Every finding on record at Mission View Health Center

Based on observation, interview and record review, the facility failed to ensure foods were kept safe, in good quality, free of contaminants and properly labeled with received and within expiration dates. This failure has the potential for food borne illnesses for the residents. Findings: During the initial tour of the kitchen on 12/16/25 at 7:30 a.m., the following items were observed: A box of strawberries had mold at the bottom of the box; an opened bag of cucumbers, an open bag of carrots and a bag of salad had no label with open and use by dates. During an Interview on 12/16/25 at 7:30 a.m. with Dietary Assistant (DA), the DA validated the findings and verbalized that the staff should have inspected the produce and have labeled the items with the opened and use by dates of the produce. During an observation on 12/16/25 10:00 a.m. at station 1, the resident refrigerator was inspected. The following were identified: 3 soup cups with the use by date of 12/14, 2 soup cups with a use by date of 12/15; 2 sandwiches with a use by date of 12/13; 6 sandwiches with use by date of 12/15. During an interview on 12/16/25 at 10:00 a.m. with CS (Clinical Supervisor), the CS verbalized that the kitchen staff should have disposed of it. During an interview on 12/17/25 at 3:30 p.m. with the DA, the DA verbalized that the dietary staff are held responsible for the foods at the patient's refrigerators. During a review of the facility's Policies and Procedures (P&P) titled, Food Storage, dated 2022, the P&P indicate in part, 7. All stock must be rotated with each new order received, rotating stock is essential to assure the freshness and highest quality of all foods. a. old stock is always used first; b. food should be dated as is placed on the shelves. c. dates should be visible on all high-risk food.

Based on interview and record review, the facility failed to ensure that licensed nurses (LNs) demonstrated competency in providing quality care for one of three sampled residents (Resident 1), as evidenced by: 1. LN1 failed to document on the medication administration record (MAR) during the medication pass.2. Medication was found at the bedside for Resident 1. These failures had the potential to result in negative resident outcomes, jeopardizing the quality and safety of resident care.1. During a concurrent interview and record review on 7/23/25, at 1:25 p.m., with the director of nursing (DON), the clinical record for Resident 1 was reviewed and the MAR indicated, Lisinopril 10 mg tablet (medication for high blood pressure) was scheduled to be administered on 7/13/25 at 8:00 p.m. there was no documentation that the medication was administered, held, or that Resident 1 refused medication administration. The DON stated the expectation is that LN1 would document on the MAR during the medication pass that the medication was administered, held, or that Resident 1 refused. DON acknowledged and confirmed that staff are not following the facility's policy and procedure (P&P). During a review of the facility's P&P titled, Specific Procedures for All Medications revised date 3/24, the P&P indicated, To administer medications in a safe and effective manner. After administration, return to cart and document administration in the MAR. If resident refuses medication, document refused on MAR. 2. During a concurrent interview and record review on 7/23/25, at 1:25 p.m., with the DON, the clinical record for Resident 1 was reviewed, Resident 1 did not have an order for bedside medication storage. The DON stated the expectation is that an LN would not leave a medication at the bedside without a bedside medication order. DON acknowledged and confirmed that staff are not following the facility's P&P. During an interview on 7/25/25, at 4:57 p.m., with LN2, LN2 stated on 7/14/25 the Ombudsman (trained advocate who helps protect the rights and well being of residents) stopped LN2 in the hallway and brought LN2 into Resident 1's room and showed LN2 that a medication was left on the bedside table of Resident1. LN2 acknowledged and confirmed that a medication was left at the bedside of Resident 1 and staff did not follow the facility's P&P. During a review of the facility's P&P titled, Specific Procedures for All Medications revised 3/24, the P&P indicated, Once removed from the package or container, unused doses should be disposed of. During a review of the facility's P&P titled, Storage of Medications revised 3/24, the P&P indicated, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications. are allowed access to medications. medications intended for internal use are stored in a medication cart or other designated area. During a review of the facility's P&P titled, Bedside Medication Storage revised 3/24, the P&P indicated, Bedside medication storage is permitted for residents. upon the written order of the prescriber.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore eye protection when they entered the room who was on droplet precaution for 1 (Resident #43) of 4 sampled residents reviewed for infection control. Findings included: A facility policy titled, Infection Prevention and Control for Residents with Suspected or Confirmed SARS-COV-2 [severe acute respiratory syndrome coronavirus 2], with a copyright date of 2021, revealed Personal Protective Equipment 13. Staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection will adhere to standard precautions and use a NIOSH [National Institute for Occupational Safety and Health]-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. [id est, that is], goggles or a face shield that covers the front and sides of the face). A Face Sheet indicated the facility admitted Resident #43 on 10/22/2019. According to the Face Sheet, the resident had a medical history that included diagnoses of epilepsy, type 2 diabetes mellitus, and dementia. A physician order dated 10/02/2024, indicated Resident #43 was on droplet precautions from 10/02/2024 to 10/15/2024 due to a diagnosis of coronavirus disease 2019 (COVID-19). During an observation on 10/07/2024 at 9:45 AM, the surveyor noted a sign outside Resident #43's room that indicated droplet precautions were to be taken prior to entry. The signage indicated that before anyone entered the room, they should ensure their eyes, nose, and mouth were fully covered. During an observation on 10/07/2024 at 9:48 AM, Licensed Vocational Nurse (LVN) #3 entered Resident #43's room and did not wear a face shield. In an interview on 10/07/2024 at 10:20 AM, LVN #3 stated when residents were COVID-19 positive staff should wear a gown, N95 mask, face shield, and gloves. LVN #3 acknowledged she did not wear a face shield. During an observation on 10/07/2024 at 9:52 AM, Certified Nurse Aide (CNA) #2 entered Resident #43's room and did not wear a face shield. In an interview on 10/07/2024 at 10:09 AM, CNA #2 stated she was required to wear a gown, gloves, N95 mask, or a face shield before she entered Resident #43's room. CNA #2 read the signage on the resident's door and stated she should have had a face shield on prior to entering the resident's room. In an interview on 10/08/2024 at 2:15 PM, the Infection Preventionist (IP) stated staff should put on personal protective equipment (PPE) to include, a gown, gloves, a N95 mask, and eye protection before they entered the room of resident who was COVID-19 positive. The IP stated she expected staff to wear a face shield when they entered a room of a resident who was COVID-19 positive. In an interview on 10/08/2024 at 2:20 PM, the Director of Nursing (DON) stated residents who were COVID-19 positive should be placed on droplet precautions. The DON stated PPE would be made available at the room, signage on the door, and a sticker to notify staff that the resident was on droplet precautions. The DON stated staff should wear a gown, N95 mask, face shield, and gloves. In an interview on 10/10/2024 at 7:46 AM, the Administrator stated staff should wear face shields prior to entering a room of a resident who was COVID-19 positive.

Based on observation, staff interviews and review of facility documents the facility failed to maintain kitchen equipment in safe operating condition when the reach in refrigerator door contained a torn gasket and there was no air gap on the food preparation sink when the pipe was directly plummed into the wall. These failures have the potential for the refrigerator to not maintain a safe temperature for food as a torn gasket can allow warm air to get into the refrigerator and lack of an air gap can lead to a backflow of sewage into the food preparation sink. The facility census was 93. Findings: 1. During the inital kitchen tour on 11/19/21 starting at 9:16 AM, an observation of the reach-in refrigerator was 42 degrees Fahrenheit (F) and on the center refrigerator door the gasket was torn. During an observation and concurrent interview with the Maintanence Director (MD) on 11/29/21 at 3:19 PM, the reach-in refrigerator door with torn gasket was shown to the MD. MD stated once a month he cleans the condensing coils however not routine to check gaskets on the doors. MD stated he relies on Kitchen staff to tell him if gaskets need to be replaced. During an interview on 12/01/21 at 11:10 AM with Registered Dietitians (RD 1, RD 2, RD 3), RD 1 stated she conducts kitchen audits on Fridays. RD 1 stated she does monthly in-depth kitchen inspections and explained the items on the inspections. RD 1 stated she has not checked gaskets on the refrigerator doors during her inspections. 2. During an observation and concurrent interview with the Maintanence Director (MD) on 11/29/21 at 3:19 PM, the food preparation sink showed the pipe was directly plummed into the wall. MD confirmed there was no air gap for this sink and that is directly plumbed into the wall. According to standards of practice within the foodservice industry, an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. (2017 FDA Food Code) According to the 2017 Food and Drug Administration (FDA) Food Code, Section 5-202.13 Backflow Prevention, Air Gap, indicated an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonFood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). During the review of the facility policy and procedure titled Maintenance, undated, indicated the policy was established to ensure the facility provides a safe, functional, sanitary and comfortable environment for residents, staff and the public. It indicated the Administrator and Maintenance Supervisor will inspect facility and equipment monthly.

Based on observation, interview and record review the facility failed to ensure documentation on the Minimum Data Set (MDS-a comprehensive assessment tool used to identify and manage resident health status and needs every three months and annually) accurately reflected a weight loss of 15 pounds (10.9%) in 6 months in one resident (Resident 68). This facility failure resulted to Resident 68 from receiving an accurate reflection of a decline in health and had the potential to prevent the provision of needed health interventions. Findings: During a lunch dining observation on 11/29 at 1:10 pm, and concurrent review of Resident 68's lunch tray ticket showed the resident was on SB6 Fort (Small & bite sized fortified) diet and a house supplement. Resident 68 stated she did not like the food provided however had not informed any staff at the facility. Surveyor observed Resident 68 ate 50% of the lunch meal. During an interview with Registered Dietitians (RD 1, RD 2 and RD 3) on 12/01/21 at 11:10 AM, RD 1 and RD 2 stated they fill out section K and L of the MDS for residents. During a telephone interview with RD 1 on 12/1/21 at 3:55 PM, RD 1 stated the MDS section K should be consistent with resident for sign weight change in 6 months and if wrote in her assessment should also be the same in MDS section K. During a record review on 12/2/21 at 12:13 p.m. the Quarterly Nutrition Assessment by RD1, dated 11/3/21 indicated Resident 68 lost 10 pounds (7.6%) in three months and 15 pounds (10.9%) in 6 months. Further review of the last three MDS Assessment of Swallowing/Nutritional Status filled out by RD1, dated 11/8/21, 8/11/21, and 4/7/21 indicated the response of 0. No or unknown in the section K0300. Weight Loss, Loss of 5% or more in the last month or loss of 10% or more in last 6 months. During a concurrent interview with the MDS Coordinator (MDS) was conducted at this time when reviewed the above documents, confirmed, and agreed RD1 entered 0. No or unknown in section K0300 Weight Loss. The MDS indicated, RD 1 [RD1 name] did not accurately identify Resident 68 [Resident 68 name] with a 10% weight loss in 6 months and decline in health. The MDS confirmed, RD 1 should have and did not enter the accurate and correct response 2. Yes, not on physician-prescribed weight-loss regimen for the question Loss of 5% or more in the last month or loss of 10% or more in last 6 months on all three previous MDS Swallowing/Nutritional Status K0300. Weight Loss assessments dated 11/8/21, 8/11/21, and 4/7/21. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments and Timing, revised 3/1/18, the P&P indicated in part, The comprehensive assessment shall include .all other evaluations and assessments completed by health care professionals treating the resident .

Based on observation, interview, review of clinical records and facility documents, the facility failed to ensure one resident (Resident 68) maintained acceptable parameters of nutritional status when the facility did not carry out the recommendations from the IDT meeting. This failure had the potential to result in the resident not maintaining her weight which can further compromise her nutritional and medical status. Findings: Weight loss in nursing home residents is linked to poor out comes, including higher rates of hospitalization and death (American Journal of Nursing, 2008). Centers for Medicare/Medicaid (CMS) suggest the following parameters for evaluating undesired weight loss. A loss of 5% (percent) after 1 month; 7.5% within 3 months and 10% within 6 months is considered significant. Weight loss greater than the described parameters are suggestive of severe weight loss (Centers for Medicaid/Medicare (CMS), Appendix PP, 2017). Additionally, insidious weight loss is defined as a gradual, unintended, progressive weight loss over time (CMS, Appendix PP, 2008). During a review of Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. During a review of facility policy and procedure titled Tracking Weight Changes, dated 2014, indicated the care team will review and document on all insidious and significant weight changes with appropriate referrals to the physician and RD. The RD will make referrals and take actions as necessary. During a review of facility Policy on fortification, dated February 2020, indicated the use of a fortification program to maintain or enhance the nutritional status of residents determined to be at risk by a qualified individual. It further indicated the facility will ensure a fortification program is initiated when there is a nutritional problem to increase caloric intake and better meet individual nutritional needs. During a lunch dining observation on 11/29 at 1:10 pm, and concurrent review of Resident 68's lunch tray ticket showed the resident was on SB6 Fort (Small & bite sized fortified) diet and a house supplement. Resident 68 stated she did not like the food provided however had not informed any staff at the facility. Surveyor observed Resident 68 ate 50% of the lunch meal. During a review of Resident 68's clinical record indicated: Resident 68 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission diet order was a regular diet. Admission weight was 146 pounds. Weight dated 2/1/21 was 151 pounds. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Comprehensive Nutrition assessment dated [DATE], RD 2 documented Resident 68's estimated nutritional needs as 1715 calories and 54 to 68 grams of protein. RD 2 documented current body weight as 151 pounds, with an average oral intake of 56% of the fortified diet, in addition to occasional snacks. RD 2 documented intakes were meeting estimated needs as evidenced by stable weight, intact skin, and no [CONDITION(S)] (swelling caused by excess fluid in the tissues). Based on the nutritional analysis of the facility's meal fortification plan, Resident 68 would need to eat approximately 70% of her meals to meet her estimated nutritional needs. Review of Resident 68's weight record dated 3/1/21 documented a weight of 139 pounds, a loss of 12 pounds (7.9%) in one month which is considered severe. From 3/8 through 8/2/21, Resident 68's weight fluctuated between 131 and 138 pounds. On 9/6/21 Resident 68's weight was documented as 128 pounds, a decrease of 4 pounds. Resident 68 continued to have a gradual continual monthly decline. On 11/1 the weight was documented as 122 pounds for a total weight loss of 29 pounds (19%) in nine months, and 15 pounds (10.9%) in six months, which is considered significant. Cross Reference F641. During Weight and Skin Committee Reviews dated 3/4 and 4/8, the Interdisciplinary Team (IDT) documented recommendations for Resident 68 to receive a house supplement (liquid nutrition supplement) twice a day with meals, and HCMP (High Calorie Med Pass - 2 calories per ml oral nutrition supplement) two ounces (60 ml) twice a day, respectively. Quarterly Nutrition assessment dated [DATE], RD 2 documented Resident 68's current weight as 137 pounds with estimated needs of 1557 to 1869 calories and 62 to 74 grams (g) protein. RD 2 re-estimated Resident 68's nutrition needs based on current weight rather than her usual body weight. RD 2 documented to continue with current plan of care with goal of weight maintenance, rather than to regain lost weight. A Weight and Skin Committee Review dated 6/10/21, RD 1 documented current weight as 132 pounds a five pound/3.6% weight loss for one month. RD 1 documented there was a new open area under the resident's breast from scratching and wound was nonhealing so far. RD 1 recommended to increase HCMP to three ounces (90 ml) three times a day and to start a Multivitamin (MVI) for healing. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Although the HCMP order was increased in quantity it was not increased in frequency as recommended by RD 1 during the Weight and Skin Committee Review notes. Weight and Skin Committee Reviews dated 6/17, 6/24, 7/1 and Quarterly Nutrition assessment dated ,d+[DATE] and 11/3/21, there was no documentation to indicate the error was identified. During an interview with RD 1 and RD 2 on 12/01/21 at 11:10 AM, RD 1 and 2 stated they see residents who trigger for weight loss of 5% or 5 pounds monthly, 2.5% weekly weights, 7.5% weight for 3 months, and 10% for 6 months. RD 1 stated the order on 6/10/21 should have been for HCMP three times a day not twice a day. RD 1 stated we usually double check the order in the system to ensure it is consistent with what we recommended. RD 1 confirmed that order was missed on Resident 68. During an interview with RD 1, RD 2, and RD3 on 12/01/21 at 2:38 PM, RD 2 stated they follow up with the monthly weight and if does not trigger for significant weight loss then they think the intervention is working. RD 2 stated if the weight is triggered again then they will check the chart to see how the intervention is working. The RD's practice of not monitoring insidious weight loss was not in accordance with the facility weight tracking policy.

Based on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 6), documentation on the informed consent for [CONDITION(S)] medication included the specific medication name, dosage, route, and diagnosis/reason for use. For Resident 6, this facility failure resulted in their representative consenting to an unspecified treatment on their behalf. Findings: During a review of the facility's policy and procedure (P&P) titled, [Facility name] Verification of Informed Consent for Psychotherapeutic Medication or Physical Restraint, (undated), the P&P indicated, .the facility has verified that the following material information has been reviewed with the resident and/or the resident's responsible party or legal representative .medication name, dosage, route and diagnosis/reason for use . During a review of Resident 6's Physician Order Sheet (Orders), dated November 2021, the Orders indicated, [MEDICATION(S)] (antipsychotic medication) 50 mg (milligram) tablet (50mg) TABLET Oral (by mouth) .One time daily . During a concurrent interview and record review on 11/30/21, at 9:26 a.m., with a licensed nurse (LN1), Resident 6's [Facility name] Verification of Informed Consent for Psychotherapeutic Medication or Physical Restraint (Consent), dated 5/14/21 was reviewed. The Consent indicated, on 5/14/21, at 3:44 p.m., the consent was obtained and verified with Resident 6's Representative. The Consent also indicated, the Physician's Order for the specific medication, dosage, route, and diagnosis/reason for use was not documented on the form. LN1 stated, The medication, dosage, and route should be identified.

Based on observation, interview, and record review, the facility failed to ensure expired medications were not stored and available for staff use, in one of four medication carts inspected. These failures had the potential for unsafe and ineffective medication administration that can cause harm to the residents. Findings: During a concurrent interview, and inspection of the facility's medication carts, on 11/30/2021 at 3:30 p.m., with the Director of Nursing (DON) and the Director in Training (DIT), the following items were observed: 1. Fiber therapy, dietary fiber supplement, 52 teaspoon doses, net weight (wt) 13 ounces (oz), 368 grams (g), with an expiration date of 10/21. 2. Geri-Lanta, regular strength antacid, anti-gas, 12 fluid (FL) ounces (oz), 355 milliliters (ml), with an expiration date of 9/21. 3. [MEDICATION(S)]/apap (medication to treat pain) tablets 5-325 milligrams(mg) pack, with an expiration date of 11/4/2021. During the concurrent interview with the DIT, the expired items were shown to him. The DIT stated, Yes they are expired. The items were then shown to the DON. The DON stated, Yes they are expired. We should of caught the expired medications prior to the expiration and removed them. During a review of the facility's policy and procedures (P&P), titled, Disposal of Medications, undated, the P&P indicated, in part, Outdated, contaminated, discontinued or deteriorated medications, and the contents of containers with no label shall be destroyed.

Based on interview and record review, the facility failed to ensure one of two sampled residents was free from significant medication error when an unsupervised student nurse (SNA) administered 15 units of insulin (a medication used to treat high sugar levels) to the wrong resident (Resident 2) This facility failure placed Resident 2 at risk for harm due to symptoms of low blood sugar which include confusion, dizziness, sweating, weakness, and headaches. Findings: During an interview on 9/9/19 at 4:27 p.m., the director of nursing (DON) acknowledged on 7/27/19 SNA administered 15 units of insulin to the wrong resident (Resident 2). The DON further acknowledged SNA administered the insulin without supervision of facility staff. During a phone interview with licensed nurse (LN1) on 9/9/19 at 5:00 p.m., LN1 acknowledged SNA went into the wrong room and administered 15 units of insulin to the wrong resident (Resident 2). LN1 stated I saw her (SNA) come out of the wrong room, I didn't see her (SNA) go in. During a review of the clinical record for Resident 2 titled Clinical Notes Report dated 7/27/19 indicated Insulin medication reviewed with SNA and order checked. This writer (LN1) was finishing up talking to another resident who just asked a question when SNA was seen coming out of a resident's (Resident 2) room. When asked, SNA said she administered previously drawn insulin to resident at room she has just been to. The Clinical Notes Report further indicated Education was done to SNA and RP/Son (responsible party, son) informed of event. The facility policy and procedure titled Free of Medication Error Rate of 5% or More/Residents Are Free of Significant Med Errors dated 3/1/18, indicated Medications are administered to residents according to all Federal and State requirements. (Insert facility's name) follow all acceptable standards of care to ensure that medication errors of five percent or greater do not occur and no significant medication errors. The facility policy and procedure titled General Guidelines undated, indicated Residents are identified before medication is administered. Methods of identification may include: Check identification band, check photograph attached to medical record, ask resident for their name if appropriate, verify resident identification with other nursing care center personnel. Review of the facility contract titled Nursing/Allied Health Program Facility Agreement indicated The AGENCY (Insert Facility Name) shall retain professional and administrative responsibility for any services rendered by Students.

Based on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of practice for three of four sampled residents (Residents 76, 180, and 128) when: 1.Resident 76 's oxygen order was not implemented as ordered by the physician.This failure placed the resident at risk for unattended breathing difficulty which can result to a compromised condition. 2.Resident 180's oxygen dose prescription was not administered as prescribed by the physician. This failure has the potential to administer oxygen dose ineffectively which can effect the resident's overall health condition. 3.Resident 128's oxygen humidification bottle (sterile water used to make delivery of oxygen more comfortable) was not dated. This failure had the potential to administer humidified oxygen to the resident from a bottle that can be expired or need to be changed due to infection risks. Findings: 1. During an observation inside Resident 76's room and concurrent interview with a certified nursing assistant (CNA1) on [DATE] at 12:33 p.m., Resident 76 was in bed without a nasal cannula (a device used to administer oxygen). CNA1 confirmed Resident 76 was not receiving supplemental oxygen and stated not on oxygen. During the review of the clinical record for Resident 76 and concurrent interview with the assistant director of nursing (ADON) on [DATE] at 12:50 p.m.,a physician orders [REDACTED]. The ADON indicated the resident should be on oxygen at 3l/min as continous as ordered by the physician. The facility policy and procedure titled Oxygen Procedure undated indicated, Patients that require oxygen as ordered by a physician will be placed on an oxygen concentrator or oxygen tank. Oxygen therapy will be administered as ordered. During an observation on [DATE] at 11:29 a.m., Resident 180 was sitting by the bed in a wheelchair wearing a nasal cannula attached to a humidified oxygen concentrator. The oxygen meter read 4 liters per minute (LPM). During an interview on [DATE] at 11:35 a.m., Resident 180 confirmed he was having difficulty breathing and thought his oxygen was set too high. During an interview on [DATE] at 11:38 a.m., Licensed Nurse (LN7) confirmed the oxygen was set at 4 LPM and the physician ordered continuous oxygen set at 3 LPM. Record review of the physician orders [REDACTED]. 3. During an observation and concurrent interview with licensed nurse (LN2) on [DATE] at 11:37a.m., Resident 128's humidification bottle was not dated. LN2 acknowledged that humidification bottle should be dated. During an interview with LN3 on [DATE] at 10:02 a.m., LN3 confirmed humidification bottle should be dated when put into use. The facility policy and procedure titled Oxygen Procedure undated indicated in part . The equipment will be maintained in a manner to ensure the best possible outcome for the patient. The facility form titled Oxygen Supplies Audit indicated in part . a column to check Humidifier Bottle Changed and Dated.

Based on observation, interview, and record review, the facility failed to: 1) Discard expired food. 2) Not store a used scoop in a food storage container. 3) Ensure used tong handles did not touch food. These failures had the potential to result in residents developing foodborne illness from cross-contamination. Findings: 1) During an observation and concurrent interview with Registered Dietician (RD) and Director of Dietary (DOD) on [DATE], at 9:05 am, in the walk in refrigerator, a bin of Mighty Shakes (nutrition shakes) were observed in refrigerator with no thaw date (Mighty Shakes expire 14 days from thaw date). Mighty Shakes were available for residents to consume. RD and DOD confirmed thaw date is required to be recorded and they are unable to determine expiration date. Review of the facility policy titled Food Storage modified 2014 indicated in part . All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Review of the manufacturer's guidelines indicated in part . shelf life is 14 days when kept refrigerated. 2) During an observation and concurrent interview with RD and DOD on [DATE], at 9:20 am, in the dry storage area, a food storage container (containing cocoa powder) had a used scoop stored inside the container. RD and DOD acknowledged used scoop should not be stored in food containers. Review of the Food Code (YEAR) section ,[DATE].11 indicated in part food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. The handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination. 3) During an observation and concurrent interview with DOD, on [DATE], at 12:25 pm, in the kitchen, used tong handles slid into food containers with onion and container with tomatoes on the steam table. DOD confirmed used tong handles should not touch food. During an interview with RD, on [DATE], at 9:26 am, RD confirmed used tong handles should not touch food. Review of the Food Code (YEAR) section ,[DATE].11 indicated in part food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. The handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination.

Based on interview, observation and record review, the facility failed to develop a care plan (a means of communicating the resident's needs and preferences and how the facility will assist in meeting them) for two of eight sampled residents (Resident 116 and 120): 1. Resident 116, did not have a care plan developed for a wrist brace. This failure placed the resident at risk for further pain and swelling of the wrist due to the inconsistent application of a wrist splint. 2. Resident 120, did not have a care plan developed for smoking. This failure resulted in the resident smoking with no plan in place to address educating them about the potential health related issues associated with smoking or offering them assistance to stop smoking. Findings: The facility policy and procedure titled: Develop/Implement Comprehensive Care Plan dated 3/1/18 indicated, The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 1. During a review of the clinical record for Resident 116 and concurrent interview on 6/19/19 at 10:17 AM, a licensed nurse (LN4) verified the Physician order [REDACTED]. Review of Resident116's Treatment Administration Record (TAR) dated (MONTH) 2019 indicated the application of the splint on (MONTH) 1, 3, 4, 8, 9, 10, 11, 12, 16, 17, and 18. During an observation and concurrent interview with LN4 and Resident 116 at the resident's bedside on 6/19/19 at 11:24 AM, LN4 verified Resident 116 was not wearing a brace on the left wrist. Resident 116 indicated it had been, A long time, since a wrist brace was applied. LN4 looked through Resident 116's belongings and was unable to locate a wrist brace. Resident 116 stated, Ouch, when LN4 examined Resident 116's left wrist. During an interview on 6/19/19, at 11:33 AM, LN4 reviewed the facility and hospice care plans for Resident 116. LN4 stated, No Care Plan, found that addressed wrist brace use. 2. During an interview: on 6/17/19 at 10:43 AM, Resident 120 indicated smoking cigarettes two to three times a day. Resident 120 holds onto their lighter and cigarettes while in the facility and signs them self out of the facility to smoke, Off property, next door. During an interview and concurrent record review with LN4 on 6/19/19 at 2:31 PM, LN4 verified Resident 120 signs them self out of the facility to smoke. LN4 was unable to locate documentation of a Care Plan that addressed the resident's smoking.

Based on observation, interview, and record review, the facility failed to ensure necessary care and services in accordance with professional standards of practice was implemented when a physician's orders [REDACTED]. This failure had the potential to result in increased pain and swelling to the resident's affected wrist. Findings: During a review of the Minimum Data Set (MDS) Assessment (a core set of screening, clinical, and functional status elements which is used for standardized communication about resident problems and conditions within nursing homes) for Resident 116 the BIMS (brief screener that aids in detecting cognitive (thinking, reasoning, remembering) impairment) dated 8/2/18 indicated a score of 15 (cognitively intact). During a review of the clinical record for Resident 116 and concurrent interview with a licensed nurse (LN4) on 6/19/19 at 10:17 AM, LN4 verified the Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) dated (MONTH) 2019 indicated application of the splint on (MONTH) 1, 3, 4, 8, 9, 10, 11, 12, 16, 17, and 18. During an observation and concurrent interview with LN4 and Resident 116 at the resident's bedside on 6/19/19 at 11:24 AM, LN4 verified Resident 116 was not wearing a brace on the left wrist. Resident 116 indicated it had been a A long time, since a wrist brace was applied. LN4 looked through Resident 116's belongings and was unable to locate a wrist brace. Resident 116 stated, Ouch, when LN4 examined Resident 116's left wrist. During an interview and concurrent clinical record review on 6/19/19 at 12:06 PM, a licensed nurse (LN5) verified initialing the TAR dated 6/17/19, shift 1, indicating the application of the brace to Resident 116's left wrist. LN5 stated, That's an error. I did not apply the brace.

Based on observation, interview and record review, the facility failed to ensure controlled medications (substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) were reconcilled (counted correctly) and documented according to the facility's policy and procedure. This failure had the potential for controlled medications to be diverted by licensed staff. Findings: During a concurrent observation, record review, and concurrent interview with licensed nurse (LN6) and director of nursing (DON) on 6/18/19 at 3:43 p.m., a document titled Shift Count, for Cart 1, dated June, 2019, showed no controlled medication counts were documented for 6/1/19 at 6am, for 6/1/19 at 6pm, and for 6/12/19 at 6am. The licensed nurse (LN6) stated it appears no reconciliation had been performed by the off-going and on-coming nurse on those dates and times.The Shift Count sheet was also noted signed off by the off-going nurse with the on-coming nurse on 6/18/19 at 6pm. LN6 acknowledged it should not have been signed yet, and stated, I must have gotten ahead of myself. The DON indicated LN6 should not have signed the log until the night nurse came in and a narcotic count was done together . The facility policy and procedure titled Controlled Medication Storage, undated, states, At each shift change or when keys are transferred, a physical inventory of all Schedule II-IV, including refrigerated items, is conducted by two licensed nurses.

Based on interview and record review the facility failed to ensure PRN (as needed) antipsychotic (medications to manage [MEDICAL CONDITION] (delusions, hallucinations, paranoia, or disordered thought)) and [MEDICAL CONDITION] (any medications affecting the mind, emotions and behavior) medications, after 14 days of use, had an order for [REDACTED]. This failure places the residents at risk for adverse side effects from the continued use of antipsychotic and [MEDICAL CONDITION] medications. Findings: 1. During a concurrent review of Resident 63's clinical record and interview with licensed nurse (LN 1) on 6/19/19 at 11:40 a.m., the physician orders [REDACTED]. The [MEDICATION NAME] order was without an end date or duration for use. The Informed Consent for Psychptherapeutic Medication (IC) was noted signed and dated 8/18/18 (7 months ago). LN 1 acknowledged the [MEDICATION NAME] order had no end date or duration and the IC was signed and dated on 8/18/18, indicating the resident was receiving PRN [MEDICATION NAME] since 8/18/18 without a duration or stop date. Review of the Pharmacist's MMR (medication monthly review) dated 1/2019, indicated . Resident 63 was on [MEDICATION NAME] for over 14 days .recommendation to evaluate [MEDICATION NAME] after 14 days per PRN order .the physician response to the recommendation was left blank. No documentation or response to the pharmacist's recommendation was located in the Resident 63's clinical record. During an interview and concurrent review of Resident 63's clinical record with LN1 on 6/19/19 at 2:00 p.m., LN 1 acknowledged the presence of a pharmacist's recommendation and indicated unable to find documentation for the rationale to continue the PRN [MEDICATION NAME] after the 14 days. During an interview and concurrent review of Resident 63's clinical record with the director of nursing (DON) on 6/19/19 at 2:39 p.m., the DON acknowledged yes (by nodding) the physician order [REDACTED]. The DON further indicated the facility could have called the physician, get the order changed, and document a rationale for the continued use of the [MEDICATION NAME]. 2. During a concurrent interview and review of the clinical record for Resident 72 with the DON on 6/19/19 at 2:39 p.m., the DON (Director of Nursing) acknowledged The physician's orders [REDACTED]. The Facility policy and procedure titled Drug Regimen Is Free From Unnecessary Drugs/Free From Unnecessary [MEDICAL CONDITION] Meds/PRN Use dated 8/26/2012 , indicated .In certain situations, [MEDICAL CONDITION] medications may be prescribed on a PRN basis, such as while the dose is adjusted, to address acute or intermittent symptoms or in an emergency .all PRN [MEDICAL CONDITION] and antipsychotic orders will have the maximum daily doses written in the order note section .PRN orders for [MEDICAL CONDITION] medication excluding antipsychotics: Limitation- for 14 days, exception- order may be extended beyond the 14 days if the attending physician believes it is appropriate to extend the order, required action- attending physician should document the rationale for the extended time period in the medical record and indicate a specific duration .PRN orders for antipsychotic medications only: Limitation-14 days, exception- none, required action-if the attending physician wishes to write a new order for PRN antipsychotic, the attending physician must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Based on observation and interview, the facility failed to maintain a schedule III medication in a permanently affixed compartment. This failure had the potential for schedule III medications to be illegally removed from the facility. Findings: During a concurrent observation and interview with the director of nursing (DON) on 6/18/19 at 4:49 p.m., a schedule III medication, [MEDICATION NAME], also known as Dronabinol (a schedule III medication used to treat nausea and vomiting caused [MEDICAL CONDITIONS], also used to treat loss of appetite and weight loss in patients [MEDICAL CONDITION], and is a man-made form of the active natural substance in marijuana) was stored in a small, single locked, non-affixed refrigerator in the unlocked nursing station. DON confirmed the refrigerator was not affixed, by easily sliding the refrigerator across the floor.

Based on observation, interview, and record review the facility failed to ensure food and ice were stored, prepared, distributed and served in accordance with professional standards for food service, when: 1. The ice machine was not maintained in a clean condition; 2. There was no system to monitor the cooling of ambient foods; 3. Flour was stored in a manner that ensured freshness of the product; 4. Meal trays and equipment were stored wet; 5. Dry storage room temperatures were not maintained. These practices have the potential to result in the growth of microorganisms and could cause food borne illness. The facility census was 135. Findings: 1. During a joint observation in the presence of the Maintenance Director and concurrent interview on 07/11/18 at 09:34 A.M., a black hard spot was observed inside the ice machine on the edge of water tray where there was water dripping into the cuber. The Maintenance Director acknowledged the black hard spot on the edge of the water tray where there was water dripping into the ice machine. Review of the ice machine manufacturer's directions showed More frequent cleaning and sanitizing may be required in some water conditions. Review of the ice machine log, showed it was externally cleaned and sanitized on 6/11/18, and internally cleaned and sanitized on 4/10/18. 2. According to the Food and Drug Administration (FDA) Food Code (YEAR), Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5 degrees C (41 degrees F) or less if prepared from ingredients at ambient temperature, such as .canned tuna P. During an observation of the reach in refrigerator on 07/10/18 at 08:46 A.M., the temperature of the tuna salad dated 7/9 was measured with a thermometer to be 40.8 degrees F. An interview with the Dietary Aid (DA) on 07/11/18 at 09:51 A.M. stated she makes the tuna salad. She stated when she makes it she uses the canned tuna from the dry store room. The DA confirmed there is no cool down tracking system to monitor the cool down process for ambient (Room temperature) foods after they are prepared and placed in the refrigerator. An interview was conducted with the Registered Dietitians RD 1 and RD 2 on 7/11/18 at 3:57 PM, they stated there was no policy regarding the cooling of ambient foods or system to monitor them. They stated the foods needed to get to 41 degrees Fahrenheit (F) or less within four hours. 3. Review of the undated facility policy and procedure (P&P) titled Food Storage, showed 4. Plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. 8. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. old stock is always used first (first in - first out method). c. Food should be dated as it is placed on the shelves. During a joint observation and concurrent interview with the Director of Dietary Services (DDS) on 07/10/18 at 08:50 A.M., an undated plastic bin half full with flour was observed. The DDS stated the bin had been recently washed and the date had not been replaced on the bin. During an observation and concurrent interview on 07/10/18 at 10:19 A.M. with the DDS, RD 1, and RD 2. It was observed that there was more flour in the bin than before, flour was now up to the top of the bin. When asked about the flour, the DDS stated The stock guy must have put more product in the bin. The DDS confirmed they should wait until product is finished then clean the bin before adding more product and then label and date it. RD 2 also stated the new product should not go on top of the old product. 4. Review of the facility P&P titled General HACCP Guidelines for Food Safety, undated, showed 10. Dishwashing; Air Dry - . do not stack dishes immediately before or after washing. a. During an observation and concurrent interview on 07/10/18 at 10:19 A.M. with the DDS, Registered Dietitian 1 (RD 1), and Registered Dietitian 2 (RD 2.) Cornmeal, flour, sugar, and thickener were observed in plastic bins with lids. Four of the six plastic bins had lids with water drops on the inside of the lids. Three of the six lids had food product in it. The DDS stated they should be air dried before being used. b. During an observation on and concurrent interview on 07/12/18 at 9:45 A.M., a sample of ten meal trays were stacked in a cart ready for use. Ten of the ten trays were observed and had water drops on the bottom and top of them. RD 2 stated she would expect the trays to be dried before being stacked. 5. Review of the undated facility policy and procedure titled Dry Storage Areas, indicated: 9. Storeroom temperature should be 50° to 70° F. During initial tour of the facilities dry storage area on 07/10/18 at approximately 9 A.M. the dry storage area was noted to be 76 degrees F. On 7/10/18 at 10:19 A.M. dry storage area was noted to be 78°F. An observation of the dry storage area temperature on 07/11/18 at 03 P.M., showed temperature on thermometer to be at 74°F. An interview with RD 2 on 07/11/18 at 03:01 P.M., confirmed that Excessively hot is greater than 80°F and ideally 50-70°F for dry storage area. She also confirmed that no log is kept for temperatures in the dry storage area.

Based on observation, interview, and record review, the facility failed to ensure physician orders [REDACTED]. 1. Aspirin (medication that acts as a blood thinner) was administered as ordered for one unsampled resident (Resident 112) 2. Oxygen was administered properly per physician orders [REDACTED]. This facility failure placed three residents at risk for harm. Findings: Fundamentals of Nursing, Potter, and Perry, Seventh Edition, page 336, physician's orders [REDACTED]. 1. During medication pass observation and a concurrent interview with licensed nurse (LN 1) on 7/11/18, at 7:58 a.m., LN 1 verified six medications were administered to Resident 112. A review of Resident 112's clinical record on 7/11/18 and 11:52 a.m., indicated Resident 112 was admitted to the facility on [DATE] for multiple [DIAGNOSES REDACTED]. The physician order [REDACTED]. During an interview and a concurrent record review with a licensed nurse (LN 2) on 7/11/18, at 11:54 a.m., LN 2 verified the finding and stated, Aspirin 81 mg has not been given since 6/19/18. The Aspirin should have been given when the medication was ordered by the doctor. The facility's undated policy and procedure titled, General Guidelines, indicated, Medications are administered in accordance with written orders of the prescriber. 2. During an observation and concurrent interview with a licensed nurse ( LN 3) on 7/10/18 at 12:30 P.M., Resident 425 was lying in bed. The oxygen was set at 3 L/m (liters per minute). LN 3 confirmed the oxygen was set at 3 L/m and stated, It should be at 2. During Resident 425's record review, the physician order [REDACTED]. During observation and concurrent interview with LN 3 on 7/10/18 at 12:57 P.M., LN 3 confirmed Resident 93 was lying in bed with oxygen set at 3.5 L/m. During Resident 93's record review, the physician order [REDACTED]. Notes: Continuous. During review of policy and procedure titled: F695 Oxygen Administration, undated, indicated: .the oxygen therapy will be administered as ordered.

Based on observation, interview, and record review, the facility failed to ensure one of 33 sampled residents (Resident 93) received food items consistent with the physician ordered therapeutic diet (pureed-a paste or thick liquid suspension usually made of cooked food ground finely). This facility failure resulted in the potential for Resident 93 eating the sandwiches and aspirating (to take into the lungs) or choking. Findings: During an observation and concurrent interview on 7/11/18 at 12:49 P.M., Resident 93 had received a lunch tray with a pureed diet. The central supply coordinator (CSC) delivered two individually wrapped egg salad sandwiches and placed on Resident 93's over bed table. The CSC stated, I don't know, when asked what type of diet Resident 93 had ordered. During an interview on 7/11/18 at 3:00 P.M., the CSC stated, I usually try to help answer call lights. Resident 93 seems with it so I got the sandwiches Resident 93 requested. I should have asked the nurse. During an interview on 7/11/18 at 3:30 P.M., the director of nursing (DON) confirmed non-nursing staff, including the CSC, had not been in-serviced about their limitations assisting residents when answering call lights. During a review of Resident 93's physician's orders [REDACTED]. During a review of the central supply coordinator's job description on 7/11/18 at 4:30 P.M., duties and responsibilities did not address assisting with resident care.

Based on observation, staff interview and review of facility documents, the facility failed to: 1)ensure food accommodated residents preferences when the facility did not have pasteurized shell eggs for one resident (Resident 67); and 2) provide an alternative of similar nutritive value when they did not like the regular food item for one resident (Resident 428). These had the potential to restrict the resident's right and preferences for a choice of having soft cooked eggs and for inadequate nutrition. The facility census was 135. Findings: 1. On 7/10/18 starting at 8:46 AM the initial kitchen tour was conducted. It was observed in the reach-in refrigerator that there was only non-pasteurized shell eggs. On 7/10/18 at 10:26 AM an interview was conducted with the DDS, and Registered Dietitian (RD) 1 and RD 2. They confirmed they do not have pasteurized shell eggs in house. They stated they do have pasteurized liquid eggs and the shell eggs are used for baking products. They stated they do not allow the residents to have an option of soft cooked eggs. If they request soft cooked eggs, then they will meet with the resident to give them options of hard boiled eggs or omelets. They stated the residents usually are happy with the omelet option. On 7/10/18 at 11:33 AM an interview was conducted with Resident 67 regarding the food. The resident stated she doesn't like the powdered eggs and likes real eggs. She stated she likes fried eggs but they don't have real eggs so she can't have them. On 7/11/18 at 3:01 PM an interview was conducted with the RD 1 and RD 2. They stated they have not bought the pasteurized shell eggs because if they had to serve it for everyone then they would need more staff in the kitchen. Review of the facility policy and procedure (P&P) titled General HACCP Guidelines for Food Safety dated 2014, showed that the use of pasteurized shell eggs or egg products is preferable and the use of pasteurized eggs for safe consumption of undercooked eggs (sunny side up fried eggs, soft cooked eggs, etc.). Not purchasing pasteurized shell eggs limited the rights and preferences for the residents at the facility to have soft cooked eggs. 2. Review of the lunch meal for 7/11/18 showed meatloaf, dinner roll, green beans and mashed potatoes with gravy. On 7/11/18 at 12:17 PM an observation of the lunch tray showed Resident 428's tray contained a half of a roll, meatloaf, and green beans. It was then put into the meal cart to go to the unit. Review of the tray ticket showed Resident 428 was on a regular, low concentrated sweets diet with half portion carbohydrates. It also showed she disliked mashed potatoes. On 7/11/18 at 12:18 PM a joint observation of the lunch tray was conducted and an interview with the RD 2. RD 2 acknowledged and confirmed the tray needed an alternate in place of the mashed potato. Review of clinical record for Resident 428 showed the physician diet order dated 7/9 showed low concentrated sweets, regular, no desserts half portions carbohydrates. Not giving an alternate of similar nutritive value when a resident did not like the regular food item could lead to inadequate nutrition.

Based on record review and interview, the facility failed to ensure, one of three sampled residents (Resident 1), was supervised by facility staff while using a cigarette lighter. This failure resulted in Resident 1 igniting his clothing and wheelchair, causing second degree (partial thickness of skin) and third degree (destruction of all the layers of skin) burns to his torso and left upper arm (15% of body surface) which resulted in a hospital stay of 30 days. During the hospitalization , on 11/7/17 and 11/10/17, Resident 1 underwent two surgical excision and homografting (a skin graft using cadaver skin to temporarily covering for excised (cleaned) wound surfaces) before autograft (permanent) placement. On 11/14/17, Resident 1 had a split thickness skin grafts harvested from his lower extremity and placed on the affected areas. Findings: Facility policy and procedure titled, Smoking Procedure, dated 8/26/12, indicated, in part, The purpose of this procedure is to provide maximum safety to all residents at all times. It is the intent of the facility to provide an environment to allow those residents who wish to smoke, the opportunity to do so in a safe environment, with optimal safety to themselves, other residents, volunteers, visitors and staff members. These procedures apply to all residents, volunteers, visitors and staff .Facility will maintain a safe environment by ensuring that: Smoking materials will be kept in a designated area accessible only by staff. Record Review of the facility face sheet (form that includes residents information and demographics) indicated Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Resident 1's comprehensive assessment, using the Minimum Data Set (MDS), dated [DATE], indicated Resident 1 has BIMS (Brief Interview for Mental Status) score of 7 (severely impaired cognitively-trouble concentrating or making decisions that affect their everyday life) and had upper and lower extremity functional impairment, used a wheel chair, needed no assistance or support for locomotion on or off the unit, and had active [DIAGNOSES REDACTED]. Clinical notes report written by a licensed nurse (LN 4), dated 11/6/17, at 11:08 a.m., stated .was alerted to smoking patio. Upon arrival resident (Resident 1) noted fire being extinguished by staff. Clothing removed and observed burns to his (Resident 1) lateral back and under left arm .Per staff who responded resident (Resident 1) was not seen smoking a cigarette. Resident (Resident 1) verbalizes that he 'wasn't smoking at time of the fire and that it was from the lighter that was in his pocket .it must've sparked.' First aid administered .911 called and requested a code 2 (immediate transfer for urgent condition) transfer to (name of) hospital. Clinical notes report written by LN 1, dated 11/6/17, at 4:24 p.m., stated, .Clutched in resident's (Resident 1) right hand was a light gray/white colored lighter which he (Resident 1) did not want to give to nursing staff. Using verbal distraction lighter was obtained .Visibly observed during this time was approximately 10% BSA (body surface area) that was located on resident's (Resident 1) left posterior trunk extending towards neck region. Affected area was observed with pale yellow/whitish colored tissue in center and as it extending toward visible wound edges it became darker in appearance and skin was pulled away/rolled inward with red superficial tissue exposed. Clinical notes report written by the Director of Nursing (DON), dated 11/6/17, at 4:50 p.m., stated .Assessment done and noted resident (Resident 1) to have burns to the left upper back as well as the inside surface of the left arm, approximately 14-18% BSA. Noted areas of open blisters to periphery of burn. Areas of full thickness burn noted, appearing pale white in between areas of reddened partial thickness burn. Review of Resident 1's interdisciplinary team conference/care plan review, dated 11/8/17, indicated on 11/6/17 Resident 1, a long term resident with a history of traumatic brain injury (occurs when an external force injures the brain) was outside on the smoking patio, when discovered his clothing was on fire. Resident 1 was not given any cigarettes prior to incident . was not smoking being that he was out of cigarettes but had a lighter . IDT believes that resident may have been playing with his lighter which he kept in his right hand and his jacket caught on fire .911 called and requested a code 2 transfer to (name of) hospital. During an interview on 12/20/17, at 2:20 p.m., the MDS nurse reported Resident 1 did not have use of his left arm and hand, but was able to propel himself in a wheelchair. Resident 1's Psychological Assessment, performed by a clinical psychologist, dated 1/11/13, indicated Resident 1's mental status was impaired . lacked mental ability and insight. Resident 1's Mental Status Evaluation, performed by a psychiatrist on 2/17/14, stated Resident 1 .has no ability to control his impulses .to behave almost childlike .Insight is poor. Judgment is poor. Resident 1's Smoking Evaluation form, dated 9/8/17, indicated Resident 1 was assessed by the facility to have a score of 9 which classified Resident 1 by the facility not to be an independent smoker. A note entered on the form by licensed nurse (LN 3) stated, Nurse to assist in management and storage of smoking materials. Physician's note, dated 9/13/17, at 4:29 a.m., indicated Resident 1 had a history of [REDACTED]. The physician noted, Seizure reported 9/10/17. physician's orders [REDACTED]. Resident 1's [DIAGNOSES REDACTED]. Resident 1's care plan for smoking, effective 6/16/15, indicated interventions in part, Resident does require nursing to assist with management of smoking materials and storage d/t his Fathers request. Resident 1's care plan for traumatic brain injury and memory loss, effective 6/16/15, indicated interventions included, assisting him to location; remind him of what is going on as needed related to memory loss; assist in decision making by giving simple choices; attempt to calm and redirect if he (Resident 1) is having an angry outburst, and staff will keep smoking materials in designated area. During an interview on 12/20/17, at 2:20 p.m. the DON, the MDS nurse, and LN 2 indicated smoking materials included cigarette lighters as well as cigarettes. Inter-disciplinary team (IDT) Conference notes, dated 7/10/17, at 9:38 a.m., indicated, in part, per father's request, require nursing to assist with management of smoking materials and storage. In an interview on 12/19/17, at 5:15 p.m., Resident 1's parent reported, as being Resident 1's decision maker and responsible party, Resident 1 should not have been allowed to have a cigarette lighter unsupervised, and as a result Resident 1 had spent five weeks in the hospital undergoing three skin-graft surgeries for burns. During an interview on 12/20/18, at 2:30, the facility's social services assistant (SSA), acknowledged Resident 1 was not able to make independent decisions. In an interview on 12/20/17, at 1:20 p.m., a certified nursing assistant (CNA 1) indicated he heard yelling and discovered Resident 1 alone on the smoking patio, aflame, with a cigarette lighter in his hand. CNA 1 yelled for help and ran onto the patio to put out the flames. Another staff member arrived and sprayed the flames on Resident 1 and his wheelchair with a fire extinguisher. When interviewed on 11/15/17, at 3 p.m., CNA 2 indicated she heard Resident 1 scream and swear loudly. CNA 2 extinguished the flames on Resident 1. Resident 1's clothing was removed and CNA 2 observed burns on Resident 1's left back and left arm. During an interview on 11/8/17, at 3:25 p.m., LN 1 indicated the fire was out when LN 1 arrived. LN 1 observed a cigarette lighter was in Resident 1's right hand. An ambulance took resident to the hospital and later to a burn unit. The ambulance record # 7- 0, indicated response priority was a 2, the call was received at 10:32, and first contact was at 10:43, and transport was at 11:04. Written narrative stated, he (Resident 1) had a lighter .2nd degree burns to the left side of back laterally from shoulder to abdomen in a 3 inch wide line (4 percent) as well as one percent to left elbow and forearm area . Review of Resident 1's Emergency Department (ED) note, dated 11/6/17, at 3:59 p.m., indicated Resident 1 arrived with 15 % of body surface burned, pain and burns to his left side, and was to be hospitalized at the burn center. Discharge summary from the burn center, dated 12/6/17, indicated, while hospitalized from [DATE] to 12/6/17, on 11/7/17 and 11/10/17, Resident 1 underwent two surgical excision and homografting; and on 11/14/17, Resident 1 had a split thickness skin grafts harvested from his lower extremity and placed on the affected areas. Resident 1 will require compression garments for scar management . PT/OT (physical and occupational therapy) for strengthening and ROM (range of motion) of LUE (left upper extremity)/axillary region.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 16) was free from verbal abuse by facility staff. Resident 16 suffered anger and did not feel safe after receiving obscene gestures and words related to his disability by a certified nursing assistant (CNA 1). As a result, Resident 16 suffered repeatedly feelings of an unsafe environment and anger. Findings: Review of comprehensive assessment dated [DATE] revealed, Resident 16's cognition as able to report correct year and month, able to repeat three words after first attempt, and able to recall two words without cueing. Resident 16's ability to hear and see were adequate and needed extensive assistance with bed mobility and transfers. Resident 16's legs were impaired and used a wheelchair for mobility. During an interview on 8/11/15 at 1:30 p.m., licensed nurse (LN 4) explained Resident 16 had difficulty communicating and sometimes, became frustrated when unable to communicate. When frustrated, Resident 16 became loud and yelled. Resident 16 understood everything well but could not speak clearly. During an interview on 8/12/15 at 10:30 a.m., Resident 16's sister revealed, Resident 16 became frustrated and loud when he could not communicate the words. Resident 16 can make his needs known through words, gestures, and writing. During an interview on 8/11/15 at 11 a.m. ,the ombudsman (residents' advocate) revealed, Resident 16 had tried to tell her something during her visit on 7/25/15 at 2:15 p.m. Resident 16 was angry and had given her a drawing to explain himself. He was angry at one of the male nursing staff. The ombudsman notified LN 7. The ombudsman explained to LN 7 Resident 16 was angry at one of the male nursing staff indicating that staff was giving Resident 16 a hard time. During a concurrent observation and interview on 8/11/15 at 11:30 a.m., Resident 16, in the presence of the ombudsman, revealed a nursing employee, he verbally described as a big, strong, bald man, had been making a hand gesture to Resident 16, with his middle finger and saying Screw you and Stroke, repeatedly, in a sarcastic and taunting tone. This interview was accomplished by both surveyor and ombudsman asking Resident 16 questions, to repeat statements, spell out words, and explain a drawing of a large and a small person-shaped figures he had drawn for the ombudsman in an earlier attempt to communicate his complaint. In the drawing, Resident 16 identified the large figure as the Big bald, strong man and himself, as the smaller figure by pointing at himself. When asked if the big figure hurt the small figure he said, yes. During this interview process, a male employee (CNA 1) walked by Resident 16's door to the hallway. Resident 16's facial expression changed. Resident 16, with widened eyes, pointing at CNA 1 said adamantly, Yes, yes! Him! (CNA 1). When asked again what that person did to Resident 16, Resident 16 picked up his call button, pushed it and pointed to the doorway (as if to indicate whenever he asked for help, CNA 1 would respond). Resident 16 said CNA 1 would say to Resident 16 Screw you! He gestured with his middle finger raised and said again, Stoke? Stroke?, in a sarcastic tone of voice. He added All the time! indicating this was a common practice of CNA 1 to Resident 16. During an interview on 8/11/15 at 5 p.m. with the administrator present, Resident 16 repeated this complaint without variation. Resident 16 confirmed CNA 1 made him feel angry and he did not feel safe with CNA 1 still working at the facility. During an interview with CNA 1 on 8/13/15 at 12 p.m. revealed, CNA 1 found it difficult to work with Resident 16 because he became loud when frustrated and sometimes yelled at him. CNA 1 stated,The shouting really gets to me.

Based on observation, interview, and record review, the facility failed to adequately supervise the functional status of the self release seat belt with alarm for one of 24 sampled residents (Resident 5). This failure resulted in Resident 5 falling from his wheelchair, sustained laceration of the head, requiring transfer to a hospital for treatment and application of eight staples. Findings: Observation on 8/4/14 at 2 p.m. revealed Resident 5 to be in his room seated in a wheelchair. Surgical staples were visible on Resident 5's forehead. Record review beginning 8/4/14 at 2:15 p.m. revealed Resident 5 had sustained two serious injuries due to fall in February and August 2014. Review of physicians orders dated 8/1/14 revealed Resident 5 had [DIAGNOSES REDACTED]. Review of a quarterly comprehensive nursing assessment dated [DATE] revealed Resident 5 had impaired memory, confusion, and a history of aggressive behaviors. Resident 5 required staff assistance with all activities of daily living, and ambulated using a wheel chair due to unsteady gait. Review of interdisciplinary progress notes dated 2/4/14 at 2:45 p.m., titled, "Addendum", revealed Resident 5 fell to the floor in his room on 2/4/14 at approximately 1:50 p.m. Resident 5 sustained a laceration to the back of his head with complaint of 10 out of 10 pain scale. Resident 5 was transferred to a community hospital for treatment of [REDACTED]. Review of interdisciplinary team (IDT) conference notes dated 2/5/14 revealed the facility attributed the cause of Resident 5's fall on 2/4/14, to be that, "IDT concurs that resident chose to remove (tab) alarm, do unassisted transfers, walk to bathroom from bedroom... then fell to side..hitting head on wall as E/B (evidenced by) blood on wall. He crawled on hands and knees to bedroom and called for help...." Resident 5 was described to have poor safety awareness and impulse control. The response of the facility included implementation of self release alarmed seat belt (SRASB), "To alert staff." Review of a care plan dated 11/26/13, titled "Potential injury from falls.....identified Resident 5 as a fall risk, and tab alarms ( a plastic box-like device which affixes by a string to a resident's clothing or bedclothes and alarms when the string is pulled) were implemented when Resident 5 was in bed as well as his wheelchair." The care plan identified the new intervention of a self release alarmed seat belt (SRASB) after a fall 2/5/14, which Resident 5 could "Remove at will, but not always on command..." Review of interdisciplinary progress notes dated 8/2/14 at 8:15 p.m., documented by a licensed nursing staff, identified Resident 5 was observed lying face down on the floor in his room, with a 2 inches laceration to the top of his head. Resident 5 was unable to describe how he fell and complained of headache. Resident 5 was transferred to a community hospital for treatment. Review of a "Re-entry Assessment", dated 8/2/14 at 11:30 p.m., revealed Resident 5 returned from a community hospital with 8 staples applied to the laceration on the top of his head. During an interview on 8/6/14 at 1 p.m., licensed nurse (LN 3), who responded to Resident 5 after his fall on 8/4/14, identified Resident 5's fall to be attributed to the SRASB not having been applied to Resident 5's wheelchair. During an interview on 8/7/14 at 3:05 p.m., a certified nursing assistant student (CNA-S) explained, she had been assigned the care of Resident 5 on 8/2/14. At approximately 9 p.m., another CNA asked CNA-S to get Resident 5 from the hallway outside his room, and put him back to bed. CNA-S explained, she found Resident 5 in the hallway asleep with a yellow blanket over his lap, sitting in his wheelchair. CNA-S said, she transported Resident 5 into his room, and as they were passing the doorway, Resident 5 leaned forward and fell face first onto the floor. CNA-S further explained the SRASB must not have been applied, or had not been working, because if Resident 5 had removed it himself, the alarm would have sounded. During an observation and concurrent interview on 8/7/14 at 9 a.m., CNA 2 demonstrated Resident 5's SRASB application. The seat belt alarm was attached at the upper back of the wheelchair, with a cord attached and descending to the back of the wheelchair seat. This cord was attached to the seat belt of Resident 5. CNA 2 confirmed that the alarm would sound if the seatbelt was unbuckled, or if the device became disconnected from the wheelchair.