Every finding on record at Park Terrace Health Campus

Based on interview and record review, the facility failed to provide showers to residents who required assistance with their activities of daily living (ADLs), for 2 of 13 residents sampled for ADL care (Resident (R)96 and R100).The findings include:1. Review of the Resident Face Sheet for R96 revealed the facility admitted the resident on 08/09/2024, with a diagnosis of end stage renal disease. Further review revealed the facility discharged R96 on 09/15/2024. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/15/2024, revealed the facility assessed R96 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Further review revealed the facility assessed R96 to require substantial/maximal assistance with showering/bathing.Review of R96's Care Plan initiated 08/12/2024, the facility developed a Profile Care Guide for R96, to communicate the resident's care needs. Continued review revealed the interventions included staff to provide R96 a shower on Tuesdays and Fridays during the second shift.Review of the facility's shower/bath history report for R96, for the timeframe of 08/09/2024 through 08/31/2024, revealed no documented evidence the resident received a shower, bath, or bed bath from 08/15/2024 through 08/22/2024, a total of eight days. Continued review of the facility's shower/bath history report for R96, for the timeframe from 09/01/2024 through 09/13/2024, revealed staff documented the resident did not receive a shower, bath, or bed bath from 09/07/2024 through 09/12/2024, a total of six days.During interview on 07/18/2025 at 10:43 AM, Certified Resident Care Associate (CRCA) 5 stated she did not recall R96. She reported residents had scheduled showers based on their room numbers, and showers were provided twice a week.2. Review of the Resident Face Sheet for R100 revealed the facility admitted the resident on 04/22/2025, with a diagnosis of displaced intertrochanteric left femur fracture. Further review revealed the facility discharged R100 on 05/14/2025.Review of the admission MDS Assessment, with an ARD of 04/28/2025, revealed the facility assessed R100 to have a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed the facility assessed R100 to require substantial/maximal assistance with showering/bathing.Review of R100's Care Plan revealed a problem statement initiated 04/23/2025, which indicated the resident required staff assistance to complete safe-care and mobility functional tasks completely and safety. Further review revealed no documented evidence of how often R100 was to be provided showers/baths or when the showers/baths were to be performed.Review of R100's Resident Progress Notes dated 05/04/2025 at 10:34 PM, revealed a family member of the resident inquired about when the last time the resident was given a shower.Review of the facility's shower/bath history report for R100, for the timeframe of 04/22/2025 through 05/14/2025 , revealed no documented evidence the resident was provided a shower, bath, or bed bath from 04/23/2025 through 04/27/2025, a total of five days; or from 05/06/2025 through 05/12/2025, a total of seven days.During interview on 07/19/2025 at 10:05 AM, the Director of Health Services (DHS) Float, the facility's former DHS, stated resident showers were scheduled to be given twice a week unless the resident wanted to have a shower more frequently. The DHS Float said a bed bath was offered as an alternative to a shower. The DHS Float stated bathing documentation was documented in the resident's electronic health record. The DHS Float further stated if a resident went six or eight days with no bathing activity, she expected a refusal to be documented. The DHS Float additionally said going six to eight days without a shower did not meet the facility's expectations.During interview on 07/19/2025 at 11:19 AM, the Executive Director (ED) stated a resident going six to eight days without bathing would not meet the facility's expectations. The ED further stated however, there could be extenuating circumstances, like being sent out to a hospital or refusals as to why there would be no documentation of bathing.Based on interview and record review, the facility failed to provide showers to residents who required assistance with their activities of daily living (ADLs), which affected 2 (Resident #96 and Resident #100) of 13 residents reviewed for ADL care. Findings included: 1. A “Resident Face Sheet” revealed the facility admitted Resident #96 on 08/09/2024. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of end stage renal disease. The Resident Face Sheet indicated the facility discharged the resident on 09/15/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2024, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with showering/bathing. Resident #96's “Care Plan” initiated 08/12/2024, indicated the resident had a “Profile Care Guide” to communicate resident care needs. Interventions directed staff to provide the resident a shower on Tuesdays and Fridays during the second shift (initiated 08/12/2024). Resident #96’s shower/bath history report, for the timeframe from 08/09/2024 through 08/31/2024, revealed no documented evidence the resident received a shower, bath, or bed bath from 08/15/2024 through 08/22/2024, a total of eight days. Resident #96’s shower/bath history report, for the timeframe from 09/01/2024 through 09/13/2024, revealed staff documented the resident did not receive a shower, bath, or bed bath from 09/07/2024 through 09/12/2024, a total of six days. During an interview on 07/18/2025 at 10:43 AM, Certified Resident Care Associate #5 stated she did not recall Resident #96, residents had scheduled showers based on their room numbers, and showers were provided twice a week. 2. A “Resident Face Sheet” indicated the facility admitted Resident #100 on 04/22/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of displaced intertrochanteric left femur fracture. The Resident Face Sheet indicated the facility discharged the resident on 05/14/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2025, revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with showering/bathing. Resident #100’s “Care Plan” included a problem statement initiated 04/23/2025, that indicated the resident required staff assistance to complete safe-care and mobility functional tasks completely and safety. The Care Plan revealed it did not include how often or when the resident was to be provided with showers/baths. Resident #100’s “Resident Progress Notes” dated 05/04/2025 at 10:34 PM, that indicated a family member of the resident inquired about when the last time the resident was given a shower. Resident #100’s shower/bath history report, for the timeframe from 04/22/2025 through 05/14/2025 , revealed no documented evidence the resident was provided a shower, bath, or bed bath from 04/23/2025 through 04/27/2025, a total of five days; or from 05/06/2025 through 05/12/2025, a total of seven days. During an interview on 07/19/2025 at 10:05 AM, the Director of Health Services (DHS) Float, the facility’s former DHS, stated resident showers were scheduled to be given twice a week unless the resident wanted to have a shower more frequently. The DHS Float stated a bed bath was offered as an alternative to a shower. The DHS Float stated that bathing documentation was documented in the resident’s electronic health record. According to the DHS Float, if a resident went six or eight days with no bathing activity, she expected a refusal to be documented. The DHS Float stated that generally going six to eight days without a shower did not meet expectations. During an interview on 07/19/2025 at 11:19 AM, the Executive Director stated that a resident going six to eight days without bathing would not meet expectations, but there could be extenuating circumstances, like being sent out to a hospital or refusals.

Based on observation, interview, record review, facility policy review, and review of the insulin pen instruction manual, the facility failed to ensure a medication error rate was not 5 percent (%) or greater for 1 of 4 residents observed during the medication administration task, (Resident (R)89).The findings include:Review of the facility policy titled, Medication Administration- General Guidelines, revised 11/2018, revealed medication were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of the policy revealed under the Procedures was included the FIVE RIGHTS- Right resident, right drug, right dose, right route and right time were applied for each medication being administered.Review of the Instructions for Use Lantus Solostar instruction manual, revised 12/01/2021, revealed under, Step 3: Perform a safety test, which noted to always perform the safety test before each injection. Per review, doing that ensured you get an accurate dose by, including ensuring the pen and needle work properly, and removing air bubbles. Per review of the manual revealed to select a dose of 2 units by turning the dosage selector clockwise, and take off the outer needle cap and keep it to remove the used needle after injection. Continued review revealed to take off the inner cap and discard it, hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, and press the injection button all the way in. Check if insulin comes out of the needle tip. The instructions indicated, You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you see insulin coming out of the needle tip, the pen was ready to use. Further review revealed if insulin was not seen coming out before taking a dose, you could get an underdose or no insulin at all. This could cause high blood sugar.Review of the Instructions for Use Humalog [NAME] KwikPen insulin lispro (100 units/mL [milliliter], 3mL pen) instruction manual, revised 03/31/2020, revealed, priming the pen was to be done before each injection. Per review, priming the pen meant removing air from the needle and cartridge that might collect during normal use. Per review, it was important to prime the pen so that it would work correctly, and if you do not prime the pen before each injection, you may get too much or too little insulin. Continued review of the manual revealed, Step 5: To prime your Pen, turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge holder gently to collect air bubbles at the top. Step 7: Continue holding your Pen with the Needle pointing up. Further review revealed to push the Dose Knob in until it stopped, and ‘0' was seen in the Dose Window, the hold the Dose Knob in and count to 5 slowly. Additionally review revealed You should see insulin at the tip of the needle.Review of the Resident Face Sheet for F89 revealed the facility admitted the resident on 06/26/2024, with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar).Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/21/2025, revealed the facility assessed R89 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Further review of the MDS Assessment revealed the facility assessed R89 to receive insulin injections each day during the seven-day assessment period.Review of R89's Care Plan revealed the facility developed a problem statement initiated 06/27/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar)/hyperglycemia related to diabetes mellitus. Further review revealed the interventions included staff to administer the resident's medications as ordered (initiated 06/27/2024).Review of R89's Physician Order Report, for the timeframe of 06/19/2025 through 07/19/2025, revealed an active order dated 01/242025, for Humalog [NAME] KwikPen U-100 insulin pen, with instructions to inject 3 units subcutaneously before meals,. Further review of the Physician Order Report revealed an order dated 01/24/2025, for Lantus Solostar U-100 insulin pen, with instructions to inject 25 units subcutaneously once a day.Observation, during medication administration, on 07/17/2025 at 5:51 AM, Registered Nurse (RN) 1 prepared R89's medications, to include Humalog [NAME] KwikPen insulin pen and a Lantus Solostar insulin pen. Per observation, RN 1 selected a dose of 3 units on the Humalog [NAME] KwikPen insulin pen and administered the medication to the resident. Continued observation revealed RN 1 selected a dose of 25 units on the Lantus Solostar insulin pen and administered the medication to the resident. Further observation revealed RN 1 did not complete the safety test for the Lantus Solostar insulin pen as specified by the manufacturer and also did not prime the needle for the Humalog [NAME] KwikPen as specified by the manufacturer prior to administering the medications. (The two medication errors out of the 26 opportunities, resulted in a 7.69% medication error for R89).During interview on 07/17/2025 at 7:01 AM, RN 1 stated she had not primed the insulin pens as required. During interview on 07/18/2025 at 7:04 AM, the Staff Development (SD) RN stated the process for insulin pen administration was to look at the physician's order for number of units, apply the needle to the insulin pen, dial the pen to two units to prime the needle and then dial to the units ordered. The SD RN reported the insulin pens should be primed to ensure there was no air in the needle. The SD RN further stated it would not be the correct process to dial the dose ordered and administer the insulin because it would not be the correct dose being administered without priming the pen. In addition, the SD RN said she expected the pen to be primed and then the ordered dose to be dialed on the pen.During interview on 07/18/2025 at 7:12 AM, the Director of Health Services (DHS) stated she expected insulin pens to be primed and administered as per the manufacturer's guidelines. The DHS said that included priming the pen, typically with two units. The DHS further stated it was important to prime the insulin to remove air and make sure the pen was working properly before administering the insulin. During interview on 07/18/2025 at 2:59 PM, the Executive Director (ED) stated he expected the facility's medication error rate to be less than 5%. The ED further stated he deferred questions related to insulin pens to the DHS.The findings include:Review of the facility policy titled, Medication Administration- General Guidelines, revised 11/2018, revealed medication were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of the policy revealed under the Procedures was included the FIVE RIGHTS- Right resident, right drug, right dose, right route and right time were applied for each medication being administered.Review of the Instructions for Use Lantus Solostar instruction manual, revised 12/01/2021, revealed under, Step 3: Perform a safety test, which noted to always perform the safety test before each injection. Per review, doing that ensured you get an accurate dose by, including ensuring the pen and needle work properly, and removing air bubbles. Per review of the manual revealed to select a dose of 2 units by turning the dosage selector clockwise, and take off the outer needle cap and keep it to remove the used needle after injection. Continued review revealed to take off the inner cap and discard it, hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, and press the injection button all the way in. Check if insulin comes out of the needle tip. The instructions indicated, You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you see insulin coming out of the needle tip, the pen was ready to use. Further review revealed if insulin was not seen coming out before taking a dose, you could get an underdose or no insulin at all. This could cause high blood sugar.Review of the Instructions for Use Humalog [NAME] KwikPen insulin lispro (100 units/mL [milliliter], 3mL pen) instruction manual, revised 03/31/2020, revealed, priming the pen was to be done before each injection. Per review, priming the pen meant removing air from the needle and cartridge that might collect during normal use. Per review, it was important to prime the pen so that it would work correctly, and if you do not prime the pen before each injection, you may get too much or too little insulin. Continued review of the manual revealed, Step 5: To prime your Pen, turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge holder gently to collect air bubbles at the top. Step 7: Continue holding your Pen with the Needle pointing up. Further review revealed to push the Dose Knob in until it stopped, and ‘0' was seen in the Dose Window, the hold the Dose Knob in and count to 5 slowly. Additionally review revealed You should see insulin at the tip of the needle.Review of the Resident Face Sheet for F89 revealed the facility admitted the resident on 06/26/2024, with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar).Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/21/2025, revealed the facility assessed R89 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Further review of the MDS Assessment revealed the facility assessed R89 to receive insulin injections each day during the seven-day assessment period.Review of R89's Care Plan revealed the facility developed a problem statement initiated 06/27/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar)/hyperglycemia related to diabetes mellitus. Further review revealed the interventions included staff to administer the resident's medications as ordered (initiated 06/27/2024).Review of R89's Physician Order Report, for the timeframe of 06/19/2025 through 07/19/2025, revealed an active order dated 01/242025, for Humalog [NAME] KwikPen U-100 insulin pen, with instructions to inject 3 units subcutaneously before meals,. Further review of the Physician Order Report revealed an order dated 01/24/2025, for Lantus Solostar U-100 insulin pen, with instructions to inject 25 units subcutaneously once a day.Observation, during medication administration, on 07/17/2025 at 5:51 AM, Registered Nurse (RN) 1 prepared R89's medications, to include Humalog [NAME] KwikPen insulin pen and a Lantus Solostar insulin pen. Per observation, RN 1 selected a dose of 3 units on the Humalog [NAME] KwikPen insulin pen and administered the medication to the resident. Continued observation revealed RN 1 selected a dose of 25 units on the Lantus Solostar insulin pen and administered the medication to the resident. Further observation revealed RN 1 did not complete the safety test for the Lantus Solostar insulin pen as specified by the manufacturer and also did not prime the needle for the Humalog [NAME] KwikPen as specified by the manufacturer prior to administering the medications. (The two medication errors out of the 26 opportunities, resulted in a 7.69% medication error for R89).During interview on 07/17/2025 at 7:01 AM, RN 1 stated she had not primed the insulin pens as required. During interview on 07/18/2025 at 7:04 AM, the Staff Development (SD) RN stated the process for insulin pen administration was to look at the physician's order for number of units, apply the needle to the insulin pen, dial the pen to two units to prime the needle and then dial to the units ordered. The SD RN reported the insulin pens should be primed to ensure there was no air in the needle. The SD RN further stated it would not be the correct process to dial the dose ordered and administer the insulin because it would not be the correct dose being administered without priming the pen. In addition, the SD RN said she expected the pen to be primed and then the ordered dose to be dialed on the pen.During interview on 07/18/2025 at 7:12 AM, the Director of Health Services (DHS) stated she expected insulin pens to be primed and administered as per the manufacturer's guidelines. The DHS said that included priming the pen, typically with two units. The DHS further stated it was important to prime the insulin to remove air and make sure the pen was working properly before administering the insulin. During interview on 07/18/2025 at 2:59 PM, the Executive Director (ED) stated he expected the facility's medication error rate to be less than 5%. The ED further stated he deferred questions related to insulin pens to the DHS.

Based on interviews, record reviews, document reviews, and facility policy review, it was determined the facility failed to ensure three (3) (Residents #39, #177, and #178) of five (5) sampled residents reviewed for abuse, were from abuse. On 08/01/2021, Resident #179 physically abused Resident #39 when the resident did not respond to Resident #179's command. On 05/09/2023, Resident #176 pulled Resident #177 from their bed. On 09/04/2022, a staff member took an unauthorized photo of Resident #178 and showed the picture to other staff. Findings include: A review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised on 08/29/2019, revealed, 3. Definitions: ABUSE is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 1. A review of Resident #39's Resident Face Sheet revealed the facility admitted the resident on 08/24/2020, with diagnoses to include dementia with behavioral disturbance and anxiety disorder. A review of Resident #39's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. A review of Resident #39's care plan, with a start date of 08/30/2020, revealed the resident demonstrated significant severe cognitive deficits. A review of Resident #179's Resident Face Sheet, revealed the facility admitted the resident on 07/17/2021, with diagnoses to include vascular dementia with behavioral disturbance and anxiety. A review of Resident #179's admission MDS, with an ARD of 07/23/2021, revealed the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). A review of Resident #179's care plan, with a problem start date of 07/19/2021, revealed the resident demonstrated significant severe cognitive deficits. A review of an Event Report, revealed on 08/01/2021 at 11:38 AM, another resident (Resident #179) became aggressive and smacked Resident #39 on their shoulders several times. The report revealed the resident was sitting in a wheelchair propelling around the unit. Resident #179 started to push Resident #39 in the wheelchair and asked the resident to turn his/her hat around and asked the resident to move. When Resident #39 did not, Resident #179 became agitated and began to hit Resident #39 on the shoulder several times. A review of the facility's final report, dated 08/05/2021, revealed staff separated the residents and completed a skin assessment on Resident #39 and noted no injury. The report revealed Social Services Director (SSD) #7 attempted to interview both residents on 08/04/2021 and neither could remember the incident. Staff assigned to the unit reported no history between the residents. The report indicated both residents had been in the common area at the same time with no further incidents. The facility made a referral to a behavioral hospital for Resident #179, and the resident was accepted for treatment on 08/05/2021. The facility determined the contact between the residents was incidental because staff responded quickly to protect both residents, there were no injuries, and there was a lack of apparent intent by either resident to harm the other. During an interview on 01/10/2024 at 3:22 PM, activities associate (AA) stated she witnessed the incident between Resident #39 and Resident #179. Per the AA, Resident #39 liked to self-propel in a wheelchair and did not like to pick up their feet. The AA stated she witnessed Resident #179 push Resident #39's wheelchair and Resident #179 smacked Resident #39 on the chest. The AA stated the smack was not a hard hit and Resident #39 had no injury and laughed about the incident. The AA stated she took Resident #39 to the nurse's station following the incident. During an interview on 01/09/2024 at 11:57 AM, Certified Resident Medication Assistant (CRMA) #2 stated she thought Resident #179 became upset or was trying to move Resident #39 out of the way. CRMA #2 could not remember which resident was hit. During an interview on 01/10/2024 at 11:20 AM, SSD #7 stated she did not remember the details of the incident between Resident #179 and Resident #39 but her role in alleged abuse investigations included checking on the residents to ensure there were no residual effects from the altercation. SSD #7 further stated neither resident had a history of behaviors towards others. During an interview on 01/11/2024 at 10:01 AM, the Director of Health Service (DHS) stated the incident between Resident #179 and Resident #39 occurred before she was the DHS. She stated Resident #39 had no behaviors and self-propelled in their wheelchair around the unit. During an interview on 01/11/2024 at 12:27 PM, the Executive Director (ED) stated he did not remember the incident on 08/01/2021 but read the reportable. He stated he did not remember Resident #179. He stated Resident #39 was always happy and smiling. The ED stated he did not think the resident provoked anything and there was no reason to believe that Resident #39 was at risk. He stated he thought it was just two residents with cognitive decline. 2. A review of Resident #176's Resident Face Sheet revealed the facility admitted the resident on 12/29/2022 with diagnoses that included which included pelvic and sacral fracture, age-related osteoporosis, anxiety, and heart disease. A review of Resident #176's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2023, revealed Resident #176 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. A review of Resident #176's care plan, with a problem start date of 01/04/2023 and revised 10/10/2023, revealed the resident demonstrated significant severe cognitive deficits. A review of Resident #177's Resident Face Sheet revealed the facility admitted the resident on 12/13/2022, with diagnoses to include Alzheimer's disease and dementia with other behavioral disturbance. A review of Resident #177's quarterly MDS, with an ARD of 02/21/2023, revealed Resident #177 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. A review of Resident #177's care plan, with a problem start date of 12/17/2022 and revised 08/21/2023, revealed the resident demonstrated significant severe cognitive deficits. A review of the facility's final report, dated 05/19/2023, revealed Resident #176 alleged Resident #177 pulled them out of bed. Resident #177 seemed confused about which room was theirs and thought Resident #176 was in their bed. Staff separated the residents, assessed them for injuries, and obtained an x-ray for Resident #176, which was negative for fractures. Staff identified a possible contributing factor to Resident #177's confusion could have been their missing shadow box outside their room because it was being updated at the time with new personal items and pictures to aid in room identification. Staff placed Resident #177 on 1:1 supervision but the resident's physician evaluated the resident and determined they were not a threat and released them from one-to-one care. The investigation could not conclude that abuse occurred due to the residents' cognitive function and the lack of witness. During an interview on 01/09/2024 at 2:30 PM, Certified Resident Medication Assistant (CRMA) #4 stated as she sat at the nurse's station, she heard Resident #177 yell. CRMA stated she responded and met Resident #177 in the doorway of Resident #176's room and Resident #176 was on the floor of their room. Per CRMA #4, one staff member took Resident #177 to their room, and she waited on the nurse to assess Resident #176 for any injury. Per CRMA #4, there was no history of behaviors between these two residents. During an interview on 01/09/2024 at 3:36 PM, Registered Nurse (RN) #5 stated Resident #177 had sustained significant cognitive decline and had no history of any similar behaviors towards others. During an interview on 01/10/2024 at 10:58 AM, Licensed Practical Nurse (LPN) #6 said she was the nurse on the other side of the hall when the incident between Resident #177 and Resident #176 occurred. LPN #6 stated staff obtained vital signs and there were no apparent injuries. She stated both residents had advanced dementia with no history of incidents involving other residents. During an interview on 01/10/2024 at 11:20 AM, Social Services Director (SSD) #7 stated neither Resident #177 nor Resident #176 had a history of behaviors towards others. During an interview on 01/10/2024 at 3:22 PM, the activities associate (AA) stated both Resident #177 and Resident #176 had no history of verbal or physical behaviors towards others. During an interview on 01/11/2024 at 10:01 AM, the Director of Health Services (DHS) stated when staff found Resident #176 on the floor, the situation first presented as a fall. However, when Resident #176 stated that Resident #177 pulled them out of bed, staff were able to piece together what happened. Per the DHS, staff reported to her that Resident #177 was in the doorway of Resident #176's room thinking someone else was in their bed. Staff redirected Resident #177 to their room and then found Resident #176 on the floor. The DHS stated staff initially placed Resident #177 on one-on-one supervision following the incident. According to the DHS, neither resident had a history of altercations with other residents. During an interview on 01/11/2024 at 12:27 PM, the Executive Director (ED) stated he monitored interactions between residents to prevent any alleged incidents of abuse or neglect and followed up on what was reported. Per the ED, when there was an altercation between two (2) residents, he expected staff to protect the residents. Once an incident occurred, the facility investigated. They interviewed the residents, if possible, completed skin and pain assessments, interviewed staff, and investigated any potential patterns. The ED stated it was important to do so to protect the residents to ensure no abusive situations occurred. The ED stated he believed someone brought staffs' attention to the room and staff found Resident #176 on the floor. The ED did not think anyone saw what happened. He believed the facility placed Resident #177 on one-on-one supervision and attended to Resident #176 to make sure there were no injuries. The ED stated there was a question whether Resident #177 was confused on the location of their room. The ED stated to prevent this from occurring again, the facility acquired an extra shadow box for personal effects in the event one needed to be taken down. 29673 3. A review of the facility policy titled, Cell Phones, Cameras & Electronic Devices, updated June 2023, revealed This policy is designed to maintain excellent customer service, comply with healthcare regulations, and protect residents' rights to privacy and confidentiality. It is of utmost importance to avoid taking or using photographs or making recordings that might be demeaning, humiliating or could potentially cause emotional or mental abuse to a resident. A review of Resident #178's Resident Face Sheet revealed the facility most recently admitted the resident on 03/09/2017, with diagnoses to include unspecified dementia, anxiety, psychosis, and major depressive disorder. A review of Resident #178's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2023, revealed the resident had Brief Interview for Mental Status (BIMS) score was 0, which indicated the resident had severe cognitive impairment. A review of Resident #178's care plan, with a problem start date of 03/09/2017, revealed the resident had impaired cognition with associated short term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to dementia. A review of the facility's Long Term Care Facility - Self- Reported Incident Form, dated 09/04/2022, revealed Housekeeper #24 allegedly took an unauthorized photo of Resident #178 on her personal cell phone. Per the form, the resident could allegedly be identified in the photo and the resident had no knowledge of the photo being taken. During an interview on 01/10/2024 at 2:04 PM, Housekeeper #24 stated she took a picture of the resident to show the Executive Director (ED) because she asked staff to help the resident and staff would not help. Housekeeper #24 stated the resident had feces on their face, hands, and on the bed. She stated the facility told her to erase the picture from the phone, then her employment was terminated. Housekeeper #24 initially stated she only showed the picture to the environmental service director (ESD) and the ED, but then stated she also showed the picture to her mother and a staff member in the kitchen. During an interview on 01/10/2024 at 3:48 PM, the ESD stated Housekeeper #24 sent her a text message about a resident who had been playing in their feces. Per ESD, approximately five (5) minutes later, she went to the resident's room to check on them and staff already had the resident in the shower. The ESD stated she told Housekeeper #24 that staff took care of the resident. The ESD stated later the ED notified her that Housekeeper #24 had taken a picture of the resident with her phone. According to the ESD, the ED asked her to contact the employee to remove the picture from their cell phone. However, the ESD stated Housekeeper #24 had already shown the picture to Dietary Aide (DA) #25. According to the ESD, Housekeeper #24 admitted to also showing the picture to her mother. During an interview on 01/11/2024 at 10:02 AM, the Director of Health Services (DHS) stated staff were told to keep their cell phones out of resident care areas. The DHS stated taking pictures of a resident in an embarrassing situation was inappropriate behavior and potential abuse. The DHS stated if staff showed the pictures to a family member it was considered abuse even if the resident was not aware of the picture being taken. During an interview on 01/11/2024 at 12:48 PM, the ED stated when he met with the ESD, the Housekeeper #24 said she took the picture so she could show him that Resident #178 had not been cared for. The ED stated Housekeeper #24 was suspended and then her employment was terminated.

Based on observations, interviews, record reviews, and review of the facility policy, it was determined the facility failed to assess two(2) (Resident #15 and Resident #19) of eighteen (18) sampled residents for the resident's ability to self-administer their medications. Findings include: A review of the facility policy titled, Medication Administration-General Guidelines, revised in November 2018, revealed 13. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 1. A review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/2023, revealed the facility readmitted Resident #15 on 11/13/2021. The MDS revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #15 had active diagnoses to include stroke, hypertension, and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage. A review of Resident #15's Care Plan, edited on 11/09/2023, revealed the resident was at risk for pain related to chronic pain. Interventions directed staff to administer medications as ordered and notify the physician of any side effects observed or lack of effectiveness. A review of Resident #15's physician orders revealed an order dated 01/18/2023, for Biofreeze (a topical pain reliever) to apply a small amount topically to areas of muscle soreness twice a day as needed. There was no indication the resident was to keep the medication at the bedside or had the ability to self-administer the medication. On 01/08/24 at 10:38 AM, the surveyor observed two (2) tubes of Biofreeze at the bedside of Resident #15. Resident #15 stated staff allowed the medication to be kept at their bedside. On 01/09/2024 at 4:00 PM and 01/10/2024 at 10:49 AM, the surveyor observed 2 tubes of Biofreeze on the over-the-bed table in Resident #15's room. During an interview on 01/10/2024 at 11:36 AM, Licensed Practical Nurse (LPN) #21 stated she had not been advised of any residents on the unit that self-administered medications. LPN #21 stated before a resident self-administered medication an assessment had to be completed to verify the resident knew what the medication was for, how to administer the medication, when to administer the medication, and how to administer the medication. LPN #21 stated residents were not allowed to keep any medications at bedside without a physician's order. LPN #21 added this would include cough medication, Biofreeze, antifungal powders and creams. LPN #21 reviewed the physician orders for Resident #15 and stated the resident had an order for Biofreeze twice a day. Per LPN #21, if the resident had a physician's order to self-administer the Biofreeze, the physician's order would include the resident may keep the medication at bedside. LPN #21 confirmed the resident did not have a physician's order to keep the Biofreeze medication at their bedside. LPN #21 observed the medication in Resident #15's room and explained to the resident that she needed to remove the Biofreeze until a physician's order for self-administration could be obtained. During an interview on 01/11/2024 at 10:20 AM, the Director of Health Services (DHS) stated Resident #15 had not been assessed for their ability to self-administration their medication. The DHS stated Resident #15 should not have had the 2 tubes of Biofreeze at bedside. During an interview on 01/11/2024 at 12:49 PM, the Executive Director stated he expected a resident assessment for self-administration competency and a system to provide safe storage of medications prior to self-administration. 2. A review of Resident #19's Resident Face Sheet, revealed the facility had admitted the resident on 04/28/2021 with diagnoses that included acute kidney failure, hypertensive heart disease and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A review of Resident #19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2023, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #19's Care Plan, edited on 12/28/2023, revealed the resident had potential for complications, functional and cognitive status decline related to respiratory disease. Interventions directed staff to administer medications as ordered. A review of Resident #19's Order History, for the time frame 12/01/2023 to 01/09/2024, did not reveal an order for the resident to be administered Delsym, a cough suppressant medication. On 01/08/2024 at 12:06 PM, the surveyor observed a bottle of Delsym at the bedside of Resident #19. Resident #19 stated their renal doctor prescribed the medication for them and the facility nurses administered the medication to the resident on 01/07/2024. On 01/09/2024 at 4:05 PM, while seated in a wheelchair in their room, Resident #19 pointed to the bottle of Delsym on their bed. Resident #19 picked up the bottle and stated they took the medication every 12 hours as directed on the label. During an interview on 01/10/2024 at 11:36 AM, Licensed Practical Nurse (LPN) #21 stated she had not been advised of any residents on the unit that self-administered medications. LPN #21 stated before a resident self-administered medication an assessment had to be completed to verify the resident knew what the medication was for, how to administer the medication, when to administer the medication, and how to administer the medication. LPN #21 stated residents were not allowed to keep any medications at bedside without a physician's order. LPN #21 added this would include cough medication, Biofreeze, antifungal powders and creams. LPN #21 reviewed the physician orders for Resident #19 and stated the resident did not have an order for Delsym. LPN #21 stated the medication should not be at the bedside of the resident. LPN #21 observed the medication in Resident #19's room and explained to the resident that she needed to remove the Delsym until a physician's order for self-administration could be obtained. During an interview on 01/11/2024 at 10:20 AM, the Director of Health Services (DHS) stated Resident #19 had not been assessed for their ability to self-administration their medication. The DHS stated Resident #19 should not have had the Delsym medication at their bedside. During an interview on 01/11/2024 at 12:49 PM, the Executive Director stated he expected a resident assessment for self-administration competency and a system to provide safe storage of medications prior to self-administration.

Based on interview, record reviews, document review, and facility policy review, it was determined the facility failed to have evidence to indicate an allegation of abuse which involved two residents, Resident #39 and Resident #179, of five (5) sampled residents reviewed for abuse prohibition, was thoroughly investigated. Findings include: A review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised on 08/29/2019, revealed f. Investigation i. The Executive Director is accountable for investigating and reporting. ii. Exercising caution in handling evidence that could be used in a criminal investigation iii. Investigating different types of allegation violations iv. Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations v. Focusing the investigation of determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. vi. Providing complete & thorough documentation of the investigation. A review of Resident #39's Resident Face Sheet revealed the facility admitted the resident on 08/24/2020, with diagnoses to include dementia with behavioral disturbance and anxiety disorder. A review of Resident #39's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident had severe cognitive impairment. A review of Resident #39's care plan, with a start date of 08/30/2020, revealed the resident demonstrated significant severe cognitive deficits. A review of Resident #179's Resident Face Sheet, revealed the facility admitted the resident on 07/17/2021, with diagnoses to include vascular dementia with behavioral disturbance and anxiety. A review of Resident #179's admission MDS, with an ARD of 07/23/2021, revealed the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). A review of Resident #179's care plan, with a problem start date of 07/19/2021, revealed the resident demonstrated significant severe cognitive deficits. A review of an Event Report, revealed on 08/01/2021 at 11:38 AM, Resident #179 became aggressive and smacked Resident #39 on their shoulders several times. The report revealed Resident #179 started to push Resident #39 in their wheelchair and asked the resident to turn their hat around and for the resident to move. When Resident #39 did not, Resident #179 became agitated and began to hit Resident #39 on the shoulder several times. A review of the facility's investigation file revealed no evidence to indicate all involved persons, to include the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation were interviewed during the investigation. During an interview on 01/11/2024 at 12:27 PM, the Executive Director (ED) stated when there was an altercation between two (2) residents, the facility conducted an investigation which included interviewing the resident, if possible, conducting skin and pain assessments, interviewing staff, and looking into any potential patterns. The ED stated it was important do so to protect the residents to ensure no abusive situations occurred. The ED acknowledged he could not find the facility's investigation into the incident that involved Resident #39 and Resident #179.

Based on record review, interviews, and facility policy review, it was determined the facility failed to follow physician's orders for one (1) of six (6) sampled residents, whose medications were reviewed, Resident #126. Findings include: A review of a facility policy titled, Medication Administration-General Guidelines, revised in November 2018, revealed If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. [exempli gratia, for example], other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication may be removed from the emergency drug supply. The policy further revealed, Medications are administered in accordance with written orders of the prescriber. A review of Resident #126's Resident Face Sheet revealed the facility admitted the resident on 10/05/2023 with diagnoses which included metabolic encephalopathy, infection and inflammatory reaction due to internal right knee prosthesis, rheumatoid arthritis, anemia, uncomplicated, unspecified asthma, personal history of thrombosis and embolism, personal history of other malignant neoplasm of the skin, and personal history of methicillin resistant staphylococcus aureus (MRSA) infection. The Resident Face Sheet revealed the facility discharged the resident on 10/09/2023. A review of a hospital Discharge Summary, dated 10/05/2023, indicated Resident #126 was to be treated with daptomycin (an antibiotic) per intravenous (IV) access for 6 weeks. The Discharge Summary also indicated Resident #126 was to receive apixaban (an anticoagulant medication), cyanocobalamin (vitamin B12 supplement), duloxetine (an antidepressant medication), esomeprazole (a medication used to treat gastrointestinal distress), flecainide (a heart medication), gabapentin (a medication used to treat neuropathic pain), and folic acid. A review of Resident #126's Medication Administration History, for 10/01/2023 through 10/09/2023, revealed staff documented that Resident #126 did not receive the cyanocobalamin on 10/06/2023 and 10/08/2023 during the day shift, daptomycin on 10/06/2023, duloxetine on 10/09/2023, apixaban on 10/06/2023 during the day shift, flecainide on 10/06/2023 during the day shift, gabapentin on 10/06/2023, 10/07/2023, and 10/08/2023, esomeprazole magnesium on 10/06/2023, and folic acid on 10/08/2023. The Medication Administration History revealed staff documented the reason for the missed medications were due to the medications not being available. The Medication Administrator History revealed entries of the missed medications were created by staff, to include Licensed Practical Nurse (LPN) #14 and LPN #18. A review of Resident #126's Resident Progress Notes, dated 10/05/2023 through 10/09/2023, revealed no evidence to indicate the pharmacy and/or physician had been notified of missed medication or medications not being received. In an interview on 01/10/2024 at 12:03 PM, LPN #14 stated admission orders were obtained from the hospital discharge summary and confirmed with the attending physician. She stated the attending physician made any needed changes to the medications. LPN #14 stated the pharmacy was typically able to get medications to the facility overnight. She stated if it was past admission and the medications had not arrived, she alerted her supervisor, called the pharmacy, and documented her actions to get the medications. LPN #14 reviewed Resident #126's medication administration record (MAR) and stated the pharmacy should have been called and the medications sent immediately to the facility. The LPN stated she was not sure there was a backup pharmacy and added she had always been able to get medications from the facility pharmacy. She stated there should be nurse's notes that explained what was done to get the medications. She stated the danger of not getting the IV antibiotics would be worsening of the infection and having to start the antibiotic cycle over again. LPN #14 stated she remembered the resident's name because she had worked on the resident's unit but was unable to remember specifics about the resident. LPN #14 stated not receiving the resident's medications was an issue and stated she would not have been able to follow the physician's orders without the medications. In a telephone interview on 01/10/2024 at 3:38 PM, Registered Nurse (RN) #15 stated she worked the 6:00 PM to 6:00 AM shift and when a resident was admitted on that shift, she usually called the pharmacy with the medication list and the medications were delivered within four hours. RN #15 stated the facility also had a first dose machine where medications could be taken. RN #15 added if a resident's medications were not delivered, she called the pharmacy and the physician to notify them the medications were not available and document the notification in the nurse's notes. The RN stated if Resident #126 had not received the ordered antibiotics for several days, it would slow down the healing process and could harm the resident. In a telephone interview on 01/11/2024 at 6:30 AM, RN #9 stated admission orders were taken from the hospital discharge summary. He stated when a resident was admitted on his shift, which was between 6:00 PM and 6:00AM, he ordered the medications immediately from the pharmacy and the medications usually arrived within 4 hours. RN #9 stated the facility had an emergency kit with some medications and he could also borrow medications from a sister facility's emergency kit if needed. He stated a resident should not go two to three days without ordered medications, especially antibiotics, since going without the antibiotic could cause the resident to have sepsis. RN #9 stated he would notify the pharmacy and the physician about missing medications and would document those conversations in the resident's progress notes. The RN stated he was unable to remember the resident and had no idea why the medications were not received and why there were no attempts documented to call the physician or the pharmacy. In an interview on 01/11/2024 at 2:14 PM, LPN #18 stated she vaguely remembered Resident #126. LPN #18 stated if the IV antibiotic for Resident #126 was not available she would have called the pharmacy and the physician and checked the first dose machine. The nurse stated she would have documented the conversations in the progress notes. LPN #18 stated if there were no notes in Resident #126's chart regarding notification of missed medications, then she probably had forgotten to call. In an interview on 01/11/2024 at 10:40 AM, the Director of Health Services (DHS) stated admission orders were received from the hospital on the discharge summary, history and physical, and then verified with the attending physician. The DHS stated if the attending physician ordered additional medications or made changes, they were entered into the electronic medical record (EMR) and stated that a written progress note was not required. She stated that when the orders were entered into the EMR, the pharmacy was able to review the orders and the medications were sent to the facility the same night, or the following day if the order was not received by the pharmacy by 3:00 PM. The DHS stated if a medication was needed on the day of admission, the nurse utilized the first dose machine but if the medication was not in the first dose machine, she expected staff to notify the physician and the pharmacy to have the medication sent immediately and was usually received within 4 hours. The DHS added if medications were not received within 24 hours, the physician was expected to be notified for further instructions and the pharmacy should be contacted to see if the medications were on the way to the facility. The DHS stated negative consequences of not receiving an ordered antibiotic would depend on the individual resident's risk factors. The DHS reviewed Resident #126's MAR and stated the nurses should have documented the provider was notified on 10/06/2023 when the medications were not available. In an interview on 01/11/2024 at 1:47 PM, the Executive Director (ED) stated he expected medications to arrive within 24 to 48 hours and for staff to remove medications out of the first dose kit if available. The ED stated he expected nurses to follow the physician orders and notify the physician if they were unable to follow the orders. In a telephone interview on 01/11/2024 at 4:02 PM, Resident #126's primary care physician (PCP) stated if medications were delayed, he expected to be notified. The PCP stated he was unsure if he had been notified or not since he did not have the chart for review. He stated the negative outcome for missed medications would be a delay in healing.

Based on observation and interview it was determined the facility failed to implement their ongoing infection prevention and control program. Observations during survey revealed State Registered Nurse Aide (SRNA) #1 removed meal trays from two (2) of thirteen (13) separate isolation rooms in the yellow zone without donning a gown or eye protection. The findings include: Review of the policy titled, Infection Prevention and Control Program (IPCP), dated 05/22/19, revealed the facility had policies to prevent, identify, report, investigate, and contain infections or communicable diseases. The policy revealed the facility monitored the residents for infections, antibiotic usage, monitoring and reporting test results, and utilization of an IPCP surveillance program. Review of the policy titled, Enhanced Infection Prevention and Control Program for COVID-19, dated 06/01/2020, revealed the facility was responsible for procedures, audits, education, personal protective equipment (PPE) supply management, monitoring, reporting, and surveillance of COVID-19. Review of SRNA #1's employee education record revealed on 08/11/2020 SRNA #1 received policy education for blood borne pathogens, hand washing/hygiene, standard precautions, airborne precautions, droplet precautions, and contact precautions. The education record revealed proper steps for donning and doffing personal protective equipment (PPE). Observation of the yellow sign posted on residents' doors on the quarantine unit, on 09/08/2020 at 1:20 PM, revealed a gown, gloves, mask, and face shield or goggles were required to enter the yellow zone rooms. Continued observations revealed PPE supply carts, with supplies, located in the hall between every other resident room. Interview with SRNA #1, on 09/08/2020 at 1:38 PM, revealed she was educated on the proper PPE for entry to the yellow zone rooms which included a gown, mask, gloves, and eye protection or face shield. She stated she should have worn the PPE to retrieve meal trays from the rooms. SRNA #1 stated wearing the proper PPE prevented the spread of infection. Interview with Licensed Practical Nurse (LPN) #2, on 09/08/2020 at 1:22 PM, revealed the facility required staff to wear PPE, including mask, gown, gloves, goggles or face shield, to enter a yellow zone room. She stated the PPE was required any time an individual passed across the doorway threshold and it included when staff retrieved meal trays Interview with Registered Nurse (RN) #2, on 09/08/2020 at 1:46 PM, revealed staff donned gown, gloves, mask, and goggles or face shield to enter the yellow zone resident rooms. She stated failing to wear the designated PPE when entering rooms could cause COVID-19 to be transmitted to staff or other residents. Interview with the Assistant Director of Health Services (ADHS), on 09/08/2020 at 2:10 PM, revealed staff were required to wear a gown, gloves, goggles or face shield, and mask in the yellow zone rooms. She stated the ADHS and the Director of Health Services (DHS) educated the staff on PPE requirements for COVID-19 isolation. Interview with the Director of Health Services, on 09/08/2020 at 6:22 PM, revealed staff were educated on the proper PPE usage for residents in the yellow COVID-19 isolation rooms during their fourteen-day quarantine period and for residents positive for COVID-19. She stated staff were instructed on how to put on and remove the PPE. The DHS stated staff were required to wear gown, gloves, mask, and goggles or face shield to enter the yellow zone rooms. She stated PPE audits were performed weekly and any instances that required further education would be addressed immediately. Interview with the Executive Administrator (EA), on 09/08/2020, at 7:40 PM, revealed staff were required to wear a gown, gloves, mask, and goggles or face shield in the yellow zone rooms. He stated the goal of proper PPE was to protect the residents, staff, and slow the spread of COVID-19. The EA stated incorrect PPE usage was concerning and could be a contributing factor to an outbreak in the facility.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in a sanitary manner. Observation of the kitchen revealed uncovered food items stored in the kitchen's walk-in refrigerator and freezer. The findings include: Review of the facility's policy, Storage Guidelines, dated 05/31/16, revealed prepared perishables such as salads, puddings, milk, etc., were stored in a refrigerator and covered, labeled, and dated until used. Further review revealed all foods in the freezer were wrapped in moisture proof wrapping or placed in suitable containers to prevent freezer burn, and labeled and dated. Observation of the kitchen, on 04/17/18 at 10:48 AM, revealed the walk-in refrigerator contained an unlabeled, undated, and uncovered salad bar with carrots, cheese, cucumbers, and tomatoes in metal pans. Further observation of the kitchen, on 04/17/18 at 10:50 AM, revealed the walk-in freezer contained an unlabeled, undated, and uncovered tiramisu cake on the 2nd shelf. Interview with the Dietary Manager, on 04/17/18 at 11:44 AM, revealed the policy was not to cover food items during meal preparation. However, food items were to be covered when stored in the walk-in refrigerator and freezer to prevent food contamination. He further stated the dietary staff had been in-serviced on covering, labeling, and dating foods in the refrigerator and freezer. Interview with Dietary Cook #1, on 04/19/18 at 10:39 AM, revealed food items placed in the walk-in refrigerator and freezer should be covered. Further, she stated she was trained on food preparation, food storage, and cleaning by the Dietary Manager and completed the ServSafe Food Handler Program online training. Interview with the Assistant Director of Food Services, on 04/19/18 at 10:53 AM, revealed the food storage policy stated food items should be covered, labeled, and dated in the refrigerated food storage. She stated she trained staff to cover the food items prior to storing them in the refrigerator and freezer. Interview with the Administrator, on 04/18/18 at 9:58 AM, revealed dietary staff was to follow the policy on food storage, to cover food items when in the walk-in refrigerator and freezer.

Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility failed to protect one (1) of four (4) sampled residents, Resident #4, from neglect. Certified Nursing Assistant (CNA) #4 failed to plug in the call light or provide care to the resident for an entire shift, resulting in the resident saturating his/her brief and bed sheets with urine. The findings include: Review of the facility's policy, Abuse and Neglect Procedural Guidelines, not dated, revealed neglect was the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of a facility investigation, dated [DATE], revealed CNA #4 left Resident #4's call light unplugged from the wall throughout the shift on [DATE]. The resident was found with his/her brief and bed sheets saturated with urine after CNA #4 concluded her shift. There was a heavily saturated brief in the bathroom garbage can, in addition to the one the resident was wearing, and Resident #4 stated he/she had to change the brief himself/herself during the night because no one had checked on him/her all night. The facility substantiated the allegation of neglect. Review of the closed clinical record for Resident #4 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of Resident #4's quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident required extensive assistance of one (1) person for bed mobility and toileting. The facility determined the resident was interviewable by completing a Brief Interview for Mental Status assessment with a score of fifteen (15) out of fifteen (15). Interview with CNA #1, on [DATE] at 1:25 PM, revealed she worked first shift on [DATE], and CNA #4 reported to her that she (CNA #4) had left Resident #4's call light off all night because he/she used it too frequently. CNA #1 stated neglect occurred when staff did not provide needed care to a resident. Interview with CNA #3, on [DATE] at 2:07 PM, revealed she worked first shift on [DATE], and she received report with CNA #1 from CNA #4 and CNA #4 stated she (CNA #4) unplugged Resident #4's call light and left it unplugged all night. CNA #3 stated after receiving report, she went to Resident #4's room and discovered the call light unplugged and on top of the bedside table. When she assisted Resident #4 to get up that morning, the resident's brief and bed sheets were saturated with urine. She stated when she assisted the resident to the restroom, she discovered an additional urine saturated brief in the garbage can. She stated Resident #4 told her he/she had to get up during the night to change himself/herself because no one checked on him/her all night. CNA #3 stated neglect included not assisting residents with toileting needs and incontinence care. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 1:04 PM, revealed CNA #3 had reported to her that CNA #4 had stated she (CNA #4) had unplugged Resident #4's call light and CNA #3 entered the resident's room and determined it was true. LPN #1 further stated when she entered Resident #4's room, she observed the bed sheets saturated with urine. She stated neglect was failure to provide incontinent care to a resident. Interview with LPN #2, on [DATE] at 1:55 PM, revealed she was the night shift nurse on [DATE], until the morning of [DATE]. She stated during report, CNA #3 informed her and the oncoming day shift nurse what she had learned in report and observed in Resident #4's room. Upon entering the room, LPN #2 stated she observed the sheets on the bed saturated with urine and the resident's brief extremely wet. She further stated she had not heard or observed Resident #4's call light on during the night, which she stated was unusual. Interview with the Director of Nursing (DON), on [DATE] at 2:57 PM, revealed she received a phone call the morning of [DATE], and LPN #1 informed her CNA #4 had left Resident #4's call light unplugged all night and CNA #3 found the resident with urine saturated brief and bed sheets. She stated the facility performed an investigation and substantiated neglect. Interview with the Administrator, on [DATE] at 3:30 PM, revealed he learned of the allegation on the morning of [DATE]. He stated he was told Resident #4 had been left in his/her room all night with the call light unplugged, and was found to have a heavily saturated brief and wet sheets by the first shift CNA. The administrator stated an investigation was initiated and neglect was substantiated.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to maintain a hazard free environment as observations revealed two (2) of four (4) treatment carts left unlocked and unattended. The findings include: Review of the facility's policy, Storage of Medications, dated 09/01/13, revealed medications and biologicals were stored safely, securely, and accessible only to staff members authorized to administer the medications. Observation during the initial tour of the facility, on 05/01/17 at 8:40 AM, revealed the treatment cart located on 2 South was unlocked and unattended. Continued observation revealed prescription powders, creams, ointments, and other medical supplies in the cart. Observation, on 05/01/17 at 1:11 PM, revealed an unlocked treatment cart on 3 North. Employees were not in the vicinity. There were residents seated nearby in a television (TV) sitting room. Interview with Licensed Practical Nurse (LPN) #1, on 05/01/17 at 1:39 PM, revealed it was never appropriate to leave a medication or treatment cart unlocked and unattended. She stated locked medication and treatment carts prevented a confused resident from consuming inappropriate substances, in addition to keeping medications safe. LPN #1 revealed on 12/07/16, she left keys to the medication cart on top of the cart, in a binder, in an effort to lessen the weight of the extra keys she carried on her person and it resulted in missing medication. Review of a facility investigation, undated, revealed a cartridge of Norco 10/325 mg, a Schedule II controlled substance, containing thirty (30) tablets was discovered missing on 12/07/16, during narcotic count at morning shift change. The facility concluded LPN #1 left keys to the medication cart in a binder on top of the cart during her shift, which resulted in a staff member taking the medication. Observation, on 05/01/17 at 02:15 PM, revealed a treatment cart on 3 North was unlocked. A non-licensed staff member was seated in the TV room with residents who were engaged in an activity. Interview with LPN #4, on 05/01/17 at 02:59 PM, revealed staff should lock medication carts when not in use. She stated medication and treatment cart keys should always be in the possession of the nurse who was in charge of the unit. She stated storage of keys on the cart or in a binder was not facility policy. She stated it was important for medication and treatment carts to remain locked when not in use because confused residents could access medications they were allergic to, or could overdose on medications. She stated treatment carts contained scissors and if a resident accessed them, they could cut or hurt themselves or others. Interview with LPN #3, on 05/01/17 at 3:06 PM, revealed licensed staff assigned to each unit was responsible for the medication and treatment carts for the unit, and were not to leave the carts unlocked and unattended. LPN #3 stated a locked cart prevented a confused resident from accessing medications. LPN #3 was responsible for the treatment cart on 2 South and was not able to verbalize the reason she left the treatment cart unlocked and unattended. Interview with the Director of Post Acute Services (DPAS), on 05/01/17 at 4:11 PM, revealed staff should lock medication and treatment carts when not in use to prevent accidental consumption of medications by a confused resident and to prevent a confused resident from administering medications to another resident. The DPAS stated she monitored for secured carts anytime she was on the units but did not document her findings. Interview with the Executive Director, on 05/01/17 at 4:45 PM, revealed staff was to lock medication and treatment carts when unattended as it was facility policy and it prevented unauthorized access to their contents.

Based on observation, interview, and facility policy review, it was determined the facility failed to store medications and biologicals in locked compartments as evidenced by two (2) of four (4) unlocked and unsupervised treatment carts. The findings include: Review of the facility's policy, Storage of Medications, dated 09/01/13, revealed medications and biologicals were stored safely, securely, and accessible only to staff members authorized to administer the medications. Observation during the initial tour of the facility, on 05/01/17 at 8:40 AM, revealed a treatment cart located on 2 South was unlocked and unattended. Continued observation revealed prescription powders, creams, ointments, and other medical supplies in the cart. Interview with Licensed Practical Nurse (LPN) #1, on 05/01/17 at 1:39 PM, revealed it was never appropriate to leave a medication or treatment cart unlocked and unattended as the assigned staff member was responsible for the contents of the carts. Further interview revealed locked medication and treatment carts prevented unauthorized access and kept medications safe. LPN #1 revealed she left the keys to the medication cart on top of the cart, in a binder, on 12/07/16, in an effort to lessen the weight of extra keys she carried and it resulted in missing medication. Review of a facility investigation, undated, revealed a cartridge of Norco 10/325 mg, a Schedule II controlled substance, containing thirty (30) tablets was discovered missing on 12/07/16, during narcotic count at morning shift change. LPN #1 admitted to leaving the keys to the medication cart in a binder, on top of the cart, during her shift. The facility determined a staff member took the medication. Interview with LPN #2, on 05/01/17 at 2:33 PM, revealed staff should never leave medication and treatment carts unlocked to help prevent theft of their contents. Interview with LPN #3, on 05/01/17 at 3:06 PM, revealed staff locked medication and treatment carts when unattended, as the assigned staff member was responsible for the medication and treatment carts. LPN #3 was responsible for the treatment cart on 2 South and not able to verbalize a reason the treatment cart was unlocked and unattended. Interview with the Director of Post Acute Services (DPAS), on 05/01/17 at 4:11 PM, revealed staff locked medication and treatment carts when not in use to prevent accidental consumption of medications by a confused resident and to prevent a confused resident from administering medications to another resident. The DPAS stated she monitored for secured carts anytime she was on the units but did not document her findings. Interview with the Executive Director, on 05/01/17 at 4:45 PM, revealed staff was to lock medication and treatment carts when unattended as it was facility policy and it prevented unauthorized access to their contents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to prevent verbal abuse for two (2) of six (6) sampled residents, Resident #5 and Resident #6. Certified Nursing Assistant (CNA) #7 spoke harshly to Resident #6 after the resident requested assistance with toileting. CNA #7 cursed at Resident #5 while using a mechanical lift to transfer the resident from the bed to the chair. The findings include: Review of the facility's policy, Abuse and Neglect Procedural Guidelines, revised 05/11/16, revealed the facility developed and implemented processes to ensure the prevention and reporting of alleged resident abuse. The facility defined mental abuse as including, but not limited to, humiliation, harassment, and threats of punishment or deprivation. The facility defined verbal abuse as including the use of disparaging and derogatory terms to the resident or within their hearing distance to describe residents. The facility provided training for new employees through orientation and with ongoing training programs to include definitions of abuse, identification of abuse, and providing protection for the residents. The facility also provided training to the staff on how to investigate and report incidents of actual or suspected abuse or neglect. To prevent abuse, the facility trained staff to identify and intervene in situations where abuse was more likely to occur. The facility provided protection to the residents by, upon identification of suspected abuse, immediately providing for the safety of the resident. Interventions to implement the protection may include moving the resident to another room or suspension of the suspected employee(s) pending the outcome of the investigation. Review of the facility's Resident Rights, undated, revealed the facility ensured residents received services in a manner that assisted in maintaining independent functioning, dignity, and well-being. The facility also ensured residents had the right to be free from all forms of abuse, including verbal, mental, and physical abuse. Review of the facility's Abuse and Neglect training material, dated 2014, revealed the facility trained staff on the various types of abuse, recognizing abuse, reporting abuse, and preventing abuse. The facility training material instructed staff to ensure the resident's safety first. The training material stated if an employee actually witnessed the abuse, they must intervene to stop it, and then get help immediately. It also stated employees must report suspicion of abuse even if they did not witness the abuse. The training material further stated the employee must make an immediate report to their supervisor. The material specifically stated employees must not wait until the end of their shift or the next time they see the supervisor, but rather make the report immediately. The training material further discussed prevention of abuse. It stated the facility identified situations that increased caregivers' stress levels and signs of burnout to allow for intervention before the caregiver lashed out at a vulnerable adult. Review of the facility's clinical record for Resident #5, revealed the facility admitted the resident on 03/25/13 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment for Resident #5, dated 08/28/16, revealed the facility assessed the resident as requiring total two (2) person assistance with all transfers and dressing activities. Resident #5 required total assistance with locomotion in the facility and required extensive assistance to complete hygiene and toileting activities. The facility conducted a BIMS examination and assessed the resident with a score of eight (8) out of fifteen (15) and determined the resident was interviewable. Review of the facility's Comprehensive Care Plan for Resident #5 with a review date of 08/31/16, revealed the resident was dependent on staff and a Hoyer lift for all transfers. The Care Plan further revealed the resident had altered cognition due to Dementia. Observation of Resident #5, on 10/05/16 at 11:30 AM, revealed the resident sitting in the common area in a(NAME)chair. The resident was friendly and talkative. Interview with Resident #5, on 10/05/16 at 11:30 AM, revealed the staff was nice and friendly with him/her today. The resident was unable to state if staff were ever not friendly with him/her. Review of the facility's clinical record for Resident #6, revealed the facility admitted the resident on 10/27/15 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #6, dated 07/20/16, revealed the facility assessed the resident as requiring extensive assistance for locomotion, toileting, and to complete personal hygiene tasks. The facility conducted a Brief Interview for Mental Status (BIMS) examination and assessed the resident with a score of five (5) out of fifteen (15) and determined the resident was not interviewable. Review of the facility's Comprehensive Care Plan for Resident #6 with a review date 07/21/16, revealed the resident had difficulty with communicating due to cognitive impairment, and had short and long term memory impairments. The Care Plan further revealed the resident was continent of bowel and bladder with occasional incontinence. Observation of Resident #6, on 10/06/16 at 8:45 AM, revealed the resident was sitting in his/her wheelchair watching a movie. Review of the facility's investigation revealed the facility investigated two (2) allegations of abuse involving Certified Nursing Assistant (CNA) #7 that occurred on 08/13/16. During the breakfast meal, Resident #6 requested CNA #7 assist him/her with toileting. CNA #7 did not take the resident to the restroom and told Resident #6 that he/she was incontinent and did not need to go to the restroom. The CNA stated to the resident that he/she had already wet himself/herself so it did not matter. The Cook notified the Weekend Manager, who was also the Staff Development Coordinator, of the incident. The Staff Development Coordinator telephoned the Executive Director (ED) and reported the incident. The second allegation of abuse occurred in Resident #5's room. CNA #3 and Licensed Practical Nurse (LPN) #3 were in Resident #5's room with CNA #7 and witnessed CNA #7 yell at Resident #5 and told the resident he/she was fat and that was why a mechanical lift was needed for transfers. The investigation report stated CNA #7 cursed at the resident and told the resident that no one wanted to take care of him/her because he/she did not help. The facility placed CNA #7 on suspension 08/13/16 pending investigation. The facility substantiated the allegations of abuse and terminated CNA #7's employment on 08/16/16. Interview with the Cook, on 10/05/16 at 2:00 PM, revealed he observed CNA #7 yell at Resident #6 in the dining room during the breakfast meal on 08/13/16. The Cook stated he and CNA #7 were the only staff in the dining room with approximately fifteen (15) to eighteen (18) other residents. He stated Resident #6 told CNA #7 that he/she needed to go to the bathroom. The Cook stated CNA #7 replied in a very loud voice that the resident was incontinent anyway and could wait until she got him/her back to his/her room. He stated the CNA said it loud enough for everyone else in the dining room to hear. The Cook stated as soon as other staff entered the dining room, he stopped cooking and went downstairs and reported the incident to the Staff Development Coordinator, who was functioning as the Weekend Supervisor. The Staff Development Coordinator asked the Cook to write a statement and told the Cook she had to contact management because it was abuse. The Cook stated he returned to the dining room and observed the resident sitting in the dining room. The Cook stated the facility trained him not leave a resident alone in a room with an alleged abuser, and to report allegations of abuse immediately. He stated he reported the abuse allegation at approximately 8:30 AM on 08/13/16. Interview with LPN #4, on 10/05/16 at 4:10 PM, revealed he had received reports of possible abuse from other staff in the facility on the morning of 08/13/16, but did not report the allegation because he did not witness the abuse. He stated the CNAs working on the unit told him that CNA #7 had spoken inappropriately to a resident in the dining room. LPN #4 stated he received second hand knowledge and did not report the allegation. LPN #4 stated he was unsure if an employee had to witness an allegation in order to report it. He further stated LPN #3 told him of an incident involving CNA #7 and Resident #5; however, LPN #4 did not report that allegation because he assumed LPN #3 had already reported it. Interview with CNA #3, on 10/05/16 at 4:00 PM, revealed she observed CNA #7 cursing at Resident #5 in the resident's room approximately 10:00 AM on 08/13/16. She stated CNA #7 asked her to help transfer the resident from the bed to the chair. CNA #3 entered the room and stated CNA #7 was aggravated and cursing loudly at the resident. CNA #3 stated that she told CNA #7 she could not talk to the resident that way; however, CNA #7 continued cursing at Resident #5. She stated the care took approximately five (5) minutes to complete. CNA #3 reported she did not ask CNA #7 to leave the room. She stated she reported the incident to the Staff Development Coordinator directly after it occurred; however, CNA #3 stated at the time, she did not know she was to try to stop CNA #7. Interview with LPN #3, on 10/05/16 at 2:45 PM, revealed she entered Resident #5's room between 9:30 AM and 10:00 AM on 08/13/16 when CNA #7 asked for assistance with a Hoyer lift to transfer Resident #5 from the bed to the chair. She stated CNA #3 also entered the room. CNA #7 said to Resident #5 that because the resident was so fat, staff had to use a Hoyer lift and that the resident was lazy. She stated CNA #7 repeatedly cursed at the resident and repeated similar phrases. She stated this went on for the duration of the care, which lasted approximately five (5) minutes. She stated she did not tell CNA #7 to leave the room because she was in shock and did not want to cause a scene. After CNA #7 left the room, LPN #3 reported the incident to The Staff Development Coordinator, who was functioning as the Weekend Supervisor. She stated she did not know to intervene at the time it occurred. Interview with the Staff Development Coordinator, on 10/05/16 at 3:00 PM, revealed she worked as the Weekend Supervisor on 08/13/16. She stated the Cook reported a possible allegation of abuse. After the report, she attempted to telephone the Director of Nursing (DON); however, she did not make contact with the DON right away. She stated by the time she heard back from the DON, who told her to send CNA #7 home, the second incident had already taken place. She did not observe Resident #6 and Resident #5 until after she spoke to the DON. Interview with CNA #7 via the telephone, on 10/06/16 at 11:00 AM, revealed the facility terminated her employment after an allegation of abuse that occurred on 08/13/16. She stated she told Resident #6, who requested to go to the bathroom, he/she had already wet his/her brief and could wait. CNA #7 stated did not remember discussing an allegation of abuse involving Resident #5 with the facility. Interview with the DON, on 10/05/16 at 4:30 PM, revealed she was out of town and her telephone was out of service on 08/13/16 when the Staff Development Coordinator called her. She stated she received a message on her phone at approximately 12:00 PM on 08/13/16. She stated she returned the phone call to Staff Development Coordinator and discovered she had contacted the Assistant Director of Nursing (ADON) and the facility sent CNA #7 home pending investigation. Further interview with the DON, on 10/06/16 at 2:40 PM, revealed the facility did not receive an abuse allegation report from an LPN pertaining to the allegation of abuse between CNA #7 and Resident #6 in the dining room. She stated LPN #4 should have reported the allegation even if it was second hand knowledge. Interview with the ADON, on 10/05/16 at 5:15 PM, revealed the Staff Development Coordinator called her at approximately 10:00 AM on 08/13/16 to report an allegation of abuse involving CNA #7 and Resident #5. She stated the Staff Development Coordinator did not inform her of the incident in the dining room involving Resident #6 until the next day, 08/14/16, when the management staff entered the facility to conduct the investigation into the allegation of abuse. She stated when the Staff Development Coordinator called her, she instructed her to send CNA #7 home at that time. The ADON stated any staff could dismiss another staff from care giving duties if that staff was inappropriate. She further stated the Staff Development Coordinator could have sent CNA #7 home after the first allegation of abuse; however, the Staff Development Coordinator would have needed to notify management when doing so. The ADON stated the Staff Development Coordinator should have called her after the incident in the dining room. She further stated each employee should have reported the allegations of abuse, even if it was hearsay. Interview with the Executive Director (ED), on 10/06/16 at 10:00 AM, revealed the facility provided training to new hires and to all employees annually on abuse. The abuse training covered resident protection and reporting abuse. The ED stated the Staff Development Coordinator was in the process of taking action on 08/13/16. She stated the Staff Development Coordinator was waiting to hear back from the DON or ADON to receive instruction on what to do. She stated the facility trained staff to refer to the leadership team for validation to ensure suspending an employee was the correct thing to do.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement their policy and procedures to protect residents from verbal abuse for two (2) of six (6) sampled residents, Resident #5 and Resident #6. Staff witnessed Certified Nursing Assistant (CNA) #7 speak harshly to Resident #6 in the dining room during a breakfast meal. The CNA was not immediately removed from providing direct care and continued to work. Later that same morning, staff witnessed CNA #7 curse at Resident #5 while using a mechanical lift in the resident's room. The findings include: Review of the facility policy, Abuse and Neglect Procedural Guidelines, revised 05/11/16, revealed the facility developed and implemented processes to ensure the prevention and reporting of alleged resident abuse. The facility defined mental abuse as including, but not limited to, humiliation, harassment, and threats of punishment or deprivation. The facility defined verbal abuse as including the use of disparaging or derogatory terms to the resident or within their hearing distance to describe residents. The facility provided training to new employees through orientation and with an ongoing training program. The training included definitions of abuse, identification of abuse, and how to provide protection to residents. The facility also provided training to staff on how to report incidents of actual or suspected abuse or neglect. The facility trained staff to provide protection to the residents by, upon identification of suspected abuse, immediately providing for the safety of the resident. Interventions to implement the protection may include moving the resident to another room or suspension of the suspected employee(s) pending the outcome of the investigation. Review of the facility's Abuse and Neglect training material, dated 2014, revealed the facility trained staff on the various types of abuse, recognizing abuse, reporting abuse, and preventing abuse. The training material instructed staff to ensure the resident's safety first. The training material stated if an employee actually witnessed the abuse, they must intervene to stop it. Then get help immediately. The training material also stated employees must report suspicion of abuse even if they did not witness the abuse. The training material further stated the employee must make an immediate report to their supervisor. The material specifically stated employees must not wait until the end of their shift or the next time they see the supervisor, but rather make the report immediately. The training material further discussed prevention of abuse. It stated the facility identified situations that increased caregivers' stress levels and signs of burnout to allow for intervention before the caregiver lashed out at a vulnerable adult. Interview with the Staff Development Coordinator, on 10/05/16 at 10:00 AM, revealed all staff received the facility training on abuse and neglect annually. Review of the facility's clinical record for Resident #5, revealed the facility admitted the resident on 03/25/13 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment for Resident #5, dated 08/28/16, revealed the facility assessed the resident as requiring total two (2) person assistance with all transfers and dressing activities. Resident #5 required total assistance with locomotion in the facility and required extensive assistance to complete hygiene and toileting activities. The facility conducted a BIMS examination and assessed the resident with a score of eight (8) out of fifteen (15) and determined the resident was interviewable. Review of the facility's clinical record for Resident #6, revealed the facility admitted the resident on 10/27/15 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #6, dated 07/20/16, revealed the facility assessed the resident as requiring extensive assistance for locomotion, toileting, and to complete personal hygiene tasks. The facility conducted a Brief Interview for Mental Status (BIMS) examination and assessed the resident with a score of five (5) out of fifteen (15) and determined the resident was not interviewable. Review of the facility's investigation revealed the facility investigated two (2) allegations of abuse involving Certified Nursing Assistant (CNA) #7 that occurred on 08/13/16. During the breakfast meal, Resident #6 requested CNA #7 to assist him/her with toileting. CNA #7 did not take the resident to the restroom and told Resident #6 that he/she was incontinent and did not need to go to the restroom. The CNA stated to the resident that he/she had already wet himself/herself and so it did not matter. The Cook notified the Weekend Manager, who was also the Staff Development Coordinator, of the incident. The Staff Development Coordinator telephoned the Executive Director (ED) and reported the incident. The second allegation of abuse occurred in Resident #5's room. CNA #3 and Licensed Practical Nurse (LPN) #3 were in Resident #5's room with CNA #7 and witnessed CNA #7 yell at Resident #5 and told the resident he/she was fat and that was why a mechanical lift was needed for transfers. The investigation report stated CNA #7 cursed at the resident and told the resident that no one wanted to take care of him/her because he/she did not help. The facility placed CNA #7 on suspension 08/13/16 pending investigation. The facility substantiated the allegations of abuse and terminated CNA #7's employment on 08/16/16. Interview with the Cook, on 10/05/16 at 2:00 PM, revealed he observed CNA #7 yell at Resident #6 in the dining room during the breakfast meal on 08/13/16. The Cook stated he and CNA #7 were the only staff in the dining room with approximately fifteen (15) to eighteen (18) other residents. He stated Resident #6 told CNA #7 that he/she needed to go to the bathroom. The Cook stated CNA #7 replied in a very loud voice that he/she was incontinent anyway and could wait until she got him/her back to his/her room. He stated the CNA said this loud enough for everyone else in the dining room to hear. The Cook stated as soon as other staff entered the dining room, he stopped cooking and went downstairs and reported the incident to the Staff Development Coordinator, who was functioning as the Weekend Supervisor. The Staff Development Coordinator asked the cook to write a statement and told the Cook she had to contact management because it was abuse. He stated he reported the abuse allegation at approximately 8:30 AM on 08/13/16. Interview with LPN #4, on 10/05/16 at 4:10 PM, revealed he had received reports of possible abuse from other staff in the facility on the morning of 08/13/16, but did not report the allegations because he did not witness the abuse. He stated the CNAs working on the unit told him that CNA #7 had spoken inappropriately to a resident in the dining room. LPN #4 stated he received second hand knowledge and did not report the allegation. LPN #4 stated he was unsure if an employee had to witness an allegation in order to report it. He further stated LPN #3 told him of an incident involving CNA #7 and Resident #5; however, he did not report that allegation because he assumed LPN #3 had already reported it. Interview with CNA #3, on 10/05/16 at 4:00 PM, revealed she observed CNA #7 cursing at Resident #5 in the resident's room at approximately 10:00 AM on 08/13/16. CNA #3 entered the room and stated CNA #7 was aggravated and cursing loudly at the resident. CNA #3 stated that she told CNA #7 she could not talk to the resident that way; however, CNA #7 continued cursing at Resident #5. She stated the care took approximately five (5) minutes to complete and CNA #7 berated the resident throughout the care. CNA #3 reported she did not ask CNA #7 to leave the room. CNA #3 stated at the time, she did not know she was to try to get CNA #7 to leave the room. Interview with LPN #3, on 10/05/16 at 2:45 PM, revealed she entered Resident #5's room between 9:30 AM and 10:00 AM on 08/13/16 when CNA #7 asked for assistance with a Hoyer lift to transfer Resident #5 from the bed to the chair. She stated CNA #3 also entered the room. CNA #7 said to Resident #5 that because the resident was so fat and lazy, staff had to use a Hoyer lift. She stated CNA #7 repeatedly cursed at the resident and repeated similar phrases. She stated this went on for the duration of the care, which lasted approximately five (5) minutes. She stated she did not tell CNA #7 to leave the room because she was in shock and did not want to cause a scene. She stated the facility provided annual abuse training on the computer that briefly discussed protection of the residents; however, she stated because it was not physical abuse, she did not know to intervene at the time it occurred. Interview with the Staff Development Coordinator, on 10/05/16 at 3:00 PM, revealed she worked as the Weekend Supervisor on 08/13/16. She stated the Cook reported a possible allegation of abuse. After the report, she attempted to telephone the Director of Nursing (DON); however, she did not make contact with the DON right away. She stated by the time she heard back from the DON, who told her to send CNA #7 home, the second incident had already taken place. She did not observe Resident #6 and Resident #5 until after she spoke to the DON. Interview with the DON, on 10/06/16 at 2:40 PM, revealed the facility did not receive an abuse allegation report from an LPN pertaining to the allegation of abuse between CNA #7 and Resident #6 in the dining room. She stated LPN #4 should have reported the allegation even if it was second hand knowledge. Interview with the Assistant Director of Nursing (ADON), on 10/05/16 at 5:15 PM, revealed the Staff Development Coordinator called her at approximately 10:00 AM on 08/13/16 to report an allegation of abuse involving CNA #7 and Resident #5. She stated the Staff Development Coordinator did not inform her of the incident in the dining room involving Resident #6 until the next day, 08/14/16, when the management staff entered the facility to conduct the investigation into the allegation of abuse. She stated when the Staff Development Coordinator called her, she instructed her to send CNA #7 home at that time. The ADON stated any staff could dismiss another staff from care giving duties if that staff was inappropriate. She further stated the Staff Development Coordinator could have sent CNA #7 home after the first allegation of abuse; however, the Staff Development Coordinator would have needed to notify management when doing so. The ADON stated the Staff Development Coordinator should have called her after the incident in the dining room. She further stated each employee should have reported the allegations of abuse, even if it were hearsay. Interview with the Executive Director (ED), on 10/06/16 at 10:00 AM, revealed the facility provided training to new hires and to all employees annually on abuse. The abuse training covered resident protection and reporting abuse. The ED stated the Staff Development Coordinator was in the process of taking action on 08/13/16. She stated the Staff Development Coordinator was waiting to hear back from the DON or ADON to receive instruction on what to do. She stated the facility trained staff to refer to the leadership team for validation to ensure suspending an employee was the correct thing to do.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide a functioning resident emergency call system in four (4) of five (5) unlocked staff and visitor restrooms accessible to residents. Per the Director of Nursing twelve (12) of eighty-three (83) residents were functionally capable of utilizing these restrooms independently. The findings include: Review of the facility's policy Guidelines for Answering Call Lights, not dated, revealed the purpose for the call lights was to respond to resident's requests and needs. Observation, on 12/23/15 at 9:13 AM, revealed there was a total of four unlocked staff and visitor restrooms that was accessible to residents. These were located in the facility on the second (2nd) and third (3rd) floors in the restroom in the living area across from the elevator; the restroom by the staff break room across from the dining area; the restroom in the hallway across from the physical therapy department and the dining area. The fourth (4 th) unlocked restroom was located on the third (3rd) floor in the living area across from the elevator. Further observation of all four (4) restrooms revealed there was no emergency pull cords nor any communication system available for residents to have the ability to directly communicate with nursing staff in the event of an emergency. Interview with the Director of Nursing (DON), on 12/23/15 at 10:17 AM, revealed twelve (12) of the eighty-three (83) residents that lived in the facility had the ability to get up on their own and self-ambulate. Interview with Certified Resident Care Assistant (CRCA) #1, on 12/23/15 at 9:55 AM, revealed there were unlocked restrooms on the second (2nd) and third (3rd) floors for staff and visitors. CRCA #1 stated the residents also had access to the unlocked restrooms and could use them anytime. CRCA #1 also stated the unlocked restroom should have a call alert system for the residents because in the event of an emergency the resident would currently have to yell for help if they needed assistance. Interview with Licensed Practical Nurse (LPN) #1, on 12/23/15 at 10:03 AM, revealed there were unlocked restrooms on the second (2nd) and third (3rd) floors for staff and visitors. LPN #1 stated she had personally helped residents into the restrooms by the staff break room because those restrooms were close to the dining room and the residents frequently used them. LPN #1 also stated all restrooms that are utilized by residents need a call system in them for the resident's safety. LPN #1 further stated she wasn't aware those restrooms did not have a resident emergency pull cord in them. Interview with the Director of Plant Operations, on 12/23/15 at 10:10 AM, revealed there were unlocked restrooms in the facility that residents, staff, and guest had access to. The Director of Plant Operations stated that all restrooms in the facility the residents had access to should have a call system available to the residents for their safety. Continued interview with the Director of Nursing (DON), on 12/23/15 at 10:17 AM, revealed the residents had free access to all the restrooms in the facility. The DON stated all restrooms the residents had access to should have a call alert system. Interview with the Executive Director (ED), on 12/23/15 at 10:21 AM, revealed she was aware there were unlocked restrooms on the second (2nd) and third (3rd) floors and that residents had access to because they were guest restrooms. The ED stated all restrooms accessible to residents should have a communication systems for residents to have direct contact to facility staff.

Based on observation, interview, record review, and review of the facility's policy and Material Safety Data Sheets (MSDS), it was determined the facility failed to ensure residents were free from potentially hazardous substances to prevent accidents. Nine (9) bottles containing hazardous chemicals were stored in an unlocked closet accessible to residents on one (1) of four (4) halls. The findings include: Review of the facility's policy regarding Storage of Hazardous Chemicals, not dated, revealed all hazardous chemicals would be stored in a locked area when not in use. Observation during the initial environmental tour, on 12/21/15 at 1:47 PM, revealed an open janitor's closet on the Woods North Hall that housed nine cleaning bottles that were labeled Wiwax Cleaning & Maintenance Emulsion, Oxivir Five 16 Concentrate, Heavy Duty Prespray Plus, Extraction Rinse SC RTD, Red Carpet Rombus Carpet Clean W145, Virex II 256, Snapback UHS Restorer, Stench and Stain Digester, and Defoamer Anti-Mousse Anties Puma. Further observation revealed the janitor's closet was located in the back corner of Woods North Hall across from resident's rooms and the janitor's closet was not visible by staff at the nursing station, nor was any facility staff close by the unlocked closet containing the chemicals. 1. Review of the Material Safety Data Sheets (MSDS) for Wiwax Cleaning and Maintenance Emulsion, dated 10/28/09, revealed Wiwax Cleaning and Maintenance Emulsion contained the cleaning ingredients of Diethylene glycol monoethyl ether and Propylene glycol. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Flush immediately with plenty of water. If irritation develops, get medical attention; SKIN CONTACT: Flush immediately with plenty of water. If irritation develops, get medical attention; INHALATION: No specific first aid measures are required; and INGESTION: No specific first aid measures are required. 2. Review of the Material Safety Data Sheets (MSDS) for Oxivir Five 16 Concentrate, dated 04/08/11, revealed Oxivir Five 16 Concentrate contained the cleaning ingredients of 2 Hydroxybenzoic Acid, Phosphoric Acid, and Hydrogen Peroxide. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Hold eye open and rinse slowly and gently with water for 15-20 minutes. Get medical attention immediately; SKIN CONTACT: Take off contaminated clothing and rinse skin immediately with plenty of water for 15-20 minutes. If irritation develops, get medical attention; INHALATION: If breathing is affected, remove to fresh air. Get medical attention immediately; and INGESTION: Call medical attendant, doctor, or poison control center immediately. Have person sip water if able to swallow. Do not induce vomiting unless told to do so by a poison control center or doctor. 3. Review of the Material Safety Data Sheets (MSDS) for Heavy Duty Prespray Plus, dated 09/04/08, revealed Heavy Duty Prespray Plus contained the cleaning ingredients of 2-Ethylhexyl Sodium Sulphate and Alcohol Ethoxylates. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Flush immediately with plenty of water. If irritation persists, get medical attention; SKIN CONTACT: Flush immediately with plenty of water. If irritation persists, get medical attention; INHALATION: No specific first aid measures are required; and INGESTION: If Swallowed, give a cupful of water or milk. 4. Review of the Material Safety Data Sheets (MSDS) for Extraction Rinse SC RTD, dated 10/09/08, revealed Extraction Rinse SC RTD contained the cleaning ingredients of Hydroxyacetic Acid. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Flush immediately with plenty of water. If irritation persists, get medical attention; SKIN CONTACT: Flush immediately with plenty of water. If irritation persists, get medical attention; INHALATION: No specific first aid measures are required; and INGESTION: If Swallowed, give a cupful of water or milk. 5. Review of the Material Safety Data Sheets (MSDS) for Red Carpet Rombus Carpet Clean W145, dated 07/02/03, revealed Red Carpet Rombus Carpet Clean W145 contained the cleaning ingredients of Surfactants. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Immediately irrigate with flowing water continuously for 15 minutes. If irritation persists consult medical personnel; SKIN CONTACT: Wash with soap and water; INHALATION: Move to fresh air. If irritation persists consult medical personnel; and INGESTION: If swallowed DO NOT induce vomiting unless directed to do so by medical personnel. If injured party is conscious, give two glasses of water. Seek medical attention if irritation persists. 6. Review of the Material Safety Data Sheets (MSDS) for Virex II 256, dated 08/03/11, revealed Virex II 256 contained the cleaning ingredients of N-Alkyk Dunethyl Benzyl Ammonium Chloride, Didecyl Dimethyl Ammonium Chloride, Ethyl Alcohol, Lauryl Dimethyl Amine Oxide. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Hold eye open and rinse slowly and gently with water for 15-20 minutes. Get medical attention immediately; SKIN CONTACT: Take off contaminated clothing and rinse skin immediately with plenty of water for 15-20 minutes. Get medical attention immediately; INHALATION: If breathing is affected, remove to fresh air. If person is not breathing call 911 or an ambulance then give artificial respiration, preferably by mouth to mouth, if possible. Get medical attention immediately; and INGESTION: Call a doctor or poison control center immediately for treatment and advice. Have person sip a glass water if able to swallow. Do not induce vomiting unless told to do so by a poison control center or doctor. 7. Review of the Material Safety Data Sheets (MSDS) for Snapback UHS Restorer, dated 10/27/11, revealed Snapback UHS Restorer contained the cleaning ingredients of Diethylene Glycol Monoethyl Ether and Dipropylene Glycol Methyl Ether. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Flush immediately with plenty of water. If irritation develops, get medical attention; SKIN CONTACT: Flush immediately with plenty of water. If irritation developers, get medical attention; INHALATION: No specific first aid measures are required; and INGESTION: No specific first aid measures are required. 8. Review of the Material Safety Data Sheets (MSDS) for Stench and Stain Digester, dated 03/07/11, revealed Stench and Stain Digester contained the cleaning ingredients of Sodium Lauryl Sulphate and Alcohol Ethoxylates. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Immediately Flush eyes with running water for at least 15 minutes, keeping eyelids open. Get medical attention; SKIN CONTACT: Flush immediately with plenty of water. If irritation persists, get medical attention; INHALATION: If breathing is affected, remove to fresh air. Get medical attention; and INGESTION: Give a cupful of water or milk. THEN IMMEDIATELY CONTACT A PHYSICIAN OR POISON CENTER. DO NOT induce vomiting unless directed to do so by medical personnel. 9. Review of the Material Safety Data Sheets (MSDS) for Defoamer Anti-Mousse Anties Puma, dated 08/11/14, revealed Defoamer Anti-Mousse Anties Puma contained the cleaning ingredients of Methanol and 1,2-Benzisothiazol-3(2H)-One. The MSDS also revealed, the product's First Aid Measures were the following: EYE CONTACT: Immediately Flush eyes with plenty of water, if irritation occurs and persists, get medical attention; SKIN CONTACT: Rinse with plenty of water. If irritation occurs and persists, get medical attention; INHALATION: Rinse mouth with water. Interview with the Director of Environmental Services Housekeeping, on 12/23/15 at 8:43 AM, revealed the janitor's closet which contained the cleaning chemicals was supposed to be kept locked at all times because the chemicals in the cleaning products were dangerous and could cause serious harm to the residents. The Director of Environmental Services stated the housekeeping staff was trained during orientation, inserviced monthly and knew the importance of keeping the janitor's closets locked. In addition, the staff must have forgotten to turn the inside lock or to close the janitor's closet door completely and the lock on the door failed to automatically lock. The Director of Environmental Services further stated the house keeping staff was supposed to double check the janitor's closet doors to ensure they were locked before they left the area. Interview with Housekeeper #2, on 12/23/15 at 8:47 AM, revealed she was the housekeeper assigned to work Woods North Hall on 12/21/15. Housekeeper #2 stated she couldn't remember if she closed the door completely or if the door was locked after she went into the janitor's closet to remove her mop bucket. Housekeeper #2 also stated she was trained by the facility to ensure the cleaning supplies were kept locked because they were potentially hazardous to staff and residents. Housekeeper #2 further stated she must have forgotten to re-check the janitor's closet door to ensure it was closed and locked appropriately. Interview with Housekeeper #1, on 12/23/15 at 9:00 AM, revealed she knew the janitor's closets on all the halls were to be kept locked because of the hazardous chemicals they housed were harmful to the residents. Housekeeper #1 stated the only times when the janitor's closet doors should be unlocked was when one of the housekeepers was close by or in the closet. Housekeeper #1 also stated the housekeeping staff had a key to unlock it and they must turn the button and push it in on the inside of the janitor's closet to relock it after it had been unlocked. Housekeeper #1 further stated staff was trained to double check the janitor's closet doors to ensure the doors were locked before they left the area. Interview with the Executive Director (ED), on 12/23/15 at 4:00 PM, revealed it was the facility's policy to keep all chemicals locked and inaccessible to the residents. The ED stated the janitor's closet on the Woods North Hall that contained the nine cleaning containers should have been locked. The ED also stated if any of the residents in the facility had come into contact with the chemicals the facility staff would have to follow the MSDS information and ensure the physician was contacted for medical direction and treatment.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain effective infection control practices for one (1) of seventeen (17) sampled residents (Resident #7). Certified Nurse Aide (CNA) #5 cleaned the stoma site for a suprapubic catheter from outer perimeters towards the stoma site. The findings include: Review of the facility's policy regarding Guidelines for Suprapubic Catheter Care, not dated, revealed the purpose was to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Review of Resident #7's clinical record revealed the facility admitted the resident on 12/05/06 with [DIAGNOSES REDACTED]. Observations, on 12/23/15 at 10:30 AM, revealed CNA #5 performed suprapubic care with Resident #7. CNA #5 cleaned the area with a cloth from the left towards the stoma site. She followed the same motion on the right side towards the stoma site. She cleaned the distal (farthest away) area of the catheter tubing towards the stoma site. The catheter was attached to a bedside drainage bag placed in a dignity bag Interview with CNA #5, on 12/23/15 at 11:20 AM, revealed the technique she utilized during the suprapubic care was done in the manner she normally completed the procedure. She stated she wiped from side to stoma and usually clean the catheter in the same manner. She paused and stated she did not know that was a problem, but it could be a concern for infection. She further stated she should be cleaning away from the catheter and away from the opening into the bladder. Interview with Licensed Practical Nurse #1, on 12/23/15 at 11:30 AM, revealed suprapubic catheter care site cleaning should be done from the stoma site outward whether cleaning the catheter or the site. She stated she was not aware any staff was cleaning in any other direction. She stated the cleaning motion towards the stoma site would be a concern for the possibility of infection for the resident. Interview with the Director of Nursing, on 12/23/15 at 11:50 AM, revealed the suprapubic catheters were like any other catheter, the staff was trained to clean around the opening, outward. Then the catheter tubing was cleaned from the opening outward. She stated she was not aware any staff was cleaning in any other manner. She stated the concern was the introduction of an infection when completed in the reverse.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User Manual Version 3.0 it was determined the facility failed to ensure two (2) of ten (10) sampled residents (Residents #5 and #8) were accurately assessed to reflect a [DIAGNOSES REDACTED]. The findings include: Review of the RAI manual, last updated 2015, revealed item I2300 Urinary tract infection [MEDICAL CONDITION] had a look-back period of 30 days for active disease instead of 7 days. This area of the assessment was to be coded only if all of the following were met: [DIAGNOSES REDACTED].g., peri-urethral site burning sensation, frequent urination of small amounts), pain or tenderness in flank, confusion or change in mental status, change in character of urine (e.g., pyuria); Significant laboratory findings (the attending physician should determine the level of significant laboratory findings and whether or not a culture should be obtained); and current medication or treatment for [REDACTED]. 1. Review of Resident #8's medical record revealed the facility readmitted the resident on 05/29/15 with [DIAGNOSES REDACTED]. Review of the 30-day Medicare Required Prospective Payment System (PPS) Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/26/15 revealed item I2300 UTI was not checked that Resident #8 had a UTI in the past 30 days. Continued review of the medical record revealed a Physician's telephone order dated 06/02/15 for a urinalysis and culture and sensitivity (C&S) due to symptoms of burning and cloudy urine. Review of an order dated 06/05/15 revealed an order for [REDACTED]. Interview with the RN MDS Coordinator on 07/08/15 at 10:45 AM revealed after reviewing the medical record, that Resident #8 had the symptoms, significant laboratory results, the treatment, and Physician diagnosis. She stated UTI should have been coded on the MDS. Interview with the Campus Support Resident Assessment Coordinator on 07/09/15 at 2:30 PM revealed she had reeducated the MDS Coordinators to only code UTI per the RAI manual, when all four criteria of a UTI were met. She stated they were previously over-coding UTIs. 2. Review of the medical record revealed the facility admitted Resident #5 on 01/25/14 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) with an ARD of 05/27/15, revealed in section C0500 a Brief Interview for Mental Status (BIMS) score of 03, revealing the resident was severely cognitively impaired and not interviewable. Review of the Infection Assessment and Review sheet dated 05/21/15 revealed Resident #5 had a mental status change which included extreme confusion and hallucinations. Review of the urine analysis (UA) and culture and sensitivity (C&S) lab report dated 05/21/15 revealed a UA and C&S was ordered and collected per physician's orders [REDACTED]. Review of a Physician Telephone Order sheet dated 05/24/15 revealed an order for [REDACTED]. Review of the Quarterly MDS dated [DATE], section I2300, revealed no documented evidence that Resident #5 had a UTI in the last 30 days. Interview on 07/09/15 at 4:51 PM with the MDS Coordinator revealed the resident met the four criteria for having a UTI, which included symptoms, documented lab report, treatment, and diagnoses, and should have been coded on the MDS as having a UTI within the past 30 days. Interview on 07/09/15 at 5:18 PM, with the Campus Support Resident Assessment Coordinator revealed it was her expectation for the MDS nurses to follow the Resident Assessment Instrument Manuel page I-8 when coding for a UTI. Continued interview with the Campus Support Resident Assessment Coordinator revealed Resident #5 met the four criteria (symptoms, lab report, diagnoses, and treatment) which should have been reflected on the MDS.

Based on observation, interview, and facility policy review, it as determined the facility failed to prepare and serve food in a sanitary manner. The dietary staff touched multiple surfaces and continued to serve food to the residents at one (1) of three (3) steam tables. Dietary and CNA staff transported and then served uncovered food and drink items to residents outside of the dining area. The findings include: Review of the facility's policy regarding Hand Washing Technique, revised March 2013, revealed the objective in washing hands was to prevent the spread of infection. The policy stated health care workers should wash their hands before and after preparing or serving meals or drinks. Review of the facility's policy regarding Room Service Meal Delivery, revised September 2014, revealed kitchen staff would facilitate all set up of the meal cart from the main kitchen area. The dining service team would ensure meal trays were marked and placed in the cabinets and would ensure the appropriate condiments and beverage choice items would be attractively and tastefully displayed on and in the cart. The policy also stated the nursing team was responsible for serving the meals and drinks from the room service cart. Review of the dietary monthly meeting training notes, dated 07/22/14, revealed staff in dietary were required to wear gloves when handling ready to eat foods. Each member of dietary signed and dated a copy of this dietary training. Review of the Dietary meeting agendas, dated 09/09/14 and 10/02/14, revealed hand washing procedures were covered in each of these meetings. Review of the employee computer based training web site records revealed a hand washing training that employees were required to complete. The record also revealed the hand washing training was completed by eight (8) of the eleven (11) kitchen staff. Food Service Assistant #1 completed the hand washing training. Observation, on 11/19/14 at 10:40 AM, revealed Food Service Assistant #2 prepared meal trays by placing silverware, napkins, condiments, and cold food items on the meal trays. The staff also placed salads and desert items on the meal trays. The kitchen staff had prewraped the salads individually with plastic wrap; however, desert items were not covered at this time. Food Service Assistant #2 then placed the meal trays onto the food service carts. Observation of the two (2) food service carts, on 11/19/14 at 10:55 AM, revealed the two (2) carts contained sixteen (16) meal trays. Ten (10) of the sixteen (16) trays contained uncovered deserts. Interview with Food Service Assistant #2, on 11/19/14 at 11:00 AM, revealed Food Service Assistant #2 prepared the trays by placing silverware, condiments, salads, and desert items on the meal trays. Food Service Assistant #2 stated after the trays were prepared, the hot plates were prepared and placed on the meal trays. Observation, on 11/19/14 at 11:45 AM, revealed the kitchen staff removed trays of food from the holding and transport system heater and placed the trays into the meal service carts. The kitchen staff then placed bowls of desert items on to the trays and placed these trays in to the same meal service cart. The desert items bowls were not covered. Interview with Assistant Food Service Director, on 11/19/14 at 11:45 AM, revealed kitchen staff was taking carts containing the meal trays to the second floor for room service delivery. The staff took the carts containing the food trays and the desert items to the steam tables on the third floor. The Assistant Food Service Director indicated there were two (2) steam tables and dining rooms on the third floor, the 3 North Unit dining room and 3 South Unit dining room. The Assistant Food Service Director also stated the kitchen staff was to take the food temperatures at those steam tables, serve the meal to the residents, and then make the plates for the room tray service. Observation, on 11/19/14 at 12:00 PM, revealed staff serving room trays to the residents in their rooms on the second floor Rehab Unit. Staff removed the meal trays from the meal transport cart in the hallway and took the meal trays in to the residents' rooms. Desert items were uncovered throughout. Staff had covered all other food and drink items on the meal trays for the second floor. Observation, on 11/19/14 at 12:10 PM, in the 3 North Unit dining room revealed kitchen staff had removed the desert trays from the meal service cart and placed the desert trays on an open cart near the steam table. Desert items continue to be uncovered. Observation at that time also revealed Food Service Assistant #1 was wearing gloves. Food Service Assistant #1 took food temperatures and recorded information holding an ink pen and the binder. Food Service Assistant #1 handled resident plates, napkins, and trays to move these items. Food Services Assistant #1 then touched his beard several times, touched his face, and touched his clothing in several places. Food Service Assistant #1 then began serving food on to resident plates. Food Service Assistant #1 did not change gloves before starting the meal service task. Observation, on 11/19/14 at 12:20 PM, revealed kitchen staff preparing resident room service meal trays off the steam tables in the dining room. Kitchen staff placed desert items on the meal trays, still uncovered. Nursing staff then placed the meal trays into the room service meal carts. Observation, on 11/19/14 at 12:25 PM, revealed CNA #2 prepared four (4) shakes for residents. CNA #2 then placed the prepared drinks on the top of the room service meal cart uncovered. CNA #2 pushed the room service meal cart out of the dining area and went down the hallway with individual uncovered drinks on the top of the cart. Certified Nursing Assistant (CNA) #2 delivered meals and drinks to residents in their rooms on the 3 North Unit. Interview, on 11/20/14 at 9:05 AM, with the Director of Food Services and the Assistant Director of Food Services revealed the dietary staff was to wash their hands frequently, including after wearing gloves. The Director of Food Service stated staff should have changed their gloves anytime they changed tasks. The Director of Food Services also stated staff should change gloves and wash their hands after touching their face. The Assistant Director of Food Services stated the dietary staff should change their gloves after recording temperatures in the logbook and before serving food. The Assistant Director of Food Service stated the kitchen staff were required to change gloves and wash their hands after touching their face. The Director of Food Service stated staff should always cover food when it left the kitchen. The kitchen staff could have covered the food items in the room service tray cart, then place a bag over the open cart or wrap the individual items. She also stated staff wrapped side dishes and salads individually to ensure freshness and to prevent infection and cross contamination. The Director of Food Service further stated the kitchen staff did not typically cover the desert items individually. Additionally the Assistant Director of Food Services stated the desert items were not typically wrapped individually. He stated he did not know why desert items were different from other items that dietary staff wrapped individually. The Assistant Dietary Manager stated desert items should be covered. The Director of Food Services further stated there were four (4) drink carts, one for each unit on the second and third floors. When the nursing staff take the room service carts out of the dining rooms on the third floor, nursing staff should also be taking a drink cart. If the nursing staff prepared drinks in the dining area, then they should have wrapped the cups individually to prevent infection and contamination. Interview with Food Service Assistant #1, on 11/20/14 at 1:20 PM, revealed the dietary staff were supposed to wash their hands after touching their face, picking something up or touching something dirty. The Food Service Assistant #1 stated kitchen staff was supposed to wear gloves when serving food, washing dishes or taking out the trash. Food Service Assistant #1 stated he generally would keep the same pair of gloves on throughout the meal service unless he had to pick up items from the floor. He stated the purpose of wearing gloves was to keep food clean and for the employee's protection. He also stated he was unaware there was a problem with not changing gloves between taking food temps, which required he touched food temp log binder, and serving the meal, and serving food. Food Service Assistant #1 stated he had previously received training and coaching from his supervisors due to touching his face and clothing while he wore gloves and stated coworkers and supervisors would tell him to wash his hands after seeing him touch his face. Food Service Assistant #1 further stated staff cover all food when putting the food on meal trays for the room service carts with the exception of the desert items. The staff would take the desert item from the open cart near the steam table and place it on the meal trays, then staff would place the trays in the room service carts. Food Service Assistant #1 stated a CNA was responsible for the drinks for the room service delivery. Interview with Executive Director, on 11/20/14 at 1:50 PM, revealed staff hand washing was important for basic infection control. The Executive Director stated staff was supposed to wash their hands any time after they touched something unclean and before they touched something clean. The Executive Director stated employees completed computer based trainings related to hand washing. These trainings were tracked using a computer system called Emerge. The Executive Director stated she had previously received reports that the kitchen management had to do increased infection control training and education with a specific employee in the kitchen. Interview with CNA #3, on 11/20/14 at 1:40 PM, revealed CNA's handed out meal trays from the room service carts to residents in their rooms. She stated the food on the trays was all covered. CNA #3 stated the CNA's get carafes of drinks from the nourishment rooms, also known as the warming kitchens, cover them with plastic, and place them on the cart. CNA's then make the drinks for the residents in their rooms. CNA #3 stated she had not observed drinks being prepared outside of the rooms for resident room service. Interview with the Assistant Director of Nursing (ADON), on 11/20/14 at 2:55 PM, revealed there had been no recent outbreaks of vomiting, diarrhea or other signs of foodborne illnesses in the facility. She also stated she provided education to the CNA's about keeping items covered and on ice to minimize the risk of cross contamination and food borne illness. The ADON stated CNAs have prepared the drinks for the room tray service on the third floor units, in the dining areas, while the tray was being prepared. CNAs then place the drink, uncovered, on the meal tray and into the meal cart for room delivery. The CNAs carry covered carafes of drinks on the top of the meal carts. The ADON stated the staff do not cover the drinks on the trays while in the cart. The ADON stated the drinks being uncovered increase the risk for contamination and spillage. The ADON also stated uncovered desert items on the tray were also at an increased risk for contamination. The ADON stated staff were trained they did not have to cover items on a tray cart, because the items were not exposed in the facility. The staff remove the tray from the cart in the hallway as a pivot point only to deliver the tray to the room.

Based on observation, interview and record review, it was determined the facility failed to repair broken, protruding tile after it was reported by staff on 10/12/14 in one (1) of four (4) Spa rooms. The findings include: Observation of the Spa Room on 3N, on 11/20/14 at 9:35 AM, revealed 3 loose tiles that protruded out of the wall at the base of the floor. There was a yellow discoloring of the tile grout in the shower with yellow, orange, and purple caked debris on the floor. Interview with the Environmental Services Assistant, on 11/20/14 at 11:00 AM, revealed the Spa Room was cleaned daily when used. She was unaware of what the substance was on the floor or how long it had been there. She stated she was aware of the broken tile and she had reported it when she noticed it. Review of the Maintenance Request, dated 10/12/14, revealed the maintenance department was notified of the broken tile in the 3N Spa Room on 10/12/14. Interview with the Environmental Supervisor, on 11/20/14 at 11:30 AM, revealed the Spa Rooms were to be cleaned daily per the schedule. She was unsure of the substance on the floor, but it appeared like iodine. The tile was noted and reported broken, but was unsure of the date. Interview with the Plant Operations Supervisor, on 11/20/14 at 11:35 AM, revealed the Spa Room tile was reported on 10/12/14. Renovations were due to the Spa Rooms and he was unaware the tile protruded or he would have fixed the tile as it could have caused injury. Interview with the Executive Director, on 11/20/14 at 1:47 PM, revealed she was unaware the tile was broken or protruded. She understood the tile to be cosmetic only, and would be resolved by the renovations to occur in the future. She expected broken tile to be fixed immediately or the Spa Room to be taken out of commission to prevent injury. She expected the Spa Room to be cleaned daily with no exceptions.

Based on observation and interview, it was determined the facility failed to ensure survey results were provided in a readily accessible location on one (1) of two (2) floors (3rd floor). The findings include: The facility did not provide a policy related to the access of a survey binder to residents or visitors. Observation of the third (3rd) floor lobby, on 11/19/14 at 4:52 PM, revealed no survey book or signage regarding the availability of the survey results. There was also an unmanned receptionist desk in the area. Interview with Unsampled Resident #A and #B, on 11/18/14 at 3:00 PM, revealed they did not know there was a survey book or binder to review. Both residents lived on the third floor of the facility and never noticed a survey binder in the front lobby of the third floor. Interview with Director of Nursing, on 11/19/14 at 4:52 PM, revealed results are available on the second (2nd) floor and the third (3rd) floor residents and family could request to see them. She further stated there was a sign on the second (2nd) floor and not the third (3rd) floor. Interview with Executive Director, on 11/19/14 at 5:23 PM, revealed she was aware there was no survey book or sign located on the third (3rd) floor. Results were located on the second (2nd) floor and could be taken to third (3rd) floor residents or family at their request. She stated she was aware, per CMS regulations, that survey results were to be accessible to all residents, and thought the requirement was met by being available on the second (2nd) floor. A survey book had been placed at the third (3rd) floor lobby area before, but had disappeared.