Every finding on record at Oak Crest

Based on observation, interview, and record review the facility failed to ensure a multi-dose vial was labeled when opened and failed to ensure controlled medications were double locked. This has the potential to affect all residents in the facility. The findings include: The CMS 671 form dated 9/10/24 showed six residents reside in the certified unit of the facility. 1. On 9/12/24 at 9:05 AM, the facility medication room was reviewed. The unit refrigerator had an opened vial of multi-dose tuberculin (TB) solution inside, and it was approximately half dispensed. The vial was not dated or labeled with an open or expiration day. V9 (Registered Nurse) was present and verified the vial was half used and there was no labeling. On 9/12/24 at 10:52 AM, V2 (Director of Nurses) stated the vial should have been dated when it was opened. It should show the date, time, and initials of the nurse that opened it. The information is important to ensure the solution is not used past the expiration day. There is no way of knowing if it is still effective if the date it was opened is missing. The facility's Maintenance of Medication Inventory policy last review dated 8/23 states: Opened multi-dose bottle such as TB solution should have a date opened sticker, if expires in 24 hours or less order replacement (expires in 30 days after opened). 2. R3's face sheet printed on 9/12/24 showed an admitted [DATE]. R3's physician order report showed an order start dated 9/2/24 for alprazolam (anxiety medication) at 0.25 milligrams every 24 hours as needed for sleeplessness. The same report showed an order start dated 8/7/24 for pregabalin (convulsion medication) at 50 milligrams two times a day for anticonvulsant. R57's face sheet printed on 9/12/24 showed and admitted [DATE]. R57's physician order report showed an order start dated 9/1/24 for pregabalin at 100 milligrams three times a day for anticonvulsant. On 9/12/24 at 9:05 AM, the facility medication cart was reviewed. The bottom drawer of the cart contained the narcotics box, and the lid was unlocked. R3's alprazolam and pregabalin medication cards where in the box. R57's pregabalin medication cards were in the box. V9 (Registered Nurse) stated the lid tends to catch on the top of the medication cards and block it from locking. It happens a lot. It should not be unlocked like that. On 9/12/24 at 10:52 AM, V2 (Director of Nurses) stated narcotics need to be under a double lock system at all times. They have a high risk of misuse and need extra close monitoring. V2 said staff need to be checking the lock even more closely knowing the medication cards cause an issue with it locking correctly. The facility's Medication Administration policy last review dated 8/23 states: 8. Medication room/Narc box/tx (treatment) cupboard is never left unlocked when unattended and the medication room/cart/cupboard key will be in the possession of authorized personnel at all times.

Based on observation, interview, and record review the facility failed to store frozen items off the floor. This failure has the potential to affect all residents in the facility. The findings include: The CMS 671 dated 9/10/24 showed 6 residents reside in certified beds. On 9/11/24 at 11:15 AM and 12:30 PM (One hour and fifteen minutes) a box of lemon and cream cakes was stored on the floor of the walk-in freezer. On 9/11/24 at 11:15 AM, V7 Kitchen Manager stated the facility did not receive a food delivery that day. On 9/11/24 at 12:43 PM, V7 stated the lemon cake was the desert for dinner that evening. V7 stated food should not be stored on the floor; it should be on a shelf. On 9/11/24 at 12:45 PM, V8 Director of Food and Nutrition stated the lemon shortcake was only stored on the floor momentarily. V8 stated food should be stored six inches off the floor. V8 stated, the purpose of storing food off the floor is to prevent pests from getting into food and floor chemicals getting on food. V8 stated, storing food off the floor also allows proper airflow around food to prevent spoilage. V8 stated, she would consider momentary to be five minutes. The facility Storage of Frozen Foods policy (Revision 2017) showed, .Appropriate storage procedures are followed: First-in-first-out. Food is stored six inches above the floor. Food is stored to allow air circulation .

Based on interview and record review the facility failed to have a Legionella (bacteria) prevention and mitigation program in place. The facility also failed to implement enhanced barrier protections (EBP) for a resident with an indwelling catheter. These failures have the potential to affect all residents in the facility. The findings include: The CMS 671 dated 9/10/22 showed 6 residents reside in certified beds. 1. On 9/11/24 at 1:04 PM, V2 Director of Nursing stated V6 Facility Director was responsible for the Legionella program (a bacteria that can cause pneumonia). The facility's Legionella policies for prevention and mitigation were requested from V2. On 9/11/24 at 2:09 PM, V6 stated he has been the maintenance director for 8 months. V6 stated he does not have a legionella mitigation and prevention program for the facility. On 9/12/24 at 8:55 AM, V2 stated Legionella bacteria live in the water in pipes with little to no flow. V2 said the elderly are more susceptible to Legionnaires infection. V2 was uncertain regarding the consequences of a resident contracting Legionella. The Centers for Disease Control (CDC) website About Legionnaires; Disease (dated 1/29/24) showed, Legionnaires' disease is a serious type of pneumonia caused by Legionella bacteria. Certain people are at increased risk for the infection, but it's treatable with antibiotics. People can get Legionnaires' disease by breathing in mist containing Legionella bacteria. To prevent Legionnaires' disease, reduce the risk of Legionella growth and spread . The CDC website How Legionella Spreads (dated 1/29/24) showed .People at increased risk of getting sick include: Current or former smokers. People [AGE] years or older . 31615 2. R 57's admission record shows he was admitted to the facility on [DATE]. His order summary report for September 12, 2024, documents admission orders for indwelling catheter care. The 8/31/24 care plan for R57 shows him to be placed on EBP (Enhanced Barrier Precautions) due to having an indwelling urinary catheter and wounds. On 9/10/24, R57's room and doorway were found to have no signs indicating EBP, or gowns available for staff to enter his room. On 9/11/24 at 9:55 AM, V5 CNA (Certified Nursing Assistant) was observed performing catheter care, and placing the leg drainage bag around R57's leg. She was not wearing any gown. After placing the leg bag, she assisted R57 to get dressed, then placed a gait belt around him and ambulated him to the recliner. On 9/11/24 at 1:04 PM, V2 DON (Director of Nursing) stated EBP is an added layer of protection for residents who have a heightened risk of infection. It is put in place for residents with chronic wounds, PICC lines (peripheral inserted central catheter), and indwelling catheters to prevent the spread of infection. EBP is required for those residents, it is not an option. Placing residents in EBP is the responsibility of the nurses on the floor and then I would be a backup when I do my 24 hour charting review. On 9/11/24 at 2:02 PM, V4 LPN (Licensed Practical Nurse) said EBP should be in place for residents with open wounds and indwelling catheters. V4 said she does realize she messed up and R57 should be on EBP due to his open wounds and catheter. She said staff should be wearing a gown and gloves when providing care and dressing changes. The facility's 5/24 policy for Enhanced Barrier Precautions documents it to be an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing home. EBP involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (for example: residents with wounds or indwelling medical devices). Staff should perform hand hygiene before entering the resident's room and applying gown/gloves and immediately upon removal.

Based on interview and record review the facility failed to have a PRN (as needed) psychotropic medication stop date to 1 of 5 residents (R59) reviewed for unnecessary medications in the sample of 5. The findings include: R59's Physician Order Sheet (POS) dated 8/2023 show, R59 has an order of: start date- 8/10/23 Risperdal Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth every 12 hours as needed (PRN) for agitation and insomnia. On 8/15/23 at 9:15 AM, V2 (Director of Nursing-DON) said all psychotropic as needed medications should have a 14 day stop date unless the physician renews the PRN meds. V2 said we will be working on this and ensure all PRN psychotropic medications have a 14 day stop date. The facility policy on Psychotropic Medications with a review date of 8/2023 show, all PRN psychotropic medications will have an automatic stop date of 14 days unless specified by the medical provider.

Based on observation, interview and record review the facility failed to wash hands after providing pericare to prevent the spread of infection to 1 of 5 residents (R58) reviewed for infection control in the sample of 5. The findings include: On 8/14/23 at 9:10 AM, V4 (Certified Nursing Assistant-CNA) toileted R58 and provided peri care after R58 had a bowel movement. V4 (CNA) then removed her soiled gloves but did not wash hands/did not perform hand hygiene. Using her contaminated hands V4 took R58's toothbrush, applied tooth paste then handed the toothbrush to R58 and gave R58 a cup of water. V4 then wheeled R58 and assisted R58 to his recliner all doing these tasks without washing her hands. On 8/15/23 at 8:50 AM, V5 (Registered Nurse) said staff should wash their hands prior to and after giving care. V5 also said every time staff remove their gloves, they should perform hand hygiene to prevent the spread of infection, The facility Policy entitled Hand Hygiene with a revised date of 4/2020 show, it is the policy of this organization to promote use of alcohol sanitizers and handwashing as the single most important means of preventing the spread of infection. Examples of situation when hand hygiene is indicated before and after direct resident contact (care, treatment).

Based on interview and record review the facility failed to offer the pneumococcal conjugate vaccines (PCV20) or the pneumococcal polysaccharide vaccine (PPSV23) for 1 of 5 residents (R58) reviewed for vaccinations in the sample of 5. The findings include: R58's face sheet shows he is an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including pneumonitis due to inhalation of food and vomit, atrial fibrillation, hypertension, and presence of cardiac pacemaker. R58's Immunization Report provided on 8/14/23 shows on 10/9/2015 he received Prevnar 13 (PCV13). There were no other pneumococcal vaccinations recorded. On 8/15/23 at 12:03 PM, V3 Assistant Director of Nursing (ADON) said R58 received Prevnar 13 in 2015, he is eligible to receive the 2nd dose of the pneumococcal vaccine. It should've been offered on admission and given if consented. Residents should receive the 2nd dose of the pneumococcal vaccine after one year of receiving PCV13. The CDC (Centers for Disease Control and Prevention) guidelines dated February 2013 shows states, the CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information .For adults [AGE] years or older who have only received PCV13, CDC recommends you either: Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after PCV13 . The facility's Flu and Pneumonia Vaccines revised 2018, states, All residents living in licensed units will be offered an annual flu vaccine in accordance with the recommendations of the Advisory Committee of the Centers for Disease Control and with the approval of their physician and the resident's consent, (if resident unable to make decision, legally responsible party will be consulted), unless they have had previous reactions to the vaccine, are allergic to eggs, have a history of Guillain Barre Syndrome, or are ill .All residents age 65 and older living in a licensed unit will be offered a pneumonia vaccine in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control upon admission and with the approval of their physician, and with the resident's consent .Administration of, refusal of, or medical contraindication of a pneumonia vaccine will be documented in the resident's medical record.

Based on observation, interview and record review the facility failed to ensure staff wore N95 face masks when testing residents for COVID-19. This applies to all residents residing in the facility. The findings include: The CMS 672 Resident Census and Conditions report dated September 12, 2022, shows, there is one resident residing in a certified bed in the facility. 1. On September 12, 2022, at 11:17 V5, V6, & V7 all lab technicians were testing residents on the skilled unit for COVID-19. They were wearing a KN95 face mask and not an N95 face mask. On September 13, 2022, at 9:59 AM, V3 Director of Nursing/Infection Preventionist stated, anyone testing residents for COVID-19 should be wearing an N95 face mask. They should not be wearing a KN95 face mask. She also stated, they had enough N95's for staff to wear. The CDC's (Centers for Disease Control and Prevention) Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing last updated July 15, 2022, shows, Collecting and Handling Specimens Safely: For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with [CONDITION(S)]-CoV-2 (COVID-19), maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown. The facility's COVID-19 staff, and resident testing policy (no date) does NOT show that staff/HCP should wear an N95 when collecting a COVID-19 specimen.

Based on observation, interview, and record review, the facility failed to ensure the dishwasher temperature was checked prior to use, failed to ensure foods were covered and labeled when stored overnight and failed to remove leftover food from circulation after six days. This has the potential to affect all facility residents. The findings include: The facility's 12/7/21 Daily Census showed there were 57 residents in the facility. 1.On 12/7/21 at 9:30 AM, V5 Food Service Supervisor, accompanied this surveyor into the facility's kitchen. V7 dietary worker, was running the dishwasher. The facility's dishwasher temperature log showed the dishwasher temperatures were checked for 12/7/21 for breakfast and lunch. At 9:32 AM, V5 stated the facility has a high temperature dishwasher/sanitizer and the temperature for the dishwasher should be checked prior to use. V5 was unable to explain why a lunchtime temperature was already logged for the day. V5 stated if dishware is not sanitized properly, cross contamination and food borne illnesses would be a concern. Employees are accountable to check the temperatures at the correct times. Supervisors oversee that the temperatures are checked at the right times and ultimately, she (V5) was the person in charge through monthly inspection. V5 stated the last time she looked at the logs was last month. V5 confirmed the dishwasher temperature log showed an entry for 12/7/21's lunchtime. V5 stated dishwasher temperatures should be checked and recorded three times a day to be certain the dishwasher is properly sanitizing the dishware. At 9:34 AM, V6 dietary stated she recorded the breakfast and lunch dishwasher temperatures in the log for today. I do it two strips at a time in the morning and record both a breakfast and lunch entry. V6 stated V8 kitchen manager told me to do it that way. At 9:36 AM, V7 dietary stated if V6 comes in before him, V6 does the dishwasher temperature checks and he doesn't check them. At 9:38 AM, V8 stated dietary staff should be doing temperature checks on the dishwasher 3 times a day to make sure it's sanitizing properly prior to putting the dishes through. The facility's dish machine temperature log showed both breakfast and lunch recordings on 12/7/21 done at the 9:30 AM observation. There were no temperatures logged for 12/3/21 at dinner through 12/4/21 dinner. The log showed on 12/3/21 breakfast and lunch temperatures were taken at 8:30 AM. On 12/2/21 there was no dinner temperature checks recorded and the breakfast and lunch temperatures were done at 8:43 AM. This pattern of recording breakfast and lunch temps in the morning continued on 12/1/21, 11/30/21, 11/29/21. This temperature log showed no dish machine temperatures were recorded from dinner on 11/25/21 through dinner on 11/28/21. The inconsistent and lack of temperature checks as well as breakfast and lunch temperatures checked in the morning recorded extends from 9/28/21 (as far back as logs were requested) to 12/7/21. It was observed that the dish machine temperature log received from the facility had 12/7/21 lunch documentation altered. The time and initials are different than this surveyor observed initially. 2.On 12/07/21 at 09:46 AM, the chill blaster had a silver deep pan with clear plastic wrap over it on the top shelf. The plastic had turkey noodle soup and 11/28 written on it with black marker. The lower shelf had an uncovered and unlabeled silver deep pan with what V8 identified as vegetable soup in it. At 9:50 AM, V8 stated the soups are on hand to serve if requested by the facility residents. V8 stated the vegetable soup was made yesterday (12/6/21). V8 confirmed the date on the turkey vegetable soup was 11/28. On 12/8/21 at 2:45 PM, V1 Administrator stated the vegetable soup should have been covered and labeled if it was stored overnight. On 12/9/21, V5 stated the date on the turkey noodle soup (11/28) reflected the date it was made. V5 was unable to provide a cooling log for the turkey noodle soup. The facility's 2017 Cooling Cooked Potentially Hazardous/Temperature Control for Safety (PHF/TCS) Policy showed to record all temperatures on form Critical Control Points Two Step Cool Down Temperature Monitoring Log. Food for which no temperatures have been taken is discarded. The facility's menus from 11/21-12/7/21 do not have turkey noodle soup listed. This menu showed vegetable soup was on the menu for lunch on 12/8/21. The facility's 2017 Storage of Refrigerated Foods showed food in the refrigerator is covered, labeled and dated with a use by date. The facility's 2017 Labeling and Dating Foods Policy showed to decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Refrigerated food prepared in the healthcare community is labeled with the date to discard or use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as Day 1. The facility's undated Blast Chiller Policy showed if associate is chilling product overnight, they are to inform a manager or supervisor to ensure proper documentation of product and storage. The facility's Blast Chiller training guide showed covering is recommended to prevent drying if product will not be removed when done or left inside overnight.

Based on interview and record review the facility failed to have advanced directives in two locations of the medical record for 2 of 2 residents (R3, R57) reviewed for advance directives in the sample of 5 and 1 resident (R8) in the supplemental sample. The findings include: 1. R8's admission record shows he was admitted on [DATE] with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic record for R8 did not have a copy of a pending DNR (Do Not Resuscitate), or code status listed on the banner of his record. The nursing progress notes for R8 shows on [DATE], V14 RN (Registered Nurse) was alerted the resident may have died . He was in his bed and was whitish gray complexion and the chest was not rising and falling, unable to find any pulse and blood pressure did not register. The time of death was noted as 9:35 PM. On [DATE] at 4:40 PM, V16 CNA (Certified Nursing Assistant) stated she was doing rounds with another CNA at 9:30 PM when she found R8, and he appeared dead. V16 stated she had seen him at dinner, helped to feed him in which he ate everything which was unusual for him. V16 stated it was around 5:30 PM-6:00 PM she laid him down in bed, and she did not hear from him again. V16 stated when she found him, he was lying in bed. She looked for breathing and tried to find a pulse. He felt cool, cold to the touch, so she reported it to the nurse. V16 stated when we were cleaning him up, he was warm on his back side and cool on the front. On [DATE] at 11:05 AM, V14 stated each resident's code status is on the electronic chart at the top by their picture. It is also in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If a full code, initiate CPR and call 911. V14 stated the supervisor is notified in any case where it is unexpected, but generally would call after calling 911. V14 stated on [DATE] she was flagged down by the CNA to check on R8, she thought he was dead. V14 stated she found him in bed not breathing and he had obviously died . He was cool to the touch and appeared waxy. V14 stated she attempted to check his blood pressure, pulse, respirations, and heart. V14 stated she found R8 without vital signs and went into the office to find his do not resuscitate order but did not find one. V14 stated she called the DON (Director of Nurses) and did not initiate or administer any CPR (Cardiopulmonary Resuscitation) because she knew the family had discussed the DNR status but could not locate the paperwork. V14 stated she called the DON to verify R8 was a DNR. On [DATE] at 2:18 PM V2 DON stated, if a resident is found without vital signs, contact the nurse, and check the code status. The resident's code status is on the main screen by their picture. She (V2) stated R8 had an updated POLST (Practitioner Order for Life-Sustaining Treatment) form, but it was out at the physician's office and not available for the nurse on [DATE]. He was listed as a full code at the time of his death, and the nurse did not have a DNR. V2 stated CPR should have been initiated. The nurse called me and said he seemed to have been dead for a couple of hours and had no warmth and had no code status. V2 stated she informed her the POA signed a pending DNR, and we were waiting for it to come back from the physician's office. On [DATE] at 2:25 PM, V21 Physician stated as long as a family has voiced their decision to make their loved one a DNR, it should be honored. The DNR cannot always be immediately signed by the doctor and put on the chart. 2. R3's admission record shows she was admitted to the facility on [DATE] with a wedge compression fracture and contusion of the left hip. A review of the electronic record shows the face sheet without a code status listed on the banner. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 8:53 AM, V11 RN stated a resident's code status can be located on the banner on the main screen of a resident's record. V11 stated it can also be found in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At 9:00 AM, V11 pulled up the electronic chart for R3, and stated she could only find the DNR in one place in the electronic chart. The POLST had a DNR order and was scanned into the record. 3. On [DATE] at 9:00 AM, V11 pulled up the electronic chart for R57, and stated the record did not show a code status on the banner of the electronic chart. V11 reviewed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V11 reviewed the scanned records and found a signed DNR, only one location in record had the DNR signed. The facility's [DATE] policy for advanced directives documents the Procedure to be followed after decision made: 1. Document discussion and decision made. 2. Complete Uniform Do-not-resuscitate (DNR) order form. If the box after 1. is marked next to the statement indicating Do No Attempt CPR the resident chart should be marked indicating DNR. 3. Notify physician by phone or fax of resident decision and request orders regarding life-sustaining treatments. 4. Signed Uniform DNR order form will be sent to the physician for signature after a copy is made and placed in the resident chart.

Based on interview and record review the facility failed to supervise and monitor a resident following an unwitnessed fall on [DATE] and failed to notify the physician the resident was on an anticoagulant (blood thinner). This applies to 1 of 2 residents (R8) reviewed for falls in the sample of 5. The findings include: R8's Admission record shows he was admitted on [DATE]. His primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] and [DATE] Medicare A shift charting for R8 show he is oriented to person only, and has difficulty being understood. He has mumbled speech and unable to effectively communicate needs to staff. The cognition assessment shows he has short-term and long-term memory problems. The [DATE] care plan for R8 shows he is a high risk for falls related to balance problems, confusion, deconditioning, gait problems, poor communication/comprehension, and medications that potentiate falls. R8's order summary report for active orders as of [DATE] shows he is on [MEDICATION(S)] 2.5 mg by mouth two times a day (anticoagulant). The [DATE] nursing progress note for R8 shows V11 RN (Registered Nurse) documented at 8:30 AM the CNA (Certified Nursing Assistant) responded to residents call pendent and found him lying on the floor on his back with legs extended next to his bed. Resident stated he crawled out of his bed. Resident denied hitting his head. Resident had no visible injuries at this time. Neuro-check was done and was within normal limits. The physician notification shows a fax notification was sent to the physician at 8:30 AM. The facility's copy of the fax sent to the physician included a pasted copy of the nursing progress note. No additional notes were included, and the notification did not include R8 taking anticoagulant medication. The next nursing progress note for R8 shows on [DATE] at 11:28 PM, V14 documented a CNA alerted her the resident may have died . Resident was in bed and had whitish gray complexion and chest was not rising and falling, unable to find any pulse and the blood pressure does not register. Time of death noted as 9:35 PM. A review of R8's progress notes show no nursing documentation between the 8:30 AM fall assessment, and the 11:28 PM note indicating R8 had expired. R8's record shows his last nursing assessment was documented on [DATE] at 1:31 PM. The vital signs documented in the electronic record show his last pulse and respirations were documented at 12:11 PM, and his blood pressure was checked at 4:22 PM. On [DATE] at 12:48 PM, V12 CNA (Certified Nursing Assistant) stated R8 was confused, some days were better than others. He was a fall risk and would try to get up on his own. V12 stated she did remember he was in the recliner most of the day and nap in the afternoon, but he would climb out of the recliner and try to get into the bed. V12 stated R8 did have a low bed and landing mats for safety, if any resident has an unwitnessed fall, check the resident for any obvious injuries and get the nurse. The nurse has to check them before being moved. On [DATE] at 1:13 PM, V13 LPN (Licensed Practical Nurse) stated for any unwitnessed fall the nurse will determine if anything is broken, survey what is around, and ask them if they are ok, and what happened. Assess for injury, ask if they have any pain, if they hit their head, check for lumps and bumps on their head. V13 stated she would check if they are near the wall or chair that they could have hit their head. If they hit their head, do neuro checks. Depending what medications, they are on, such as blood thinners, neuro checks are documented. Neuro checks are done every 2 hours for any fall whether witnessed or unwitnessed. If any changes in vital signs, cognition, pupils, appetite or nausea we would notify the physician. Any fall or incident is passed on in report to the next shift, and the resident is monitored for 72 hours. On [DATE] at 2:18 PM V2, DON (Director of Nursing) The fall protocol is for whoever observes the resident is to stay with them until the nurse can check ROM (range of motion), see if there is any bleeding, if any severe injuries are noted then the nurse is to call 911. Otherwise, the staff will get them up if no sign of injury. The nurse will do vital signs, a skin assessment, and an initial fall assessment, part of that includes an environmental check. The nurse will try and determine if they hit their head or if we are uncertain if they hit their head, we do an initial neuro check, and additional neuro checks every 4 hours for 24 hours. V2 said every shift will document a post incident check for 72 hours after the fall. Neuro check flow sheet under the assessments, and in the body of their charting. If a resident is on a blood thinner, we call the doctor, and if the doctor wants additional orders, we will need to follow those new orders. If the physician is called, it should be documented in the progress notes. A review of R8's record shows a neurological check documented for [DATE] at 7:30 AM, and 11:30 AM. No further neurological checks are noted in the record. On [DATE] at 8:53 AM, V11 RN stated when a resident falls, the first thing to do is get information from the resident such as if they have any pain, or if they are bleeding. If the resident is confused, we still try to get information and do an assessment. We check ROM, if they have pain with touch, verbal or non-verbal signs of pain. V11 stated she then calls the POA (power of attorney), find out if they want the resident to go out for an evaluation. We tend to follow what the POA wishes for the resident. We do notify the doctor of any fall by fax, and if it is urgent, we will call. A situation that would warrant a call would be the POA wanting the resident sent out, if they hit their head or on [MEDICATION(S)] (blood thinner). If the fall was unwitnessed, we just ask the resident. If they are confused, we would call the POA first to see if they need to be sent out. V11 stated if we can determine if a head injury, start neuro check every 4 hours as a precaution. The nurse will document an incident form, a paper form that is sent to restorative, and in the computer a 72-hour monitoring note is initiated. V11 stated neuro checks are on a separate form and is completed every 4 hours for 24 hours. The incident is passed on to the next shift by verbal report, reports sheet and the communication book for any oncoming staff. V11 stated R8 was very dependent upon staff. He was a sit to stand for transfer, he did have a decline while he was here. V11 stated R8's cognition was good some days, but others were not so good. Sometimes he could talk fine and others very confused. R8 did have a couple of instances where he would have a leg off the bed or scoot himself out of the recliner. He was a fall risk, he could not stand or walk on his own, and had generalized weakness. He had a fall mat, and we keep his bed low. V11 stated on [DATE] R8 had a fall early in the morning, we were still getting everyone up. The CNA was going in to get him ready and he was already on the floor by his bed, so it was an unwitnessed fall. V11 stated she asked him what happened, he wanted us to get him up. He did not have any clothes on at the time, he had no visible injuries, and no complaints of pain. He answered all the questions appropriately. V11 stated she does not recall if he was alert and oriented at the time. After the assessment, staff got him up and, in his wheelchair, dressed and brought him to the family room for breakfast. V11 stated she completed a neuro check and had no findings and called the POA. V11 stated the POA said ok, and they did not feel the need to send him out, then I sent a fax to the MD. The note to the physician should include how we found the resident, any complaints the resident may note, vital signs, and if there were injuries present. It would be important to note he was on a blood thinner. V11 stated if a resident has an unwitnessed fall, and says they did not hit their head, then we usually don't call the physician. If it is obvious, they hit their head, then we would call. V11 stated she continued to monitor R8 every 4 hours after his fall. The neuro checks should have continued for 24 hours, if started at 7:30 AM, he should have had assessments completed at 11:30 AM, 3:30 PM, 7:30 PM, 11:20 PM, and 3:30 AM, neuro checks include vital signs, pupil reaction, assess orientation, pain, gasp strength, smile, and stick out their tongue. The purpose of the neuro checks is to assess for a head or brain injury. V11 stated the nurse should contact the MD (medical doctor) and POA for a head injury and on blood thinner. V11 stated she would call the POA and let the physician know what the POA wants. And then notify the manager. On [DATE] at 11:05 AM, V14 RN stated if a fall is unwitnessed, the nurse completes an assessment and if they are an accurate historian, we get their take on what happened and if they have any injuries. If no injury we get them up. If they hit their head, we do neuro checks and check if they are on blood thinner. V14 stated if the resident is on a blood thinner, we call the doctor. If the resident is confused and only oriented to person, would not be a good historian. V14 stated she was not given report on [DATE] and was not informed about R8's fall. V14 stated she was assigned in the AL (assisted living) part, and that is where she received report. V14 stated there really was no nurse assigned to R8's hall, all of the nurses were all trying to share the hall duties. V14 stated she did not perform any neuro checks or assessments on R8 for the second shift of [DATE]. On [DATE] at 4:25 PM V15 LPN stated she found out about 4:30 PM on that day ([DATE]), the nurse on West wing was sent home. She was on East 2 rounding with the doctor. I moved over to the skilled wing and began to get medications ready to pass. V15 and I were sharing duties, we did not split the people. When I got on the wing it was around 4:30 PM. V15 stated she was not given report about the wing and was unaware of R8's fall. V15 stated she did give him his medications around 8:00 PM that evening. He was in bed, helped him sit up then laid him down after he took his meds. I asked if he needed anything, he said just turn the light out and that was the only time I saw him, and he was found expired about 9:30 PM. V15 stated she did not do any neuro checks or assessments, she just gave him his medications. V15 stated for any unwitnessed fall the nurse will do an assessment, neuro checks every 4 hours, contact the physician after checking to see if the resident is on anticoagulant medications. If on a blood thinner, the doctor must be notified by phone. It is important to notify the physician because there may be a brain bleed. That is why the neuro checks are done. On [DATE] at 3:10 PM, V21 Physician stated it is so important to have consistency of care for the residents. The report of residents from shift to shift among the nurses, they are caring for human beings, no excuse for not following through with care. The staff need to be very vigilant about how they are caring for the residents. If a resident has a fall and requires monitoring, then it needs to be done as ordered. If one assessment if fine, there may be a change such as vital signs, he may have had [CONDITION(S)] or had intracranial changes, we will never know because there was no assessment. The facility's [DATE] policy for resident falls documents: Response to falls, if a resident is suspected to have hit their head, the licensed nurse on duty will complete a neurological assessment every 4 hours for the first 24 hours post incident. The physician should be notified of all falls. If a resident is taking blood thinners and hits their head, the physician should be notified via phone immediately.

Based on observation, interview, and record review the facility failed to ensure a resident's door remained closed for a resident on droplet isolation precautions related to suspected exposure to COVID-19 for 2 of 3 residents (R104, R105) reviewed for infection control in the sample of 3. The findings include: A facility list dated March 1, 2021 showed R104 and R105 were on droplet isolation due to suspected COVID-19 exposure. On March 1, 2021 at 10:08 AM, R105 was in bed with the door to his room wide open. Signage for droplet isolation hung on R105's open door. On March 1, 2021 at 10:10 AM, R104 was seated in the chair in her room, looking out into the hallway, with no mask on. The door to R104's room was wide open. Signage for droplet isolation hung on R104's open door. On March 2, 2021 at 9:45 AM, R104 was seated in a recliner in her room with no mask on. The door to R104's room was wide open with a pink sign on the door that showed, Please keep door closed. A sign for droplet isolation also hung on R104's door. On March 1, 2021 at 11:00 AM, V3 Assistant Director of Nursing/Infection Preventionist stated R104 and R105 are new admissions that are to be on droplet isolation for 14 days upon admission because we assume they are COVID positive or have been exposed to COVID-19 in the hospital. V3 stated R104 and R105 are to be in their rooms with their doors closed while under droplet isolation. The facility's COVID-19 Preparedness Plan dated September 1, 2020, c. Residents with suspected or confirmed COVID-19 will remain in their private room/apartment with door closed at all times.

Based on observation, interview, and record review the facility failed to follow the physician orders. This applies to 1 or 7 residents (R208) in the sample of 7 reviewed for following physician's orders [REDACTED]. The findings include: On 08/14/18 11:43 AM R208 had three pieces of foam tape over an absorbent dressing on R208's right knee. On 08/13/18 09:32 AM V5 CNA-Certified Nursing Assistant said, I just gave R208, (R208's) shower. R208 was showered with (R208's) dressing on. I did not remove it. On 08/13/18 09:55 AM V4 LPN-Licensed Practical Nurse said, the dressing is changed by the night shift. R208's Care Plan dated (MONTH) 9, (YEAR) shows, Monitor this site for signs and symptoms of infection and update Surgeon. (MONTH) shower with bandage off and pat incision dry. R208's Wound Care Orders dated [DATE], (YEAR) shows, keep your bandage intact for 5 days after surgery. Keep the dressing dry. After 5 days you may remove your dressing and apply a new one daily. Be vigilance for infection. After 5 days you may get the wound wet in the shower with the bandage off. When out of shower pat incision dry.

Based on observation, interview, and record review the facility failed to ensure the concentration of sanitizer was within limits for the 3-part sink and failed to use the 3-part sink per guidelines. This applies to all 4 residents. The findings include: The CMS census and conditions report dated September 26, 2017 shows 4 residents residing in the facility. On September 26, 2017 at 9:15 AM, E3, dining room manager, checked the three part sink in the dishing washing area. The sink with sanitizer in it was 500 parts per million (ppm). E3 stated, it should be at 200 ppm. On September 26, 2017 at 10:28 AM, E4, dietary aide, was preparing pureed food for the noon meal. E4 was using the three part sink by the food prepping area. E4 rinsed the blender pitcher out with water and set it in the sink with soapy water. After that E4 placed the blender pitcher in the sink with sanitizer in it. This surveyor asked E4 to check the solution of sanitizer. It was 150 ppm. E4 waited approximately 1 one minute and removed the blender pitcher from the sink and placed it on the drying mat next to the sink. E4 prepared the rest of the items to puree the vegetables. E4 did not let the blender pitcher air dry and used it while it was still dripping wet. On September 26, 2017 at 1:55 PM, E3 dining room manager, checked the three part sink again in the dish washing area. The sink with sanitizer in it was 500 ppm. On September 26, 2017 at 1:56 PM, E3 dining room manager stated, they should, first rinse all the food off of the dishes, Second clean and wash in the sink with soapy water, third rinse the dishes, and finally sanitize. When they are done they should set the dishes on the mat to air dry. The facility's steps to manually wash, rinse, and sanitize policy (no date) shows, policy: equipment, utensils, tableware, pots and pans will be washed, rinsed, and sanitized in a method which complies with the Federal Food Code and any state or local ordinances. Procedure: 1. A three compartment sink will used for cleaning and sanitizing utensils and equipment that can be completely submerged. It may also be used if needed for tableware. 2. First compartment is the wash tank. Wash in water at 110 degrees with a good detergent. 3. Second compartment is the rinse tank. Rinse thoroughly in clean hot water after washing to remove cleaners and abrasives. (In cook's prep area, wash dishes in second compartment with soap, fill third compartment with rinse water in sink, and fill with sanitizing solution. See step 4.) 4. Third compartment is the sanitizing tank. Sanitize in warm, 75 degree water with sanitizer for one minute. Test water with ph paper to be sure that the sanitizing solution is at the correct concentration. Quaternary sanitizer should test at 200 ppm. 5. Air dry. Sanitizer contact time is important. Do not towel dry.

Based on observation, interview, and record review the facility failed to provide nutritional supplement for a resident being fed by a [DEVICE] (gastrostomy tube). This applies to 1 of 3 residents (R1) reviewed for specialty care in the sample of 3. The findings include: R1's Census Sheet shows she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's November 9, 2016 admission sheet showed she was NPO (nothing by mouth). R1's Physician order [REDACTED]. R1's Physician order [REDACTED]. A facility supplied form shows R1 is cognitively intact. On November 30, 2016 at 9:00 AM, R1 was seated in a wheelchair in her room. R1 had a [DEVICE] protruding from under her shirt at the waist line. R1 stated, I use this tube to be fed. I came from the hospital with it. Eating is a chore for me since my stroke in September (2016). It is difficult for me to swallow. On November 30, 2016 at 11:55 AM, E2 (Registered Nurse) stated she cared for R1 on November 12, 2016 (3 days after admit), E2 stated her shift began at 6:30 AM and R1 was completely out of her tube feeding that she had come to the facility with. E2 said she was not scheduled to work the day before, therefore was unsure how long R1 had been without the nutritional supplement. E2 said R1 had come into the facility with nutritional supplement but that supply had been used and no additional supplement was available for her to give. E2 stated she called the local pharmacy to obtain more, which arrived at the facility around one o'clock on November 12, 2016. On November 30, 2016 at 12:30 PM, E7 (Assistant Director of Health Services/Registered Nurse) stated R1's [DEVICE] feeding pump was off throughout the day on November 11, 2016. E7 said it was turned off because R1 was out of nutritional supplement. On November 30 at 3:00 PM, Z1 (Speech Language Pathologist) stated she evaluated R1's swallow technique on November 10, 2016 (one day after admit). Z1 stated she did recommend and obtain an order for [REDACTED]. Z1 said the order was for one-half teaspoons only and to be given by trained staff. Z1 said the order would not meet R1's calorie needs without the tube feeding running on a continuous basis. On November 30, 2016 at 3:05 PM, E5 (Director of Nurses) stated it is an expectation for nurses to follow doctors' orders. E5 said if an order states continuous feeding, the nutritional supplement should be given on a continuous basis. E5 said it is documented on the MAR (medication administration sheet) each shift it is running. If the administration sheet is blank or an initial is circled, it was not given. E5 said, I don't see any documentation on (R1's) MAR that she received the tube feeding on (November 11, 2016). On November 30, 2016 at 3:25 PM, E3 (LPN-Licensed Practical Nurse) stated she cared for R1 on November 11, 2016 from 6:30 AM to 3:15 PM. E3 said she was told at morning report that R1's nutritional supplement had run out during the night and there was no other supply. E3 stated she attempted to order more but it turned into a cluster mess and R1 still did not have a new supply at the end of her shift. E3 stated she relayed the information to the evening nurse (E8-LPN) at the end of her shift, around 3:15 PM. On November 30, 2016 at 3:45 PM, E8 (LPN) stated she cared for R1 on November 11, 2016 from 3:00 PM to 11:00 PM. E8 said there was no nutritional supplement the entire shift and nothing was given to her during the next shift (11:00 PM to 7:00AM). E8 said when she returned for her next shift which was on November 12, 2016 (the 3-11 shift) R1's tube feeding was running as ordered. R1's Medication Administration Sheet dated November 11 to November 30, 2016 shows no nutritional supplement given via [DEVICE] on November 11th during the day, evening, and night shifts. R1's Care Guide dated November 11, 2016 stated: Diet-I have an order for [REDACTED]. The facility's Gastrostomy Tube Policy reviewed dated 6/16 states: Check physician order [REDACTED].Document tube feeding on MAR and unusual findings in nurses' notes.

Based on observation, interview and record review, the facility failed to label a Tuberculin Antigen multiple dose vial showing the date the vial was opened. This applies 3 of 3 residents (R1, R2, R3) reviewed for labeling medications in the sample of 3. The findings include: On June 23, 2015 at 11:40 AM, in the medication room, an opened multiple dose vial of Tuberculin Antigen had open date. On June 23, 2015 at 11:40 AM, E3 (Registered Nurse) stated all multi-dose vials should be labeled when they are opened. E3 stated she had no idea when the vial was opened. On June 24, 2015 at 12:00 PM, E2 (Director of Nursing) said all multi-dose vials should be labeled with the date it was opened. The facility's Medication policy dated 2014 states, Date Tuberculin Antigen when opened and discard unused portion in 30 days.

Based on Interview and Record Review the facility failed to offer bedtime snacks. This applies to 2 of 3 residents (R2, R3) reviewed for bedtime snacks in the sample of 3. The findings include: On June 22, 2015 at 2:00 PM, R3 stated she has never been offered a bedtime snack, you have to ask if you want one. On June 23, 2015 at 10:00 AM, R2 stated am I supposed to ask or do they just give it to me (regarding bedtime snacks). On June 22, 2015 at 2:40 PM, E8 (Dietary Manager) stated dietary staff put snacks on cart and delivery the snacks to the nursing staff who distribute them to the residents. E8 stated she believes that the nursing staff track who gets snacks. On June 23, 2015 at 12:02 PM, E5 (Health Unit Coordinator) stated a bedtime snack log is located on each unit with names and room numbers. E5 stated when residents receive or refused snacks staff is to document on bed time snack log. E5 reviewed the bedtime snack logs no documentation was found. The facility's Bedtime Nourishment policy dated January 2014, states Bedtime nourishments are offered to residents.

Based on observation, interview and record review facility staff failed to have facial hair covered during food preparation. This affects 2 of 3 residents (R2, R3) in a sample of 3. The findings include: On June 24, 2015 at 10:15 AM, E10 (Cook) was at the stove preparing tomato macaroni casserole for the noon meal. E10's heavy beard was not fully covered with the beard net. E8 (CDM-Certified Dietary Manager) said E10's entire beard should be covered. The facility's revised policy dated 6/2015 Food Service Uniform and Dress Code shows, The food Service employee uniform and appearance policies are as follows: #4. All hair must be free from the face and restrained in a hair net and off the collar.Beards should be covered with beard net.

Based on interview and record review the facility failed to promptly resolve a resident's complaint about missing clothing/articles and keep the resident apprised of the progress toward a resolution. This applies to 1 of 3 residents (R1) reviewed for grievance resolution in a sample of 3. The findings include: On June 22, 2015 at 1:30 PM, during the group meeting, R1 complained of missing some new pajamas. R1 said he had told facility staff. On June 23, 2015 at 8:30 AM, R1 said, I'm going home (being discharged ) at 10 o'clock and I'm still missing a pair of pajamas and a black belt. I would really like them before I leave. R1 said no one had contacted him about finding the missing items. R1's nurse's note dated June 22, 2015 documented, E9 (Resident Services) searching for blue pajamas. Resident denies caregiver took home to launder when here today. On June 23, 2015 at 11AM, E6 (Housekeeping/Laundry Supervisor) said she did not think a list of missing clothing was kept but she would check with laundry staff. E6 presented handwritten papers for 4 residents who were missing clothing and bed sheets. Two of the papers were dated 5/14/15 and 6/12/15 and the other two were not dated. There was no resolution to show if the items had been found or not. On June 23, 2015 at 1:35 PM, E4 (Resident Services) said, The laundry person first investigates when clothing is missing. E4 said there is no tracking logs or resolution. I can't pay to replace everything. The facility's grievance/unusual occurence reports were reviewed. There was no report filled out for R1 missing items. The other reports showed occurences but did not document follow up or resolutions.

Based on observation, interview and record review, the facility failed to honor residents choice for apple sauce to receive medication. This applies to 1 of 3 resident, (R2) reviewed for medication pass in the sample of 3. The findings include: On June 23, 2015, at 8:20 AM, during a medication pass, E3, RN (Registered Nurse) gave R2's morning pills. ( A total of 7 pills) were prepared. R2 took each pill one at a time. When the 4th pill was given. R2 started choking. R2 said I need apple sauce to swallow the rest of my pills. R2 continued to attempt to swallow but continued to choke. E3 said, just try to take it. Tomorrow I'll put it in apple sauce. E3 tried again to swallow the pill but she spit out twice and said, This thing just doesn't go down! E3 said here, take more water. R2 said, I really can't swallow, I'm trying but I really need apple sauce, please give me the apple sauce. E3 went to get the apple sauce. R2 then ask E3 to add the rest of her pills to the apple sauce. R2 swallowed the pills with apple sauce without difficulty. R2 said See, I told you that was easy for me with apple sauce. On June 23, 2015 at 10:45 AM, E2, DON- Director of Nursing said E3 should have just gotten the apple sauce the first time R2 requested. The facility's medication administration policy and procedure dated February 2013 shows, Staff will ask resident's preference when taking medications (e.g. pills, whole, crushed including applesauce, ice water, tap water).

Based on record review and interview the facility failed to show a resident's assessment accurately reflected a resident's diagnoses. This applies to 1 of 3 residents (R1) reviewed for accuracy of the Minimum Data Set (MDS) in a sample of 3. The findings include: The June 2015 Physican's Order Sheet shows R1was admitted on [DATE]. R1 is receiving an anti-parkinson medication and a medication to treat [MEDICAL CONDITIONS]. The MDS dated [DATE] under Section I. [DIAGNOSES REDACTED]. On 6/24/15 at 10:20 AM, E3 (RN-Registered Nurse) verified R1 receives anti-[MEDICAL CONDITION] and a medication to treat [MEDICAL CONDITION] and the MDS does not list [DIAGNOSES REDACTED].