Every finding on record at NHC Healthcare, Pulaski

Based on facility policy review, facility documentation review, medical record review, and interviews, the facility failed to protect 3 of 12 sampled residents (Resident #30, Resident #50, and Resident #75) reviewed related to falls with injury which resulted in actual harm (Resident #30 had a laceration, bruising and bump to the head that required one staple. Resident #50 had a contusion to right hip and shoulder. Resident #75 had a left forehead laceration, approximately 5 mm [millimeter] requiring steri-strips with an acute traumatic subdural hematoma). The Findings include: Review of the facility policy titled, Incident and Accident Process revised 8/13/2013 revealed, .examples of incidents/accidents are: Falls, Found on floor . Review of the facility policy titled, Nursing Services revised 2/2022 revealed, .The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the undated facility policy titled, Fall Prevention Program revealed, .Purpose: To reduce patient's risk of falling .Apply fall risk interventions as appropriate for the patient . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Senile Degeneration of Brain, Unspecified Fracture of Right Pubis, and History of falling. Review of the current Care Plan for Resident #30 revealed a problem/assessment for falls. Interventions included, .Approach start date: 05/03/2021 Bolsters to both sides of bed to form perimeter .04/02/2021 Apply fall mats to left and right sides of bed .04/02/2021 Bed in safest, lowest position . Review of the Progress Notes for Resident #30 dated 8/5/2022 revealed, .04:30 AM Pt [patient] was found on floor at 0315 by tech .Fall interventions were not in place at time of fall. She had rolled out of bed and hit her head .sent to [Named Hospital] .received one staple at the ER [emergency room ] .08/25/2022 05:19 PM Post fall investigation summary: Patient was FOF [found on floor] on 8/5/22 at 3:45 AM after rolling out of bed. Careplanned bolsters and fall mats not in place at time of fall .Pt sustained laceration, bump, and bruising to top of head, was sent to ER, and returned with staple to laceration .Physical Therapy . Review of the hospital records for Resident #30 dated 8/5/2022, revealed she was admitted to the emergency department with a laceration to her scalp. Continued review revealed the laceration was closed with 1 staple. Radiological exam revealed soft tissue swelling of the frontal scalp. During a telephone interview on 10/18/2022 at 5:04 PM, Licensed Practical Nurse (LPN)#1 confirmed Resident #30 had a fall and sustained a laceration to her head which required a staple closure. She stated the Certified Nursing Assistant (CNA) was not aware of Resident #30's required interventions. She stated the bed bolsters and the fall mats were not in place at the time of the fall. She confirmed Resident #30's care plan included bed bolsters and fall mat interventions related to her high fall risk evaluation. Review of the facility document titled, FSI-Fall Scene Investigation Report, dated 8/5/2022 revealed, .fell out of bed. Bolsters/fall mats not in place .Root Cause of this Fall .Assistive/Protective device .Pt did not have bed bolsters in place . Review of the East Hall CNA shift report form revealed Resident #30 was not listed as a fall risk and not indicated as on the Fall Focus Program. During an interview on 10/19/2022 at 12:35 PM, Physical Therapy Assistant #1 stated he had completed the investigation for Resident #30's fall with injury. He confirmed the fall interventions were not in place at the time of the fall on 8/5/2022. During an interview on 10/19/2022 at 5:00 PM, the Director of Nursing (DON) confirmed Resident #30's fall with injury resulted when care planned interventions were not implemented. Review of the Significant Change in status assessment dated [DATE], revealed Resident #50 was admitted to the facility on [DATE] and had Brief Interview for Mental Status Score (BIMS) of 15 which indicated intact cognitive abilities. Continued review revealed he required extensive assistance of 2 or more caregivers for bed mobility, total dependence on transfers of 2 or more caregivers, extensive assistance for dressing of 1 caregiver, and extensive assistance for toileting of 2 or more caregivers. Review of the Care Plan for Resident #50 revealed, .Fall risk for injury related to physical limitations in functional mobility .history of falls . Approach for fall prevention included, . 4/11/2022 bed in lowest, safest position .9/10/2022 Bumpers in place while pt [patient] is in bed. Educate staff to keep bed in low position while pt is in bed . Review of Resident #50's Safety Events - Fall dated 9/10/2022, revealed, .05:23 AM pt was found on the floor .pt stated that he was asleep in bed and next thing he knew he was in the floor .pt was assisted back to bed lifted manually by 4 people .once back in bed pt c/o [complained of] severe right hip pain .upon examination pt hip found to be internally rotated with resistance to ROM [range of motion} and was shorter than left leg .pain med admin [administered] with little help. MD notified, order given to transport pt to hospital for further evaluation . Continued review of the Safety Events - Fall revealed, .9/10/2022 at 10:18 AM pt returned from ER [emergency room ] with diagnosis of contusion to hip and shoulder . Further review of the Safety Events - Fall revealed, .10/6/2022 05:16 PM post fall investigation summary: Pt was FOF [Found on floor] beside bed on 9/10/22 at 3:48 AM after rolling out of bed while sleeping. Pt was sleeping on winged mattress and fall mats were in place, but bed was not in lowest position . Review of Resident #50's Fall Investigation Report dated 9/10/2022, revealed, .Factors observed at time of fall .Bed height not appropriate .Describe initial interventions to prevent future falls .educate staff to have bed in low position . Review of Resident #50's ER visit dated 9/10/2022, revealed Diagnosis of Pelvic and Right shoulder Contusion. During an interview on 10/19/2022 at 1:55 PM, the Physical Therapist Assistant (PTA) confirmed Resident #50's bed was not at the appropriate height which contributed to his injury on 9/10/2022. During an interview on 10/19/2022 at 4:20 PM, the DON confirmed she would expect Certified Nursing Staff to lower a resident's bed to the lowest position prior to leaving the resident's room after providing care. Review of the medical record revealed Resident #75 was readmitted to the facility on [DATE] with diagnoses which included [NAME]-[NAME] Syndrome [[CONDITION(S)] disorder characterized by muscle weakness], Myasthenia Neoplasm, and Alzheimer's Disease. Review of Resident #75's Quarterly MDS dated [DATE] revealed Resident #75 had a BIMS score of 99 indicating the resident could not complete the assessment. Continued review revealed Resident #75 required extensive assistance for bed mobility and transfers with two staff. Resident #75 had bilateral impairment of the upper extremities. Review of Resident #75's Care Plan interventions dated 1/6/2021 revealed .keep bed in low position. Ensure safe environment, free from clutter and obstacles . Review of the facility's documentation dated 8/2/2022 revealed .Summoned to Pt [patient] room at 11 pm per CNA [Certified Nurse Aide]. Pt laying on floor on left side on top of fall mat. Pt nursing alert. Baseline orientation Normal. Noted bleeding on floor. Pt assessed for injury 1/2 inch. Laceration to left side of forehead. First aid initiated. MD notified. with orders received for transfer to ER [emergency room ]/ via ambulance for further eval [evaluation]. Pt wife notified .this nurse took call from ER at this time stating they were admitting patient for observation noted Subdural Hematoma [blood between brain and its outermost covering], nonsurgical .On 8/2/2022 at 11:00 PM, Patient was FOF [found on floor] beside bed on fall mat. CNA reports that patient had been changed within an hour of incident, but bed was apparently not in lowest position . Review of the History and Physical dated 8/3/2022 revealed .Admission Diagnosis 1. Status post bed height fall with [MEDICATION(S)] head trauma and 5 mm [millimeter] left forehead laceration, reapproximated with Steri-strip with secondary 2.5 cm [centimeter] acute traumatic Subdural Hematoma .This is a [AGE] year old nursing home resident with [NAME]-[NAME] Syndrome and Dementia, who is non ambulatory and nonverbal who last evening fell from bed height. He did sustain [MEDICATION(S)] head trauma with 5 mm laceration to left forehead and was found to have 2.5 mm acute Subdural Hematoma . During an interview on 10/19/2022 at 2:15 PM, the PTA stated he had interviewed another agency CNA who assisted Resident #75 from the floor and she revealed the bed was not in the lowest position and the bedside table was close to the side of the bed. During a telephone interview on 10/19/2022 at 4:57 PM, Registered Nurse (RN) #3 stated she was at the nurses' station and a LPN had approached her and told her Resident #75 had fallen out of bed. Resident #75 was found on the floor facing the door. During an interview on 10/19/2022 at 3:14 PM, the DON stated she had not reviewed the post fall investigation for Resident #75. The DON expected staff to ensure a resident's bed was in a low position and the floor was clutter free before exiting the room.

Based on facility policy review, facility documentation review, medical record review, hospital record review, and interviews, the facility failed to implement care plan interventions for 3 of 12 sampled residents (Resident #30, Resident #50, and Resident #75) reviewed for falls with injury which resulted in actual harm. Resident #30 had a laceration, bruising and bump to the head that required one staple. Resident #50 had a contusion to right hip and shoulder. Resident #75 had a left forehead laceration, approximately 5 mm [millimeter] requiring steri-strips with an acute traumatic subdural hematoma). The findings include: Review of the facility policy titled, Nursing Services revised 2/2022 revealed, .The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the undated facility policy titled, Fall Prevention Program revealed, .Purpose: To reduce patient's risk of falling .Apply fall risk interventions as appropriate for the patient . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Senile Degeneration of Brain, Unspecified Fracture of Right Pubis, and History of falling. Review of the current Care Plan for Resident #30 revealed a problem/assessment for falls. Interventions included, .Approach start date: 05/03/2021 Bolsters to both sides of bed to form perimeter .04/02/2021 Apply fall mats to left and right sides of bed .04/02/2021 Bed in safest, lowest position . Review of the Progress Notes for Resident #30 dated 8/5/2022 revealed, .04:30 AM Pt [patient] was found on floor at 0315 by tech .Fall interventions were not in place at time of fall. She had rolled out of bed and hit her head .sent to [Named Hospital] .received one staple at the ER [emergency room ] .08/25/2022 05:19 PM Post fall investigation summary: Patient was FOF [found on floor] on 8/5/22 at 3:45 AM after rolling out of bed. Careplanned bolsters and fall mats not in place at time of fall .Pt sustained laceration, bump, and bruising to top of head, was sent to ER, and returned with staple to laceration .Physical Therapy . Review of the hospital records for Resident #30 dated 8/5/2022, revealed she was admitted to the emergency department with a laceration to her scalp. Continued review revealed the laceration was closed with 1 staple. Radiological exam revealed soft tissue swelling of the frontal scalp. Review of the facility document titled, FSI-Fall Scene Investigation Report, dated 8/5/2022 revealed, .fell out of bed. Bolsters/fall mats not in place .Root Cause of this Fall .Assistive/Protective device .Pt did not have bed bolsters in place . Review of the East Hall CNA shift report form revealed Resident #30 was not listed as a fall risk and not indicated as on the Fall Focus Program. During a telephone interview on 10/18/2022 at 5:04 PM, Licensed Practical Nurse (LPN)#1 confirmed Resident #30 had a fall and sustained a laceration to her head which required a staple closure. She stated the Certified Nursing Assistant (CNA) was not aware of Resident #30's required interventions. She stated the bed bolsters and the fall mats were not in place at the time of the fall. She confirmed Resident #30's care plan included bed bolsters and fall mat interventions related to her high fall risk evaluation. During an interview on 10/19/2022 at 12:35 PM, Physical Therapy Assistant #1 stated he had completed the investigation for Resident #30's fall with injury. He confirmed the fall interventions were not in place at the time of the fall on 8/5/2022. During an interview on 10/19/2022 at 5:00 PM, the Director of Nursing (DON) confirmed Resident #30's fall with injury resulted when care planned interventions were not implemented. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included History of Falling, Cerebral Infarction, and Dementia. Review of the Significant Change in status assessment dated [DATE], revealed Resident #50 was admitted to the facility on [DATE] and had Brief Interview for Mental Status Score (BIMS) of 15 which indicated intact cognitive abilities. Continued review revealed he required extensive assistance of 2 or more caregivers for bed mobility, total dependence on transfers of 2 or more caregivers, extensive assistance for dressing of 1 caregiver, and extensive assistance for toileting of 2 or more caregivers. Review of the Care Plan for Resident #50 revealed, .Fall risk for injury related to physical limitations in functional mobility .history of falls . Approach for fall prevention included, . 4/11/2022 bed in lowest, safest position .9/10/2022 Bumpers in place while pt [patient] is in bed. Educate staff to keep bed in low position while pt is in bed . Review of Resident #50's Safety Events - Fall dated 9/10/2022, revealed, .05:23 AM pt was found on the floor .pt stated that he was asleep in bed and next thing he knew he was in the floor .pt was assisted back to bed lifted manually by 4 people .once back in bed pt c/o [complained of] severe right hip pain .upon examination pt hip found to be internally rotated with resistance to ROM [range of motion} and was shorter than left leg .pain med admin [administered] with little help. MD notified, order given to transport pt to hospital for further evaluation . Continued review of the Safety Events - Fall revealed, .9/10/2022 at 10:18 AM pt returned from ER [emergency room ] with diagnosis of contusion to hip and shoulder . Further review of the Safety Events - Fall revealed, .10/6/2022 05:16 PM post fall investigation summary: Pt was FOF [Found on floor] beside bed on 9/10/22 at 3:48 AM after rolling out of bed while sleeping. Pt was sleeping on winged mattress and fall mats were in place, but bed was not in lowest position . Review of Resident #50's Fall Investigation Report dated 9/10/2022, revealed, .Factors observed at time of fall .Bed height not appropriate .Describe initial interventions to prevent future falls .educate staff to have bed in low position . Review of Resident #50's ER visit dated 9/10/2022, revealed Diagnosis of Pelvic and Right shoulder Contusion. During an interview on 10/19/2022 at 1:55 PM, the Physical Therapist Assistant (PTA) confirmed Resident #50's bed was not at the appropriate height which contributed to his injury on 9/10/2022. During an interview on 10/19/2022 at 4:20 PM, the DON confirmed she would expect Certified Nursing Staff to lower a resident's bed to the lowest position prior to leaving the resident's room after providing care. Review of the medical record revealed Resident #75 was readmitted to the facility on [DATE] with diagnoses which included [NAME]-[NAME] Syndrome [autoimmune disorder characterized by muscle weakness], Myasthenia Neoplasm, and Alzheimer's Disease. Review of Resident #75's Quarterly MDS dated [DATE] revealed Resident #75 had a BIMS score of 99 indicating the resident could not complete the assessment. Continued review revealed Resident #75 required extensive assistance for bed mobility and transfers with two staff. Resident #75 had bilateral impairment of the upper extremities. Review of Resident #75's Care Plan interventions dated 1/6/2021 revealed .keep bed in low position. Ensure safe environment, free from clutter and obstacles . Review of the facility's documentation dated 8/2/2022 revealed .Summoned to Pt [patient] room at 11 pm per CNA [Certified Nurse Aide]. Pt laying on floor on left side on top of fall mat. Pt nursing alert. Baseline orientation Normal. Noted bleeding on floor. Pt assessed for injury 1/2 inch. Laceration to left side of forehead. First aid initiated. MD notified. with orders received for transfer to ER [emergency room ]/ via ambulance for further eval [evaluation]. Pt wife notified .this nurse took call from ER at this time stating they were admitting patient for observation noted Subdural Hematoma [blood between brain and its outermost covering], nonsurgical .On 8/2/2022 at 11:00 PM, Patient was FOF [found on floor] beside bed on fall mat. CNA reports that patient had been changed within an hour of incident, but bed was apparently not in lowest position . Review of the History and Physical dated 8/3/2022 revealed .Admission Diagnosis 1. Status post bed height fall with blunt head trauma and 5 mm [millimeter] left forehead laceration, reapproximated with Steri-strip with secondary 2.5 cm [centimeter] acute traumatic Subdural Hematoma .This is a [AGE] year old nursing home resident with [NAME]-[NAME] Syndrome and Dementia, who is non ambulatory and nonverbal who last evening fell from bed height. He did sustain blunt head trauma with 5 mm laceration to left forehead and was found to have 2.5 mm acute Subdural Hematoma . During an interview on 10/19/2022 at 2:15 PM, the PTA stated he had interviewed another agency CNA who assisted Resident #75 from the floor and she revealed the bed was not in the lowest position and the bedside table was close to the side of the bed. During a telephone interview on 10/19/2022 at 4:57 PM, Registered Nurse (RN) #3 stated she was at the nurses' station and a LPN had approached her and told her Resident #75 had fallen out of bed. Resident #75 was found on the floor facing the door. During an interview on 10/19/2022 at 3:14 PM, the DON stated she had not reviewed the post fall investigation for Resident #75. The DON expected staff to ensure a resident's bed was in a low position and the floor was clutter free before exiting the room.

Based on observation and interview the facility failed to maintain dietary equipment in a sanitary manner for 1 of 3 observations in the dietary department. The findings include: Observation and interview in the dietary department on 10/17/2022 at 10:25 AM, with the Certified Dietary Manager (CDM), revealed 2 areas of pink debris on the right and left edge of the vertical plastic covering in the ice machine. Further observation revealed ice was touching the vertical plastic covering. The CDM confirmed the 2 areas of pink debris on the vertical plastic covering in the ice machine.

Based on facility policy review, medical record review, observation, and interview the facility failed to prevent the spread of infection for 3 of 21 residents (Resident #27, Resident #53, and Resident #58) related to proper storage/sanitation of nebulizer equipment and failed to maintain dietary equipment in a sanitary manner for 1 of 3 observations in the dietary department related to pink debris in the ice machine where ice was kept. The findings include: Review of the facility's policy titled, ORAL INHALATION ADMINISTRATION, dated 1/1/2019 revealed, .When equipment is completely dry, store in a plastic bag with the resident's name and the date on it . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-[MEDICATION(S)] solution for nebulization . Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-[MEDICATION(S)] solution for nebulization . Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] sulfate solution for nebulization . Observation in Resident #27 and Resident #58's room on 10/19/2022 at 10:45 AM revealed nebulizer equipment uncovered on each of the bedside tables. Observations in Resident #53's room on 10/17/2022 at 12:40 PM, 10/18/2022 at 8:30 AM, and 10/19/2022 at 10:55 AM, revealed her nebulizer equipment uncovered and laying on her bedside table. During an interview on 10/19/2022 at 10:50 AM, Licensed Practical Nurse (LPN) #3 stated after giving a nebulizer treatment the equipment should be cleaned and stored in a bag to prevent contamination between uses. She confirmed Resident #27 and Resident #58's nebulizer equipment was uncovered and left in a basket on their bedside tables. Observation and interview on 10/19/2022 at 10:58 AM, Registered Nurse (RN) #2 confirmed Resident #53's nebulizer equipment was uncovered on the bedside table. She stated the nebulizer equipment should be cleaned and stored in a bag to prevent contamination. During an interview on 10/19/2022 at 11:44 AM, Respiratory Therapist #1 stated she had in-serviced the nursing staff to store nebulizer equipment in a bag with the resident's name and date on it. She confirmed that Professional Standards of Practice for storing nebulizer equipment required storage in a closed container or bag. Observation and interview in the dietary department on 10/17/2022 at 10:25 AM, with the Certified Dietary Manager (CDM), revealed 2 areas of pink debris on the right and left edge of the vertical plastic covering in the ice machine. Further observation revealed ice was touching the vertical plastic covering. The CDM confirmed the 2 areas of pink debris on the vertical plastic covering in the ice machine.

Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan for 1 of 37 sampled residents (Resident #7) reviewed for weight loss. The Findings include: Review of the facility's undated policy titled, Nursing Services, revealed, .The patient care plan is developed to address the immediate need of the patient .the center will include the attending physician in the development of the patient's plan of care by incorporating the physician's plan of care [orders] into the care plan .planning is based on identified needs/problems .and is made available for use by all patient care personnel . Review of medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 has a Brief Interview for Mental Status (BIMS) score of 7 which indicated severely impaired cognitive abilities. Continued review of the MDS revealed Resident #7 required limited assistance with bed mobility, transfers, and dressing. Further review of the MDS revealed Resident #7 required set up help with eating. Review of Resident #7's Vitals Report revealed her weight on 4/28/2019 was 147 lbs (pounds), 4/6/2020 139.7 lbs., 2/7/2022 Resident #7's weight dropped to 128 lbs., and one month later her weight dropped 19.5 lbs to 108.5 lbs on 3/21/2022. Further review of the Vitals Report revealed on 7/4/2022 Resident #7's weight was 123.5 lbs then on 8/11/2022 Resident #7's weight was down 9.1 lbs to 114.4 lbs which indicated significant weight loss in one month. Resident #7's current weight continues to be down at 115.1 lbs. Review of the FNS (Food Nutritional Services) Progress Notes dated 3/22/2022 revealed .[Named Resident] showing 15% weight loss x [times] one month. WT [weight] : 108.5 [3/21], 109 [3/17], 128 [2/7]. She has had increased confusion with increased drowsiness. Appetite has decreased .still able to feed herself after set-up but needs total set-up and encouragement to eat .added Med Pass [Fortified Nutritional Shake] 3 oz [ounce] tid [three times day] to increase calorie/protein intake. Will add Ensure plus at lunch daily .Nursing reported she has been eating < [less than] 50 percent at all meals. Will start weekly weight to monitor. MD [Medical Director] informed of weight loss .3/31/2022 .was started on [MEDICATION(S)] [medication to treat loss of appetite] on 3/23 .accepting Ensure at lunch some days .7/20/2022 .[Named Resident] is at risk for malnutrition and will proceed with PCP r/t [related to] decreased appetite with increased confusion r/t dementia, and need for set-up at meals with poor vision .09/09/2022 .now at 3.4 % weight loss x one month .weekly weight until 9/20 or until stable . Review of the Care Plan dated 4/29/2019, revealed Resident #7 was assessed for Nutritional Status, stable weight, and long-term goal will continue to feed herself with no significant weight loss. Continued review of the Care Plan revealed Resident #7's approach to assist with meals as needed. Further review of the Care Plan revealed no updated approaches since 6/1/2022 to reflect the resident's weight loss. During an interview on 10/19/2022 at 2:45 PM, the MDS Coordinator confirmed Resident #7's Care Plan did not reflect her weight loss since 3/2022 nor were additional approaches added to prevent weight loss.

Based on facility policy review, procedure manual review, medical record review, observation, and interview, the facility failed to label and date enteral feeding for 1 of 4 residents (Resident #231) requiring enteral feedings. The findings include: Review of the facility's policy titled, Storage of Medications, dated 1/1/2019, revealed, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Review of the facility's undated procedure manual titled, Changing the tubing, bottle or bag, revealed, .Pour bags: Pour only enough feeding for 8 hours at a time, rinse bag before adding next 8 hour feeding .Bottle/bag will be labeled with time of hang date, rate of flow and nurses initials . Review of the medical record revealed Resident #231 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #231's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations in Resident #231's room on 10/17/2022 at 11:14 AM, 12:30 PM, and 2:14 PM revealed an unlabeled and undated bag of tan liquid hung on a pole being administered to the resident at 65 milliliters/hour (ml/hr) per pump. Observation and interview in Resident #231's room on 10/17/2022 at 2:15 PM, Registered Nurse (RN) #1/Unit Manager confirmed the bag of tan liquid was unlabeled and undated.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored securely and safely when 2 of 3 (Licensed Practical Nurse (LPN) #1 and #2) nurses left medications out of site and unattended. The findings include: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy dated 6/2016, documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel .B .medication supplies are locked when not attended by persons with authorized access . 2. Observations during medication administration in Resident #35's room on 10/8/19 at 3:10 PM, revealed LPN #1 entered Resident #35's room to administer a medication and a bolus enteral feeding. LPN #1 placed a crushed medication on the overbed table, and entered the bathroom, leaving the medication out of site and unattended. LPN #1 returned to administer the enteral bolus feeding, but then entered the bathroom to obtain water for the enteral water flush, leaving the medication on the overbed table out of site and unattended. LPN #1 returned to administer the enteral bolus feeding, after LPN #1 administered the feeding, LPN #1 entered the bathroom to rinse out the enteral syringe, leaving the medication out of site and unattended. 3. Observations during medication administration in Resident's #20's room on 10/9/19 at 9:44 AM, revealed LPN #2 entered Resident #20's room to administer oral medications and insulin. LPN #2 placed the medication and the insulin syringe on the overbed table, and entered the bathroom, leaving the oral medications and insulin syringe out of site and unattended. LPN #2 returned to administer the insulin, gave Resident #20 a glass of water, and then returned to the bathroom, leaving the oral medications out of site and unattended. Interview with the Assistant Director of Nursing (ADON) on 10/9/19 at 2:05 PM, in the ADON Office, the ADON was asked if medications should have been left at the bedside out of site and unattended. The ADON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 2 of 3 (Licensed Practical Nurse (LPN) #2 and 3) nurses failed to perform hand hygiene during medication administration. 1. The facility's INFECTION CONTROL MANUAL .HANDWASHING procedure documented, Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . 2. Observations on the 300 hall on 12/12/17 at 11:00 AM, revealed LPN #2 removed a bottle of Aspirin from the cart, donned gloves, placed an Aspirin in a plastic medication cup, removed her gloves, finished preparing medications, entered room [ROOM NUMBER]A, donned gloves, administered nasal spray and medications, removed gloves, walked out to the medication cart, donned gloves, cleaned the nozzle on the nasal spray bottle, removed gloves, and signed out the medications. LPN #2 failed to perform hand hygiene between glove changes during medication administration. 3. Observations on the 200 hall on 12/12/17 at 12:01 PM, revealed LPN #3 donned gloves, mixed an intravenous (IV) medication, cleaned a glucometer with a bleach wipe, removed her gloves, set up oral medications, donned gloves, obtained supplies and set up the glucometer, removed her gloves, entered room [ROOM NUMBER]A, donned gloves, connected the IV to the pump, picked up the call light and bed control off the floor, removed her gloves, donned new gloves, administered oral medications, performed a finger stick, removed her gloves, donned new gloves, connected the IV to the resident and started the pump, exited the room, disposed of the lancet, cleaned the glucometer, removed her gloves, and signed out the medications. LPN #3 failed to perform hand hygiene between glove changes during medication administration. 4. Interview with the Director of Nursing (DON) on 12/13/17 at 11:25 AM, in the DON's office, the DON was asked what she expected her staff to do between glove changes. The DON stated, Wash their hands.

Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate and report timely an allegation of abuse for 1 of 1 (Resident #109) sampled residents. The findings include: Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy documented, .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately .It is the policy of this facility that abuse allegations .are reported per Federal and State Law . Medical record review revealed Resident #109 was admitted to the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated 9/3/17 documented, .pt (patient) upset this afternoon stating that two men came into her room and was beating her and whipping her with many items. Stated that they hit her so hard they made her pee herself and they almost threw her off the bed. Pt stated they looked mexican . Interview with the Director of Nursing (DON) on 12/11/17 at 2:27 PM, in the conference room, the DON stated, .I wasn't aware that nursing note was in the record . The DON was asked if there had been an investigation. The DON stated, No. The DON was asked what was facility policy regarding allegations of abuse. The DON stated, .report it immediately .I spoke with the nurse and the nurse said she didn't think of it as abuse but screened her for hallucinations since she has had hallucinations in the past . Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 9:04 AM, in the conference room, LPN #1 was asked why she did not report Resident's 9/3/17 allegation of abuse. LPN #1 stated, .It's my bad .she has hallucinations at times .I was trying to document her behaviors .I should have reported it to the DON . Interview with the Administrator on 12/13/17 at 9:15 AM, in the DON's office, the Administrator was asked what he expected his staff to do when there are allegations of abuse. The Administrator stated, .report it to us (administration) immediately .

Based on medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse to the state agency timely for 1 resident (#3) of 2 residents reviewed for abuse. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed an allegation of abuse was reported by Certified Nursing Assistant (CNA #1) on 5/31/17 at 2:30 PM. Continued review revealed the CNA reported the abuse to the Charge Nurse who reported to the Director of Nursing and Social services. Interview with the Administrator confirmed the facility failed to report the allegation of abuse to the State Agency until June 1, 2017 at 10:30 AM. Continued interview confirmed the facility failed to report the abuse within two hours as required.

Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by carbon build-up and grease on pots and pans, grease buildup on the floor under the stove and deep fryer, can opener with brown sticky build-up around the blade, cookware and serving trays stacked and stored while wet, grease traps on the floor with dark brown build-up, kitchen staff with hair not completely covered, and dirty steam tables during 2 of 2 (9/26 and 9/27/16) days of observations. The facility had a census of 89, with 89 of those residents receiving a meal tray from the kitchen. The findings included: 1. The WEEKLY CLEANING schedule documented, .Monday, and Friday Decarbon pots and pans . Observations in the kitchen on 9/26/16 at 11:10 AM, and on 9/27/16 at 8:10 AM, revealed carbon build-up and grease on pots and pans. Interview with the Corporate Dietitian (CD) on 9/26/16 at 11:20 AM, in the kitchen, the CD was asked if it was acceptable to have carbon and grease build-up on pots and pans. The CD stated, No. 2. The facility's FLOORS policy documented, .Using short handle broom, sweep under all equipment, around legs, and in corners, etc. Use push broom to sweep remaining floor to remove all loose soil/debris. Use short handled broom to sweep debris into dustpan .Apply floor cleaner/degreaser/sanitizer evenly over floors with deck brushes or mops . Observations in the kitchen on 9/26/16 at 11:10 AM, and on 9/27/16 at 8:10 AM, revealed grease build-up on the floor under the stove and deep fryer. Interview with the CD on 9/27/16 at 11:20 AM, in the kitchen, the CD was asked if it was acceptable to have grease build-up under the stove and fryer. The CD stated, No. 3. The WEEKLY CLEANING schedule documented, . on Wednesday can openers inc (including) base . Observations in the kitchen on 9/26/16 at 11:10 AM, revealed a can opener with brown, sticky build-up around the blade. Interview with the CD on 9/26/16 at 11:10 AM, in the kitchen, the CD was asked if it was acceptable to have brown sticky build-up around the blade. The CD stated, No. 4. The facility's MANUAL WAREWASHING policy documented, .Air-dry items. Make sure all items are completely dry before stacking to prevent wet-nesting . Observations in the kitchen on 9/26/16 at 11:10 AM, revealed 6 wet sheet pans stacked under the prep table, and 4 wet half pans on the clean rack. Interview with the CD on 9/26/16 at 11:10 AM, in the kitchen, the CD was asked if it was acceptable to have stacks of wet cookware. The CD stated, No. Observations in the kitchen on 9/27/16 at 11:20 AM, revealed 10 wet serving trays stacked on the serving line. Interview with the CD on 9/27/16 at 11:20 AM, in the kitchen, the CD was asked if it was acceptable to have stacks of wet trays on the serving line. The CD stated, No. 5. The facility's WASTE MANAGEMENT policy documented, .Grease traps, if used shall be located to be easily accessible for cleaning . Observations in the kitchen on 9/26/16 at 11:10 AM, and on 9/27/16 at 8:10 AM, revealed two floor grease traps with large amounts of dark brown build-up. Interview with the CD on 9/27/16 at 11:10 AM, in the kitchen, the CD was asked if it was acceptable to have the dark brown build-up in the grease traps. The CD stated, No. 6. The facility's HYGIENIC & SAFETY PRACTICES policy documented, .Dietary Partners .shall wear hair restraints .to effectively keep their hair from contacting exposed food . Observations in the kitchen on 9/26/16 at 11:00 AM, revealed the CD, Dietary Staff (DS) #1, DS #2, DS #3, and DS #4 with their hair not completely covered. Observations in the kitchen on 9/27/16 at 8: 15 AM, revealed DS #5, DS #6, and maintenance staff #1 with their hair not completely covered. Interview with the CD on 9/27/16 at 11:00 AM, in the kitchen, the CD was asked if it was acceptable for staff to be in the kitchen with their hair not completely covered. The CD stated, No. 7. Observations in the day room on the 100 hall on 9/26/16 at 11:30 AM, and 9/27/16 at 8:30 AM, revealed the steam table with dry white substance around the steam table, and dark substance inside of the steam table. Interview with the CD on 9/27/16 at 11:25 AM, in the day room, the CD was asked if it was acceptable to have dry white substance and dark particles on and inside of the steam table. The CD stated, No. Observations in the dining room on the south hall on 9/27/16 at 11:00 AM revealed the steam table in the south hall dining room noted with a dark substance inside the steam table. Interview with DS #7 on 9/27/16 at 2:07 PM, in the south dining room, DS #7 was asked who is responsible for cleaning the steam table. DS #7 stated, .we all are . DS #7 was shown the steam table and was asked what the dark substance was inside the steam table. DS #7 stated, .dried food . DS #7 was asked should the steam table look like this. DS #7 stated, .no .

Based on policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 4 (Licensed Practical Nurse (LPN) #1and 2) nurses failed to use a barrier or to clean the over-the-bed tables prior to placing reuseable resident equipment on the tables during medication (med) administration. The Findings included: The facility's SPECIFIC MEDICATION ADMINISTRATION PROCEDURES policy documented, .Use a barrier (e.g., clean disposable tray or plastic cup) to carry medication containers into the resident's room .This will serve as a barrier between the supplies and the over-the-bed table or other surface on which the supplies are placed while the medication is administered . Observations in Resident #125's room on 9/27/16 at 8:05 AM, revealed LPN #2 removed the plunger from the 60 cc (cubic centimeters) syringe and laid it on the over-the-bed table with no barrier on the table, and without cleaning the surface of the table. Observations on 9/27/16 at 8:11 AM, in Resident #125's room, revealed LPN #2 used a gloved finger to stir the diluted crushed meds in the 4 med cups. Observation on 9/27/16 at 3:47 PM, in Resident #1's room, revealed LPN #1 removed the plunger from the 60 cc (cubic centimeters) syringe and laid it on the over-the-bed table without placing a barrier, or cleaning the surface of the table. Interview with the Director of Nursing (DON) on 9/28/16 at 3:50 PM in the DON's office was asked, what should nurses do with the plunger when it is removed from the syringe while administering Percutaneous Endoscopic Gastrostomy (PEG) medications. The DON stated, Hold it in your hand or place it on the over-the-bed table on a barrier. The DON was asked if a nurse should stir the diluted medications in the med cups with a gloved finger. The DON stated, .no .

Based on medical record review, observation, and interview the facility failed to follow physician's orders for carrot splints and finger separators for 1 of 3 (Resident #125) sampled residents of the 15 residents with contractures in the stage 2 review. The findings included: 1. Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #125 was severely cognitively impaired and totally dependent in functional status. Review of the physician's order dated 5/4/16 documented, .APPLY CARROT SPLINTS AND FINGER SEPARATORS TO BOTH HANDS AT 10AM, REMOVE AT 3PM Q (every) DAY . The resident's care plan dated 8/23/16, documented, .Apply carrot splints and finger separators to bilateral hands at 10 am remove at 3 pm q day . Observations in Resident #125's room on 9/26/16 at 12:54 PM, revealed the resident lying in bed and finger separators not applied. Observations in Resident #125's room on 9/27/16 at 11:18 AM, revealed resident lying in bed, carrot splints and finger separators not applied. Interview with CNA #1 on 9/27/16 at 12:03 PM, at the South Nursing Station, CNA #1 was asked if Resident #125's carrot splints and finger separators were in place as ordered. CNA #1 stated, No Ma'am they weren't . Interview with the Director of Nursing (DON) on 9/28/16 at 10:15 AM, in the DON's office, the DON was asked if it is appropriate for the splints finger separators to not be applied as ordered. The DON answered, No .I think if they are ordered they are ordered for a reason .

Based on medical record review, observation, and interview, the facility failed to follow care plan interventions for nutrition, carrot splints, and finger separators for 2 of 20 (Residents #60 and #125) sampled residents of the 36 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #60 was cognitively intact, had no weight loss of 5 percent (%) or more in the last month or weight loss of 10% or more in the last 6 months, and that Resident #60 received a mechanically altered diet. The care plan dated 8/18/16 documented, Problem Altered food/fluid needs related to .Wounds .Mechanically altered diet .Risk for weight variance .Offer Hs (hour of sleep) snacks .Nsg (nursing) to offer Promod TID (three times a day) .Offer Readyshakes at lunch and supper . Review of Resident #60's Meal% (percent) Tracking Sheet, dated September 2016 revealed no documentation that the HS Snack was provided. The physician's orders [REDACTED].PROMOD LIQUID PROTEIN (SUPPLEMENT) .30ML (milliliters) BY MOUTH THREE TIMES DAILY . Review of the Medication, Treatment and Task Administration Record Report (MAR) for July 2016 revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 7/1/16, 7/3/16, 7/5/16 - 7/8/16, 7/10/16, 7/15/16 - 7/17/16, 7/19/16 - 7/24/16, 7/27/16 - 7/29/16. Review of the MAR for August 2016 revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 8/2/16 - 8/5/16, 8/7/16 - 8/10/16, 8/12/16 - 8/31/16. Review of the MAR for September 2016 revealed that Resident #60 refused the Promod Liquid Protein Supplement 9/1/16 - 9/27/16. Review of Resident #60's meal tray card for the lunch meal on 9/28/16 at 1:02 PM revealed that Resident #60 was to receive a READYSHAKE. Observations in the resident's room at 9/28/16 at 1:03 PM, revealed Resident #60 received a pureed lunch meal. Resident #60 did not receive a Readyshake on her lunch tray. Interview with the Registered Dietitian (RD) on 9/28/16 at 2:19 PM, in the Conference Room, the RD was asked how do you ensure your recommendations are effective. The RD stated, .interview of resident, staff and CNA's (certified nursing assistant) .it is not a check list or anything . The RD was asked when she would look at Resident #60's weight again. The RD stated, .if she has significant weight loss . Interview with Registered Nurse (RN) #1 on 9/28/16 at 2:45 PM, in the south hall, RN #1 was asked if the care plan was followed for providing the Readyshake to Resident #60 at lunch. RN #1 stated, No . Interview with the RD on 9/28/16 at 3:35 PM, in the Conference Room, the RD was asked if there was a policy on nutrition and weight loss. The RD stated, I don't have a set policy . Interview with the Director of Nursing (DON) on 9/28/16 at 2:02 PM, in the DON's office, the DON was asked if a resident is ordered a readyshake how is it documented. The DON stated .we don't document . Interview with Registered Nurse (RN) #2 on 2/28/16 at 2:40 PM, in her office, RN #2 was asked how do you expect the care plan to be implemented. RN #2 stated, .if its in the care plan we alert the nurses . Interview with RN #1 on 9/28/16 at 2:45 PM, in the south hall, RN #1 was asked if the care plan was followed for providing the Readyshake to Resident #60 at lunch. RN #1 stated, No . Interview with the Director of Nursing (DON) on 9/29/16 at 9:54 AM, by telephone, the DON was asked how the physician is notified when a resident refuses a supplement. The DON stated, (Named physician) looks at the MAR's every 2 weeks .we print them off for him and the nurse practitioner looks at them every week . When asked if there was evidence that the physician or nurse practitioner had reviewed Resident #60's MAR, the DON stated, They don't sign it (the MAR) and we don't keep them. When asked if the nurses document that the physician or nurse practitioner was informed that Resident #60 was refusing the Promod, the DON stated, Not that I'm aware of. The facility was unable to provide documentation that the physician was notified of Resident #60 refusing Promod. 2. Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #125 was severely cognitively impaired and totally dependent in functional status. The resident's care plan dated 8/23/16, documented, .Apply carrot splints and finger separators to bilateral hands at 10 am remove at 3 pm q (every) day . Observations in Resident #125's room on 9/26/16 at 12:54 PM, revealed the resident lying in bed and finger separators not applied. Observations in Resident #125's room on 9/27/16 at 11:18 AM, revealed resident lying in bed, carrot splints and finger separators not applied. Interview with CNA #1 on 9/27/16 at 12:03 PM, at the South Nursing Station, CNA #1 was asked if Resident #125's carrot splints and finger separators were in place as ordered. CNA #1 stated, No Ma'am they weren't . Interview with the DON on 9/28/16 at 10:15 AM, in the DON's office, the DON was asked if it is appropriate for the carrot splints and finger separators to not be applied as ordered. The DON answered, No.

Based on medical record review, meal tray card review, observation, and interview, the facility failed to provide nutritional supplements and bedtime snacks as ordered and recommended for 1 of 5 (Resident #60) sampled residents of the 11 residents with nutritional issues included in the stage 2 review. The findings included: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #60 was cognitively intact, had no weight loss of 5 percent (%) or more in the last month or weight loss of 10% or more in the last 6 months and that Resident #60 received a mechanically altered diet. The Vitals Report revealed Resident #60's weight on 8/1/16 was 153 pounds and on 9/1/16 her weight was 149 pounds, which is a 2.6% loss in a month. The Registered Dietitian's (RD) note dated 8/12/16 documented, .She receives promod 30ml (milliliters) BID (twice daily) providing 20g (grams) of protein and 200 calories .has inadequate protein/calorie intake r/t (related to) poor intake, increased needs for wound healing as evidence by leaves 50+ (50 percent (%) or more) uneaten at lunch and supper. Will add readyshake at lunch and supper and increase promod to 30ml TID all providing 700 calories, 42g protein. She is at nutritional risk . The care plan dated 8/18/16 documented, Problem Altered food/fluid needs related to .Wounds .Mechanically altered diet .Risk for weight variance .Offer Hs (hour of sleep) snacks .Nsg (nursing) to offer Promod TID (three times a day) .Offer Readyshakes at lunch and supper . Review of Resident #60's Meal% Tracking Sheet dated September 2016, revealed no documentation that the HS Snack was provided as ordered. The physician's orders [REDACTED].PROMOD LIQUID PROTEIN (SUPPLEMENT) .30ML (milliliters) BY MOUTH THREE TIMES DAILY . Review of the Medication, Treatment and Task Administration Record Report (MAR) for July 2016 revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 7/1/16, 7/3/16, 7/5/16 - 7/8/16, 7/10/16, 7/15/16 - 7/17/16, 7/19/16 - 7/24/16, 7/27/16 - 7/29/16. Review of the MAR for August 2016 revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 8/2/16 - 8/5/16, 8/7/16 - 8/10/16, 8/12/16 - 8/31/16. Review of the MAR for September 2016 revealed that Resident #60 refused the Promod Liquid Protein Supplement 9/1/16 - 9/27/16. Review of Resident #60's meal tray card for the lunch meal on 9/28/16 at 1:02 PM revealed that Resident #60 was to receive a Readyshake. Observations in the resident's room at 9/28/16 at 1:03 PM, revealed Resident #60 received a pureed lunch meal. Resident #60 did not receive a Readyshake on her lunch tray. Interview with the Director of Nursing (DON) on 9/28/16 at 2:02 PM, in the DON's office, the DON was asked if a resident is ordered a readyshake, how it is documented. The DON stated .we don't document .the dietitian keeps up with the weight loss . Interview with the Registered Dietitian (RD) on 9/28/16 at 2:19 PM, in the Conference Room, the RD was asked how do you ensure your recommendations are effective. The RD stated, .interview of resident, staff and CNA's (certified nursing assistant) .it is not a check list or anything . The RD was asked when she would look at Resident #60's weight again. The RD stated, .if she has significant weight loss . Interview with Registered Nurse (RN) #1 on 9/28/16 at 2:45 PM, in the south hall, RN #1 was asked if the care plan was followed for providing the Readyshake to Resident #60 at lunch. RN #1 stated, No . Interview with the RD on 9/28/16 at 3:35 PM, in the Conference Room, the RD was asked if there was a policy on nutrition and weight loss. The RD stated, I don't have a set policy . Interview with the Director of Nursing (DON) on 9/29/16 at 9:54 AM, by telephone, the DON was asked how the physician is notified when a resident refuses a supplement. The DON stated, (Named physician) looks at the MAR's every 2 weeks .we print them off for him and the nurse practitioner looks at them every week . When asked if there was evidence that the physician or nurse practitioner had reviewed Resident #60's MAR, the DON stated, They don't sign it (the MAR) and we don't keep them. When asked if the nurses document that the physician or nurse practitioner was informed that Resident #60 was refusing the Promod, the DON stated, Not that I'm aware of. The facility was unable to provide documentation that the physician was notified of Resident #60 refusing Promod.

Based on review of the United States Department of Agriculture (USDA) food keeper guidelines, policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by expired food, opened unlabeled and undated food in the walk in refrigerator, and a dirty microwave oven in 1 of 2 (South hall pantry) nourishment areas. The facility had a census of 96, with 95 of those residents receiving a meal tray from the kitchen. The findings included: 1. The USDA, food keeper guidelines documented, .The Food Keeper contains valuable storage advice to help you maintain the freshness and quality of foods . Refrigerate food to preserve freshness. However, over time, even chilled food begins to go bad. The Food Keeper charts indicate refrigerator storage times for a wide variety of food items . Cooked meats (after home cooking) . 3- (to) 4 days . deli foods . Salads containing meat, fish, poultry or eggs . 3-4 days . Canned goods . such as . stew, soups . 3-4 days . 2. The facility's safety and sanitation best practice guidelines for refrigerators and freezer storage policy documented, .Foods will be stored in their original container or . approved container . Clearly labeled with the contents and the use by date . b) Once food is cooked, such perishable items must be labeled with the discard date before placing in the refrigerator . Leftovers will be placed in . approved containers, covered, labeled, dated, and stored in refrigerator . The designated partner will check leftovers on a daily basis and plan for their use . Refrigerated leftovers not used within time frame .will be discarded . 3. Observations in the kitchen on 8/31/15 at 10:42 AM, revealed the following items in the walk in refrigerator: a. A container labeled pulled pork dated 8/26/15. b. A container labeled tuna salad dated 8/25/15. c. An opened container labeled Cream of Chicken soup dated 8/25/15. d. An opened container labeled Chicken soup dated 8/24/15. e. An opened 1/2 gallon container of Fat Free Milk with an expiration date of 8/4/15. f. An unopened container of French onion dip with an expiration date of 8/20/15. g. An unopened 1/2 gallon container Half and (&) Half with an expiration date of 8/24/15. h. An opened package of deli turkey with a sell by date of 6/9/12. i. Two unlabeled and undated bowls containing cottage cheese with fruit. j. An opened, unlabeled and undated package of sliced roast beef. k. An opened, unlabeled and undated package of hot dogs. l. An opened, unlabeled and undated package of sliced deli ham. m. An opened, unlabeled and undated package of cooked ham. n. Three unlabeled and undated plates of salad. The facility did not follow their policy of labeling cooked foods with a discard date before placing it in the refrigerator. Interview with the Certified Dietary Manager (CDM) on 8/30/15 at 11:00 AM, in the walk in refrigerator, the CDM was asked how long they keep opened food items in the refrigerator. The CDM stated, 7 days. I usually check everything on Mondays and Thursdays. The CDM was asked if opened food items should be labeled and dated. The CDM stated, Yes. 4. Observations in the walk in refrigerator on 8/31/15 at 9:12 AM, revealed an unopened carton of French Onion Dip with an expiration date of 8/20/15. Interview with the CDM on 8/31/15 at 9:17 AM, in the kitchen, the CDM verified the French Onion dip was expired. 5. Observations in the south hall pantry on 8/31/15 at 9:30 AM, revealed a dirty microwave with a build up of food particles inside. Interview with the CDM on 8/31/15 at 9:31 AM, in the south hall pantry, the CDM was asked if the microwave was clean. The CDM stated, No. The CDM was asked who is responsible for cleaning the microwave in the nourishment room. The CDM stated, Housekeeping. I'll get her on it right now. Interview with the CDM on 9/1/15 at 9:25 AM, in the conference room, the CDM stated, Housekeeping said they are supposed to clean the microwaves everyday.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 3 (South shower room) shower rooms was clean and sanitary and failed to ensure 2 of 5 (East and West hall exit doors) exit doors were maintained. The findings included: 1. The facility's daily cleaning schedule documented, .Group #1 Cleans all of East Hall . east shower room . Group #2 Cleans all of West Hall . west shower room . Group #3 Cleans all of Richland Hall . Group #4 Cleans all of Rehab Hall . Group #5 Cleans . south shower room . 2. Observations in the south hall shower room on 8/30/15 at 10:35 AM and 3:50 PM and on 8/31/15 at 11:49 AM, revealed white paint chips on the floor and an offensive odor. There were several brown areas on the floor of the shower stall. Interview with Student Nursing Assistant (SNA) #1 on 8/31/15 at 12:03 PM, at the south nurses station, SNA #1 was asked if she saw the brown substance on the floor. SNA #1 stated, I did not notice that (brown substance) on the floor. Interview with Licensed Practical Nurse (LPN) #1 on 8/31/15 at 12:08 PM, in the south hall shower room, LPN #1 was asked if she saw the brown substance on the floor this morning when a shower was given. LPN #1 stated, I did not notice that on the floor this morning. Interview with the Director of Nursing (DON) on 8/31/15 at 12:10 PM, in the south hall shower room, the DON was asked what was her expectation of housekeeping regarding the cleaning the shower room. The DON stated, It should be cleaned every day. 3. Observations on 8/30/15 at 11:00 AM, in the west hall at the exit door across from room 122, revealed a large amount black/scuffed/scratches to the doors. Interview with the Director of Maintenance (DOM) in front of the exit door across from room 122 on 9/1/15 at 9:55 AM, the DOM confirmed this door was very scuffed and stated, This is where we get deliveries. Observations in the west hall at the exit door beside room 126 on 9/1/15 at 9:00 AM, revealed the exit door with peeling paint at the bottom of the doors. 4. Observations in the east hall at the exit doors beside room 107 on 9/1/15 at 9:00 AM, revealed these doors were scuffed and brown stains were noted to the bottom of the door. Interview with the Director of Environmental Services (DES) and the DOM in front of the exit doors on 9/1/15 beginning at 10:00 AM, they confirmed these doors were scuffed and had stains. The DES was asked about the doors cleaned. The DES stated, Daily with the rooms The DOM stated, The doors are a never ending job, we paint them, and they get scuffed almost immediately again.

Based on observation and interview, the facility failed to ensure infection control practices were maintained to prevent the potential spread of infections as evidenced by an ice cart stored in 1 of 3 (South shower room) shower rooms. The findings included: Observations in the south hall shower room on 8/30/15 at 10:35 AM, on 8/30/15 at 3:50 PM, and on 8/31/15 at 11:49 AM, revealed a metal ice cart with ice. Interview with Licensed Practical Nurse (LPN) #1 on 8/31/15 at 12:08 PM, in the south hall shower room, LPN #1 was asked if the ice cart was always stored in the shower room. LPN #1 stated, They leave the ice cart in the shower room to drain. Interview with the Director of Nursing (DON) on 8/31/15 at 12:10 PM, in the south hall shower room, the DON was asked if the ice cart should be stored in the shower room. The DON stated, No, it should not be in here.

Based on observation and interview, the facility failed to ensure safe storage of toxic chemicals as evidenced by unsecured cleaning chemicals in 1 of 3 (West shower room) shower rooms. The findings included: Observations in the west shower room on 8/30/15 at 10:55 AM, and 12:55 PM, and on 8/31/15 at 8:20 AM, 11:40 AM and 2:17 PM, revealed an environmental services cart was stored with 2 full bottles of (named brand) Urine Remover and 1 full bottle of (named brand) Disinfectant on the cart. The shower room door was not locked, and could be accessible to residents. Interview with the Director of Nursing (DON) on 8/31/15 at 2:25 PM, in the west shower room, the DON was asked if an environmental services cart with unsecured chemicals should be accessible to the residents. The DON stated, No. The DON was asked how she would keep the residents from gaining access to the cart with the unsecured chemicals. The DON stated, Well we couldn't. There is no way to lock the door. I don't know why it (environmental services cart) is in here. I'm going to tell them to get it out of here right now.

Based on policy review, observation, and interview, the facility failed to provide effective housekeeping services to maintain a sanitary, orderly and comfortable environment as evidenced by holes in the ceiling, stains on the wall, peeling wallpaper, holes in a door, missing caulking and black substance to base of a commode, scuffed walls and doors, peeling paint to a window sill, missing paint to walls and door facings, black substance to a resident's room shower, peeling paint to doors, and odors in a room in 7 of 57 (Rooms 107, 109, 110, 115, 124, 218, and 320) resident rooms. The findings included: 1. The facility's daily cleaning schedule documented, .Group #1 Cleans all of East Hall . on South Hall . and patients rooms 203 and 205 . Group #2 Cleans all of West Hall . Group #3 Cleans all of Richland Hall . Group #4 Cleans all of Rehab Hall . Group #5 Cleans all 204, 206, 207, 208, 209, 211, 213, 215, 216, 217, 218 . 2. Observations in room 107 on 8/31/15 at 9:59 AM, revealed a small hole in the ceiling above B bed, the wall under B side's television had stains and splatters noted. 3. Observations in room 109 on 8/30/15 at 10:50 AM, revealed peeling wallpaper below the window with a black substance underneath the peeling wallpaper. 4. Observations in room room 110 on 8/31/15 at 9:52 AM, revealed a small hole in the ceiling above the B bed, the bathroom door with 2 small holes to the outside of the door, in the bathroom, the commode was missing caulking, and a thick black substance around the base of the commode. 5. Observations in room 115 on 8/31/15 at 10:09 AM, revealed the bathroom walls scuffed, and the wall gouged under the paper towel holder. 6. Observations in room 124 on 8/30/15 at 12:17 PM, revealed paint peeling in the window sill in the room, the bathroom walls in front of the commode were scuffed and missing paint, missing paint to the door facings scuffed, and the wooden doors scuffed and scratched (doors to the bathroom and closets). 7. Observations in room 218 on 8/31/15 at 8:06 AM, revealed the shower in the bathroom noted with black, slimy substance along edges of tile against the wall, and inside of the door of the bathroom with peeling paint and scuffed. 8. Observations in room 320's bathroom on 8/30/15 at 10:35 AM, 12:58 PM and 4:06 PM, and on 8/31/15 at 8:17 AM, revealed a clothes hamper had dirty clothes running over with the presence of a strong odor. Interview with the Director of Environmental Services (DES) on at 8/31/15 at 5:24 PM, at the East/West nurses station, the DES was asked to discuss the process for resident's dirty clothes being placed in the hampers in the bathrooms and how they get laundered. The DES stated, The tech (technician) places the clothes in it and the families come to get them and wash them, if the family does their laundry. The DES was asked about the process if the hamper in the residents bathroom was overflowing. The DES stated, If it is overflowing, we contact the family to see if they need us to do the laundry for them. The DES was asked what the process was if the laundry was soiled. The DES stated, If they are heavy soiled, then they go to laundry. The DES was asked what if the clothing was soiled with an odor. The DES stated,They should send them straight to laundry. Interview with the DES on 8/31/2015 at 5:31 PM, the DES was asked to walk with surveyor to room 320 and look at the laundry in the hamper in the bathroom. The DES entered the bathroom in room 320 and stated, Usually the CNAs (Certified Nursing Assistants) tell me if a resident's laundry is running over as she picked up clothes hamper to take it out of room. The DES was then asked if a resident's laundry should be left in this condition. The DES stated, This should not be this way, and it should not be smelling like this. 9. Interview with the DES and the Director of Maintenance (DOM) while touring the building with the environmental concerns on 9/1/15 beginning at 9:45 AM, the DOM was asked about the hole in the ceiling of room 107. The DOM stated, There is fire caulk in it, will have to sheetrock mud it, and go over it, think was a cable in it at one time, have had to fix several of these. Need to regrout the shower. The DES stated, The bathrooms and rooms are cleaned on a daily basis, and there is a monthly deep cleaning schedule also. The DES and DOM confirmed the environmental issues with rooms 107, 109, 110, 115, 124, 218, and 320.