Every finding on record at Park Rest Hardin County Health Center

Based on facility policy review, facility working schedule review, facility time punches and interview, the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours, 7 days a week, for 15 days out of 54 days ranging from 6/1/2026 through 7/24/2026. The census was 32. The findings include: Review of the facility policy revised 2025, Nursing Services-Registered Nurse (RN), revealed It is the intent of the facility to comply with Registered Nurse staffing requirements.The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day.The facility will designate a Registered Nurse to serve as a Director of Nursing on a full-time basis. Review of the facility's working schedule dated 6/1/2026 - 7/24/2026, revealed the Director of Nursing (DON) was scheduled to work for 4 hours daily Monday - Friday. Review of the facility's time punches for 6/1/2026 - 7/24/2026, revealed the DON worked the following hours (hr.), resulting in less than 8 consecutive hours of RN coverage due to working part of the day at a sister facility for an undetermined amount of time: A. 6/2/2026 8.23 hr. B. 6/3/2026 8.37 hr. C. 6/4/2026 8.0 hr. D. 6/11/2026 8.17 hr. E. 6/12/2026 8.08 hr. F. 6/16/2026 8.05 hr. G. 6/19/2026 8.37 hr. H. 6/23/2026 8.33 hr. I. 6/26/2026 8.42 hr. J. 7/3/2026 8.0 hr. K. 7/8/2026 8.35 hr. L. 7/9/2026 8.18 hr. M. 7/10/2026 8.42 hr. N. 7/13/2026 8.43 hr. O. 7/15/2026 8.17 hr. During an interview on 7/29/2026 at 9:00 AM, Licensed Practical Nurse (LPN) D was asked where the DON was. LPN D stated, He has gone to the other building [a sister facility] to help out. During an interview on 7/29/2026 at 9:52 AM, Certified Nurse's Aide (CNA) E was asked does the DON work only in this building, or does he split between the two facilities (the facility and the sister facility). CNA E stated, The DON works at both facilities, and the Administrator does also. During an interview on 7/29/2026 at 9:53 AM, CNA F was asked does the DON work at both buildings. CNA F stated, [Named DON] yes. During an interview on 7/29/2026 at 9:53 AM, LPN H was asked does the DON work only in this facility or do they provide services in both facilities. LPN H stated, I believe he does a little bit here and a little bit there, maybe he fills in for [Named] RN C when she is not able. During an interview on 7/29/2026 at 9:55 AM, LPN D was asked does the DON work for both buildings. LPN D stated, He works for both buildings, he goes where he needs to go .he spends equal time at both places . During an interview on 7/29/2026 at 9:58 AM, CNA G was asked does the DON work at both buildings. CNA G stated, Yes. During an interview on 7/29/2026 at 10:13 AM, LPN I was asked if she did the facility schedule. LPN I stated, Yes. LPN I was asked who the RN during the week was. LPN I stated, DON. LPN I was asked does he work in this facility a consecutive 8 hours a day in this facility. LPN I stated, Yes, he may go next door to assist, they are a sister facility. LPN I was asked if the DON goes to the sister facility and helps, can you tell me for certain he (the DON) works 8 consecutive hours in this facility. LPN I stated, No. LPN I was shown the schedule that revealed the DON worked 4 hours a day and asked if that was correct. LPN I stated, He [DON] should have 8 on there. LPN I was asked can you show me on this schedule that the DON works 8 hours a day. LPN I stated, No, I cannot. LPN I was asked if the DON goes to the other building and helps. LPN I stated, Yes. During an interview on 7/29/2026 at 12:40 PM, the DON was asked was he a full-time DON for this building. The DON stated, Yes. The DON was asked did he go to the other building and help. The DON stated, .I will help [RN C] if she needs me.I do help her with keeping up with day to day. I help with infection control [at the sister facility]. The DON was asked how much time he spends over there [at the sister facility] daily. The DON stated, about 10-15 minutes.2 to 3 times day. The DON was asked to look at his time punches. The DON was asked if you spend 30 - 45 minutes a day in the other facility, would you agree you are not in this building for 8 consecutive hours. The DON stated, Yes, During an interview on 7/29/2026 at 12:57 PM, the Administrator was asked would he agree the DON goes to the other building daily. The Administrator stated, Yes. The Administrator was asked to look at the DON times sheets and was then asked if the DON is working and helping at the other facility would that mean he is not working a consecutive 8 hours in this facility. The Administrator stated, I can see that. The Administrator was asked about the facility schedule with RN C being on this facility's schedule working full time. The Administrator stated, RN C should not be on this facility's schedule, she strictly works next door .it is not supposed to be like that, I don't think the scheduler was told.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure sitters are screened for a history of abuse, neglect, exploitation, or misappropriation for 1 of 1 (Resident #2) reviewed for outside sitters. The findings include: 1. Review of the undated facility policy titled, Policy- Sitters and Family Members, revealed .All sitters who may be employed here must abide by our policies and procedures.No sitter shall have the right, and must refrain from, giving orders to any of the staff.No sitter is allowed to interfere with treatments or medications ordered by the physician.Sitters will be required to change beds, give baths if needed, offer bed pans, urinals when required and feed patient, if need be.Any sitter reported to abuse a patient, either verbally, physically or mentally will be required to leave immediately, regardless of who employs them.A sitter will only give care only to the patient they are assigned to and never interfere or perform services for another patient.A sitter will not give any medications or perform treatments to the patient .No sitter shall call a physician. The policy did not reflect the need to ensure sitters are screened for a history of abuse, neglect, exploitation, or misappropriation prior to providing services for residents. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnosis including Senile Degeneration of Brain, Pressure Ulcer, Psychosis, Dementia, and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not completed. Resident #2 was severely impaired for cognitive skills for daily decision making. Review of the Care Plan dated 5/11/2026, did not reflect Resident #2 having an outside sitter. Observation in Resident # 2's room on 7/27/2026 at 11:47 AM, revealed Resident #2 was in bed with eyes closed with a woman at bedside, sitting in chair, who announced herself as a sitter. During an interview on 7/29/2026 at 9:15 AM, the Administrator was asked for personnel files on all sitters. The Administrator stated, We didn't get anything on these sitters, they don't do any care, they do feed. The Administrator was asked if he could provide any abuse or background checks for the sitters. The Administrator stated, No. The Administrator confirmed Resident #2 has 2 sitters who are paid for by her family. During an interview on 7/29/2026 at 1:19 PM, the Administrator was asked if the facility had a policy for outside/non-employee sitters. The Administrator stated, That is the only policy we have (referring to the Sitters and Family Members policy). The Administrator was asked if sitters in the facility receive any information regarding their role and the facilities' expectations. The Administrator stated, No, the family kind of did this on their own, they (the sitters) just kind of started coming in. The Administrator was asked if facility staff should be aware of all sitters in the facility. The Administrator stated, Yes. The Administrator was asked how the sitters would be aware of the facility policy or expectations of sitters in the facility if not provided that information. The Administrator stated. They have only came and done lunch and we never had an issue, so we never had to bring anything up. The Administrator was asked if abuse and background checks should be completed on all sitters. The Administrator stated, Yes. The Administrator was asked if all sitters should be provided with any policies or information regarding their roles in the facility. The Administrator stated, Yeah.and it should be part of our admission packet as well.

Based on facility policy review and interview, the facility failed to provide evidence of meaningful participation by the Medical Director and facility staff in the Quality Assurance and Performance Improvement (QAPI) program. The findings include: Review of the undated facility policy titled, .Preamble for 2019 QAPI Plan for [Named Facility], revealed .Our organization encourages the input of all staff in all departments to address areas and ways in which we can improve the care we provide.Our organization makes decisions based on data, which includes the input and experience of caregivers, residents, health care professionals, and families.We achieve our goals in providing quality care for each Resident as an individual by determining appropriate care with an interdisciplinary team. Our team includes our Nurses, Certified Nurse Assistants, Administrative Staff, Dietary Personnel, Activity Worker, Social Worker, and Physicians. Review of the facility's QAPI program revealed the facility held quarterly meetings on12/16/2025, 3/12/2026, and 6/17/2026. There was no sign in sheet or documentation of who attended the meetings. The facility failed to provide proof of participation by the Medical Director and facility staff in the QAPI program. During an interview on 7/29/2026 at 2:42 PM, the Administrator was asked, can you show me on the QA form where the members and the Medical Director signed in and were present for the QA meetings. The Administrator stated, I cannot, I can't tell you if I was there.we haven't put names on these forms in about a year. During an interview on 7/29/2026 at 3:45 PM, the Administrator was asked if he could provide proof of who attended the QA meetings for the past 3 meetings. The Administrator stated, .No, I can't but I will change that on the very next meeting.

Based on policy review, facility working schedule review, calculated time by calendar day list review, Employee Timesheet review, and interview, the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 37 days ranging from January 2025 through June 2025. The census was 35. The findings include: 1. Review of the facility undated policy titled, Nursing Staff-Staffing Policy, revealed .The facility will assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychological well-being .The facility will provide at a minimum .55 hours of licensed nursing staff per resident day . 2. Review of the facility Nurses Working Schedule for January 2025, February 205, March 2025, April 2025, May 2025, and June 2025, revealed there was no RN scheduled for 1/4, 1/5, 1/11, 1/12, 1/18,1/19, 1/26, 2/1, 2/2, 2/8, 2/9, 2/15, 2/16, 2/22, 2/23, 3/1, 3/2, 3/8, 3/9, 3/15, 3/16, 3/22,3/23, 3/29, 3/30, 4/5, 4/6, 5/10, 5/11, 5/17, 5/18, 5/24, 5/25, 5/31, 6/1, 6/7, and 6/8. Review of the facility's Calculated Time by Calendar Day, report for May 2025, revealed there was no RN calculated time for RN hours worked on 5/10, 5/11, 5/17, 5/18, 5/24, 5/25, 5/31, and 6/1. Review of RN A ' s Employee Timesheet dated January 2025, February 2025, and March 2025, revealed RN A did not have any hours worked on 1/4, 1/5, 1/11, 1/12, 1/18, 1/19, 1/26, 2/1, 2/2, 2/8, 2/9, 2/15, 2/16, 2/22, 2/23, 3/1, 3/2, 3/8, 3/9, 3/15, 3/16, 3/22, 3/23, 3/29, and 3/30 which indicated there was no RN coverage for those days. Review of the Director of Nursing's (DON) Employee Timesheet dated January 2025, February 2025, and March 2025, revealed the DON did not have any hours worked on 1/4, 1/5, 1/11, 1/12, 1/18, 1/19, 1/26, 2/1, 2/2, 2/8,2/9,2/15, 2/16, 2/22, 2/23, 3/1, 3/2, 3/8, 3/9, 3/15, 3/16, 3/22, 3/23, 3/29, and 3/30 which indicated there was no RN coverage for those days. 3. During an interview on 6/10/2025 at 8:15 AM, the DON confirmed there was no RN coverage on the following weekends of 2025 for the dates 5/10, 5/11, 5/17, 5/18, 5/24, 5/25, 5/26, 5/31, and 6/1 on the licensure sheet. The DON was asked if the facility had RN coverage on any weekends. The DON stated, No. During an interview on 6/10/2025 at 8:29 AM, the DON was asked what the facility does when there is not an RN available to work the required 8 consecutive hours a day. The DON stated, If anything requires an RN, the charge nurse calls me or RN A. Our sister facility staffs an RN on weekends next door, and they can come if there is an emergency. During an interview on 6/10/2025 at 1:19 PM, the Administrator confirmed that the facility did not have RN coverage on any weekend. The Administrator stated, We applied for a waiver, but it hasn ' t been granted.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to report an allegation of abuse and failed to report to local law enforcement, Adult Protective Services (APS), and the Long-Term Care Ombudsman, within 24 hours for the allegations of suspected abuse for 5 of 5 (Resident #11, #12, #17, #19, and #25) sampled residents reviewed for abuse and resident rights. The findings include: 1. Review of the facility undated policy titled, Resident Rights, revealed The resident has the right to a dignified existence, self-determination .The resident has the right to be treated with respect and dignity . Review of the facility undated policy titled, ABUSE, NEGLECT, AND EXPLOITATION, revealed Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Residents must not be subject to abuse by anyone, including but not limited to .facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving resident, family members, legal guardians, friends or other individuals .Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should .Respond to the needs of the resident and protect them from further incident (document) .Notify the Director of Nursing and Administrator (document) .Initiate an investigation immediately .Contact State Agency and the local Ombudsman office to report the alleged abuse .If a crime, or suspicion of a crime has occurred, notify the local law enforcement agency .Each covered individual shall report to the State Agency and one or more law enforcement entities .any responsible suspicion of a crime against any individual who is a resident of or is receiving care from the facility .Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause suspicion result in serious bodily or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . 2. Review of the Facility Reported Investigation dated 3/11/2025, revealed an allegation of physical and verbal abuse when Certified Nursing Assistant (CNA) C reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) that while working with CNA B on 3/9/2025, CNA B handled Resident #12 in a rough manner when assisting CNA C with repositioning Resident #12 and when CNA B ripped off Resident #19 ' s brief in a rough manner and spoke to the Resident in a harsh tone. CNA C did not report the occurrences until 3/11/2025, 2 days later. As a result of the facility ' s investigation, it was determined that Residents #11, #17, and #25 were all subject to abusive behavior from CNA B while receiving care and services and it was not reported. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Dementia, Muscle Weakness, Anxiety, Depression, Diabetes and Benign Prostatic Hyperplasia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #11 has a Brief Interview for Mental Status (BIMS) score of 5, indicated the resident had severe cognitive impairment, dependent on staff for Activities of Daily Living skills (ADLs), and incontinent of both bowel and bladder. 4. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s Cerebrovascular Disease, Hemiplegia and Hemiparesis, Catatonic Disorder, and Psychomotor Deficit. Review of the annual MDS dated [DATE] revealed Resident #12 had a BIMS score of 8, indicated the Resident had moderate cognitive impairment, dependent on staff for ADLs, and incontinent of both bowel and bladder. 5. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s, Rheumatoid Arthritis, Urinary Tract Infection, Dementia, and Anxiety. Review of the significant change MDS dated [DATE], revealed a BIMS of 14 which indicated the Resident was cognitive intact, required substantial/maximal assistance with ADLs, and incontinent of both bowel and bladder. 6. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s, Muscle Weakness, Dementia, Age Related Debility, Adjustment Disorder, and Pain in Right Hip. Review of the significant change MDS dated [DATE], revealed no BIMS score assessed and Resident with short-long term memory problems and severely impaired for cognitive skills for daily decision making, dependent on staff for ADLs, and incontinent of both bowel and bladder. 7. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Diabetes, Age-Related Physical Debility, Muscle Weakness, Depression, and Incontinence. Review of the annual MDS dated [DATE], revealed a BIMS of 13 which indicated the Resident was cognitive intact, dependent on staff for ADLs, and incontinent of both bowel and bladder. 8. During a telephone interview on 610/2025 at 11:32 AM, CNA F confirmed she had provided a written statement to the facility regarding the allegation of abuse involving CNA B. CNA F confirmed that she witnessed several incidents in the past involving CNA B and stated she did report to some nursing staff but was unsure their names. CNA F was read her witness statement and confirmed that she wrote the statement and all information in the statement was witnessed at various times and was unsure of the dates or times. CNA F confirmed she witnessed CNA B being rough, rude, and belittling residents. CNA F confirmed she witnessed CNA B speaking hateful and slapping Resident #25 on the leg telling him to straighten out his legs when giving him incontinent care. CNA F confirmed that in her statement she wrote that she witnessed CNA B being rough with Resident #11 and pointing her finger in his face aggravating him. CNA F confirmed that in her statement she witnessed CNA B talking and belittling Resident #17 for having an incontinent incident. CNA F confirmed she has witnessed CNA B being hateful and rude and she failed to report it and that she should have. During an interview on 6/10/25 at 1:57 PM, LPN D confirmed she had given a handwritten statement regarding CNA B and her attitude towards residents. LPN D confirmed she had spoken with CNA B on one occasion about her attitude towards residents especially how she responded to residents and was not being patient with residents. LPN D confirmed that residents had requested for CNA B not to come into their rooms to take care of them because of her attitude. LPN D confirmed she did not report that to the DON, ADON, or the Administrator, and that she should have. During an interview on 6/10/2025 at 2:15 PM, the ADON confirmed that CNA C reported on 3/11/2025 to both her and the DON that CNA B had been both physically and verbally abusive to Resident #12 and #19 on 3/9/2025. The ADON confirmed that CNA C should have reported it the same day it occurred and not 2 days later. The ADON confirmed that initially they thought it may have been that CNA B was having a bad day but as they began to speak with other staff it was disclosed that other residents were involved and that it was more than a bad day. The ADON confirmed the other 3 residents that were involved were Resident #11, Resident #17, and Resident #25, with staff alleging physical and verbal abuse from CNA B. During an interview on 6/10/25 at 2:18 PM, the DON confirmed that on 3/11/2025 CNA C told both him and the ADON that she witnessed some disturbing behavior from CNA B on 3/9/2025 involving 2 residents. The DON confirmed that the staff member was CNA B and the initial residents involved were Resident #12 and Resident #19 and the date of occurrence was 3/9/2025. The DON confirmed that CNA C did not report the occurrences to anyone until 3/11/2025 when she returned back to work and then an investigation was started. The DON confirmed that once the investigation began that other staff reported other incidents that they witnessed that involved other residents. The DON confirmed the other residents were Resident #11, Resident #17, and Resident #25. The DON confirmed that it was reported that CNA B was rude, hateful in speaking with residents, and was very rough when caring for the residents. The DON confirmed that neither Adult Protective Services, Local Law Enforcement, and/or the Ombudsman were notified of the occurrences. The DON confirmed that it should have been reported by staff on 3/9/2025 when it was witnessed and an investigation should have been started on that date. During an interview on 6/10/25 at 3:22 PM, the Administrator confirmed that on 3/11/2025 he was told about an incident that occurred on 3/9/2025 that involved CNA B and 2 residents. The Administrator stated that when he was initially told he thought maybe it was just a staff member having a bad day but then after further investigation he realized it was more than that and it involved other residents. The Administrator confirmed the staff member was CNA B and the initial residents involved were Resident #12 and Resident #19 and that it was reported to him that CNA B was rough during care and had a bad attitude and by the 3rd or 4th staff statement that it was definitely an allegation of abuse. The Administrator confirmed that CNA C reported it to the DON and the ADON on 3/11/2025 but it occurred on 3/9/2025 and she should have reported to the nurse when it was witnessed. The Administrator Stated that all suspected allegations or any allegation should be reported immediately when witnessed and an investigation should be started at that time to include statements from staff and residents, assess the residents, skin sweeps, and informing the physician and the family. During an interview on 6/10/2025 at 3:46 PM, CNA C confirmed that on March 9th she was working with CNA B on Hall 2 and she asked CNA B for assistance in giving care to Resident #12 and Resident #19. CNA C confirmed they went into Resident #12 ' s room first to give her care and instead of unfastening the resident ' s brief she just ripped the brief off of the resident and then she assisted me in Resident #19 ' s room and was speaking rude and abusive to the resident. CNA C confirmed she was in disbelief of her actions in both rooms. CNA C confirmed that neither Resident #12 or Resident #19 could assist with their care or could give the care to themselves, or could make their needs or wants known, and that staff has to assist with all their care needs. CNA C confirmed she had heard that she was rough and had an attitude with residents but had never witnessed it until that day, 3/9/2025. CNA C confirmed that she did not report to anyone about the 2 occurrences until 3/11/2025 when she reported to the DON and the ADON, 2 days later when she returned back to work. CNA C confirmed that she should have reported to the nurse on the date she witnessed the incidents.

Based on facility policy review, medical record review, and interviews, the facility failed to follow a physician's order related to contact isolation precautions for 1 of 2 residents sampled (Resident #12) reviewed for infection control. The findings include: 1. Review of the facility policy titled, Infection Control and Prevention Policy, dated 2017, revealed It is the policy of this facility to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection by providing a safe and sanitary environment .A resident with an infection .shall be placed in isolation precautions . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnosis including Alzheimer, Cerebrovascular Disease, Hemiplegia, and Polyneuropathy. Review of a Microbiology report dated 6/8/2025, revealed Resident #12 had a urine culture that grew out Extended-Spectrum Beta-Lactamases (ESBL) (bacteria is resistant to a wide range of antibiotics) in her urine. Review of a Physician's Order dated 6/8/2025, revealed an order for CONTACT ISOLATION PRECAUTIONS RELATED TO UTI (urinary tract infection) with ESBL . During an observation on 6/9/2025 at 11:25 AM and 4:41 PM, and 6/10/2025 at 7:50 AM, revealed on Resident #12's door a Personal Protective Equipment (PPE) door organizer with a purple square and code key that indicated Resident #12 was in enhanced barrier precautions. During an interview on 6/10/2025 at 10:48 AM, the Assistant Director of Nurses (ADON) was asked what kind of isolation Resident #12 was in. The ADON stated, Contact Isolation. The ADON was showed Resident #12's door that had enhanced barriers signage on it, she stated, It will be changed to contact isolation. During an interview on 6/10/2025 at 2:37 PM, the Director of Nurses confirmed Resident #12 was in Contact Isolation and the room signage was incorrect.

Based on policy review, facility working schedule, calculated time by calendar day list, and the facility detailed hours report, the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 29 days ranging from April 1, 2023, through 10/20/2023. The facility's census was 39. The findings include: 1. Review of the facility's undated policy titled, The facility will assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychological well-being .The facility will provide at a minimum .55 hours of licensed nursing staff per resident day . 2. Review of the facility's Nurses Working Schedule for April 2023, revealed there was no RN scheduled to work 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023 and 4/30/2023. Review of the facility's Calculated Time by Calendar Day, report for April 2023, revealed there was no RN calculated time, indicating a RN worked 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023 and 4/30/2023. Review of the facility's Detailed Hours report for April 2023, revealed no RN punched in or out indicating working hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023 and 4/30/2023. 3. Review of the facility's Nurses Working Schedule for May 2023, revealed there was no RN schedule to work for 8 consecutive hours on 5/6/2023, 5/7/2023, 5/13/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023, and 5/29/2023. Review of the facility's Calculated Time by Calendar Day, report for May 2023, revealed there was no RN calculated time indicating that a RN worked 8 consecutive hours on 5/6/2023, 5/7/2023, 5/13/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023, and 5/29/2023. Review of the facility's Detailed Hours report for May 2023, revealed no RN punched in or out indicating that a RN worked 8 consecutive hours on 5/6/2023, 5/7/2023, 5/13/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023, and 5/29/2023. 4. Review of the facility's Nurses' Working Schedule for June 2023, revealed there was no RN schedule to work 8 consecutive hours on 6/3/2023, 6/4/2023, 6/10/2023, 6/18/2023, 6/19/2023, 6/20/2023, 6/21/2023, and 6/27/2023. Review of the facility's Calculated Time by Calendar Day, report for June 2023, revealed there were no RN calculated hours, indicating that an RN worked 8 consecutive hours on 6/3/2023, 6/4/2023, 6/10/2023, 6/18/2023, 6/19/2023, 6/20/2023, 6/21/2023, and 6/27/2023. Review of the facility's Detailed Hours report for June 2023, revealed no RN punched in or out, indicating that a RN worked 8 consecutive hours on 6/3/2023, 6/4/2023, 6/10/2023, 6/18/2023, 6/19/2023, 6/20/2023, 6/21/2023, and 6/27/2023. 5. Review of the facility's Nurses' Working Schedule for October 2023, revealed there was no RN schedule to work 8 consecutive hours on 10/7/2023, 10/8/2023, 10/14/2023, and 10/15/2023. Review of the facility's Calculated Time by Calendar Day, report for October 2023, revealed there were no RN calculated hours, indicating that an RN worked 8 consecutive hours on 10/7/2023, 10/8/2023, 10/14/2023, and 10/15/2023. Review of the facility's Detailed Hours report for October 2023, revealed no RN punched in or out, indicating that a RN worked 8 consecutive hours on 10/7/2023, 10/8/2023, 10/14/2023, and 10/15/2023. 6. During an interview on 10/24/23 at 11:24 AM, Licensed Practical Nurse (LPN) #4 was asked does she work the weekends. LPN #4 confirmed that she works every other weekend. LPN #4 was asked if there was RN coverage on the weekends that she work. LPN #4 confirmed that there is not always RN coverage and sometimes the RN only works a half day. During an interview on 10/24/23 at 3:57 PM, LPN #5 was asked if there is RN coverage on the weekends. LPN #5 confirmed that there is not always RN coverage on the weekends that she is scheduled to work. During an interview on 10/25/23 at 1:03 PM, the Staffing Coordinator was asked how many RNs are on the facility's employee roster. The Staffing Coordinator confirmed that the only RN is the Director of Nursing (DON). The Staffing Coordinator was asked what hours does the DON work. The Staffing Coordinator confirmed the DON generally works Monday through Friday 8 AM to 5 PM. The Staffing Coordinator was asked is there 8 consecutive hours of RN coverage 7 days a week. The Staffing Coordinator confirmed that there is no RN coverage on the weekends and the only RN in the building is the DON. The Staffing Coordinator confirmed that there are times when the DON is out that there is no RN coverage. The Staffing Coordinator confirmed she was aware that there should be 8 consecutive RN coverage hours for 7 days a week. The Staffing Coordinator confirmed that if there was a RN on duty that the time punches would indicate that information and if there are no hours, then there was no RN on duty for those days. During an interview on 10/25/23 at 1:25 PM, the Interim DON confirmed that she has been the Interim DON since the end of September. The Interim DON was asked has there been times on the weekend, during the week and on holidays when the facility did not have RN coverage for 8 consecutive hours. The Interim DON confirmed that there has been times since April 2023 that the facility has been without RN coverage and when there has been less than 8 consecutive RN hours. The Interim DON confirmed that both she and the former DON would work some weekends, but their hours of employment were Monday through Friday and they did not always work the weekends. The Interim DON confirmed she was aware that there should be 8 consecutive RN hours 7 days a week. The Interim DON confirmed that if there were no RN hours showing on the facility's Detailed Hours Report and the facility's Calculated Time by Calendar Day report that no RN worked that day. During an interview on 10/25/23 at 1:41 PM, the former DON confirmed that he was aware that there was no 8 consecutive hours of RN coverage for 7 days a week and on the weekends in April 2023, May 2023, and June 2023. The former DON confirmed that if he covered as the RN he would have clocked in and if it was not on the Detailed Hours Report or the Calculated by Calendar Days Report then there was no RN coverage. The former DON confirmed that he was aware that the RN hours had to be consecutive and could not be less than 8 consecutive hours.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 10 staff members (Certified Nursing Assistant (CNA) #1, CNA #2, Licensed Practical Nurse (LPN) #1, and Assistant Director of Nursing (ADON) observed during dining failed to use courtesy titles to address residents, failed to provide privacy while assisting with dining, and stood over residents while assisting with dining. The findings include: 1. Review of the facility's undated policy titled, Residents Dignity revealed, .Dignity .means .our interactions .should maintain/enhance his/her self-esteem and self-worth .ensure dignity is provided by .pulling privacy curtain and closing door .respect residents space .knock on door .request permission to enter room .address the resident with the name of their choice . 2. Observation in Resident #35's room during dining on 10/23/2023 at 11:49 AM, revealed CNA #1 entered the room with Resident 35's meal tray and failed to knock on door or acknowledge self before entering. Observation in Resident #35's room during dining on 10/2/2023 at 7:35 AM, revealed CNA #2 entered the resident's room with their meal tray and failed to acknowledge self or knock on the door. CNA #2 sat down to assist Resident #35 with their meal and failed to pull the privacy curtain or shut the door for privacy while assisting Resident #35 with their meal. 3. Observation in Resident #24's room during dining on 10/23/2023 at 11:52 AM, revealed CNA #1 entered the resident's room with the meal tray and asked, Are you hungry, honey. CNA #1 failed to use a courtesy title when addressing Resident #24. 4. Observation in Resident #29's room during dining on 10/23/2023 at 11:53 AM, revealed that CNA #1 entered Resident #29's room with the meal tray, placed the meal tray on the over bed table, sat to assist Resident #29 with the meal and failed to pull the privacy curtain or close the door. Observation in Resident #29's room during dining on 10/24/2023 at 7:31 AM, revealed CNA #2 assisted Resident #29 with their meal and failed to pull privacy curtain or shut the door for Resident #29's privacy while assisting with their meal. 5. Observation in Resident #6's room during dining on 10/23/2023 at 11:52 AM, revealed LPN #1 entered with the meal tray for Resident #6 and failed to knock or acknowledge self. Observation in Resident #6's room during dining on 10/23/2023 at 12:08 PM, revealed LPN #1 assisted Resident #6 with their meal and failed to pull the curtain or shut the door to provide the resident with privacy while assisting with the meal. LPN #1 exited Resident #6's room to assist another resident and failed to knock or acknowledge self upon re-entrance into Resident #6's room. Observation in Resident #6's room during dining on 10/24/2023 at 7:30 AM, revealed CNA #1 entered Resident #6's room with the meal tray and failed to pull the privacy curtain or shut the door to ensure privacy for Resident #6 while assisting with their meal. 6. Observation in Resident #5's room during dining on 10/23/2023 at 11:54 AM, revealed LPN #1 took a meal tray from the cart, entered Resident #5's room, and placed the meal tray on the over bed table, sat at bedside to assist Resident #5 with their meal while visible from the hallway. CNA #1 failed to provide Resident #5 with privacy while assisting with the meal. Observation in Resident #5's room during dining on 10/24/2023 at 7:32 AM, revealed the ADON entered the room with a meal tray and stood over Resident #5 while assisting with their meal. 7. Observation in Resident #13's room during dining on 10/23/2023 at 12:00 PM, revealed CNA #1 entered Resident #13's room with the meal tray and stated to the resident, Is your foot hurting, baby and Here's your sweater, baby, and Come put your sweater on, baby, and referred to her as sweetheart. CNA #1 failed to address Resident #13 with a courtesy title. 8. Observation in Resident #7's room during dining on 10/24/2023 at 7:34 AM, revealed CNA #2 entered the resident's room with a meal tray, placed the tray on the over bed table, sat and began to assist Resident #7 with their meal and failed to pull the privacy curtain or shut the door for privacy while assisting Resident #7 with their meal. 9. During an interview on 10/25/23 at 2:42 PM, the ADON was asked how residents should be addressed. The ADON confirmed that all residents should be addressed with their appropriate name and titles unless otherwise care planned and should not be referred to with a pet name. The ADON was asked what position staff should be in when assisting a resident with a meal. The ADON confirmed that staff should be in the sitting position when assisting with resident meals. The ADON was asked what should staff do before entering a resident's room. The ADON confirmed that staff should knock, announce themselves before entering a resident's room, and they should close the privacy curtain while assisting with a meal.

Based on policy review, medical record review, observation, and interview, the facility failed to date and label Percutaneous Endoscopic Gastrostomy (PEG) tube (plastic tube inserted into the stomach to administer liquid food/supplement) feedings for 1 of 2 (Resident #16) sampled residents reviewed for enteral feeding. The findings include: 1. Review of the facility's undated policy titled, Gastrostomy/Nasogastric Tube Feeding, revealed .Provide nourishment to the resident who is unable to obtain nourishment orally. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of Dementia, Gastro-Esophageal Reflux Disease, Aphasia, Gastrostomy, and Dysphagia. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #16 was assessed as being severely cognitively impaired and receiving nutrition through a feeding tube (peg). Review of a Physician's Order dated 10/21/2023 revealed, .Nutren 1.5 per peg tube at 66 ml (milliliters)/hr (hour) and 46 ml/hr H2O (water flush). Observation in Resident #16's room on 10/23/23 at 8:23 AM, revealed an enteral feeding bag without the date, time, or label indicating description of the solution in the bag. Observation and interview in Resident #16's room on 10/24/23 at 8:54 AM, revealed an enteral feeding bag without a date, time, or label. The Assistant Director of Nursing (ADON) entered the resident's room with a marker and added a date of 10/24/2023, time of 4:00 AM, rate of 66 ml/hr and name of the solution to the enteral feeding bag. The ADON was asked were you the nurse who hung this bag at 4 AM. The ADON stated, No. The ADON confirmed that she was not present at the time the enteral feeding system was started on 10/24/2023 at 4:00 AM and without being present she was unsure what the solution was in the enteral feeding bag. During an interview on 10/25/23 at 2:42 PM, the ADON confirmed that all enteral feeding bags should be labeled, dated, and timed with the name of the solution in the bag.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when 1 of 3 Licensed Practical Nurse (LPN) left unsecured and unattended medication on top of a medication cart. The findings include: 1. Review of the facility's undated policy titled, Medication Cart, revealed .all containers will be labeled and dated .medication will be kept locked . Review of the facility's undated policy titled, Medication Storage Room, revealed .Medication .will be kept locked when not in use . 2. Observation outside Resident #23's room on 10/24/2023 at 7:34 AM, revealed an orange liquid in a clear medication cup on top of Medication Cart #2. 3. During an interview on 10/24/2023 at 7:35 AM, LPN #4 confirmed that she left the oral medication on top of the medication cart outside Resident #23's room. LPN #1 was asked should medication be left open, unsecured, and out of sight of the nurse during medication administration, LPN #4 stated, No. During an interview on 10/25/2023 at 6:25 PM, the Assistant Director of Nursing (ADON) was asked should medication be left outside of a resident's room on top of the medication cart unsecured and unattended. The ADON stated No.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) failed to administer the ordered dose of Sliding Scale Insulin for 1 of 9 sampled residents (Resident #18) observed during medication administration. The findings include: Review of the facility's undated policy titled, .ADMINISTRATION OF DRUGS . revealed .Medications must be administered in accordance with the written orders of the attending physician . Review of the facility's undated policy titled, .SLIDING SCALE INSULIN . revealed .PURPOSE: To ensure insulin is administered .Use resident specific sliding scale as ordered by MD [Medical Doctor] . Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .greater than 400 give 12 units and notify MD [Medical Doctor] . Observation and interview in the resident's room on 12/13/2021 at 4:41 PM, revealed LPN #1 performed a blood glucose check on Resident #18. The resident's blood glucose was 484 milligrams/deciliter (mm/dL). LPN #1 returned to the medication cart and checked the Physician's Sliding Scale Insulin order. LPN #1 was asked what was the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .I'm going to give the 10 units and notify the doctor and see if he wants to do anything else . LPN #1 dialed the insulin pen to 10 units and showed the surveyor the pen. Observation in the resident's room on 12/13/2021 at 4:52 PM, revealed LPN #1 administered 10 units of [MEDICATION(S)] insulin to Resident #18 using an insulin pen. During an interview on 12/14/2021 at 8:30 AM, the DON was asked to review Resident #18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed Resident #18 was administered 10 units of insulin.

Based on medical record review, observation, and interview, the facility failed to ensure documentation of medications when 2 of 3 nurses (Licensed Practical Nurse (LPN) #1 and LPN #2) failed to document medications administered on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's undated policy titled, .Administration of Drugs, revealed .The nurse administering the medication must record such information on the resident's MAR before administering the next resident's medication .The nurse administering the medications must initial the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room during medication administration on 12/13/2021 at 10:55 AM, revealed Resident #28 was administered Acetaminophen 325 mg by LPN #1. LPN #1 failed to document that Acetaminophen 325 mg was administered on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/14/2021 at 8:30 AM, the Director of Nursing (DON) confirmed the Acetaminophen should have been documented as administered on the MAR. During an interview on 12/14/2021 at 11:39 AM, LPN #1 confirmed that she did not document the Acetaminophen administration on 12/13/2021 on the MAR until 12/14/2021. Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a.[CONDITION(S)] [urinary tract infection] HEAL 30 ML [milliliters] PER PEG [percutaneous endoscopic gastrostomy tube] .BID [two times a day] . b.[MEDICATION(S)] Solution 250 MG/5ML .Give .via [through] PEG-Tube .two times a day . c.LORazepam .Give 0.25 mg via PEG-Tube .two times a day . d.[MEDICATION(S)] .Give 10 ml via PEG-Tube .two times a day . e.[MEDICATION(S)] HCL [[MEDICATION(S)]] .Give 5 mg . f.[MEDICATION(S)] .10 MG .via PEG-Tube .in the evening . Observation in the resident's room during medication administration on 12/13/2021 at 4:55 PM, LPN #2 administered the [CONDITION(S)] Heal 30 ml, [MEDICATION(S)] Solution 250mg/5ml, Lorazepam 0.25 mg, [MEDICATION(S)] 10 ml, [MEDICATION(S)] HCL 5 mg, and [MEDICATION(S)] 10 mg per PEG tube. Review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. [CONDITION(S)] Heal 30 mg b. [MEDICATION(S)] Solution 250mg/5ml c. Lorazepam 0.25 mg d. [MEDICATION(S)] 10 ml e. [MEDICATION(S)] HCL 5 mg f. [MEDICATION(S)] 10 mg During an interview on 12/14/21 at 8:30 AM, the DON confirmed LPN #2 did not document the medications were administered on 12/13/2021 at 5:00 PM.

Based on policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for siderails for 1 of 2 sampled residents (Resident #9) reviewed for physical restraints/siderails. The findings include: Review of the facility's undated policy titled, .Resident Rights, revealed .The resident has a right .to be free from any physical .restraints . Review of the facility's undated policy titled, .Restraints, revealed .if a restraint is needed it will be the least restrictive possible . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders dated 8/5/2021, revealed .Side Rails ½ [one-half] x [times] 2 to assist with repositioning and safety . Review of the Care Plan dated 9/22/2021, revealed, .SIDE RAILS .½ rails up x 2 to assist with repositioning as per Dr.s [Doctor's] order . Observation in the resident's room on 12/12/2021 at 10:18 AM, 12:23 PM, and 2:45 PM, and on 12/13/2021 at 8:44 AM, revealed Resident #9 was resting in bed and all four ½ side rails were raised. During an interview on 12/13/2021 at 5:02 PM, the Director of Nursing (DON) confirmed that Resident #9 should have had two ½ side rails raised on the bed.

Based on policy review, medical record review, observation, and interview, the facility failed to monitor physical restraints for 1 of 2 (Resident #20) sampled residents reviewed for physical restraints. The findings include: 1. The facility's undated POLICY-RESTRAINTS policy documented, .PURPOSE .To ensure each resident attains and maintains his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience .DON (Director of Nursing) will assess the need for a restraint and if a restraint is needed it will be the least restrictive possible .The restraint device will be checked every 30 minutes and released every 2 hours and documented . 2. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, had hallucinations and delusions, and required staff assistance for all activities of daily living. Medical record review revealed there was no documentation of the restraint being released every 30 minutes or Resident #20 being repositioned every 2 hours. Observations in the Lobby on 9/9/19 at 2:40 PM, 9/10/19 at 8:31 AM, and 9/11/19 at 9:51 AM, revealed Resident #20 seated in a wheelchair with a vest restraint on and fastened with velcro. Observations in the Dining Room on 9/10/19 at 11:24 AM, revealed Resident #20 seated in a wheelchair with a vest restraint on and fastened with velcro. Continuous observations in the Lobby on 9/10/19 from 1:40 PM to 4:16 PM, revealed Resident #20 seated in a wheelchair with a vest restraint on and fastened with velcro. No staff checked or released the vest restraint. Observations in the Lobby on 9/11/19 at 9:51 AM, revealed Resident #20 seated in a wheelchair with a vest restraint on and fastened with velcro. Licensed Practical Nurse (LPN) #1 asked Resident #20 to remove the vest. Resident #20 was not able to comprehend the request, and did not remove the vest. Interview with LPN #2 on 9/11/19 at 10:21 AM, in the Director of Nursing (DON) Office, LPN #2 was asked how often staff should check and release the vest. LPN #2 stated, They should be repositioning every 30 minutes . The facility used a trunk restraint for Resident #20 that she was unable to release on her own, and failed to check and release the trunk restraint every 30 minutes.

Based on policy review, medical record review, observation, and interview, the facility failed to follow their Bowel Protocol for 1 of 1 (Resident #36) residents reviewed for constipation. The findings include: The facility's undated Policy -- BM (Bowel Movement) documented, The night nurse will fill out BM list every night with names of residents who have not had an adequate BM in 3 days. This will be checked using the ADL (Activity of Daily Living) Book. Give this list to the dayshift nurse. Day nurse will start PO (Oral Administration) laxatives or suppository or enema per standing orders or specific MD (Medical Doctor) orders .If no BM on dayshift, night nurse will continue treatment with suppository or enema per standing orders or specific MD orders and results charted . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #36 was cognitively intact. Resident #36 was occasionally incontinent of bowel. Review of the Physician Standing Orders revealed orders were in place for PO medication, suppository, and enema as needed (prn) for constipation. Review of the Comprehensive Care Plan dated 12/10/18 revealed Resident #36 had bowel incontinence and constipation related to immobility. Review of the facility's ADL documentation dated 7/1/19-7/31/19 revealed Resident #36 did not have a BM on 7/24/19, 7/25/19, 7/26/19, and 7/27/19. Review of the (MONTH) 2019 BM List revealed Resident #36 was added to the BM List on 7/28/19, 5 days after his last BM. Review of the (MONTH) Medication Administration Record [REDACTED]. Review of the facility's ADL documentation dated 9/1/19-9/11/19 revealed Resident #36 did not have a BM on 9/5/19, 9/6/19, 9/7/19, and 9/8/19. Review of the (MONTH) 2019 BM List revealed Resident #36 was not added to the BM List on any day from 9/1/19-9/9/19. Review of the (MONTH) MAR indicated [REDACTED]. Observations in Resident #36's room beginning 9/9/19 at 9:30 AM, revealed Resident #36 was alert, oriented, and interviewable. Interview with Resident #36 on 9/9/19 at 3:51 PM, in the resident's room, Resident #36 was asked if he had any problems with constipation. Resident #36 stated, Yes . Resident #36 was asked if he had gone longer than 3 days without having a bowel movement. Resident #36 stated, .Sometimes it's more than 3 days . Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #3 on 9/10/19 at 3:30 PM, in the DON Office, the DON and LPN #3 were asked to explain their Bowel Protocol. LPN #3 stated, .Night shift does the BM List, checks to see the resident hasn't had a BM in 3 days, they (Resident) then get something by mouth first, then an enema or suppository if it's (PO medication) not effective . The DON and LPN #3 were asked if Resident #36 had a BM on 7/24/19-7/27/19. The DON stated, It's not documented . The DON and LPN #3 were asked when should Resident #36 have been put on the BM List. LPN #3 stated, Should have been on the 27th (July 27th) . The DON and LPN #3 were asked if the Bowel Protocol was followed. The DON stated, No ma'am. The DON confirmed Resident #36 did not have a BM on 9/5/19-9/8/19 and he was not placed on the BM List. The DON was asked if the facility's Bowel Protocol was followed. The DON stated, No .

Based on policy review, observation and interview, the facility failed to ensure food was prepared under sanitary conditions during observations on 1 of 3 (10/31/16) days during the survey as evidenced by chemicals found in the food preparation areas. The findings included: 1. The facility's POLICY-DIETARY SERVICES documented, .FOOD STORAGE .Toxic cleaning materials must be identified, stored, and used in such a manner as not to contaminate food. They are stored in a separate room . 2. Observations in the kitchen during initial tour on 10/31/16 beginning at 9:10 AM, revealed a 3 compartment sink containing a pan of frozen deli meat with water running over it, and a red bucket containing liquid and rags sitting next to the pan of deli meat in the first compartment, a large pan containing frozen chicken with water running over it in the second compartment, and the third compartment was 1/2 full of a bluish-colored liquid. The Certified Dietary Manager (CDM) was asked what the liquid in the bucket and in the sink were. The CDM stated, .sanitizer . Interview with the CDM on 11/1/16 at 6:15 PM, in the kitchen, the CDM was asked if it was acceptable to have meat thawing in a sink that had a bucket of sanitizer in the sink with it, chicken thawing in the middle sink and a sink 1/2 full of sanitizing water in the sink next to it. The CDM stated, I don't know .I guess it's not .

Based on medical record review and interview, the facility failed to provide the family written notification of the bed hold policy for hospital transfers for 1 of 2 (Resident #12) sampled residents that had been discharged to the hospital. The findings included: Medical record review revealed Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The PHYSICIAN'S TELEPHONE ORDERS AUDIT dated 12/16/15 documented, .May send to .ER (emergency room ) . The NURSE'S NOTES documented, .12/16/15 .transport to .ER .12/22/15 .arrived back at facility .readmission . Interview with the Social Services Director (SSD) on 11/2/16 at 3:50 PM, in room [ROOM NUMBER], the SSD was asked when was the last time Resident #12 had gone out of the facility. The SSD stated, .discharged to hospital on December 16th, 2015, and returned to the facility on [DATE] . The SSD was asked whether a written bed hold policy was provided for Resident #12's family member when the resident was transferred to the hospital. The SSD stated, .I can't honestly say I did . The facility was unable to provide documentation that the written bed hold agreement was provided for the resident's legal representative when Resident #12 was transferred to the hospital on [DATE].

Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared and distributed under sanitary conditions when 3 of 6 (Dietary Staff (DS) #1, 2, and 3) dietary staff members did not have their hair completely covered. This had the potential to affect 43 of 48 residents who received a meal tray. The findings included: Review of the facility's dietary services policy documented, .IV. PERSONAL HYGIENE A. Proper attire for food handlers should include a hair covering. Observations in the Kitchen on 9/9/15 at 7:20 AM, revealed DS #1 and 2 were serving food from the tray line with hair outside the hair covering. DS #3 was serving coffee to the residents and coming in and out of the kitchen food preparation area with hair outside the hair covering. Interview with the Certified Dietary Manager (CDM) on 9/9/15 at 7:50 AM, in the CDM's office, the CDM was asked what she expected of her staff regarding hair coverings. The CDM stated, I expect them to put them (hair covers) on when they first get here, and all their hair should be covered.

Based on review of a job description, policy review, observation and interview, the Registered Dietician (RD) failed to provide oversight of the facility's kitchen by planning, managing, and implementing dietary service activities in order to assure that 1 of 48 (Resident #37) residents received adequate nutrition, and failed to ensure food was stored, prepared and distributed under sanitary conditions when 3 of 6 (Dietary Staff (DS) #1, 2, and 3) dietary staff members did not have their hair completely covered. The findings included: 1. The Clinical Dietitian. (RD). documented, .Responsibilities. Review facility resident's weights as available and recommend interventions to prevent weight loss. The facility's weight loss / gain policy documented, .All residents will maintain their adequate body weight. Medical record review revealed Resident #37 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The weight records for Resident #37 documented, .USUAL WEIGHT: 190 lbs (pounds) and the following monthly weights: a. March, 2015: 185 lbs. b. April, 2015: 179 lbs. c. May, 2015: 169 lbs. d. June, 2015: 169 lbs. e. August, 2015: 150 lbs. f. September, 2015: 141 lbs, which indicated a 9 lb (6.4 percent (%) weight loss over 30 days, a 28 lb (19.9%) weight loss over 90 days, and a 44 lb (31.2%) loss over 180 days. Interview with the Certified Dietary Manager (CDM) on 9/9/15 at 8:30 AM, in room 7, the CDM was asked about Resident #37's continued weight loss. The CDM stated, Trying to come up with something. The CDM was asked what interventions are in place now for Resident #37's weight loss. The CDM stated, All I do is talk to her. The CDM was asked who is supposed to follow up on inventions for weight loss. The CDM stated, I try to get my RD to look at her once a month. I know it has fell through the cracks. Interview with the Assistant Director of Nursing (ADON) on 9/9/15 at 9:32 AM, in room 7, the ADON was asked what was in place now for Resident #37's weight loss. The ADON stated, Still on weekly weights. A telephone interview with the RD on 9/9/15 at 9:46 AM, the RD was asked about Resident #37's weight loss. The RD stated, I remember the name. Don't have the chart in front of me. The RD was asked if the facility notified her of residents with significant weight loss. The RD stated, Let me know when I come in. The RD was informed of Resident #37's weight loss and she was not currently on any interventions. The RD was asked what should be done for Resident #37's weight loss. The RD stated, Can't comment on anything, significant weight loss would expect them to let me know. I can't give you an answer, don't have the chart in front of me. I just can't verify what you are saying, will definitely see her in September. My calendar says I'm coming September 30th. 2. Review of the facility's dietary services policy documented, .IV. PERSONAL HYGIENE A. Proper attire for food handlers should include a hair covering. Observations in the Kitchen on 9/9/15 at 7:20 AM, revealed DS #1 and 2 were serving food from the tray line with hair outside the hair covering. DS #3 was serving coffee to the residents and coming in and out of the kitchen food preparation area with hair outside the hair covering. Interview with the Certified Dietary Manager (CDM) on 9/9/15 at 7:50 AM, in the CDM's office, the CDM was asked what she expected of her staff regarding hair coverings. The CDM stated, I expect them to put them (hair covers) on when they first get here, and all their hair should be covered.

Based on observation and interview, the facility failed to ensure the environment was clean and sanitary as evidenced by doors, door facings, walls and baseboards were dirty, cracked or in disrepair for 6 of 31 (Rooms #6, 11, 26, 27, 28 and 37) resident rooms. The findings included: 1. Observations in room #6 on 9/8/15 at 3:53 PM and on 9/9/15 at 11:02 AM, revealed brown dry drippings around the night light in the bathroom. The wall behind the toilet was in disrepair with a small hole at the baseboard, and a piece of baseboard was coming apart from the wall. In the bedroom the dry wall was exposed on the corner edge of the wall by the cabinet, and the baseboard was jagged and missing part of the corner underneath the dry wall. 2. Observations in room #11 on 9/8/15 at 3:45 PM and on 9/9/15 at 11:05 AM, revealed the door protector was peeling away from the bottom of the door. 3. Observations in room #26 on 9/8/15 at 3:50 PM and on 9/9/15 at 11:10 AM, revealed dirt and grime build up between wall and the Heating, Ventilation, and Air Conditioning (HVAC) unit. There was a gap in the baseboard behind the commode with a hole in the wall. 4. Observations in room #27 on 9/8/15 at 3:54 PM and on 9/9/15 at 11:11 AM, revealed the baseboard next to the HVAC unit was detached from the wall. There were holes in the wall under the television (TV) mount area. The wall behind the door had dry brown dripping stains and a gouged area at the bottom of the wall area. 5. Observations in room #28 on 9/8/15 at 3:56 PM and 9/9/15 at 11:12 AM, revealed cobwebs between the wall and the HVAC unit. The door facings around both bathroom doors were chipped and rusted. 6. Observations in room #37 on 9/8/15 at 4:00 PM and 9/9/15 at 11:14 AM, revealed a dry brown substance on the wall under the toilet paper holder, and on the light vent in the bathroom. 7. Interview with the Housekeeping Supervisor (HS) and the Maintenance Director (MD) on 9/9/15 at 2:50 PM, the HS was asked how often the rooms are cleaned. The HS stated, Daily. The HS was asked how often the rooms are deep cleaned. The HS stated, Weekly according to the special assignment sheet. The HS was asked if cleaning between walls and HVAC units was a part of that deep cleaning. The HS stated, Yes ma'am and we have a shop vac to help with that. The MD was asked about issues in rooms like drywall and baseboards coming loose and how he is made aware of things that need repair. The MD stated, We make rounds one time a month to check. A building tour was made on 9/9/15 beginning at 3:00 PM with the HS and MD, and both the HS and MD confirmed the presence of the issues as noted above in rooms 6, 11, 26, 27, 28 and 37.