17 at 10:36 a.m. of the walk-in refrigerator revealed two (2) fans full of dust, two (2) 60 ounces (oz) bottles of expired Ocean Spray Grapefruit, two (2) bags of opened unlabeled and undated whipped topping, one (1) 16 oz black container of bacon bits unlabeled and undated. Observation on 2/6/17 at 11:13 a.m. of the dry storage area revealed a storage bin with two (2) bags of opened curly noodles unlabeled and undated, two (2) bags of opened spaghetti noodles unlabeled and undated, one (1) bag of opened white cake mix undated, one (1) bag of opened white Domino confectioners sugar undated, four (4) cans of expired 7 pounds (lbs) Banana Pudding, one (1) can of expired 6 lbs Hormel Chili, four (4) cans of expired, 6 lbs Sliced Fancy Carrots. During an interview on 2/6/17 at 10:45 a.m. with the Dietary Manager (DM) she stated she expects all opened packages in the walk-in refrigerator to be labeled and dated with the use by date and all expired foods to be discard. She also confirmed the unlabeled and undated food items in the walk-in refrigerator and the expired Ocean Spray Grapefruit Juice. During an interview on 2/6/17 11:20 a.m. with the DM she stated she expects all expired can goods to be removed from the dry storage area and opened packages to be labeled and dated with the use by date and also confirmed the above findings that were not labled, dated and that the can goods were expired and had not been discarded. Review of the facility policy titled, Food Receiving and Storage with a revised date of December 2008 revealed a policy statement: foods shall be received and stored in a manner that complies with safe food handling practices; policy interpretation and implementation: clean storage areas: food services, or other designated staff, will maintain clean food storage areas at all times. Dry Foods Stored in Bins: Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Labeling Foods Stored in Refrigerator/Freezer: All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on observation and interview, the facility failed to maintain an environment free from worn, stained and cracked tiles, strong odor, worn toilet seats and an unpatched section of wall in 3 of 34 resident rooms and in one of three common shower rooms. Findings include: 1. On 2/6/17 at 10:40 a.m., in the female common shower room, the plastic coating on the toilet seat was peeling up. 2. On 2/6/17 at 1:50 p.m., in the bathroom of room 117, the toilet seat finish was worn off in multiple areas. There was a large unpatched, unpainted section of the wall above the sink, behind the wall mounted light. Above the sink, there were two stained cracked ceiling tiles. 3. On 2/6/17 at 1:55 p.m., in the bathroom of room 113, the toilet seat finish was worn off in several places. 4. On 2/6/17 at 2:13 p.m., in the bathroom of room 114, there were stained floor tiles, especially near the toilet. There was also a strong, pervasive urine odor in the bathroom. The above referenced findings in rooms 113, 114, 117 and the common female shower room were observed again on 2/9/17 at 10 a.m. During an observation and interview on 2/9/17 at 10:30 a.m., the above referenced findings were confirmed by the administrator.