Every finding on record at New Castle Nursing & Rehab

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an effective pest control program to ensure the facility remained free of pests. Observations conducted from 01/21/2020 through 01/24/2020, revealed flying insects throughout the building, which included resident rooms 105, 106, 107, 108, 110, 111, 117, 120, 121,122, 124, 127, and 129. In addition, observations revealed the flying insects in the facility's corridors and kitchen area. The findings include: Review of the facility's policy titled, Pest Control, revision date of May 2008, revealed the facility maintained an effective pest control program. Continued review revealed pest control services were provided by a contracted vendor. Per the policy, the facility's maintenance services assisted, when appropriate and necessary, in provision of pest control services. Review of the facility's policy titled, Quality of Life, Homelike Environment, revised date of May 2017, revealed residents were to have a safe, clean, and comfortable environment. Per the policy, a clean, sanitary, and orderly environment was the desired characteristics for the facility. Review of the Commercial Pest Management Service Agreement, revealed services were initiated May 2019, and extended through May 2020. Review revealed the Agreement automatically renewed unless the facility allowed it to expire. Per the Agreement, flying insects were in the pest exclusions section, signed and dated 05/01/2019. Continued review revealed the Agreement service specifications and instructions included general pest control for the nursing home (facility), to include service in the kitchen, dining room, and laundry room areas on a monthly basis. In addition, the Agreeement revealed services were to be provided in individual rooms on an as needed basis. Review of the Pest Control Vendor's Details of Service document, dated [DATE], revealed food debris was found on the wall outside of the dish room window, as documented in the service observations section. In addition, the Pest Control Vendor's Details of Service document also revealed the vendor's observation identified food debris were on the baseboards, and service provider documented this was a breeding environment for fruit flies. Review of the Pest Control Vendor's Details of Service document, dated 01/16/2020, revealed the service provider had documented in the service observations that food debris was identified on the wall outside of the dish room window. In addition, the Vendor's service provider noted food debris was identified against the baseboards. Per review of the Pest Control Vendor's Details of Service document the service provider had documented the food debris was a breeding environment for fruit flies. Observation, on 01/21/2020 at 11:56 AM, revealed numerous large flying insects flew in and out of the sink for room one hundred and twenty-nine (129). The large flying insects flew into the surveyor's mouth with the in section of the sink. Observation, on 01/21/2020 at 11:59 AM, revealed the north hallway contained copious large flying insects in the open area of the hall. Further, observation revealed staff swiped at the bugs during medication pass. Observation, on 01/21/2020 at 12:16 PM, revealed resident room number one hundred and eleven (111) bathroom light fixture contained numerous dead black objects. Observation, on 01/21/2020 at 12:29 PM, revealed resident room one hundred and seven (107) bathroom light fixture contained numerous black objects with wing like texture to the side. Observation, on 01/21/2020 at 12:30 PM, revealed resident room one hundred and five (105) bathroom light fixture contained numerous black objects with wing like texture to the side. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 11:04 AM, revealed two (2) tiny, flying insects (which had the appearance of being gnat like) in the room. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 11:19 AM revealed a black flying insect landed on the lavatory (sink) in the resident's room. Interview with Resident #40 while seated in his/her recliner, in room [ROOM NUMBER], on 01/21/2020 at 11:19 AM, revealed he/she did not like bugs being in his/her room. Resident #40 stated he/she was fearful of bugs. Continued observations of room [ROOM NUMBER] and 108's shared bathroom, on 01/21/2020 at 11:19 AM, revealed a dark colored insect on the bathroom wall, near the ceiling corner. Observation in the corridor, near the entrance of room [ROOM NUMBER], on 01/21/2020 at 11:58 AM, revealed a black flying insect in the hallway. Observation of the dining room drop lighting fixtures, on 01/21/2020 12:42 PM, revealed six (6) of the eight (8) light fixtures contained what appeared as dead insects in the fixtures. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 2:29 PM, revealed two (2) black winged bugs located on the privacy curtain located at the entrance to the room. Observation of resident room [ROOM NUMBER], on 01/22/2020 at 8:45 AM and at 9:06 AM, revealed flying insects in the room. Observation of resident room [ROOM NUMBER], on 01/22/2020 at 8:50 AM, revealed winged insects located on the bathroom door. Continued observation revealed additional winged insects flew out of the bathroom as the resident re-entered his/her room from the bathroom. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 11:04 AM, revealed two (2) flying insects (which appeared gnat like) in the resident's room. Further observation of resident room [ROOM NUMBER], on 01/22/2020 at 08:57 AM, revealed a black flying insect which had landed on the ceiling. Interview with Resident #28, who resided in room [ROOM NUMBER], during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed the resident had experienced gnats flying into his/her mouth while he/she was sleeping. Continued interview revealed Resident #28 stated it was terrible when the gnats had flown into his/her mouth. Per interview, the resident stated he/she had spit the gnats out, and rinsed his/her mouth. According to Resident #28, he/she had told the nurse about the gnats, and asked her to do something about it. Further interview revealed however, the nurse never returned to do anything about the gnats. In addition, Resident #28 stated I have to try to keep my mouth closed to keep the gnats out of my mouth. Interview with Resident #38 during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed he/she continued seeing gnats in the building. Interview with Resident #127 during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed the gnats were still in his/her room. Interview with Resident #23 during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed the gnats were also in his/her room. Observations in the bathroom of resident room [ROOM NUMBER], on 0[DATE]20 at 8:51 AM, revealed four (4) insects, flying from the waste container, and into the toilet bowl area. Continued observation revealed flying insects landed on the ceiling, and upper walls in the bathroom. Further observation revealed a strong, urine-like odor was in the bathroom. In addition, observation revealed the sealer on the floor around the base of the toilet bowl was discolored with dried orange, yellow, and brown stains. Interview with Certified Nursing Assistant (CNA) #3, on 0[DATE]20 at 8:55 AM, revealed gnats were frequently found in the bathroom of resident room [ROOM NUMBER]. She stated the gnats were an ongoing issue in the residents' room. Per interview, the bathroom smelled of urine, which did not help the situation with the gnats. Further interview revealed housekeeping staff cleaned the resident bathrooms every day, but the urine smell stayed. Interview with Registered Nurse (RN) #1, on 0[DATE]20 at 9:15 AM, revealed there were gnats continually flying around inside the facility. She stated the gnats were usually in the sink areas. According to RN #1, she and other staff usually let the housekeepers know about where the gnats were located and they cleaned up those areas. She reported the facility had a resident friendly spray the housekeeping or maintenance staff used to get rid of the gnats. Further interview revealed she had seen many gnats during the holiday season with all the fruit present. Observation of resident room [ROOM NUMBER], on 0[DATE]20 at 9:30 AM, revealed flying insects located on the curtains. Continued observations revealed resident rooms 124, 125 and 126 also had flying insects located within the rooms. In addition, observation of resident room [ROOM NUMBER] revealed the bathroom light fixture contained an which appeared as dead. Interview with Housekeeper (HSKP) #1, on 0[DATE]20 at 10:25 AM, revealed the facility had an ussue with gnats. She stated if cited she would spray the area and then she notified her supervisior. Interview with the Housekeeping Supervisor, while in the soiled utility room, on 0[DATE]20 at 10:25 AM, revealed gnats were here and there throughout the facility. She revealed the housekeepers and herself had sprayed for the insects in attempt to get rid of them. Per interview, she only used the spray for the gnats when residents were not in the same location. Interview with HSKP #2 on 0[DATE]20 at 10:35 AM, revealed she cleaned offices, the lobby, the Nurse's Station, and resident rooms. She stated she did see a few gnats in the facility. Per interview, she had a product they used on the flying insects when she saw them. According to HSKP #2, she had seen the gnats in resident rooms before. Continued interview revealed she had not reported anything about the flying insects, she had observed in the facility, in the maintenance binder located at the Nurse's Station. She stated she just tried to take care of the situation herself when she saw the gnats flying around. Further interview revealed she had not documented in the maintenance binder when other staff had also reported seeing the flying insects. Telephonic interview with Licensed Practical Nurse (LPN) #6, on 01/24/2020 at 11:07 AM, revealed she frequently took care of the residents residing in resident room [ROOM NUMBER]. She stated the bathroom in room [ROOM NUMBER] had both odors and gnats located there. In addition, she stated she worked nights and had not seen anyone spraying for gnats on night shift. Observation during the environmental tour on 01/24/2020 at 2:30 PM, revealed the dish washroom had flying insects located in it. Continued observation revealed a pan which contained water located under the dishwasher drain pipe. Interview with the Administrator on 01/24/2020 at 4:31 PM, revealed the facility currently had a pest control contract. He stated they were aware resident rooms had gnats and bugs present. He stated they had especially had a problem during the holiday season with the gnats, as there was more fresh fruit in the building at that time. According to the Administrator, the facility had not be able to identify the source or cause of the gnats.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for twelve (12) of thirty-five (35) residents, Resident #1, #2, #3, #4, #15, #24, #28, #41, #46, #51, #200, and #153. The findings include: Interview with the MDS Coordinator, on 12/05/18 at 3:30 PM, revealed the facility did not have a policy related to completing MDS assessments, but the facility followed the RAI guidelines. Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 12/04/18, revealed twelve (12) of thirty-five (35) MDS records were transmitted late. The facility received warning error message -3810a, record submitted late, submission date was more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment (A0310A equals 01,03 04, or 05) for Resident #24, #200 and #153. The facility received warning error message -3810b, record submitted late, submission date was more than 14 days after A2000 on this new (A0050 equals 1) death in facility tracking record (A0310F equals 12) for Resident #46. The facility received warning error message -3810c, record submitted late, the submission date was more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment (A0310A equals 01, 03, 04, or 05) for Resident #1 and #3. The facility received warning error message -3810d, record submitted late, submission date was more than 14 days after the Z0500B on this new assessment for Residents #2, #3, #4, #15, #28, #41, and #51. Interview with the MDS Coordinator, on 12/06/18 at 10:29 AM, revealed a new batch was created a few weeks ago and submitted at that time. The batch was found open on 12/04/18, and then resubmitted to CMS. The batch was accepted but received late submission warnings. The Coordinator stated the batch did not go through due to possible internet issues; however, she did not check it to ensure the batch was accepted by CMS. Interview with the Director of Nursing (DON), on 12/06/18 at 10:42 AM, revealed MDS assessments should be accurate and timely. The DON stated if MDS assessments were submitted late, it was likely due to internet issues.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective infection control program related to hand hygiene during wound care for one (1) of twenty-five (25) sampled residents, Resident #45. The findings include: Review of the facility's policy, Wound Care, dated (MONTH) 2010, revealed the purpose of the procedure was to provide guidance for the care of wounds to promote healing. Steps in the procedure included washing hands thoroughly and donning gloves before treatment, and using a sterile tongue blade and applicators to remove ointments and creams from containers. In addition, staff was to wear sterile gloves when physically touching a wound, or holding a moist surface over a wound. Review of the facility's policy, Handwashing/Hand Hygiene, dated (MONTH) (YEAR), revealed the facility considered hand hygiene the primary means to prevent the spread of infections. All staff was to follow hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Further review of the policy revealed staff was to wash hands with soap and water or use alcohol based hand rub at multiple times including: before and after direct contact with residents; before donning sterile gloves; and before handling clean or soiled dressings, gauze pads, and additional items, (wound treatment materials including wipes used to clean). Additionally, staff was to wash hands before moving from a contaminated body site to a clean body site during resident care; after contact with resident's intact skin; and after handling used dressings and contaminated equipment. In addition, hand washing occurred after contact with objects in the immediate vicinity of the resident. Review of Physician order [REDACTED]. Review of the Initial Wound Evaluation and Management Summary, dated 12/04/18, revealed the physician noted an open sheer wound was present to Resident #45's gluteal cleft. Observation, on 12/05/18 at 9:35 AM, revealed Licensed Practical Nurse (LPN) #1 completed a treatment to Resident #45's buttock, including gluteal cleft. The LPN, with gloved hands, pulled the privacy curtain, held a jar of Magic Butt Cream with her left gloved hand, and wiped the resident's gluteal cleft with an incontinence-cleansing wipe with her right gloved hand. The LPN discarded the used wipe, opened the jar with both gloved hands, held the jar of cream with her right gloved hand, and used her left gloved hand and dipped fingers into the jar and applied the cream to the resident's buttock and gluteal cleft. The LPN did not perform hand hygiene or change gloves after touching the curtain or the jar of Magic Butt Cream. In addition, the LPN did not perform hand hygiene before cleaning the wound on Resident #45's gluteal cleft. LPN #1 did not perform hand hygiene or change her gloves before dipping her gloved fingers into the jar of cream and applying it to the resident's open wound. Interview with LPN #1, on 12/5/18 at 9:40 AM, revealedthere was an open area of skin in the resident's gluteal cleft. The LPN stated she did not remove her gloves, wash her hands, and don clean gloves after cleaning the resident's gluteal cleft and before applying the Magic Butt Cream to the open skin on Resident #45's gluteal cleft. LPN #1 stated she contaminated the gloves she wore when she touched the privacy curtain, held the jar of Magic Butt Cream, and wiped the resident's gluteal cleft. The LPN further stated she contaminated the cream in the jar when she dipped her fingers into the jar. In addition, she stated she contaminated the resident's open wound when she applied the Magic Butt Cream to the wound without performing hand hygiene and changing gloves first. The LPN stated Resident #45 was a diabetic, and contamination of an open wound could lead to the resident developing a skin ulcer and infection. Interview, on 12/06/18 at 8:27 AM, with the Infection Prevention Nurse (IPN) revealed nurses should perform hand hygiene at several points while providing a treatment to a resident, including immediately before beginning the treatment, and whenever hands encounter contaminated surfaces. The IPN further stated LPN #1 contaminated her gloves when she closed the privacy curtain, held the Magic Butt Cream jar, and cleaned the resident's wound and gluteal cleft with a wipe, then held the jar with the same hand. She further stated when LPN #1 dipped her gloved fingers into the jar of Magic Butt Cream without performing hand hygiene and donning new gloves, she contaminated the cream. The IPN stated she preferred nurses use a tongue blade or applicator to get medicated creams and ointments out of jars, place the creams in a clean medication cup, and then use an applicator to apply the creams to the resident's skin. The IPN stated when LPN #1 applied the cream to the resident's wound; the LPN transferred any organisms that were on the curtain and the jar. She stated contaminating the wound could lead to the resident developing an infection,[MEDICAL CONDITION], and could result in death. Interview, on 12/06/18 at 9:34 AM, with the Wound Nurse revealed nurses were to perform hand hygiene by washing hands and changing gloves after they contacted any contaminated surfaces, and before completing treatments to resident's skin. She stated staff not performing hand hygiene could lead to cross contamination, which could introduce germs and cause infection, worsening an infection, or deterioration of the wound. Interview, on 12/06/18 at 1:59 PM, with the Director of Nursing (DON) revealed staff should follow facility policies related to hand hygiene. She stated nurses should wash hands before donning gloves, when they removed gloves, and after touching anything soiled or potentially contaminated, after providing direct care to a resident, and at other times as stated in the facility policies. She stated nurses should always wash hands and don new gloves in preparation for wound care. She further stated nurses should not touch anything with a gloved hand before using the gloved hand to apply ointment to a resident's skin. The DON stated she preferred nurses to wash hands, don clean gloves, and use a clean applicator, like a tongue depressor or cotton tipped applicator, to apply ointment. She additionally stated a nurse with gloved hands should not touch a curtain, hold a jar of medicated cream, and then touch a resident's wound. She stated the nurse should have stopped to perform hand hygiene before applying the cream, and when the nurse did not do so, the nurse transferred bacteria and contaminated the wound. The DON stated the contaminated wound could result in an infection; deterioration of the wound, decline in the resident's condition, or the resident could [MEDICAL CONDITION] or worse outcomes. Interview, on 12/06/18 at 2:26 PM, with the Administrator revealed he referred to the in-services and competency training for hand hygiene during wound care, provided through nursing. In addition, all staff should practice good hand hygiene as stated in the facility policies and trainings to help prevent the spread of infection.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of twenty-one (21) sampled residents, Resident #1, related to falls. The findings include: Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised (MONTH) (YEAR), revealed each resident's care plan would be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and/or items included in the plan of care. The policy revealed the care plan would describe the services that would be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review revealed the facility admitted Resident #1 on 10/19/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance with transfers. Review of a Fall Investigation, dated 10/08/18, revealed Resident #1 fell on [DATE] in another resident's room when he/she attempted to transfer from the wheelchair to the bed. There had been two (2) other falls in other resident rooms, on 09/23/18 and 08/31/18. The investigation into all three (3) falls indicated the resident was unsupervised when the falls occurred. Review of Nurses' Notes revealed Resident #1's falls occurred on 08/31/18 at 2:00 PM, 09/23/18 at 9:30 AM, and 10/06/18 at 8:40 PM. Review of the Care Plan for Resident #1, dated 06/22/18, revealed the resident was at risk for elopement with an intervention to check the location of the resident frequently. The Falls Risk Care Plan, dated 11/05/18, revealed the resident was at risk for falls related to attempts to transfer unassisted. The care plan included an intervention, initiated on 11/16/18, to redirect the resident away from other resident rooms to easily observed areas. Observation, on 12/05/18 at 10:09 AM, revealed Resident #1 was not in his/her room and the Certified Nursing Assistant (CNA) did not know where the resident was. Interview, on 12/06/18 at 1:35 PM, with CNA #5 revealed Resident #1 was a fall risk and staff placed a wheelchair alarm to alert staff when he/she tried to stand from the chair unassisted. The CNA stated staff seated the resident near the nurses' station because he/she wandered and there was usually someone there to keep an eye on him/her. She revealed there was a CNA hall partner to monitor all residents on the hall when a CNA was off the unit during breaks. She revealed it was difficult to monitor all the residents when she was alone on the hall. She stated she looked at the care plans to determine if residents were at risk for falls. Interview, on 12/06/18 at 2:20 PM, with CNA #4 revealed she checked on Resident #1 typically every hour or two (2). In addition, CNA #4 stated the hall partner and the nurse were responsible for monitoring her assigned residents while she was on break. She stated it was important to monitor residents to prevent falls. The CNA stated interventions to prevent falls were listed on the care plan. Interview, on 12/06/18 at 2:42 PM, with the CNA Team Leader revealed she was not aware of any trends related to Resident #1's falls. According to the Team Leader, staff tried to ensure the resident was in a well-observed area such as the nurses' station, but there was not always someone at the nurses' station and sometimes he/she just wheeled off. The Team Leader stated she monitored care plan interventions were implemented by going room-to-room and ensuring safety equipment, cushions, mattresses, and boots were in place. Interview, on 12/06/18 at 3:12 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #1 wandered the hallways and into other resident rooms. The LPN stated she monitored Resident #1 while she documented at the nurses' station or passed medication. According to LPN #2, it was important to monitor Resident #1 to prevent potential falls and stated the facility did not follow the care plan related to monitoring of the resident. Interview, on 12/06/18 at 3:35 PM, with the Unit Manager (UM) revealed staff attempted to keep Resident #1 near the nurses' station because he/she wandered into other resident rooms. According to the UM, Resident #1 was fast and could not be monitored every second. Interview, on 12/06/18 at 3:56 PM, with the Director of Nursing (DON) revealed staff monitored Resident #1's whereabouts frequently and redirected him/her as needed. The DON revealed she had not identified any concerns related to monitoring the resident to prevent falls.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to prevent accidents and hazards for four (1) of nine (9) sampled residents, Resident #1, #7, #24, and #153. The facility failed to supervise Resident #1 to prevent falls and failed to ensure medicated cream was not left in the resident's bathroom, accessible to residents. Resident #7, #24, and #153 received oxygen therapy and the facility failed to ensure a No Smoking/Oxygen in Use sign was posted on the entryways of the residents' rooms to alert staff and visitors that oxygen was in use. The findings include: 1. Review of the facility's policy, Fall Risk Assessment, revised (MONTH) (YEAR), revealed staff, with the support of the attending physician, would evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The policy further revealed staff and the attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable. Review of the facility's policy, Managing Falls and Fall Risk, revised (MONTH) (YEAR), revealed based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Review of the clinical record revealed the facility admitted Resident #1 on 10/19/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance of two (2) staff for transfers. Per the MDS, the resident had no falls since the previous assessment. Review of a Fall Investigation for Resident #1, dated 10/08/18, revealed the resident attempted to transfer unassisted from the wheelchair to the bed, in another resident's room, on 10/06/18, and fell . Continued review of fall investigations for Resident #1 revealed he/she had two (2) previous falls in other resident rooms, on 09/23/18 and 08/31/18. Review of Resident #1's Nurses' Notes revealed the resident fell on [DATE] at 2:00 PM, on 09/23/18 at 9:30 AM, and on 10/06/18 at 8:40 PM. Review of the Care Plan, dated 06/22/18, revealed Resident #1 was at risk for elopement and included an intervention to check his/her location frequently. In addition, the resident was at risk for falls related to attempts to stand, transfer, or walk alone unsafely, Dementia, gait problems, history of falls, impaired judgement, and impaired safety awareness. The care plan included an intervention, initiated 11/16/18, to redirect the resident away from other resident rooms to easily observed areas. Observation of Resident #1's room, on 12/05/18 at 10:09 AM, revealed Resident #1 was not in his/her room and the Certified Nursing Assistant (CNA) did not know where the resident was. Interview with CNA #5, on 12/06/18 at 1:35 PM, revealed Resident #1 was a fall risk and had a wheelchair alarm to let staff know when he/she tried to stand from the chair unassisted. The CNA stated the resident also wandered and staff seated him/her near the nurses' station because there was usually someone there to keep an eye on him/her. She revealed the facility assigned two (2) CNAs to a hall and the hall partner was responsible for monitoring all residents on the hall when the other CNA took a break. She stated she did not feel she could adequately monitor the residents when she was alone on the hall. Interview with CNA #4, on 12/06/18 at 2:20 PM, revealed she typically took breaks after resident meals and signed out on a sheet kept at the nurses' station. The CNA stated the hall partner and the nurse were responsible for monitoring her assigned residents while she was on break. She stated it was important to monitor residents to prevent falls. Interview with the CNA Team Leader, on 12/06/18 at 2:42 PM, revealed CNAs were responsible for signing out and notifying the nurse and hall partner when taking a break. The Team Leader stated she did not review the break sign out sheets and turned them in to the Director of Nursing (DON). She stated she participated in the interdisciplinary team (IDT) standards of care meeting and was not aware of any trends related to Resident #1's falls. According to the Team Leader, staff tried to keep the resident in a well-observed area such as the nurses' station, but there was not always someone at the nurses' station and sometimes the resident just wheeled off. Interview with Licensed Practical Nurse (LPN) #2, on 12/06/18 at 3:12 PM, revealed Resident #1 wandered the hallways and into other resident rooms. The LPN stated the CNAs were busy answering call lights and getting residents to bed so she monitored Resident #1 while she documented at the nurses' station or passed medication. Additionally, LPN #2 revealed it was important to monitor Resident #1 to prevent a potential fall. Interview with the Unit Manager (UM), on 12/06/18 at 3:35 PM, revealed Resident #1 had chair/bed alarms due to frequent falls and wandering in the halls, including other resident rooms. She stated staff attempted to keep the resident at the nurses' station when he/she was out of bed. The UM revealed the falls recorded for Resident #1 occurred in other residents' rooms when he/she attempted to get into their bed. According to the UM, Resident #1 was fast and could not be monitored every second. Interview with the Director of Nursing (DON), on 12/06/18 at 3:56 PM, revealed staff monitored Resident #1's whereabouts frequently and redirected him/her as needed. The DON stated she had not identified any trends related to the times of Resident #1's falls and was not aware of any issues related to staffing during breaks or shift change. She revealed CNAs were responsible for notifying the nurse and hall partner when leaving for break. She stated the facility used the break sign out sheet as an extra communication tool and CNAs did not always sign out. The facility did not provide a copy of the CNA break sign out sheets. 2. Review of the facility's policy, Medication Administration-General Guidelines, revised 12/18/12, revealed medications were administrated in accordance with written orders of the attending physician and once a medication was removed from a package or container, unused doses should be discarded. Further record review revealed Resident #1's Annual MDS, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) and determined the resident was not interviewable. Review of Resident #1's Physician Order, dated 11/25/18, revealed an order for [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Further review of Resident #1's Care Plan, updated 11/25/18, revealed the resident's peri area was noted as red related to moisture with a goal to maintain skin integrity. Interventions included applying antifungal [MEDICATION NAME] 2% powder to the peri area every shift and as needed. Observations of Resident #1's bathroom, on 12/04/18 at 2:30 PM and 12/05/18 at 10:09 AM, revealed a small clear medication cup containing white powder with peri groin marked on it located on top of the sharps container that was secured to the wall. LPN #2 was alerted by the surveyor and the LPN removed the medication cup from Resident #1's bathroom. LPN #2 identified the white powder in the medication cup as [MEDICATION NAME]. Interview with CNA #6, on 12/05/18 at 10:18 AM, revealed she had not identified the medication cup in Resident #1's bathroom. She stated she assisted Resident #1 to the bathroom, as well as the resident used the bathroom on his/her own. Interview with LPN #2, on 12/05/18 at 10:25 AM, revealed she did not provide care to the resident on 12/04/18 when the medication cup was found in Resident #1's bathroom; however, LPN #5 worked that day and was responsible for medication administration for Resident #1. Additionally, she stated residents that had access to the bathroom could have ingested the medication and it could have caused harm. Interview with the Staff Development Nurse, on 12/06/18 at 8:59 AM, revealed on 10/18/18 at 3:00 PM, a medication administration training was scheduled but was cancelled by their contract pharmacist. Continued interview revealed LPN #5 completed new employee orientation on 11/08/18. She stated LPN #5 forgot to discard the medication in the bathroom, which was a human error. She stated she provided medication administration in-services annually. Review of LPN #5's LPN Competency Skills Checklist, dated 11/08/18, revealed she successfully performed transcribing and administering medications according to the facility policy and procedures. Interview with the Regional Director of Clinical Services, on 12/06/18 at 9:23 AM, revealed medication administration should be performed according to the medication administration policy. Interview with the DON, on 12/06/18 at 3:32 PM, revealed she contacted LPN #5 at home on 12/05/18, and the LPN told her she pulled Resident #1's medication, entered the resident's room, assisted the resident to the bathroom, applied some of the powder to the resident's perineal area, then placed the medication cup on the sharps container. LPN #5 further revealed she forgot to discard the medication cup after placing the resident in the bed. Interview with the Administrator, on 12/06/18 at 09:16 AM, revealed the facility had not identified any issues with medication administration. He expected medications to be administered and disposed of properly. Further interview revealed LPN #5 was toileting Resident #1 in the bathroom and the medication was accidentally left in the bathroom. 3. Review of the facility's policy, Oxygen Administration, dated (MONTH) 2010, revealed the following equipment and supplies were necessary when performing this procedure: portable oxygen cylinder (strapped to the stand); nasal cannula, nasal catheter, mask (as ordered); humidifier bottle; No Smoking/Oxygen in Use signs; regulator; and personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Record review for Resident #24 revealed the facility admitted the resident on 06/06/17, and the resident had a [DIAGNOSES REDACTED]. Review of Resident #24's Physician Order, dated 11/12/18, revealed supplemental oxygen at 2 liters (L) per minute via nasal cannula as needed to keep the resident's blood oxygen saturation above 90%. Observation, on 12/06/18 at 11:04 AM, revealed Resident #24 resting in bed receiving oxygen per nasal cannula. There was no signage at the doorway or within view of the entryway to the resident's room to alert staff and visitors of oxygen usage in the resident's room. Record review revealed the facility admitted Resident #153 on 11/13/18, with a [DIAGNOSES REDACTED]. Review of a Physician Order, dated 11/13/18, revealed oxygen at 2L per minute per nasal cannula, continuous. Observation and interview, on 12/04/18 at 9:02 AM, with Resident #153 revealed he/she had been on oxygen for years and was utilizing oxygen during the interview. There was no sign on the resident's doorway alerting staff and visitors that oxygen was in use. Observation of Resident #153's room, on 12/04/18 at 11:38 AM, revealed an oxygen concentrator in the room; however, no signage alerting staff or visitors regarding the use of oxygen was within view of the entryway to the resident's room. Resident #153 entered his/her room in a wheelchair with portable oxygen attached. Record review revealed the facility admitted Resident #7 on 02/25/12, with [DIAGNOSES REDACTED]. Review of Resident #7's (MONTH) (YEAR) Physician order [REDACTED]. Observation, on 12/04/18 at 8:51 AM, 12/05/18 at 10:12 AM, and 12/06/18 at 11:02 AM, revealed Resident #7 in bed with oxygen administered by nasal cannula; however, there was no oxygen sign posted at the doorway to the resident's room. Interview with LPN #2, on 12/06/18 at 11:07 AM, revealed there should have been an oxygen sign posted at Resident #7's door, per facility policy. Resident #7 had been receiving oxygen since the start of LPN #2's employment, (MONTH) (YEAR), and she had not noticed there was no oxygen sign posted on the door. Further interview revealed nursing staff was responsible for setting up the resident's oxygen and placing the oxygen sign on the door. Interview with the DON, on 12/06/18 at 11:09 AM, revealed Resident #7 did have an oxygen sign posted at the door at one time. The DON stated there should have been an oxygen sign posted at Resident #7's door at all times, per facility policy. Interview with the Administrator, on 12/06/18 at 11:13 AM, revealed nursing staff was responsible for ensuring the oxygen sign was posted on the door. The Administrator further stated the Maintenance Director had been painting in the 100 hallway recently. Interview with the Maintenance Director, on 12/06/18 at 11:20 AM, revealed he removed the oxygen signs from resident rooms last week while he painted the outside doorframes and did not reapply them.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure sanitary storage of dry goods. Observation revealed dry storage supplies of lids, plates, napkins, and cups located in a hallway with holes in the structure to the outside. Eight (8) of thirty-one (31) cardboard boxes, which contained opened plastic bags of supplies, contained dead and living insects in direct contact with the contents. The findings include: Review of the facility's policy, Disposable Dishes and Utensils, dated December 2008, revealed single-service articles related to food services should be stored in the original protective package or stored by using other means that provided protection from contamination until used. Observation of the dry storage supplies, on 10/12/17 at 12:45 PM, revealed eight (8) of thirty-one (31) cardboard boxes, on wooden shelves, were not taped closed and contained opened plastic sleeves of items. There were two (2) sleeves of Styrofoam and plastic cups, six (6) sleeves of Styrofoam and plastic lids, one (1) sleeve of plates, and one (1) package of paper napkins. The boxes were located in a hallway, which was not temperature nor humidity controlled, and had holes in the walls and at the base of the walls to the outside. Three (3) of four (4) wooden shelves contained dead insects and cobwebs and six (6) large flying insects were in and on the boxes and supplies in direct contact with the contents. Multiple dead insects were on the ground around and beneath the wooden shelves. Review of Resident #15's Brief Interview for Mental Status (BIMS) revealed the facility assessed the resident on 10/11/17, with a score of twelve (12) out of fifteen (15) and determined the resident interviewable. Observation and interview with Resident #15, on 10/12/17 at 1:17 PM, revealed he/she had a Styrofoam cup at the bedside that contained a lid and straw. Resident #15 stated staff brought the cup, containing a soft drink, earlier in the morning. Review of Unsampled Resident A's BIMS revealed the facility assessed the resident on 09/12/17, with a score of ten (10) out of fifteen (15) and determined the resident interviewable. Interview with Unsampled Resident A, on 10/12/17 at 1:25 PM, revealed staff brought him/her a supplemental shake earlier in the day in a Styrofoam cup with a lid and a straw. Review of Unsampled Resident B's BIMS revealed the facility assessed the resident on 09/13/17, with a score of seven (7) out of fifteen (15) and determined the resident not interviewable; however, the resident was alert and able to answer questions on 10/12/17. Interview with Unsampled Resident B, on 10/12/17 at 1:30 PM, revealed the facility served food and drinks on Styrofoam items on multiple occasions. Review of Resident #7's BIMS revealed the facility assessed the resident on 09/13/17, with a score of twelve (12) out of fifteen (15) and determined the resident interviewable. Interview with Resident #7, on 10/12/17 at 1:33 PM, revealed the facility served food and drinks using Styrofoam supplies on multiple occasions when something broke in the kitchen. Interview with Dietary Aide #1, on 10/12/17 at 1:25 PM, revealed Styrofoam goods were utilized to serve food to residents when the dishwasher broke or in case of an emergency. She stated the products were stored in the connector hallway between buildings. She stated the boxes were taped closed and if the boxes or contents were open, then insects could have access to the items and create a hazard. Interview with Dietary Aide #2, on 10/12/17 at 1:29 PM, revealed the facility used Styrofoam products on occasion. She stated she used the Styrofoam products from the long connecting hallway for residents in the past. She stated she had no concern about the products being in that location because the items were always wrapped in plastic and inside taped cardboard boxes. Interview with the Interim Dietary Manager, on 10/12/17 at 2:35 PM, revealed she was aware the Styrofoam supplies were stored in the hallway connecting the two (2) buildings. She stated the facility utilized the items for emergencies only and was not concerned with the conditions of the hallway or the open cardboard boxes because most of the supplies were wrapped in plastic. She revealed she was unaware if there was a facility policy regarding the storage of paper goods. Interview with the Administrator, on 10/12/17 at 4:10 PM, revealed he took responsibility for the facility on 12/16/16. He stated he rounded the facility multiple times a day, focused on care areas, and spoke directly with residents and families often. He stated he was not concerned about the dry stock in the breezeway being open and soiled. He explained the stock was for emergency use only and did not think the soiled dry stock items would pose a health risk to the residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident bathroom was equipped with an operational call system to communicate with nursing staff for one (1) of eighteen (18) sampled and unsampled residents, Unsampled Resident C. The findings include: Review of the facility's policy, Call Lights, undated, revealed it was the policy of the facility to assure the call system was in proper working order and staff would ensure call light cords were positioned correctly and within reach of the residents, prior to leaving their rooms. Review of the facility's protocol, Maintenance Inspection/Grand Rounds Checklist/Resident Rooms, undated, revealed Bathroom Inspection and Call Light System were categories for inspection. The facility did not provide any historical completed Inspection/Checklists. Observations during initial tour, on 10/10/17 at 8:50 AM, revealed the bathroom call light cord in resident room 127 was disabled as it was wrapped three (3) times around a fixture (dormant shower head) near the call light panel. Unsampled Resident C was one (1) of four (4) residents in the room and the only ambulatory resident in the room. Review of Unsampled Resident C's clinical record revealed the facility admitted the resident on 11/04/14, with [DIAGNOSES REDACTED]. Review of Unsampled Resident C's Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) and determined the resident not interviewable. The facility assessed the resident was ambulatory with staff encouragement and required set up help only. Unsampled Resident C's balance was described as unsteady but able to steady self without staff intervention. The MDS stated Unsampled Resident C did not need mobility devices. Observation of Unsampled Resident C, on 10/12/17 at 1:45 PM, revealed he/she in bed positioned within five (5) feet of the bathroom door. Interview with Certified Nursing Assistant (CNA) #4, on 10/12/17 at 1:45 PM, revealed she had cared for Unsampled Resident C for many years and he/she accessed the bathroom. She stated it was a routine part of CNA rounding to ensure call lights were accessible to residents but they did not normally check the bathroom call lights, just the lights closest to the residents' beds. Upon viewing Unsampled Resident C's call light cord wrapped around the fixture; CNA #4 expressed that if the resident needed assistance, he/she could not pull the cord for help if he/she fell in the bathroom. Interview with Licensed Practical Nurse (LPN) #1, on 10/12/17 at 1:55 PM, revealed she was taught to round with other nurses at shift change and she checked each resident's condition at that time. She was unsure who was responsible to check call lights. She expressed concern after seeing Unsampled Resident C's wrapped call light cord as she stated the resident could not pull the light if he/she fell . LPN #1 stated no one would know and no one would be likely to hear the resident yell out as the resident's room was the farthest from the nurses' station. Interview with the Environmental Manager, on 10/12/17 at 2:00 PM, revealed Unsampled Resident C's wrapped call light concerned him, as the resident might not be able to get up independently if he/she fell and injured himself/herself. He was not sure who checked on call light functionality regularly. Additional interview at 2:30 PM, revealed environmental staff was trained and expected to check call light functionality when cleaning restrooms, he did not provide orientation or environmental rounding information. Interview with the Maintenance Director, on 10/12/17 at 2:45 PM, revealed the facility had recently replaced their call light system when they renovated the nurses' station. He expected nursing staff to let him know if there were any issues. His rounding was done along with the Environmental Manager and he was not sure if bathroom call lights were listed. Interview with the Director of Nursing (DON), on 10/12/17 at 3:45 PM, revealed it was her expectation that all residents' call lights functioned properly and answered timely. She stated she was unaware of any system in place to check call light functionality and accessibility. Continued interview revealed it was important for the facility to have a functioning call light system so residents could let staff know when they needed help. The DON further stated in the absence of functioning call lights, resident safety was at risk related to possible falls and accidental injuries. Interview with the Administrator, on 10/12/17 at 4:10 PM, revealed it was his expectation that the facility had a properly functioning call light system at all times to meet each resident's needs and to ensure the safety and health of each resident. He further stated he rounded two (2) to three (3) times a day to ensure residents and families knew him and were comfortable expressing their concerns to him. He did not include call light functionality as part of his rounding and was not sure who checked the bathroom call lights.

Based on observation, interview, and review of the facility's cleaning schedule and pest control logs, it was determined the facility failed to store food under sanitary conditions as evidence of multiple flying insects observed in the dry storage room. The findings include: Review of the facility's Equipment Cleaning Schedule, not dated, revealed the dry storage room was not listed on the schedule. Review of the Commercial Pest Management Service Agreements, dated 11/17/2014 and 08/23/2016, revealed services excluded flying insects. Review of the Commercial Pest Management Service Log revealed on 02/22/16, a pest control inspection found water and food under the tiles under the ice machine that created a breeding area for gnats. Further review of the service log revealed a pest control inspection on 04/14/16 found water and food residue on the floor of the dish room that created a breeding area for fruit flies. Observation of the kitchen, on 08/23/16 at 8:37 AM, 10:00 AM and 11:30 AM, revealed multiple small black flying insects in the dry goods storage room. Interview with the Dietary Director, on 08/23/16 at 8:37 AM, revealed she was aware of the flying insects in the dry goods storage room and felt it was due to the grease trap, which the facility had since removed. She stated she had seen an improvement, but continued to see flying insects that were more than likely due to the drainage problem from the dish room. She stated maintenance had scheduled repairs for the drainage problem. Further interview with the Dietary Director, on 08/25/16 at 2:00 PM, revealed the facility had removed the grease trap approximately six weeks prior and initially there had been no pest problems. She stated she believed the flying insects observed in the dry storage room were the result of eggs that the previous flying insects had laid. She further stated the pest control person told her there was nothing he/she could do. She continued to state that the Health Department Inspector told her everyone had flying insects.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in fourteen (14) of twenty-nine (29) resident rooms. Observations revealed a broken window, a broken window blind, missing or loose cove base, doorframes in disrepair, and iron grab bars in four (4) resident restrooms that appeared corroded. The findings include: Review of the facility policy titled Maintenance Service, dated December 2009, revealed the Maintenance Director was to round weekly with the facility Administrator to inspect the facility to ensure the facility was in good repair. Additionally, the Maintenance Director was to perform maintenance on doors as needed. Observation, on 08/23/16 at 1:36 PM, of room 127 revealed loose cove base on the wall extending from the bathroom. Additionally, the window blind that covered the window on the same wall had a broken bottom rail that caused the blind to hang in a u-shape. Observation, on 08/23/16 at 1:38 PM, of room 125 revealed the window had a crack in the glass and a dislodged windowpane that rested on the bottom of the window and leaned to the left side of the window. Continued observation on 08/24/16 at 12:13 PM, revealed the door to the bathroom was scuffed and nicked. Inside the bathroom, the doorframe was broken near the floor and there were areas of rust-like substances. The inside door of the bathroom was scuffed and chipped. Interview, on 08/24/16 at 12:13 PM, with Unsampled Resident A revealed the resident chose not to pay attention to the condition of his/her room; however, the facility should make repairs. The resident stated everyone deserved a room that looked nice. Further interview, on 08/25/16 at 9:38 AM, revealed he/she had reported the broken window to facility staff within the past couple of weeks but was unable to recall to whom he/she had reported it to. Observation, on 08/23/16 at 1:40 PM, in room 114 revealed the cove base in the restroom was loose and pulled away from the wall. Observation, on 08/23/16 at 1:44 PM, of room 103 revealed the cove base was loose and pulled away from the wall. Observation, on 08/23/16 at 1:50 PM, of room 106 revealed the restroom doorframe had multiple gouges with paint missing. Observation, on 08/23/16 at 3:43 PM, of room 126 revealed a section of cove base was loose and pulled away from the wall that was adjacent to the restroom. Continued observation, on 08/24/16 at 12:22 PM, revealed the door that led into the room was covered with a sticky substance. Interview, on 08/24/16 at 12:22 PM, with Unsampled Resident B revealed the resident was unsure what was on the door, however, the resident was concerned regarding anything that might stick to the door. Observation, on 08/24/16 at 9:12 AM, of room 123 revealed the closet door was painted white and had multiple black marks, varying in width and length, that covered a large portion of the bottom third of the door panel. Observation, on 08/24/16 at 9:14 AM, of room 122 revealed the doorframe around the door to the restroom had multiple scrapes and missing paint. Observation, on 08/24/16 at 9:18 AM, revealed the restroom between resident rooms 101 and 103 had inner doorframes with multiple gouges and missing paint. Observation, on 08/24/16 at 9:19 AM, revealed the restroom between resident rooms 105 and 107 had inner doorframes with multiple gouges and missing paint. In addition, the restroom had iron grab bars next to the toilet that had dark brown and reddish colored rust-like areas along the length of the bars. Observation, on 08/24/16 at 9:20 AM, of room 108 revealed a section of cove base missing from the wall. In addition, the restroom doorframe had multiple gouges with paint missing. Observation, on 08/24/16 at 9:23 AM, of the restroom between resident rooms 115 and 117 revealed iron grab bars were next to the toilet that had dark brown and reddish colored rust-like areas along the length of the bars. Observation, on 08/24/16 at 9:27 AM, of the restroom between resident rooms 109 and 111 revealed iron grab bars were next to the toilet that had dark brown and reddish colored rust-like areas along the length of the bars. Observation, on 08/24/16 at 9:30 AM, of room 113 revealed the restroom had iron grab bars next to the toilet that had dark brown and reddish colored rust-like areas along the length of the bars. Interview with Certified Nursing Assistant (CNA) #3, on 08/25/16 at 10:47 AM, revealed she was unaware of the cracked window glass and dislodged windowpane in room 125. CNA #3 stated the window blind in room 127 was not in good repair and was unsure if staff had reported it to maintenance. She stated the cove base in room 114 was loose and not in good repair. Additionally, CNA #3 stated maintenance repair was necessary for the closet door in room 123. CNA #3 revealed there was a maintenance binder at the nurse's station for staff to list items that required maintenance or repair. Interview with the Acting Maintenance Director (AMD), on 08/25/16 at 1:38 PM, revealed he was unaware of the cracked window in room 125 or the broken window blind in room 127. The AMD stated the window and window blind were not in good repair. He stated the missing and loose cove base in resident rooms 103, 108, 114, 126, and 127, needed repair. He acknowledged the doorframes in resident rooms 106, 125, and the six (6) resident restrooms needed painting. Interview with the Administrator, on 08/25/16 at 3:00 PM, revealed he and the AMD performed walking rounds weekly to identify maintenance issues. The Administrator was unaware of the cracked window in resident room 125 or the broken blind in room 127. The Administrated acknowledged the condition of the missing and loose cove base in the facility. The Administrator revealed maintenance had neglected items of an aesthetic nature previously, but with the recent change in facility ownership, a renewed focus was underway and any maintenance items of regulatory nature would receive priority.

Based on observation, interview, record review, and review of the facility's pest control records, it was determined the facility failed to have an effective pest control system in place to prevent flying insects throughout the facility. Small flying insects were observed in eight (8) of twenty-nine (29) resident rooms and two (2) common areas. The findings include: Review of the facility's agreement with a commercial pest control company revealed an agreement for monthly and as needed inspections and treatments for pest control issues. In addition, review of the commerical pest control company's inspections for May 2016, June 2016, and July 2016 documented the presence of flies and small flies in increasing amounts. Observation, on 08/23/16 at 1:36 PM and 3:45 PM, of resident room 127 revealed four (4) flying insects were flying in the room and were on the ceiling. Continued observation, on 08/27/16 at 9:05 AM, revealed three (3) small flying insects were on the ceiling. Observation, on 08/23/16 at 1:40 PM, of resident room 114 revealed three (3) small flying insects were on the ceiling. Continued observation, on 08/24/16 at 9:22 AM, revealed four (4) small flying insects were in the room on the ceiling and walls. Observation, on 08/23/16 at 3:43 PM, of resident room 125 revealed six (6) small flying insects were flying in the room, on the ceiling, and on the privacy curtain. Continued observation, on 08/25/16 at 10:47 AM, revealed seven (7) small flying insects were in the room on the privacy curtain, ceiling, and walls. Observation, on 08/24/16 at 9:10 AM, of resident room 126 revealed three (3) small flying insects were in the room, one (1) insect was flying around and two (2) were on the ceiling. Observation, on 08/24/16 at 9:11 AM, of resident room 124 revealed three (3) small flying insects were in the room on the ceiling and walls. Observation, on 08/24/16 at 9:12 AM, of resident room 123 revealed two (2) small flying insects were on the ceiling. Observation, on 08/24/16 at 9:14 AM, of resident room 122 revealed one (1) small flying insect was on the ceiling. Observation, on 08/24/16 at 9:20 AM, of resident room 118 revealed four (4) small flying insects were in the room on the ceiling and wall. Observation, on 08/24/16 at 9:22 AM, revealed two (2) flying insects were in the hallway on the ceiling outside of resident room 114. Observation, on 8/24/16 at 12:01 PM, of the resident dining room revealed three (3) small flying insects were flying throughout the room. Interview with Unsampled Resident A, on 08/25/16 at 9:38 AM, revealed the resident was aware of the flying insects. The resident stated the flying insects were frustrating but he/she believed the facility was working on getting rid of them. Interview with Unsampled Resident B, on 08/25/16 at 9:43 AM, revealed the resident was aware of the flying insects but stated he/she did not mind killing the insects. Interview with Certified Nursing Assistant (CNA) # 3, on 08/25/16 at 10:47 AM, revealed the facility was aware of the presence of the flying insects. CNA # 3 stated the flying insects were annoying and should not to be in the building. Interview with the Acting Maintenance Director (AMD), on 08/25/16 at 1:38 PM, revealed the facility was aware of the presence of the flying insects and was working with the pest control company to resolve the problem. The AMD stated the facility had replaced/resealed a grease trap and would be replacing/resealing a drain in the kitchen based on the recommendation of the pest control company in an effort to eradicate the problem. Interview with the Administrator, on 08/25/16 at 2:00 PM, revealed the facility was aware of the presence of the flying insects and was working with the pest control company to stop the problem. The Administrator stated the facility had recently replaced/resealed a grease trap at the recommendation of the pest control company and the presence of the flying insects had diminished briefly. The facility would be replacing/resealing a drain in the kitchen at the recommendation of pest control company. The Administrator stated the pest control company had been investigating additional measures the facility may employ in an effort to eradicate the flying insects.

Based on observations, interviews, and review of the facility's policy, it was determined the facility failed to store, prepare, and distribute and serve food under sanitary conditions. Observation of the facility's kitchen during tour revealed three (3) glasses filled with fluid were stored in the refrigerator uncovered, undated, and unlabeled. Continued observation revealed dishes, with food particles on them, were stored with other clean dishes. Further observation revealed cartons of thickened liquids were stored in the refrigerator past their recommended open date, magic cups stored in the freezer, undated, and one dented can was stored in the dry storage area with other usable cans. The findings include: Review of the facility's policy, titled Refrigerated Storage, undated, revealed it was the policy for the facility to store, prepare, and serve foods in accordance with federal, state, and local sanitary codes. Continued review of the policy revealed that all foods would be properly wrapped and/or stored in sealed containers and dated, tabled and monitored so they were used by the specified use-by date. Further review of the policy revealed the food would be discarded within appropriate shelf life. Review of the facility's policy titled Purchasing/Receiving/Storage, undated, revealed damaged canned food containers would be stored together in the store room in a separate and distinct area away from other food items. Continued review of the policy revealed damaged containers were defined as all dented containers. Review of the facility's policy titled, Leftover Foods, undated, revealed it was the policy of the facility to store leftovers in a safe and sanitary manner in compliance with federal, state, and local sanitation codes. Continued review of the policy revealed all refrigerated leftover foods were to be used within seventy-two (72) hours or discarded. Review of the facility's guidelines for Thick and Easy, dated 08/05/15, revealed Thickened Orange Juice shelf life after opening would be up to ten (10) days at thirty-four (34) degrees to forty (40) degrees. Continued review of the guidelines revealed the Thickened Dairy Nectar had a shelf life after opening up to four (4) days at thirty-four (34) degrees to forty (40) degrees. Observation of the Kitchen during tour, on 08/04/15 at 9:05 AM, revealed a kitchen pan, stored with other cleaned dishes, was observed to have dried red substance on the bottom of the pan. Continued review of the cleaned kitchen pans revealed a lid, stored away as clean, was observed to have dried white substance on the lid. Observation of the freezer revealed there were several magic cups that was stored in the freezer, undated. Additionally, two (2) cartons of thickened orange juice dated 06/11/15 and 06/25/15. There were two (2) boxed containers of Apple Juices dated 07/16/15 and one (1) boxed container of Prune Juice dated 07/02/15. Continued tour of the kitchen revealed one (1) dented can of Cheddar Cheese was stored with the other cans for residents use and three (3) glasses of a liquid substance was stored in the refrigerator that was uncovered, undated, and was not tabled. Interview with Dietary Aide #5, on 08/06/15 at 10:30 AM, revealed the dishes should not have been stored with food particles left on them. She stated that if they found food particles left on the dishes, then the dishes would have to be re-washed. She reported it was important to re-wash the dishes due to contamination and bacteria would build up on the food that was left on the dishes. Continued interview with Dietary Aide #5 revealed that the juices should have been covered, tabled, and dated. Additionally, she reported this was to prevent cross contamination with juice or milk. She reported you would want to make sure no bacteria got in them. Continued interview with Dietary Aide #5 revealed everything in the refrigerator should be labeled to let staff know what the product was and items should be dated to make staff aware of what items should be tossed. Dietary Aide #5 reported all items should be thrown away after three (3) days, so that bacteria does not set up in the items. Further interview with Dietary Aide #5 revealed the kitchen staff should not use dented cans. She reported it was important to get rid of those cans because bacteria can set up in the cans and contaminate the food. Interview with the Food Service Assistant Manager, on 08/06/15 at 11:00 AM, revealed the dishes should not have been stored with food particles on them. She reported she was sure this might have occurred before, but reported it should not be done for cross contamination. She further revealed the dishes should not have been put away with the clean dishes if it was still dirty. Continued interview with the Food Service Assistant Manager revealed it was her job to label and date everything. The Food Service Assistant Manager reported the three (3) glasses in the refrigerator should have been covered, tabled, and dated. She reported this was an oversight by her and she would continue to educate the staff. Additionally, she revealed it was her job to pull dented cans as they come into the facility's kitchen. She stated the dented cans could carry food bourne illnesses, adding, something could come off the can. Further interview with the Food Service Assistant Manager revealed it was the policy that after opening a product, it should be used within three (3) days and the carton of juices/dairy thickened product should be used within the recommended guidelines. The Food Service Assistant Manager reported it was an oversight on her part and added the cartons should have been removed from the refrigerator. Interview with the Food Service Director, on 08/04/15 at approximately 9:06 AM and 08/05/15 at approximately 4:00 PM, revealed the pan used to cook food in should not have had food substance on it. She reported she believed the substance to be spaghetti sauce. Continued interview revealed the lid to the pan had dried water and some food particles, but was not certain of what the food particle might have been. She reported the pan and the lid was not washed properly and needed to be re-washed. Further interview with the Food Service Director revealed she believed that there were over seventy-five (75) magic cups (nutrition shakes) in the freezer that should have been dated. The Food Service Director revealed she was not certain of the expiration date of the juices and the dairy product, but added she thought it was okay because of the expiration date on the cartoon, not the date that the carton was opened. Additionally, the Food Service Director reported the dented can should not have been stored with the regular cans for distribution because the dented can could carry food bourne illness and if severe enough, it could cause an outbreak. Continued interview with the Food Service Director revealed the three (3) glasses with liquid in them was poured for the day. It contained a red substance, light brown substance, and bright yellow substance. The Food Service Director reported the glasses should have been covered and reported she just placed the juices in the refrigerator as this surveyor should take her word for it. An additional interview with the Food Service Director revealed she thought the time a product could rest in the refrigerator after opening was seventy-two (72) hours. Interview with the Dietitian Consultant, on 08/05/15 at approximately 3:30 PM, revealed it would be her expectation that the juice in the cartons in the refrigerator would be kept no longer than six (6) days after opening. She reported she was not sure how long the milk could sit in the refrigerator after opening, but thought it was a shorter period. The Dietitian Consultant reported that while she was not sure of the exact expiration date of the items after opening them, she would rely on the policy and the recommendation for holding the juice/dairy products after opening. Further interview with the Dietitian Consultant revealed, it would have been her expectation that the items in the refrigerator would have been covered, dated, and labled. She reported it was the facility's policy, as well as, within the regulations.

Based on interview and facility policy review it was determined the facility failed to have a system in place to provide uninterrupted access to continuous oxygen therapy as required to four (4) residents out of fifty (50) in the event of a power failure and the generator of the facility had to be activated. In addition, residents could not be transferred using any of the facility's six (6) mechanical lifts in the event of a facility power failure. The findings include: Review of facility policy titled Auxiliary Power for Life-Support Systems, with a revision date of August 2008 revealed if the normal power supply was disrupted the emergency generator would provide auxiliary power to established areas within the building. Continued review of the facility policy revealed life support equipment was located at each nurse's station and was to be used only during an emergency. Interview with the facility Maintenance Director on 08/06/15 at 11:03 AM revealed he had identified the generator would not automatically transfer power on 07/09/15 and had contacted the generator vendor to assess the generator to determine the problem. Continued interview with the facility Maintenance Director revealed the generator vendor had incorrectly identified the problem with the generator and that the Maintenance Director discovered on 07/16/15 after the generator vendor had replaced the transfer switch that the generator did not automatically transferring power to the facility. Further interview with the facility Maintenance Director revealed that according to the generator vendor the emergency power generator needed a new controller in order for the system to automatically transfer power. Continued interview with the facility Maintenance Director revealed he had to get bids on getting the controller replaced because it was over a certain amount of money. The facility Maintenance Director stated he got final pricing on replacing the controller on 07/16/15 and conveyed the information to the former Facility Administrator. Interview with the Regional Director of Operations on 08/06/15 at 1:00 PM revealed he was not made aware of the generator issue until he was contacted on 07/27/15 about getting approval from the corporate office to purchase a new controller for the generator. Continued interview with the Regional Director of Operations revealed he was under the impression that the facility had emergency power available in the event of a power failure. Interview with the Facility Administrator on 08/06/15 at 1:21 PM revealed he had been the administrator of the facility for four (4) days and was under the impression that the facility could do a manual power transfer in the event of a facility power failure.

Based on observation, interview and review of the facility's Serving Meals policy, it was determined that the facility failed to ensure residents were served food that was at the proper temperature and was palatable for the lunch served on 05/29/14. The findings include: Review of the facility's policy regarding Serving of Meals (Dining and Resident Room), not dated or approved, was identified as Policy A:5.22 revealed the facility would serve hot food hot and cold food cold when it reached the resident. Interview during the group meeting, on 05/28/14 at 2:00 PM, revealed two (2) of five (5) residents (Resident #4 and Resident #5) voiced concerns of food being cold and the meat sometimes was not tender enough to cut or chew. Resident #4 stated sometimes the meat was very tough and he/she was unable to chew it, and stated many times the bacon was cold. Resident #5 stated the food was cold most of the time, especially in the morning. Interview with Resident #4, and Unsampled Resident A and D, on 05/29/14 at 11:50 AM, revealed the pork chop served at lunch was tough and dry. They stated they could not cut the meat. Interview with CNAs #4 and #5, on 05/29/14 at 12:15 PM, revealed the pork chop at lunch was tough and difficult to cut. Observation of a test tray, on 5/29/14 at 12:20 PM, revealed a test tray was placed on the last cart in the kitchen at 12:11 PM. The cart arrived on the last unit to be served, Oak Street hallway, at 12:15 PM. At 12:20 PM, all residents trays were served, and the test tray was removed from the cart. Temperatures were obtained at 12:21 PM with readings of Au Gratin potatoes were 100 degrees Farenheit (F); carrots were 110 degrees (F); pork chops were 80 degrees (F), and the roll was 80 degrees (F). The food tasted cold, and bland. There was no seasoning tasted. The potatoes tasted of processed potatoes from a box that were grainy and were undercooked. The carrots had a metallic taste of tin. Interview with the Food Service Manager (FSM), on 5/29/14 at 12:30 PM, revealed the food tasted good to her and the food was warm, but could be a little hotter. The FSM stated the Registered Dietician (RD), completed a point of service check each month, and stated the RD had not had any issues with taste and temperature of the food. Review of the RD's reports from the last six (6) months revealed that four (4) out of six (6) months RD reports relating to temperatures revealed there were no temperatures above 135 degrees (F) at point of service. In addition, review revealed two (2) out of six (6) months food temperature reports indicated the food had to be reheated at point of service. Two (2) out of the six (6) months food reports stated the food was reported to be undercooked. All six (6) months reports were given a score of "acceptable" by the RD.

Based on interview, record review, and review of the Catheter Care policy, it was determined the facility failed to revise the comprehensive care plan for four (4) of fourteen (14) sampled residents (Residents #2, #4, #6 and #8). The care plan failed to reflect Resident #2's preference for a leg strap to secure the tubing, and the care plan for Resident #4 failed to reflect the use of leg straps to secure the catheter tubing. The care plan for Resident #8 failed to reflect positioning for leaning while sitting in a wheelchair. The care plan for Resident #6 failed to direct staff in who and when monitoring would occur for potential side effects and failed to specify the specific side effects for [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (antipsychotic). The findings include: Interview with Administrator, on 05/30/14 at 11:25 AM, revealed the facility did not have a care plan policy, but followed the Resident Assessment Instrument User Manual Version 3.0 for development of comprehensive and revisions of care plans for facility residents. She further stated resident care plans were to be individualized to the resident's needs. Review of the Resident Assessment Instrument User Manual Version 3.0 for development of comprehensive and revisions of care plans for facility residents indicated care plan goals should be measurable. Including a subject, verb, modifiers, time frames, and goals and chapter 4 stated re-evaluate the resident's status quarterly, annually or if a significant change occurs and following the decision to address a triggered condition on the care plan, key staff or the Interdisciplinary Team should subsequently review and revise the current care plan as needed. Interview with Quality and Assurance Registered Nurse, on 05/30/14 at 3:05 PM, revealed the latest care plan information was written by the staff nurses when physician orders [REDACTED]. She stated the physician's verbal orders are written on a multiple part form and the form contained the physician order [REDACTED]. She stated the nurse was required to write a care plan, with problem, goal and intervention based on the order received from the physician. The nurse stated the care plan updates were not added to the comprehensive care plan if they were for acute medical concerns. She further stated the facility practice was to update the comprehensive care plan quarterly using the care plan update slips within 14 days. Review of the facility's policy regarding Catheter Care, Indwelling Catheter for the Licensed Nurse's basic responsibility, not dated, revealed under general resident care plan documentation guidelines the nursing staff was to identify the underlying problem and develop an individualized care plan. 1. Observation of Resident #2, on 05/28/14 at 9:45 AM, revealed an indwelling catheter tubing in a dignity bag connected to his/her wheelchair. Resident #2 declined skin assessment requests on 05/29/14 and 05/30/14 as the resident was up in wheelchair and did not want to go back to bed or had family visitors. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 08/18/12 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly assessment, dated 02/07/14, revealed the facility assessed Resident #2 with an indwelling catheter and was always incontinent of bowel. The resident had a Brief Interview Mental Status (BIMS) score of five (5). Review of the comprehensive care plan, dated 08/31/12, revealed interventions were a Foley Catheter per order, care and change of the catheter was per facility policy and a handwritten intervention #9 was to anchor the indwelling catheter to the thigh to prevent pulling and trauma to the bladder. Interview with the Director of Nursing, on 05/30/14 at 3:36 PM, revealed Resident #2 did not care for the tape fasteners, the resident preferred the velcro band that went around the leg to secure the tubing. In addition, she stated the care plan was individualized for this resident to reflect the resident's preference. 2. Observation of Resident #4, on 05/29/14 at 9:30 AM, revealed during the skin assessment the resident was lying on the bed with an indwelling catheter connected to a bedside drainage bag that was observed to be anchored to the bed frame. Resident #4 was observed with a suprapubic catheter without a securing device to prevent movement and possible trauma. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 09/23/13 with [DIAGNOSES REDACTED]. Review of the MDS Admission assessment, dated 09/30/13, revealed the facility admitted the resident with a suprapubic catheter and was frequently incontinent of bowel and had a BIMS score of fifteen (15) with no cognitive impairment. Review of the comprehensive care plan, dated 10/26/13, revealed Resident #4 had an intervention for a Foley Catheter (indwelling catheter) per physician orders, the care and changing of the catheter ordered per facility policy. There were no interventions to address how to secure the indwelling catheter for the resident. Interview with License Practical Nurse (LPN) #1, on 05/30/14 at 2:45 PM, revealed the comprehensive care plans for Resident #2 and Resident #4 were not individualized. She further stated the care plan did not reflect the special placement of Resident #4's suprapubic catheter nor did the care plan for Resident #2 reflect the use of a strap or a tape device. Interview with the Wound Care LPN, on 05/30/14 at 2:25 PM, revealed after reviewing the comprehensive care plans for Residents #2 and #4 she indicated she was responsible for resident assessments and then the development of the wounds, and bowel and bladder function comprehensive care plans. She further stated the care plans were not individualized to either Resident #2 or #4 and should have been. Interview, on 05/30/14 at 10:00 AM, with the Director of Nursing (DON) revealed the care plan update slips used in the facility did not have to be on the comprehensive nursing care plan. 3. Observation of Resident #8, on 05/29/14 at 11:40 AM, revealed the resident was sitting in a wheelchair in the main dining room. The resident was leaning to the left over the arm of his/her wheelchair. Resident #8 attempted to reposition his/herself and sit upright on multiple occasions without success. Staff members were passing lunch trays and did not intervene to assist the resident with repositioning. Further observation, on 05/29/14 at 12:00 PM, revealed Resident #8 was sitting in his wheelchair in the main dining room. The resident continued leaning to the left over the arm of his/her wheelchair. There were no positioning devices on the resident's wheelchair. Staff members in the dining room did not intervene to assist the resident with repositioning. Review of the clinical record for Resident #8 revealed the facility admitted the resident on 06/20/08 with [DIAGNOSES REDACTED]. The facility completed an Annual MDS assessment on 05/30/13 which revealed the resident was cognitively impaired and required extensive assistance with Activities of Daily Living. Review of Resident #8's Comprehensive Care Plan (reviewed by the facility on 5/15/14) for preventative skin impairment revealed the resident required the total assist of staff for bed mobility and transfers. In addition, the care plan indicated staff could use positional devices as needed to offload pressure. According to the care plan, Resident #8 was also at risk for falls. The fall risk interventions included screening of the resident as needed by Physical Therapy (PT) and Occupational Therapy (OT). Review of the clinical record for Resident #8 revealed the Licensed Practical Nurse (LPN) had documented a Condition Change Form, on 05/07/14 at 2:00 PM, in the nurse's notes. The condition change indicated the resident was leaning to the left while sitting in the wheelchair. Further review of the clinical record revealed a physician's orders [REDACTED]. Review of the nurse's notes, dated 05/07/14 at 9:30 PM, revealed Resident #8 returned to the facility from the hospital emergency room with no new physician orders. Review of the comprehensive care plan for Resident #8, revealed the care plan had not been updated to reflect interventions for the change of condition. Interview with the LPN #2, on 05/30/14 at 4:35 PM, revealed all new physician orders [REDACTED]. She stated the MDS Coordinator was responsible for updating and revising the resident care plans. LPN #2 stated all new orders and condition change forms were given to the Minimum Data Set (MDS) Coordinator at the daily nurses meeting. The LPN further stated Resident #8's care plan had not been revised to reflect the change of condition to include the appropriate clinical interventions for wheelchair positioning. 4. Review of the clinical record for Resident #6, revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The facility completed a quarterly Minimum Data Set (MDS) assessment on 01/22/14 which indicated the resident was moderately impaired in cognition and required extensive assistance with bathing, grooming and dressing. The resident received antidepressants, [MEDICATION NAME] and [MEDICATION NAME]. Review of the comprehensive care plan for Resident #6, revealed the facility identified that the resident received [MEDICATION NAME] and [MEDICATION NAME]. The facility interventions included monitoring for side effects of the medications, however, there were no documented interventions for who would monitor and when monitoring would occur. In addition, the side effects were in one intervention and there were no side effects listed separately for each medication. The facility was monitoring for side effects of nausea, restlessness, agitation, dizziness for both medications. revealed the side effects for [MEDICATION NAME] included: anticholenergic The side effects for [MEDICATION NAME] included: sore throat, excessive sweating, burning in hands and feet, uncontrolled shaking, gas, decreased appetite, nausea, vomiting, excessive tiredness, weight changes, dry mouth, dizziness. Interview with Licensed Practical Nurse (LPN) #1, on 05/30/14 at 2:25 PM, revealed there was no certain time to monitor residents for medication side effects and monitoring should be done all the time. She stated the care plan should have been revised to show each antidepressant and the side effects for each medication. She stated she would need to know the side effects for each medication in order to effectively monitor the resident and did not feel the care plan was adequately revised. Interview with LPN #2, on 05/30/14 at 2:15 PM, revealed she did not think the care plan was revised to contain the information needed to explain what the side effects were for each medication. Attempted interview with the MDS Coordinator regarding care plans were unsuccessful as she was out of the building for personal reasons.

Based on observation, interview, and review of the facility's Infection Control policy, it was determined the facility failed to provide housekeeping staff with training on cleaning of isolation rooms to ensure isolation rooms were cleaned in a manner to prevent the spread of infection for one (1) of three (3) rooms with contact isolation for Clostridium Difficile (C-diff). Housekeeper #1 took a cleaning cloth and mop into an isolation room, and when finished, took the items back outside the room and placed them back on the housekeeping cart. During that time, she touched the cart numerous times with soiled gloves. The housekeeper removed the personal protective equipment (PPE) and placed it in the trash on the cart. In addition, Housekeeper #1 used a disinfectant to clean the room that was not effective against[DIAGNOSES REDACTED] spores. The findings include: Review of the facility's Infection Control Policies, revealed it did not address how or when to clean isolation rooms and did not address the appropriate disinfectant to use. Review of the in-service training for employees, dated July 2013, revealed employees were trained to clean using Standard Precautions; however, no in-service training for isolation could be provided by the facility. Observation of Housekeeper (Hskg) #1, on 05/30/14 at 2:45 PM, revealed Hskg #1 gowning and gloving in the hall outside room [ROOM NUMBER]. The signage on the door revealed the resident was in isolation. Hskg #1 removed a rag from the pail of water on the cart and entered the room and wiped down the contact surfaces. She then returned to the cart and placed the rag back in to the bucket of water on the cart. She took a mop from the mop bucket and squeezed the water from the mop head touching the bucket wringer with her soiled gloves. She mopped the room then returned the mop to the mop bucket again touching the bucket wringer with her soiled gloves. Continued observation of Hskg #1, on 5/30/14 at 2:52 PM, revealed she removed her PPE in the hallway next to the cart and placed the items in the trash bag on the cart. She removed the PPE items from the trash and deposited them in a small uncovered trash can in the resident's room. She then pushed the cart down the hall towards the back of the facility. Interview with Hskg #1, on 05/30/14 at 2:58 PM, revealed she was returning the cart to the housekeeping room. She stated she had been trained on cleaning an isolation room; however, she could not remember when the training occurred. She stated she used a disinfectant that the facility always used for cleaning and stated she thought the cleaner killed all germs. Observation of the bottle's label revealed it was not marked as to the solution inside the bottle. She stated she did not mix the cleaner herself, but was not sure who prepared the cleaning solution, as it was already on the cart. She stated the facility practice was to take the cart to the housekeeping room and wipe down all the surfaces. She stated she was not trained to bag the cleaning rag or the mop head and remove them from the room. She denied that she removed her PPE in the hallway next to the housekeeping cart. She stated she did place the PPE in the cart trash then removed them and placed them back in the resident room. She indicated she did not know why she did that. She stated she had cleaned the other two resident rooms who had[DIAGNOSES REDACTED] that day; however, she was not sure which chemical she used or if she had used the same cart all day. She stated germs could be spread to others if the wrong chemical was used. Interview with the Housekeeping Director (HD), on 05/30/14 at 3:08 PM, revealed he trained the Housekeeping employees on cleaning isolation rooms; however, he was not able to provide any evidence of when the training was provided. He stated the cleaner on the cart was a solution mixed with chemical and water and was effective for killing[DIAGNOSES REDACTED] spores. He brought the bottle of chemical to review and stated he had under lined[DIAGNOSES REDACTED]; however, when the label was read, it stated it was effective against Methicillin Resistant Organisms. Documentation was not located on the bottle to indicate it was effective against[DIAGNOSES REDACTED]. He stated he did not realize the chemical was not effective against[DIAGNOSES REDACTED] and they might have used the wrong chemical to clean all the rooms of the residents with[DIAGNOSES REDACTED] that day. He stated germs could spread and cause other residents to be sick. No other housekeepers were available to interview. Interview with the Administrator, on 05/30/14 at 3:14 PM, revealed she was not aware Housekeepers were cleaning with the wrong chemicals needed to eliminate the[DIAGNOSES REDACTED] spores in isolation rooms.

Based on observation, and interview, it was determined the facility failed to ensure resident rooms and equipment were in good repair. Four (4) of twenty-eight (28) bathroom doors (Rooms 115, 116, 118 and 122) were found with tape residue all over the doors. Blue pillows used to prop up residents' feet were found in three (3) of twelve (12) rooms to be soiled with brown and black marks (Rooms 104-1, 105-1, 107-1 and 114). In addition, a wheelchair in Room 123-1 had a metal bar behind the seat back which was broken and repaired with white medical tape. The findings include: Interview with the Maintenance Director, on 05/29/14 at 10:00 AM, revealed there was no policy for maintenance. Observation of the facility, on 05/29/14 at 9:00 AM, revealed the bathroom doors in Rooms 115, 116, 118, and 122 were heavily covered with tape residue. The doors were shiny and the residue easily seen. A wheelchair in Room 123-1 had a metal bar going horizontally across the back side of the seat back that was broken and had white medical looking tape wrapped around the bar where it attached to the wheelchair. Foot pillows in four (4) rooms (Room 104-1, 105-1, 107-1 and 114) were soiled with brown and black particles and marks. Interview with Certified Nurse Aide (CNA) #4, on 05/30/14 at 2:40 PM, revealed the foot pillow covers should have been removed and sent to the laundry. Interview with the Maintenance Director, on 05/29/14 at 2:30 PM, revealed he received no request from nursing regarding the broken wheelchair. He stated he had not noticed a problem with the bathroom doors. Interview with Licensed Practical Nurse #2, on 05/30/14 at 2:20 PM, revealed work orders for maintenance were sent to maintenance and the repairs were then completed. She stated she had no knowledge of the broken wheelchair or the bathroom doors with tape residue. She stated she did not remember requesting repair of the wheelchair or the doors covered with tape residue. She stated the covers on the blue pillows were to be removed by nursing and sent to the laundry when soiled. She indicated she had made rounds on residents; however, the soiled pillows were not noted.

Based on observation, interview, record review, and facility policy, it was determined the facility failed to ensure three (3) of twenty-one (21) residents in the dining room (Residents #8, B, and D) were treated with dignity by the facility staff at breakfast and lunch on 05/29/14. Nursing staff brought Resident B to their assigned table and let go of the wheelchair, without warning, leaving the resident to coast to the table. Nursing staff approached Resident #8's table, grab the wheelchair and moved the resident to a different table without speaking to the resident or providing a reason for the move. Nursing staff accidentally, hit Resident B's wheelchair with Resident D's wheelchair and failed to speak to either resident about the incident. In addition, the facility posted a paper sign taped to the shared bathroom wall with information about Unsampled Resident D's care plan. The findings include: Interview with the Administrator, on 05/30/14 at 10:00 AM, revealed the facility did not have a policy regarding treating residents with dignity. She stated the facility practice was to treat all residents with dignity and respect. Observation of Resident #8, on 05/29/14 at 7:10 AM, revealed Resident #8 sitting in a wheelchair at a table. Another resident entered the dining room and complained that Resident #8 was seated in his/her place. Certified Nurse Aide (CNA) #1 went to Resident #8 and quickly removed the resident and placed him at another table without explanation to Resident #8. A few minutes later CNA #1 moved Resident #8 to the back of the dining room without explanation. The resident was leaning over the left armrest and struggled several times to sit up to eat. Staff were present; however, no assistance was provided to the resident. CNA #2 was observed at 7:16 AM to wheel Resident B into the dining room. The resident had a specialty chair and she could not maneuver the resident to the right table as the walk way was too crowded. She walked up behind Resident #4, without speaking to the resident, and pushed the resident's wheelchair hard to move it out of the way. Resident #4 was already close to the table edge and the push caused the dining table to move and for the resident to look around to see what happened. The resident then grunted at the staff. The CNA then pushed Resident B towards the table, accidentally, hitting the wheelchair of Resident D. The CNA did not stop or inquire if both residents were all right. When CNA #2 reached Resident B's table, she let go of the wheelchair and Resident B coasted to the table. She was not observed to speak to any of the residents and left the dining room. Observation, on 05/29/14 at 7:25 AM, of Resident D's bathroom in the four (4) bed room [ROOM NUMBER], revealed a paper sign taped to the wall in the bathroom. The sign revealed details regarding the resident's toileting. Interview with Unsampled Resident D, on 05/29/14 at 7:25 AM, revealed the hit to the wheelchair did shake the resident up; however, the resident was all right now. The resident stated he/she was not aware of a paper sign taped to the wall in his/her shared bathroom and did not want it there. Interview with CNA #1, on 05/29/14 at 7:30 AM, revealed she did not realize she did not give Resident #8 a reason for moving to another table. She stated she had been trained to explain procedures before doing them. She stated she should not have treated the resident that way. She indicated she did not show the resident respect. Interview with CNA #2, on 05/29/14 at 7:36 AM, revealed she was in a hurry and she did not intend to harm the residents dignity. She stated she should have made room for the wheelchair by telling the residents what she was doing. She revealed she should have checked with Unsampled Resident D to ensure she was not harmed when hit by Unsampled Resident B's wheelchair. She stated she was trained to treat residents with dignity and respect. Interview with the Director of Nursing, on 05/29/14 at 8:20 AM, revealed CNAs were trained to treat residents with respect and dignity. She stated she was not aware of the paper sign in Unsampled Resident D's bathroom and that the sign was not appropriate.

Based on observation, interview, and record review, it was determined the facility failed to ensure the side effects that should be monitored for [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (antidepressant), were monitored for one (1) of fourteen (14) sampled residents, (Resident #6). The facility administered [MEDICATION NAME] and [MEDICATION NAME], to Resident #6 on a routine basis; however, failed to accurately identify and monitor the correct side effects of these medications. The findings include: Interview with the Administrator, on 05/30/14 at 4:00 PM, revealed the facility had no policy regarding the monitoring of [MEDICAL CONDITION] medications. Observation of Resident #6, on 05/28/14 at 10:20 AM, 10:52 AM, 2:10 PM, 2:46 PM, 3:09 PM and on 05/29/14 at 7:02 AM, 7:22 AM and 11:55 AM, revealed the resident was either in bed or in the wheelchair. Severe behaviors were not noted. Review of the clinical record for Resident #6, revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The facility completed a Quarterly Minimum Data Set (MDS) assessment, on 01/22/14, which revealed the resident had a moderate cognitive impairment and required extensive assistance with bathing, dressing and walking. The resident could eat independently after tray set-up. Review of the comprehensive care plan for Resident #6, dated 04/24/14, revealed the resident received [MEDICATION NAME] and [MEDICATION NAME]. The side effects of [MEDICATION NAME] and [MEDICATION NAME] were listed as nausea, tiredness, weight changes, dizziness and fatigue. The same side effects were listed for both medications. Review of Table 1 in the State Operations Maual revealed [MEDICATION NAME]'s side effects included: diarrhea, constipation, vomiting, dry mouth, gas, loss of appetite, drowsiness, headache, excessive sweating, uncontrollable shaking, and pain/burning in hands or feet. There was no evidence provided to validate the facility monitored Resident #6 for the common side effects of [MEDICATION NAME]. Review of Table 1 in the State Operations Manual revealed [MEDICATION NAME]'s side effects included: [MEDICATION NAME] effects; cardiac arrhythemias; orthostatic [MEDICAL CONDITION] Tardive Dyskenesia; Parkinsonism; elevated blood glucose levels; lethergy; and falls. There was no evidence provided to validate the facility monitored Resident #6 for the common side effects of [MEDICATION NAME]. Interview with Licensed Practical Nurse (LPN) #2, on 05/30/14 at 2:15 PM, revealed she would have to research the side effects for [MEDICATION NAME] and [MEDICATION NAME] in order to monitor for the side effects of these medications. She stated she usually monitored for nausea, dizziness, and restlessness; however, she was not sure what other side effects each medication could cause. A request for evidence of monitoring was made; however, no evidence of monitoring for side effects was received. The Minimum Data Set (MDS) Coordinator was not available in the facility for interview.

Based on observation, interview, record review, and review of the facility's Catheter Care policy, it was determined the facility failed to ensure residents with an indwelling catheter were provided a devise to secure the catheter tubing in place to prevent trauma for two (2) of fourteen (14) sampled residents, (Residents #2 and #4). The findings include: Review of the facility's policy regarding Catheter Care, Indwelling Catheter, basic responsibility for the licensed nurse, not dated, revealed catheter care procedures were to prevent catheter associated Urinary Tract Infections [MEDICAL CONDITION] and to reduce irritation. The policy detailed how to provide catheter care which included a handwritten statement regarding securing the tubing and to document in the medical record the date and time catheter care was completed with signature and title of the person recording the data. Interview with the Administrator, on 05/30/14 at 11:25 AM, revealed the facility utilized the Lippincott Manual 6th edition, for nursing procedures as a standard of practice. Review of the Lippincott Manual of Nursing Practice 6th Edition, copyright date 1996, revealed in Chapter 19: Renal and Urinary Disorders, page 596, revealed management of the patient's indwelling catheter should be secured with the rational to prevent catheter movement and traction on the urethra. 1. Observation of Resident #4, on 05/29/14 at 9:30 AM, revealed during the skin assessment the resident was lying on the bed with an indwelling catheter to a bedside drainage bag that was observed to be anchored to the bed frame. Resident #4 was observed with a suprapubic catheter without a securing device to prevent movement and possible trauma. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 09/23/13 with [DIAGNOSES REDACTED]. Review of the admission nursing assessment and the initial Minimum Data Set (MDS) Admission assessment, dated 09/30/13, revealed the facility assessed the resident with a catheter and as frequently incontinent of bowel. Review of the comprehensive care plan, dated 12/26/13, revealed interventions of a Foley Catheter per order, care and change of the catheter were per facility policy. Interview with License Practical Nurse #1 (LPN), on 05/29/14 at 9:30 AM, during Resident #4's skin assessment revealed the suprapubic catheter was not secured to the resident's leg. The nurse stated the resident did not have a strap on today, and needed one. Further interview on 05/30/14 at 2:45 PM with LPN #1 revealed the facility had two devices to secure catheter tubing, one was an adhesive tape and the other was a strap that went around the resident's leg to secure the tubing. 2. Observation of Resident #2, on 05/28/14 at 9:45 AM, revealed an indwelling catheter tubing in a dignity bag connected to his/her wheelchair. Resident #2 declined skin assessment requests on 05/29/14 and 05/30/14 due to the resident being up in a wheelchair and did not want to go back to bed and the resident had family visitors. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 08/18/12 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly assessment, dated 02/07/14, revealed the facility assessed Resident #2 with an indwelling catheter and as always incontinent of bowel. Review of the comprehensive care plan, dated 08/31/12, revealed interventions of a Foley Catheter per order, care and change of the catheter per facility policy and a handwritten intervention #9 was to anchor the indwelling catheter to the thigh to prevent pulling and trauma to the bladder. Interview with the DON, on 05/30/14 at 6:36 PM, revealed Resident #2 preferred the use of the strap device, but the device was on back order and the facility currently did not have any devises available. Interview with the Wound Care LPN, on 05/30/14 at 3:35 PM, revealed the purpose of securing the catheter tubing was to prevent trauma, if the tubing was pulled. Continued interview with the Director of Nursing (DON), on 05/30/14 at 3:36 PM, revealed the facility's nursing practice was to secure catheter tubing to prevent residents from pulling or causing irritation and the catheter tubing could be removed or dislodged if pulled on too hard causing trauma that might prevent re-insertion of another catheter. The DON further stated the facility had two devices to secure catheters with, one was a tape device and the other was a strap device.

Based on observation and interview, it was determined the facility failed to provide telephone privacy for two (2) of fourteen (14) sampled residents (Residents #4 and #5), and one (1) of four (4) Unsampled Residents (Unsampled Resident A). The findings include: Interview with the Administrator, on 05/30/14 at 2:50 PM, revealed there was no policy related to privacy for residents during telephone usage. Interview during the resident group meeting, on 05/28/14 at 2:00 PM, revealed Residents #4 and #5 did not have adequate phone privacy during conversations, and revealed they were required to use the phone at the nurse's station or the phone on the wall behind the desk. Observation of the telephone system at the nurse's station, on 05/30/14 at 12:00 PM, revealed a desk phone with a long cord attached and a phone hanging on the wall behind the desk. Further observation, on 05/30/14 at 12:49 PM, revealed Unsampled Resident A talking on the desk telephone, sitting outside the nurse's station, with the phone cord pulled over the top of the counter Interview with Unsampled Resident A, on 05/30/14 at 1:25 PM, revealed she had only been a resident at the facility for a couple of weeks, and revealed he/she had just used the phone at the nurses's station. Unsampled Resident A was his/her own Power of Attorney and stated he/she had been told on admission that residents could use the phone at the desk, or the phone on the wall, but had not been told he/she could use any of the private offices. Interview with LPN #1, on 05/30/14 at 1:25 PM, revealed resident's always use the phone at the nurse's desk, either on the wall or the desk. The LPN stated sometimes resident's would go to the dining room and use the phone there. Interview with the Social Services Director, on 05/30/14 at 1:05 PM, revealed they allowed residents to use the phones in the private offices for phone calls; however, there was no evidence or documentation to show resident's had been informed of this process. Interview with the Administrator, on 05/30/14 at 2:50 PM, revealed there was no privacy policy, and residents were allowed to go to the conference room, if needed, to use the phone. However, interview with residents revealed they were not informed of this, and there was no documented evidence to support it.